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Title: Practical pathology
Author: Aldred Scott Warthin
Release Date: July 4, 2023 [eBook #71116]
Language: English
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*** START OF THE PROJECT GUTENBERG EBOOK PRACTICAL PATHOLOGY ***
Transcriber’s Note
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Practical Pathology
A Manual of Autopsy and Laboratory
Technique
FOR
STUDENTS AND PHYSICIANS
BY
ALDRED SCOTT WARTHIN, Ph.D., M. D.
Professor of Pathology and Director of the Pathologic Laboratories
IN THE
UNIVERSITY OF MICHIGAN,
ANN ARBOR
SECOND EDITION
Rewritten and Enlarged
MORTUI VIVOS DOCENT
310 PAGES AND 55 FIGURES
ANN ARBOR
GEORGE WAHR, PUBLISHER
1911
Copyright 1897, by GEORGE WAHR
Copyright 1911, by GEORGE WAHR
ERRATA.
Page 155.—Thickness of gall-bladder wall 1-2 mm. instead of 1-2 cm.
Page 240.—Langhans’ for Langhan’s.
Page 264.—v. Kossa instead of Kossa.
Page 295.—v. Kölliker instead of Kölliker.
HERRN PROFESSOR ALEXANDER KOLISKO
Zur Erinnerung
an die ertragreichen, im Sektions-saale des
Wiener allgemeinen Krankenhauses
zugebrachten Sommertage
der Jahre
1893, 1894, 1895
gewidmet.
PREFACE TO THE SECOND EDITION.
The first edition of this book, in spite of numerous typographic
errors beyond the control of the writer, was very soon exhausted. An
apology is due the many, to whom, during the last ten years, a new
edition has been repeatedly promised. The writer’s only excuse for
the failure to fulfill these promises has been the pressure of other
work that has prevented such fulfillment. In the final accomplishment
of these promises the book has been practically rewritten and more
than doubled in size.
The autopsy method given in the main text is a composite one, made
up from the Rokitansky, Virchow, Chiari and Nauwerck methods,
according to the judgment of the writer as to what was the best in
these, and put together with modifications and additions arising
out of his own experience. The aim has been to offer a method by
which an autopsy can be performed with the greatest speed and ease,
and at the same time with the greatest completeness, the various
steps of the operation following in logical order in such a way that
nothing can be lost or destroyed, and thereby revealing a complete
picture of the pathologic conditions present. A choice of methods
is offered whenever the aims of the examination may be so varied as
to make variations in method advantageous. The general order of the
autopsy is the same as that given in the Protocol Blank-book, the
present book being designed as a guide and reference-book for that.
The points to be noted in the examination of each region are given
in connection with the method of examination of that region, and
represent the condensed special pathology of the latter. This should
be of great service to the beginner in autopsy work, as affording a
concise but complete guide to the most important conditions of each
region. A textbook on Special Pathology should be used as a reference
book in connection with these condensed statements of special
pathology.
The technical methods for microscopic examination given in Part
II have been brought up to date, and all recent methods of value
included. Original methods have been given in preference to
modifications; the latter, when of value, are also mentioned. As a
rule that method has been chosen which in the light of the writer’s
laboratory experience has yielded uniformly the best results. An
effort has been made to reduce the number of methods to the lowest
number as representing the best and most indispensable ones. During
the fourteen years of laboratory experience since the publication
of the first edition there has been plenty of time for changes
in points-of-view concerning laboratory methods. Then an ardent
exponent of celloidin-imbedding as a routine method, the writer has
now practically discarded it in favor of paraffin-imbedding and
the celloidin-sheet made by the dextrin-sugar or molasses method.
This combination method is so superior in every way to ordinary
celloidin-imbedding that the latter becomes obsolete except for a
limited number of conditions. A number of personal modifications of
various methods will also be found in this part of the book; indeed,
it is intended to be an expression of individual opinion concerning
laboratory methods.
The writer’s views concerning the value of teaching by
_unknowns_,—that is, giving the student preparations or case-material
for his own analysis and independent working-out to a diagnosis—are
stronger now than they were when the preface to the first edition
was written. Experiments with other methods of teaching have always
brought me back to this as yielding by far the best results. It
accomplishes two things—it not only teaches a knowledge of pathology,
but it develops objectivity and the faculties of diagnosis, and
accomplishes these with more marked success than any other method of
teaching pathology.
ALDRED SCOTT WARTHIN, Ph.D., M.D.
ANN ARBOR, MICHIGAN, May, 1911.
PREFACE TO THE FIRST EDITION.
Pathologic Histology deals with departures from the normal in the
various tissues of the body, which, occurring as the sequelæ of
disease-processes, or standing in the closest causal relationship to
the clinical symptoms and physical signs, constitute the foundation
of all diagnostic conclusions, and of all rational therapeutic
treatment. Without a definite knowledge of these abnormal changes, of
their various forms, of the manner in which they arise and progress,
no physician can deal intelligently with disease. The knowledge of
the _natural history_ of disease, based upon a knowledge of the
normal body, makes the wise and successful practitioner; and to such,
the autopsy, the microtome and the microscope must ever stand as
constant aids in the satisfying of his intellectual curiosity.
It is, therefore, essential that the student in his undergraduate
work should be so trained that, in addition to a broad conception of
General Pathology, he may acquire also such a technical knowledge
as to fit him to carry on his investigations after leaving the
laboratory. Not only in everyday practice in certain lines is a
knowledge of this technique necessary for diagnostic purposes, but
the true physician should so hold himself toward every problem of
diagnosis which presents itself to him, that with every opportunity,
he will, through excision, curettage or autopsy, make use of his
technical skill to further his knowledge of disease, and to aid his
science toward a solution of its great problems.
It is for these reasons, that in my laboratory courses in pathologic
histology, I wish to give each student a practical working knowledge
of the technique of pathologic investigations. That the student
become an expert as the result of such undergraduate courses is
neither possible nor desirable; it is only hoped that he may be
placed in a position to cope intelligently with the questions
awaiting him in the field of practice.
For the guidance of the student toward this end, I have compiled
this little book of laboratory methods, endeavoring to make it as
practical as possible, but yet thorough and complete. The methods
given are taken from the original papers, or from the compilations
of Friedländer and von Kahlden, but are modified in many instances
according to the writer’s own experience. The autopsy methods are,
in the main, those used by Kolisko of Vienna; but methods of Virchow,
Chiari, Nauwerck, and others, are also given.
It is from the study of the material itself, and not from the
textbook alone, that the student can obtain a proper knowledge of
pathologic changes. The most comprehensive textbook can give no
adequate idea of the infinite variety of these changes; there is no
absolute _type_, but an endless variety of appearances more or less
closely related. Only from a contemplation of this variety is it
possible for the student to build up a point-of-view, and to arrive
at an independent and unbiased conclusion.
The student who seeks in a preparation only the appearances described
in a textbook is not studying in a scientific way. He will constantly
accept the author, instead of using his own impressions for the
basis of deductions, guided by the experience of others. With an
unbiased mind the student should take each specimen for that alone,
which it, itself, presents; and upon this he should build his
conclusions. He should seek in the textbook the things he _finds_ in
the material; not _seek_ in the latter the things he _reads_ in the
former. Thus may he escape superficiality, avoid errors and hasty
judgments, and build up for himself a sure foundation of knowledge.
For these reasons the students in my laboratory course, having been
thoroughly prepared for such work by the study of normal tissues
in the histologic laboratory, are given the pathologic material as
_unknowns_, which under careful guidance, they are enabled to work
out for themselves to a satisfactory conclusion.
The student is further aided in the fixing of his impressions, and in
their expression, by means of the drawings and written descriptions
which he is required to make of the preparations. In this way the
faculties of observation and expression receive a training that is
not otherwise possible. It is true that such a course of instruction
is difficult for the student whose previous training has been
deficient in the cultivation of these most important faculties; for
this reason it is the more necessary that he should now apply himself
to work in the scientific method.
That this method of teaching takes much more of the instructor’s time
is true; that it takes too much time cannot be granted when measured
according to the results obtained. The frequent objection of the
student that he cannot draw only emphasizes the necessity of that
student’s receiving the necessary training to enable him to reproduce
his visual impressions.
A greater difficulty lies with the teacher. Not only must he select
his preparations with wisdom, so that in the necessarily limited
time of the course, the student may receive the greatest benefit; but
he must be tactful and patient in leading the student to work for
himself. It is easy to give a demonstration and then tell the student
to work; it is very much more difficult and nerve-consuming to make
the student _see_ and _demonstrate_ for himself. The relation of the
microscopic preparation to the gross anatomy must be shown, and,
when possible, demonstrated by macroscopic preparations; further,
the relation to the clinical symptoms and physical signs must be
made clear, so that the student receive not a narrow conception of
pathologic histology as something in itself separate and complete,
but as a foundation-stone to the broadest conception of diagnosis,
whereby the real unity of his studies will be revealed. Moreover, the
teacher must be fully awake to individual differences and needs, and
carefully shape his teaching influence upon each student accordingly.
The problem of the individual equation becomes especially difficult
in a course of this kind.
The laboratory course in histologic pathology, in the University
of Michigan, follows the general order given in the second part
of this book, beginning with the diseases of the blood and the
circulation, and finishing with the special pathology of the most
important organs. A preparatory training in general technique is
first given. About one hundred and seventy-five prepared specimens,
each illustrating some especial pathologic point, are given to the
class as unknowns for diagnosis. In addition each student is required
to prepare about fifty slides from fresh material, performing for
himself all of the necessary technical manipulations, according to
the methods given in this manual. To further the work in this course,
and to meet the needs of advanced students and of practitioners, this
book is primarily intended.
ALDRED S. WARTHIN, Ph.D., M.D.
ANN ARBOR, January, 1897.
CONTENTS
PART I.
THE SOURCES OF PATHOLOGIC MATERIAL AND THE
METHODS OF OBTAINING IT FOR EXAMINATION.
CHAPTER PAGE
_Introduction_ 1
I. The Autopsy: General Considerations 3
II. The Order of the Autopsy 24
III. The Protocol 33
IV. The External Examination 41
V. The Examination of the Spinal Cord 53
VI. The Examination of the Head 63
VII. The Main Incision: Thorax and Abdomen 96
VIII. The Examination of the Thorax 106
IX. The Examination of the Mouth and Neck 131
X. The Examination of the Abdomen 140
XI. The Examination of the Pelvic Organs 160
XII. Special Regional Examination 173
XIII. The Autopsy of the New-born 177
XIV. The Medicolegal Autopsy 187
XV. The Restoration of the Body 193
XVI. Other Sources of Pathologic Material 196
PART II.
THE TREATMENT OF THE MATERIAL.
_Introduction_ 199
XVII. The Laboratory Outfit 201
XVIII. The Examination of Fresh Material 208
XIX. The Preservation of Macroscopic Preparations 222
XX. The Fixation and Hardening of Tissues 225
XXI. Decalcification 232
XXII. Imbedding 234
XXIII. Section-cutting 238
XXIV. The Preparation of Mounted Sections 243
XXV. Staining and Staining Methods.—Nuclear and Protoplasmic
Stains 253
XXVI. Special Staining Methods for the Demonstration of
Pathologic Conditions in Cells or Tissues 262
XXVII. The Staining of Pathogenic Micro-organisms in Tissues 277
XXVIII. The Staining of Special Organs and Tissues 288
XXIX. Microscopic Examinations for Medicolegal Purposes 305
XXX. The Study of Mounted Preparations 309
LIST OF ILLUSTRATIONS
FIGURE PAGE
1. Large section, or cartilage knives 10
2. Scalpels 10
3. Long section knife 11
4. Myelotome 11
5. Autopsy scissors of various types 12
6. Enterotome 13
7. Costotome 13
8. Large autopsy saw 13
9. Small autopsy saw 14
10. Hey’s saw 14
11. Luer’s rhachiotome 14
12. T-chisel or skull-opener 14
13. Hatchet chisel 14
14. Straight bone chisel 14
15. Brunetti chisels 15
16. Steel hammer 15
17. Wooden mallet 15
18. Forceps 15
19. Bone-forceps 16
20. Bone-nippers 16
21. Probe 16
22. Blow-pipe 16
23. Hand bone-drill 17
24. Needles 18
25. Brass measuring-stick 18
26. Author’s method of removing skull-cap 65
27. Skull-cap after removal, showing interlocking joint 67
28. Method of examination of brain (after Nauwerck) 71
29. Section of brain. Ventricles opened (after Nauwerck) 72
30. Method of Pitres 75
31. Base of cranium after removal of brain (after Nauwerck) 79
32. Incisions for examination of orbit, ear and nose 80
33. Tympanic cavity after removal of tegmen (after Politzer) 81
34. Sagittal section through left middle ear, outer half (after
Politzer) 84
35. Sagittal section through left middle ear, inner half (after
Politzer) 84
36. The main incision completed (after Nauwerck) 97
37. Method of disarticulating sternoclavicular articulation
(after Nauwerck) 101
38. Section of left ventricle and auricle (after Nauwerck) 108
39. Removal of heart (after Nauwerck) 112
40. Section of right auricle and ventricle, Nauwerck method 114
41. Incision for opening of aortic ring (after Nauwerck) 115
42. Section of left lung (after Nauwerck) 118
43. Section of right lung (after Nauwerck) 119
44. Removal of neck organs (after Nauwerck) 132
45. Section of male pelvic organs (after Nauwerck) 162
46. Section of female pelvic organs (after Nauwerck) 164
47. Method of opening abdomen of new-born (after Nauwerck) 178
48. Section of pulmonary artery in new-born (after Nauwerck) 179
49. Method of demonstrating Béclard center (after Nauwerck) 180
50. A satisfactory microscope for the working laboratory 202
51. A good practical microtome 206
52. Cathcart freezing microtome 212
53. Carbonic-acid freezing microtome, Becker model 213
54. Bardeen freezing microtome 214
55. Knife for Bardeen freezing microtome 215
PART I.
SOURCES OF PATHOLOGIC MATERIAL AND METHODS OF OBTAINING IT FOR
EXAMINATION.
INTRODUCTION.
The chief sources of pathologic material are the autopsy, surgical
operation, diagnostic excision and curetting, the spontaneous
discharge of diseased tissue, and the experimental production of
pathologic conditions in animals. To these sources may be added the
blood and other body-fluids, as well as pathologic fluids, exudates,
effusions, cyst-contents, etc., particularly the cellular elements
found in the sediment of such fluids.
That an accurate pathologic diagnosis be secured, the material must
first be properly obtained, its gross characteristics carefully
noted, the portion to be examined microscopically chosen with
discrimination, and, finally, the microscopic examination itself
carried out along the various lines indicated. All of these
procedures require the knowledge of a certain amount of technique,
and the general principles of such technique should be familiar
to every student of medicine. While it is not possible that every
medical graduate can enter into the active practice of his profession
as an expert pathologist, yet the possession of the technical
knowledge necessary to perform an autopsy properly and to select
with discrimination the tissue for microscopic examination gives to
a physician a distinct practical advantage. This advantage becomes
the greater if to the possession of this knowledge there be added
also a practical working knowledge of the technique necessary for the
microscopic examination and diagnosis. Not that this knowledge should
be so extensive as to cover the great field of special methods; all
that is really essential is a knowledge of the general principles of
laboratory examinations; and a very large proportion of practical
work can be successfully carried out if the physician possesses
this foundation knowledge. In the first days of practice a young
physician so equipped often finds that his laboratory training comes
to be his chief source of income and opens the way to a successful
professional career. It constitutes a professional asset which the
older practitioner usually does not possess.
CHAPTER I.
THE AUTOPSY: GENERAL CONSIDERATIONS.
1. =AUTOPSY= (=Postmortem examination=, =necropsy=, =necroscopy=,
=obduction=, =mortopsy=, =section=; Latin, =sectio cadaveris=,
=sectio anatomica=, =autopsia cadaverica=, =sectio=, =obductio=;
French, =autopsie cadaverique=, =nécropsie=; German, =Leichenschau=,
=Section=, =Obduction=) is the term preferably applied to the
examination of the dead body, conducted for the purpose of
ascertaining the cause of death, for the study of the pathologic
conditions present with reference to their nature and cause, or
for the obtaining of anthropologic, anatomic or surgical data.
When carried out primarily with the view of obtaining evidence of
legal importance, as in the case of a suspected crime, accidental
death, the identification of a body, in damage suits for injuries
received, malpractice, insurance, etc., the autopsy is usually styled
=medicolegal=, or the German term =obduction= is not infrequently
applied. The terms =prosector= and =obducent=, although used
originally in a medicolegal sense, are now generally applied to the
person performing the autopsy whether medicolegal or not.
2. =IMPORTANCE OF THE AUTOPSY.= The opportunity of performing an
autopsy should be regarded by the physician and student as a very
great privilege. Even to the prosector with an experience of several
thousand autopsies to his credit, each new examination of a dead body
becomes a new revelation and extends still farther his intellectual
horizon. To the student and physician in practice each autopsy may,
if performed in the proper spirit, become in itself an educational
factor of the greatest value. In no other scientific procedure
is there such a demand made upon the faculties of observation,
judgment and interpretation, and in no other is there such intimate
correlation between methods of technique and the higher intellectual
processes. It is unnecessary to add that the ability to perform an
autopsy in the proper manner presupposes a foundation of accurate
anatomic and pathologic knowledge as well as a capacity for careful
work.
Primarily, the aim of the autopsy is to ascertain the cause of death
and to acquire knowledge of the changes produced in the tissues and
organs by the disease-process. If for no other purpose than that of
extending our knowledge of disease, the autopsy becomes the most
valuable factor in furthering the development of medical science.
We have but entered into the broad, rich fields of pathology; at
any time new facts may be discovered or observations of the most
far-reaching nature made. From year to year the statistics of the
most common diseases must be revised in the light of new conceptions
of disease. Through the autopsy there lies within the reach of every
practitioner the opportunity of contributing something worth while
to the general sum of medical knowledge. There is not a pathologic
condition in the medical category that does not call out for
illumination upon some point or other. The phenomena of malignant
tumors, the earliest stages of the so-called chronic affections, as
well as the majority of the infectious diseases, require further
autopsy observations for their elucidation. The autopsy establishment
of the diagnosis is also of the greatest importance in giving value
to vital statistics. Until we have a more universal confirmation of
the clinical diagnosis by the pathologic our vital statistics must of
necessity be imperfect.
To the practitioner the autopsy offers further a most valuable
control of subjectivity and a guide to methods of diagnosis and
treatment. Without such a control no one is so likely to get into
a dangerous rut as the practicing physician. The disclosures of
the autopsy will enable him to correct faulty methods, and should
effectually check any tendency to superficial diagnosis. Particularly
is this the case with regard to such diagnostic methods as palpation,
percussion and auscultation. Postmortem percussion offers a most
valuable means of acquiring precision in this important branch of
physical diagnosis. The percussion boundaries may be marked upon the
body by pencil, or long pins may be inserted, so that when the body
is opened the exact relation of the percussion area to the organ in
question may be noted. In the case of palpable tumors the results of
palpation before the body is opened should be carefully controlled by
the findings when the actual conditions are exposed. Even when the
cause of death seems obvious it is worth while to perform an autopsy
at every opportunity offered, both for the sake of controlling
technical methods and for the pictures of disease revealed. More
accurate knowledge of the nature of the processes of disease can
be obtained through one autopsy than through months of textbook
reading. To the surgeon the opportunity of examining cases dying
after surgical operation should be a source of great satisfaction.
The review of anatomic relationships offered by the autopsy is in
itself worth while, and in the case of healthy individuals killed
by accident the survey of the normal appearances of the organs and
tissues offers an opportunity for study too valuable to be neglected.
Further, it is justifiable to practice upon the cadaver any surgical
operation that does not disfigure it. Removal of the spleen,
transplantation of thyroid tissue into the spleen, decapsulation of
the kidney, transplantation of ovarian tissue, gastric and intestinal
operations, anastomosis of blood-vessels, operations upon the uterus
and cervix, prostate, vas deferens, thyroid, nose, ear, etc., and
many other surgical procedures may be practiced with profit upon
a cadaver during the course of an autopsy. The feasibility of a
new operative method or the improvement of an old one may thus be
demonstrated.
In the case of medicolegal autopsies the ends of justice as well
as the life, liberty or reputation of some individual may depend
upon the results of the postmortem examination. In all cases to
which there is any suspicion attached, or in which the cause or
manner of death is doubtful an autopsy should be legally required,
but unfortunately this is not yet done in this country. Physicians
individually should endeavor to create in the public mind a more
healthy attitude toward the autopsy and an appreciation of its
usefulness. As to his own share in the advantages derived from it,
it is safe to say that no physician can perform an autopsy properly
without having his experience widened, his knowledge of disease
increased, his diagnostic faculties sharpened and his tendency to
subjectivity controlled. Last, but far from being the least, should
be his gain in honesty and humility.
3. =LEGAL ASPECTS OF THE AUTOPSY.= The individual cannot dispose of
his dead body without the consent of his nearest heirs, except in
those States (New York) providing by statute that a person may direct
the disposition of his cadaver. The legal rights to the corpse are
vested first in the husband or wife of the deceased; if none, then
first in the father, then in the mother; after the parents, in the
brothers or sisters; after them in the next of kin, according to the
course of common law; and then to the remotest degree according to
the law of descent of personal property. An autopsy performed with
the consent of the relative having the body in custody cannot be
questioned, if it is properly performed. In the case of members of
societies requiring autopsies the membership cards or certificates
should be endorsed by the nearest heir.
A physician who performs an autopsy without the consent of the person
having the custody of the deceased does so at his own risk, except
in those cases in which the autopsy is in accordance with legal
statutes. In the majority of the States there are statutes providing
that the Coroner or Board of Health shall order an autopsy whenever a
person is found dead and the cause of his death is not apparent, and
cannot be ascertained from the evidence given, or from a superficial
examination of the body. In such cases no permit from the relatives
is necessary, and an autopsy performed under the direction of law is
never subject to legal punishment, if it has been performed according
to approved methods. Nevertheless, even in these cases it is a better
policy to secure the consent of the custodian of the body, when this
is possible.
When consent to an autopsy is withheld and the physician feels that
such an examination is necessary, he should turn the case over
to the Coroner or Board of Health, and act under such direction.
Conflicting decisions, however, have been made in different States.
The Supreme Court of Indiana (1909) held that a Coroner cannot order
an autopsy unless there was a reasonable supposition that death had
occurred from violence or casualty. A suit brought by an Indiana
physician to recover fee for an autopsy held on the order and under
the direction of a Coroner was set aside on the ground that there was
not the slightest suspicion of death from casualty or violence. Such
a decision is too narrow and not framed in accordance with the actual
needs of the times in so far as the protection or enlightenment of
the community is concerned. Under such a decision a Coroner or Board
of Health could not in safety order an autopsy in the case of a death
in which the diagnosis had not been established clinically, when no
suspicion of violence or casualty exists, although the establishment
of the diagnosis through an autopsy might be of the greatest
importance to the family or community.
On the other hand the Court of Appeals in Kentucky (1906) affirmed
judgment for the defendant in a suit for damages brought against a
physician for performing an unauthorized autopsy to secure a burial
permit, the court holding that, if the autopsy was made in good
faith for the purpose of ascertaining the cause of death in order
that a burial certificate might be granted, and if the autopsy was
made decently with due regard to the sex of the deceased and without
unnecessary incisions or mutilations, there could be no grounds for
damages. This is a reasonable and just decision and laws framed upon
it should be passed in all the States. Autopsies performed under
such conditions, however, should always be conducted in the presence
of several witnesses competent to testify as to the methods used.
In several States legal authority is given to the Board of Health to
order an autopsy whenever the health interests of the people demand
such an investigation. Autopsies performed under such orders against
the desire of the relatives should always be carried out with extreme
care and in the presence of proper witnesses.
State and charitable hospitals cannot be made liable for autopsy
performed by Coroner or Board of Health, when the consent of
the relatives is withheld. It is high time that all charitable
institutions in this country should require an autopsy from
all patients dying within their walls. The cards of admission
should contain a clause to this effect, and such cards should be
counter-signed by the nearest relatives.
Inasmuch as some life-insurance policies contain clauses requiring
the presence of a representative of the company at the autopsy or a
forfeiture of the claims, it is best to ascertain if such policies
exist in any given case, and to notify the company. The Supreme Court
of Missouri has decided that an autopsy made in ignorance of such an
insurance clause is no bar to recovery if the company be notified in
time for a re-examination of the body.
Supreme Court decisions also hold that consent for an autopsy implies
removal of organs and tissues for microscopic study, when such is
necessary to fulfill the object of the autopsy.
One of the great needs of this country is a uniform autopsy law
and the establishment of a proper medicolegal autopsy code, as in
Germany. As conditions exist at the present, crimes may be easily
concealed, the safety of the community endangered by failures
in diagnosis of communicable affections, and our morbidity and
mortality statistics become a shame and reproach to the nation.
The majority of our medicolegal autopsies are made by ignorant
and imperfectly trained coroners and coroners’ physicians, mostly
political appointees of inferior material. We need in our medical
schools a greater amount of attention paid to the teaching of
autopsy-technique and gross pathology. The community must also be
educated to a realization of the value of autopsies. It is the duty
of every physician and layman to work diligently for the improvement
of existing conditions. Had the ideas of a former Governor of the
State of Michigan been realized there would have been compulsory
autopsies upon the bodies of every person dying within the State,
and far-reaching results would have been attained. The economic
importance of tuberculosis and the venereal diseases would have been
made clear, the profession and laity alike educated, and the progress
of preventive medicine tremendously aided.
4. =PERMISSION FOR AUTOPSY.= It is a desirable and certainly a wise
precaution to obtain a written permit for the autopsy from the next
of kin or from the legal representative of the body, in case the
examination has not been ordered by law. Some of the legal decisions
quoted above offer sufficient grounds for this precaution. The
following form is in use in the University of Michigan Hospital.
NO........ ANN ARBOR, MICHIGAN..................., 19..
PROFESSOR OF PATHOLOGY........................
UNIVERSITY OF MICHIGAN.
Permission has been given by........................., who bears
the relationship of..................to........................, to
hold a postmortem upon the remains of...........................,
with the understanding that the object of such postmortem
is to ascertain the cause of death, and that you are to use
such means as you deem best to make a thorough examination
for the proper attainment of the object desired, excepting
that...............................................
...............................Superintendent.
There can be no doubt that the public in general is beginning to
appreciate the usefulness of autopsies, as it is much easier to
obtain them now than it was ten years ago. The proper display of
tact and a reasonable exposition of the object of the examination
will practically always meet the objections urged on sentimental
grounds. Aside from these the chief objection usually met with is the
fear of mutilation of the body. Emphatic assurance may be given in
this respect, not only as to the entire absence of any disfigurement
resulting from the examination, but also as to the marked improvement
in the general appearance and condition of the cadaver as the result
of the autopsy.
While it is obviously difficult to give any specific rules as to
the method to be pursued in seeking permission for an autopsy,
there are certain arguments that can be used to advantage. Natural
curiosity, the general good to humanity, the control of diagnostic
and therapeutic methods, new knowledge to be gained, the question of
inherited or infectious conditions, the strengthening of insurance
claims, etc., are some of the lines that may be followed in working
for an autopsy. Satisfaction is always expressed when definite light
is thrown upon the hereditary or infectious nature of the condition.
Religious scruples may often be overcome by an appeal to the pastor
or priest.
In a certain number of cases the matter is hopeless from the
beginning, but in the majority the autopsy may be secured by the
exercise of proper tact and patience. The laity should be educated
to ask for the autopsy; and even at the present time laymen often
show a greater willingness in this direction than some members of
the profession. That physicians and undertakers who discourage or
oppose autopsies should be avoided is a principle that should be
instilled into the minds of the public at large. Undertakers soon
come to recognize the aid given them by the autopsy in the matter
of embalming and preserving the body, and the prosecutor should
always show his readiness to allow the undertaker to profit by his
operations, and to render him such definite help as may be within his
power.
As a last resort the offer of a small amount of financial aid in
the burial expenses will secure sometimes a permission otherwise
refused. In extreme cases the physician may decline to sign the death
certificate, or the Coroner may be called in, or the case turned
over to the Board of Health. Under suspicious circumstances such
procedures are necessary, but threats to resort to these expedients
should not be made without good reasons.
With the request for the autopsy should be included the right to take
such portions of organs or tissues as is necessary for a microscopic
examination and for the complete diagnosis. It is, of course, never
necessary and certainly unwise in the majority of cases to make any
definite statements as to what or how much shall be taken away or
left. No specimens should be taken if this is absolutely forbidden;
and, while a half autopsy is better than none, the importance of the
microscopic examination should be urged, if necessary, as strongly as
the performance of the autopsy. The use of a written permission, such
as is given above, obviates the necessity of making a special request
for material and avoids the complications that such a request often
brings about. Moreover, the legal decision above quoted grants the
right to microscopic examination as included in the permit for the
autopsy when such an examination is necessary to complete the aims of
the autopsy.
5. =AUTOPSY INSTRUMENTS.= An autopsy can be properly performed with
very few instruments; indeed, a knife and a saw, with a needle to
close up the body, would suffice for the majority of cases. But
there are very great advantages in the use of certain instruments
adapted especially to autopsy needs, and these the physician should
gradually acquire for his work. It is not advisable to purchase the
so-called “postmortem sets” sold by the dealers, but far better
to start with two or three of the most necessary instruments and
gradually add to these. Surgical instruments as they become discarded
can often be made to do good service in the autopsy outfit. In
private practice the fewer instruments one can get along with the
better, as there is much less trouble in carrying them about and in
taking care of them, and it is better to make the performance of the
autopsy as inconspicuous as possible. In teaching institutions and in
hospitals the number and variety of instruments that can be utilized
in autopsy work are limited only by the financial means at disposal,
but even under the most favorable conditions in this respect it is
better to simplify as much as possible. The list given below will
meet all requirements.
[Illustration: FIG. 1—Large Section, or Cartilage Knives]
[Illustration: FIG. 2—Scalpels]
=Knives.= The _large section-_ or _cartilage-knife_ is the most
important cutting instrument used in autopsy work. It is a strong,
heavy knife 20-22 cms. long, with handle and blade of about equal
length. The blade has a heavy back, a bluntly rounded rather than
a sharp point (more blunt than appears in the illustration), and
bellies at its anterior third, narrowing toward the handle. In its
widest part the blade should measure about 1¾ cms. The handle is
heavy, 1½ cms. broad, and a little over 1 cm. in thickness toward the
blade, gradually diminishing to about ¾ cm. at the posterior third,
then increasing to 1 cm. toward the end. This variation in thickness
gives a gentle curve to the handle that is of great importance in
adapting the latter to the form of the closed hand, so that the knife
becomes practically a cutting extension of the fore-arm. With this
knife all the chief incisions are made, and it is rarely out of the
hands of the operator during the autopsy. The handle or blade may
be made shorter or longer according to preference, but the other
features of the instrument are most important.
=Scalpel.= (See Fig. 2.) A number of _dissecting scalpels_ of varying
sizes are needed for finer dissections. They should have a metal
handle, and are preferably of one-piece construction.
=Long Section- or Brain-Knife.= In place of the broad thin
brain-knife usually advised, an _amputation-knife_ can be used to
much better advantage in the section of the brain and in making the
chief incisions in the large organs. It should have a sharp point
rather than a blunt one.
[Illustration: FIG. 3—Long Section Knife]
=Myelotome.= This is used only for the purpose of cutting the spinal
cord squarely across in the removal of the brain. It has a slender
steel stalk with wooden handle, and a short, thin, narrow blade set
obliquely at the end of the stalk. This instrument is not absolutely
necessary, as the cord may be satisfactorily cut with the point of
the long section knife.
[Illustration: FIG. 4—Myelotome]
=Scissors.= (See Fig. 5.) A number of these are of service: one
large and strong pair with long handles and short stout blades,
another large pair curved or bent with the longer blade blunt- or
probe-pointed, a small pair with a narrow, probe-pointed blade for
opening small vessels or ducts.
=Enterotome.= (See Fig. 6.) For opening the intestine the enterotome
or intestinal scissors are used. These consist of one long
probe-pointed blade bluntly rounded at its end, and a shorter blade
with straight end fitting into the longer blade. Neither blade should
be sharp-pointed.
=Costotome.= (See Fig. 7.) The cartilage-shears have two short, thick
blades, the upper one with a broad belly, the lower one curved.
Between the strong handles a spring is placed, and the construction
should be such that when the blades are closed the ends of the
handles do not touch. The form in which the handles meet and are
secured with a catch is a dangerous autopsy instrument because of the
severe pinching that the operator’s hand is sure sooner or later to
receive.
=Saws.= (See Figs. 8, 9, 10.) A _small hand-saw_ (_bone-saw_) is
necessary for opening the skull, and the same saw may be used to
open the spinal canal. It is sometimes made with a rounded point
(_“fox-tail” saw_). For sawing vertically through the base of the
skull when exposing the nasal tract a larger _butcher’s saw_ with a
high frame may be used. For sawing the angles of the skull-cap _Hey’s
saw_ may be of service but is not essential. A _metacarpal saw_ may
be used for opening small bones or the long bones of an infant. _Band
saws_ are sometimes used in opening up the nasal tract.
[Illustration: FIG. 5—Autopsy Scissors of Various Types]
=Rhachiotome.= (See Fig. 11.) This instrument consists of two curved
saw blades placed parallel to each other in such a way that the
distance between them can be regulated by screws. There are two
handles, a horizontal one for the right hand, and an upright one for
the left hand attached to the fixed saw blade. It is used in opening
the spinal canal.
=Chisels.= (See Figs. 12, 13, 14.) A very convenient autopsy
instrument is the _T-chisel_ or _skull-opener_, used for springing
off the skull-cap and in detaching the periosteum. _Side-_
and _guarded-chisels_ may be used for the same purpose. The
_hatchet-chisel_ may also be used on the skull or spinal column.
_Straight_ and _curved bone-chisels_ are also necessary for the
examination of the bones and bone-marrow.
=Brunetti Chisels.= (See Fig. 15.) These are of great service in
opening the spinal canal, but require some practice for their proper
use. When used with skill they are preferable to the rhachiotome.
The chisels are rights and lefts, and have a long, heavy, curved
blade, broadening toward the cutting end, which has on its right or
left side a small blunt projection that is introduced into the spinal
canal after the removal of a portion of one of the vertebræ. This
projection serves as a director and lever, while the cutting edge
of the chisel is driven through the lateral portions of the bony
covering of the canal by means of blows from a wooden mallet received
upon the heavy handles.
[Illustration: FIG. 6—Enterotome]
=Hammer.= (See Fig. 16.) The steel hammer of the amputation- or
bone-sets is often of great service in autopsy work. The hook at the
end of the handle may be used to lift up the skull-cap after the
sawing is completed.
=Mallet.= (See Fig. 17.) A wooden mallet is necessary for the use of
the Brunetti chisels. It may be loaded with lead or the end may be
covered with felt to deaden the sound of the blows.
=Forceps.= (See Figs. 18, 19, 20.) _Dissecting forceps_ of various
types are useful in the finer dissections. _Cover-glass forceps_
should be at hand for use in the taking of smears. A pair of strong
_bone-forceps_ may be of occasional service in cutting ribs or small
bones. When the spinal canal is opened by means of the Brunetti
chisels or rhachiotome the loosened fragments of the vertebræ should
be jerked off by means of lion-forceps, or a strong pair of ordinary
nippers may be used for the same purpose.
[Illustration: FIG. 7—Costotome]
[Illustration: FIG. 8—Large Autopsy Saw]
=Miscellaneous Instruments.= (See Figs. 21, 22, 23, 24, 25.) Probes
of various sizes, grooved and curved directors, retractors,
catheters, both metal and flexible, injection-syringe, blow-pipe
with valve, trocar, cannulas, hand-drill for wiring bones, an
iron-vise, etc., all find a place of usefulness in autopsy technique.
In institution work motor band-saws, trephining or dental engines,
drills, etc., may greatly facilitate the progress of autopsies when
the daily number of these is great and when special examinations of
the ear or nose are required. The needles for sewing up the incisions
should be large, strong and slightly curved. A strong linen thread
should be used for stitching and for ligatures.
[Illustration: FIG. 9—Small Autopsy Saw]
[Illustration: FIG. 10—Hey’s Saw]
[Illustration: FIG. 11—Luer’s Rhachiotome]
[Illustration: FIG. 12 T-Chisel or Skull-Opener]
[Illustration: FIG. 13 Hatchet-Chisel]
[Illustration: FIG. 14 Straight Bone-Chisel]
Besides the instruments mentioned above there should be brass or
nickel measuring sticks, one 10 cms. long and one 30 cms. long, a
flexible metal measuring tape, graduated glass vessels for measuring
fluids, graduated glass cones for orifices, etc. Suitable scales
should also be provided. Rounded or triangular wooden blocks are
needed to elevate portions of the body. For the display of gross
specimens as they are removed from the body, agate dishes or wooden
trays that have been infiltrated with paraffin should be at hand.
The necessary outfit for the taking of material for bacteriologic
examinations should always be present. Likewise cover-glasses and
slides for smears, and reagents for the examination and preservation
of tissue should be at hand. Sponges, pails, towels, tow or excelsior
for filling up the body-cavities, disinfectants, etc., must be
supplied.
The autopsy outfit may be extended indefinitely to suit the
requirements of the conditions or the ideas of the pathologist. In
actual practice, however, the physician may confine his requirements
to the limits of a cartilage knife, dissecting scalpel, forceps,
one small probe-pointed pair of scissors, enterotome, saw, T-chisel,
needles, thread, sponge and specimen bottles. Five or six dollars
would cover the initial expense, and the set may be gradually
increased. It would seem unnecessary to decry the use of surgical
instruments for the autopsy. Once an instrument is used in an autopsy
it should be left in the autopsy set.
[Illustration: FIG. 15—Brunetti Chisels]
[Illustration: FIG. 16—Steel Hammer]
[Illustration: FIG. 17—Wooden Mallet]
[Illustration: FIG. 18—Forceps]
=CARE OF INSTRUMENTS.= The cutting instruments should always be kept
sharp and bright. Care should be taken that when the knives are
sharpened the blunt points and rounded bellies are not ground off.
After use the knives should be cleaned, disinfected and wiped dry. A
tight galvanized iron box containing wire trays and a bottom pan for
holding formalin is very practical in institution work. In private
practice the knives after cleaning and disinfection may be kept in a
holder made of Canton flannel or chamois skin having pockets fitted
to the instruments; the whole may be rolled up into a small and
compact bundle.
6. =PREPARATION FOR THE AUTOPSY.= Permission having been obtained,
the autopsy should be performed without delay. It is very important
that the examination should be carried out before the body has
become cold, if any thorough microscopic study of the tissues is to
be made. Changes in the finer structure of cells and nuclei quickly
take place, and certain tissues, such as parts of the nervous system,
the medullary portion of the adrenals, the pancreas, mucosa of
gastro-intestinal tract, etc., within an hour or so after death are
usually no longer fit for microscopic study. In all cases, therefore,
it is best to make the autopsy as soon as possible after death, that
is, as soon as positive signs of death appear. In the majority of
cases this takes place within an hour, and the most favorable time
for the performance of the autopsy falls within one to three hours
after death. Under certain circumstances it may be necessary to make
the examination sooner, but for various reasons the operation is very
repugnant when performed within the first half-hour after death. For
ordinary purposes an autopsy performed within twelve to twenty-four
hours is usually satisfactory. Occasionally it becomes necessary for
medicolegal purposes to examine a body some days, weeks, or even
months after death and burial.
[Illustration: FIG. 19 Bone-Forceps]
[Illustration: FIG. 20 Bone-Nippers]
[Illustration: FIG. 21 Probe]
[Illustration: FIG. 22 Blow-Pipe]
The body should not be frozen if microscopic studies are to be made.
When the autopsy is delayed cold storage just above the freezing
point produces less change in the gross pathologic picture, as
well as in the finer structure. No embalming fluids, injections,
punctures, etc., should be allowed, and undertakers should be
instructed not to do these things until after the question of
autopsy has been decided and the operation completed. If the use of
an embalming fluid becomes necessary, formalin, not stronger than a
ten per cent solution, should be advised, as it does not damage the
tissues and hinders but little the operations of the autopsy. Strong
solutions, as found in the usual embalming fluids, render the tissues
stiff and hard and cause color changes, while the strong vapors are
very unpleasant to the obducent. The use of arsenical embalming
fluids or preparations should be wholly discountenanced. When it
is desired to study the mucosa of the stomach or intestine, it may
be fixed soon after death by the introduction of a fixing fluid
into the stomach or intestine by means of a tube and pump. Finally,
instructions should be given that the body shall not be dressed for
burial until after the autopsy.
The necessity of making special preparations for an autopsy depends
upon its performance in a regularly appointed autopsy room or
under the conditions of private practice. In the former case the
autopsy room should be constructed to meet the demands of the
work. In teaching hospitals it should be a large, well-lighted and
properly-ventilated room with proper facilities for teaching-staff
and students, and should be so connected with the hospital wards
that the conveyal of bodies may be protected from observation. In the
same building there should be the pathological laboratory, library
and museum, a waiting-room, and under some conditions a chapel for
funeral services. The autopsy room itself should have a grooved
concrete floor sloping to a central drain, the furniture should be
of simple construction, and so built that the entire room may be
washed with a hose. The seats should be arranged in an amphitheatre
facing the northern side of the building, which should be constructed
practically wholly of glass, the lower sashes containing ground glass
or prisms. The northern half of the roof should likewise be of glass.
[Illustration: FIG. 23—Hand Bone-Drill]
In the pit, in the field of strongest illumination, should be placed
the autopsy table. This should be strongly built, of marble, slate,
soapstone, artificial stone, copper, zinc, etc., about seven feet
long, thirty inches wide, and thirty to thirty-six inches high. A
high table is much preferable to a low one. It should have a top
with grooves slanting toward a central perforated plate fixed in the
central hollow standard in such a way that the top may be freely
revolved. In the standard there should be a drain and ventilating
shaft connected with a fan revolving outward. The drain from the
table as well as the others from the laboratory should empty into a
large catch-basin where the contents may be sterilized before passing
into the main sewer. Above the table a combination gas and electric
light with hot and cold water-pipes should be arranged. A sheet of
blue glass of the proper tint may be used in connection with the
illuminating apparatus to give daylight effects.
Extra tables, weighing and measuring apparatus, sinks, lavatories,
bacteriologic outfit, sterilizer, instrument-case, etc., may be
supplied as needed. In the case of delayed permission, or when the
law requires that the bodies be kept a certain length of time before
the autopsy, it becomes necessary to provide a proper cold-storage
apparatus. The local conditions will suggest the most convenient and
appropriate construction. In routine autopsy service well-trained
assistants and attendants become a necessary factor in the
satisfactory performance of the work.
In private practice the autopsy is usually made in a private dwelling
or, more rarely, in an undertaker’s shop. Under such conditions much
depends upon the ability of the operator to make the best of things.
In place of a proper table, the cadaver must be examined upon the
bed, undertaker’s body-rest or shutter, in or upon the coffin, on
the coffin lid, box, door, shutter, table or board. It is always
advisable to move the body from the bed when anything else can be
found upon which it can be placed. The support should be put in front
of the window giving the best light and the cadaver placed upon this
with its left side toward the window. Care should, of course, be
always taken that the operation cannot be witnessed from without. A
piece of oil-cloth or several layers of newspapers should be placed
upon the floor beneath and around the support. When it is necessary
to make the autopsy on the bed or in the coffin an abundant supply
of old newspapers tucked under and around the cadaver will usually
prevent the escape of blood or fluids.
An abundance of cold water should be provided, also a slop-pail,
several basins, towels, old cloths, sponges, etc. Before the
operation is begun the instruments and utensils, specimen bottles,
needle and thread, etc., should be arranged. A stick of wood may
serve as a head-rest. Material for filling up the body and restoring
its form should be secured, according to the need for such. Hay,
bran, tow, excelsior, old cloths, paper, etc., may be used for this
purpose.
[Illustration: FIG. 24 Autopsy Needles]
[Illustration: FIG. 25—Brass Measuring-Stick]
When all is ready for the operation members of the family or of the
laity should be tactfully gotten out of the room. It is always well
to ask members of the family if they desire to be present, but this
invitation should be given in the expectation that it will not be
accepted. The effect of an autopsy upon the minds of the laity is
not always a pleasant one, and harm is sometimes done through the
misinterpretation of necessary procedures and the resulting gossip.
In private practice it is worth while, as a matter of courtesy, to
invite several of one’s colleagues to witness or take part in the
autopsy. An ideal way would be to have one of these perform the
operation in expectation of future reciprocation. In the interests of
objective observation a clinician should never perform the autopsies
of his own cases, but should turn them over to a trained pathologist
or to a colleague. The operator is usually in a better position to
know what to do than the onlookers, and while the suggestions of the
latter are usually futile they may be endured for the occasional
great help derived from them.
As far as the obducent himself is concerned he may prepare himself
simply by removing his coat and rolling up his sleeves, or he may
wear an autopsy coat or apron. While an autopsy can without doubt
be best performed with hands bared, the danger to the operator is
sufficiently great to lead him to sacrifice the undoubtedly greater
technical skill thus gained, to his own safety, by the use of some
protective. Rubber gloves of a medium weight, reaching half way to
the elbows, are a great protection when carefully cleaned, sterilized
and cared for. The sleeves of the coat may overlap the gloves and
be fastened to these by an elastic band. When gloves are not used
the hands may be covered with carbolized vaseline, or a six per cent
solution of guttapercha in benzin. Cuts, abrasions, hang-nails, etc.,
must be protected by surgeon’s-plaster, collodion, finger-cots,
etc. When these are used it may be necessary to remove them during
the course of the autopsy, as they are easily torn or become loose.
Frequent washing in flowing water lessens the danger of infection.
Blood and other fluids from the body should never be allowed to dry
upon the skin or upon anything used in connection with the autopsy.
Gloves should be thoroughly washed and scrubbed; and, when clean,
washed in four per cent formaldehyde and dried before they are
removed from the hands. They should be then dusted inside and out
with talcum powder and put away dry. When they are again used they
should be tested for holes by filling them with water. After having
been used several times they easily tear. If the autopsy has been
performed with unprotected hands, thorough disinfection of these,
particularly of the finger-nails, should be carried out. Unpleasant
odors may be removed from the hands by the use of mustard, dilute
tincture of benzoin, turpentine, etc., and then washing with tincture
of green soap. Rubbing with cornmeal is very effective in removing
discolorations of the skin, particularly the blood-stains fixed by
formaldehyde that occur so often in the course of autopsies on bodies
injected by the undertaker.
Postmortem infections should receive prompt surgical attention, as
the smallest one is dangerous and may develop in a few hours to such
an extent as to cause the most alarming constitutional symptoms.
In a way all autopsy work, like surgical operations, offers a
risk to the operator. This is particularly great in all cases of
pyogenic infection, tuberculosis, blastomycosis, syphilis and the
acute specific infectious diseases. Any of these infections may be
received through the unbroken skin by way of a hair-follicle; but
previous cuts, abrasions, hang-nails, etc., form a frequent avenue
of entrance for the infecting agent, as well as punctures, scratches
and cuts received during the autopsy from instruments, spicules of
bone, needles, etc. It is particularly dangerous to allow blood, pus
or exudates from the peritoneal or thoracic cavity to enter a glove
through a hole. A finger or hand so bathed is very likely to develop
hair-follicle infections. All wounds received during the autopsy
should be allowed to bleed freely, and then should be thoroughly
washed in sterile water, alcohol and ether and an antiseptic.
Tuberculous warts are very common on the hands of prosectors
having a large autopsy service and not using gloves. A generalized
tuberculosis may follow. These warts are easily removed by repeated
painting with fuming nitric acid, just sufficient to keep the skin
yellow. If this treatment fails such warts should be excised.
Syphilis has been reported only a few times as due to postmortem
infection; but observations tend to show that the spirochætes may
remain virulent for several hours (7-24) after death.
_7._ =AUTOPSY TECHNIQUE.= _The object of the autopsy is to examine
thoroughly, in as short a time as possible, and in the easiest and
most convenient method, all of the organs and tissues of the body,
with reference to the occurrence of disease-changes, in such a way
that nothing will be overlooked or obscured._ The preservation of
relationships becomes, therefore, a very important matter; and
nothing should be done to disturb these until a complete pathologic
picture has been obtained. All unnecessary handling and cutting must
be avoided. No hasty or ill-advised cuts should be made. Careful
deliberation is often necessary as to the proper course to be
pursued in order to obtain the proper result. Each autopsy is a law
unto itself in this regard. New complications constantly arise and
must be studied before the right way of revealing the solution of
the pathologic problem is found. _Above all things nothing should
be destroyed until its relationships have been fully determined._
False steps taken in an autopsy cannot be retraced, and the complete
investigation and the successful attainment of a diagnosis may be
made impossible by improper methods of technique. As in all other
technical matters there is a _best_ way of carrying out the different
steps of the autopsy; and as this best way must be altered to suit
the conditions as they arise, it follows that there is both a
_science_ and _art_ of autopsy-making. Some general rules can be laid
down that apply consistently to all autopsies, but strict adherence
to one method is impossible in all cases. As in everything else the
prosector should be master of his technique and not let it master him.
When everything is ready for the autopsy the operator should take
his place at the right side of the cadaver, unless he happens to
be left-handed, when it may be more convenient for him to stand at
the cadaver’s left. This position at the cadaver’s side he does not
leave, except when opening the cranium, when he stands behind the
head. When the spinal cord is removed posteriorly he still remains on
the same side of the table, although the cadaver, having been turned
over, presents its left side toward him. The instruments arranged
in proper order should be on a tray close at his right hand, either
on a neighboring table or placed on the autopsy table. As they are
used they should be washed and returned to their proper place and not
allowed to lie on the body or table.
The cutting technique employed in the autopsy is, as a rule, quite
different from that employed in surgical operations or in dissection.
For the large incisions the cartilage-knife is used. It should be
held in the palm of the hand so that when the arm is extended the
knife-blade becomes an extension of the axis of the arm, and used
with a free arm-movement, fingers and hand being firmly fixed to
the knife-handle. Long, sweeping cuts, adequate in pressure, and
giving smooth and even incisions, are made by moving chiefly from the
shoulder, with secondary movement from the elbow. The knife-blade
should not be pressed or pushed into the tissues, but should be drawn
through them rather quickly, cutting as it is drawn. The greater
the force used, the more swift the drawing-motion should be. All
cuts should be clean; if made in the wrong place they will do less
damage than ragged, uneven incisions. The toe of the cartilage knife
is used for the beginning and end of long incisions and for cutting
in hollow or depressed surfaces. For flat surfaces the belly of the
knife is employed. The heel of the blade can be used for cutting
cartilages. The incisions made in the body should be directed away
from the operator, especial care being taken to avoid injuring his
left hand or the hands or arms of anyone assisting in the operation.
When the knife is held as directed there is not much danger of a
slip except at the end of the incision when, the resistance being
overcome, the knife goes through with a rush. To avoid this, pressure
should always be slackened toward the end of the incision. The main
incisions in the organs should be made with the brain-knife or short
amputation knife, by a long, sweeping cut made from heel to toe of
the knife-blade and beginning at the part of the organ farthest
from the operator, drawing the blade through the organ toward the
operator. For finer dissections the smaller scalpels are to be
employed, and in such cases the dissection-technique of fixed arm and
free finger movement must be used. In many places within the body
the cutting-edge of the knife should be directed outward rather than
inward so that underlying structures may not be injured. Often the
fingers of the left hand are used in such cases to take the place
of a grooved director. The application of these and other points of
technique will be elucidated in the chapters following, whenever
it is of advantage to use some especial method. In general nothing
should be done to disturb relationships until these have been noted,
and cuts should be made into organs in such a way that they may be
reconstructed in their original shape and condition.
Order and cleanliness should characterize the autopsy. Abundance of
water should be at hand, and after every incision the knife should
be dipped into a vessel of water standing on the autopsy table.
Practically all cuts should be made with a _clean wet_ knife; only
in the case of the chief-incisions of the large organs is it of
advantage to cut with a _clean dry_ knife, when it is desirable to
obtain a judgment of the moistness or dryness of the cut surface.
Never cut with a dirty knife, as the cut-surface may be obscured.
A gentle scraping with the knife-blade often gives a more distinct
picture of the cut surface. The water-stream should not be used too
freely upon cut surfaces; it should be employed only when there is
so much blood or fluid that the surfaces are obscured, or when it
is desired to float up certain tissues or parts of organs. A better
picture of the cut-surface can sometimes be obtained by blotting it
with absorbent paper free from lint. Organs and tissues removed from
the cadaver should not be allowed to dry. Nor should they be left in
water. Both conditions will quickly ruin material in so far as its
after-use for microscopic study is concerned. They should be kept
covered with moist cloth or paper. As the organs are removed from
the body they may be quickly dipped into water and quickly rinsed,
but beyond this the use of water is not advisable.
Blood and fluids within the cavities of the body should be quickly
removed as soon as their character is determined. Stomach and
intestinal fluids in particular should not be allowed to escape
within the body-cavities. They should not be washed out, but removed
by the aid of beakers and sponges. Drops of blood or other fluids
upon the surface of the cadaver should be removed before they become
dry. All respect should be paid to the dead body. The face and hair
should be covered after they have been examined; and great care
should be taken to prevent any accidental cuts on the surface; and
the entire field of operation as well as the autopsy-table must be
kept clean. In private practice the external genitals should be kept
covered except for their examination. An abundance of large sponges
and a gently-flowing stream of water under low pressure permit a
clean and orderly autopsy. The use of a hose with water under high
pressure is dangerous because of the accidental spattering that
is sure to occur. Blood and fluids from a dead body should not be
spattered about because of the great danger of spreading infection.
When accidents do happen prompt cleaning up and disinfection should
be carried out. Particularly in private practice is it of the
greatest importance that no blood-stains be left behind.
The time required for an autopsy varies with the conditions of
the individual case. A complete and well-performed autopsy under
ordinary circumstances requires at least one hour, usually an hour
and a half. It is true that all the organs can be removed from the
body in a much shorter time, but the removal and inspection require
at least the time given above, if properly done. Some cases present
great difficulties and may require 4-12 hours for a satisfactory and
complete examination. For a medicolegal examination 2-3 hours is
usually necessary. No prosector should make more than two autopsies
in one day, and, if he is making them every day, one daily is quite
sufficient. The intellectual and nervous energy required for a
good autopsy is so great that it is impossible for anyone to do
justice to a large number made in quick succession. In many German
laboratories this fact is recognized and the autopsies are assigned
proportionately to members of the pathologic staff.
At the close of the autopsy the cadaver must be thoroughly cleaned
and restored, as far as possible, to its natural appearance.
Directions for the restoration and closure of the autopsied body will
be given in a later chapter.
CHAPTER II.
THE ORDER OF THE AUTOPSY.
=ORDER OF THE AUTOPSY.= In so complicated a piece of work as the
complete autopsy it is absolutely necessary that a definite order
of procedure be followed at every autopsy, altered when necessary
to suit the requirements of individual cases. In medicolegal
examinations a definite autopsy order should be prescribed by law.
For the average case, in fact for nearly every autopsy, I believe the
following order, as given in my protocol book, to be the best one. It
is based upon topographic and anatomic relationships, preservation of
blood-content, ease and convenience of method, etc. As the protocol
should follow this order, it is given here in full.
Autopsy-Protocol No.
1. Name: 2. Sex: 3. Age:
4. Nationality: 5. Status: 6. Occupation:
7. Day and Hour of Death: 8. Time of Autopsy:
Clinical Diagnosis:
Pathologic Diagnosis:
_Prosector:_
A. External Examination. General.
==============================+==========================
9. Build: | 27. Muscles:
10. General Nutrition: | 28. Rigor Mortis:
11. Head: +——————————————————————————
12. Facies: | 29. Panniculus:
13. Eyes: | 30. Oedema:
14. Neck: +——————————————————————————
15. Thorax: | 31. Body Heat:
16. Abdomen: +——————————————————————————
17. Back: | 32. Hypostasis:
——————————————————————————————+——————————————————————————
18. Anomalies: | 33. Putrefaction:
19. Deformities: +——————————————————————————
20. Signs of Trauma: | 34. Orifices:
21. Surgical Wounds: | Mouth:
22. Scars: | Nose:
——————————————————————————————+ Ears:
23. Skin: | Genital:
24. Hair: | Anus:
25. Teeth: +——————————————————————————
26. Mucous Membranes: | 35. Postmortem
| Percussion:
——————————————————————————————+——————————————————————————
B. Internal Examination.
I. SPINAL CORD.
==============================+===========================
1. Dorsal Incision: | 4. Inner Meninges:
——————————————————————————————+——————————————————————————
2. Vertebrae: | 5. Cord:
——————————————————————————————+——————————————————————————
3. Dura: | 6. Inner Surface of
| Vertebrae:
——————————————————————————————+——————————————————————————
II. HEAD.
==============================+==========================
1. Scalp: | 13. Ventricles:
2. Periosteum: | Left Lateral:
3. Skull-Cap: | Right Lateral:
——————————————————————————————+ Third:
4. Dura: | Fourth:
5. Longitudinal Sinus: +——————————————————————————
6. Meningeal Vessels: | 14. Chorioid Plexus:
| 15. Pineal Gland:
| 16. Cerebral Ganglia:
——————————————————————————————+ 17. Peduncles:
7. Basal Vessels: +——————————————————————————
8. Inner Meninges, Left: | 18. Cerebellum:
9. Inner Meninges, Right: | 19. Pons:
| 20. Medulla:
——————————————————————————————+——————————————————————————
| 21. Hypophysis:
10. Cerebrum: | 22. Basal Sinuses:
11. Right Hemisphere: | 23. Basal Dura:
12. Left Hemisphere: | 24. Cranial Nerves:
| 25. Base of Skull:
——————————————————————————————+——————————————————————————
III. THORAX AND ABDOMEN. (Main Incision.)
==============================+==========================
1. Panniculus: | 6. Position of Diaphragm:
2. Musculature: |
——————————————————————————————+——————————————————————————
3. Abdominal Cavity: |
4. Omentum: | 7. Mammæ:
——————————————————————————————+ 8. Costal Cartilages:
5. Position of Abdominal | 9. Sternum:
Organs: |
——————————————————————————————+——————————————————————————
IV. THORAX.
==============================+==========================
1. Thoracic Cavity: | 11. Left Lung:
2. Position of Thoracic |
Organs: | 12. Right Lung:
——————————————————————————————+——————————————————————————
3. Anterior Mediastinum: |
——————————————————————————————|
4. Thymus: | 13. Bronchi:
——————————————————————————————| 14. Bronchial Glands:
5. Pericardium: |
——————————————————————————————+——————————————————————————
6. Heart: | 15. Pulmonary Vessels:
——————————————————————————————+——————————————————————————
7. Right Heart: | 16. Great Vessels of
| Thorax
——————————————————————————————| 17. Thoracic Portion of
8. Left Heart: | Oesophagus
——————————————————————————————+——————————————————————————
9. Cardiac Orifices and | 18. Thoracic Duct:
Valves: | 19. Thoracic Vertebræ.
10. Coronary Vessels: |
——————————————————————————————+——————————————————————————
V. MOUTH AND NECK.
==============================+==========================
1. Mouth: | 9. Thyroid:
2. Tongue: | 10. Parathyroids:
3. Pharynx: +——————————————————————————
4. Tonsils: | 11. Cervical Lymphnodes:
5. Nose: | 12. Parotid:
——————————————————————————————| 13. Submaxillary Gland:
6. Larynx: +——————————————————————————
7. Trachea: | 14. Cervical Vessels and
——————————————————————————————| Nerves:
8. Cervical Portion of | 15. Deep Muscles of Neck:
Oesophagus: |
——————————————————————————————+——————————————————————————
VI. ABDOMEN.
==================================+==============================
1. Peritoneum: | 15. Left Adrenal:
——————————————————————————————————+——————————————————————————————
2. Spleen: | 16. Left Kidney and Ureter:
——————————————————————————————————+——————————————————————————————
3. Large Intestine: | 17. Right Adrenal:
4. Appendix: +——————————————————————————————
——————————————————————————————————| 18. Right Kidney and Ureter:
5. Small Intestine: |
——————————————————————————————————+——————————————————————————————
6. Duodenum: | 19. Abdominal Aorta:
7. Bile Passages: | 20. Iliacs:
| 19. Ascending Vena Cava:
——————————————————————————————————+——————————————————————————————
8. Stomach: | 22. Lymph Vessels:
——————————————————————————————————| 23. Retroperitoneal
9. Pancreas: | Lymphnodes:
| 24. Hemolymph Nodes:
——————————————————————————————————+——————————————————————————————
10. Liver: | 26. Psoas Muscles:
——————————————————————————————————+——————————————————————————————
11. Gall Bladder: | 27. Vertebræ
——————————————————————————————————+——————————————————————————————
12. Portal Vein: |
——————————————————————————————————+——————————————————————————————
13. Mesentery: |
14. Mesenteric Lymphnodes: |
——————————————————————————————————+——————————————————————————————
VII. MALE PELVIS.
=================================+==============================
1. Penis: | 6. Prostate:
+——————————————————————————————
2. Scrotum: | 7. Seminal Vesicles:
—————————————————————————————————+——————————————————————————————
3. Testis: | 8. Seminal Duct:
—————————————————————————————————+——————————————————————————————
4. Epididymis: | 9. Urethra:
—————————————————————————————————+——————————————————————————————
5. Rectum: | 10. Bladder:
—————————————————————————————————+——————————————————————————————
VIII. FEMALE PELVIS
==================================+=============================
1. Rectum: | 9. Tubes:
——————————————————————————————————+—————————————————————————————
2. Vulva: |
3. Urethra: | 10. Ovaries:
4. Bladder: |
——————————————————————————————————+—————————————————————————————
5. Vagina: | 11. Blood and Lymph
6. Uterus:11. | Vessels of Uterus:
7. Cervix: |
8. Body: | 12. Ligaments of Uterus:
——————————————————————————————————+—————————————————————————————
IX. SPECIAL REGIONAL EXAMINATION.
==================================+=============================
1. Bones: | 6. Peripheral Nerves:
——————————————————————————————————+—————————————————————————————
2. Marrow: | 7. Sympathetic:
——————————————————————————————————+—————————————————————————————
3. Joints: | 8. Organs of Special Sense:
——————————————————————————————————| Eye:
4. Lymph Glands: | Ear:
——————————————————————————————————| Nose:
5. Peripheral Blood Vessels: |
——————————————————————————————————+—————————————————————————————
X. MICROSCOPIC AND BACTERIOLOGIC FINDINGS.
XI. SUMMARY OF CASE.
The organs may be inspected and opened in the body without removing
them; but when weights and measures are desired they should be
removed and sectioned on the table. When the spinal cord is removed
posteriorly it should be done at the beginning of the autopsy, for
the sake of convenience and cleanliness. If the thorax and abdomen
are examined first there is a loss of solidity and resistance,
making the posterior opening of the spinal canal more difficult.
The head may be opened while the cadaver is face downward and the
brain removed with cord attached. If the cord is examined anteriorly
this should be done at the close of the autopsy after the thorax and
abdomen are completely cleaned out. The head should be opened before
the heart and great vessels are cut in order to avoid bleeding the
sinuses and pial veins. It should be kept elevated until the heart
has been examined to avoid bleeding the latter through the jugulars.
The abdomen is opened before the thorax so that the position of the
abdominal organs and the height of the diaphragm can be correctly
noted. A complete survey of the peritoneal cavity should be made at
once before the appearances are changed through the loss of blood or
other fluids, or through drying or handling. The size of the liver
should be estimated before the heart is cut out, inasmuch as the loss
of blood through the cut inferior vena cava may reduce its size as
much as one-half. The pleural cavities should be examined before its
vessels are cut, as the escape of blood may alter the appearances
of the pleuræ. The heart is opened before the lungs are removed, so
that its blood-content may be judged. The section of the neck organs
is conveniently carried out according to anatomic relationships,
beginning with the tongue. In the abdomen the spleen is removed first
because it is the most easily gotten out of the way. The intestines
up to the duodenum may be taken next, or the adrenals and kidneys,
followed then by the gastro-intestinal tract, pancreas and liver.
When necessary the kidneys may be removed in connection with the
pelvic organs. In the case of extensive growth of neoplasms, marked
inflammatory processes, adhesions, malformations, anomalies, etc.,
the order must be changed to meet in the best way the demands of
the situation. Such changes in the order must always be mentioned
in the protocol. It is a great mistake to begin the autopsy with a
local examination of a supposed fatal lesion, except in the cases of
wounds, particularly in medicolegal cases, in which a most careful
and minute description of the wound is necessary.
Some writers (_Letulle_, _Heller_, _et al._) advocate the removal
of neck, thoracic, abdominal and pelvic organs _en masse_ and their
examination outside of the body. Except in rare cases in the adult,
and more frequently in the child, this method does not present any
special advantages aside from the preparation of museum specimens. It
may be convenient to follow it when a very short time is allowed for
the autopsy, just sufficient to remove the organs so that they can be
examined later. When this method is followed the order should be:
1. Organs should be turned over without twisting, so that their
posterior aspect is uppermost. Then the examination in the
following order: right and left azygos veins; thoracic duct;
removal of adrenals; opening of ureters; removal of kidneys;
opening of aorta, inferior vena cava, portal vein and branches, and
common duct; examination of pancreas; removal of aorta as far as
arch; opening of œsophagus; examination of mouth, pharynx, palate,
tonsils, tongue and sublingual glands, epiglottis, larynx, trachea
and large bronchi; roots of lungs, prevertebral lymphnodes, and the
pneumogastric nerves.
2. Organs are then turned over again without twisting, and examined
from anterior surface as follows: removal and examination of thymus
and thyroid; opening of superior vena cava, termination of thoracic
duct and right lymph-trunk; opening of pericardium, examination of
cardiac plexus, opening of arch of aorta; section and examination
of pulmonary arteries and veins and hilum of lung; examination
and removal of heart and lungs; examination of diaphragm, liver,
gall-bladder and bile-ducts; external examination and separation
of spleen, stomach, pancreas and duodenum; removal of œsophagus,
stomach, pancreas and duodenum; external examination, dissection
and removal of intestine to the rectum; examination of peritoneum,
mesentery and omentum; separation and examination of kidneys,
ureters, bladder and urethra; separation and examination of genital
organs (in male, prostate, seminal vesicles, vasa deferentia and
testes; in the female, oviducts, broad ligaments, ovaries, vulva,
vagina and uterus).
For the ordinary clinical autopsy this method is more inconvenient
and time-consuming, and offers not a single advantage over the
order advocated above. I use it only in young children and in
adult cases of generalized carcinomatosis, sarcomatosis, pulmonary
embolism, congenital cardiac lesion, tuberculosis, aortic aneurism
with tracheal or bronchial erosion and a few other rare generalized
conditions. For all other cases I advise that the first mentioned
order be followed, varying it as occasion demands. The autopsy should
be individualized. Departures from the routine order will take place
chiefly in the thoracic and abdominal cavities. It is often more
convenient to remove the kidneys before taking out the intestines,
to examine the liver before the spleen, or to make other similar
variations in the order. The order of examination of the larger
divisions of the body (head, thorax, abdomen and pelvis) should
always be followed strictly; but the neck and thoracic organs, or the
thoracic organs alone, may be removed _en masse_ and examined outside
of the body, and the same procedure may be carried out in the case of
the abdominal or pelvic organs whenever advisable. Removal _en masse_
with examination on the table is especially indicated in the case of
the neck and thoracic organs in aortic aneurism, pulmonary embolism,
congenital cardiac lesions, mediastinal neoplasms, generalized
carcinoma or sarcoma of thoracic organs, etc. The same procedure
is indicated in the case of the abdominal organs in generalized
carcinomatosis or sarcomatosis, inflammation and tuberculosis of the
abdominal organs or peritoneum, aneurism of the abdominal aorta,
pseudomyxoma peritonei, etc.
In my judgment it is extremely bad practice to examine first
that part of the body which the clinician believes to be chiefly
affected. Still worse is it to limit the autopsy to such a regional
examination. Imperfect and subjective conclusions will be avoided if
the regular order is followed and each organ examined objectively.
In all cases a complete autopsy should be made if permission can be
obtained, and the permit for an autopsy should be regarded as one for
a complete examination unless definite exceptions have been made.
The examination of any organ or part should never be neglected. Many
prosectors habitually omit the section of the neck-organs, intestines
and genital tract when there is nothing to attract especially their
attention to these parts. The examination of the spinal cord, orbits,
nasal tract, ears, joints and bones may be omitted in the ordinary
autopsy in the absence of especial considerations directing attention
thereto; all other parts should be systematically examined. The
pathologist must always maintain an unprejudiced state of mind toward
the clinical diagnosis—rather a doubting mind than a disposition to
accept the suggestions of the clinical opinions. The best cure for
subjectivity is the complete performance of the autopsy in regular
routine order, and the dictation of the protocol at the autopsy table
during the operation.
CHAPTER III.
THE PROTOCOL.
=THE PROTOCOL.= Autopsy findings should be recorded in the form of
complete, concise notes, following the order of the autopsy. Such a
protocol should consist of _descriptive_ statements of the pathologic
changes found, as well as of all negative conditions. It must be a
guarantee that all organs have been examined and that nothing has
been overlooked. Herein lies the great value of the use of a protocol
blank book with printed autopsy forms. When such are used and both
positive and negative pathologic findings are recorded during the
progress of the autopsy the chances of omission are reduced to a
minimum.
The protocol must be purely objective and exact. All appearances
should be so carefully described that from the protocol itself a
diagnosis may be formulated. Conclusions and diagnoses have no
place in the protocol until the final summing up. It is better to
describe the appearance of organs than to class them as “normal”
or “negative,” “nothing notable,” etc. The only excuse for the
employment of such phrases is a lack of time for the dictation of a
proper protocol, but the scientific value of the autopsy is thereby
impaired. As the complete description of the normal appearances
would require too much time and lessen that available for the
pathologic examination, the prosector should describe briefly the
chief characteristics of the normal organ, any variation in any one
of these characteristics being sufficient evidence that the organ
had suffered pathologic change. The description of the normal organ,
however, usually offers the greatest difficulty to the beginner, and
so much time may be spent upon this that the pathologic changes are
slighted. However, the relatively small number of points constituting
the criterion for the normal organ may be learned by experience and
by the study of autopsy-protocols made by experts. The latter study
is also necessary for the acquisition of the extensive protocol
terminology that has been developed. A knowledge of this terminology
lightens greatly the difficulties of the protocol; but its misuse
leads to confusion and incorrect interpretations.
It is not a good plan to write up the protocol after the autopsy
has been finished. It should be dictated during the progress of
the autopsy. Only in this way can an accurate and purely objective
description be obtained. The use of simple, terse English and the
proper employment of autopsy terminology are also chief factors in
the production of a good protocol.
The importance of following a definitely-outlined routine of
procedure is very evident in the case of protocol-making. The general
order of the autopsy should be followed strictly in the protocol; and
all deviations from the usual method noted and described. Aside from
this general order, each organ or part as it is examined should be
systematically described according to the following scheme:
1. =Location and relation to other parts.=
2. =Size and weight.=
3. =Shape. (Contour, lobes, edges, borders, character of surface,
etc.)=
4. =Color.=
5. =Consistence.=
6. =Odor.=
7. =Cut surface.=
8. =Blood-content.=
9. =Histologic features in detail. (Capsule, surface, parenchyma,
stroma, vessels, etc.)=
10. =General and localized pathologic conditions.=
For the _hollow viscera_ and _body-cavities_ the following points
should be systematically noted in addition:
1. =Size and shape of cavity.=
2. =Free gas or air?=
3. =Fluid or solid contents? (Amount, odor, color, cloudiness,
consistency, precipitation or separation on standing, presence
of blood, fibrin, pus, parasites, etc.)=
4. =Condition of wall of cavity (serosa or mucosa).=
1. =Location and Relation.= The organs and parts should be located
according to the landmarks of regional anatomy. Brain-lesions may be
charted upon the printed outline sheets of the different parts of the
brain. Similar outline sheets may also be used for other parts of the
body.
2. =Size and Weight.= The exact weights and measurements should be
given in the metric terms. Organs should be weighed and measured
after the removal of other tissue in which they may be imbedded
(fatty capsule of kidney, etc.) or to which they are attached
(diaphragm from liver, blood-vessels from heart, etc.). The volume
of the organ may be estimated by putting it into a graduated vessel
containing water and noting the amount of displacement. In the
absence of facilities or the time necessary to take weights and
measurements an approximate estimate of size and bulk may be given
by comparisons with well-known objects, such as peas, mustard-seed,
pepper-corns, walnuts, apple, hen’s egg, etc., but such terms are
only relative and not accurate, and their use should be avoided as
much as possible. That the weight and measurements of any given organ
fall within normal limits cannot be taken as evidence that the organ
is normal. The judgment as to the size and weight of the organ must
always be controlled by a consideration of the pathologic conditions
present as to the exact factor in the increase or the loss of size or
weight.
3. =Shape.= The organs should be removed with the least possible
disturbance of shape. If it is not possible to do this, the shape of
the organ should be noted as it lies within the body. A knowledge of
the normal form of the organs must serve as the basis for judgment.
Comparison of pathologic alterations in form with the shape of some
familiar object is permissible (horse-shoe, hour-glass, shagreen,
cauliflower, mushroom, coral, polypoid, hog-backed, etc.) Borders,
contours, edges, external surfaces, etc., are rounded, sharp,
flatter, thinner, saccular, lobulated, smooth, wrinkled, folded,
villous, polypoid, granular, nodular, fissured, etc. All possible
anomalies of form exist from the very slightest deviations up to the
most marked distortions.
4. =Color.= The color of an organ or part should be noted as soon
as possible after its removal from the body, or, better, as soon as
the cadaver is opened, since oxidation, evaporation, loss of blood,
and contact with water quickly cause color-changes. Venous blood may
quickly become bright red, notably in the spleen and cerebral veins
and sinuses. It is not to be supposed that, even when the cadaver
is opened within a very short time after death, the color is that
of the living body. Certain color-changes always take place as soon
as death occurs, but it is necessary to create a color-standard for
the different organs as seen under the conditions of the ordinary
autopsy. Injections of formalin and other undertaker’s fluids destroy
all color, and should not be permitted before the autopsy. Freezing
likewise changes the color of many of the organs.
The judgment of the color of the tissues and organs of the human
body is extremely difficult because of the fact that only rarely
is a pure simple color seen. Ordinarily a combination of colors is
present, and the analysis of these is often not easy. If the organ
is held before the eyes at a distance of about a yard an impression
of a single color-unity may be obtained, but when brought nearer to
the eyes the surface presents a variegated, mottled, speckled or
streaked effect of many colors, sometimes running the entire range
of the spectrum. The colors most frequently seen in the body are
yellow, red and brown in all possible combinations and shades. Blue,
gray, slate, black, green and purple are also common in combination
with these three or with one another. The analysis of the color is
concerned, first with the color proper of the parenchyma, secondly
with the color of the blood and the blood-content, thirdly with
the color of some pathologic substance contained in the tissue,
as blood- or bile-pigment, carbon, melanin, etc. In describing
color-combinations use the predominant color last; as, for example,
a reddish-yellow-brown means that the predominant color is brown
with more yellow in it than red. Innumerable combinations of these
three colors exist (light brown, chocolate, yellowish-brown, brownish
yellow, brownish red, etc.). The macroscopic color will not be
apparent in microscopic preparations except when due to a true
pigment.
The term discolored is applied to dirty, cloudy colors, particularly
gray or greenish, as in gangrene. Spotted, mottled, streaked,
variegated, etc., have the same application in the autopsy-protocol
that they have elsewhere. The judgment of the color of an organ
should be made twice: as seen through the capsule or external
covering, and again on the cut surface of the organ. In the latter
case the transparency, translucency or opacity of the surface should
be noted with the color. Normally translucent structures become
opaque as the result of inflammatory thickening, parenchymatous
degenerations, leukocyte infiltrations, tubercles, postmortem
digestion, etc. An increase in translucence may be due to œdema,
hydropic degeneration, amyloid, mucoid and colloid degenerations,
liquefaction necrosis, anæmia, atrophy, loss of pigment, etc.
(translucent, transparent, jelly-like, colloid, mucoid, lardaceous,
sago, bacon, ham-fat, pearly, etc.).
5. =Consistence.= This is best estimated by placing the four fingers
of the right hand beneath the edge of the organ as it lies on the
board or in the body and lifting it slightly upward and inward toward
the main mass of the organ. This should be done in several places,
so that an idea of the general consistence of the organ is obtained.
Hollow organs must be tested before and after opening, in the latter
case, to get an idea of the consistence of the wall. Organs with
capsules should be tested through the uncut capsule and also on the
cut surface. After the general consistence has been determined an
examination of the entire organ by thumb and fingers should be made
to determine localized areas of different consistence (soft: abscess,
cyst, œdema, areas of degeneration, etc.; hard: amyloid, tubercles,
tumors, chronic passive congestion, fibroid indurations, pneumonic
areas, etc.). The size and location of such areas should be carefully
noted. The presence of fluctuation, loss of elasticity, pitting on
pressure, friability, hardness, etc., should be described in ordinary
terms, although a comparison with familiar objects often gives a more
definite impression than the simple use of adjectives describing the
condition (consistence of leather, dough, mush, pea-soup, putty,
wood, jelly, stone, iron, etc.). The relaxation or softness of an
organ is often judged by its flattening on the board, or by its
hanging down over the index-finger when this is placed beneath its
middle and the organ raised, or by the jelly-like tremors of the
organ when the dish containing it is agitated.
An increased friability is noted in diseased bones, muscles,
pneumonic lungs, organs showing acute congestion, etc. An increase
or a loss in elasticity is to be noted chiefly in the large
blood-vessels, lungs, skin, etc. In describing a condition of loss
of normal firmness the German School makes frequent use of the
termination _malacia_ (softening) in such words as _myomalacia_,
_osteomalacia_, _gastromalacia_, _myelomalacia_, _encephalomalacia_,
etc. When such softening is the result of postmortem autolysis
or digestion, as is so often the case in the stomach (postmortem
perforations), thymus, pancreas, adrenals, brain, etc., the term
_postmortem softening_ is more frequently used in this country. Soft
tumors are described as medullary, encephaloid, etc. In all judgments
as to consistence the normal differences between the organs must
be considered, as well as the length of time between death and the
autopsy, the cause and manner of death, undertaker’s manipulations,
temperature, moisture, rigor mortis, putrefaction, etc.
6. =Odor.= But little attention is paid in the average autopsy
to the odors of the body, and very little has been written about
their importance. This is probably due to the fact that the average
individual more or less consciously or unconsciously suppresses the
sense of smell. Yet a keen sense of odors and an ability to analyze
them are of the very greatest importance in autopsy work. Certain
infections, and other diseases as well, have peculiar and distinctive
odors (small-pox, measles, colon-bacillus infections, pulmonary
gangrene, diabetes, uræmia, acute yellow atrophy, leukaemia, etc.).
The odor of many drugs and poisons may also be distinguished in the
tissues, gastro-intestinal tract or body-cavities (alcohol, ammonia,
amyl nitrite, aromatic and ethereal oils, assafétida, carbolic acid,
chloral, chloroform, creosote, ether, hydrocyanic acid, iodoform,
musk, nicotine, nitrobenzol, phenacetin, phosphorus, etc.) Many
foods may be recognized in the stomach by the odor (onions, garlic,
cabbage, turnips, pineapple, oranges, apples, peaches, vinegar,
grape-juice, caraway and anise seeds, celery, sage, cardamom, and
many others). In describing odors we should compare them with natural
odors or class them as sweet, sweetish, sour, bitter, pungent, sharp,
heavy, yeasty, pus-like, fruity, etc.
7. =Cut Surface.= The cut surface of the organs and tissues should
be examined immediately after the organ is sectioned. During the
examination the organ should be moved in different planes so that the
light may fall upon the surface in various angles. Color-changes,
differences in reflection and refraction, minute inequalities of
the surface, etc., are often brought out in this way when otherwise
they might be overlooked. During the examination the surface may be
gently scraped over by the blade of the large section-knife held
at an angle of 45° to the surface. The character and amount of the
blood and fluid exuding from the surfaces and vessels should be
noted; after this has been done the cut surface may be gently washed
with water and examined with regard to histologic and pathologic
details. During the inspection pressure may be made upon the organs
to determine still further the blood- and fluid-content. The color,
moisture or dryness, consistence, reflection or “shine” (dry-shining,
moist-shining, fatty shine, pearly shine, etc.), cloudiness,
translucency, transparency or opacity of the cut surface must also be
considered. Normal organs are never perfectly dry, although they vary
greatly in the amount of moisture shown on the surface. They have,
therefore, always a certain degree of reflecting power. Different
parts of the cut surface of the same organ should be compared as
to color, moisture and dryness. (Areas of suppuration, congestion,
œdema, inflammation, recent hemorrhage, hydropic degeneration,
liquefaction necrosis, etc., are more moist than normal; old thrombi,
fibrinous exudates, old hemorrhages, simple, coagulation, caseous and
Zenker’s necrosis, dry gangrene, anæmic and hemorrhagic infarctions,
amyloid, concretions of cholesterin, bile-pigment, lime-salts,
urates, etc., contents of dermoid cysts and cholesteatomata, etc.,
are dry.) The cut surface must be described also as to its even
or uneven character, finely or coarsely granular, shagreened,
rough, nodular, elevated or depressed portions, fissures, folds,
umbilication.
The cut surface of neoplasms is examined especially by scraping it
with a dry knife held at an angle of 45°. The cells thus obtained
constitute the _tissue-juice_ (“_cancer- or sarcoma-milk_”). Soft
medullary neoplasms yield an abundance of such cell-scrapings,
hard tumors but little. The cells thus obtained may be treated
according to the various methods given on Page 219, and then examined
microscopically. The cut-surface of the soft parenchymatous organs
(bone-marrow, spleen, thymus, lymphnodes, liver, pancreas and
kidneys) also yields material for examination by this method.
8. =Blood-Content.= The blood-content of the organs should be
estimated both before and after they are sectioned. This estimation
should be based upon the color of the organ, condition of the
blood-vessels, amount of blood exuded from the cut surface, number
of bleeding-points (anæmia, hyperæmia, stasis). Capillary, arterial
and venous hyperæmia should be differentiated when possible. Only
rarely are evidences of arterial congestion seen in the cadaver. It
is also necessary to observe the occurrence, location and extent
of hypostasis and to differentiate antemortem and postmortem
(lungs, brain, intestines, etc.). The association with œdema and
inflammation, particularly in the lungs (hypostatic pneumonia)
speaks for antemortem hypostasis. A red color in parts possessing
no blood-vessels (heart-valves, endocardium, intima of aorta,
cartilage, etc.) indicates an imbibition of diffused hæmoglobin
(hæmatin-imbibition). Changes in the color of the blood (carbon
monoxide, hydrocyanic acid, and hydrogen sulphide poisoning, all
poisons producing methæmoglobinæmia, icterus, leukæmia, etc.) should
be described and recorded; likewise all hemorrhages, extravasations,
etc.
9. =Histologic Features.= After the general points given above have
been considered the histologic features of the organ should be taken
up in routine. For example, in the case of the spleen, the capsule,
trabeculæ, pulp, stroma, follicles and vessels should be examined;
in the liver, the capsule, trabeculæ, liver-acini, blood-vessels
and bile-ducts; in the kidneys, capsules, cortical surface, cortex,
labyrinths and medullary rays, glomeruli, columns of Bertini,
medullary pyramids, vessels, pelvis and beginning of ureter. When the
organs are thus systematically examined there is but little chance
that anything visible to the naked eye has been overlooked.
10. =Pathologic Lesions.= Anomalies, defects, erosions, ulcers,
evidences of trauma, inflammations, abscesses, tubercles, gummata,
neoplasms, parasites, and all forms of pathologic changes, local
or general, must be accurately located and described. The changes
peculiar to certain diseases and infections must always be borne in
mind during the examination of any organ in which such conditions are
likely to be found. The relationship of lesions in different parts
of the body must be recognized. Localized lesions must be described
according to position, size, form, color, consistence, etc. Their
nature must be recognized, their relation to other or to pre-existing
conditions determined, the stage of the process estimated, and the
part played in the causation of death ascertained.
In the examination of the _body-cavities_ and _hollow organs_, as
well as _pathologic hollow structures_, the first thing to note is
the escape of gas or air under pressure. Occasionally it is best to
open the organ under water to note the escape of bubbles. The odor
of the gas, inflammability, etc., are to be noted. The fluid or
solid contents (blood, bile, urine, féces, mucus, pus, exudates and
transudates, altered secretions, food-remains, concretions, foreign
bodies, parasites, etc.) are described as to their amount, color,
consistence, odor, reaction, chemical nature, precipitate, presence
of cellular elements, etc. The size of the cavity, monolocular
or multilocular, the character of its lining (transparency,
translucency, cloudiness or opacity, color, “shine,” moisture,
smoothness, roughness, villous or polypoid, consistence, thickening,
swelling, elevations, atrophy, incrustations or deposits on the
lining, etc.) are to be considered. In the case of cystic tumors
(adenocystomata, dermoid cysts, cholesteatomata, etc.) especial
attention should be paid to the character of the cyst-contents
(mucoid, glairy, colloid, jelly-like, pea-soup-like, pultaceous,
mushy, doughy, caseous, pearly, laminated, flaky, powdery, etc.).
CHAPTER IV.
THE EXTERNAL EXAMINATION.
=THE BEGINNING OF THE AUTOPSY.= The autopsy begins with the
examination of the exterior of the body. The cadaver should be
completely stripped of clothing and examined as a whole, then as
to its separate parts. Time is saved and omissions prevented if a
definite order is followed in the external examination, such as
follows here.
1. =Identification of the Body.= In ordinary cases the name of the
deceased will be given upon the autopsy-permit, and this will serve
as sufficient identification. In large autopsy-services, when several
cadavers may be brought in at the same time, each one should be
properly tagged so that no mistake is possible. It is necessary in
medicolegal cases to make a more formal identification by having the
cadaver positively identified by persons having knowledge of the
individual during life, or by those who first saw the body, or who
took it in charge. In such cases when identification is impossible
at the time of autopsy the protocol should give in full details
the place, time, and conditions of discovery of the body, with an
accurate description of its external characteristics, clothing,
articles found on the body, surroundings, etc. Bertillon measurements
and finger-markings may be taken; dental work should be carefully
described; false teeth and hair, eyeglasses, etc., should be
preserved, and the most careful attention should be paid to bodily
anomalies or peculiarities, birth-marks, tattoo, etc. Photographs,
casts, Roentgengrams, etc., may be taken. Powder-marks, blood-stains,
as well as those of semen and other discharges, should be described
and, if necessary, preserved. Legal names, as well as aliases, should
be recorded and attested in all cases of legal significance. In fact,
the only proper way to conduct any autopsy is with the assumption
that the results will have legal value; and such an assumption is the
best safeguard against important omissions.
2. =Sex.= This should always be mentioned in the protocol. In the
case of pseudohermaphrodism the determination of the real sex may
be difficult and may eventually be decided by microscopic studies.
Likewise in bodies that have been burned or mutilated the question of
sex becomes a matter of anatomic and histologic study. The character
of the bones, pelvis, remains of sexual organs, etc., are used as
criteria to decide the question. In cases of burning, the uterus
in the female and the prostate in the male may often be recognized
microscopically when the head and extremities are burned off and only
a charred mass of flesh and bone remains.
3. =Age.= When the true age is not known the apparent age must
be estimated by considering the general appearance of the body,
development, bones, epiphyses, sutures, blood-vessels, skin, hair,
teeth, sexual organs, etc. Roentgengrams of the epiphyses, hands
and feet may be made. The presence of an arcus senilis should be
noted. Arteriosclerosis of the temporal and radial arteries may be
determined by inspection and palpation. The determination of the age
of the new-born will be considered in a later chapter.
4. =Nationality.= When not definitely known this may be estimated
by such criteria as color of skin, finger-nails, character of hair,
facies (cheek-bones, jaw, forehead, cephalic index, facial angle,
eyes, etc.), hands, feet, general build, etc. For ethnologic and
anthropologic data the body may be described according to the
primitive type it represents (Australioid, negroid, mongoloid,
xanthochroic, melanchroic, Iberian, dolichocephalic, etc., according
to the different classifications).
5. =Status.= Unmarried, married, widow, widower, divorced, legal
status, citizen of what country, state, county or town, etc.
6. =Occupation.= As this often throws light upon the pathologic
condition present in the body, the trade or occupation should be
ascertained and stated in the protocol. When no direct information
is available a judgment concerning it may be made on the basis of
certain conditions, occupation or industrial diseases found in the
body (anthracosis, argyrosis, siderosis, silicosis, chalicosis,
lead-poisoning, chronic phosphorus poisoning, nitrobenzol and other
forms of poisoning, localized muscle-hypertrophy or atrophy, callus,
etc.).
7, 8. =Time of Death and Time of Autopsy.= The day and hour of death
and the time of autopsy should be noted. When the time of death is
not known with certainty it can only approximately be estimated
by the condition of the body with respect to such postmortem
changes as rigor mortis, algor mortis, hypostasis, diffusion-spots,
decomposition, etc. From no one of these signs of death can an
absolute statement be made as to the time of death; so great a
variation may occur with any one or with all of these so-called
_positive signs_ of death that only very relative estimates can
be given. Between the actual time of death and the appearance of
positive signs of this event there exists a variable period in
which death announces its appearance by _negative_ signs only; the
cessation of the vital functions, respiration, circulation and
nervous excitability. These functions may, however, be reduced to so
low a degree of strength that their existence cannot be made out by
the usual methods, and a condition of _apparent death_ or “_suspended
animation_” may be present. Such a condition is most frequently
seen in cases of cholera, hysteria, catalepsy, hypnosis, excessive
fatigue, prolonged exposure to cold or to high temperatures,
concussion, severe hemorrhage, action of certain poisons, electrical
currents and lightning stroke, strangulation, asphyxia, suffocation,
drowning, etc. The condition of apparent death may last hours or even
days, but as a rule it is one of very short duration. Granting the
existence of such a possibility of apparent death before absolute
signs of death appear, it follows that in all autopsies made very
soon after death has occurred, the prosector must bear such a
possibility in mind, and satisfy himself beyond all doubt of the
actual occurrence of death before beginning the autopsy.
=Tests for the Determination of the Occurrence of Death.= Loss of
reflexes or response to stimuli are early signs. Mirror, flame or
feather held before the mouth and nose, or vessel containing fluid
placed on epigastrium show absence of respiration. Opening of artery,
temporal or radial; if death has occurred vessel will be empty. Tests
with blood-pressure apparatus are negative in dead body. Electrical
tests and Roentgengrams of heart and lungs show no movement in
these organs. Subcutaneous injection of ammonia; no congestion or
vesicle formed in the dead body. Subcutaneous injection of fluorescin
(_Icard’s test_): in the living body a greenish color soon appears
in skin, mucous membranes and conjunctivæ; but not in the dead body.
Heat applied to the skin causes no reddening in the dead body, and,
if a vesicle forms, the fluid contained in it has no albumin and the
underlying skin is dry and glazed and not red. The application of
caustics produces no eschar in the dead body. A steel needle inserted
into the living tissues becomes quickly tarnished; in the dead body
oxidation will not take place after many hours. Glazing of the
eyes (if these are open) takes place very quickly after death; the
eye-ball collapses ordinarily, but may remain prominent in death from
hanging, suffocation, apoplexy, etc. The eye loses its elasticity;
the pupils can be made oval by compressing the globe (_Ripault’s
test_). The patch of dark discoloration on the part of the sclerotics
exposed to evaporation is known as _Larcher’s sign_. The hands held
against a strong light lose the pink tinge between the fingers,
and the soles and palms become yellow. A tight ligature about a
finger or limb causes no reddening (_Magnus’s test_). Relaxation
of the sphincters occurs soon after death. It should be borne in
mind in this connection that the discharge of gas and féces is not
uncommon after death, that a fetus may be expelled by the increase of
intra-abdominal pressure due to rigor mortis and gas-formation, that
a discharge of semen or prostatic fluid almost always occurs in the
adult male, that electric contractility may last several hours after
death, that muscles may twitch during this period, and that atropine
will dilate the pupils for some time postmortem.
9. =Build.= The body should be measured by stretching in a straight
line a metal tape-measure from the vertex to the centre of the
external arch of the instep, the foot being held at a right angle
to the surface of the table. Giantism or dwarfism, partial or
complete, asymmetrical development, etc., should be noted and the
type determined (rachitic, cretinoid, congenital and acquired
deformities of bones may cause dwarfism; giantism may be congenital
or due to disease of the hypophysis as in acromegaly). In all cases
of abnormal development of the skeleton the possibility of diseased
conditions of the hypophysis, thyroid, thymus, adrenals and sexual
glands must be borne in mind. In a general way the build of the body
may be described as large, heavy, strong, medium, small, delicate,
etc. Racial, sex and age differences should be noted. Roentgen-ray
examination may here also be made use of in the determination of
stages of skeletal development. Approximate estimates of the general
build may be made when only part of the body is preserved. Such
rules as nineteen times the length of the middle finger equals the
approximate height, four times the length of the femur equals the
height, the distance from the tip of the olecranon to the tip of the
middle finger is five-nineteenths of the height, etc., are obviously
very uncertain.
10. =General Nutrition.= The body should be weighed. Nutrition good,
medium, poor, emaciated, etc. Condition of skin, muscles, panniculus,
etc. Differentiate loss in fat from loss in muscle. Distinguish
physiologic fat from pathologic (lipomatosis, etc.).
11. =Head.= The size and shape of the head should be noted, and
any peculiarity or pathologic condition described (microcephalic,
macrocephalic, dolichocephalic, brachycephalic, etc.).
12. =Facies.= Aside from individual and racial characteristics the
face of the cadaver may show varying expressions (Hippocratic
facies, hepatic facies, expression of peace, pain, horror,
distortion, etc.). Note all anomalies and pathologic conditions
(leontiasis ossea, leonine expression of leprosy, hare-lip, etc.).
13. =Eyes.= Closed or open, shape, size, color, deep-set, changes
due to death, condition and size of pupils, arcus senilis, color of
conjunctivæ and sclerotics, eye-lids. The pupils are usually dilated
at death, but after a short time they contract, usually unequally,
and remain so for several days. Note particularly all anomalies and
pathologic conditions (corneal scars, coloboma, cataract, strabismus,
etc.).
14. =Neck.= Short and thick, long and narrow, thin or fat, smooth
or wrinkled, scars, enlargements, marks of rope, fingers, string,
evidences of strangulation, hemorrhages, abrasions, etc., other forms
of trauma, cysts, enlarged glands, condition of thyroid, etc.
15. =Thorax.= Shape, length, breadth and depth, angle of Louis,
epigastric angle, symmetry of sides, prominence or depressions,
pigeon-breast, shoemaker’s or funnel breast, rachitic rosary,
character of ribs and interspaces, mammæ, degree of hairiness,
eroding tumors or aneurisms, etc.
16. =Abdomen.= Depressed, scaphoid or elevated, distended,
tympanitic, presence of fluctuation, symmetry, results of palpation
(neoplasms), character of abdominal wall (tightly stretched or lax,
wrinkled), presence of linea fusca or lineæ albicantes (pregnancy,
ascites, tumor). The existence of enteroptosis or gastroptosis can
often be told by inspection of the abdomen.
17. =Back.= General build and contour, bedsores, etc. Spine should
be carefully examined (anterior, posterior or lateral curvatures,
evidences of trauma, etc.).
18. =Anomalies.= Malformations and anomalies of any region should
be thoroughly examined and carefully described. The most common
ones found in adults are hare-lip, cleft palate, branchial
cysts, bifid sternum, accessory ribs, malformations of fingers
and toes, hypertrophy of great toe, hypospadias, cryptorchidism,
pseudohermaphrodism, congenital dislocations, particularly of
hip, lumbosacral meningoceles and dermoid cysts, microcephalus,
club-foot and hernia, its variety, location, size and condition.
Under anomalies may be considered the stigmata of degeneracy and
the _homo delinquens_ type. These should also be mentioned in the
identification of the cadaver.
19. =Deformities.= Location, degree, character, probable cause, etc.
Most commonly caused by tuberculosis, rachitis, gonorrhœa, syphilis,
osteitis deformans, trauma, burns, osteomalacia, tabes, muscular
atrophies, gout, rheumatism, tumors, aneurism, diseases of the
lung causing asymmetry of the thorax, acromegaly, etc. Most common
forms are Pott’s disease, spondylitis, ankylosis, spinal curvature,
contractions and retractions of parts, bow-leg, knock-knee, changes
in the pelvis, dwarfism, shortening of extremities, exostosis,
drumstick or clubbed fingers, flat foot, loss of bones, amputations,
occupation deformities, swelling of joints, tophi, Charcot’s joint,
hygroma, ganglion, etc.
20. =Signs of Trauma.= Location, size, character and condition of
wound (bruises, bloody suffusions, hæmatoma, erosion, denudation,
lacerations, punctures, crushing, blister, fractures, dislocations,
bullet-wounds, marks of hanging, strangulation (abrasions in the neck
caused by hanging show minute hemorrhages in and about their edges,
particularly in the upper border; section of the neck shows small
hemorrhages in the cervical tissues), or drowning, burns, action
of corrosives (brown spots on lips), effects of electric currents,
etc. In the case of powder-markings note number, direction, burning,
singeing of hairs, etc.) In medicolegal cases the description of
traumatic lesions should be especially minute and complete. An effort
should be made to distinguish postmortem from antemortem wounds.
Recent wounds have clean cut walls and edges covered with blood; old
wounds show reaction, vascularization, granulations, adhesion of
edges of wound, or of exudate. Postmortem wounds are usually free
from blood unless large veins are ruptured. Loss of the epidermis
before or after death causes in the cadaver yellowish or brown, firm,
leather-like spots.
21. =Surgical Wounds.= Location, size, nature of operation, state of
wound, character of surgical dressings, drainage, etc., discharge
from wound as blood, pus, féces, urine, etc., odor of wound, age as
shown by stage of repair, evidence of infection, etc. Hypodermic
marks, saline injections, blisters, venesection, cupping, exploratory
punctures, recent vaccination marks, etc., should be noted.
22. =Scars.= Location, size, character, recent or old, pigmented
or pale, rough or smooth, contractures, keloids, traumatic or
surgical, nature of injury or surgical operation, hypodermic scars,
vaccination, acne, cupping, small-pox, chicken-pox, shingles,
“electric belt,” croton oil, burns, etc.
23. =Skin.= Color (racial differences), brown, gray or black
pigmentations in Addison’s disease, pellagra, syphilis, vitiligo,
xanthoma, chloasma, pigmented nodes or nævi, argyria, arsenical
poisoning, pernicious anæmia, xeroderma pigmentosum, chronic
jaundice, vagabond’s skin, tan, following blisters, plasters,
cupping, use of croton oil, Roentgen irradiation, effects of violet
rays, melanotic tumors, pregnancy, etc.; bronzing in Addison’s
and chronic icterus; lemon yellow in chlorosis and pernicious
anæmia; yellow to dark green in icterus; grayish-brown in potassium
chlorate poisoning; bluish-red (cyanotic) in cardiac insufficiency;
yellowish-bluish-red (“Herz-farbe”) in cases of complete loss
of compensation; cherry-red or rose-red in carbon-monoxide or
hydrocyanic acid poisoning, rarely as the result of an erythema,
although this condition usually disappears after death; dirty sallow
to grayish or greenish in tumor cachexia and poisoning with H_{2}S;
white after severe hemorrhage, cachexia of chronic Bright’s disease,
leucoderma, vitiligo, albinism, leprosy, etc.; red, yellow, green
or brown in hemorrhages according to their age. Eruptions should
be classified and described as to location, abundance, stage, etc.
(macules, papules, wheals, desquamation, scales, blebs, bullæ,
pustule, tubercles, ulcers, abscess, phlegmon, herpes, crusting,
granuloma, etc.). With the exception of chicken-pox and small-pox
the eruptions of the acute exanthemata disappear after death, as do
all erythematous rashes except in rare instances. Emphysema of the
skin should be differentiated from œdema. The most common lesions
of the skin are acne, eczema and syphilis. Tuberculosis (lupus)
is not uncommon; anthrax, favus, rhinoscleroma, actinomycosis and
blastomycosis and Aleppo or Delhi boil are more rarely seen. Tinea
versicolor and tricophyton (barber’s itch and the various forms
of ringworm) are the most common parasitic affections. In the
Southern states ground-itch due to the hook-worm is the most common.
Leprosy should be considered in connection with individuals coming
from Norway, Sweden and Finland and other leper-foci. The most
common tumors of the skin are all the various forms of hæmangioma
and lymphangioma (freckles, moth patches, naevi, moles, warts,
birth-marks), fibroma, lipoma and squamous-celled carcinoma (horny
and basal-celled types). The latter is the most common form of
malignant tumor. Sarcoma of the skin is more rare; the melanotic
sarcoma, arising usually in a pigmented mole, is the most common
form. Next to this is the round-cell sarcoma or lymphosarcoma
(mycosis fungoides, leukaemic and aleukaemic lymphocytoma, etc.).
Spindle-cell sarcoma, angiosarcoma, endothelioma and other forms
are less common. Sebaceous cysts (wen, atheroma, steatoma) are
very common. Less frequent are molluscum contagiosum, xanthoma
(endothelioma lipomatodes), myoma, myxoma, chondroma and osteoma.
Adenoma sebaceum and sudoriparum are rare. Other conditions of the
skin to be noted are cleanliness, elasticity, general nutrition,
moisture, presence of scales, atrophy, hyperplasia (ichthyosis,
horny warts, cutaneous horns, the various forms of elephantiasis),
scleroderma, keloid, xeroderma pigmentosum, albinism, leucoderma,
vitiligo, myxœdema, seborrhœa, alopecia, erysipelas, dermatomyositis,
psoriasis, impetigo, rhinophyma, herpes, miliaria, sudamina,
symmetrical gangrene, trophic changes, “goose-flesh,” hemorrhages,
scars, tattoo-marks, etc. The various forms of skin-diseases should
be described and recorded whenever present.
The presence of petechiæ or ecchymoses in the skin (purpura) is
characteristic of all the forms of essential purpura (simplex,
peliosis rheumatica, hæmorrhagica, senilis, morbus maculosis
Werlhofii, scurvy, Möller-Barlow disease, etc.); such skin
hemorrhages occur also as the result of trauma, congenital
hæmophilia, in the course of many infections (small-pox, plague,
typhus, yellow fever, endocarditis, measles, scarlet fever,
septicæmia, pyæmia, rheumatism, meningitis, typhoid fever), in many
intoxications (snake-bite, icterus, nephritis, iodine, bromine,
phosphorus, chloroform, etc.), also in severe anæmia, pernicious
anæmia, leukæmia, sarcoma, carcinoma, acute yellow atrophy of
the liver, hysteria, vicarious menstruation, reflex hemorrhages,
stigmatization, etc. The number, size, color and location of all
cutaneous hemorrhages should be recorded.
24. =Hair.= Color, abundance, distribution, character, quality,
condition, length, pathologic conditions (alopecia areati, senilis,
præsenilis, pityrodes, syphilitica and symptomatica, trichorrhexis
nodosa, hypertrichosis, parasites, etc.). In prolonged fevers and
wasting diseases the diameter of the hair is diminished. Symptomatic
alopecia occurs after syphilis, typhoid fever, scarlet fever,
measles, erysipelas, anæmia, Roentgen irradiation, etc. The length,
color and quality of the hair as well as amount and distribution
vary in different races. Hypertrichosis is often associated with
degeneracy, criminal tendency, epilepsy, idiocy and certain forms
of insanity. An apparent growth of hair after death may be caused
by retraction of the tissues; an actual postmortem growth is not
conceded by the majority of authorities in spite of the numerous
tales to that effect. Loss or absence of pigment is seen in albinism,
leukotrichia due to infection, Graves’ disease, exposure, burns,
nervous affections, fright, worry, etc. The presence on or about
the body of hairs not belonging to the cadaver is a point of great
importance in medicolegal cases and one that should be thoroughly
investigated as to their source. Human hair can be identified
microscopically, and it is possible to recognize different specimens
according to their variation in color, length, quality, etc.
The =nails= should be considered in connection with skin and hair,
with reference to the following points: presence or absence,
hypertrophy, atrophy, color, condition, length, development,
onychia, hyperonychia, paronchyia, onychogryphosis, longitudinal and
transverse ridges, fissures and cracks, opacity, brittleness, etc.
25. =Teeth.= Number, character, condition, anomalies, dental work,
caries, Hutchinson’s teeth, odontoma, dental osteoma, dentigerous
cysts, epulis, papilloma, etc.
26. =Mucous Membranes.= Color, deposits or incrustations, eruptions,
erosions, herpes, mucous patches, rhagades, ulcers, fissures,
moisture, trauma, effects of corrosives, burns, pigmentation, as in
Addison’s disease, leukoplakia, hairy tongue, hemorrhages, tumors,
etc.
27. =Muscles.= Musculature and condition of muscles (slight,
athletic, well developed, poor, flabby, soft, etc.), anomalies, etc.
28. =Rigor Mortis.= Postmortem rigidity is one of the absolute signs
of death. It begins usually 1-2 hours after death, the involuntary
muscles and heart showing it first. Externally it shows first in
the muscles of lower jaw and neck, extends downward, involving the
lower extremities last and disappearing in the same order. Its
appearance, however, is subject to the greatest variation, and the
presence or absence of rigor mortis cannot be used as a criterion
for the estimation of the length of time the body has been dead.
Instantaneous rigor has been reported in suicides and in people
killed in battle. Intense excitement, great muscular exertion, etc.,
favor its rapid appearance. It also comes on very quickly after
death from rabies, tetanus, strychnine poisoning, cholera and a
number of other conditions. It sometimes is delayed or absent after
heat-stroke; chronic alcoholism also delays its appearance. Usually
the contraction lasts 24-48 hours, but under certain conditions may
persist for several days. It is prolonged in muscular individuals,
after death by suffocation, rabies, strychnine poisoning, etc. The
stiffening of the muscles may be broken by application of heat or the
use of force (removal of clothes from the body); when once broken it
rarely returns. In a case of death from rabies seen by the writer
the rigor was so strong that it required the united efforts of two
men to straighten the limbs, and before the close of the autopsy the
rigor had returned as strong as in the beginning. Rigidity due to
undertaker’s injections and freezing must not be mistaken for rigor
mortis. The possibility of rigidity due to ankylosis must also be
borne in mind.
29. =Panniculus.= The subcutaneous panniculus is estimated by
pinching up a fold of skin between the thumb and fingers of the
right hand and the thickness determined. The amount is described as
panniculus abundant, moderate, absent, etc. Estimates should be made
of panniculus of upper extremities, thorax, abdomen, back and lower
extremities. Pathologic conditions, such as general obesity, adiposis
dolorosa, multiple lipomata, elephantiasis lipomatosa, fatty collar,
etc., should be described in full.
30. =Oedema.= At the same time that the panniculus is being examined,
the presence or absence of œdema (pitting on pressure) should be
noted in the same regions. When present it may be described as
slight, moderate, marked, extreme, localized, universal, etc.
_Emphysema_ of the subcutaneous tissue is shown by the presence of
elastic swellings of the skin, not pitting on pressure, but giving a
crepitation when palpated.
31. =Body Heat.= The absence or presence of the body heat is of great
importance in giving some idea as to the relative length of time the
body has been dead. The nose, ears and extremities first become cool,
the liver region retaining the heat longest. The rate of cooling
depends upon the external temperature and the conditions of the body.
Nude bodies, cadavers exposed to water and cold, and bodies that
have suffered severe hemorrhages lose their heat more rapidly. Under
ordinary conditions the rectal temperature is the same as that of the
surroundings in about forty hours. During the formation of the rigor
there may be a slight increase in the temperature of the cadaver.
An increase above the normal temperature has also been noted in the
dead body immediately after death from tetanus, cholera, small-pox,
peritonitis, electric currents, suffocation, gangrene, etc.
32. =Hypostasis.= After death the blood passes into the veins and
very soon through gravity collects in the greatly distended veins
of the lowest portions of the body, except where these are pressed
upon by the weight of the body. Such a settling of the blood begins
usually within 1-2 hours after death, but may take place even
before death (hypostatic congestion) in cases of long-standing
recumbent position, cardiac lesions with failure of compensation,
wasting diseases, acute infections, death from suffocation, etc.
Postmortem lividity should be described as to its extent, location
and color. In anæmia the color is pale purplish red, in congestion
dark purple, in cyanosis the color may be dark bluish red and the
fingers, toes, ears, etc., retain the cyanotic appearance for some
hours after death; in potassium-chlorate poisoning the color is
chocolate, in hydrogen-sulphide poisoning grayish green, in poisoning
with hydrocyanic acid or carbon monoxide it is rose or cherry red.
Fresh hypostatic patches can be made pale by pressure and when cut
they will bleed freely. Hemorrhages cannot be pressed out nor will
hemorrhagic areas bleed as freely as hypostatic patches. In all
medicolegal cases care should be taken to differentiate bruises and
ecchymoses from hypostatic patches, as in the popular mind the latter
are often regarded as evidences of trauma or violence. The location
of the hypostasis is of importance in showing the position of the
body after death; if the anterior portion of the body is hypostatic
the cadaver must have been lying upon its face for some time after
death; suspension of the body for some time after death by hanging
causes a hypostasis of the lower extremities. Of the internal organs
the brain, lungs, stomach and coils of intestine chiefly show
hypostasis. Antemortem hypostasis of the lungs is distinguished from
postmortem by its deeper color, firmer consistence, more marked
œdema and microscopic signs of beginning inflammation (hypostatic
pneumonia). Cadaveric lividity reaches its maximum in 24-48 hours,
and after this time diffusion gradually occurs. In connection with
the examination of hypostatic areas the condition of the superficial
vessels as to size, distention, etc., should always be noted.
33. =Putrefaction.= The first signs of putrefaction are seen in the
transformation of the hypostatic areas into _diffusion spots_ and
_stripes_ following the course of the larger veins. The color is at
first a dirty red or brownish-red, but soon becomes gray or green
as a result of the action of hydrogen sulphide diffusing from the
intestines. Diffusion spots cannot be made pale by pressure, nor do
they bleed when cut. The greenish coloration begins first over the
abdomen and lower intercostal spaces, and this gradually spreads over
the body, showing first in the hypostatic areas and along the veins.
The abdomen then becomes distended; gas may form in the subcutaneous
tissues so that the skin becomes swollen, crackles on pressure and
gives off gas-bubbles when cut. The epidermis becomes loosened in
spots, forming blebs containing a dirty-brown exudate, while the
tissues become soft and are easily torn. The odor of putrefaction
is evident. Decomposition sets in more quickly in infants, in fat
and plethoric individuals, and after death from snake-bite, active
syphilis, plague, sepsis, heat-stroke, suffocation, acute infectious
fevers, icterus, gangrene, diabetes, etc.; it is delayed by
hydrocyanic acid and other poisons. When putrefactive bacteria are
present in the body, decomposition may begin immediately after death.
34. =Orifices of the Body.= The _mouth_, _nose_, _ears_, _anus_,
_urethra_ and _vagina_ are to be examined with special regard to
their condition and contents (open, closed, gaping, torn, bleeding,
discharge of pus, blood, mucus, féces, stomach contents, semen,
urine, foreign substances, parasites, ear-wax, etc.). In cases of
suspected rape an especial examination of the orifice of the vagina
or anus is indicated.
35. =Percussion and Palpation.= The external examination may be
closed by the percussion of the heart, lung, spleen, liver and
stomach boundaries, and by the palpation of the abdomen. The fine
opportunity for control of technique, judgment as to sound, size,
consistence, shape, etc., should not be lost. Rigor mortis of the
abdominal muscles can be removed by kneading the muscles or by the
application of hot cloths.
CHAPTER V.
THE EXAMINATION OF THE SPINAL CORD.
1. =METHODS OF EXAMINATION.= The spinal cord may be opened anteriorly
or posteriorly. The choice of method is largely a matter of
convenience or of individual skill in using certain instruments,
such as the Brunetti chisels. The method of opening posteriorly is
more commonly used in this country, as it requires less skill. It
necessitates, however, an additional long skin incision that must
be tightly stitched together to prevent leakage of blood and fluids
after the restoration of the body. For this reason it is not as
clean a method as the anterior opening, which requires only the one
main skin-incision. In private practice the latter method is often
advisable, as by it an examination of the cord can often be secured
when the relatives would not consent to its removal posteriorly, on
the ground of undue mutilation of the body. The anterior examination
also permits a better inspection and an easier removal of the spinal
ganglia and nerves.
=Examination of Cord Posteriorly.= For the _opening of the spinal
cord posteriorly_ the cartilage-knife, bone-forceps, bone-nippers and
rhachiotome are necessary; in place of the latter the single saw,
double chisel, Brunetti chisels or single chisel may be employed. The
posterior examination of the cord should take place at the beginning
of the autopsy, after the external inspection of the cadaver, before
the thorax and abdomen are examined. The removal of the sternum
gives a loss of resistance to the manipulations upon the back of the
cadaver, and the turning-over of the body after it has been opened
anteriorly is usually an unpleasant procedure because of the dripping
of blood and other fluids. When it is found necessary to examine the
cord posteriorly after the opening of thorax and abdomen it is better
to fill these cavities with tow or excelsior, replace the sternum and
sew up the anterior skin-incision before turning the body over.
The cadaver is placed face downwards, with medium-sized blocks
beneath the cervical and lumbar regions, the arms being folded
underneath the body. With the cartilage-knife an incision is then
made through the skin and subcutaneous tissues in the median line,
over the spinous processes, beginning above at the occipital
prominence and ending at the lower border of the sacrum. The skin
and subcutaneous tissues are then dissected back by bold slashing
strokes for a distance of a hand’s breadth on both sides of the
spine, thus laying bare the muscles of the neck and back. The muscles
may be stripped back with the skin, but the heavy flaps thus formed
are very likely to fall back and cover the seat of operation. Chain
retractors may be used to hold the skin flaps back, particularly in
the case of a very fat individual, but usually the separate stripping
of the skin and muscles is sufficient. To remove the muscles the
cartilage knife is set close against the spinous processes of the
uppermost vertebræ and a deep cut made on each side of the spine
throughout its entire length, severing the vertebral attachments of
all muscles and tendons. About four finger-breadths outside of these
cuts there should now be made from above downwards on both sides
another deep cut through the muscles parallel with the first two
incisions. The bundles of tendons and muscles between these parallel
cuts on both sides of the spine are then separated from the bones as
cleanly as possible, beginning either above or at the sacral end,
severing the muscle-mass at the end at which the separation begins,
but leaving it attached at the other end, where it is laid over the
side of the body out of the way, and replaced after the examination
of the cord is completed; or the two bundles of muscle may be cut off
at both ends and disposed of without further trouble. Portions of
tissue clinging to the vertebræ should then be scraped or cut away
with the chisel or knife.
When the vertebræ are bared the next step is the removal by saw,
bone-forceps or chisel of the posterior bony wall of the spinal canal
in such a manner as to expose the cord and permit of its removal
without causing any damage to it, either from the instruments or
from fragments of broken bone. A single-bladed saw with curved ends
may be used to saw through the laminæ on both sides of the spinous
processes; or even the small bone-saw (Fig. 9) may be used for this
purpose. The blade of the saw should be held obliquely against the
spinous processes with the sawing edge directed outward so as to
cut the laminæ close to the medial borders of the ascending and
descending transverse processes. The sawing is complete when the
spinous processes become movable. The straight-edged chisel may be
used to cut any adhesions left after sawing, and the bone-forceps
may be used to cut the atlas and axis. When the laminæ have been cut
through on both sides of the spinal column for its entire length,
including the sacrum, the posterior ligament between the atlas and
occiput is cut with the cartilage knife; and the strip of bone and
ligaments loosened by sawing is torn off from above downward by
grasping it in the upper cervical region with a pair of bone-nippers
and jerking it off forcibly downward toward the sacrum, thus exposing
the spinal canal. It may be taken off in the opposite direction by
cutting the ligament between the last lumbar vertebra and the sacrum
and stripping upward.
The use of the single saw is not advised, however, as it is too
time-consuming. The laminæ on both sides of the spinous processes
may be cut at the same time by the use of _Luer’s rhachiotom_e (Fig.
11). The blades are separated according to the size of the vertebral
arches and are set so as to include the spinous processes and cut the
outer border of the laminæ close to the transverse processes in such
a manner as not to injure the cord. Since the spinal canal is broader
in the cervical and lumbar regions than in the dorsal, the distance
between the saw-blades must be regulated accordingly. The dorsal
portion is first sawed. The sawing should be in long cuts without too
great pressure, the instrument being steadied by placing the left
hand on the upright bar. As soon as the spinous processes become
movable on slight pressure the sawing should be stopped. Should the
blades become caught in the saw-cuts great care should be taken to
avoid injuring the cord while releasing them. The straight-edged
chisel may be inserted into the cuts and any parts still adherent
may be carefully sprung apart. This is necessary particularly in the
upper cervical region. The entire posterior wall of the canal may be
loosened in this way, the sacrum being also sawed, when it is desired
to open this part of the canal. When all the spinous processes are
movable the attachments either above or below are cut with the
cartilage-knife, and the spinous processes and laminæ torn off by the
bone-nippers in one piece, either toward the head or sacrum as is the
more convenient.
The laminæ may be cut by a chisel instead of a saw. The
straight-edged or curved single chisel, the “tomahawk” chisel, or
the double-bladed chisel of _Esquirol_ may be employed. The latter
instrument has adjustable chisel-blades that can be set to include
the spinous processes. These blades are very strong and short, and
have convex cutting edges. The use of a wooden mallet (Fig. 17) is to
be preferred to that of the steel hammer in driving chisels of any
type. The straight, curved and tomahawk chisels are held with their
cutting edges directed slightly outwards. The _Amussat rhachiotome_
is a chisel-knife with a curved metallic handle, the cutting edge
running along the length of the chisel. When set at an angle of 45°
to the laminæ it is driven through them by means of blows from a
wooden mallet delivered upon the chisel-back over the cutting edge.
The _Brunetti chisels_ are shown in Fig. 15. In using these to open
the spinal cord posteriorly, a block should be placed beneath the
abdomen so as to raise the lumbar vertebræ above the level of the
dorsal. The intervertebral ligaments of the last lumbar vertebræ
are then cut through with the belly of the cartilage-knife held at
right angles to the spine. The laminæ and spinous process of the last
lumbar vertebra are then cut out with the straight-edged chisel or
bone-forceps, exposing the canal. The _right_ and _left_ Brunetti
chisels are then alternately used, beginning usually with the “left”
chisel, the blunt probe-point being introduced into the canal, while
firm pressure downward is made upon the handle, while at the same
time the cutting edge is driven through the outer borders of the
vertebral arches by blows from a wooden mallet delivered upon the
head of the handle. Great care must be taken to keep the cut at the
same level throughout. It is better, however, to cut too high rather
than too low. In the latter case the cord may be injured, while in
the former the bone may later be easily trimmed off sufficiently
without causing any damage. The arches of three to four or even more
vertebrae may be cut without removing the chisel. The same thing is
then done on the other side, using the “right” chisel. The loosened
portion of bone and ligaments is then cut or torn off with the
bone-forceps or nippers. The cut bone should not be touched with the
hands because of the danger of injury and subsequent infection from
the sharp spicules and splinters of bone. As the canal is opened the
block under the body is pushed towards the head, the object being
always to cut _down hill_ and not upward. When the cervical region is
reached the head of the cadaver should be firmly held by an assistant
so as to give sufficient resistance to the blows of the mallet. The
skilful use of the Brunetti chisels is difficult to acquire and a
great deal of practice is necessary, but when once the knack is
obtained the spinal canal can be opened in this way more quickly than
by any other method. In private practice the noise made by the hammer
upon the head of the handles of the chisels is unpleasant, and should
be avoided by the use of felt or something else on the head of the
chisel or mallet to deaden the sound.
Another easy and convenient way of opening the spinal canal
posteriorly is the cutting of the laminæ by means of special
bone-forceps designed for this purpose. The cutting-edges may engage
the laminæ from without or the lower blade may be introduced into
the canal as a blunt probe, while the upper blade cuts down upon it
through the side of the arch. Such bone-forceps should be very strong
and have long handles to give sufficient purchase, as a good deal of
force is necessary to cut through the laminæ. With a good instrument
the canal can be opened in this way in about 10-15 minutes. It
requires much less skill than is needed for good and quick work with
the Brunetti chisels, and for that reason is recommended, as is also
the use of Luer’s rhachiotome, for the general practitioner.
In the case of marked curvatures of the spine it may be impossible
to use either rhachiotome or Brunetti chisels. The straight single
chisel and small saw can be used on the concave and convex sides of
the curvature respectively. In children and young adults the canal
can be easily opened with the bone-forceps.
After the removal of the posterior wall of the spinal canal the
peridural adipose tissue and the dural sac are exposed in the canal.
The cord may now be removed with dural sac intact, and when the cord
is soft this should be done, but in so doing the spinal fluid is
likely to be lost; and, as it is very important to obtain a knowledge
of the amount and character of this fluid, care should be taken to
preserve it. With the block placed under the cervical region to keep
the cervical and dorsal vertebræ higher than the lumbar the dural sac
may be opened in the median line from above downward. The cervical
dura is grasped with a pair of forceps and lifted so that a cut can
be made in it with the small bent, probe-pointed shears. The blunt
probe-point is then introduced into the subdural space and the dura
cut in the median line downward toward the sacrum. With care the
arachnoideal sac with its fluid may be preserved intact. What fluid
there is in the subdural space will collect in the lumbar region
and may be secured while the lumbar dura is cut. The fluid in the
subarachnoideal space will likewise collect in the lower portion of
the cord, and it is best at this stage of the operation to introduce
a sterile pipette through the delicate arachnoid and draw up the
fluid, preserving it for bacteriologic and microscopic examination.
The thirty pairs of spinal nerves are now cut from above downward,
beginning on the right side. The cut edge of the dura or a dural
fold, if the dura is left uncut, is seized with the dissecting
forceps and pulled over to the left, so that as much of the nerve
can be secured as possible. A long, narrow, sharp-pointed scalpel
is inserted, outside of the dura, into the intervertebral foramina,
as far as possible, and the nerves are cut while traction is made
upon the dura to the opposite side. The same procedure is then
carried out upon the left side. When all of the spinal nerves are
cut, the scalpel is introduced in the spinal canal upward, as near
to the foramen magnum as possible, and the cord and dura are cut
transversely. The cord should be held by the dura; direct pressure
with forceps or fingers upon the soft substance of the cord should
never be made. If the forceps cannot be used to hold the dura with
advantage, then the cord enclosed in the dural sac may be gently
but firmly held in the _palm_ of the left hand and lifted and drawn
downward towards the sacrum with the greatest care. As the cord is
removed the fibrous attachments between the dura and the longitudinal
fascia of the anterior wall of the canal are cut with the small
scalpel by means of oblique cuts upon the bodies of the vertebræ.
Any fragments of bone impeding the removal of the cord should be
trimmed off with the bone-forceps. The forcing of the cord through a
tight aperture in the open canal may ruin that portion of the cord.
In some cases it may be better to sever the dura and cord at the
sacral end, below the cauda equina, and remove it toward the head,
using the same method of holding the dura, and cutting the spinal
nerves and peridural tissue. When this is done the importance of
saving the spinal fluid should be borne in mind. Some prosectors
prefer to sever the dura and cord above before cutting the spinal
nerves, and to cut these and the epidural fascia while removing the
cord. An experienced operator may save time in this way, but there
is greater danger of injuring the cord. The cord may also be removed
by severing the spinal nerves and vessels inside of the opened dura
and lifting the cord out of the dura, but it is more likely to be
damaged by this method. When the brain has been removed before the
cord the dural attachments as high as the foramen magnum should be
severed and the cord removed up to the point where it was severed
from the brain. If it is desired to remove the cord attached to the
brain, the cord is first loosened throughout its length from below
up to the foramen. It is then carefully protected while the skull
is opened; and after the brain-connections have been severed it is
drawn up through the foramen as the brain is lifted out of the skull.
After its removal from the body the cord is stretched out upon table
or board and the dura opened in the median line both anteriorly and
posteriorly, if the latter cut was not made before its removal from
the body. If it is desired to make sections of both cord and dura for
microscopic study the dura may be left uncut or attached to the cord
after it has been opened in the median line. It then helps to hold
the pieces of cord together after the latter has been cut. Otherwise
the dura may be removed from the cord by cutting the nerve-roots
and denticulate ligaments on both sides. The cord is now examined by
making transverse cuts through it with a clean knife which is dipped
into clean water before each cut. The cord is allowed to hang over
the index-finger of the left hand while the knife is drawn across
it, severing it down to the underlying pin which is left uncut to
hold the pieces together. The cuts are usually begun in the cervical
region and are made at the level of the spinal nerves. When the dura
is left attached to the cord it may be laid back and the cord cut
within it, or if it has not been opened, the cuts may be made through
it and the cord at the same time, if a very sharp knife is used.
Areas of softening should not be cut, but should be preserved intact
for examination after fixation and hardening. If the segments of cord
are left attached to the dura or pin the cord and membranes may be
fixed and hardened _en masse_ so as to permit future orientation.
=Examination of Cord Anteriorly.= After the complete examination
of the neck, thoracic and abdominal organs the spinal column is
divested of all remaining tissues, including the psoas muscles. A
block is then placed beneath the lumbar vertebræ. With the belly of
the cartilage-knife held transversely across the spinal axis the
intervertebral disks on both sides of the next-to-the-last lumbar
vertebra are cut down to the level of the canal. If the lumbar
vertebræ are sufficiently elevated by the block placed beneath the
abdomen, the cutting of the disks allows the neighboring vertebræ
to spring away, so that the body of the vertebra thus separated
can be cut out by the bone-forceps or chisel. The spinal canal is
thereby exposed; so that the Brunetti chisels may now be used in
cutting the pedicles and stripping off the vertebral bodies. As
this stripping progresses upward the block is moved toward the head
so that the cutting is always down hill. The chisels are driven
through the pedicles of five or six vertebræ at a time; the handle
is forced down until the long chisel-blade is nearly parallel with
the vertebræ. At the same time the cutting-edge must be sent forward
at a uniform level, just high enough to expose the canal. If the cut
is too high the chisel will enter the body of the vertebra, if too
low the probe-point will be pushed into the cord. When the cervical
vertebræ are being cut the head of the cadaver must be steadied
by an assistant. As the sections of vertebræ are loosened the
intervertebral disks are cut with the cartilage-knife and the pieces
of bone pulled away with the bone-nippers. When the canal is fully
exposed the examination of the dura and the removal of cord and
dura proceed as when the canal is opened posteriorly. The straight
chisel and the bone-forceps are also used to open the spinal canal
anteriorly, but the Brunetti chisels are especially recommended for
this operation.
=Examination of Spinal Ganglia.= While these may be examined when
the canal is opened posteriorly, they can be exposed with less
danger of damage in the anterior examination. To expose them in the
posterior examination they must either be drawn forcibly through the
intervertebral foramina, or the articular processes must be cut away
with the chisel.
When it is desired to remove a part of the spinal column for
preservation as a specimen, the intervertebral cartilages and the
cord above and below the portion to be removed are cut through with
the knife, and the ribs severed with a chisel, while the adherent
soft parts are cut away. The saw or chisel is then used to complete
the disarticulation if necessary and the loosened portion is removed.
The entire spine may be removed, if desired; and may be bisected with
a band-saw. A stick of wood may be put in the place of the spine and
covered with plaster-of-Paris.
After the cord and dura have been removed the inner surface of the
canal should be examined. The character of the cut surface of the
vertebral bodies is also noted, and the bones examined for pathologic
conditions.
=2. POINTS TO BE NOTED IN THE EXAMINATION OF THE SPINAL COLUMN=.
1. =Dorsal Incision.= Note color of skin as it is cut, number
of bleeding points, moisture, bedsores, amount and character of
panniculus, color and blood-content of muscles, hemorrhages, purulent
and tuberculous processes (usually infiltrations from diseased
vertebræ) trichina in spinal muscles, etc.
2. =Vertebrae.= Necrosis from bedsores, surfaces smooth or rough,
purulent and tuberculous processes (most common anteriorly),
exostoses, curvatures, fractures, dislocations, erosions,
malformations (spina bifida and supernumerary vertebræ most common),
neoplasms (secondary carcinoma, primary sarcoma, myeloma and chloroma
most common), actinomycosis, syphilis, rachitis, etc.
3. =Dura.= Note epidural tissue first, then dura, its thickness,
color, translucency, blood-content, intradural pressure, character of
inner surface (normally it is grayish-white, smooth and shining).
defects, bone-formation, organizing blood-clots, hæmatoma, gumma,
neoplasm, etc. Most common pathologic conditions are chronic
pachymeningitis, syphilis, tuberculosis, traumatic lesions and
secondary carcinoma. Primary tumors (sarcoma) and parasites
(echinococcus and cysticercus) are rare. Teratomata occur in sacral
and coccygeal regions. A diffuse formation of adipose tissue is
common, as is also the development of bony plates in the dura in old
chronic pachymeningitis (usually syphilitic). Note character and
amount of contents of subdural space (blood, pus, serous exudate,
etc.).
4. =Inner Meninges.= Normally gray, transparent, delicate. Note
intrameningeal pressure, contents of subarachnoid space, color,
thickness and translucency of arachnoid and pia, blood-vessels,
presence of blood, pus, fibrinous exudates, localized thickenings,
calcification, etc. Most common pathologic conditions are acute and
chronic leptomeningitis, results of trauma, hemorrhage, syphilis,
tuberculosis, cerebrospinal meningitis, leprous meningitis, etc.
Bony plates (osteomata) are found in the arachnoid of the majority
of people over forty-five years of age. In small number and size
they have no pathologic significance; they are often large and very
numerous in old cases of syphilitic leptomeningitis, sometimes
encasing the cord. Primary tumors (fibroma, myxoma and sarcoma) are
rare. Teratoid tumors (lipoma, myolipoma, neuroma) are occasionally
found in the lumbosacral region, often associated with spina bifida.
Secondary carcinoma and sarcoma, and metastases of the so-called
glioma of the eye are also rarely found.
5. =Cord.= Size and form. Average length about 45 cms.; weight, 30
grms.; weight of cord to that of brain, 1:48.
Anteroposterior diameter of cervical cord 0.9 cm.
Anteroposterior diameter of dorsal cord 0.8 cm.
Anteroposterior diameter of lumbar cord 0.9 cm.
Transverse diameter of cervical cord 1.4 cm.
Transverse diameter of dorsal cord 1.0 cm.
Transverse diameter of lumbar cord 1.2 cm.
Adhesions to inner meninges, consistence (should be uniform; changes
in form and consistence are often the results of postmortem changes),
color (gray-white, as seen through the pia), translucency (sclerotic
areas in the white matter are firmer, depressed and gray or
brownish-gray in color, and more translucent when present in the gray
matter), moisture, color and blood-content of cut surface, relation
of white and gray matter, symmetry of parts, size of central canal,
presence of cavities, areas of softening (soft, yellowish-white,
loss of structure), hemorrhages, congestion, anæmia, œdema, gumma,
tubercle, tumors, parasites, etc. The normal consistence of the lower
portion of the cord is usually somewhat firmer than that of the upper
part. The “butterfly-figure” should stand out distinctly on the
freshly-cut surface; the outlines between the white and gray matters
should be sharp, and the gray matter should be grayish-red in color.
Normally the white matter tends to rise above the gray. Inasmuch
as the cord is often injured accidentally during its removal it is
important to distinguish such artefacts from pathologic softenings.
This can be easily done by taking a small portion of the doubtful
area and examining in the fresh state under the microscope. In true
softening numbers of “fat-granule” cells and also capillary walls
showing fat-degeneration are seen.
The pathologic lesions of the cord easily recognized by the naked-eye
are areas of sclerosis or gray degeneration, yellow degeneration,
hemorrhage, anæmia, œdema, congestion, tabes dorsalis, amyotrophic
lateral sclerosis, acute poliomyelitis, syringomyelia, ascending
and descending degenerations, glioma, gumma, tubercle, certain
malformations, neoplasms and parasites. Other important pathologic
conditions are: Malformations (myelocele, hydrorrhachis interna,
diastematomyelia, etc.), atrophy, myelitis, sclerosis, effects
of trauma, syphilis and intoxications, infections, tuberculosis,
etc. Primary tumors are: Glioma, gliosarcoma, gliomyxoma, sarcoma
(spindle-cell, myxo-, angiosarcoma, etc.), neuroepithelioma,
neuroma, diffuse gliosis, etc. All are rare with the exception of
the gliomata. Metastatic carcinoma and sarcoma are relatively rare.
Cysticercus and echinococcus are rare.
The thickness, color, consistence and translucence of the spinal
ganglia should be noted. Atrophic nerves are smaller, more gray and
more translucent.
6. =Inner Surface of Vertebrae.= The remains of the epidural tissue
and the inner surface of the spinal canal should also be carefully
examined, noting the consistence of the vertebræ, the character of
the ligaments, fascia, periosteum, etc. The anterior wall of the
canal should be smooth, the color of the vertebræ grayish-red, that
of the intervertebral disks grayish-white. Caries, tuberculosis and
syphilis lead to roughening of the bony wall of the canal.
CHAPTER VI.
THE EXAMINATION OF THE HEAD.
I. METHODS OF EXAMINATION.
1. =Removal of Skull-Cap.= For the section of the head the cadaver
is placed upon its back with its head near the end of the table.
The head may be elevated by a block placed beneath the neck, or it
may be elevated and at the same time firmly held in position by
the use of a special head-rest, different varieties of which are
offered by instrument-makers. It is better to use the simple block
of wood and to control the position of the head with the hands
during the operation. The prosector takes his position behind the
head of the table. The hair of the cadaver is then arranged in such
a manner as to be out of the way, and protected by towels so that
it will not become matted with blood and bone-dust. When the hair
is short it is parted in a line extending from just behind the ears
across the vertex. The shape of the head and the degree of baldness
will determine the exact position of the primary incision through
the scalp; sometimes it must be made farther back than the line
connecting the ears in order that the incision may be concealed.
In the great majority of cases it will be made as follows: The
head is steadied with the operator’s left hand, and turned as far
to the right as possible. The point of the cartilage-knife is then
inserted into the scalp, just within the hair-line, behind the left
ear, and with the belly of the knife the scalp is cut through to the
periosteum, in the line of the hair-part, over the vertex, and as the
head is turned to the left, down to the hair-line behind the right
ear, the knife, as it approaches the end of the incision being raised
so as to make the point finish the cut. This scalp-incision should be
made with a strong and quick drawing movement, but the knife should
not be pressed so firmly against the bone as to cut through the
periosteum, else hemorrhages, collections of pus. etc., may escape
before they are seen.
The scalp is next loosened anteriorly by means of the hands, using
the tip of the cartilage-knife occasionally to nick the fascia and
thus facilitate the working forward of the anterior flap until it
has been loosened as far as the supraorbital ridges anteriorly and
down to the level of the beginning and ending of the incision made
across the vertex. When sufficiently loosened the anterior scalp-flap
is turned over the face, and stretched over the chin, where it will
remain, out of the way, and with both face and hair protected. The
posterior flap of the scalp is then worked back to the same level
at the sides and to the lower border of the occipital protuberance
posteriorly. It is then turned under between the back of the neck and
the wooden block. In stripping the scalp the greatest care should
be taken not to cut or tear off the periosteum. Scars, tumors,
adhesions, traumatic lesions, etc., in the scalp should be carefully
worked out and described as the flaps are loosened. The convex margin
of the fascia of the temporal muscles is now cut with the point of
the cartilage-knife and the muscles are stripped down on both sides
to the level of the folded-over scalp-flaps, where they are either
left hanging down out of the way or are cut off and laid aside. If
they cannot be easily stripped down, they may be scraped off with the
chisel. Some prosectors remove them at the same time with the scalp,
but this is usually not well done. The skull now should be bare,
except for the periosteum, down to the level of a line passing just
above the upper margin of the orbits anteriorly, at the sides just
above the aural opening, and posteriorly just below the occipital
protuberance.
The periosteum is next removed over the entire cranial surface by
means of the chisel, bone-scraper or dull knife. In medicolegal cases
particularly it is of the greatest importance that the periosteum
be removed in this way and the surface of the skull-cap carefully
examined. In ordinary cases the periosteum is often left attached
to the skull-cap when the external examination shows no pathologic
conditions to be present.
After the examination of the periosteum and external surface of the
cranium the skull-cap is removed by sawing in such a way that a space
large enough for the convenient and safe removal of the brain is
afforded. This may be done in several ways. A circular incision may
be made through the skull around its entire circumference just above
the level of the folded-over flaps of scalp. The left hand should
be protected by a folded towel. The head is held firmly in the left
hand and turned slightly toward the left. The saw-cut is then begun
anteriorly about ½ cm. above the supraorbital margins, and continued
around to the right, while the head is turned more and more to the
left. The ear should be held down out of the way by an assistant. The
saw-cut is continued then at the same level to the posterior median
line just below the level of the occipital protuberance. The saw is
then removed and the head turned as far as possible to the right;
the saw-cut is then continued around the left side from the posterior
median line until the beginning of the cut in front is reached and
the circular incision is complete.
[Illustration: FIG. 26.—Author’s method of removing skull-cap.]
Another method of sawing the skull-cap is to saw in two planes,
forming an angle just behind and below the ear (angular method). The
anterior cut is made above the hair-line of the forehead and carried
down at the sides to meet just below and behind the ear the posterior
semicircular cut made at this level. A modification of this method is
to make the anterior and posterior cuts join at a sharper angle in
front of the ears. Both of these methods have for their object the
prevention of disfigurement of the forehead. When the circular method
is used a depression or ridge is often seen in the forehead, after
the restoration of the body, due to the slipping of the skull-cap
after it has been replaced. Such an accident may happen even when the
bones are wired together, unless great care has been taken in wiring.
A more satisfactory way of opening the skull, and one that makes
slipping of the skull-cap after restoration practically impossible,
is the method used by the writer, and illustrated in Fig. 26. The
scalp-incision and the folding back of the flaps are carried out as
described above. The right half of the anterior flap of the scalp
is then taken in the left hand and used to control the position of
the head, the latter being turned to the left as far as possible. An
oblique saw-cut is then made on the right side in a line extending
from the posterior margin of the site of the posterior fontanel, over
the right parietal eminence toward the right mastoid prominence. The
sawing begins on the greatest convexity and is continued upward a
slight distance beyond the median line, and downward far enough to
cross the level of the connecting horizontal cut to be made later at
a level just above the aural canal. The left half of the posterior
scalp-flap is now taken into the left hand and used to steady the
head while it is turned over to the right as far as possible. A
similar oblique cut is then made on the left side, crossing the
one made on the right, in the median line, behind the site of the
posterior fontanel, and extending down across the left parietal
eminence in the direction of the left mastoid prominence. While the
head is still held by the left half of the posterior scalp-flap a
horizontal saw-cut is begun on the left side, just above the aural
canal, intersecting the oblique cut posteriorly and continued around
to the front at a level just above the supraorbital ridges. When the
frontal region is reached the head is steadied by holding the left
half of the anterior portion of the scalp-flap. When the horizontal
cut reaches the right temple the right half of the anterior flap
is taken in the hand, and the head turned to the left while the
cut is carried around the right temporal region to intersect the
right oblique cut. When the skull-cap is removed there is formed
an interlocking joint (Fig. 27) which under ordinary conditions
holds the restored skull-cap firmly without wiring and without the
formation of a ridge or crease on the brow, since the bone cannot
slip. It is best, however, in the event of the shipment of a cadaver
by rail to wire the bones to prevent any forcible dislodgement.
[Illustration: FIG. 27.—Skull-cap after removal, showing posterior
interlocking joint.]
Whatever method is used the greatest care should be taken to saw the
skull-cap without injuring the brain. The difference in thickness
of different portions of the cranium must be borne in mind. Sight,
sound and “the feel” are taken as guides. The outer and inner tables,
the diploë, and the dura have an entirely different resistance and
give a different sound. The saw-dust of the outer table is white,
that of the diploë red, that of the inner table white. As soon as
the saw strikes the dura a peculiar “rustling” or “scraping” sound
is heard, and this should be taken as the warning to stop sawing. On
curved surfaces it is best to begin sawing on the greatest convexity
and to continue until the saw is through and then to extend the cut
from this point. The sawing should be done lightly and quickly,
without too strong pressure. Set the saw carefully at first, to avoid
slipping. The small bone-saw is usually used for this operation; saws
attached to electric or dental engines are sometimes employed. Care
should be taken to bring the beginning and ending of the saw-cut into
the same plane; and the oblique cuts should be symmetrical.
As soon as the sawing is completed, no matter what method is used,
the T-chisel or skull-opener (Fig. 12) is used to spring off the
skull-cap. The chisel-blade is inserted into the saw-cut in the right
frontal region, and turned sideways with a quick, powerful movement
of the right hand. Any portions of the inner table not completely
sawed through (usually in the region of the petrous portion of the
temporal) are thus broken, and the dura is loosened sufficiently from
the inner table to allow the prosector to introduce the fingers of
the right hand beneath the skull-cap in the frontal region and to
hold down the dura while the fingers of the left hand inserted into
the frontal saw-cut pull the skull-cap backward with a powerful tug,
completely separating it from the dura, unless the dura is adherent
throughout, as is the case in very young children, old people, and in
certain pathologic conditions. In the latter case it may be necessary
to cut the dura along the line of the horizontal saw-cut and to
remove it with the skull-cap, cutting the falx as the skull-cap is
lifted. In young children the dura must always be removed with the
skull-cap. In the case of pathologic adhesions an attempt should be
made first to separate them from the lamina vitrea by cutting them
with a knife or chisel-blade inserted through the saw-cut. As the
adhesions are severed the skull-cap is lifted gradually backward.
Too much force should not be used in jerking off the skull-cap, else
the brain may be damaged. Whenever possible the dura should be left
intact, as a better judgment is thereby obtained of the intradural
pressure, and there is less danger of losing the contents of the
subdural space.
Some prosectors use hammer and chisel to remove the skull-cap.
This is a bad method, particularly so in the case of medicolegal
autopsies, as artificial fractures of the skull may thus be produced.
It is safest never to use a hammer in the opening of the skull.
The skull-cap is examined as soon as taken off. If the periosteum
was not previously removed it is now scraped off, and the skull-cap
examined against the light. After its complete examination the
operator proceeds to the removal of the brain.
2. =Removal of the Brain.= The convexity of the dura is first
examined. The narrow-bladed brain-knife or long section knife
(Fig. 3) is now taken in hand, and with the cutting edge directed
upward the point of the blade is inserted into the anterior end
of the superior longitudinal sinus and the sinus cut open as far
posteriorly as the opening in the cranial vault will admit. Its
walls and contents are then examined. With cutting edge outward the
point of the brain-knife is then inserted through the dura just to
the left of the anterior end of the falx and the dura cut around to
the left at the level of the horizontal saw-cut. The knife is then
inserted through the dura just to the right of the falx and the
dura cut in the same way on the right side. The two halves of the
dura are now loosened from the convexity of the brain by breaking
the blood-vessels connecting the dura with the inner meninges. The
index-finger is swept over the convexities and along the sides of
the longitudinal sinus, tearing the pial veins. Pathologic adhesions
should be carefully worked out. The finger is then used to raise
the falx anteriorly so that the point of the brain-knife can be
introduced beneath it to cut it upward and forward. The dura is then
carefully examined and turned back over the brain and allowed to hang
down over the occiput. The inner meninges over the exposed portion of
the brain are now examined; and the brain is then removed as follows:
The four fingers of the left hand are placed beneath the frontal
lobes, lifting these sufficiently for the prosector to be able to cut
the I, II, III, IV and VI cranial nerves, the carotids and pedicle of
the hypophysis down to the tentorium cerebelli. The tentorium is then
cut with the tip of the brain-knife, which is held perpendicularly,
by a gentle up-and-down sawing motion, from left to right along the
superior border of the petrous bones. The V, VII, VIII, IX, X, XI
and XII cranial nerves are then cut as closely as possible to their
exits. As they are cut the brain is lifted gradually more and more,
and supported by the left hand. When all the connections have been
cut except the cord and vertebral arteries these are severed by the
myelotome (Fig. 4), or by the brain-knife, the point of which is put
down through the foramen magnum as far as possible, and the cord and
vertebral arteries severed by a transverse cut made from left to
right as nearly horizontal as possible. The knife is now laid aside
and the first two fingers of the right hand put beneath the two
cerebellar lobes so that the medulla and portions of cervical cord
fall between these fingers, which are then used to lift them upward
and backward. The freed brain is now rolled over backward out of the
cranial cavity upside down onto the palm of the left hand, and is
then placed upon a board, tray or dish ready for examination. If the
cord has already been removed, any portion remaining is taken out
with the brain. In case the cord has been freed and is to be removed
with the brain it is only necessary to cut the vertebral arteries and
then to lift up the brain, drawing the cord up through the foramen
magnum.
3. =Section of the Brain.= (_Modified Virchow Method._) The brain as
it is taken from the cranium is placed upside down, with occipital
lobes toward the prosector. The basal meninges and blood-vessels
are then carefully examined. The hemispheres and convolutions are
separated and the arachnoid torn by the tip of the index-finger or
the handle of a scalpel; and the branches of the cerebral vessels
to their deepest ramifications are thus exposed, giving a complete
picture of the circle of Willis and all of its branches to the point
where they enter the brain-substance. The larger vessels are opened
by transverse or longitudinal cuts and their walls and contents
noted. The brain is then turned over, and the meninges examined over
the entire convexity. The pia and arachnoid are then removed together
over the entire convex and median surfaces of the hemispheres. If
the blood-vessels between the convolutions are seized with the
forceps the meninges can be easily stripped off, the fingers aiding
the forceps, using great care not to tear the brain substance. The
meninges are removed about half-way down the outer sides of the
hemispheres and are there left intact so as to hold the pieces of
brain together after it has been cut, and so permit orientation. The
cortical surface is then examined; if bloody, it should be washed
with a weak stream of water.
[Illustration: FIG. 28.—Method of examination of brain. Opening of
left ventricle. Line showing direction of cuts. (After Nauwerck.)]
The hemispheres are now separated until the corpus callosum comes
into view. The left hemisphere is then held by the left hand, with
the thumb on the median surface and the fingers on the outer and
under sides, so that the hemisphere is turned outward and yet raised
slightly at the same time, thus stretching the corpus callosum over
the cavity of the left lateral ventricle. The point of the narrow
brain-knife (Fig. 3) with cutting edge upward is then introduced
with great care through the corpus callosum about midway between the
genu and splenium and close to the gyrus cinguli (gyr. forn., Fig.
28). The corpus callosum at this point is about 2 to 3 mm. thick and
it is gently nicked with the point of the knife until an opening is
made into the cavity of the ventricle. The knife-point must not be
allowed to slip through to damage the basal ganglia beneath. Into the
small opening thus made the brain-knife, held nearly horizontal,
with cutting edge upward, is introduced and the corpus callosum cut
forward until the anterior horn of the ventricle is reached. The
point of the knife is then passed into the horn and the knife-handle
raised and turned over forward, cutting slightly outward through
the frontal lobe to its apex and disclosing the anterior horn. The
knife is then reversed, held horizontally, with cutting edge upward,
and the corpus callosum cut posteriorly from the beginning of the
first cut, until the posterior horn is reached, when the point of
the knife is inserted into the horn and the knife turned over toward
the operator, cutting backward and somewhat outward through the
occipital lobe to its apex and opening up the posterior horn. (See
Fig. 28.) By this method the lateral ventricle is opened first at the
highest point of its cavity, and the fluid contents collect in the
anterior and posterior horns so that the amount and character can be
easily noted.
[Illustration: FIG. 29.—Section of brain. Ventricles opened.
Lines show direction of large longitudinal incisions through
brain-substance. (After Nauwerck.)]
The left hemisphere is now turned still more to the left, and with
the brain-knife a broad, smooth cut is made through it downward and
outward at an angle of 45°, reaching nearly to the cortical surface,
in a line connecting the cut through the frontal lobe with that
through the occipital and passing along the outer borders of the
corpus striatum. The left hemisphere is thus separated in the form of
a prism-shaped mass having a convex under surface. (See Fig. 29.) The
severed hemisphere falls back by the force of its own weight and the
flat cut-surface of the cerebrum is then bisected by a cut made at
right angles to it, from before backward, and extending nearly to the
cortical surface. (See Fig. 29.) In the case of both of these large
incisions of the hemisphere the severed parts are left connected by
a small portion of cortical tissue and the pia. The knife should be
perfectly dry and clean while making these cuts, and the cut surfaces
should not be touched with the fingers or knife-blade, or wet with
water, until they have been carefully inspected. Other straight
parallel cuts may be made through the brain substance toward the
cortex, the severed portions being left connected by the pia so as to
permit future orientation.
The right lateral ventricle is now opened. The four fingers of the
left hand are placed outside and beneath the right hemisphere with
the thumb on the median surface, gently raising the hemisphere toward
the left, taking care to see that the corpus callosum is not pulled
over to the right of the median line. The knife is held in the right
hand beneath the left one. The right ventricle is then opened in the
same way as the left, beginning in the middle of the corpus callosum
near to the gyrus cinguli, and opening first the anterior horn and
then the posterior. The operation is somewhat more difficult on the
right side than it is on the left, owing to the lack of tension
in the cut corpus callosum, so that greater care must be taken to
avoid injuring the floor of the ventricle. After the opening of the
ventricle the right hemisphere is cut by long parallel incisions made
in the same way as on the left side. (See Fig. 29.)
Some prosectors in opening the right ventricle prefer to turn the
board around so that the frontal lobe points to the operator.
The right hemisphere is then held in the left hand and the right
ventricle opened just as if it were the left ventricle, except
that the posterior horn is opened before the anterior. The method
given above can be just as easily learned, and time is saved by not
turning the board around twice, as is necessary in the latter case.
After the right ventricle has been opened the corpus callosum and
fornix are raised by the thumb and index-finger of the left hand,
putting the septum pellucidum on the stretch. The narrow brain-knife
is then introduced through the interventricular foramen from the
right, its blade flat, with cutting edge directed forward and upward,
and the fornix and the corpus callosum are cut anteriorly, exposing
the cavity of the septum pellucidum. To expose the third ventricle,
the corpus callosum, septum pellucidum and fornix are then lifted up
and laid back from the velum chorioides. The tela chorioidea is then,
with the chorioid plexus of the third ventricle, pulled backward from
over the pineal body and the corpora quadrigemina, care being taken
not to tear away the pineal body. The veins entering the tela from
the great ganglia are cut with the point of the knife. The right
descending posterior pillar or crus of the fornix is then lifted with
the thumb and index-finger of the left hand, the brain-knife on the
flat side with cutting edge to the right is introduced beneath it,
and the crus is cut toward the right. The corpus callosum, fornix and
tela are then turned over to the left (see Fig. 29), fully exposing
the pineal body and the corpora quadrigemina.
The cerebellum and medulla are now supported by the index-finger
of the left hand placed beneath the latter; while the brain-knife
is held nearly horizontally in the right, and a deep sagittal cut
is made into the vermis exactly in the median line so as to make
a small opening into the fourth ventricle. The point of the knife
with cutting edge upward is then introduced into this opening and
the incision through the vermis increased anteriorly and posteriorly
until the two cerebellar hemispheres fall apart and the fourth
ventricle is wholly opened. The point of the knife, with cutting
edge upward may then be introduced into the posterior opening of the
aqueduct and the latter opened to the third ventricle, the pineal
body being removed before the cut through the roof of the aqueduct
is made. In the Virchow method the corpora quadrigemina and the
vermiform portion of the cerebellum are sectioned in the median line
by a cut opening up both aqueduct and the fourth ventricle. Other
prosectors open the aqueduct from the third ventricle toward the
fourth. The left cerebellar hemisphere is now cut through in the line
of the middle branch of the arbor vitæ, exposing the dentate nucleus.
Each half of the hemisphere is again bisected by a cut made at right
angles to the surfaces exposed by the first cut. The right cerebellar
hemisphere is then similarly sectioned.
The section of the brain now shows all of the ventricles and their
relations, as well as the condition of a large part of cerebral
and cerebellar brain-substance. (See Fig. 29.) All cut portions
are connected with each other and it is possible to fix the entire
brain as it now stands and later find no difficulty in topographic
orientation. There still remains, however, the demonstration of the
conditions in the basal ganglia, pons, medulla, etc. These structures
are best shown by transverse cuts made across the entire brain as
it lies after the opening of the ventricles. The hemispheres may be
cut singly, but it is better to cut both of them at the same time,
using a dry blade and drawing the knife from left to right, making
identical cuts on the two sides, that the histologic features may
be compared. The transverse cuts may be made in the same region as
recommended in the method of Pitres (see below), or they may be made
closer together. As the cuts are made the sections are separated from
each other by the knife-blade and the cut surfaces examined. After
the cerebrum has been cut transversely in this way the peduncles,
pons, medulla and cervical cord are elevated on the index-finger of
the left hand and also sectioned transversely and the cut surfaces
examined. If the index-finger be placed beneath the medulla parallel
with its long axis, and medulla and pons raised up the cerebellar
lobes fall to the side out of the way. All transverse cuts are
made from left to right and so deep that only a small portion of
brain-tissue, or the basal meninges hold the parts together for
future orientation. The brain is now completely sectioned, with
all parts preserved and capable of being restored to their normal
relations. The parts may be re-assembled and the entire brain put
into the fixing fluid, when it is desirable to save the entire organ
for microscopic study.
[Illustration: FIG. 30.—Method of Pitres. _1, Sectio præ-frontalis_;
_2, Sectio pediculo-frontalis_; _3, Sectio frontalis_: _4,
Sectio parietalis_; _5, Sectio pediculo-parietalis_: _6, Sectio
occipitalis._]
=Other Methods of Opening Brain.= For the demonstration of large
localized pathologic conditions the brain may be opened by a
very simple method of transverse or sagittal incisions extending
entirely through the organ. The broad-bladed brain-knife should
be used and the blade should be wet. The cuts should be made
symmetrically on the two sides and with due reference to anatomic
landmarks. They may be made either from the convexity or from the
basal side.
The method of =Pitres= (see Fig. 30) is also employed for the same
purpose. After the inspection of the meninges and basal vessels
and opening of lateral ventricles, the brain is divided into three
parts, consisting of the two hemispheres and one part made up
of the cerebellum, pons and medulla. The anterior ends of the
cerebral peduncles are cut transversely in front of the corpora
quadrigemina, and the hemispheres are then separated by a sagittal
median incision through the corpus callosum, septum pellucidum,
commissure of third ventricle, substantia perforata posterior,
tuber cinereum and infundibulum, the optic chiasm and neighboring
optic tract having first been removed. The hemispheres are then cut
as follows: The hemisphere is laid upon its median surface with
the occipital lobe toward the operator. The four fingers of the
left hand are then put into the central fissure and six parallel
transverse cuts (see Fig. 30) are made through the hemisphere with
a dry brain-knife, as follows:
1. _Sectio praefrontalis_, through the frontal lobe about 5 cm. in
front of and parallel to the central fissure, exposing the cortex
and medulla of the three frontal convolutions, gyrus orbitalis, and
the convolutions of the median surface of the frontal lobe.
2. _Sectio pediculo-frontalis_, through the “foot” of the frontal
convolutions, exposing the three frontal convolutions, anterior
end of the island of Reil, gyrus orbitalis, corpus callosum, head
of caudate nucleus, anterior portion of lentiform nucleus and
lenticular striated portion of the internal capsule.
3. _Sectio frontalis_, through the anterior central convolution,
showing the anterior central convolution, island of Reil, the
temporal convolutions, corpus callosum, tail of caudate nucleus,
the optic thalamus, middle portion of lentiform nucleus, the
anterior portion of the lenticular part of the internal capsule,
the external capsule and claustrum.
4. _Sectio parietalis_, through the posterior central convolution,
showing the same, the island of Reil, temporal convolutions, corpus
callosum, tail of caudate nucleus, posterior end of optic thalamus
and lentiform nucleus, posterior end of the lenticular-optic part
of internal capsule, the external capsule and the claustrum.
5. _Sectio pediculo-parietalis_, through the foot of the parietal
convolution, 3 cm. posterior to the fissure of Rolando, showing
superior and inferior parietal lobules, temporal convolutions,
corpus callosum, extreme posterior portion of optic thalamus and
tail of caudate nucleus.
6. _Sectio occipitalis_, about 1 cm. in front of the
parieto-occipital sulcus, showing cortex and medulla of occipital
lobe.
After the third cut the fingers of the left hand are taken out of
the central fissure. The sections of brain as they are cut are left
lying in their order with the posterior face of the cut upward. The
same incisions are then made in the other hemisphere and the two
series of sections compared. The cerebellum, pons and medulla are
then examined as described above.
=Section of Brain in Skull.= When the skull-cap is removed by a
circular saw-cut the brain may be cut through with the saw at the
same time; or, after the skull-cap and dura have been removed, the
upper portion of the hemispheres may be sliced off by a horizontal
cut made at the level of the saw-cut. The portions removed are
examined further by sagittal cuts. The lateral ventricles are then
examined in the skull, and the remaining portion of the brain
either cut transversely _in situ_ or removed and sectioned outside
of the cranium. This method is mentioned to be condemned.
For special neuropathologic studies a number of methods have been
advised, the main purpose of which has been to preserve intact
parts of the brain having definite anatomic relationships so that
lesions may be studied by means of serial sections of the entire
system involved. The methods of =Déjerine= and =Meynert= are
employed for this purpose.
_Method of Déjerine._ After a careful examination of the cortical
surface for the presence of lesions, and of the inferior
surfaces of the crura for secondary degenerations, the pons is
cut horizontally in a plane parallel with the inferior surface
of the hemispheres and passing just above the great root of the
trifacial. The brain is thus divided into two portions, one
consisting of the two peduncles and superior portion of the
pons, the other containing the remaining portion of the pons,
the cerebellum and the medulla. The cut surfaces of the pons are
examined for evidences of degeneration in the pyramidal tracts,
and the hemispheres are separated after it has been determined
in which one the lesion is located. If the lesion is found to
be central the degenerations of importance will be found in the
tracts of the internal capsule and in the region of the tegmentum.
The hemispheres are then opened by horizontal incisions passing
through the superior third of the optic thalamus. If the lesion
is cortical the hemispheres are divided into three segments by
two transverse vertical incisions, one passing just posterior to
the splenium of the corpus callosum, the other just anterior to
the knee. The posterior segment consists of the occipital lobe
and part of the parietal; the central one contains the regions
adjacent to the fissure of Rolando, the middle portion of the
temporal convolutions, the basal ganglia, the cerebral peduncle and
corresponding portion of the pons; the anterior segment consists of
the forepart of the frontal lobe. The segments are then fixed and
hardened and cut on a brain-microtome. The anterior and posterior
segments are sectioned vertically transversely, the central segment
is cut horizontally. By this method cortical lesions may be
accurately located, and the entire course of degenerating fibres
followed out.
_Method of Meynert._ This method aims to separate all portions
of the brain possessing differences of internal structure that
may be taken as indicating difference in significance, and to
compare them by weight. The natural furrows or fissures are used as
incision-lines, and three series of dissections are made, the first
of which, here given, is the separation of the brain into three
parts, the brain-mantle, brain-stem and cerebellum. The brain, with
pia still intact, is placed base upward, with cerebellum toward
operator. The arachnoid covering the fissure of Sylvius is cut
or torn, and the island exposed. The three furrows bounding it
must be plainly seen. The pia between the optic tract and uncus,
as well as that in the middle portion of the transverse fissure
between corpora quadrigemina and corpus callosum, is cut, and the
under surface of the splenium of the corpus callosum is freed from
membranous adhesions to the corpora quadrigemina and the pineal
body. When the medulla with pons and cerebellum is now elevated the
transverse fissure gapes open, and permits a free look into the
lateral ventricles.
The brain-mantle on both sides is now separated from the brain-stem
at the basal portion of its frontal end. The knife, held nearly
horizontal, is introduced into the fissure between the posterior
border of the orbital convolutions and the anterior border of the
lamina perforata anterior; and a cut is made slightly downward, not
quite parallel with the orbital surface, about 3 cm. anteriorly
in the medulla of the orbital convolutions, around the under
surface of the head of the corpus striatum. The temporal ends of
the brain-mantle are then cut through, the knife moving externally
between the temporal lobe and the island, inside between the
descending horn of the lateral ventricle and the optic tract. As
soon as the inner cut has been extended beyond the outer corpus
geniculatum on both sides, the knife is turned downward at right
angles, in a curving stroke, to cut through the junction of the
occipital lobes with the stem, internally along the portion of the
corpus striatum adjacent to the optic thalamus, externally between
the junction of the first temporal convolution with the operculum
on one side, and the posterior end of the island on the other.
When this has been done on both sides the blade of the knife is
turned forward in a semicircular stroke. The posterior end of the
brain-stem is gradually lifted up out of the mantle by elevating
the cerebellum and medulla oblongata. The upper peduncle of the
arch of the brain-mantle along the upper border of the island and
the outer border of the corpus striatum is severed from the stem
as far as the anterior end of the upper border of the island,
which bends downward into the anterior border. The peduncle of
the fornix with the pedicle of the septum and the lamina of the
knee of the corpus callosum are severed close above the anterior
commissure, and the knife following the anterior border of the
island is carried downward from the head of the corpus striatum.
The remaining connections between the frontal lobes and stem are
put on a moderate stretch and the incision is completed by bringing
the knife back into the first cut made from the opposite direction
parallel with the orbital surface over the upper surface of the
stem. The three arms of the cerebellum are then severed and the
brain-stem, consisting of the island of Reil, the basal ganglia,
crura, pons, medulla and cerebellum, is completely freed and lifted
out of the mantle.
A combination of the Meynert and Virchow methods is used by many.
The lateral ventricles are opened and an incision made along
the fornix into the descending horn. The stem-ganglia are then
cut out and brain-mantle and stem separated. The hemispheres
are then cut by frontal sections made from the anterior end as
far as the central convolutions. From the central convolutions
backward horizontal sections are then made; the series of sections
are numbered in order and fixed and hardened for microscopic
examination.
It is evident that the section of the brain can be modified to meet
the individual requirements, according to the nature, location and
extent of the lesion and the character of the study to be made of
the latter. The brain may be fixed and hardened either before or
after sectioning.
[Illustration: FIG. 31.—Base of cranium, after removal of brain.
(After Nauwerck.)]
4. =Examination of Base of Cranium.= After the section of the brain
the prosector returns to the head and examines the basal sinuses
(see Fig. 31) by cutting them open with the point of the brain-knife
or by using small shears and forceps. When cut open the walls of
the sinuses should be laid back for inspection. Ordinarily the
_sinus transversus_, _sinus petrosus superior_, _sinus petrosus
inferior_, _sinus cavernosus_ and the _sinus sigmoideus_ are opened.
The last-named is given especial attention because of the frequency
of thrombosis and its involvement from carious conditions of the
neighboring portions of the temporal bone. In purulent mastoid
inflammation the infection often reaches the meninges by this
route. The _carotids_ and the _exits of the cranial nerves_ (see
Fig. 31) are then examined. The _hypophysis_ (see Fig. 31) is
then removed by making semicircular cuts through the overlying dura
mater around the gland and then lifting it out of the sella. This
is best accomplished by means of the small scalpel and forceps. It
is sometimes necessary to chisel away the overhanging bony parts in
order to remove the hypophysis without damaging it. When removed it
may be sectioned by a sagittal cut made either to the left or right
of the pedicle.
[Illustration: FIG. 32.—Incisions for examination of orbit, ear and
nose. x y marks line of incision for exposing nasal tract according
to method of Harke.]
The basal dura is next removed by means of forceps and knife, chisel
or dura-forceps. The bones are then carefully examined for fractures,
caries, etc. Particularly in cases of middle-ear disease, meningitis,
etc., should the dura be removed from the temporal bone and the
latter carefully examined.
5. =Examination of the Orbit.= When the eye-ball cannot be enucleated
anteriorly the orbit may be opened by removing its roof with small
bone-chisel and hammer according to the lines of incision given
in Fig. 32. The dura is, of course, first removed. The bony plate
covering the orbit is thin and easily splintered, so that the chisel
should be very carefully used. The pieces of bone should be removed
with the forceps. The optic foramen and the superior orbital fissure
may be opened at the same time. After the removal of the roof of
the orbit the orbital fat and muscles are dissected away until the
optic nerve and eye-ball are exposed. The sclera is then seized with
the forceps and the eye-ball pulled back and cut quickly around its
equator with sharp shears or scalpel. The head should be held so that
the eye looks downward, so that when cut the vitreous humor falls
out, leaving the retina well spread out over the posterior half of
the bulb. If the retina is thrown into folds it may be straightened
by blowing into it or filling it with water. After the retina has
been examined it may be washed off from the chorioid, leaving it
attached around the papilla. The pigment-layer remains attached to
the chorioid, and when the latter is examined for the presence of
tubercles it should be removed. When removed for microscopic studies
the eye should be placed at once in a suitable fixing fluid.
[Illustration:
FIG. 33.—Tympanic cavity after removal of tegmen. an, mastoid
antrum; ha, hammer-anvil articulation; s, tendon of musc. tens.
tymp.; t. musc. tens. tymp.; g, genu of facial nerve; a, auditory
nerve; f, facial nerve; n, nerv. petros. superfic. major. (After
Politzer.)
]
6. =Examination of the Ear.= The dura is removed from over the
temporal bone and the _tegmen tympani_ cut off with chisel and hammer
as indicated in Fig. 32, _1_, _2_, _3_, _4_, _5_, thus exposing
the tympanic cavity as shown in Fig. 33. When the tegmen tympani
is very hard and compact the hammer and chisel are used to remove
that portion of the tegmen lying laterally to the eminence formed by
the upper semicircular canals. As the ear-ossicles lie immediately
beneath the roof of the tympanic cavity care should be taken not to
injure them with the chisel, and this can be best accomplished by
beginning to chisel so far posteriorly that the tegmen of the mastoid
antrum is first cut away, and from this opening the cut is extended
carefully until the tegmen tympani is removed. When the tegmen of
the tympanic cavity is very thin and porcelain-like, as is often the
case, it may be most quickly and expediently removed by means of
the pointed bone-forceps. A complete view of the tympanic cavity is
obtained by removing the coverings of the mastoid antrum posteriorly
and the bony canal anteriorly after first drawing out the musc.
tensor tymp. from the canal. The mastoid process may be opened with
the saw or with chisel and hammer. The labyrinth may be exposed by
cutting anteriorly with the chisel held horizontally in such a way
as to spring off the upper half of the bony labyrinth, exposing the
vestibule and cochlea. The superior and posterior semicircular canals
come off, and from their open spaces the membranous semicircular
canals can be lifted out with the forceps and then examined in water.
The external auditory canal may be opened and the outer surface of
the ear-drum examined by carrying the anterior flap of the scalp
downward and forward until the entrance into the bony canal is
reached. The external ear is then cut off close to the bone, using
slight pressure so as to avoid tearing out the lining of the canal
or injuring the tympanum. The anterior bony wall of the canal, and
a part of the lower, are then carefully chiseled away until the
membrane is exposed. Any bony projections on the thicker upper or
lower wall of the canal may be trimmed off to give an unobstructed
view. When pathologic changes are present upon any part of the wall
of the canal the latter should be opened from the other side so as to
expose the condition fully.
For the _removal of the auditory apparatus and its examination
outside of the body_ a number of methods are advised. The temporal
bone may be resected by extending the scalp-incision half-way down
the neck along the anterior edge of the trapezius. The anterior flap
with the external ear is carried forward as far as the middle of
the zygoma and below to the angle of the lower jaw. The posterior
flap is carried backward to the middle of the occipital bone. All
soft parts are cut as closely to the bone as possible. A saw-cut
is now made across the posterior cranial fossa, beginning just
behind the mastoid process and extending to the median line of the
clivus half-way between the anterior border of the foramen magnum
and the sella turcica. The sinus sigmoideus is thus included in
the part to be removed. A second saw-cut is then made across the
middle cranial fossa, in a line nearly parallel with the transverse
diameter of the skull, cutting the middle of the zygomatic arch,
the anterior portion of the squama, the great wing of the sphenoid
and the pterygoid process, to the tuberculum sellæ. The median ends
of the two saw-cuts are then united by a chisel-cut in the median
line of the sella and clivus. All bony connections remaining are
then cut with the chisel. The soft parts are then cut, beginning
with those attached to the mastoid process; the loosened bone is
then raised and pulled anteriorly so that the posterior capsule of
the maxillary joint can be cut and the jaw-bone disarticulated. All
remaining soft parts of neck and nasopharynx are now cut and the
temporal bone with the complete ear-apparatus and neighboring portion
of nasopharynx is removed. When both temporal bones are removed the
saw-cuts should not be carried to the median line, but should stop
at the borders of clivus and sella, and then united on each side by
sagittal chisel-cuts made along these borders, leaving the clivus
and sella as a firm connecting bridge between anterior and posterior
portions of the skull. The resected bone may now be examined by means
of a saw-cut made perpendicularly through the apex of the eminence
of the superior semicircular canals and parallel with the crista of
the petrous bone. The tegmen should be removed before the saw-cut is
made and the covering of the tympanic cavity and the outer wall of
the external auditory canal also removed. The tendon of the tensor
tympani is cut and the anvil-stapes articulation severed so that the
saw-blade passes between the drum, hammer and anvil on one side and
the head of the stapes on the other without damaging or displacing
the ossicles. This can be accomplished by pushing outward the drum
with hammer and anvil so that the saw-blade can pass between the
anvil and the head of the stapes. The bone should be held in a vise
and a fret-saw used. On one side of the cut will be seen the drum,
hammer, anvil and anterior portion of the mastoid cells; on the other
the stapes, wall of the labyrinth and posterior half of the mastoid
cells. The Eustachian tube may be easily worked out from the tympanic
cavity or from the pharyngeal opening.
A sagittal section of the middle ear may be made, giving pictures as
shown in Figs. 34, 35. The temporal bone is resected as above, the
tegmen tympani removed and the bony covering of the Eustachian tube
removed with hammer and chisel until the tube is exposed from its
pharyngeal opening to the isthmus. The temporal bone is then divided
into an outer and an inner half by cutting the roof of the tube with
fine straight scissors from the pharyngeal mouth to the bony portion
and then cutting the membranous floor of the canal likewise. The
bony canal, the floor of the tympanic cavity and the mastoid process
are then cut sagittally with a fine fret-saw, passing between the
lower annular segment of the sulcus tympani and the inner wall of
the tympanic cavity. By altering the direction of the saw-cut the
Eustachian tube may be removed in connection with either outer or
inner portion of the temporal bone.
[Illustration:
FIG. 34.—Sagittal section through left middle ear, outer half.
an, mastoid antrum; n, niche of the hammer-anvil body; op, mouth
of Eustachian tube; te, Eustachian tube; it, isthmus of tube; mt,
tympanum; ww, mastoid cells. (After Politzer.)
]
[Illustration:
FIG. 35.—Sagittal section of left middle ear, inner half. op, mouth
of Eustachian tube; te, Eustachian tube; tp, musc. tensor tymp.;
p, promontory; st, stapes; sp, musc. staped; f, facial nerve; an,
mastoid antrum; ww, mastoid cells; ot, ost. tymp. tubæ; u, lower
wall of tympanic cavity. (After Politzer.)
]
Other methods of examining the ear are shown in Fig. 32. The
tympanic cavity and labyrinth may be removed intact by cutting
with a chisel having a cutting edge 3 cm. broad, in the lines _1_,
_2_, _3_, _4_, _5_, as shown in Fig. 32. The cut _1_ is made with
the chisel held nearly horizontal and parallel with the base of
the skull. Cuts _2_, _3_, _4_ and _5_ are made vertically. Great
care must be taken not to splinter the bone. A small chisel can be
used to connect the ends of the cuts. Soft parts are cut away with
the chisel. An elevator is then introduced into cuts _1_ and _2_
and the part lifted out by cutting the remaining soft parts and
the articulation of the lower jaw. The portion removed contains
the inner section of the external auditory canal, tympanic cavity,
ear-drum, a portion of the mastoid cells, the entire labyrinth,
auditory and facial nerves.
_Politzer’s method_ of removing the auditory apparatus in
connection with the nasopharynx and the Eustachian tubes is
also shown in Fig. 32 by the lines _a_, _b_, _c_, _d_, _e_. Two
drill-holes are made in the floor of the anterior fossa at _a_, 1
cm. to the right and to the left of the crista galli, extending
vertically through the nasal cavity to the under surface of the
hard palate. A fine key-hole saw is then introduced through the
right drill-hole, and the base of the skull is then sawed in
the lines _ab_, _bc_, _cd_ and _de_ as indicated in Fig. 32.
Symmetrical cuts are then made on the left side following the same
lines and the two drill-holes connected by a transverse saw-cut.
Any remaining bony connections are then cut with a wide chisel.
In order to cut the bony bridges in the region of the nasopharynx
it may be necessary anteriorly to use the Hey-saw through the
mouth-cavity as well as from the cranial side. To facilitate the
removal of the loosened portion two parallel saw-cuts are made in
the occipital bone 3 cm. to the left and right of the median line,
extending nearly to the posterior edge of the foramen magnum and
connected below by a slightly rounded cut as shown in Fig. 32. A
long-armed chisel can now be used conveniently through the opening
thus made, for horizontal manipulations upon the base of the
skull, while the loosened portion of the base is lifted with the
bone-forceps or nippers set in the posterior saw-cut _e_ and the
_sella turcica_. As the bone is raised the posterior and lateral
pharyngeal walls are cut with the cartilage-knife, the posterior
wall of the capsule of the maxillary articulation on both sides
severed, the jaw disarticulated, and all muscular and membranous
connections cut, until the preparation is completely freed. The
auditory apparatus and the Eustachian tubes can now be examined by
any one of the methods given above.
7. =Examination of Nose and Neighboring Cavities.= Of all the methods
advised for the examination of the nasal cavities the method of
_Harke_ (Fig. 32) is the easiest and gives the best views of the
nasal tract. After the brain has been removed the scalp incision
is carried downward to the middle of the neck on both sides,
following the anterior edge of the trapezius, as for the removal
of the temporal bone. The anterior flap is then carried forward
as far as the bridge of the nose and the edges of the orbits, and
the flap pulled down over the face. The posterior flap is carried
back as far as the upper cervical vertebræ, removing the muscles
with the scalp. The head of the cadaver is now raised and firmly
held by an assistant or clamped in a head-holder; and with the
large meat-saw the occipital bone is sawed through in the median
line, cutting first the squama and then the clivus. The saw is then
set anteriorly into the frontal bone, to the left or right of the
septum, in order not to injure the septum narium. (Fig. 32.) The
sawing then proceeds through the sella turcica, body of the sphenoid,
ethmoid and frontal bones until the base of the skull is divided
into halves. The cartilage-knife is then introduced through the
foramen magnum and the basal ligaments cut. The right and left sides
of the skull posteriorly are then taken in the two hands and with
a quick, powerful tug forced outward until the nasal bones, hard
palate and alveolar processes break apart. The two halves of the
base of the skull then open like a book, turning on an axis, running
through the inferior maxillary articulation and the occipito-atloid
ligaments. If there is too great resistance in the region of the
foramen magnum, the anterior and posterior arches of the atlas may
be cut with a chisel. The sphenoidal sinus, septum narium, frontal
sinus and the nasal cavity on one side of the septum with the
nasopharynx are thus exposed, and their walls and contents may now be
examined. Material for bacteriologic examination should be secured
before further cutting is done. The septum may then be removed with
forceps and scissors, the nasal cavity on the other side examined,
the nasopharynx inspected, and the antrums opened with small
bone-forceps. After the examination is complete the halves of the
base are brought together and fastened with copper wire anteriorly
and posteriorly, taking care that the anterior wire will not be
visible through the skin of the forehead.
8. =Examination of Face.= When the anterior flap of the scalp is
carried down to the edge of the orbits and half-way across the lower
jaw as advised above for the removal of the temporal bone, the
_parotid_ region may be examined. The _upper_ and _lower maxillary
bones_ are best examined after the removal of the neck-organs. A
transverse incision is made in the skin of the neck low enough to
be concealed by the clothing, and connecting with the longitudinal
scalp-incisions. The facial flap is then dissected upward with
great care as far as the infraorbital edges, exposing the maxillary
bones, from which the soft parts must be so carefully removed that
restoration of the face can be made. For the examination of the
anterior nasal-cavities the upper lip must be separated from the
bones.
II. POINTS TO BE NOTED IN SECTION OF HEAD.
1. =Scalp.= Note wounds, hemorrhages, inflammations, scars,
parasites, neoplasms, number and location of bleeding-points on
section, color of different portions, adhesions to periosteum or
cranial bones, etc. Most common pathologic conditions are wounds,
hemorrhages, wens, lipoma, squamous-celled carcinoma, syphilis,
tuberculosis, favus, pediculi, tricophytia, angioma and round- and
spindle-celled sarcomata. The temporal muscles should be examined
for hemorrhages, œdema, purulent inflammations and trichinæ. The
postmortem hypostasis of the back of the head should not be regarded
as pathologic.
2. =Periosteum.= Subperiosteal hemorrhages, purulent infiltrations,
adhesions, indurations, chronic inflammation with new-formation of
bone, and neoplasms are the most common pathologic conditions.
3. =Skull-Cap.= The measurements (circumference, 49-65 cms.; long.
diam., 18 cms.; trans. diam., 13-15 cms.), form, asymmetry, character
of surface (normally smooth and moist), color of cranial bones,
character of sutures and fontanels (easily traced?), supernumerary
sutures and bones, consistence (softened in craniotabes, purulent
inflammations, syphilis, neoplasm), new-formations of bone,
perforations (syphilis, neoplasms, Pacchionian granulations, purulent
inflammation), elevations, depressions, fractures, areas of erosion
or absorption, thickenings of external surface (crater-like due to
organized cephalhæmatoma, chronic periostitis, neoplasm or gumma),
radiating scars or indurations (syphilis), red, soft, spongy
thickenings (rachitis). The temporal and frontal regions are most
frequently the seat of syphilitic (corona veneris) and rachitic
changes (frontal and temporal bosses, square forehead, etc.) Note
ease or difficulty in sawing, relation of external table, diploë and
inner table, measure thickest and thinnest portions, character and
amount of diploë, weight of skull-cap (heavy in sclerosis, light
in atrophy), dural adhesions, examine by transmitted light (color,
blood-content, presence of pus in diploë may be shown by greenish
or yellow color), smooth or rough inner table, erosions (rough,
more or less reddened), grooves of meningeal vessels, Pacchionian
erosions, hyperostosis, exostosis, osteoma, osteophytes (not uncommon
in pregnant women, also in hydrocephalus, acromegaly), atrophy (old
age, craniotabes, hydrocephalus), sclerosis (syphilis). In marked
cachexias (cancer of stomach) the inner table often shows a high
degree of erosion and atrophy.
4. =Dura.= Collections of pus may be found between skull-cap and
dura in purulent inflammations of scalp or diploë. Rupture of middle
meningeal artery or its branches, with or without fracture of the
skull, gives rise to hemorrhagic extravasations in same location. Old
hemorrhages may be partly organized. In young infants the dura is
adherent to the skull-cap and cannot be separated. In youth and adult
life it is adherent only along the longitudinal sinus and about the
blood-vessels; in old age it becomes more adherent. Extent, location
and strength of adhesions should be noted. The normal dura should
be grayish-red, smooth, symmetrically stretched, so that a small
fold only can be taken up by the fingers in the frontal region, and
just translucent enough to show the outlines of the convolutions
and the pial vessels. An increased tension is caused by exudates,
tumor, abscess, hydrocephalus, hemorrhage, congestion, œdema, etc.
Diminished tension occurs in atrophy of the brain, especially marked
in the frontal region, where the dura may be wrinkled and loose.
Perforations of the dura by Pacchionian bodies are very common along
the longitudinal sinus in late life, and should not be regarded as
pathologic. Small osteomata are not uncommon in the same place and
in the falx; they may be very numerous in acromegaly, late syphilis
and cachectic conditions. Changes in the color of the surface of the
dura may be due to hemorrhage, purulent or syphilitic inflammation,
old thickenings, etc. Thickenings are more easily seen from the
inside surface of the dura; they appear as hard, tendon-like, opaque
areas. The normal inner surface is smooth, grayish and moist-shining.
In pachymeningitis it may be dry, dull, roughened, and covered with
blood, pus or fibrin. The most frequent pathologic condition on the
inside of the dura is the organizing or encapsulated hemorrhage
(pachymeningitis hæmorrhagica chronica, hæmatoma duræ), so common
in chronic alcoholics. Miliary tubercles of the dura are common in
meningeal tuberculosis. A gummatous pachymeningitis is not infrequent
in late syphilis. Pachymeningitis fibrosa is also common in old
syphilitics. Actinomycosis occurs in connection with actinomycotic
encephalitis. The primary tumors of the dura are fibroma, osteoma,
fibro-endothelial tumors (psammoma) and angiosarcoma, etc. Secondary
carcinoma or sarcoma is rare.
5. =Longitudinal Sinus.= Character of walls and contents. Thrombosis,
with purulent or gangrenous inflammation, is the most important
condition. Note mouths of superior cerebral veins.
6. =Meningeal Vessels.= Note grooves, rupture, thrombosis,
hemorrhage, infection, amount of blood, symmetry of distribution,
etc. Traumatic rupture of middle meningeal is the most important
condition.
7. =Basal Vessels.= Anomalies in size and distribution, thickness
and character of vessel-walls (sclerosis, atheroma, aneurism,
calcification). Thrombosis, embolism, aneurism, sclerosis, atheroma,
calcification, obliterative endarteritis due to syphilis, are the
most common conditions. The changes in the middle cerebral arteries
are of especial importance in cases of apoplexy, softening, etc.
8. =Inner Meninges.= The arachnoid, subarachnoid space and pia are
usually considered together. The arachnoid bridges over the sulci,
the pia dipping down following the brain substance. The contents
of the subarachnoideal space are best seen, therefore, between the
convolutions. The inner meninges are gray, delicate and transparent;
the pial veins show plainly, the arteries are empty and lie deeper,
while the more superficial veins are uniformly filled with blood.
Sclerotic arteries run more superficially and are more prominent.
The removal of the skull-cap often gives rise to the presence of
air-bubbles in the pial vessels, and this should not be mistaken
for any pathologic condition. Hypostasis likewise should not be
regarded as a pathologic condition. Normally the membranes are
moist; in increased intracranial pressure (tumors, hydrocephalus,
hemorrhages) they are dry and dull. Inflammation is shown by a loss
of transparency of the membrane and by the presence of exudate in
the subarachnoideal space. Old thickenings are white and opaque. The
amount of fluid in the subarachnoideal space may be so great as to
cause the arachnoid to bulge out over the sulci. Note character of
exudate (purulent, fibrinous, serous or hemorrhagic). In purulent
meningitis greenish-yellow or yellowish-white collections of
thin pus are found in the meshes of the arachnoid; in fibrinous
inflammation the exudate is grayish or milky white. The normal fluid
(cerebrospinal) of the subarachnoideal space is clear and small in
amount. It is increased in œdema and congestion, as well as in serous
inflammations. In inflammatory conditions the membranes are dull and
cloudy and the fluid more or less turbid. Pathologic adhesions may
exist between dura and inner meninges, and between the latter and
the brain-substance. In the latter case the meninges do not strip
easily, but pull off portions of the cortex. Over tumors, gummata,
areas of softening, the meninges may be so adherent that they cannot
be separated from each other. In old syphilitics, alcoholics,
cachexias of old age, etc., the pia may be thickened, white and
opaque (leptomeningitis chronica fibrosa). Aneurisms of the pia
vessels are of great importance in cases of meningeal hemorrhage.
They may be very small (size of pea) and often are found only after
very careful search. Atheroma, infective emboli, etc., are also
causes of meningeal hemorrhage. Meningeal tubercles are very common
and often hard to recognize. They are usually best seen over the
basal meninges. Often they can be demonstrated by stripping off the
meninges and floating the membrane in mercuric chloride or formalin
fixing-fluids. After a few minutes’ fixation the tubercles appear as
minute grayish or opaque points, the membrane often appearing as if
sprinkled with fine sand or powder. The Pacchionian bodies of the
arachnoid must not be mistaken for tubercles. They are grayish in
color, and most abundant along the longitudinal sinus. The meninges
over the two hemispheres should be compared as to transparency,
thickness, blood-content, amount of fluid in arachnoideal space, etc.
The most important pathologic conditions of the inner meninges are
anæmia, hyperæmia, stasis (asphyxia), œdema, hemorrhages (stasis,
anthrax, aneurism, atheroma, infective emboli), serous, purulent
and fibrinous inflammation (pyogenic cocci, bacillus pneumoniæ,
pneumococcus, bac. coli, diplococcus intracellularis), chronic
leptomeningitis (syphilis, alcoholism, toxæmia, etc.), tuberculosis,
syphilis (gummatous meningitis), blastomycosis, actinomycosis and
neoplasms. The last named are not common. Cholesteatoma, hæmangioma,
lymphangioma, endothelioma, fibroma, osteoma and lipoma represent
the benign tumors found here. Primary sarcoma is the most common
tumor, usually angiosarcoma, perithelioma, cylindroma, round-cell-,
spindle-cell- or myxosarcoma. Secondary sarcoma and carcinoma occur.
Animal parasites are cysticercus and echinococcus.
8. =Cerebrum.= Weight of brain as a whole 1,200-1,400 grms. (15-50th
year). Cerebrum averages 1,039 grms. in the female, 1,155 grms. in
the male. A weight of 1,100 grms. may be taken as the minimum normal,
and 1,700 grms. as the maximum for the brain as a whole. The relation
of the brain-weight to that of the body is 2-100. In old age there
is a loss of weight. Sagittal diameter 15-17 cm., transverse 14,
vertical 12.5 cm.
Examine the convexity, comparing hemispheres, noting convolutions
and sulci (size, number, symmetry, etc.) Atrophy of the gyri is
shown by increased width of sulci and the narrower, sharper gyral
apex. With increased intracerebral pressure the gyri are flattened
and broader, and the sulci smaller. Note color and consistence
of cortex, adhesions with pia, areas of fluctuation, induration,
depressions, yellow softening, recent and old hemorrhages, effects
of trauma, tumors, tubercles, gummata, etc. Examine median surfaces,
note arching of corpus callosum. On section of the brain note _color_
(pale in anæmia, red in capillary hyperæmia; hemorrhages, areas of
softening, tumors, tubercles, gummata, sclerotic areas, abscesses,
etc., all show color variation from the normal gray or white);
_consistence_ (soft in degeneration and abscess, hard in sclerosis),
_moisture_ (normally is moist-shining; moisture increased in œdema,
inflammation, abscesses, soft tumors, recent degenerations; dry in
old caseous tubercles and gummata, and in anæmia), _blood-content_
(number of bleeding-points, distinguish from punctate hemorrhages),
_character of cut surface_ (normally smooth, sclerotic areas,
abscesses and areas of softening are uneven and depressed, hard
tumors and sclerotic blood-vessels are elevated above the surface).
The absolute and relative size of cortex and medulla, and the
distinctness of the boundary between them, should be noted.
Hemorrhages may occur in any part of the brain, and may be large
or small. Rupture into a ventricle is always fatal. The large
hemorrhages are due to rupture of a diseased artery; small punctate
hemorrhages throughout cortex are usually embolic (fatty embolism).
Old hemorrhages are brownish in color (pigment). Areas of softening
are usually the result of embolism, thrombosis or sclerosis. They are
usually yellow, yellowish-white or brownish-yellow or red.
9. =Ventricles.= Contain about a teaspoonful of clear fluid. This
may become purulent, cloudy, hemorrhagic, fibrinous. Note size of
ventricles and horns. (Fluid increased and ventricles dilated in
hydrocephalus.) Character of ependyma normally gray-red, delicate;
may be pale or red, indurated, thickened, roughened (chronic
ependymitis), hemorrhagic, etc. Compare floors of lateral ventricles
as to symmetry (corpus striatum large in hemorrhages), color, etc.
Adhesions are found most frequently in posterior horns. A fine
granulation of the ependyma is caused by miliary tubercles. Large
solitary tubercles may be found in the ventricles. Do not mistake
postmortem softening of ependyma for pathologic changes. In the third
ventricle note the presence of any abnormal contents, character of
wall, symmetry of corpora quadrigemina, etc. Look for same changes in
fourth ventricle as in lateral. Lining is gray-white and delicate;
floor should be gray-white, firm, and show anatomic structures. Gray
sclerotic areas are often present in floor. Solitary tubercles,
tumors (glioma, neuroepithelioma, gliosarcoma, sarcoma), dermoids and
cysticercus-cysts may be found here. Examine aqueduct of Sylvius for
abnormal contents.
10. =Chorioid Plexus.= The tela chorioidea is normally delicate and
translucent. Note color (red, pale, cloudy), swelling, purulent
infiltration, condition of blood-vessels, tubercles, etc. Psammoma,
sarcoma, papillary epithelioma, carcinoma, fibroma, angioma,
cholesteatoma, cysticercus and echinococcus may be found in the tela
and plexus. Cysts due to œdema are very common, also aneurismal
dilatations of the vessels. In cases of hydrocephalus the veins of
Galen should be examined for thrombi or compression from without. In
acute hydrocephalus the plexus is deep red; hyperæmic, its vessels
distended with blood.
11. =Pineal Gland.= The most common pathologic findings are:
psammoma, adenoma, teratoma, sarcoma, formation of cysts (hydrops
cysticus glandulæ pinealis), hypertrophy, abscess (purulent
meningitis), metastatic tumors. In all cases of giantism especial
attention should be paid to the pineal gland as well as to the
hypophysis.
12. =Cerebral Ganglia.= Color, consistence, moisture, blood-content,
hemorrhage, degeneration, sclerosis.
13. =Peduncles.= As above.
14. =Cerebellum.= Cerebellar cortex is 2 mm. thick, grayish-red
in color. Note irregularities in thickness, color, consistence,
blood-content, moisture. Compare hemispheres. White substance
should be shining and moist. Abscesses, tubercles (solitary or
conglomerate), gummata and neoplasms are the most common pathologic
conditions.
15. =Pons.= Consistence firm normally. Note blood-content, relation
of white and gray stripes, hemorrhage, degenerations, cysts,
neoplasms, etc.
16. =Medulla.= Color grayish-white, consistence firm. Note
blood-content, hemorrhages, degenerations and cysts (syringomyelia).
17. =Hypophysis.= Cysts are common, also calcareous concretions.
Adenomatous hyperplasia is the most common tumor (acromegaly,
obesity). Carcinoma, sarcoma, lipoma and teratoma are rare. Gumma and
tubercle occasionally occur; even when the gland is wholly destroyed,
acromegaly does not result. Epithelial tumors of the infundibulum may
occur in association with hypoplasia of the genitals. In diseases
of the thyroid the condition of the hypophysis should be especially
considered.
18. =Basal Sinuses.= Note contents (marantic and infective thrombi),
especially in middle-ear disease and meningitis. Distinguish
postmortem clots from thrombi, the former being dark-red, soft and
moist, and are not adherent to the walls. The walls of the sinus
should be gray, delicate, and shining.
19. =Basal Dura.= Note same conditions as in dura covering convexity.
20. =Cranial Nerves.= Examine and trace to exits. Note atrophy,
degenerations, compression, indurations, thickenings, neoplasms
(neuroma), etc.
21. =Base of Skull.= After the removal of the basal dura the bones of
the base should be smooth and gray-yellowish-red in color. Look for
fractures, caries, roughened areas, exostoses, collections of pus,
hemorrhage, neoplasms, etc.
The most important pathologic conditions of the brain are congenital
defects or malformations (hydrocephalus, microcephalus, etc.),
anæmia, hyperæmia, œdema, hemorrhage (traumatic, spontaneous,
capillary, apoplexy), embolism, thrombosis, arteriosclerosis,
aneurism, anæmic infarction, encephalomalacia (white, yellow and
red softening), pigmented scars, atrophy, secondary degeneration,
encephalitis, (non-purulent, purulent, hemorrhagic, syphilitic,
metastatic, chronic), sclerosis (diffuse, disseminated, focal,
hypertrophic), tuberculosis, syphilis, actinomycosis, blastomycosis,
rabies, primary neoplasms (glioma, neuroglioma ganglionare,
angiosarcoma, spindle-cell sarcoma, polymorphous-cell sarcoma,
perithelioma, endothelioma, angioma, myxoma, fibroma, osteoma,
teratoma, lipoma), primary epithelial tumors of ventricles, pineal
gland and hypophysis (adenoma, cholesteatoma, papillary epithelioma,
carcinoma), metastatic tumors (all forms of carcinoma and sarcoma,
malignant chorio-epithelioma), cysts, parasites (cysticercus,
echinococcus) and traumatic lesions (commotio cerebri, contusio
cerebri, hemorrhage, red softening, puncture and shot-wounds,
infected wounds, traumatic abscess). Especial examination of the
brain should be made in all cases of acromegaly, epilepsy, cretinism,
congenital idiocy, degeneracy, criminal tendency, insanity, chorea,
caisson disease, locomotor ataxia, paralysis agitans, syringomyelia,
spastic paralysis, infantile paralysis, hereditary ataxia, rabies,
all forms of paralysis, motor or sensory disturbances and neuritis.
3. POINTS TO BE NOTED IN EXAMINATION OF EYE.
The fat-tissue in the orbits should be yellowish-white; from it the
red muscles and the white nerves should be easily distinguishable. On
section of the eye-ball the vitreous normally is clear and the retina
uniformly grayish-black and smooth. The most common and important
conditions to be looked for are phlegmonous inflammations, purulent
panophthalmitis, orbital hemorrhage, thrombosis of ophthalmic vein
and sinus cavernosus leading to pachy- and leptomeningitis, neoplasms
of orbit, wall of orbit, eye-ball or lachrymal gland (melanosarcoma,
glioma, gliosarcoma, neuroepithelioma, various forms of sarcoma,
angioma, lipoma, adenoma, carcinoma), affections of individual
muscles (myositis, atrophy), atrophy of optic nerve, choked disk,
retinitis, choroiditis, iritis, glaucoma, etc.
4. POINTS TO BE NOTED IN EXAMINATION OF EAR.
Note condition of scalp (hyperæmia, œdema, hemorrhage) about ear,
condition of external canal (dry, moist, character of contents),
condition of periosteum, particularly over the mastoid process
(normally grayish-red), condition of bone after removal of periosteum
(normally smooth). Inflammatory œdema, purulent infiltrations in the
soft parts, collections of pus beneath the periosteum, roughness
of bone beneath elevated periosteum, presence of pus or blood in
external auditory canal, perforations of drum, etc., should be noted.
Normally the drum should be grayish-white and shining. Note contents
of middle ear, Eustachian tube, condition of ossicles, mastoid cells
and bone. Lining of middle ear should be grayish-red and smooth; the
cut edges of bone should be uniformly grayish-red. When infiltrated
with pus they are brown or greenish. The mucous membrane is deep-red
or greenish in purulent inflammation; yellow, creamy pus, often of
very offensive odor, may be found in middle ear, Eustachian tube or
external canal. Note character of perforations; old ones have smooth
and thickened edges. The most important pathologic conditions are:
otitis media purulenta, inflammation of mastoid cells, caries of
mastoid process, sinus-thrombosis (leading to meningitis or pyæmia),
otitis media tuberculosa, granulomatous polypi, cholesteatoma,
sclerosis, congenital anomalies, foreign bodies, parasites, neoplasms
(chiefly of external ear).
5. POINTS TO BE NOTED IN EXAMINATION OF NOSE.
The normal mucosa of the nasal tract is light grayish-red. Note
character of contents of the cavities (mucus, blood, pus, dry
clots or scabs), congestion, hemorrhage, erosions, ulcerations,
diphtheritic membrane, diffuse or localized thickenings of the mucosa
(polypi), adenoids, exostoses, caries, foreign bodies, parasites
(maggots) and neoplasms (sarcoma, fibroma, carcinoma). The most
important conditions are acute and chronic catarrhal inflammations,
ozæna, croupous or diphtheritic inflammations, syphilis, atrophy or
hyperplasia of the mucosa, polypi, and more rarely tuberculosis.
Syphilis causes inflammations and gummatous infiltrations of the
mucosa, gummatous periostitis, foul-smelling necrosis of the bony
portions (ozæna syphilitica). Dense hard fibromata developing from
base of skull may fill up the nasopharynx or erode the cranial base
and press upon the brain. Softer sarcomatous growths may arise
from the hypophysis, or from the lymphoid tissue of the mucosa.
Squamous-celled carcinoma is not infrequently primary in the antrum
and thence invades the nose. Primary malignant tumors of nasal tract
not common. Leprosy, glanders, blastomycosis, and rhinoscleroma are
more rarely seen.
CHAPTER VII.
MAIN INCISION: THORAX AND ABDOMEN.
I. METHOD OF OPENING TRUNK.
1. =The Main Incision.= After the examination of the cranium has been
completed, the skull-cap is replaced and the anterior flap of the
scalp drawn up over it, to hold it in place until the close of the
autopsy. The head is then wrapped in a towel to protect the face and
hair.
The prosector then stands at the right side of the cadaver (if
left-handed, on the left side), the body being brought as near as
possible to the edge of the table. The cartilage-knife is then held
in the palm of the right hand and with it an incision is made through
the skin in the median line of the body, extending from just below
the thyroid cartilage to the base of the penis in the male, and to
the anterior commissure in the female, passing to the left of the
umbilicus. If pathologic conditions (hernia, surgical wound, tumor,
etc.) are present in the median line the main-incision should deviate
to right or left as expedient. The incision in the suprasternal notch
is made with the point of the knife, the thumb and fingers of the
left hand being used to put the skin of the neck on a stretch. Over
the sternum the knife is held horizontally and the tissues cut to the
bone. As soon as the epigastrium is reached less force is used, and
the cut should not be deeper than through the skin and subcutaneous
tissue over the abdominal portion of the incision. At the end of the
incision the knife is raised, vertically and the cut finished with
the point of the knife. The incision is then carefully deepened in
the epigastrium, just below the ensiform, until a small opening is
made through the peritoneum into the abdominal cavity. To determine
the presence of gas within the peritoneal cavity the peritoneum
should first be nicked with the point of the knife to make a very
small opening through which the escape of any free gas within the
cavity can be easily noted. When bacteriologic examinations of the
peritoneal fluid are to be made, the incision should be extended down
to the peritoneum, which should then be seared, and the fluid secured
by means of a sterile pipette forced through the seared portion. If
it is more expedient to secure the fluid through an incision, the
opening should be made with a sterilized knife and the fingers should
not be put into the cavity, but are used to lift up the abdominal
wall at the sides of the incision. In cutting through the peritoneum
great care should be taken not to injure the stomach or intestines,
which, often greatly distended, are pressed tightly against the
peritoneum. If the opening is made just below the ensiform the knife,
should it slip through unexpectedly, usually strikes the liver
without causing any damage.
[Illustration:
FIG. 36.—The main incision completed. Lines show incisions through
costal cartilages, and for disarticulation of sternoclavicular
joints. (After Nauwerck.) The incision in the neck is begun higher
than is usual in this country.
]
The abdominal incision is now extended downward to the pubis. The
first and second fingers of the left hand are introduced into the
peritoneal cavity and used as directors to lift up the abdominal
wall and to keep the intestines from the knife, the latter cutting
between them in the line of the first incision through the skin and
subcutaneous fascia. When the main incision is complete the knife
is introduced into the abdominal cavity with cutting edge directed
outward and the abdominal muscles are divided on either side just
above the pubis by cuts extending outward to the skin. (See Fig. 36.)
Care should be taken not to cut the latter. These transverse cuts
made from the peritoneal surface permit the opening of the peritoneal
cavity to the necessary extent, so that transverse incisions through
the skin are not necessary.
The main incision is carried to the left of the umbilicus and then
back to the median line, in order not to injure the umbilical
vessels, the ligamentum teres of the liver, or a concealed hernia
or persistent omphalomesenteric duct. In the case of the new-born
the incision to the left of the umbilicus is extended to the pubis
in an oblique line diverging from the median line. After the
examination of the umbilical vessels through the main incision
a second diverging cut is made from just above the umbilicus,
passing to its right, across the umbilical vessels and hepatic
ligament down to the pubis, forming a triangular flap including the
umbilicus, urachus and umbilical arteries.
The abdominal flaps are now held back and a thorough inspection of
the cavity made, noting particularly the position of the abdominal
organs, contents of cavity, condition of peritoneum and appendix,
occurrence of perforations, etc. The position of the diaphragm is
then determined on both sides, by passing the right hand up under
the ribs to the highest part of the dome of the diaphragm and then
pressing outward against the chest-wall so that the height can be
estimated by rib or interspace.
The skin and muscles are now stripped from the thoracic wall on
both sides of the median incision, beginning first on the right.
(See Fig. 36.) The right flap of the abdominal wall is taken in the
left hand just above the umbilicus and turned over the right lower
border of the ribs, and pulled forcibly upward and outward to the
right, putting the peritoneum, the ligamentum teres of the liver and
abdominal muscles upon a stretch over the edge of the ribs. These are
then cut by the cartilage-knife in an incision extending from the
median line along the edge of the ribs deep down into the flank. The
loosened flap of skin and muscle is then pulled over to the right
with the left hand, while the right hand holds the cartilage-knife,
with its cutting edge turned obliquely to the surface of the ribs,
and makes long, sweeping cuts from above downward, severing the
thoracic muscles and fascia as closely as possible to the costal
cartilages and ribs. The skin and muscles are thus stripped off from
below upward until the right side is laid bare as far back as the
anterior axillary line and to the middle of the clavicle above. (See
Fig. 36.)
In stripping the muscles from the ribs it is necessary only
to do it sufficiently to show the costal cartilages and their
articulations with the ribs. Too clean dissecting is not necessary.
On the other hand, careless slashing cuts should be avoided, as
they might cut through into the pleural cavity.
The right mammary gland is next examined. The index-finger of the
left hand is put upon the nipple, the skin-flap turned over, and an
incision made from the inner surface, extending through the gland to
the nipple. Parallel incisions may then be made. The axillary glands
may be examined by carrying the skin and muscle flap farther down
into the axilla. The thoracic wall is then laid bare on the left
side, in exactly the same way as on the right, except that the right
hand works underneath the left, as the latter pulls the flap over to
the left. When the left side is stripped, the left mamma is examined
in the same way as the right.
The thorax is now opened, beginning with the right second costal
cartilage. This is cut with the belly of the cartilage-knife about
½-1 cm. from the costal articulation so as to leave as much of the
cartilage attached to the sternum as possible. (See Fig. 36.) The
cut is made with a rocking motion so that the knife-blade will
strike upon the next lower cartilage instead of going through into
the thoracic cavity. The cartilages and intercostal muscles are cut
in this manner in succession down to the tenth, the cut flaring
outward below with the outward curve of the costal articulations.
The cartilages forming the lower edge of the ribs are left uncut at
this time. When the first opening into the pleural cavity is made
attention should always be paid to the possible escape of gas or
air (pneumothorax). When pneumothorax is suspected the opening may
be made through a little pocket of water formed by holding up the
skin-flap and filling the hollow with water. A similar incision is
then made through the cartilages on the left side from the second
to the tenth. The lower right edge of the ribs is now lifted with
the right hand, and the cartilage-knife, held on the flat, with
cutting edge toward the abdomen, is put through the opening of the
incision through the cartilage and through the diaphragm, and the
last cartilages cut by a stroke made outward and slightly upward to
avoid injuring the abdominal organs. The last cartilages on the left
side are then cut by putting the blade of the cartilage-knife, held
on the flat with cutting edge outward, through the diaphragm from the
abdominal side, into the incision through the cartilages, and cutting
through the lower edge of the ribs in the same manner as on the right.
The lower part of the sternum and cartilages is then lifted in the
left hand and the diaphragm trimmed off closely beneath it. Still
lifting the sternum the tissues of the anterior mediastinum are
cut close to its under surface, care being taken not to cut the
pericardial sac. The sternum is thus freed up to the cartilage of the
first ribs and the sternoclavicular attachments. With the sternum
lifted as high as it is possible to do so without breaking it the
cartilages of the first ribs are now cut with the blade of the
cartilage-knife turned outward to avoid cutting the large vessels
and flooding the part with blood from the distended veins. This
is possible since the cartilages of the first ribs extend farther
outward than those of the second ribs. (See Fig. 36.)
After the first costal cartilages have been cut on both sides,
the sternum is lifted nearly perpendicularly and twisted slightly
toward the right so that the capsule of the left sternoclavicular
articulation can be put upon a stretch. The latter is then opened
from below until the joint is exposed. With the sternum still
pulled firmly upward and toward the right the left sternoclavicular
articulation is completely severed, the left sternocleidomastoid
and other muscles and fascia attached to the sternum are cut from
left to right; and the sternum, twisted over to the right, is
disarticulated in the same manner from the right clavicle, and the
right sternocleidomastoid cut. The freed sternum is now examined. It
may be cut through in the median line with the saw, or cuts made into
it with knife or chisel.
[Illustration: FIG. 37.—Method of disarticulating sternoclavicular
articulation and cutting cartilage of first rib from above. (After
Nauwerck.)]
Ossification of the cartilages of the ribs is very common in late
middle life and old age, more rarely in younger persons. The first
cartilages, particularly the left one, and the lower ones usually
show it in the most marked degree. It may be impossible to cut
them with a knife, and the hand-saw must be used. Ankylosis of the
sternoclavicular articulation is also not rare, and it is sometimes
necessary to saw through the clavicles. The sternoclavicular
articulation and the cartilage of first rib may also be opened from
above downward with a long, narrow-bladed scalpel, the incision
following the articular surfaces.
Many prosectors prefer this method. (See Fig. 37.) The
location of the joint and the direction of the incision may be
ascertained by moving the arm and shoulder of the cadaver. The
sternocleidomastoids may be cut when the skin-flaps are stripped
off. In case bacteriologic examination is to be made of the
contents of the pleural cavity the incisions into the cavity should
be made with a sterilized knife, or the material for culture may
be obtained by means of a pipette introduced through a seared
interspace.
2. POINTS TO BE NOTED IN THE MAIN INCISION.
1. =Panniculus.= Note thickness at different points in the incision,
color (straw-color, rosy or almost white in early life, orange or
reddish-yellow in atrophy or old age, brown in severe anæmias),
moisture (œdema, serous or purulent inflammation, transfusion; the
latter should not be mistaken for pathologic œdema), dryness in
atrophy, long-continued fevers, cachexias, etc., number of bleeding
points (passive congestion, hypostasis), hemorrhages (recent, old,
pigmented).
2. =Musculature.= The muscles of the neck, thorax and abdomen are
examined with reference to the following points: size (atrophy,
hypertrophy), color (normally bright brownish-red, may be paler
than normal, deep brown, yellow or grayish), consistence (pale
muscle usually tears easily, brownish muscle usually tears less
easily), moisture (moist in œdema, inflammation, and as a result
of transfusion; dry in anæmias, severe diarrhœas, long-continued
fevers), translucency (increased in Zenker’s necrosis, fatty
infiltration, fatty degeneration, atrophy, anæmia; diminished
in cloudy swelling and simple necrosis), blood-content (anæmia,
hyperæmia), hemorrhages (trauma, surgical, hypodermic injections,
toxic, infective, hæmatoma of abdominal rectus in typhoid fever),
inflammation (acute, chronic, focal, diffuse, primary, secondary,
abscess, fibroid, etc.), bony formations (myositis ossificans),
parasites (trichina the most common, especially frequent in muscles
of neck and in the intercostals and diaphragm, small whitish, oval
bodies looking and feeling like grains of sand; echinococcus and
cysticercus are more rare), neoplasms (not common, the spindle-cell
fibrosarcoma or “recurrent fibroid” of abdominal wall the most
frequent form). Zenker’s necrosis (hyaline, waxy or “fish-flesh”
degeneration) is of frequent occurrence in the abdominal muscles
in typhoid and other severe fevers and intoxications. Anomalies of
sternal and pectoral muscles are not rare.
3. =Abdominal Cavity.= Watch carefully for the escape of gas when
the first cut through the peritoneum is made. A lighted match may
be held over the opening, or the skin incision may be filled with
water and the peritoneum opened through the water, noting the escape
of bubbles. The odor (sour, sweetish, yeasty, fécal, putrid, etc.)
should be noted. Abnormal contents of the peritoneal cavity are to
be measured and described as to color (amber, greenish-yellow, color
of bile, red, bloody, brown, gray, creamy, milky, opalescent, etc.),
consistence (thin, clear, watery, serous, pea-soup-like, gruel-like,
creamy, jelly-like, colloid, semi-solid, etc.), odor (fécal or foul,
due usually to the presence of the colon bacillus; acid or yeasty
in perforation of stomach; fruity in diabetes, acute hemorrhagic
pancreatitis; odor of ether, chloroform, alcohol, etc.), contents
(blood, bile, féces, stomach-contents [distinguish perforations due
to postmortem digestion], fibrin, fat, chyle, pus, foreign-bodies,
mucin or pseudomucin, parasites) and reaction (acid, alkaline).
Non-inflammatory ascites occurs in portal stasis, hepatic cirrhosis,
thrombosis or compression of portal or splenic veins, chronic
passive congestion, chronic valvular lesions with incompensation,
nephritis, severe anæmia, obstruction or rupture of thoracic
duct, etc. The fluid of transudates is usually clear, odorless,
alkaline, low specific gravity (below 1.016), small albumin- and
fibrin-content, few flocculi, and relatively small number of white
cells. Inflammatory exudates are turbid, often foul-smelling, usually
acid, specific gravity over 1.016, high albumin-, fibrin- and
urea-content, numerous thick flocculi and numerous cells. In early
peritoneal tuberculosis the fluid may be clear and resemble that of
a transudate. Milky and opalescent fluids are found in diabetes,
lipæmia, new-growths of the peritoneum, obstruction or rupture of
thoracic duct or receptaculum. Hemorrhagic exudates may be traumatic
(rupture of spleen, liver, intestines, extra-uterine pregnancy,
etc.), inflammatory (severe acute peritonitis), or due to new-growths
or tuberculosis of the peritoneum, extreme portal stasis, perforation
of gastric or typhoid ulcers, severe intoxications, chronic icterus,
etc. Red effusions may be due to diffused hæmoglobin. In such cases
there is no settling of the color, and coagulation may not occur.
When red cells are present settling takes place on standing. Rupture
of gall-bladder or bile-ducts may lead to presence of free bile
in the peritoneal cavity. Postmortem diffusion of bile through
the gall-bladder wall should not be mistaken for a pathologic
condition. In normal conditions there is just enough fluid in the
peritoneal fluid to make the surfaces moist, and about a teaspoonful
in all may be collected from the flanks and pelvis. The amount
may be greatly increased just before death in all cases of slowly
progressive cardiac weakness. Note character of peritoneum (normally
moist-shining, grayish, translucent, cloudy, dry, lustreless,
thickened, hyaline (“iced” or “Zuckerguss”) in chronic inflammation.)
4. =Omentum.= Note position of lower border, amount of fat, condition
of blood-vessels, dry or moist-shining surface, adhesions (to
appendix, cæcum, oviducts), indurations, contractions (edges rolled
up), character of lymphnodes, cysts, tubercles, secondary tumors,
snared-off tumors from ovary or uterus (parasitic cysts, fibroids),
encysted foreign bodies, etc., exudates on surface, fat-necrosis,
accessory spleens, encysted parasites, hernia, etc. Most common
pathologic conditions are inflammation (secondary to appendicitis,
salpingitis, etc.), metastic carcinoma and tuberculosis.
5. =Position of Abdominal Organs.= Note situs viscerum inversus,
gastro-enteroptosis, displacements due to spinal curvatures and
deformities, and hernia, anomalies or malformations, locate organs by
usual landmarks (edge of ribs, ensiform, umbilicus, etc.), position
of lower and left borders of liver, gall-bladder, spleen, pylorus and
fundus of stomach, appendix, colon, etc. Malposition of transverse
colon especially common. Note volvulus, ileus, invaginations,
etc. Examine stomach and intestines carefully for perforations.
Differentiate postmortem perforations and those due to pathologic
conditions. (Edges of postmortem perforations soft, slimy, without
evidences of disease.) The appendix should also be carefully examined
at this time. Note also peritoneal surface (color, thickness,
translucency, tubercles, adhesions), color and blood-content of all
abdominal organs before acted upon by exposure to air. In the female
examine pelvic organs. Do not mistake postmortem perforations of
stomach or intestine, postmortem imbibition and diffusion of bile
in region of gall-bladder, postmortem contraction of intestines,
dilatations of lymphatics with lymph or chyle, agonal transudates,
accessory spleens, etc., for pathologic conditions.
6. =Position of Diaphragm.= Normally fourth rib or interspace on
right, fifth rib on left, higher in the young, lower in old age.
Raised in conditions of increased abdominal pressure (pregnancy,
ascites, enlargement of liver or spleen, subdiaphragmatic abscess,
dilatation of stomach, urinary or gall-bladder, tumors of any
abdominal or pelvic organ, especially ovarian cysts, etc.), low
in increase of intrathoracic pressure (pleuritic effusions,
pneumothorax, pericardial effusion, hypertrophy of heart, tumors,
aneurism, etc.).
7. =Mammae.= Condition varies according to age, pregnancy, lactation,
etc. In resting glands the structure is lobulated, connective-tissue
white with yellow fat between; in the white connective-tissue are
small grayish-red nodules of gland-tissue (“breast-grains”). During
lactation the fat disappears entirely or to a large extent, the
entire organ consisting of a more homogeneous grayish-white glandular
tissue, distinctly granular on section, and resembling the section
of a salivary gland. Note size of ducts, presence of secretion
(colostrum or milk) on pressure, congestion, œdema, abscess, fistula,
caseous tubercles or gummata, cysts (milk, “soap,” “butter,”
senile, new growths), neoplasms, atrophy, hypoplasia, hypertrophy,
accessory nipples, parasites (echinococcus). The most common tumors
are adenofibromata and carcinomata. Tuberculosis is not rare. In
the male breast hypertrophy has been noted in association with
malignant chorio-epithelioma of the testis; and in the female with
pseudopregnancy and tumors of the genital tract. Adenofibroma, gumma
and tuberculosis are the most common conditions of the mammæ in males.
8. =Costal Cartilages.= Note color (ochronosis), degree of
ossification, anomalies, separations, fractures, caries,
tuberculosis, alteration in shape (pigeon-breast, emphysema, Pott’s
Disease, erosions of tumors or aneurisms, rickets, etc.). The
costochondral edges are thickened as a result of rachitis (rachitic
rosary). In old age the costal cartilages may undergo the so-called
“asbestos-like” degeneration, becoming yellowish- or grayish-brown,
streaked with shining whitish granules, with calcification or
ossification and new-formation of blood-vessels. Degeneration cysts
(senile) are not infrequent, and the cartilages sometimes appear as
if soaked with oil, soft and translucent. Fibroid or calcified areas
may be present. Spaces and clefts within the cartilage may be filled
with new-formed bone-marrow.
9. =Sternum.= Note shape (pigeon-breast, “shoemaker’s,” rounded,
scaphoid, bifid, anomalies of ensiform, etc.), fractures (in
marked osteoporosis the bones may break during removal), erosions
(aneurisms, tumors), tuberculous and syphilitic caries, gummata,
perforations, etc. Under surface of sternum should be smooth,
shining, translucent and grayish. In chloroma the under surface
may present a uniform greenish layer ½-1 cm. thick. Bone-marrow of
sternum is normally red and lymphoid in character; may be green
in chloroma, pyoid in leukæmia, hyperplastic in severe anæmias.
Sclerosis and osteoporosis of sternal bones are not rare. In the
former condition the marrow may be entirely absent; in the latter
hyperplastic.
CHAPTER VIII.
THE EXAMINATION OF THE THORAX.
I. METHODS OF EXAMINATION.
1. =Thoracic Cavity.= As soon as the sternum is removed the =anterior
mediastinum= and the =pleural cavities= are examined, noting first
the =position= and =relation= of the =thoracic organs=, quantity and
character of mediastinal fat, the contents of the pleural cavities,
pleuritic adhesions, etc. Pleuritic exudates should be removed before
they have become mixed with blood from the cut vessels or heart; and
the pleural surfaces should be examined before their appearance has
been changed by exposure to the air or to fluids. Pleuritic adhesions
should be broken or cut, beginning with the left side and then on the
right, and the entire surface of both lungs wholly freed.
2. =Thymus.= The thymus is then examined by means of transverse cuts;
or, when large, is dissected from below upward, turned up onto the
neck, and removed later in connection with the neck organs. When
no traces of thymic tissue are visible to the naked eye the thymic
fat should always be cut transversely and examined for the presence
of small lymphoid nodules. In the case of hypertrophic thymus
the question of pressure upon the trachea becomes of very great
importance, and, to settle this, the trachea should be opened above
the sternum before the thymus is removed; or the thymus may be taken
out in connection with the trachea and both sectioned horizontally
at the same time. In cases of sudden death, in which the thymus may
be an etiologic factor, it is safest to examine the trachea from
above the sternum before the thorax is opened, or to fix the whole
body (infant’s or child’s) in formalin and then to remove thymus with
trachea, and examine by means of transverse sections.
The heart is examined before the lungs chiefly for two reasons:
Its blood-content can be more accurately determined, and the blood
caught in the pericardial sac, so that when the pulmonary vessels
are cut in the removal of the lungs there is no gush of blood into
the pleural cavity.
3. =Pericardial Sac.= This is next examined with respect to the
degree of intrapericardial tension. Its anterior wall is then picked
up at about its middle by the thumb and index finger of left hand,
and the point of the long section-knife, with cutting edge outward,
is pushed through the pericardium and a small slit made into the sac.
The escape of gas or air should be noted at this time. A sterile
pipette may now be introduced and the fluid contents of the sac
secured for bacteriologic examination; or before the pericardial sac
is opened the pericardium may be seared with a hot iron and a sterile
pipette pushed through it into the cavity. The longitudinal incision
through the pericardium is now extended upward to its attachment to
the great vessels, and through the opening thus made the character
and amount of the pericardial fluid are determined. The incision is
then extended to the left at its lower end by cutting the sac-wall
toward the apex of the heart. Through the three-cornered incision
thus made the heart is lifted out of the sac and the surfaces of the
parietal and visceral layers of the pericardium examined. Localized
adhesions of the pericardium may be cut or torn, extensive or
complete adhesions may be separated when this is possible; if this
cannot be done, the pericardial layers are cut with the heart wall.
4. =Section of the Heart.= The heart may be examined either in the
body or outside. The choice of several methods may be taken, and
the one most convenient and easy of performance is advised, rather
than a method based upon such considerations as the direction of
the blood-current in the normal body. The chief essential is to
expose completely the interior of the heart with the least possible
disturbance of anatomic relationships, and to accomplish this in
the simplest and easiest way. Such a method must leave the heart
in such shape that it can be reconstructed for histologic study or
utilized as a museum specimen. This can be accomplished by a modified
_Rokitansky_ method, as follows:
The heart is first carefully inspected as it lies in the pericardial
sac. The apex is then lifted in the left hand and the posterior wall
inspected. The heart is then drawn up over the right edge of the
ribs, so that the left border of the heart presents uppermost as
the line of greatest convexity. The point of the narrow brain-knife
(amputation-knife), with cutting edge upward, is then inserted
through the wall of the left ventricle at the apex, just to the left
of the septum, and the knife pushed into the cavity until the point
can be forced through the ventricular wall just below (ventricular
side) the left auriculoventricular ring, and the ventricle-wall is
then cut upward (as the heart is held) to the apex, in the line of
greatest convexity, exposing the cavity of the left ventricle. The
knife is laid aside and the ventricle is explored with the fingers
of the right hand and the size of the mitral opening estimated.
Before the fingers are introduced through the valvular openings
the flaps should be carefully examined to see that no vegetations,
thrombi, etc., are in danger of being loosened by them. With the
opening of the heart-chambers the blood, if fluid, may pour out into
the pericardial sac and flood the pleural cavity if not prevented
by sponging or by removing it by means of a beaker. The knife is
then introduced on the flat through the mitral opening into the left
auricle in a line continuing the first incision with the junction of
the left pulmonary veins. (See Fig. 38.) The knife is then turned
with cutting-edge upward, the point thrust through the upper left
pulmonary vein or between the left pulmonary veins, and the auricular
wall is cut upward (downward anatomically) to meet the first incision
below the mitral ring. The incision should pass between the mitral
segments. The left auricle, mitral ring and flaps and the greater
portion of the left ventricle are thus exposed and should be
inspected.
[Illustration: FIG. 38.—Section of left ventricle and auricle, when
heart is examined in the body. (After Nauwerck.)]
The heart is then taken in the left hand and held by the anterior
flap of the left ventricle, with the fingers inside the ventricle
and the thumb on the outer surface of the anterior wall of the left
ventricle, and lifted up vertically out of the pericardium. The
brain-knife held perpendicularly, with cutting-edge to the right, is
pushed through the right ventricular wall just to the right of the
septum, carried across the cavity of the ventricle, to engage again
in the ventricular wall in the line of greatest convexity, just below
(anatomically) the right auriculoventricular ring, and the wall is
then cut upward to the apex. The right ventricular cavity is thus
opened, the fingers are introduced to explore the tricuspid ring, and
the cavity and contents are inspected. The knife, held flat, is then
carefully introduced through the tricuspid opening into the right
auricle, the cutting edge outward, and its point thrust through the
wall of the auricle midway between the superior and inferior venæ
cavæ, and the auricular wall and tricuspid ring are cut upward toward
the apex to meet the first incision into the right ventricle. If
sufficient care is taken the incision will fall between the anterior
and posterior cusps. Right auricle, tricuspid flaps and ring, and the
right ventricle are thus exposed for inspection.
The heart is then drawn downward and allowed to lie flat in the
pericardial sac, and the pulmonary artery is then explored with the
fingers of the right hand. While the anterior wall of the right
ventricle is held by the thumb and index-finger of the left hand the
knife is then introduced, on the flat, along the right side of the
septum, into the pulmonary artery; the edge is turned upward and the
point pushed through the wall of the artery, about 3 cm. beyond the
ring, and a cut made toward the apex through the anterior wall of the
artery, pulmonary ring and anterior wall of right ventricle, just
to the right of the septum. The pulmonary artery, ring, pulmonary
flaps, and right side of auricular and ventricular septum are now
inspected. In cutting the pulmonary ring care should be taken to make
the incision between the two anterior cusps.
With the heart still lying flat in the pericardial sac, the aortic
opening is explored by the index-finger of the right hand and the
size of the ring estimated. The knife is then introduced on the flat,
into the left ventricle, along the left side of the septum, through
the aortic opening and as far as possible into the aorta. It is then
turned, with the cutting edge upward, and the point pushed through
the anterior wall of the aorta. The heart is then drawn downward and
slightly raised by the left hand, holding it at the apex by the two
flaps of the right ventricle. The knife is then drawn from above
downward toward the apex, cutting in succession the anterior wall of
the aorta, across the pulmonary artery, through the aortic ring, and
the anterior wall of the left ventricle, just to the left side of
the septum. By dissecting away the pulmonary artery from the aorta
the incision through the former may be avoided. (See Fig. 41.) When
desired this cut may be brought down through the septum instead, but
if the bundle of His is to be studied in serial sections the cutting
of the septum should be avoided. The enterotome or long straight
shears may be used for all the incisions except the first ones made
into the ventricles. For these the knife is necessary. The incision
through the aortic ring usually cuts the anterior segment, but by
making the cut more to the right the incision will pass between the
anterior and the right posterior flaps.
Before the valvular orifices are cut it is often expedient to test
the adequacy of the valves by means of water or air. The hydrostatic
test is employed to the best advantage in the case of the pulmonary
and aortic valves, either by pouring water into the vessels, or by
immersing the heart in water and then lifting it up quickly. In the
case of the auriculoventricular valves the air-test is carried out
by inserting the nozzle of a bellows through an opening made in
the ventricular wall and noting the effect of blowing and suction.
Graduated cones or balls may be used for more accurate measurement of
the orifices, or they may be measured after they have been cut.
If sufficient care is exercised in cutting the valvular rings
the incision can be carried between the flaps without injury to
the latter. This is often desirable in cases of valvular lesion,
endocarditis, etc. In such cases the valvular rings may be left
uncut, the line of incision being broken by the auriculoventricular
ring, when the mitral and tricuspid valves are concerned. The
pulmonary and aortic rings may also be left uncut; the incisions are
stopped at the rings, and then begun again in the vessel-walls beyond
the valves.
When bacteriologic examinations of the heart-contents are to be made
the wall of the auricles or right ventricles can be seared with a
cautery and a pipette introduced through the seared area; or the
heart can be opened with a sterile knife, care being taken not to
introduce the fingers into the opening or to permit the entrance of
water.
Excellent preparations for the museum or for demonstration purposes
can be made by distending the heart with alcohol or formalin. Blood
and blood-clots should first be washed out. When fixed the heart may
be sectioned in various planes, leaving the segments attached by the
epicardium posteriorly, or openings may be cut in the walls. A very
good picture of hypertrophy and dilatation is obtained by making a
transverse cut through the ventricles midway between apex and base.
Alterations in the form and position of the ventricular septum are
best seen by this method.
After the opening of the heart and the inspection of the orifices,
valves and auricular and ventricular septa, the coronary vessels
should be examined by transverse cuts, or opened by fine
probe-pointed scissors, beginning at their origin in the aorta. The
auricular septum should be carefully examined for possible defects.
While this is being done the wall should not be put on the stretch,
but should be lax. The auricular appendages should be cut open from
the auricles and examined for thrombi, which are of not infrequent
occurrence in them. The mouths of the coronary veins and the veins
of Thebesius should be examined also. The cardiac muscle is examined
by parallel, vertical or horizontal incisions. The papillary muscles
should be cut longitudinally from apex to base. The cardiac plexus
and the ganglion of Wrisberg should be examined before the heart is
removed.
When the heart is in a state of rigor mortis the contraction should
be made to pass away by kneading or by the application of heat,
before the organ is opened, or before any measurements are taken.
After the heart has been opened it may be removed for weighing.
The heart may be removed first and then opened outside of the
body. The organ is grasped in the left hand and lifted vertically
and upward toward the head as far as possible, putting all of the
attachments on the stretch. The vessels are then cut from below
upward, first the inferior vena cava, then the pulmonary veins, the
superior vena cava, pulmonary artery and lastly the aorta. (See
Fig. 39.) The vessels should be cut as closely as possible to their
exits through the pericardium, and care must be taken to get out the
auricles entire.
[Illustration: FIG. 39.—Removal of Heart. Dark line shows incision
through vessels. (After Nauwerck.)]
After removal from the body the heart is placed upon the board with
its anterior surface up, and the apex toward the operator. It may
then be opened by the same method given above, by inserting the
point of the brain-knife into the left ventricle just to the left of
the septum, and cutting first the wall of the left ventricle along
its left border as far as the mitral ring, exploring the mitral
orifice, and then cutting it and the auricular wall into the upper
left pulmonary vein with the long shears. The right ventricle,
right auricle, pulmonary artery and finally the aorta are opened
in succession, using the enterotome for all cuts except the first
opening of the ventricle. The first incisions into the ventricles
can be made very conveniently by holding the heart vertically with
apex up, and the ventricle to be opened toward the prosector. The
brain-knife is held vertically and its point inserted into the
ventricle, just to the right or left of the septum, according to the
ventricle to be opened, then carried across the cavity and pushed
through the ventricular wall below the auriculoventricular ring, and
the wall is then cut toward the apex. The remaining incisions are
most easily made with the enterotome when the heart is held flat on
the board with its anterior surface up. When the heart is opened
outside of the body the Virchow method of opening in the direction
of the blood-stream may also be used. (See below.)
Under certain conditions other methods must be employed for the
examination of the heart. In cases of suspected aneurism, pulmonary
embolism, patent ductus arteriosus, etc., the thoracic organs should
be removed _en masse_ and dissected on the table. They may be removed
in connection with the neck-organs or alone. In the latter case the
trachea is cut transversely above the sternum, the fingers of the
left hand introduced into the trachea, and, while traction downward
is being made with force, the œsophagus and cervical vessels are cut
transversely, the trachea and vessels stripped down to the level
of the clavicle, and the subclavian vessels cut on both sides. The
thoracic organs are then stripped from the vertebræ down to the
diaphragm and cut off just above the latter.
The pulmonary artery may be examined _in situ_ before the heart is
opened by thrusting a sharp-pointed scalpel through the wall of the
artery just beyond the valves and cutting upward to the branches
going to the right and left lungs. This incision may be extended
downward through the pulmonary valve and the anterior wall of the
right ventricle, and the right side of the heart first exposed.
=Virchow Method.= The heart is rotated toward the left side
of the cadaver so as to bring the venæ cavæ into view, and is
held by the index-finger and thumb of left hand. An incision is
then made in the wall of the right auricle, beginning midway
between the two cavæ and extending downward as far as the right
auriculoventricular ring, in the direction of the right ventricular
ridge. The tricuspid is examined from above. The tricuspid ring
may be left uncut and an incision made in the ventricle-wall,
beginning just below the valve and extending downward along the
right ventricular ridge to the septum, or the incision may be
carried down in the same line passing through the tricuspid ring.
The long narrow-bladed knife or the enterotome is introduced into
the right ventricle and an incision made from the middle of the
first incision, just above the insertion of the anterior papillary
muscle, through the pulmonary orifice into the pulmonary artery,
passing between the two anterior leaflets of the pulmonary valve.
The heart is now drawn up on the right edge of the ribs so that
the left ventricular border presents uppermost. The left auricle
is then opened by an incision beginning in, or just below, the
lowermost pulmonary vein and extended in the direction of the left
ventricular ridge as far as the auriculoventricular ring. Beginning
just below the ring an incision is made through the entire length
of the left ventricular ridge as far as the apex and to the septum,
which lies usually beyond the apex. A second incision is then made
in the left ventricle from the apex, extending through the anterior
ventricular wall close to the septum, parallel to the descending
branch of the anterior coronary artery and about 1 cm. from it,
and passing through the aortic opening between the anterior and
the right posterior cusps. This is the more easily accomplished
if the pulmonary artery has been dissected away from the aorta, so
that the incision can be carried well over to the right. (See Fig.
41.) As the chambers of the heart are opened the contents should
be inspected, clots removed, and the valvular orifices examined
from the upper side. The coronary arteries are then opened with the
fine probe-pointed scissors. When the heart has been removed from
the body it may be opened on the board by following the method as
given above. The heart is held very conveniently for the Virchow
incisions by putting the four fingers of the left hand beneath it
and the thumb on the anterior surface; complete pronation puts
the heart in the position for opening the right side; complete
supination gives the position for opening the left side.
[Illustration: FIG. 40.—Section of right auricle and ventricle,
according to Nauwerck.]
[Illustration: FIG. 41.—Incision for opening of aortic ring; same
for all methods described in text. (After Nauwerck.)]
=Nauwerck Method.= By this method the left auricle, left ventricle,
right auricle and right ventricle are opened in succession. The
heart is seized in the left hand, and without rotation is drawn
upon the right edge of the ribs. Beginning in the upper left
pulmonary vein or between the veins an incision is made through
the wall of the auricle to the sulcus circularis, avoiding any
injury to the coronary vessels. Beginning below the mitral ring
an incision is carried along the left ventricular ridge to the
apex. The left auricle and ventricle are then cleared of blood
and the mitral opening examined. The heart is then put back into
its natural position; the left thumb is placed in the apex of the
left ventricle and the four fingers passed over the right border
of the heart to its posterior surface, rotating the heart to the
left until the right auricle is brought uppermost. (See Fig. 40.)
Then an incision is made through the wall of the right auricle,
beginning midway between the superior and inferior venæ cavæ and
extending to the tricuspid ring, then begun again 1 cm. below, is
carried along the right border of the heart, or slightly anterior
to it, as far as the septum. (See Fig. 40.) The contents of right
auricle and ventricle and the tricuspid valves are now inspected.
The heart is then removed from the body by lifting it up vertically
as far as possible and cutting the vessels from below upward as
close as possible to their exits through the pericardial sac. The
hydrostatic test is then applied to the aortic and pulmonary valves
by pouring water into these vessels, or by immersing the heart an
water and then lifting it out. The heart is then laid flat on the
board with apex toward the operator. The enterotome is introduced
into the right ventricle and through the pulmonary orifice and an
incision made through the anterior wall of the right ventricle,
beginning just above the anterior papillary muscle at about the
middle height of the ventricle, and cutting through the pulmonary
conus and pulmonary valve well to the left, close to the septum,
following the narrow ridge of fat at the base of the artery so as
to pass between the left anterior and posterior segments. The heart
is then rotated on its vertical axis so that the right auricle is
turned toward the prosector, and the tricuspid ring is opened with
the intestinal shears. The auricular appendage is then cut open
from the auricular incision. The heart is then held in its former
position and an incision is made in the anterior wall of the left
ventricle just to the left of the septum, from the apex through the
aortic ring and the left wall of the aorta, while the pulmonary
artery is pulled to the right. (See Fig. 41.) Care must be taken
not to damage the right border of the base of the mitral; the cut
should pass half way between the pulmonary orifice and the left
auricular appendage, cutting the left aortic flap. If it is desired
to save the cusps the pulmonary artery may be dissected from the
aorta and the incision carried between the right posterior and the
anterior valve-flaps. The heart is again rotated toward the right
and the mitral ring is cut with the enterotome, which is introduced
from the left auricle into the left ventricle. The left auricular
appendage is then cut open. The heart-wall is then examined by
means of parallel vertical or horizontal incisions. The papillary
muscles are cut longitudinally from apex to base. The coronary
vessels and their branches are then examined, partly from the aorta
and partly from the incisions through the muscle.
=Prausnitz Method.= The heart is removed and held in the palm of
the left hand and two vertical incisions are made on either side
of the septum, parallel with it, and extending from base to apex.
Two other incisions are then made from base to apex on the outer
borders of the ventricles, connecting at the apex with the first
incisions. The ventricles are opened by the triangular flaps of
the anterior wall thus formed, these flaps being attached at the
base of the heart. The contents of the cavities are examined and
removed; the valvular orifices and flaps are examined, and the
pulmonary and aortic rings are cut through with the shears by
extending the two incisions made on each side of the septum, taking
care to pass between the cusps.
The heart can also be opened with the long shears alone. The
openings of the two cavæ in the right auricle are connected by
an incision. The auricular appendage is opened by a second cut.
The shears are then put through the tricuspid ring, and this with
the right ventricle is cut, the incision following the right
ventricular border. The pulmonary orifice is then opened by a cut
made along the right side of the septum. The left heart is opened
through the pulmonary veins, cutting first the auricle-wall, then
the mitral ring and ventricular wall to the apex. An incision is
then made along the left side of the septum, through the aortic
orifice into the aorta.
5. =Section of the Lungs.= The general inspection of the pleural
cavities and pleural surfaces is made as soon as the thoracic cavity
is opened, as indicated above. If a pneumothorax is present the
pleural cavity on the affected side is filled with water, the neck
organs are exposed and a tube inserted into the trachea. When air
is forced through this bubbles will escape from the perforation
and the opening can be easily located. When extensive or complete
pleural adhesions are present, so that they cannot be separated, it
becomes necessary to remove the costal pleura in connection with
the visceral layer. This is accomplished by loosening the costal
pleura and subpleural fascia at the cut edge of the ribs with the
blade of the knife, until the fingers and, finally the hand, can be
worked in between the costal pleura and the chest-wall, gradually
separating the two until the entire lung is freed with both layers
of pleura adherent. Firm adhesions at the apex may have to be cut
with the knife. Similar adhesions with the pericardium or diaphragm
may make it necessary to cut out the adherent portion with scissors
or knife and remove it in connection with the lung. When the pleural
adhesions are very firm upon the right side the prosector may find
it most convenient to stand at the left side of the cadaver and
from this position separate the right costal pleura from the chest
wall. An assistant may be of great service in pulling the thoracic
wall outward. The edge of the ribs or cartilages may be covered
with a towel or the skin may be drawn over it to protect the hands.
In extreme cases it may be necessary to saw the ribs and remove
them in connection with the lungs. Sometimes the adhesions may be
separated more easily if the neck-organs are first removed down to
the clavicle, and then, in connection with the lungs, are removed _en
masse_, by means of powerful tugs, from above downward. The apical
and posterior adhesions may be torn fairly easily in this way when
ordinary manipulations in the thoracic cavity have no effect upon
them.
When the pleural surfaces are free the =left lung= is lifted out
of the cavity onto the right edge of the chest-wall, pulling it
forcibly over to the right so that its posterior surface becomes
uppermost. In this position the lung may be sectioned by one or more
main incisions made with the long section-knife, cutting the organ
from apex to base, down upon the ribs in the direction of the main
bronchi and vessels. After the examination of the cut surfaces the
organ may be returned to the cavity. It is better, however, to remove
the lung, and section it outside the body. This is done by cutting
the mediastinal pleura, pulmonary vessels and main bronchus with the
cartilage-knife, while the lung is held upon the right edge of the
thoracic opening, holding the knife so that its blade strikes the
edge of the costal cartilages.
[Illustration: FIG. 42.—Section of left lung. (After Nauwerck.)]
The lung, when free, is placed upon the board with its hilus downward
and base toward the prosector. (See Fig. 42.) It is then held in the
left hand, as shown in the illustration, the thumb holding the lower
lobe, the index-finger between the lobes with its tip upon the main
bronchus, the other fingers holding the upper lobe. With the long
section-knife held slightly obliquely toward the anterior edge the
main-incision is now made in one sweeping cut from apex to base,
along the line of greatest convexity, down upon the main-bronchus
and its chief branches and the large vessels. Care should be taken
not to cut off the bronchi of the two lobes from the main bronchus.
Incisions parallel to the main one may be made, if desired. Usually
it suffices to go carefully over the remaining part of the lung,
feeling it carefully for airless solid areas; if such are present
they may be sectioned separately. The =bronchi= are then opened from
the cut surface by means of the probe-pointed scissors, cutting as
near to the pleura as possible. The sound or director may be used
with advantage in opening up cavities from the bronchi. The position
of the lung should be so changed that the bronchi always extend
away from the prosector in a straight line. The portion of the lung
containing the uncut bronchus should be left hanging over the left
hand to put it on the stretch, thereby facilitating greatly the
opening of the bronchus. The =pulmonary vessels= are opened with
fine probe-pointed scissors from the cut surface. The bronchial
lymphglands are then sectioned with the knife.
[Illustration: FIG. 43.—Section of right lung. (After Nauwerck.)]
The =right lung= is then lifted up out of the thorax onto the
right side of the thoracic opening, and is either sectioned in
this position, or the mediastinal pleura, pulmonary vessels and
bronchus are cut from below upward with the knife, its edge being
directed against the ribs. When freed the lung is placed on the
board, root downward and apex toward the prosector. (See Fig.
43.) The index-finger is put between the upper and lower lobes,
the thumb holds the upper lobe, the other fingers are spread out
over the surface of the lower lobe. The main-incision is then made
in a sweeping cut, from base to apex, along the line of greatest
convexity, the knife-blade being held slightly obliquely toward the
anterior border (see Fig. 43), cutting down upon the main bronchus
and its first division. Other parallel cuts may be made. The middle
lobe is then sectioned by a sagittal incision on its anterior
surface, directed toward its anterior border. The =bronchi, pulmonary
vessels= and =bronchial lymphnodes= are then opened as in the case of
the left lung.
Bacteriologic examinations may be made from smears or cultures made
from the cut surfaces; or, to avoid contamination, the surface
may be seared with a hot iron and the material obtained by means
of a sterile pipette pushed through the seared surface into the
lung-tissue.
The lungs may also be removed by drawing them downward and outward,
away from the root, while the bronchi and pulmonary vessels are
cut, the knife being directed against the vertebræ, care being
taken to avoid cutting the aorta and œsophagus. The lungs are then
lifted up toward the middle line, while the mediastinal pleuræ are
cut. The section of the lungs may be carried out, if so desired,
from the root, the main bronchus and then all of the branches as
far as the pleuræ being opened up by means of the probe-pointed
scissors. Other incisions may be made if desired.
As mentioned above, it is sometimes more convenient to remove the
thoracic organs _en masse_, either alone, or in association with
the neck organs. When this is done the dissection follows the
method of Letulle (see above), or the organs may be separated and
sectioned according to the methods just given.
The section of the heart usually precedes that of the lungs, in
order that the blood-content of the former may be more correctly
estimated. Under certain conditions it may be more convenient or
expedient to section the lungs first, beginning with the left one.
When the neck-organs are not removed the section of the thorax closes
with the examination of the =aorta, oesophagus=, =thoracic duct= and
=thoracic vertebrae=. The blood-vessels and œsophagus are opened
with the curved scissors, from above downward, the contents noted,
and the walls examined. The thoracic duct is best dissected out
from the right side, by cutting along the right side of the aorta
and turning the latter over to the left. The duct is more easily
recognized at its lower end. It may be inflated with the blow-pipe,
or opened with a probe and fine probe-pointed scissors. Sometimes
the duct can be most easily found by removing the left lung and
then turning the right lung over into the left pleural cavity. The
posterior mediastinal tissues are put on a stretch, so that the duct
can be recognized through the pleura. For the examination of the left
subclavian vein the left clavicle should be removed.
II. POINTS TO BE NOTED IN THE EXAMINATION OF THE THORAX.
1. =Thoracic Cavity.= Presence of gas or air (pneumothorax,
infections with colon bacillus, gas-forming bacillus, proteus,
etc.), relative degree of pressure, odor, etc. Measure contents of
each pleural sac; note character of fluid (clear, turbid, bloody,
chyliform, chylous, purulent, fibrino-purulent). Normally the pleuræ
are moist-shining, smooth, grayish, transparent; only a few drops
of fluid found in the cavities. In cases of slowly progressive
cardiac insufficiency large amounts of clear fluid may collect in
the cavities just before death. Non-inflammatory collections of
fluid also occur in general œdema. In these conditions the pleuræ
are not cloudy or dull, while in the case of inflammation the
pleural surfaces are dry, cloudy, dull-shining, injected, rough
or covered with fibrinous or purulent exudate. Examine pleural
surfaces particularly for evidences of inflammation, recent and old
tuberculosis, primary and secondary neoplasms (carcinoma).
2. =Position of Thoracic Organs.= Locate anterior borders of lungs,
apex and borders of heart. The normal lung collapses after the
removal of the sternum. How much of the pericardial sac is left
uncovered by the lungs?
3. =Anterior Mediastinum.= Note character of connective-tissue,
amount and color of fat-tissue, number and size of lymphnodes,
occurrence of œdema or emphysema. An artificial œdema may be caused
by the injection of large quantities of salt solution in the pectoral
region just before death. An artificial emphysema may be produced by
the removal of the sternum. The condition of the large veins in the
upper portion of the mediastinum should be noted before the heart
is removed. Are they lax, moderately full, or distended? Secondary
tumors, hemorrhages, abscesses, œdema and emphysema are the most
common pathologic conditions.
4. =Thymus.= The writer believes that the weights usually given
for the thymus in the new-born are too high, and that 7-10 grms.
represents the usual normal weight. A gland weighing 20 grms. or
more must be regarded as enlarged. The organ reaches its fullest
development at the end of the second year. Atrophy begins then,
developing slowly up to the age of puberty, after that more rapidly.
In adults the thymus normally consists of a mass of adipose
tissue containing lymphoid nodules, in some of which corpuscles
of Hassall persist to old age. Postmortem softening should not
be mistaken for abscesses. The most important pathologic change
is hypertrophy. Pressure of the enlarged gland upon the trachea,
nerves or great vessels may cause thymic stridor, asthma, or thymic
death (“lymphatic constitution”). Enlargement of the thymus may
occur in “status lymphaticus,” exophthalmic goitre, cretinism,
myxœdema, Addison’s disease, acromegaly, myasthenia gravis, epilepsy,
scorbutus, rachitis, tonsillar hyperplasia, adenoids, congenital
syphilis, Hodgkin’s disease, leukæmia, anencephaly, anæmia, acute
infections, or it may exist as an independent affection. Oedema,
congestion, inflammation, tuberculosis, neoplasms, etc., may also
cause an enlargement. Absence of the thymus has been observed.
Primary and secondary forms of atrophy in association with marasmus
occur in children. Note relation of size of thymus to condition of
child; atrophy of the organ is usually coincident with marasmus.
Inflammation, tuberculosis, cysts, primary and secondary neoplasms,
gummata, etc., are not common.
5. =Pericardium.= Note tension of sac, fluctuation, adhesions,
thickness, character of inner surface, contents (amount, color, odor,
presence of fibrin, blood or pus, gas). Normally there are about 5-10
c. c. of clear yellow fluid in the sac. Both peri- and epicardium
normally are moist-shining, smooth, grayish and transparent. Large
amounts of clear watery fluid may collect in the pericardial
sac in slow death in cases of chronic valvular lesions, chronic
nephritis, bronchitis and emphysema, but the surface of the peri-
and epicardium remains smooth and shining. In inflammatory increase
of the pericardial fluid the serous surfaces are dull, cloudy or
dry, and may be covered with a layer of fibrin, the fluid is more
or less cloudy and contains flakes or strings of fibrin, or may be
purulent. The fibrinous exudate may be very extensive and from the
movement of the heart be drawn out into bands, threads or villus-like
prominences (cor hirsutum or villosum). Pericarditis is common in
acute rheumatism, septicæmia, pyæmia, puerperal fever, osteomyelitis,
pneumonia, and as a terminal infection in cardiac and renal
disease. Tuberculosis is one of the most common causes of purulent,
fibrinous and hemorrhagic pericarditis, particularly of the cor
villosum. Examine surfaces for tubercles. The presence of blood in
the pericardial exudate points usually to tuberculosis or malignant
neoplasm, but in small amount may be found in various infections
and intoxications. The age of the pericarditis may be judged by the
amount of organization of the exudate, adhesions, thickenings, etc.
“Milk spots,” “soldier’s spots,” “tendinous patches” or “friction
scleroses” represent hyaline thickenings of the pericardium due
to old pericarditis. Total synechia or atresia of the cavity may
occur. As the result of calcification of an old pericarditic exudate
the heart may be surrounded by a calcareous sheath (“stony heart,”
“petrified heart”). Hæmopericardium results from the rupture of the
heart, aorta, pulmonary artery or coronary vessel. Petechiæ of the
peri- and epicardium are found in pyæmia, septicæmia, hæmophilia,
scurvy, severe anæmia, leukæmia, chronic nephritis, and death from
suffocation and various intoxications. Pneumopericardium may be due
to perforating wounds, or to perforations from lungs, stomach or
œsophagus, or to infections with gas-forming bacilli. Malformations
are rare (diverticula, ectopia). Tuberculosis is usually secondary.
Gummata are rare. Actinomycosis is usually secondary to actinomycosis
of the neck or lungs. Primary neoplasms are rare. Secondary
carcinoma and sarcoma (especially lymphosarcoma) are more frequent.
Cysticercus, trichina and echinococcus are rare.
6. =Heart.= Note more carefully its position, whether displaced to
right or left, location of apex, borders, etc. Relative size compared
to cadaver’s right fist, which is usually a little smaller than the
heart. Weight and measurements:—(The heart should be weighed after it
has been opened, and its cavities freed from blood and clots.)
Average weight in adult male, about 300-350 grm.
Average weight in adult female, about 250 grm.
Normal limits, 200-350 grm.
Weight of heart to body-weight in adult male, 1:169; in the female,
1:162.
Circumference at base of ventricles 25.8 cm., length of ventricles
8-9 cm., breadth 8.5-10.5 cm., thickness 3-3.6 cm.; minimal
measurements are for the female. Auricles are 5-6 cm. in length.
Compare ventricles as to size.
Note form (long, cylindrical, pyramidal, broad, short, round, etc.)
In hypertrophy of the left ventricle the heart is longer and more
cylindrical; in hypertrophy of the right it is broader and more
rounded. Normally the apex is formed by the left ventricle, the
sulcus longitudinalis running to the apex and nearly dividing the
heart into halves. In hypertrophy of the right ventricle the apex
is formed by this ventricle, the sulcus longitudinalis passing to
the left of the apex; in hypertrophy of the left ventricle the
longitudinal sulcus runs to the right of the apex. What part of the
heart lies anteriorly? (Normally a large part of the right ventricle.)
The consistence of the organ, particularly that of the ventricles,
should be noted (firm, flabby, soft, etc.). Condition of the
heart-chambers (empty, contracted, dilated, full). Rigor mortis
should be removed by kneading or by the application of heat. The
amount of subepicardial fat, its color, translucency, occurrence
of serous atrophy, œdema, subepicardial hemorrhage, etc., are
to be noted. In marasmus a serous or mucoid degeneration of the
subepicardial fat is not uncommon. The subepicardial fat increases
with age, and is normally most abundant along the grooves and
blood-vessels, particularly the auriculoventricular grooves and
on the right ventricle. Normally the color of the heart-muscle
of the ventricles should be seen through the epicardium. The fat
is increased in obesity, chronic alcoholism, chronic anæmia,
tuberculosis, etc. When the fat-infiltration is so marked that
the muscle cannot be seen the condition is known as adipositas or
obesitas cordis, or in extreme cases as _lipoma cordis capsulare_.
7. =Right Heart.= Note amount of blood contained in right chambers
(over-distended in death from asphyxiation, pneumonia, etc.), also
its consistence (thick, thin, watery), color (light, dark, red,
yellowish, chocolate, purplish), blood-clots (size, color, cruor,
lardaceous clots, chicken-fat clots, pus-like clots, consistence,
moisture), presence of free fat, gas or air, diffusion of hæmoglobin,
presence of bile-pigment in blood. Note also amount and character
of blood in venæ cavæ. The size of auricular and ventricular
cavities should be estimated, noting condition of trabeculæ and
papillary muscles (atrophic, flattened, hypertrophic, fatty,
fibroid, calcification). The musculature of the ventricular walls
is examined as to its thickness (normally the right ventricle wall
is 4-5 mm. thick). Postmortem contraction should not be mistaken
for hypertrophy. The color of the heart-muscle normally is pinkish
in infants, flesh-red in adults, and brownish-red in old age and
in atrophy following compensatory hypertrophy (brown atrophy).
Under normal conditions the muscle is translucent. In cloudy
swelling the heart-muscle appears cloudy and opaque as if cooked.
Fatty degeneration appears as yellowish, opaque patches or streaks
(“tiger-heart”), particularly in the papillary muscles and trabeculæ.
In severe intoxications the process may be diffuse, and the entire
musculature appear cream-colored or yellowish and opaque. The
consistence may be firm, flabby, soft, putty-like; localized areas
may be caseous. Infarcted areas are soft when fresh (myomalacia
cordis). The consistence is increased in atrophy, fibroid heart,
chronic interstitial myocarditis, syphilis, etc. Cloudy swelling and
fatty degeneration make the heart muscle softer and more friable. In
postmortem decomposition the heart as a whole becomes soft. Normally
the endocardium should be gray, delicate, thin and transparent. The
chordæ tendinæ are long, narrow and delicate. Note thickenings of
endocardium and chordæ tendinæ, presence of thrombi (dry, brick-red,
yellowish or gray, firmer than clots and adherent to the endocardium,
often show simple softening, which should not be mistaken for pus;
may be parietal, polypoid, valvular or free). The endocardium may be
stained diffusely yellow (bile) or brown (methæmoglobin). Creamy or
yellowish opacities of the intima are due to fatty degeneration.
8. =Left Heart.= Note same things in left side of heart as on
right. In cardiac paralysis left ventricle is filled with blood
if rigor mortis has not set in. Left ventricle wall is 10-15 mm.
thick normally; may become 30 mm. thick in hypertrophy. Papillary
muscles and trabeculæ may be markedly hypertrophic, but in the
greatly dilated heart (aortic insufficiency) may be much flattened.
The septum of the ventricles may share in the hypertrophy of either
ventricle and when hypertrophic bulges into the cavity of the
unaffected side. Examine wall of left ventricle, particularly near
the apex, for infarcts, fibroid patches, aneurismal dilatation,
rupture, fatty degeneration, thrombi, etc. Look particularly for
pathologic conditions involving the atrioventricular bundle.
9. =Orifices and Valves.= Orifices should measure as
follows:—Tricuspid (12-12.7 cm.), mitral (10.4-10.9 cm.), pulmonary
(8.9-9.2 cm.), aorta (7.7-8 cm.). Rough measurements may be
taken with the fingers, tricuspid admitting three, mitral two,
pulmonary one and a half, aorta thumb. The orifices may be measured
by graduated cones, or in the ordinary way after the heart is
sectioned. Normally the edges of the valve-flaps should be delicate,
smooth and thin. Examine for vegetations, thrombi, induration,
thickening, contractions, ulcerations, tears, perforations, defects,
calcification, atheroma, valvular aneurism, etc. Note thickening,
contraction, adhesion, shortening, etc., of the chordæ tendinæ. When
the tendons are long, narrow and thread-like, and without adhesions,
the probabilities are that a lesion of the mitral orifice was not
present.
10. =Coronary Vessels.= Walls should be uniformly delicate and
thin, and the intima should be delicate, gray and transparent.
Note contents of arteries and veins. Examine arteries especially
for thrombi, emboli, arteriosclerosis, atheroma, calcification,
obliteration of lumen, thickening of wall, loss of elasticity,
opacity of intima and increased tortuosity of course.
The most important pathologic conditions of the heart
are:—endocarditis (ulcerosa, maligna, verrucosa, simplex, chronica
fibrosa, sclerosing), valvular insufficiency and stenosis,
hypertrophy, dilatation, atrophy, fatty infiltration, fatty
degeneration, cloudy swelling, anæmic infarction, calcification,
acute and chronic myocarditis, abscess, fibroid heart, cardiac
aneurism, rupture, thrombosis, embolism, malformations (septum
defects, patent ductus arteriosus, stenosis or atresia of orifices),
tuberculosis (not rare, in association with tuberculous pericarditis,
or general miliary tuberculosis), syphilis (gumma not common,
localized or diffuse interstitial myocarditis the most common
manifestation), actinomycosis, cysticercus, echinococcus, trichina
and neoplasms (primary rare, in part congenital, fibroma, lipoma,
angioma, myxoma, rhabdomyoma; secondary sarcoma less rare than
secondary carcinoma, most common forms are melanotic sarcoma and
lymphosarcoma).
11. =Left Lung.= Weighs 350-500 grm. _Size_ (voluminous, collapsed,
compare lobes); _form_ (edges rounded, sharp, nodular, saccular or
cystic, contractions, depressions, emphysematous enlargements);
_pleura_ (examine again more closely. Circumscribed dull-shining
or cloudy areas point to some pathologic condition of the lung
beneath. Look for evidences of healed tuberculosis, particularly
in the pleura of the apices. Secondary carcinoma of the pleura is
very common. Primary tumors are rare; endothelioma and sarcoma are
the most common forms. Small circumscribed areas of pigmentation
usually represent old tubercles); _color_ (depends upon degree of
anthracosis, blood-content and condition of pleura, areas showing
especial color should be examined closely; most common colors are
pinkish-gray normally, grayish, slaty, black, red, brown, dark-red
to black); _size of air-cells_ (normally can be seen with naked
eye, best seen at apex and borders, about size of pin-points, when
larger than the head of a pin they are emphysematous); _lobules_ can
also be seen with naked eye, usually polygonal in shape, 2-3 mm. in
diameter; _consistence_ (estimate by going over entire lung, pressing
the lung-substance between thumb and fingers; air-containing lung is
soft, elastic and crepitates; airless areas are hard, firm and do not
crepitate).
On the cut surface the following points should be noted:
_Blood-content_ (anæmia, hyperæmia, hypostatic congestion), _color
of cut-surface_, _air-content_, _exudate_ (serous, purulent),
_consistence_ (hard, soft, elastic, caseous, brittle, crumbling),
_character of surface_ (smooth, granular, nodular, cavities).
Cavities should be described according to their position, size,
shape, contents and character of their walls.
12. =Right Lung.= Weight 420-620 grms. Note size, form, color,
surface, size of air-cells, lobules, consistence, blood-content,
air-content, exudate, consistence and character of cut-surface, as in
case of left lung.
Evidences of healed tuberculosis are found in practically all
adult lungs in the form of localized thickenings or puckering
of the pleura, especially at the apices, hyaline or anthracotic
nodules, encapsulated, caseous or calcified tubercles. Old scars
and indurations are firm, hard and usually black in color. Caseous
areas are smooth, dry, white or grayish, and opaque. Very young
tubercles are elevated, grayish and translucent. Atelectatic areas
are depressed and bluish-red in color. Areas of hepatization are red
or gray, elevated, granular, crumbling, moist in early stage, dry in
caseous hepatization. In bronchopneumonia the areas of hepatization
are usually sharply circumscribed. Metastatic abscesses lie usually
beneath the pleura, are usually multiple and distributed over both
lungs. Bronchopneumonic areas are usually found in the dependent
portions, particularly in right lung. An abundance of foamy, watery
fluid on the cut-surface indicates œdema; when very bloody there
is usually a marked stasis or beginning hepatization present. In
atelectasis and fibrinous hepatization the exudate from the surface
is not foamy. Emphysematous areas are white or grayish-white and
are most frequently found along the borders. Large air-spaces are
often found along the interlobular septa (interstitial emphysema),
particularly in children following trauma, croup, whooping-cough,
etc. In chronic passive congestion the lung is firmer than normal,
deep-red or brownish in color. Hemorrhagic infarcts lie usually
beneath the pleura, are wedge-shaped, with base toward pleura, firm,
smooth on section, or granular, and when fresh are nearly black;
older ones are lighter and brownish. Cavities in the lung occur in
tuberculosis, embolic and primary abscesses, actinomycosis, gangrene,
bronchiectasis, primary and secondary tumors, etc. Gangrenous
areas have diffuse borders, are gray or greenish in color, with
central softened areas, with ragged borders and stinking smell. In
bronchiectatic cavities the smooth mucosa of the bronchus passes
directly into the wall of the cavity. Primary carcinomata of the
lungs appear as cavities having a white medullary wall, or as
medullary strands running along the bronchi. Tuberculous cavities
have caseous walls, are more or less encapsulated, and usually
show younger tubercles in the neighborhood of the wall. Antemortem
hypostasis is usually darker and firmer than postmortem, and is
usually associated with inflammation (hypostatic pneumonia).
The most important pathologic conditions of the lungs are:—Anomalies
(anomalous lobes common, infradiaphragmatic accessory lungs,
agenesia, congenital bronchiectasis), atelectasis (fœtal,
compression, obstruction, paralytic, etc.), emphysema (acute,
chronic, vicarious, senile, atrophic, hypertrophic, interstitial,
gangrenous), hyperæmia, stasis, brown induration, hypostasis,
œdema (universal, stasis, hypostatic, atelectatic, acute, chronic,
terminal), hemorrhage, hemorrhagic infarction, thrombosis, embolism,
fatty embolism, pneumonia (croupous, atypical, bronchopneumonia,
acute and chronic interstitial), abscess, gangrene, tuberculosis
(acute miliary, caseous pneumonia, peribronchial, tuberculous
bronchopneumonia, indurative, fibroid, phthisis pulmonum), syphilis
(gumma, white pneumonia), actinomycosis, neoplasms (primary
adenoma, lipoma, papilloma, chondroma, osteoma, sarcoma, carcinoma
and teratoma are rare; metastatic sarcoma and carcinoma are
common; malignant chorio-epithelioma is not infrequent), parasites
(echinococcus, cysticercus, hook-worm embryos, pentastomum and
distomum pulmonale).
13. =Bronchi.= Note size, contents, thickness of wall, color and
thickness of mucosa. Normally the bronchi are empty, and the mucosa
grayish-red. In pulmonary œdema they contain clear, foamy fluid;
in bronchitis they may contain a mucous, mucopurulent, purulent,
fibrinous, hemorrhagic or putrid exudate. In acute bronchitis the
mucosa is red; in chronic bronchitis the mucosa may be red or
brownish, and thickened or folded. Material from the stomach may
enter the bronchi postmortem and cause a postmortem digestion of the
mucosa or wall.
The most important pathologic conditions of the bronchi
are:—Inflammation (acute and chronic catarrhal bronchitis, fibrinous,
putrid, atrophic, obliterans), bronchial asthma, tuberculosis,
syphilis, stenosis, bronchiectasis, perforation (aneurisms, abscess,
carcinoma, tubercles, etc.), bronchial calculi, foreign bodies,
neoplasms (adenoma, papilloma, carcinoma, chondroma, osteoma),
parasites (cysticercus, echinococcus, hook-worm embryos, distomum
pulmonale, pentastomum).
14. =Bronchial Glands.= Note size, pigmentation (gray, dark-gray,
black), consistence, character of cut-surface, caseation, fibroid
induration, calcification, œdema, congestion, abscess, neoplasm.
Tuberculosis and secondary neoplasms are the most common conditions.
Lymphosarcoma is the most frequent primary tumor.
15. =Pulmonary Vessels.= Character of walls and contents. Normally
the intima is smooth, grayish-white and translucent. Fatty
degeneration of the intima is not rare (acute infections and
intoxications); atheroma and aneurismal dilatation are infrequent.
Occasionally parietal thrombi and thickening of the wall due to
organization of a thrombus are seen. The pulmonary arteries are
normally empty or contain soft cruor or agonal white clots. These
are not adherent to the wall, do not fill the lumen and are soft and
moist. Emboli fill the lumen as if forced into it (at the branchings
of the artery they form “rider’s” emboli); they are more dry and
brick-red, brownish or grayish in color. Occasionally they may be
unrolled into long fibrinous strands. Older emboli may show more or
less organization and adherence to the vessel-wall. In air-embolism
the pulmonary arteries contain a mixture of blood and air looking
like a stiff-beaten white of egg of red color. Large emboli of
liver-tissue or liver-cells may be found in the pulmonary arteries
after traumatic rupture of the liver. Fat-emboli of the smaller
arteries can be recognized by the naked-eye. Thrombosis of both
pulmonary arteries and veins is very common in chronic valvular
lesions, pneumonia, terminal infections, burns of the skin, poisoning
with hemolytic agents, etc.
16. =Great Vessels of Thorax.= Note size of lumen, condition of
walls, particularly of intima, and the contents. Circumference
of thoracic aorta 4.5-6.0 cm., thickness of wall 1.5-2 mm. Test
elasticity of wall by stretching; note if it retracts and becomes
shorter than the œsophagus, which was cut at the same level. Note
consistence of wall (stiff and hard in sclerosis and calcification).
Normally the intima of the aorta is smooth, grayish-white and
semitranslucent; the wall is elastic. Fatty degeneration, sclerosis,
atheroma and aneurismal dilatations are the most common pathologic
findings. Fatty degeneration shows itself in yellowish spots or
streaks, more opaque and slightly elevated. Sclerotic areas are hard,
white and tendon-like. Atheromatous “plaques” and “ulcers” are white
or yellowish, elevated, rough, scaly, with loss of substance, often
more or less calcified. Thrombi are frequently formed upon such
atheromatous patches. Hemorrhage into the intima may occur (aneurysma
dissecans). Radiating or linear sclerotic folds and depressions
in the intima, with or without dilatation of the lumen, usually
result from syphilis (mesaortitis). A dirty brownish discoloration
of the intima is due to an imbibition of diffuse hæmoglobin, usually
postmortem. In chronic icterus the intima may be bile-stained.
Thrombosis of the aorta is not common. Congenital or acquired
stenosis at the isthmus is rare. Tuberculosis of the aorta-wall is
also very rare.
17. =Thoracic Portion of Oesophagus.= Note size (stenosis,
dilatation, diverticulum), contents (food, stomach-contents, blood,
pus, foreign-body), thickness of wall, color of mucosa (normally
grayish-white), neoplasms (carcinoma), perforations, erosions
(aneurism, abscess, neoplasm), inflammation. Anomalies, tuberculosis,
syphilis, actinomycosis and neoplasms (with the exception of
carcinoma) are rare. The most common location of carcinoma is
toward the cardia. Thrush is the most common parasite. Varices of
the œsophageal veins are common, and from these fatal hemorrhages
may occur. In the thoracic portion they are usually the result of
collateral distention to offset a portal stasis (hepatic cirrhosis,
Banti’s disease, thrombosis of splenic or portal veins). The passage
of stomach-contents through the cardia into the œsophagus may cause a
postmortem softening or perforation of the œsophageal wall.
18. =Thoracic Duct.= Note size, contents and character of wall.
Tuberculosis, malignant neoplasms, obstruction, rupture and purulent
inflammations are the most important pathologic conditions. In
miliary tuberculosis the thoracic duct may be the primary focus
or the avenue by which the bacilli enter the blood. The duct also
plays an important part in the dissemination of malignant tumors and
infections from the abdominal cavity and pelvis. Chylothorax and
chylopericardium are usually caused by the blocking of the thoracic
duct by malignant neoplasms (lymphosarcoma, carcinoma), or by rupture
of the duct.
19. =Thoracic Vertebrae.= Note surfaces of vertebræ (normally
smooth), curvatures, softening, erosions, exostoses, neoplasms,
fractures, dislocations. Tuberculosis, curvatures and malignant
tumors (secondary carcinoma, primary sarcoma, myeloma, chloroma) are
the most common conditions. Aneurismal erosions are not rare.
CHAPTER IX.
EXAMINATION OF THE MOUTH AND NECK.
I. METHODS OF EXAMINATION.
1. =Removal of the Neck-Organs.= The block is left beneath the neck,
and the chin pulled upward by an assistant, so as to put the skin of
the neck on a tight stretch. If the main-incision cannot be extended
to the symphysis of the chin, the cartilage- or long section-knife is
run up beneath the skin in the median line to the point of the chin,
and, with the blade held nearly flat, the skin is loosened from the
tissues of the neck, first on the left side, then on the right, as
far back as the mastoid processes and the spinal column and to the
ends of the clavicles. Great care should be taken not to cut through
the skin. The long section-knife, with blade flat, is then pushed
through the floor of the mouth, to the left of the median line,
taking care not to damage the tongue, and with the blade of the knife
closely hugging the inner border of the lower jaw, the floor of the
mouth is cut through as far as the angle of the jaw. The knife is
then turned with its cutting edge toward the right and a similar cut
made through the floor of the mouth as far as the right angle of the
jaw. The knife must be held at right angles to the floor of the mouth
to avoid cutting the tongue. When the mouth is open the course of the
knife can be seen, but usually the mouth is tightly closed in rigor
mortis. When cutting the floor of the mouth it is better to make
short sawing movements with the knife than to attempt to cut it with
one sweeping cut. Instead of cutting from the median line the knife
may be inserted at the right or left angle of the jaw and the cut
extended upward to the chin and thence toward the other angle. (See
Fig. 42.)
[Illustration:
FIG. 44.—Removal of neck-organs, when skin-incision is carried to
the chin. The same cuts through the soft palate are made, when the
knife is pushed up beneath the loosened skin of the neck. (After
Nauwerck.)
]
As soon as the floor of the mouth is opened and the tongue loosened
from the lower jaw the left hand is introduced beneath the skin,
through the incision, into the mouth, and the tongue seized by
thumb and middle finger, and drawn forcibly downward, while the
other fingers are used to lift up the skin from the knife. The long
section-knife, with cutting edge turned toward the left, is then
introduced in the median line, along the left hand, until its point
reaches the hard palate, taking care to work the point back slowly
until it reaches the border between soft and hard palate. This must
be done by feeling rather than by sight. The block under the neck
is then pushed up under the head and the chin thrown forward so
that the point of the knife is directed at right angles against the
cervical vertebræ. The soft palate is then cut to the left, while
the tongue is pulled firmly downward and toward the right, putting
the uvular arch on a stretch so that the knife passes around the
left tonsil. The knife is then turned and the same cut made on the
right, severing the right faucial pillar and tonsil, while the
tongue is pulled downward and to the left. The point of the knife
is then pushed back to the pharyngeal wall and the latter is cut
from right to left by a strong, firm stroke directed at right angles
to the surface of the upper cervical vertebræ. The cut through the
pharyngeal mucosa should be at the level of the boundary between the
laryngeal and nasal portions, at about the height of the axis. While
this cut is being made firm traction should be kept up on the tongue,
pulling it downward, and alternately to the left and right. The loose
retropharyngeal and retroœsophageal fascia tears easily and the
mouth organs can now be pulled so far downward that first transverse
and then oblique cuts through this fascia can now be made upon the
vertebræ, severing the vagi, carotids and jugulars, and working
from above downward, until the mouth and neck organs can be lifted
up through the skin-incision and the entire mass of the neck-organs
separated from the spinal column as far as the clavicles. Pulling the
mass toward the right, the left subclavian vessels and fascia are
severed by a cut directed downward and outward beneath the clavicle.
Traction is then made toward the left and the right subclavians cut
beneath the clavicle. If the thoracic organs have been removed the
œsophagus and aorta may now be stripped down to the diaphragm and
there cut off, or the neck-organs may be cut off at the level of the
bifurcation of the bronchi.
The organs, having been removed, are placed on the board, œsophagus
upward, and the tip of tongue toward the prosector. The =tongue= is
then cut in the median line and the cut surfaces examined. Transverse
cuts may be made when indicated. The uvula is then lifted up and
examined; and the =tonsils= and =palate= next examined, the former
by means of longitudinal incisions. The intestinal shears are now
introduced through the fauces into the œsophagus and the left pillar
cut between the uvula and the tonsil. The posterior wall of the
=pharynx= and that of the =oesophagus= for its entire length is
then cut in the median line, and these structures examined. After
the examination of the larynx from above, the long blade of the
intestinal shears is introduced into the =larynx= and =trachea=, and
these are cut in the posterior median line into the right bronchus.
The œsophagus is pulled to the left (prosector’s right) out of the
way. The left bronchus is opened by a special incision to avoid
cutting aorta and œsophagus. The larynx is now lifted up and held in
both hands with the thumbs on the horns of the thyroid cartilage, and
the fingers outside, and the larynx opened by forcibly bending back
or breaking the cartilage, so that the entire interior of the larynx
can be examined without touching the mucosa.
The neck-organs are now turned over, with the aorta toward the
prosector and the tongue pointing away. The right and left lobes of
the thyroid are opened by oblique cuts running from above downward
and inward, and the isthmus is cut sagittally. The =parathyroids=
must be dissected out behind and below the thyroid, along the
course of the terminal branches of the inferior thyroid artery.
The =parotid=, =submaxillary= and =sublingual glands= and the
=cervical lymphnodes= are opened by longitudinal cuts. The =aorta=,
=carotids=, =jugulars= and their branches are opened with the curved
or probe-pointed scissors. The =vagus=, =superior= and =inferior
laryngeal nerves= and the =cervical sympathetic ganglia= are to
be examined when the case requires it. The examination of the
neck-organs then closes with the inspection of the =muscles= of the
neck and the =cervical vertebrae=.
If permission cannot be obtained for the complete removal of the
mouth-organs, the neck-organs may be removed by cutting them
transversely against the vertebræ between the hyoid bone and
thyroid cartilage and then stripping them from the vertebræ and
removing them as in the method given above. The skin-incision in
such cases need not be carried higher than the collar-line, the
skin of the neck being loosened by a subcutaneous dissection.
When permission is withheld for the removal of the neck-organs
they may be examined _in situ_, by freeing the skin of the neck
by a subcutaneous dissection, cutting the lobes and isthmus of
the thyroid in place and then opening the trachea and larynx by
an anterior median incision. The salivary glands, parathyroids,
cervical lymphnodes, vessels and nerves can all be examined by this
method without removing the organs as a whole.
In cases of aortic aneurism, corrosive poisoning, carcinoma of
œsophagus, trachea or bronchi, it is best to remove the neck-organs
in connection with the thoracic, removing first the neck-organs
down to the clavicles and then stripping all down to the diaphragm,
where they may be cut off and examined outside of the body. In
cases of poisoning it is often necessary to remove the œsophagus
in connection with the stomach. The mass of neck- and thoracic
organs are removed as far as the diaphragm and then allowed to lie
over the edge of the thorax or are turned down over the abdomen so
that the œsophagus is upward and the tongue toward the prosector.
The œsophagus and aorta are then separated from the other organs
and left in the thorax to be examined later in connection with the
abdominal organs.
If the thoracic duct was not examined when the thoracic organs
were, it may be examined after the section of the neck-organs is
finished, but it is more easily found after the method given above
by turning the right lung over into the left side of the thorax and
then looking for it in the neighborhood of the diaphragm, on the
right side behind the aorta and between it and the azygos vein.
It runs upward toward the left to the body of the last cervical
vertebra, then over the left subclavian artery downward to the left
innominate vein.
II. POINTS TO BE NOTED IN EXAMINATION OF THE MOUTH- AND NECK-ORGANS.
1. =Mouth.= Contents (blood, mucus, stomach-contents, foreign-bodies,
etc.), color of mucosa (normally grayish-red), vesicles (aphthæ),
cheilitis, gingivitis, various forms of stomatitis, noma,
scorbutus, Ludwig’s angina, ulcers (syphilis, carcinoma, decubital,
tuberculosis), hyperkeratosis, macrocheilia, thrush, scars, wounds,
action of corrosives, lead-line, neoplasms, etc. Note pillars of
fauces, size, shape and condition of uvula. If the teeth have not
been inspected during the general examination they should receive
attention at this time. Note malformations, anomalies, neoplasms
(adamantoma, odontoma, dental osteoma, various forms of cysts,
epulis, giant-cell sarcoma, papilloma, fibroma, etc.)
2. =Tongue.= Mucosa normally is moist and grayish-red. Note
discolorations, coatings, crusts, scabs, exudates, various
forms of stomatitis, “geographical tongue,” glossitis, abscess,
fissures, ulcers (syphilis, carcinoma, decubital), chancre, wounds,
action of corrosives, scars (epilepsy, syphilis), tuberculosis,
neoplasms (carcinoma, lymphangioma, hæmangioma, papilloma, leukæmic
lymphocytoma, adenoma, thyroid adenoma [struma baseos linguæ], and
rarely sarcoma, congenital fibroma, lipoma, myxoma, chondroma,
osteoma and dermoid cysts), thrush, actinomycosis, leprosy, trichinæ,
cysts (lymphangiectatic), hyperkeratosis, leukoplakia, “black hairy
tongue,” macroglossia, partial or total hypertrophy. All forms of
syphilitic lesions may be found upon the tongue (chancre, condyloma,
plaques, papules, fissures, rhagades, ulcers, gumma, etc.) “Smooth
atrophy” of the base of the tongue is regarded by various authors as
pathognomonic of tertiary or congenital syphilis. Cysticercus and
echinococcus are very rare.
3. =Pharynx.= Normal mucosa is smooth and gray-red. Note contents,
color and character of mucosa, atrophy, congestion, œdema, exudations
(mucous, purulent, croupous, diphtheritic, thrush), ulcers, scars,
hyperplasia of lymph-follicles, adenoids, various forms of acute and
chronic pharyngitis, retropharyngeal abscess, syphilis, tuberculosis,
neoplasms (nasal polypi, lymphosarcoma, leukæmic lymphocytoma,
aleukæmic lymphocytoma, carcinoma, retropharyngeal dermoids, lipoma,
cysts, fibroma, chondroma, etc.), glanders, leprosy, actinomycosis,
rhinoscleroma, cysticercus and echinococcus.
4. =Tonsils.= Size (how far do they project?), smooth or showing
depressions, color (normally uniformly gray-red), atrophy,
hypertrophy, hyperkeratosis, various forms of inflammation (acute and
chronic tonsillitis, diphtheria, angina superficialis, lacunaris,
follicularis, pseudomembranosa, purulenta and phlegmonosa, tonsillar
ulcers, cysts and abscess), syphilis, tuberculosis, actinomycosis,
thrush, concretions, neoplasms (carcinoma, primary is rare, secondary
from primary in tongue or larynx more common; lymphosarcoma or
lymphocytoma, either aleukæmic or leukæmic, is the most common
neoplasm of the tonsil, other forms of sarcoma and connective-tissue
tumors are rare), cysticercus and echinococcus are rare.
5. =Nose.= If the brain is not removed and the nasal tract not
examined by the method of Harke, as much of the nose as possible
should be inspected, and the various conditions noted, as described
in Chapter VI.
6. =Oesophagus.= Contents, size (dilatation, stenosis, diverticula),
color and character of mucosa (normally smooth, transparent, pale,
grayish-white, often hypostatic on posterior surface), inflammation,
swelling of mucosa, leukoplakia, œdema, erosions, ulcers, action of
corrosive poisons, perforation, foreign bodies, varices (cirrhosis,
splenic anæmia), hemorrhage, aneurismal erosion, infective
granulomata (tuberculosis, syphilis and actinomycosis are all rare),
neoplasms (benign are rare, sarcoma rare; carcinoma most common
usually at the lower or middle third), parasites (thrush the most
important infection). Postmortem softening of the œsophagus from the
regurgitation of stomach-contents must not be mistaken for pathologic
conditions. Oesophagomalacia is of the rarest occurrence during life.
7, 8. =Larynx and Trachea.= Nature of contents, character and
position of _epiglottis_ and _plicæ aryepiglotticæ_ (the latter
should be thin; greatly thickened in inflammation and œdema),
mucosa (normally gray-red and smooth); _vocal cords_ (position and
relations as viewed from above; should be thin and tendon-like;
mucosa thickened in inflammation and œdema; may be atrophic),
œdema, inflammation, diphtheritic membranes, ulcers, syphilis,
tuberculosis, leprosy, glanders, actinomycosis, rhinoscleroma,
neoplasm, foreign-bodies, etc. An extreme œdema of the glottis may
disappear after death, and its occurrence be shown only by the
wrinkled appearance of the mucous membrane. Anomalies are rare,
the most common being a laryngocele. In typhoid fever erosions and
ulcers are not rare in the larynx. In small-pox ulcers, diphtheritic
inflammations and hemorrhages may occur. The most common tumor is
the fibroma or fibro-epithelioma (papilloma), occurring particularly
in children and singers (“children’s nodule,” “singer’s nodule”).
Angioma, myoma, lipoma and chondroma are rare. Thyroid adenoma, the
so-called “amyloid-tumor” and adenoma of the mucous glands are rare.
Sarcoma is also rare. Lymphosarcoma and leukæmic infiltrations are
not common. Primary carcinoma is more frequent than sarcoma, but
is relatively rare. It occurs most frequently in men, arising on
the true vocal cords, and is squamous-celled. In trichinosis the
laryngeal muscles usually show an early and abundant invasion. The
most important pathologic conditions of the trachea are anomalies
(diverticula, fistula, tracheocele), inflammation (catarrhal,
membranous, pseudomembranous), tuberculosis, syphilis, secondary
erosions, ulcers and perforations (tumors of thyroid, cancer of
œsophagus, tuberculosis and suppurating lymphnodes, aneurisms),
stenosis, compression from enlarged thyroid, thymus or lymphnodes,
dilatation, tracheotomy, intubation, and neoplasms (relatively rare).
The cartilages of both trachea and larynx should be examined for
inflammation, pigmentation, etc.
9. =Thyroid.= _Weight_ is 30-60 grms. The _dimensions_ of the lateral
lobes are: Length 5-7 cm., breadth 3-4 cm., thickness 1.5-2.5 cm.
They should be symmetrical. Note variation in _form_, character of
_cut-surface_ (normally glassy, granular and yellowish-pink). The
colloid is transparent, yellow or brown in color, and rises above
the cut-surface. Cysts of varying size are very common, likewise
encapsulated adenomata. A firm, yellowish, moderately enlarged
thyroid is often seen in cases of pulmonary tuberculosis. Increase
of the stroma with hyaline change and calcification is common.
The most important pathologic conditions of the thyroid are:
_goitre_ (struma diffusa, nodosa, maligna, benigna, parenchymatosa,
hyperplastica, adenomatosa, colloides, gelatinosa, cystica,
vasculosa, fibrosa, hæmorrhagica, calculosa, ossea, amyloides,
inflammatoria, etc.), _inflammation_ (thyreoditis simplex, purulenta,
abscess), _neoplasms_ (carcinoma the most common form of malignant
tumor, sarcoma not rare, adenoma and cystadenoma very common,
combinations of sarcoma and carcinoma have been observed; other forms
rare), _granulomata_ (tubercles and gummata are rare), _parasites_
(echinococcus). Especial examination should be made of the thyroid
in cretinism, myxœdema, all forms of cachexia of unknown etiology,
infantilism, lymphatic constitution, unexplained death, rachitis,
chondrodystrophia, acromegaly, giantism, idiocy, etc. In marked
constitutional disturbances conditions of athyreosis, thyreoplasia
and hyperplasia of the thyroid may play an etiologic rôle. Accessory
thyroids are not uncommon in the neck, in the supraclavicular fossæ
and behind the sternum. They usually show the structure of fœtal
adenomata, but may become cystic or undergo carcinomatous change.
10. =Parathyroids.= These organs are usually four in number,
sometimes more, sometimes only one or two. They are usually paired,
and are found near the inner posterior borders of the lobes of the
thyroid, near the two terminal branches of the inferior thyroid
artery. They vary in size from 3-15 mm. in length, 3-4 mm. broad,
by 1-2 mm. in thickness. They are normally brown in color, and
soft in consistence. It is often difficult to distinguish them
from the hæmolymph nodes that are common in this region. The
parathyroids should be examined in all cases of tetany, paralysis
agitans, acromegaly, epilepsy, infantile atrophy, myotonia and
obscure cachexias. Conditions of supposed hypoparathyreosis have
been reported. Hypertrophy of the parathyroids has been observed in
acromegaly. Adenoma has been described by several writers. Cysts,
fatty degeneration, fatty infiltration, colloid degeneration, cloudy
swelling and tuberculosis have been reported as occurring.
11. =Cervical Lymphnodes.= Note _number_, _size_, _color_,
_consistence_, _character of cut-surface_, etc. The most important
pathologic conditions are: tuberculosis, secondary carcinoma,
Hodgkin’s disease, lymphosarcoma (leukæmic and aleukæmic), various
forms of inflammation, dermoid and epidermoid cysts, cystic
lymphangioma (congenital cystic tumor of the neck), branchiogenic
carcinoma, and hyperplasia in syphilis, rachitis and status
lymphaticus. In acute inflammation the lymphnodes are red and soft;
in chronic inflammation they are usually grayish-white and firm.
12. =Salivary Glands.= The _parotid_, _submaxillary_ and other
_salivary glands_ are examined as to _size_, _color_, _consistence_
and _character of cut-surface_. The most important conditions are:
parotitis (epidemic and secondary), chronic inflammation, calculi,
cystic dilatation of ducts [ranula], Ludwig’s angina, salivary
fistula, granulomata (tuberculosis, syphilis and actinomycosis),
neoplasms (most common forms are the mixed tumors containing
cartilage, fibrous connective-tissue and myxomatous tissue and cords
or rows of cells regarded by some observers as endothelial, by
others as epithelial; other less common tumors are adenoma, fibroma,
carcinoma and sarcoma). Symmetrical enlargement of the salivary
and lachrymal glands occurs as the result of aleukæmic or leukæmic
lymphocytoma (“Mikulicz’s disease”).
13. =Cervical Vessels and Nerves.= Examine the arteries and
veins, noting contents, thickness and character of walls, size of
lumen, changes in the intima, sclerosis, atheroma, calcification,
thrombosis, embolism, etc. In death from strangulation or hanging the
intima of the carotids may be torn. The _aorta_ is usually examined
after the section of the neck-organs. Note size of lumen. In the
adult it usually admits the index-finger or thumb. The circumference
of the thoracic aorta is 4.5-6 cm.; that of the abdominal aorta
is 3.5-4.5 cm. Note its elasticity, contents, thickness of wall,
changes in intima, etc. Fatty degeneration of the intima, sclerosis,
atheromatous plaques and ulcers, calcification and thrombosis are
the most common conditions. Syphilis is a very common cause of
mesaortitis, shown by linear or radiating depressions of the intima.
The _carotid gland_ (paraganglion intercaroticum) at or near the
division of the carotids should be noted. It is about the size of
a rice-grain, oval, vascular and of firm consistence, resembling
very much the superior cervical ganglion. Alveolar tumors apparently
primary in this gland have been observed by a number of writers. Its
epithelial nature is denied by some observers who class it with the
sympathetic system. The _nerves_ and _ganglia_ should be examined
and any change from the normal noted, such as atrophy, effects of
pressure, involvement in scar-tissue, hæmorrhage, inflammatory
processes, neoplasms, etc.
14. =Deep Muscles of Neck.= Note same conditions in these muscles as
mentioned above for abdominal and thoracic muscles. Retropharyngeal
abscesses and hemorrhages resulting from fractures and luxations of
the vertebræ are the most common conditions.
15. =Cervical Vertebrae.= Anterior surface should be smooth.
Fractures, luxations and tuberculosis are the most common conditions.
In caries of the vertebral bodies the surfaces become rough and
sharp. In luxations irregular prominences and deviations are found.
The prominent portion usually shows sharp edges.
CHAPTER X.
THE EXAMINATION OF THE ABDOMEN.
I. METHODS OF EXAMINATION.
The preliminary general inspection of the peritoneal cavity was made
after the main incision. (See Chapter VII.) After the examination
of the neck and thoracic organs has been completed, the abdominal
organs are removed and examined separately. The method to be followed
must be varied to meet the conditions. In the case of extensive
carcinomatosis, general peritonitis, peritoneal tuberculosis,
pseudomyxoma peritonei, etc., when adhesions are numerous and the
abdominal organs matted together, the examination becomes very
difficult, and it may be necessary to remove the abdominal organs
_en masse_ and dissect them on the table. If the œsophagus and aorta
have not been removed from the thorax they are stripped down to the
diaphragm, which is cut on both sides, so that aorta, œsophagus and
the abdominal organs en masse can be stripped down to the brim of the
pelvis and there cut off to be examined outside the body.
For the ordinary autopsy the following order of examination of the
abdominal organs is recommended: The spleen is first examined. It
is lifted up from beneath the left under-surface of the diaphragm
by tearing or stretching the ligamentum phrenico-lienale and the
gastrosplenic omentum. In the case of wandering spleen the technique
of removal must be modified to suit the conditions. When the spleen
is very soft great care must be taken not to tear or rupture it.
When adhesions to the diaphragm are present these must be torn or
cut. The spleen is then laid upon the left edge of the ribs. In this
position it may be sectioned by an incision made from upper to lower
pole, and then, after it has been examined, it is allowed to slip
back into the abdominal cavity, when its removal from the body is not
desired. If it is to be removed and examined outside of the body,
its ligaments and vessels are cut with the knife directed against
the edge of the ribs, taking care not to cut the stomach or tail of
the pancreas. It is then weighed and measured, and examined by means
of a chief incision through its convex surface, from upper to lower
pole, and reaching to the hilus. Parallel sagittal or transverse cuts
may be made as desired. The cut surface is then thoroughly examined.
Bacteriologic examinations should be made when indicated, before
the organ is sectioned. A portion of the capsule is seared and the
pipette introduced through the seared area.
The =intestines= are examined next. They may be opened inside the
body without separating them from the mesentery, but the best method
by far is to remove and open them outside of the body. The middle
portion of the transverse colon is lifted up by the left hand and
the ligamentum gastrocolicum and the mesocolon transversum cut close
to the intestine, toward the left, separating the left half of the
transverse colon, then the splenic flexure and the descending colon
and the sigmoid flexure to the rectum. After the splenic flexure has
been separated the descending colon can usually be stripped down to
the sigmoid by the hands without using the knife. When the sigmoid
has been freed from its mesocolon two ligatures are put around the
upper portion of the rectum, about an inch apart, and the intestine
is then cut between the ligatures. The freed portion of the large
intestine is then carried over into the right side of the abdomen
and as much of the lower portion as is possible is put into a pan or
tray resting upon the cadaver’s right thigh. The right half of the
transverse colon, the hepatic flexure and the ascending colon are
now freed down to the beginning of the ileum, care being taken not
to cut off the appendix when loosening the cæcum. The entire large
intestine is then gathered into the tray resting on the cadaver’s
thighs, and the intestine is pulled down firmly by the left hand in
a line corresponding to the main axis of the right thigh. The coils
of small intestine are left in their natural position. The ileum is
then severed from the mesentery as follows: The intestine is pulled
by the left hand straight down in the middle line of the right thigh,
putting the mesentery on a stretch. The long section-knife is used
by the right hand to cut the mesentery close to the intestine in a
manner resembling the use of the bow in violin-playing. The blade
of the knife is held slightly obliquely against the mesenteric
insertion of the intestine, and as the left hand pulls up the coils
of intestine against the knife, the latter in the bowing or sawing
movement severs the mesentery from the intestine as close to its
insertion as is possible without cutting the intestine. The freed
portions of intestine are caught in the tray resting on the thighs,
and the left hand grasps in succession new portions of the small
intestine and pulls them against the knife until the entire intestine
is freed up to the duodenum and the root of the mesentery. A double
ligature is put around the jejunum and the intestine severed between
the ligatures, and the freed jejunum, ileum and large intestine
are now removed in the tray for examination. The severing of the
intestine from the mesentery in this manner can be carried out very
quickly after a little practice. Care must be taken to cut the
mesentery as close as possible to the intestine without nicking the
latter. If too much mesentery is left on the intestine it cannot be
laid out straight and its opening is made more difficult. If the
coils of the small intestine are left in their natural position,
and if the ileum when it is first taken up by the left hand is
not twisted, the coils will unroll before the knife without any
difficulty. Some prosectors begin with the jejunum, ligating it at
the point where it comes out from beneath the mesentery, cutting it
between the ligatures and separating it from the mesentery downward
until the entire intestine as far as the rectum has been freed. The
latter is ligatured and the freed portions removed. When the saving
of time is of great importance the large intestine may be freed as
described above, a ligature put around the upper end of the jejunum,
and the mesentery severed at its root, so that the entire mass of
small intestine with its mesentery is removed for further separation
from the mesentery outside of the body. When peritoneal adhesions
that cannot be easily torn are present it may be necessary to remove
the intestines with mesentery attached.
After the removal of the intestines from the body they are opened
by the intestinal shears, beginning either with the jejunum or the
large intestine, the cut being made in the line of the mesenteric
attachment. As the intestine is opened careful attention should be
paid to the contents of each portion. It is very poor technique to
dilate the intestine with water or to run water through it before
it is opened. There is danger of washing away parasites, blood,
etc. When the intestine is distended the opening is easy, but when
collapsed it can be more easily opened if an assistant straightens
it out and holds it on the stretch in advance of the enterotome. It
may be opened on the table, in the tray, or in a pail. The latter
method is a clean and convenient one. As the intestine is opened it
is passed on the flat beneath the handle of the pail as it rests on
the rim, so that the intestinal contents are scraped off into the
pail and the clean mucosa examined as it is pulled from the pail into
a basin or tray. The ileocæcal valve should be carefully examined
from above before it is cut through. The appendix may be opened from
the intestine by the small probe-pointed shears, the cut being made
on the side opposite the mesenteric attachment. Transverse sections
can be made, if desired. When the intestines are opened within the
body, the enterotome is introduced into an opening made in the ileum
just above the ileocæcal valve and the intestine is cut upward to the
duodenum, along its mesenteric attachment, the coils being drawn upon
the probe-pointed blade of the enterotome with the left hand. After
the small intestine is opened the enterotome is introduced through
the ileocæcal opening and the large intestine cut in the anterior
tænia as far as the rectum. The opening of the intestine within the
body should be left until all the other abdominal organs have been
examined, because of the disagreeable mess made by the escape of the
intestinal contents into the cavity.
The =duodenum= is opened next. The curved scissors, or the
enterotome, is introduced into its lower end through an opening
made above the ligature, and the inferior and descending portions
of the duodenum are cut in the middle line of the anterior wall.
The superior portion is then cut up to the pylorus, the cut passing
through the inferior wall of this portion, the enterotome being
held in the axis of the canal and pylorus, while the duodenum is
pulled over to the right by the left hand. Before the pylorus is
cut it should be explored, as to its width or constriction, by the
index-finger of the left hand. The duodenum may also be opened
first in the lower part of the descending portion. The root of the
mesentery is pushed over to the left and a fold of the anterior wall
is picked up by the thumb and index-finger of left hand and cut with
the shears, so that when let free by the left hand there is formed
a longitudinal incision in the duodenal wall large enough to admit
the long blade of the enterotome. The duodenum is then cut up to
the pylorus as described above. The inferior part of the duodenum
is then opened from the point where the first incision is begun.
The duodenum may also be opened downward, beginning at the pylorus,
a small transverse cut being first made in the stomach wall just
above the pylorus and the stomach opened along the greater curvature
as far as the cardia. The enterotome is then placed through the
pylorus and the duodenum cut in the median line of its anterior
wall throughout its entire length. When the duodenum is opened, the
_papilla_, the _ductus choledochus_ and the _ductus Wirsungianus_ are
to be carefully examined. The papilla can usually be easily found
by stretching the duodenal mucosa transversely over the head of the
pancreas. It lies below the middle of the head of the pancreas, and
about four finger-breadths below the pylorus. Pressure should be made
upon the gall-bladder to force bile through the duct and papilla,
and thus demonstrate their patency. When this cannot be done a sound
should be introduced, and the common duct opened into the hepatic
and cystic ducts. If the duodenal mucosa just below the papilla be
stretched forcibly downward the duct can usually be opened by the
small scissors without the aid of a grooved director. The duct of
Wirsung may be explored with the sound from the papilla to the left
of the common duct, or from its separate opening when the two ducts
do not open in common. Both the bile-duct and the duct of Wirsung
may be opened in the opposite direction, from the liver and pancreas
respectively.
The =stomach= is opened from the pylorus after the size of the latter
has been ascertained. The anterior wall may be cut midway between
the greater and lesser curvatures, or the cut may follow the greater
curvature, extending through the cardia into the œsophagus. As the
stomach is opened its contents are inspected and removed. They
should not be allowed to escape into the abdominal cavity. When the
organs are removed _en masse_ the stomach may be opened from the
cardiac end. The organ may also be opened by an incision through its
posterior wall or along its lesser curvature, as occasion may demand.
If it is desired to save the pyloric ring the incision may stop
above or below it and begin again on the other side. The stomach,
with the lower portion of the œsophagus and the superior portion of
the duodenum, may be separated from their attachments and examined
outside of the body.
The =pancreas= is examined by turning the stomach toward the
thoracic cavity, cutting or tearing the gastrocolic omentum, and
cutting the exposed organ by a longitudinal incision through head,
body and tail, or by means of parallel transverse incisions made
through the different parts of the organ. The ducts of Wirsung and
Santorini should be explored. It must be freed from the duodenum
before it is weighed. The pancreas may be removed in connection with
stomach, duodenum and liver and examined outside of the body. This
is advisable in all cases of perforation of the stomach, ulcer,
carcinoma and surgical anastomoses, carcinoma of pancreas, acute
pancreatitis, obstruction of common duct, duodenal ulcer, etc.
The =liver= may be examined in the body without removal. The left
hand is put between the diaphragm and the convex surface of the
right lobe of the organ, and the liver raised up out of the cavity.
With the long section-knife a main incision is made deep into the
organ, from left to right, about a hand’s-breadth above the lower
border. Parallel incisions to the main incision may be made. After
the examination of the cut surface the organ is dropped back into the
abdomen. When the liver is to be weighed and measured it is removed
from the body by cutting first the ligamentum hepatoduodenale,
examining, as they are cut, the _common duct_, _hepatic artery_
and the _portal vein_. The left lobe of the liver is then taken in
the left hand and raised as high as possible. The left triangular
ligament, the left half of the coronary ligament, the suspensory
ligament, the right half of the coronary ligament and the right
triangular ligament are cut from left to right. The inferior vena
cava is cut at the same time. In the case of adhesions between liver
and diaphragm these must be cut or the diaphragm itself removed
in connection with the liver. In such a case the diaphragm must
be trimmed off before the liver is weighed. The liver may also be
removed in the opposite direction, raising up the right lobe and
severing all connections as far as the median line of the spinal
column. The right lobe is then pulled upon the right edge of the
thorax-wall, and the connections with the left lobe are severed. In
separating the under surface of the right lobe care must be taken not
to damage the right adrenal. The liver is then weighed and measured,
and placed upon the board with the right lobe toward the prosector. A
long, deep cut is then made by drawing the long-section-knife across
the left and right lobes, extending the cut through to the porta.
Additional cuts may be made parallel to this chief-incision. When
occasion demands a number of sagittal incisions may be made instead.
As mentioned above, it is often best to remove the liver with
stomach, pancreas and duodenum and examine on the table.
The =gall-bladder= is opened from its fundus with the fine
probe-pointed shears; its contents are caught in a vessel and
examined. The cystic, hepatic and common ducts may be explored
from the gall-bladder, if they have not been from the intestine.
The gall-bladder may be dissected from the liver and removed in
connection with the duodenum.
The =portal vein= is opened into its radicles; the examination of the
splenic vein is of especial importance. The =portal lymphnodes= are
examined at this time.
The =mesentery= and the =mesenteric lymphnodes= are now examined. The
former may be cut off at its root and examined outside of the body.
The lymphnodes may be opened by longitudinal or transverse incisions.
The left =adrenal= and =kidney= are now examined. If the pancreas
and stomach have not been removed from the body they are turned over
toward the thoracic cavity, so as to expose completely the left
adrenal. The movability of the kidney is then tested. Beginning
above the adrenal an incision is made through the peritoneum and
underlying tissue, curving outward around the kidney and downward to
its lower pole, taking care not to bring the incision too far around
the lower pole of the organ for fear of cutting the ureter. The knife
is then laid aside, and the adrenal and kidney are pulled upward
toward the median line until they are entirely free save for the
blood-vessels and ureter. The loose tissue about the fatty capsule
of the kidney is usually easily separated. The blood-vessels are
then cut from above downward against the spinal column, the ureter
being left uncut. Holding the kidney in the two hands, it is pulled
downward toward the pelvis, stripping the ureter free as far as
the pelvic brim. At this level the ureter may be cut, or, if it is
desired to remove the kidneys in connection with the pelvic organs,
the ureter is left uncut and the kidney laid over the pubis until the
pelvic organs are removed. When the kidney and adrenal are removed
they are placed upon the board and the adrenal separated. The latter
organ is then examined by means of parallel transverse incisions, or
by an incision in its longest axis in the middle of its flat surface.
When the adrenal is left in the body it may be examined by means
of the same incisions. The fatty capsule is then stripped from the
kidney and the organ weighed and measured. It is then held in the
palm of the left hand with the ureter between the middle fingers, the
convex border up, the thumb placed on one flat surface, the fingers
on the other, holding the organ tightly. The kidney is then opened by
means of a long incision made with the long section-knife, beginning
at the upper pole, drawing the knife through the convexity, to the
lower pole, and extending the cut through the organ to the pelvis.
As the knife approaches the hilus the grasp of the left hand upon
the organ is loosened and pressure upon the knife lessened so as not
to cut through the hilus. The edges of the fibrous capsule are then
caught by the fingers or forceps and the capsule stripped from the
cortical surfaces. The external surface and the cut surfaces are then
examined. When indicated other incisions into the kidney substance
may be made. The ureter is sounded from the pelvis, and opened with
the fine probe-pointed shears. The renal artery and vein may be
examined now, or better when the kidney is being removed.
The =right adrenal= and =kidney= are removed in the same way, by
making a curved incision around the outer border of the organs,
pulling them up toward the median line and cutting the blood-vessels
from above downward against the spine, and then stripping the ureter
downward to the pelvis. After removal the adrenal is separated from
the kidney and examined as directed above for the left adrenal. The
kidney and ureter are then examined in the same way as on the left.
When it is desired to remove the right kidney with the pelvic organs
the same procedure is carried out as advised above in the case of the
left one. In the removal of the right adrenal care should be taken
not to injure the vena cava. In the case of displacement of either
kidney the incisions for the removal of the organ must be altered to
suit the case.
When the kidneys are removed before the examination of the
intestines and liver, the removal of the left adrenal and kidney
usually follows the examination of the spleen. The small intestines
are pulled over to the right; the peritoneum is incised over the
left kidney between the descending colon and the spinal column so
that the right hand can be worked beneath the peritoneum up above
the adrenal and kidney, freeing them, and lifting them toward
the median line. The vessels are then cut as directed above, and
the ureter stripped down to the pelvis. On the right side the
cæcum and ascending colon are raised and a cut made through the
peritoneum at the brim of the pelvis. The cæcum, ascending colon
and peritoneum are now stripped upward with the left hand until the
right hand can be passed up above the right adrenal to loosen it
and the kidney toward the median line. When this is accomplished
the adrenal and kidney are held in the left hand, while the right
cuts the blood-vessels from above downward against the spine,
sparing the ureter, which with the two organs is stripped downward
to the pelvic brim. The close proximity of the right adrenal to
the under surface of the liver makes the removal in this way much
more difficult than when the liver is removed first. Usually, when
the method of removing the kidney after the spleen is adopted, the
adrenal is left in the body until after the removal of the liver.
So many variations in the order of section of the abdominal organs
are given by different writers that it is impossible to escape
the conclusion that the best order is the one best adapted to the
individual case. A very common order is _spleen_, _left adrenal_
and _kidney_, _right adrenal_ and _kidney_, _duodenum_, _stomach_,
_pancreas_, _liver_, _intestines_, _pelvic organs_ and _genitalia_.
Beneke advises the removal of spleen, then the removal of the
entire intestines, stomach and pancreas, in connection with the
gall-bladder, which is stripped from the liver and removed in
connection with common duct and duodenum, the whole mass removed
from the body and examined outside. Other prosectors begin with the
_liver_, then the _spleen_, _urinary bladder_ and _kidneys_ and
_genital organs_, the _gastro-intestinal tract_ being left to the
last. It may then be opened inside the body without inconvenience
resulting from the escape of its contents into the peritoneal
cavity. After surgical operations when permission for autopsy
is refused, the abdominal, and also the thoracic organs, may be
removed through the laparotomy wound.
After the examination of the abdominal viscera is completed the
=abdominal aorta= is opened in the median line of its anterior wall
and followed into its branches, the iliacs and hypogastrics. When
occasion demands it may be stripped from the spine and opened outside
of the body. The =inferior vena cava= is also opened throughout
its length and followed into its branches. The abdominal portion of
the =thoracic duct= should receive attention before the aorta is
removed. The receptaculum chyli is found by lifting up the right edge
of the aorta at the level of the second or third lumbar vertebra
and dissecting out the duct up to its thoracic portion. It may then
be opened by the fine probe-pointed shears. The =retroperitoneal
lymphnodes= and =haemolymphnodes= are examined _in situ_, or removed
with the blood-vessels and examined outside of the body. The
=sympathetic ganglia=, particularly the _suprarenal_ and the _cœliac
plexuses_, and the _splanchnic nerves_ are to be examined, especially
in cases of Addison’s disease. The section of the abdomen closes
with the examination of the =ileopsoas muscles= and =diaphragm= by
means of longitudinal or transverse incisions, and the inspection of
the =vertebrae=. Pathologic conditions in the latter are examined
according to indications.
II. POINTS TO BE NOTED IN THE EXAMINATION OF THE ABDOMEN.
1. =Peritoneum.= Normally the peritoneum is moist-shining, grayish
and translucent. It is cloudy, dry, lustreless, injected, swollen
or covered with exudate in acute inflammation; thickened, hyaline
(“iced” or “Zuckerguss”) in chronic inflammation. Note degree,
character and location of adhesions. The most common pathologic
conditions are inflammation, tuberculosis, secondary carcinoma
and pseudomyxoma peritonei. Lymphomata are found in cases of
typhoid fever and in leukæmia. Primary neoplasms (lymphangioma,
endothelioma, carcinoma, lymphosarcoma, angiosarcoma, etc.) are
rare. Ovarian cysts of the structure of cystadenoma may give rise
to implantation-metastases over the peritoneum. The parasites are
echinoccocus and cysticercus.
2. =Spleen.= Weight 150-250 grms., length 12 cm.; breadth 8 cm.,
thickness 3 cm. Varies greatly in size and weight. Describe shape,
character of borders, number of notches, etc. Accessory spleens
are common in the gastrosplenic omentum. _Capsule_ should be
delicate, smooth, shining and transparent. Note _tension of capsule_
(loose, wrinkled, tense), adhesions, hyaline thickenings, exudates
or neoplasms. _Color_ of spleen through capsule is bluish-red.
Fresh anæmic infarcts appear as yellowish or reddish-yellow areas
surrounded by a darker red zone. Cicatricial depressions on the
surface of the spleen are usually the result of healed infarcts.
_Consistence_ of spleen normally is that of muscle. In acute
hyperplasias and congestions the spleen is softer and more friable
(acute infections, typhoid fever). In chronic hyperplasias and
congestions, atrophy, amyloid degeneration, etc., the consistence is
firmer than normal, even to that of a wooden hardness in advanced
amyloid disease. (Apply iodin test.) The large, firm spleen is
characteristic of leukæmia, splenic anæmia, syphilis and chronic
malaria. On section note the _pulp_, _follicles_ and _trabeculæ_. In
the normal spleen the cut surface is dark red or bluish-red, smooth,
and the trabeculæ and follicles easily seen. In acute hyperplasias
the pulp swells up over, the trabeculæ as a thick red or grayish-red
gruel-like substance. In chronic hyperplasias the pulp is atrophic,
grayish-red, and firm. In subacute hyperplasias the cut-surface often
presents a shagreened appearance. The _color_ of the cut-surface
is blood-red in typhoid fever, grayish-red in septicæmias,
chocolate-brown in potassium-chlorate poisoning and hemosiderosis
due to other causes. In amyloid spleen the amyloid portions are
glassy; when confined to the follicles the latter look like grains
of boiled sago. The _follicles_ are about the size of medium
pin-heads, grayish in color, not elevated and cannot be scraped
out with the knife. They are more numerous and larger in young
individuals than in adults. Note size and number, degenerations,
etc. The _trabeculæ_ appear as fine gray lines, sharply outlined,
increasing in size toward the hilus and capsule. They are more
distinct in atrophy and chronic hyperplasias. In anthracosis of
the spleen black granules are seen in the pulp, particularly about
the trabeculæ. Tubercles appear as grayish-white, semitranslucent
nodules, elevated above the surface, and can be scraped out with the
knife-point. When caseation has begun their centres are opaque and
yellowish. Gummata are grayish-white, with opaque centers, and have
a periphery of vascular granulation-tissue or hyaline scar-tissue.
The most important pathologic conditions of the spleen are: acute
and chronic passive hyperæmia, embolic infarctions, abscess, acute
and chronic hyperplasias (typhoid, malaria, plague, pneumonia,
septicæmia, leukæmia, pseudoleukæmia, splenic anæmia, hepatic
cirrhosis, syphilis, Kala-azar, other forms of tropical splenomegaly,
tuberculosis, rachitis, idiopathic splenomegaly of the Gaucher type,
etc.), wandering spleen, absence of spleen, amyloid disease, atrophy,
syphilis, tuberculosis, actinomycosis, traumatic rupture, cysts
(peritoneal), neoplasms (primary are rare [angioma, angiosarcoma,
fibroma, chondroma, osteoma, lymphangioma, endothelioma]; secondary
sarcoma [chiefly lymphosarcoma and melanosarcoma] and carcinoma
are also infrequent; secondaries of malignant syncytioma are
more frequently found), parasites (echinococcus, cysticercus and
pentastomum).
3. =Intestines.= In the examination of the _large intestine_,
_appendix_ (average length about 9 cms.), _small intestine_ and
_duodenum_ note the _contents_ of the various portions with respect
to amount, color, odor, consistence, presence or absence of bile,
food-remains, parasites, foreign-bodies, blood, pus, concretions,
etc. Note _character of wall_, _size of lumen_, _color_ (normally
gray) and _character of mucosa_, _folds_ and _villi_, _solitary
follicles_, _Peyer’s patches_, _mouths of bile-duct_ and _pancreatic
ducts_, _ileocæcal valve_ and _opening into appendix_. Postmortem
digestion of the mucosa, often leading to perforations, postmortem
hypostasis, imbibition of bile, pseudomelanosis, and contractions
of portions of the bowel must not be mistaken for pathologic
conditions. Redness of a portion of the intestine does not in itself
mean inflammation; the latter condition is shown by excess of mucus,
swelling of the mucosa, hyperplasia of the follicles, hæmorrhage,
etc. The contents of the small intestine are usually gruel-like in
consistence, thinner in the upper part, thicker toward the ileocæcal
valve. The _hook-worm_, _ascaris lumbricoides_ and _intestinal
trichina_ occur in the duodenum; _tænia solium_, _saginata_ and the
_bothriocephalus latus_ in the jejunum and ileum, _tricocephalus
dispar_ in the cæcum, and _oxyuris vermicularis_ in the large
intestine and rectum. _Ulcers_ of the intestine may be due to typhoid
fever, tuberculosis, carcinoma, dysentery, embolism or thrombosis
of mesentery vessels, etc. Diphtheritic ulcers are caused by a
variety of infections and poisons. They are usually found in the
large intestine, but occasionally occur in the small intestine in
cases of uræmia. Typhoid ulcers usually have their longest diameter
parallel with the longitudinal axis of the intestine; tuberculous
and carcinomatous ulcers usually encircle the intestine, forming
“ring ulcers;” diphtheritic and dysenteric ulcers are irregular,
involving the surfaces of the folds. Solitary round or peptic ulcers
occur in the duodenum and jejunum. Decubital ulcers, associated
with fécal concretions, gall-stones or foreign-bodies are found in
appendix and rectum most commonly, more rarely in other portions of
the intestines. _Perforations_ of the intestines may be traumatic, or
due to infections (typhoid, tuberculous, purulent, dysenteric, etc.),
neoplasms (carcinoma), embolic gangrene, ileus, fécal impaction,
erosion of calculus or foreign-body, parasites (round-worm?),
over-distention, etc.
The most important pathologic conditions of the intestines are:
anomalies (atresia, diverticulum, stenosis, dilatation, hernia),
acute and chronic passive congestion, hæmorrhage, stasis, embolism
and thrombosis, hæmorrhagic infarction, gangrene, traumatic
injuries, ileus, volvulus, strangulated hernia, enteritis
(catarrhal, follicular, hyperplastica, cystica, purulent, ulcerative,
croupous, diphtheritic, dysentery, cholera, typhoid, etc.),
appendicitis (catarrhal, ulcerative, perforative, obliterative),
tuberculosis, syphilis (chiefly in rectum, ulcers, stenosis and
perforations), actinomycosis, anthrax, intestinal sand, concretions,
foreign-bodies, and neoplasms (primary carcinoma the most
important [adenocarcinoma, colloid, scirrhous, medullary, etc.],
most frequent in large intestine and rectum, secondary carcinoma
is rare; adenomatous polypi are common, particularly in rectum;
primary sarcomata [lymphosarcoma chiefly] are much less common than
carcinoma, secondary sarcoma more common than primary [melanotic
sarcoma, lymphosarcoma]. Benign connective-tissue tumors [lipoma,
fibroma and myoma] are relatively rare. Primary carcinoma and sarcoma
occur in the appendix, as well as secondary carcinoma). Leukæmic
infiltration is common in leukæmia.
4. =Bile-passages.= Note patency, character of mouth, contents,
etc. The most important conditions are inflammation, gall-stones,
obstruction, stenosis, dilatation, perforation, carcinoma, and
anomalies (in the new-born). Round-worms may obtain entrance and
block the duct.
5. =Stomach.= On the external examination the size (dilatation,
contractions due to scirrhous carcinoma or scars), shape (hour-glass,
etc.), position, color of surface, consistence of wall, presence of
adhesions, etc., should be noted. When the stomach is opened note
presence of _gas_ (odor), _character of contents_ (fluid, gruel-like,
food-remains, curds, foreign bodies, mucus, pus, blood, parasites,
drugs, etc.), _odor_ (yeasty, sour, acid, sweetish, foul, H_{2}S,
odor of foods or drugs), _reaction_ (acid or alkaline), _color_
(yellow, greenish, grayish, brown, black, bloody, etc.) Describe
the character of mucus on the mucosa (tough, glassy, difficult to
remove in acute catarrh; softer, grayish or grayish-red, often
containing small black blood-specks in chronic catarrh). Bile gives
a yellow or greenish color. The presence of blood may give to the
stomach-contents the appearance of “coffee-grounds;” in hæmorrhage
by diapedesis the contents may be brownish. Cloudy swelling of the
glands is common in sepsis, chronic anæmia and various poisonings.
It affects cells in deepest portion of glands, as shown by excising
a bit of the mucosa and examining microscopically. The brownish or
black discoloration of the mucosa associated with softening of the
latter (gastromalacia, postmortem digestion) must not be taken for a
pathologic condition. The mucosa becomes soft, cloudy or jelly-like
and strips easily from the whitish submucosa. Softening of the entire
wall leads to perforations that must not be mistaken for pathologic
ones. Their edges show no signs of disease. The normal mucosa is
grayish in _color_. In chronic passive congestion the color may
be dark red. Hypostatic congestion is common in the large veins
of the fundus. Hæmorrhages occur chiefly in the fundus and along
the greater curvature (caused by vomiting). In potassium cyanide
poisoning the mucosa is often rosy-red in color and has a soapy
feel. The normal mucosa is nearly smooth when the folds caused by
contraction are spread out. Localized hyperplasias occur in chronic
gastritis (etat mamelonné) and cannot be smoothed out by stretching.
Erosions (common in chronic passive congestion) and ulcers (round or
peptic, carcinomatous, due to corrosives, very rarely to tuberculosis
and syphilis) are to be carefully examined and described. The
different layers of the stomach wall are to be examined with
respect to their absolute and relative thickness. Thickening of the
submucosa may be caused by œdema, purulent infiltration, increase
of connective-tissue, carcinomatous or sarcomatous infiltration.
Hyperplasia of the muscular coat occurs chiefly at the pylorus in
cases of stenosis.
The most important conditions of the stomach are anomalies
(congenital stenosis of pylorus, situs inversus), acute and chronic
passive congestion (portal stasis), hæmorrhages, hæmorrhagic erosions
(portal stasis), gastritis (acute, chronic, catarrhal, purulent,
fibrinous, diphtheritic, phlegmonous, atrophic, hypertrophic),
tuberculosis (rare), syphilis (rare), anthrax, action of corrosive
poisons (acids, concentrated lye, carbolic acid, mercuric
chloride, silver nitrate, oxalic acid, potassium cyanide), round
or peptic ulcer, perforation, neoplasms (carcinoma the most common
[adenocarcinoma, medullary, scirrhous, colloid]; primary sarcoma rare
[lymphosarcoma], secondary are less rare; metastases of malignant
syncytioma may occur in the stomach wall; benign tumors are rarely
important. The most common are adenomatous polypi, fibroma, myoma and
fibromyoma), stenosis, dilatation, contraction, wounds, concretions,
foreign bodies and parasites (temporary as gordius, round-worms
occasionally enter, intestinal form of trichina).
6. =Pancreas.= Weight 60-100 grms.; measures 17-20 cm. long, 3-4.5
cm. broad, and 2.5-3 cm. thick. _Color_ reddish-grayish-yellow;
_consistence_ firm; _lobules_ distinct. Postmortem change occurs
quickly. The most common pathologic conditions are: atrophy, fatty
infiltration, hyperæmia, hæmorrhage, inflammation (degenerative,
parenchymatous, hæmorrhagic, necrotic, gangrenous, purulent, chronic
fibroid or interstitial [inter- and intra-acinar], cirrhosis of
pancreas), tuberculosis (very rare), syphilis (gumma not common,
interstitial pancreatitis most common form), fat-necrosis, cysts,
congenital cystic pancreas, concretions in duct, hæmosiderosis,
neoplasms (primary carcinoma the most important [scirrhous,
medullary, adenocarcinoma]; primary sarcoma rare; secondary melanotic
sarcoma and lymphosarcoma occur, secondary carcinoma less frequently;
benign tumors rare, cystadenoma being the most common), and parasites
(echinococcus, round-worm in duct). In fat-necrosis or acute
pancreatitis the pancreatic ducts should be examined for obstruction
due to calculi or stenosis. Areas of fat-necrosis appear as opaque,
white, yellow or brown, firm nodules. Accessory pancreatic tissue not
rare in wall of intestine. May occur more rarely in stomach-wall,
omentum or abdominal wall.
7. =Liver.= Weight 1,500 grms.; measures 22 cm. sagittally, 30
cm. transversely and 8 cm. thick. A dimension of over 30 cm. is
enlarged; when all dimensions are under 20 cm. the liver is smaller
than normal. Note _size_ (enlarged in congestion, cloudy swelling,
fatty infiltrations, leukæmia, neoplasms; smaller in atrophy,
acute yellow atrophy, cirrhosis), _changes of form_ (congenital
furrows, deep furrows with thickened capsule in syphilis, fine or
coarse granulations and contractions in cirrhosis, edge rounded in
fatty and amyloid liver, sharper in atrophy, capsule wrinkled in
acute yellow atrophy), _capsule_ (normally smooth and transparent;
thickened, white, and opaque in chronic inflammation, the thickening
being usually most pronounced along the ligaments, blood- and
lymph-vessels. Small, hyaline nodules or patches may be scattered
over the capsule, or the entire capsule may be tendon-like [“iced”
or “Zuckerguss-leber”]. Adhesions with diaphragm, stomach, omentum,
spleen, intestine and abdominal wall may occur. Fibrinous and
purulent exudates may be found on the capsule, particularly on the
diaphragmatic surface; when encapsulated by adhesions they form
the so-called subdiaphragmatic abscess), _consistence_ (increased
in fat-infiltration, cirrhosis, atrophy and amyloid; diminished
in acute parenchymatous degenerations, leukæmia, acute yellow
atrophy, acute congestion; fluctuation is present over abscesses,
echinococcus cysts and softened tumors), _color_ (normally brown-red;
dark-brown in atrophy, dark red or bluish-red in passive congestion,
“nutmeg” appearance in chronic passive congestion, chocolate-brown
in hæmosiderosis, greenish in chronic icterus, yellow in acute
icterus, fatty liver, leukæmia and anæmia, grayish-white or yellow
in cloudy swelling and fatty degeneration; sharply circumscribed dark
bluish-red areas are caused by cavernous angiomata), _cut-surface_
(normally smooth and of uniform color, blood-content abundant, before
the age of puberty lobules are seen with difficulty; in adults
they are recognizable from their yellowish-brown periphery and red
central zones. They are about 1-2 mm. long by 1-1.5 mm. broad. Note
size of lobule, color of central, intermediate and peripheral zones,
distinctness of boundary of lobules, elevation of lobules above
surface. Lobules are elevated in fatty infiltration and in cirrhosis,
depressed in atrophy. In acute yellow atrophy they cannot be made
out. Fatty infiltration begins usually in the peripheral portion
of the lobules, fatty degeneration in the central zone, amyloid
in the intermediate zone, hæmosiderin is found in the peripheral
and hæmatoidin in the central zone. In extreme fatty infiltration
affecting the entire lobule the outlines of the lobules cannot be
made out. The normally shining surface is dull, cloudy, appearing as
if cooked in cloudy swelling and fatty degeneration). Note amount
of stroma; it is increased in cirrhosis, so that the lobules may be
entirely surrounded by connective-tissue, or the connective tissue
may invade the lobules. Note also size and contents of hepatic and
portal blood-vessels and bile-ducts.
The most important pathologic conditions of the liver are acute and
chronic passive congestion, thrombosis of portal veins, atrophy
(simple and brown), fatty infiltration, cloudy swelling, fatty
degeneration, acute yellow or red atrophy, amyloid, phosphorus-liver,
abscess (metastatic, tropical, purulent cholangitis), cirrhosis
(Lænnec’s or atrophic, Hanot’s or hypertrophic, fatty, biliary,
cardiac), pericarditic pseudocirrhosis, tuberculosis, syphilis
(very common: gummata, interstitial hepatitis, cirrhosis, hepar
lobatum), actinomycosis, leukæmic infiltrations, glycogen
infiltration (diabetes), pigmentations (hæmosiderosis in pernicious
anæmia, malaria, hæmolytic poisons, etc., hæmatoidin in atrophy,
bile-pigment in icterus, anthracosis, argyrosis, malaria pigment,
melanin), neoplasms (most common tumor is the cavernous angioma,
usually in old people, rarely of clinical significance; primary
carcinoma and sarcoma rare; secondary very common [melanotic sarcoma,
lymphosarcoma, metastases from carcinoma of gall-bladder and duct,
stomach, pancreas and intestine, metastases of malignant syncytioma],
adenoma and cystadenoma are rare), cysts, congenital cystic liver,
parasites (echinococcus hydatidosus, granulosis and multilocularis,
cysticercus, distomum hepaticum, pentastomum denticulatum, coccidium
oviforme).
8. =Gall-bladder.= Note _size_ (length 8-17 cm., diameter 3 cm.,
thickness of wall 1-2 mm.), _amount_ and _character of contents_
(clear and watery in hydrops, seropurulent or purulent in
inflammation, excess of mucus in catarrhal inflammation), calculi,
bile-sand, thickening and indurations of wall, œdema, character of
mucosa, carcinoma (adenocarcinoma, squamous-celled). Note size,
contents, thickness of wall and character of mucosa of ducts.
9. =Portal Vein.= Note contents, character of wall, occurrence of
stenosis, thrombosis, pylephlebitis, thrombopylephlebitis, syphilitic
changes, calcification, pressure from without.
10. =Mesentery.= Amount of fat, color, condition of vessels,
blood-content, occurrence of œdema, inflammation, abscesses,
hæmorrhages, infarction, gangrene, fat-necrosis, aneurism,
embolism, thrombosis, cysts, parasites (bilharzia hæmatobia),
tumor-infiltrations and primary tumors (lipoma).
11. =Mesenteric Glands.= Size, appearance on section (rose-red
in acute inflammation, grayish-white in chronic), occurrence of
tubercles, secondary tumors, calcification, abscesses, pigmentation,
typhoid necrosis, primary lymphosarcoma, leukæmic hyperplasia,
Hodgkin’s, etc.
12. =Adrenals.= Weight 4-7.5 grms. measurements are 5-6 cm. long,
2.5-3.5 cm. broad, 0.5-1 cm. thick. Normally the consistence is firm;
it is increased in amyloid degeneration, tuberculosis, syphilis,
fibroid induration and atrophy; diminished in hæmorrhage, soft
caseating tubercles, degenerating tumors. Postmortem autolysis
of the medulla takes place very quickly, the cortical portion
remaining as a hollow capsule. On section note the relations of the
grayish-white cortex (more yellow and opaque in adults from the
amount of fat contained in the cells), the intermediate brown zone
and the central grayish, translucent portion of the medulla. The
most important pathologic conditions are tuberculosis, syphilis,
atrophy, compensatory hypertrophy, hæmorrhage, infarction, thrombosis
of adrenal vessels, secondary tumors (melanotic sarcoma, carcinoma),
primary neoplasms (hypernephroma, accessory adrenals typical and
atypical, lipoma, glioma, neuroma, sarcoma), parasites (echinococcus).
13. =Kidneys.= Right kidney weighs 110-145 grms., and measures
10-12 cm. long, 4.5-5.0 cm. broad, and 3-4.5 cm. thick. Left kidney
weighs 150-180 grms. and measures 12 cm. long, 5-6 cm. broad, 3-4.5
cm. thick. The left kidney is usually larger and heavier than the
right. Note position and movability of kidneys, thickness and color
of fatty capsule (increased in lipomatosis, atrophy of kidney),
purulent infiltrations and fibroid thickenings of the perirenal fat.
Normally the fibrous capsule is thin and translucent, easily stripped
off, the inner layer remaining attached around the blood-vessels
passing from capsule into cortex. The capsule is adherent in chronic
inflammations and over healed infarcts and localized inflammatory
processes, tubercles, tumor-nodules, etc. Note alterations in
_shape_ and _size_ (“horse-shoe kidney,” “hog-back,” round, fœtal
lobulations, fissures; enlarged in acute parenchymatous nephritis,
pyelonephritis, hydronephrosis, chronic passive congestion, etc.;
diminished in atrophy, chronic interstitial nephritis, etc.).
_Character of cortical surface_ (normally smooth, grayish-brown in
color; a fine or coarse, regular or irregular granulation of the
surface occurs in chronic nephritis, the elevations corresponding to
the preserved portions of the parenchyma, the depressed portions to
the areas of connective-tissue increase; localized depressions or
fissures may be caused by old or recent scars of infarcts, abscesses,
rupture, etc. Distinguish fœtal furrows from pathologic depressions.
Flat, puckered or radiating scars point to syphilis. Elevations of
the surface may be due to fresh infarcts, tubercles, abscesses,
neoplasms, etc. Accessory adrenal tissue (resembles adipose tissue)
and small papillary adenomata are very common on the cortical
surface. Retention- and degeneration-cysts are also very common,
particularly in the kidneys of adults). In atrophic kidneys the
glomeruli can be seen through the cortical surface. Note condition
of superficial vessels (stellate veins). The _color_ of the cortical
surface depends essentially upon the blood-content and the condition
of the parenchyma. In acute or chronic parenchymatous nephritis the
color is whitish or grayish-white. Localized fatty degeneration and
cloudy swelling cause pale, grayish-yellow, opaque spots or streaks.
Hæmorrhages appear as red or brown-red spots. In extreme passive
congestion the kidney may be a dark purplish-blue (cyanotic kidney).
In hæmorrhagic nephritis the surface may be covered with pin-point
or pin-head hæmorrhages. In pyæmia or acute ascending pyelonephritis
the surface may be dotted with gray or yellowish pin-head abscesses.
Metastatic abscesses are uniformly distributed; others are arranged
in groups. In miliary tuberculosis the surface may contain numbers
of grayish translucent miliary tubercles, with opaque centers when
caseation has taken place. They cannot be so easily scraped out with
the knife as the abscesses. Calcified glomeruli may also appear as
white spots. Proliferations of the interstitial tissue cause large,
red kidneys. Anæmic infarcts are yellow, brick-red or rusty, with
a deeper red zone about them. Pseudomelanosis (usually postmortem)
gives a gray-green color to the kidney. In icterus the color may vary
from brownish-yellow to deep bronze. The _consistence_ of the kidney
is increased in chronic passive congestion, atrophy, interstitial
nephritis and amyloid degeneration; decreased in acute degenerations
and inflammations.
On section note _color_, _blood-content_ and _consistence of
cut-surface_, _relations of cortex and medulla_. The cortex is
normally 0.5-1.0 cm. broad (increased in acute degenerations and
inflammations, diminished in chronic inflammation and atrophy).
Note number, size and color of the _glomeruli_. They appear as
red pin-head points in congestion; in anæmia as small colorless
granules; in the normal kidney as small reddish points against the
lighter color of the labyrinths. In amyloid disease they are enlarged
and glassy. Calcified glomeruli are white and opaque. In venous
congestion the interlobular veins appear as bluish-red stripes;
hæmorrhages appear as red points in the glomeruli and convoluted
tubules, as red stripes in the collecting tubules. The blood-content
is increased in chronic passive congestion and chronic alcoholism. On
the cut-surface anæmic infarcts are usually wedge-shaped, with the
base toward the cortical surface. The color of the kidney-parenchyma
is usually gray; in fatty degeneration and cloudy swelling it
becomes yellow or grayish-yellow. The areas of greatest degeneration
appear as cloudy, opaque, yellowish points and stripes. Slight
degenerations are shown by slight cloudiness of the cortex. The
contrast between the grayish-white cortex and the dark-red medulla is
often very striking in severe parenchymatous nephritis. In uric-acid
infarction of the new-born ochre-yellow or vermilion-red stripes
or lines are seen in the medullary pyramids; white lines indicate
chalk-infarction; golden-yellow lines a bilirubin infarction. In gout
whitish deposits of urates occur in the kidney; they are usually
surrounded by scar-tissue. In purulent pyelonephritis yellow stripes
of pus surrounded by hæmorrhage occur in the pyramids. Tuberculosis
begins usually in the papillæ, destroying the pyramids first and then
the cortex, forming a multilocular sac lined with caseating tissue.
In hydronephrosis due to obstruction of the ureter the kidney becomes
converted into a multilocular sac without ulceration or caseation of
its papillæ. Note size of _pelvis_ and calices, contents, character
of mucosa, concretions, etc. The normal mucosa is grayish-red and
delicate; it is rose-red in inflammation and often shows petechiæ.
In severe inflammations grayish-white sloughs encrusted with urates
are often found. Concretions of urates, phosphates or oxalates may
be present, often associated with decubital ulcers of the mucosa.
Tuberculous ulcers of the pelvic mucosa are common. The _ureters_ are
straight and about 4 mm. thick. Note size, contents, thickness of
wall, changes in the mucosa, obstruction, dilatation, concretions,
etc.
The most important pathologic conditions of the kidneys are anomalies
(horse-shoe kidney, dystopia, double ureters, congenital lobulation),
floating kidney, congestion, anæmia, infarction, thrombosis and
embolism of renal vessels, atrophy (simple, arteriosclerotic),
hydronephrosis, nephrolithiasis, nephritis (parenchymatous,
hæmorrhagic, secondary contracted, primary contracted), rupture,
amyloid degeneration, abscess, pyelonephritis, tuberculosis,
syphilis, actinomycosis, uric-acid infarct, hæmatoidin- and
hæmosiderin-infarct, bilirubin-infarct, chalk-infarct, argyrosis,
retention- and degeneration-cysts, congenital cystic kidney,
neoplasms (hypernephroma and adenoma the most common; carcinoma
infrequent, sarcoma more common, particularly the congenital
adenosarcoma or rhabdomyosarcoma; fibroma, leiomyoma, lipoma and
angioma are relatively rare. Secondary carcinoma and sarcoma are
common), pyelitis, ureteritis (cystica, polyposa, diphtheritica,
purulenta), pyonephrosis, parasites (distomum hæmotobium,
echinococcus, filaria, cysticercus, pentastomum and dioctophyme
renale).
14. =Abdominal Aorta=, =Iliacs= and =Vena Cava=. Note size of lumen,
thickness of wall, character of endothelium and contents. Sclerosis,
fatty degeneration of intima, atheroma, calcification, aneurism,
inflammation, thrombosis, stenosis, dilatation, compression, and
infiltrations with pus or neoplasm are the most important conditions.
15. =Lymphatic Vessels.= Inflammation, obstruction, rupture,
tuberculosis and invasion by malignant neoplasms are the most
important conditions. (See also Thoracic Duct, Chapter VIII, Page
130.)
16. =Lymphnodes.= The retroperitoneal _lymphnodes_ and _hæmolymph
nodes_ are described as to their number, size, color, consistence,
occurrence of hyperplasia, lymphadenitis, atrophy, congestion, œdema,
hæmorrhage, pigmentation, tuberculosis, metastatic tumors, primary
tumors (lymphosarcoma), leukæmic hyperplasias and Hodgkin’s disease.
17. =Sympathetic.= The solar plexus, semilunar ganglia and adrenal
plexus should be examined, particularly in Addison’s disease, for
atrophy, degenerations, involvement in inflammatory processes,
hæmorrhages, tumor-infiltrations, etc.
18. =Psoas Muscles and Diaphragm.= Examine for purulent, phlegmonous
or gangrenous inflammations, tuberculosis, actinomycosis,
trichinosis, atrophy and scar-tissue. Pus from carious processes in
the thoracic and lumbar vertebræ burrows downward along the psoas
muscle.
19. =Vertebrae.= Fractures, dislocations, curvatures, deviations,
tuberculosis, caries, actinomycosis, etc.
CHAPTER XI.
THE EXAMINATION OF THE PELVIC ORGANS.
I. METHODS OF EXAMINATION.
1. =Male Pelvis.= When the removal of the external genitals is
permitted the fundus of the bladder is taken in the left hand and
pulled toward the head of the cadaver while the anterior wall is
separated from the pubis. This can be done with the fingers of the
right hand or the point of the knife. The loose connective-tissue
is torn on both sides around the urethra and rectum until the hand
can be passed beneath the rectum, completely encircling it and the
prostate which must be freed as far as its anterior border. The
legs of the cadaver are then separated, and an incision is made
with the large section-knife, through the skin, beginning above at
the root of the penis, at the termination of the main incision, and
following the arch of the pubis around the external genitals down to
the left, passing around the anus to the coccyx. A similar incision
is then made on the right side of the external genitals to meet the
first incision behind the anus. The outer genitals are then held in
the left hand and pulled downward between the legs while they are
dissected from the pubis, cutting the suspensory ligament of the
penis, to the level of the posterior border of the symphysis. The
knife is then run through into the pelvis just beneath the symphysis,
and while traction is made upon the external genitals toward the
right, a sweeping cut is made downward to the left along the pubic
arch, severing the insertion of the cavernous portion of the penis on
that side. A similar cut is then made on the right side. The penis
thus freed is then pushed up beneath the symphysis into the pelvis
and the scrotum pulled up after it, putting the perineum on the
stretch and pulling up the anus so that it can be seen. While the
external genitals are forcibly pulled upward in the pelvic cavity
toward the head, the encircling incision behind the anus is deepened,
cutting the fat-tissue, connective-tissue, and muscle around and
behind the rectum, until the whole mass of genital organs and rectum
is so loosened that it strips up easily to the brim of the pelvis,
where any remaining attachments of peritoneum or blood-vessels are
severed and the entire mass removed for examination on the board.
The mass is laid upon the board with _rectum_ uppermost. The latter
is then opened from the anus, using the intestinal shears, and
scraping off the contents into a pail so as not to contaminate the
other tissues. The rectum is then separated from the base of the
bladder and prostate, guiding the incision along the outer muscular
layer of the rectum, and stripping off the latter until the _seminal
vesicles_ are wholly exposed. These are then examined by means of
transverse cuts, or are opened longitudinally with the knife or fine
probe-pointed scissors. The _prostate_ may also be sectioned from its
posterior surface, if it is desired to preserve the urethral side
intact. _Cowper’s glands_ are also accessible from this incision.
The organs are then turned over, the penis put on a stretch and the
anterior wall of the urethra cut in the median line from the meatus
to the bladder. A pair of strong, medium-sized probe-pointed scissors
should be used. The incision is extended through the anterior wall
of the bladder. The mouth of the _ureters_, _ejaculatory ducts_ and
ducts of _Cowper’s glands_ are examined. If the prostate has not
been examined from the rectal side it may now be examined by means
of transverse incisions across the urethra and extending entirely
through the gland. The section of the genitalia is then finished
by the examination of the _testicles_. The latter are removed by
enlarging the inguinal canal on each side, slipping the testicles
up through them, and bisecting each gland so that the incision
falls through the head of the epididymis. The testicles may also be
examined by means of incisions made in the scrotum over the glands,
which are forced through the incisions and then bisected. If the vasa
deferentia are to be preserved they should be dissected out before
the semicircular cuts on each side of the external genitals are made.
When the kidneys have been removed, and the ureters left uncut, to be
examined in connection with bladder and external genitals, they are
usually left lying on the thighs until the abdominal examination is
finished. They are then laid in the abdomen until the pelvic organs
have been separated up to the brim of the pelvis. At this point
care should be taken to see that the ureters are not cut when the
whole mass of pelvic organs, ureters and kidneys is removed. When
placed upon the board the ureters are laid straight and the kidneys
placed in their respective positions. The _ureters_ are sounded from
the bladder and when desired opened upward from the bladder to the
kidneys. The section of the kidneys may then proceed according to the
directions given in the last chapter.
[Illustration: FIG. 45.—Section of male pelvic organs. Arrows mark
line of incisions through prostate and rectum. (After Nauwerck.)]
When the external genitals cannot be removed, the _testicles_ can be
examined by enlarging the inguinal rings and canal, and forcing each
testicle up from below, through the ring. The gland is then sectioned
and, after examination, returned to the scrotum. The anterior wall
of the bladder is then separated from the pubis and the tissues
about rectum and prostate loosened until the hand can completely
encircle the rectum and prostate. These organs and the bladder are
then pulled up firmly toward the head of the cadaver, and with the
cartilage-knife hugging the pubic bone the rectum is cut just above
the internal sphincter, and the urethra just anteriorly to the
prostate. When it is desired to get as much of the penis as possible,
its attachments to the pubis are cut from the pelvic side, and the
body of the penis pulled up into the pelvis, while the skin of the
organ is loosened as far as the glans. The body of the penis may be
severed from the glans or the glans may be freed from the prepuce
and removed with the entire organ, leaving only the skin to be used
for the restoration of the part. After the rectum and urethra are
severed, the mass of pelvic organs is stripped up to the brim of the
pelvis and removed, as given above. They are examined upon the board,
opening first the _rectum_, then the _seminal vesicles_, _prostatic
urethra_, _bladder_ and _prostate_. The prostatic urethra and
anterior bladder-wall are cut with the small probe-pointed shears,
while the prostate is cut transversely with the long section-knife.
The _bladder_, _prostate_ and _seminal vesicles_ may be examined
in situ, or separated from the rectum and examined outside of the
body. The anterior wall of the bladder is freed from the pubis,
and the lateral connections of the prostate separated. The bladder
is then opened in its anterior wall by an incision from its fundus
into the prostatic portion of the urethra. The prostate is then
cut transversely at about its middle, the cut extending entirely
through the organ. The fore-finger of the left hand is then hooked
underneath the prostate, and the bladder stripped forcibly from the
rectum, upward toward the pelvic brim. The base of the bladder is
thus brought up into view, exposing the seminal vesicles, which are
examined by transverse incisions.
In the employment of any one of these methods, the urine, if it is to
be saved for examination, should first be drawn through a catheter.
This is also the cleanest way of emptying the bladder, particularly
when it is greatly distended. The employment of force to squeeze the
urine out of the bladder through the urethra is not advisable when
there is any disease of bladder or urethra present.
[Illustration: FIG. 46.—Section of female pelvic organs. Urinary
bladder bisected and vagina opened in anterior median line. Arrows
show direction of incisions. (After Nauwerck.)]
2. =Female Pelvis.= The contents of the pelvis and the external
genitalia are removed from the female cadaver in the same way as in
the male. The anterior wall of the bladder is first freed from the
pubis and the tissues separated around and behind the rectum so
that the hand can be carried around the vagina and rectum. When the
external genitalia are to be removed with the internal organs, an
encircling incision is made on both sides of the external genitals,
beginning above at the termination of the main incision at the
beginning of the anterior commissure, and meeting behind the anus.
The external genitals are then dissected away from the arch of the
pubis until the knife can be passed up beneath the symphysis and the
attachments to the posterior border of the arch cut on both sides,
so that the vulva can be pulled up beneath the pelvic arch, putting
the perineum on the stretch. The posterior portion of the encircling
incision is then deepened until the entire mass of external genitals
and anus can be stripped up with the internal organs to the brim of
the pelvis, where they are held up perpendicularly and any remaining
attachments of peritoneum and blood-vessels cut, care being taken to
cut outside of the ovaries and tubes. The mass thus removed is laid
on the board with _rectum_ uppermost and the latter opened first.
The organs are then turned over, and the _urethra_ and _bladder_
opened in the anterior median line with the probe-pointed shears. The
_vagina_ and _uterus_ are then opened in the anterior median line,
bisecting the urethra and bladder. A heavy pair of shears having one
blunt-pointed blade should be used. If it is desired to save the
bladder and urethra, they can be dissected over to the right, or the
vaginal wall can be cut on its left side. When the cervical canal
will not admit the scissors the _uterus_ may be cut in the median
line with a knife. The horns may then be opened with the scissors.
Additional cuts may be made into the uterine wall as desired (tumors,
placental site, etc.). The _tubes_ may be sounded from the abdominal
extremity and then opened for their entire length with the fine
probe-pointed shears, or they may be examined by means of transverse
cuts. The _ovaries_ are held with their flat surfaces between
thumb and index-finger and then sectioned in the plane of greatest
dimension from the convex border to the hilus. The _broad ligaments_,
_parametrium_, _parovarium_ and _lymphnodes_ are examined by means of
cuts made parallel with the sides of the uterus.
When the external genitals cannot be removed, the vagina and rectum,
after they have been freed from the surrounding tissues, are put on
the stretch toward the head of the body and cut through as close
to the pubic outlet as possible. When this is carefully done it is
possible to secure the inner labia and the urethra intact. The rectum
is cut as close to the anus as possible. The organs are then stripped
up to the brim of the pelvis, then held up perpendicularly while
the remaining connections are severed. The organs thus removed are
examined on the board in the same manner as given above. When the
organs cannot be removed from the body, the bladder and urethra are
examined by an anterior median incision after they have been freed
from the symphysis. The uterus and vagina are then cut with the knife
in the anterior median line, either through the bladder or after
the latter has been dissected away. The ovaries, tubes and broad
ligaments are then examined as directed above. The uterus and vagina
may also be dissected from the rectum and opened by a posterior
median incision. This method is used in medicolegal examinations.
To facilitate the removal of the genital organs in either sex a
symphysiotomy may be performed and the pubic arch pulled apart, or
a portion of the pubis may be cut out with the saw.
When permission to open the body by means of the usual
main-incision cannot be obtained, it is possible to remove the
thoracic and abdominal organs through the vagina or rectum. The
cadaver is placed on its back, with buttocks near the end of the
table, the thighs separated as widely as possible and flexed upon
the body. In the male the scrotum is drawn up out of the way. A
circular perineal incision is then made, beginning anteriorly at
the perineoscrotal junction and extending around the anus. The arm
may be introduced through this opening after the removal of the
rectum and the abdominal and thoracic organs pulled downward and
removed. In the female the uterus and vagina are removed through
the vaginal opening; the arm is then introduced and the abdominal
and thoracic organs removed.
II. POINTS TO BE NOTED IN THE EXAMINATION OF THE PELVIS.
=I. MALE PELVIS.= 1. =Penis.= Size, anomalies, condition, character
of prepuce, evidence of circumcision, presence of smegma, character
of meatus, discharge, wounds, scars (on and back of corona),
evidence of syphilis, neoplasms, etc. Postmortem priapism occurs
particularly in leukæmia. It may be caused also by traumatic or
infective thrombosis and hæmorrhage, tumor-metastases, inflammatory
infiltrations, and in death from hanging. The most important
pathologic conditions of the penis are: inflammations (balanitis,
posthitis, cavernitis, gonorrhœa, etc.), gangrene, phimosis,
paraphimosis, præputial concretions, soft chancre, hard chancre,
secondary syphilides, traumatic lesions (fracture, hæmorrhage,
urine-infiltrations, etc.), anomalies (hypospadias, epispadias,
etc.), tuberculosis (rare), condylomata, elephantiasis, cornu
cutaneum, carcinoma, sarcoma (rare; melanotic sarcoma the most common
form), secondary carcinoma (primary in prostate), lipoma, angioma and
teratoma.
2. =Scrotum.= The most important pathologic conditions of the scrotum
are: œdema, inflammation, gangrene, trauma, burns, elephantiasis,
carcinoma, melanotic sarcoma, lipoma, fibroma, myofibroma,
lymphangioma and teratoma.
3. =Testis and Epididymis.= Testis and epididymis weigh 15-30 grms.
Note _size_, _form_ and _consistence_. Normal color of cut-surface
is grayish yellow; becomes brown in atrophy. Note character of
tunics (color, lustre, smoothness, consistence, etc.), and contents
of sacs (hydrocele, hæmatocele, empyema, etc.). The most important
conditions affecting the testes are: inflammation (orchitis,
epididymitis, vaginitis, abscess, hæmatogenous inflammations in
pyemia, mumps, scarlet fever, typhoid fever, variola, chronic fibroid
orchitis in syphilis, gonorrhœal epididymitis), tuberculosis,
gonorrhœa, syphilis, actinomycosis, leprosy, leukæmic infiltrations,
atrophy, compensatory hypertrophy, cryptorchidism, hydrocele,
varicocele, spermatocele, cysts, malignant teratomata (syncytioma,
cysts, cystocarcinoma, adenocarcinoma, adenoma, adenosarcoma,
cystosarcoma, rhabdomyosarcoma, chondroma, osteoma, myxoma, etc.),
carcinoma, sarcoma, lipoma, fibroma, etc., metastatic sarcoma and
carcinoma, dermoid cysts, benign teratoma, parasites (echinococcus
is rare). Tuberculosis is most common in the epididymis; syphilis
more frequently affects the body of the testis. Torsion of the vas
deferens may occur; atrophy of the testis may result. Twisting
or thrombosis of the spermatic vessels may cause gangrene of the
testicle.
4. =Rectum=. Note _contents_ (amount, color, consistence, odor,
etc.), _color_ and _character of mucosa_ (normally grayish red
or reddish gray, smooth and translucent, solitary follicles just
visible). Normally the rectum should contain formed brownish féces;
in catarrh the contents are fluid and not formed, while the mucosa is
covered with a thick glassy mucus. In obstruction of the gall-ducts
the féces are gray (“clay-color”). In catarrhs and chronic passive
congestion the mucosa is red. Decubital ulcers are often green from
the imbibition of bile, and are surrounded by hæmorrhages. They are
circular or correspond in shape to the fécal mass pressing upon them.
Traumatic ulcers, hæmorrhages, diphtheritic inflammation, follicular
ulcers, foreign bodies, stricture, fécal impaction, hæmorrhoids,
fissures, fistulous tracts, tuberculosis, syphilis, adenomatous
polyps and carcinoma are the most common pathologic conditions. The
oxyuris vermicularis is the most common animal parasite. Gonorrhœa
of the rectum is not uncommon. Stricture is most commonly caused by
syphilis.
5. =Prostate.= Normal size is about that of a walnut or
horse-chestnut. Weighs 19-25 grm. Average dimensions are 2.7
cm. long, 4.0 cm. broad, 2.0 cm. thick. Note form, consistence,
color of cut-surface (smooth or granular), amount of secretion,
corpora amylacea (color brown to black), size of gland-spaces,
cysts, abscesses, tubercles, neoplasms. The most common pathologic
conditions are: hyperplasia (usually inflammatory, the result of
old gonorrhœal infection, less commonly due to chronic pyogenic
infection), neoplasms (carcinoma is relatively common, usually
developed in a prostate showing chronic inflammatory hyperplasia,
adenoma, myoma, fibroma, myofibroma), cysts, acute inflammation
(usually gonorrhœal), typhoid prostatitis, abscesses, tuberculosis,
syphilis (rare) and atrophy. Thrombosis and the formation of
phleboliths are very common in the prostatic veins; they are usually
associated with gonorrhœal infection. The inflammatory hyperplasia
may involve one or all three lobes of the prostate. In old men
showing no evidences of prostatic inflammation the prostate may be
atrophic.
6. =Seminal Vesicles and Duct.= Should be symmetrical. Note size,
contents, character of wall, and appearance of lining membrane. They
measure 3-5 cm. long, 1-2 cm. broad and 0.7-1.5 cm. thick. Gonorrhœal
inflammations and tuberculosis are the most common conditions. In
old men the vesicles contain a brownish-yellow mucoid substance.
As a result of chronic inflammation the walls of the vesicles are
thickened, often hyaline; the lumen is sometimes wholly obliterated.
Calcification of the wall is not uncommon. Concretions are found in
the vesicles following obstruction. Cystic dilatation may occur.
Primary neoplasms (carcinoma and sarcoma) are rare.
7. =Urethra.= Mucosa should be grayish-red, smooth, shining and
transparent. The most common and important pathologic condition
is gonorrhœa (acute, chronic, anterior, posterior, erosions,
ulcers, abscesses, perforation, stricture, periurethral abscess,
cavernitis, etc.). Non-gonorrhœal urethritis is rare (colon- and
influenza-bacillus, streptococcus, pneumococcus, etc.). Trauma
(crushing, laceration, perforation, urine-infiltration, hæmorrhage,
periurethral abscess, phlegmon, gangrene, stricture, urinary fistula,
etc.), soft chancre, hard chancre, secondary and tertiary syphilitic
lesions (gumma), tuberculosis (lupus), leprosy and neoplasms
(rare: adenoma, carcinoma, melanotic and round-cell sarcomata
[lymphosarcoma], fibroma, angioma) may occur. The most common
anomalies are hypospadias and epispadias.
8. =Bladder.= _Size_, _degree of distention_, _amount_ and
_character of contents_, _character_ and _color of mucosa_ (normally
gray-red, smooth and transparent), _muscle-coats_ (hypertrophic,
atrophic). The most common pathologic conditions are: anomalies
(ectopia, ecstrophia, vesica bipartita, vesica bilocularis,
diverticula), congestion, œdema, cystitis (acute and chronic
catarrh, cystitis granulosa, cystica, purulent, phlegmonous,
diphtheritic, emphysematous, interstitial, peri- and paracystitis,
erosions, ulcers, gangrene, malakoplakia), tuberculosis, dilatation,
trauma (rupture, perforation, fistula), neoplasms (papillary
fibro-epithelioma, carcinoma, adenoma, myxoma, myoma, rhabdomyoma,
angioma cavernosum, sarcoma, dermoids, secondary carcinoma [usually
from prostate], and sarcoma [melanotic sarcoma]), concretions
(urates, uric acid, oxalates, phosphates, carbonates, cystin and
xanthin), and parasites (filaria sanguinis, distomum hæmatobium,
echinococcus, trichomonas, ascaris and oxyuris).
=II. FEMALE PELVIS.= =1. Rectum.= Note same things as given above
for the examination of the rectum in the male. Gonorrhœa, stricture
due to syphilis and traumatic fistula (due to child-birth) are more
common in the female.
2. =Vulva.= The most important pathologic conditions are:
congestion, œdema, hæmorrhage, hæmatoma, trauma (laceration),
vulvitis (catarrhal, gonorrhœal, chronic, diphtheritic, gangrenous,
phlegmonous, ulcerative, abscess), erythema, eczema, herpes, acne,
furunculosis, pruritus, kraurosis vulvæ, leukoplakia, Bartholinitis,
retention-cysts, cysts of the glands of Bartholin, hydrocele
muliebris, syphilis (primary, secondary and tertiary lesions),
tuberculosis (lupus), elephantiasis, condylomata, neoplasms (lipoma,
fibroma, lymphangioma, papilloma, fibromyxoma, fibromyoma, chondroma,
neuroma, carcinoma [usually very malignant in type], sarcoma [rare]
and metastatic tumors [very rare]).
3. =Urethra.= Same conditions as noted above for the male. Small
polypoid granulomata (caruncles) are very common; usually gonorrhœal
in origin. Primary carcinoma is more common in the male.
4. =Bladder.= Note same conditions as given above. Rectovesical and
vesicovaginal fistulas are not rare as the result of child-birth.
Secondary carcinoma is more common than in the male (from uterus and
cervix), primary carcinoma more rare. Ascaris and oxyuris may enter
bladder from vagina through a rectal fistula.
5. =Vagina.= Note size (about 5-8 cm. long), contents (foreign
bodies, pus, blood, etc.), color of membrane, condition of rugæ,
hymen, etc. The color of the mucosa varies from a delicate rosy
red to a bluish purple in the late stages of pregnancy. The most
important conditions are: colpitis (acute and chronic, catarrhal,
diphtheritic, gangrenous, emphysematous, granular, nodular, adhæsiva,
exfoliativa, vetularum, ulcerative; gonorrhœa the chief cause;
also caused by mercuric chloride and other poisons; occurs also in
cholera, typhoid fever, variola, scarlatina, diphtheria and other
infections), ulcers, abscesses, erosions, strictures, varices,
prolapse, atresia, trauma (lacerations, rupture, hæmatoma, fistula),
tuberculosis (rare), syphilis (primary less common than on vulva,
secondary lesions common, gumma rare), thrush, cysts (retention,
remains of Müllerian and Wolffian ducts, gas-cysts), neoplasms
(papillary fibro-epithelioma, fibroma, myxoma, myoma, rhabdomyoma,
rhabdomyosarcoma, myxosarcoma), carcinoma (primary rare, secondary
relatively common, particularly of malignant chorio-epithelioma;
primary ectopic chorio-epithelial tumors occur in vagina also),
and parasites (trichomonas vaginalis, oxyuris vermicularis). Note
particularly condition of hymen.
6. =Uterus.= The developed uterus weighs 33-41 grms. In women who
have not borne children the dimensions are 7-8 cm. long, 4 cm. broad,
2.5 cm. thick; in women who have borne children the dimensions are
8-9 cm. long, 5-6 cm. broad, and 3 cm. thick. The dimensions of the
postpartum uterus vary greatly, where normal contraction has taken
place the length is 8-9 cm., breadth 5-6.1 cm., thickness 3.2-3.6
cm., and weight 102-120 grms. Note _size_, _shape_, _character of
peritoneal coat_, _consistence, character of cut-surface_, _size_
and _contents of cavity_. Length of uterine cavity 5.2-5.7 cm.
Note relations between body of uterus and cervix. In adults the
circumference of the body of the uterus is greater than that of
the cervix; before the age of puberty it is less than that of the
neck. In old age the entire organ contracts, but the body more than
the cervix, so that the organ again assumes an infantile form. The
external os in the virgin uterus is round or oval; in women who have
borne children it appears as a transverse cleft. The most common
conditions of the cervix are the so-called erosion and ectropion,
cystic glands (ovula Nabothi), cervical catarrh, hyperplasia, ulcers,
polypi, myofibroma and carcinoma. Note contents of cervical canal
(normally glassy, tough mucus; in catarrh becomes thin, cloudy or
purulent); length and shape of canal (elongations, dilatations,
stenosis, etc.). Color of mucosa should be grayish-red; the folds
should be distinct and symmetrical. Purulent and diphtheritic
inflammations, lacerations, polypi, cysts, fibromyoma, carcinoma and
tuberculosis are the most common conditions affecting the cervical
canal.
The uterine cavity is normally empty; during menstruation or as
the result of inflammation it may contain blood and bloody mucus;
and the mucosa may be deep-red. The normal mucosa is gray-red
and 0.5-1.0 mm. thick. In the puerperal uterus portions of the
placenta, fœtal membrane, purulent or bloody lochial discharges
are present. The placental site is shown by its uneven surface and
presence of blood-clots. Gangrenous and purulent areas are greenish,
gray, brownish-green, and black, with opaque and ragged surface.
Gas-bubbles may be present. The normal consistence of the uterus
is firm, diminished in the puerperal uterus, increased in chronic
metritis. The cut-surface is smooth in the virgin uterus, rough in
the uteri of women who have borne children and in chronic metritis.
The most common pathologic conditions of the uterus are: abortion,
hæmorrhage, apoplexia uteri, hæmatometra, hydrometra, pyometra,
rupture, perforation, traumatic lesions, endometritis (acute,
chronic, hæmorrhagic, interstitialis, glandularis, hyperplastica,
cystica, polyposa, adenomatosa, infective, decidual, atrophic, etc.),
foreign bodies, tuberculosis, syphilis, actinomycosis, hyperplasia,
metritis (acute, chronic, hyperplastic, atrophic), perimetritis,
parametritis, atrophy, neoplasms (myoma and myofibroma the most
common; adenoma, adenomyoma, adenomatous polypi are very common;
carcinoma [adenocarcinoma, cystocarcinoma, medullary, papillary,
colloid, scirrhous, squamous-celled, malignant chorio-epithelioma]
very common; sarcoma less common but it is not rare [myosarcoma the
most common form; often represents a sarcomatous transformation
of a myofibroma]; metastatic carcinoma and sarcoma are rare), and
parasites (echinococcus).
7. =Tubes.= Note _length_, _thickness_, _shape_, _character of
peritoneum_, _patency_, _fimbriated extremities_ (swelling, redness,
exudate, tubercles, hæmorrhage), _contents_, _color_ and _thickness
of mucous membrane_, _thickness_ and _consistence of entire wall_.
Tubes should be straight, not tortuous; in inflammation they are
usually twisted, tortuous or bent. Hæmatosalpinx is usually caused
by a tubal gestation. The most common pathologic conditions are:
salpingitis (usually gonorrhœal, acute, chronic, catarrhal, purulent,
pyosalpinx, hydrosalpinx, interstitial, perisalpingitis, tubo-ovarian
abscesses and cysts), tuberculosis, actinomycosis (rare), syphilis
(very rare), hæmatoma (ectopic gestation relatively frequent),
neoplasms (rare: adenomyoma, fibromyoma, fibroma, myosarcoma,
sarcoma, carcinoma, chorio-epithelioma and teratoma; secondary
carcinoma from uterus, ovary and intestine).
8. =Ovaries.= Note _size_, _form_, _consistence_, _color_, _character
of cut-surface_, number of Graafian follicles, corpus luteum, etc.
Ovary at puberty weighs about 10 grm., measures 4-5.2 cm. long,
2-2.7 cm. broad, 1.0-1.1 cm. thick. The adult ovary weighs about
7 grm., and measures 2-4 cm. long, 1.4-1.6 cm. broad, 0.7-0.9 cm.
thick. A corpus luteum is 1.0-2.0 cm. in diameter. Ovary is compared
to an almond in size and shape. In young individuals the surface
is grayish-white and smooth; with age the surface becomes more
and more irregular, the organ smaller and its consistence firmer.
The cut-surface in young individuals is normally very moist (this
should not be regarded as œdema). The most important conditions
are: inflammation (acute and chronic, hæmorrhagic, purulent, etc.,
oöphoritis, abscess), tuberculosis, cystic follicles, lutein-cysts,
cystadenoma (multilocular, monolocular, surface papilloma, simplex,
papillary), parovarian cysts, carcinoma, fibroma, sarcoma, dermoid
cysts, teratomata, malignant teratomata, embryoma, parasites
(echinococcus is very rare).
9. =Uterine Ligaments, Vessels and Lymphatics.= Peritoneum over the
broad ligament should be moist-shining, delicate and transparent.
Inflammatory processes are very common in the parametrium,
particularly in puerperal cases. The peritoneum is cloudy, opaque,
injected, or covered with fibrinous or purulent exudate. Great
numbers of small cysts containing clear fluid are often found in the
peritoneum of the broad ligament as the sequelæ of inflammation. Note
contents of blood-vessels (thrombi, concretions, neoplasms), and
character of walls. Parovarian cysts, myomata, adenomyomata (round
ligament), secondary carcinoma, chronic inflammations, hæmatoma and
tubercles are the most common pathologic conditions.
CHAPTER XII.
SPECIAL REGIONAL EXAMINATION.
I. METHODS OF EXAMINATION.
1. =Bones and Bone-Marrow.= The methods employed will depend wholly
upon the indications in any given case, the anatomic relations and
the aim of the examination. Anatomic knowledge should be applied in
the removal of any bone. In the case of the extremities adequate
incisions should be made in the skin extending the entire length of
the bone which is to be removed, and the soft parts dissected from
the bone before the latter is disarticulated or cut out. When the
bone is examined _in situ_ it may be opened with hammer and chisel or
cut with a saw, either transversely or longitudinally, so as to give
the most instructive picture of the condition present. The spinal
column may be cut longitudinally. The symphysis pubis is first cut
through, a block of wood is placed beneath the lumbar vertebræ, and
the vertebral bodies are sawed through in the median line, from below
upward, moving the block toward the head as the sawing proceeds.
The cut-surfaces of the vertebræ are then inspected. The _pelvis_
may be removed whole in connection with the lumbar vertebræ and the
upper halves of the femurs. The _spinal column_ and the _pelvis_ may
also be removed entire by sawing the ribs on each side of the spine,
cutting the occipito-atloid ligaments above, and disarticulating
the femurs or sawing them at their upper half or third and removing
them with the pelvis. Of the long bones the _femur_ is the one most
frequently examined. An incision is made in the skin from the groin
in the direction of the large vessels extending to the middle of the
leg. The ligamentum patellæ is cut through and the skin and muscles
turned back at the knee until the joint is laid bare; the capsule
of the joint is opened and the femur disarticulated. The skin and
muscles are then separated from the upper part of the femur, the
hip-joint opened, and the femur disarticulated and removed. When
held in a vise it may be opened longitudinally by sawing. Other
bones are removed as indicated; the chief points to be observed in
their removal are the anatomic considerations and the making of the
incisions in such a way as to cause the least possible disfigurement.
For the examination of the _bone-marrow_ the tibia or femur,
sternum, a rib and the body of one of the vertebræ are usually opened
by means of the saw or chisel.
2. =Joints.= The joints are opened for examination with attention to
the same considerations given above for the examination of the bones.
Approved surgical incisions may be used. If fistulous openings into
the joint are present these should not be cut until the joint is
open. When bacteriologic examinations are to be made the joint should
be opened with a sterile knife, or the capsule seared and punctured
with a sterile pipette through which the contents of the joint-cavity
are secured. The articular surfaces, epiphyses and diaphyses should
be examined by transverse or vertical incisions.
3. =Lymph-glands.= The cervical, axillary and inguinal lymphnodes
can be secured for examination by carrying the skin-flaps of the
main-incision far enough back to make these regions accessible. For
the examination of other glands, such as the cubital, popliteal,
interscapular, posterior cervical, etc., the cadaver should be placed
in a convenient position, and the skin-incisions should be made so as
to expose sufficiently the part to be examined, without unnecessary
mutilation.
4. =Peripheral Blood-vessels and Nerves.= Skin-incisions are made
along the course of the vessels and nerves, and these are then
exposed by careful dissection. In the case of the upper extremity the
clavicle is removed when the entire course of the nerves and vessels
of the arm is to be exposed.
5. =Sympathetic System.= The cervical, thoracic and abdominal
sympathetic systems are examined either at the close of the
examination of each one of these regions or at the end of the
autopsy. Careful anatomic dissections are necessary for the
demonstration of the sympathetic ganglia and nerves.
6. =Organs of Special Sense.= These may be examined at the close of
the autopsy, according to the methods given above, if they have not
been examined at the close of the section of the brain.
II. POINTS TO BE NOTED IN SPECIAL REGIONAL EXAMINATION.
1. =Bones and Bone-marrow.= Note size, form, color of surface,
consistence (diminished in necrosis, osteomalacia, rachitis, senile
osteoporosis, etc.; increased in sclerosis), fragility, fractures,
separation of epiphyses, fissures, dislocations, elevation or
separation of periosteum, periosteal defects, changes in periosteum
(thickened, indurated, and showing hard white elevations in
chronic inflammation; swollen and easily stripped from the bone
in acute inflammation; hæmorrhages and collections of pus beneath
periosteum cause separation of periosteum; in chronic inflammation
the periosteum may become more firmly adherent to the bone and
contain spongy, compact, cartilaginous or osteoid osteophytes that
vary in color according to the degree of calcification [bluish-red,
yellowish, dirty-white, shining-white]; the normal periosteum is
grayish-white in color; it is reddened in hyperæmia and hæmorrhage).
The surface of bones normally is smooth and grayish-yellow in color;
it becomes red with an increase in the number and size of the
medullary spaces, and paler, grayish-white or white in necrosis;
a dull, rough, uneven surface indicates lacunar absorption. Note
localized or general thickening (exostoses, hyperostosis). On section
note thickening of the bone (osteomyelitis ossificans), thinning
(osteoporosis, excentric atrophy), enlargement of medullary spaces,
obliteration of spaces by newly-formed bone (osteosclerosis; bone
becomes heavy and solid like ivory), and caries (pyogenic infection,
tuberculosis, syphilis, actinomycosis, neoplasm). Caries occurs in
both spongy and compact bone, but more often in the former. The
necrotic bone appears as soft, friable granules (molecular necrosis)
or sequestra, between which living bone or granulation-tissue may be
found. The necrotic granules feel like fine grains of sand when the
finger is rubbed over the cut-surface. The color depends essentially
upon the amount of granulation-tissue present (gray, grayish-red or
deep bluish-red). Purulent areas are cloudy, opaque and yellowish.
Tubercles appear as round, grayish, semitranslucent areas, with
opaque yellowish centers when calcification has occurred. In young
subjects the developing portions of the bone (epiphyses, cartilages)
should receive especial examination. Note _amount_, _color_ and
_consistence_ of bone-marrow. In the young individual the marrow is
red; after puberty the red marrow gradually becomes restricted to
the flat bones and the short spongy bones, while in the long bones
there develops a yellow, fatty marrow. In old age the marrow of the
long bones may become brownish, transparent, myxomatous or soft like
colloid, or contain large cystoid spaces filled with a thin mucoid
fluid or liquid fat. Red lymphoid marrow is found in the long bones
in severe anæmias; it is grayish-red or deep red according to its
blood-content. In leukæmia the marrow may be red, violet, pink,
grayish or grayish-yellow (pyoid); in chloroma the marrow may be
greenish. In cachexias the marrow may become gelatinous as in old
age. A hyperæmic fatty marrow should not be mistaken for lymphoid
marrow; the fatty shine serves to distinguish the former. Cloudy
yellowish areas in the marrow point to purulent infiltration. Firm
sulphur-yellow masses are gummata.
The most important pathologic conditions of the bones are: atrophy,
osteomalacia, rachitis, fractures, dislocations, periostitis,
osteomyelitis, ostitis, acromegaly, necrosis, syphilis, tuberculosis,
actinomycosis, leprosy, exostosis, hyperostosis, hyperplasia,
defects, hypoplasia, dwarfism, giantism, neoplasms (primary sarcoma
the most common malignant tumor [periosteal, myelogenous, myeloma,
lymphosarcoma, chloroma, leukæmia]; secondary carcinoma [primary in
mamma, thyroid, prostate, adrenal] also relatively common; osteoma,
lipoma, exostosis cartilaginea, fibrosa and ossificans, fibroma,
myxoma, lipoma, angioma, chondroma, etc.), cysts, and parasites
(echinococcus, cysticercus).
2. =Joints.= _Capsule_ (thickness, tension, defects, tears,
perforations, adhesions), _cavity_ (contents [normally a few
drops of light-yellow, clear fluid, more in knee-joint than in
other joints; may be serous, purulent, hæmorrhagic or fibrinous],
adhesions, granulation-tissue, rice-bodies, free bodies, joint-mice,
obliteration of cavity, osseous, fibrinous or cartilaginous
ankylosis, changes in internal articular ligaments), _synovial
membrane_ (a delicate pale grayish, smooth membrane; rough from
exudate or formation of granulation-tissue; red in hyperæmia or
hæmorrhage. Note folds and villi; subserous fat-tissue), _articular
surfaces_ (loss or increase of cartilage, separation of cartilage,
newly-formed bone, granulation-tissue, deposits of lime-salts
or urates, necrosis or purulent infiltration of the cartilage,
erosions, eburnations, defects or enlargement of ends of bones; in
degeneration and necrosis the bluish-white, transparent cartilage
becomes opaque, cloudy and yellowish). The most important pathologic
conditions of the joints are: arthritis (acute, chronic, serous,
purulent, gangrenous, primary, secondary, gonococcal, pneumococcal,
streptococcal, tuberculous, syphilitic, deformans, villosa, prolifera
cartilaginea, adhæsiva, ulcerosa, sicca, neuropathic), dislocations,
deformities, abnormal position, congenital anomalies, chondritis,
spondylitis, gout, necrosis, ankylosis, tuberculosis, syphilis,
free bodies, neoplasms (rare: angioma, sarcoma, chondroma, lipoma;
secondary more common from an extension of sarcoma of neighboring
structures; metastatic tumors rare), and parasites (echinoccocus very
rare).
3. =Lymphnodes, Peripheral Vessels and Nerves, Sympathetic and Organs
of Special Sense.= The pathologic conditions of these structures have
been given above.
CHAPTER XIII
THE AUTOPSY OF THE NEW-BORN.
I. METHODS OF EXAMINATION.
The =Section of the New-Born= differs from that of the adult in
several particulars, as follows:—
_a. Spinal Cord._ The spinal canal may be opened with the scissors
alone, as the soft, bony structures of the spinal column are easily
cut.
_b. Skull._ The cranium is opened, after the removal of the scalp,
in the usual way, by cutting with the scissors into the posterior
angle of the anterior fontanel and then introducing the shears into
the longitudinal sinus, and cutting the latter posteriorly in the
line of the sagittal suture. The sinus is then opened anteriorly.
The sutures between the frontal and parietal bones, and between the
parietal and occipital bones, are now cut with the shears down to
the level of the greatest circumference of the cranium. The cranial
bones with the adherent dura are then pressed outward from the
brain, and are either held in this position or cut through with the
bone-shears so that sufficient room for the removal of the brain is
afforded. The anterior falx is then cut and the brain removed as in
the adult, using great care because of its very soft consistence.
When too soft to be removed the brain may be opened within the skull;
or a horizontal section may be made with the large, flat brain knife
at the level of greatest circumference. Some prosectors freeze the
brain before removal, or remove it while the cadaver is immersed in a
strong solution of brine.
_c. Section of Thorax, Neck-organs and Abdomen._ A small block of
wood is placed beneath the lumbar vertebræ, and the main-incision
reaching from thyroid cartilage to the pelvic crest is made, the
incision passing to the left of the umbilicus, and diverging outward
below it so as not to cut the left umbilical artery. The incision is
now extended through the abdominal wall into the peritoneal cavity,
the right half of the abdominal wall turned up so as to expose the
umbilical vein, which is cut loose from the abdominal wall, so
that a second diverging incision can be made through the abdominal
wall, beginning just above the umbilicus and passing down to the
right of the right umbilical artery, without cutting the umbilical
vein. There is left between the two diverging cuts a triangular
flap of abdominal wall (see Fig. 47) containing the umbilicus,
urachus and umbilical arteries, and connected with the liver by the
umbilical vein. The umbilical vessels are then probed and examined
by transverse sections; and the triangular flap of abdominal wall
turned down over the pubis. After the height of the diaphragm has
been noted the thorax is opened by cutting the ribs outside of the
costochondral articulations so as to give more room. The thymus gland
is then examined and removed. The heart may be opened in the same
way as in the adult, extending the cut into the pulmonary artery up
to the ductus arteriosus, which is examined by the probe. The ductus
arteriosus is easily found by cutting the pulmonary artery in the
middle of its anterior wall. In the median line beyond the right and
left branches of the pulmonary artery is the opening of the duct,
which can be probed into the descending aorta. (See Fig. 48.) The
heart may then be removed, and the foramen ovale carefully examined.
[Illustration:
FIG. 47.—Method of opening the abdomen in the new-born, with
especial reference to the examination of the umbilical vessels.
Note triangular flap, including umbilicus, urachus and umbilical
arteries, and attached to umbilical vein. (After Nauwerck.)
]
[Illustration:
FIG. 48.—Section of pulmonary artery and pulmonary ring in the
new-born, showing openings of right and left pulmonary arteries and
ductus arteriosus (containing probe). (After Nauwerck.)
]
[Illustration: FIG. 49.—Method of demonstrating the Béclard center of
ossification in the lower epiphysis of the femur. (After Nauwerck.)]
It is usually better to take out the neck and thoracic organs _en
masse_ and examine on the table. This must always be done in cases
of suspected thymic death and when the question of the child having
been born alive or dead is to be settled. The position of the
diaphragm must be taken before the thorax is opened. The upper air
passages are then ligated. The thoracic cavity is then opened; the
pericardium and heart opened and examined. The larynx and trachea
are opened above the ligature, and the whole respiratory tract with
the ligature in position is removed from the thorax and placed in a
vessel of clean water. The air passages below the ligature are then
opened, and the lungs, after their floating power has been tested,
are cut beneath the water in order to see if air-bubbles arise from
the cut-surface or from the bronchioles. The lungs are examined piece
by piece for air-containing portions, noting their floating power,
crepitation, occurrence of bubbles, etc. In the case of suspected
thymic enlargement the trachea should be explored from above for a
stenosis, before the thorax is opened. If evidences of pressure upon
the trachea cannot be demonstrated in this way the body of the child
can be fixed in formalin and then opened. The thymus and trachea are
then examined by means of transverse sections. The stomach should be
ligated at both ends and then removed, and opened under water. The
presence of air points to extra-uterine “swallowing” movements. This
test is worthless if decomposition has set in. When the thoracic
organs are taken out _en masse_ the ductus arteriosus can be examined
from the aorta. The removal of neck, thoracic and abdominal organs
_en masse_ is often of advantage in the examination of the infant
cadaver, as the organs can be much more easily examined on the table
than in the body. The neck organs are first removed after ligating
trachea and œsophagus, and with the thoracic organs are stripped down
to the diaphragm and then lifted up out of the body and laid over
the left side of the body. The diaphragm is then cut laterally and
posteriorly. The rectum is ligated and cut between ligatures. The
crura of the diaphragm, the cœliac vessels and root of mesentery are
then cut, and the viscera, including the kidneys, are stripped down
to the brim of the pelvis, where the peritoneum and blood-vessels are
cut.
The _ear-test_ (the demonstration of the opening-up of the Eustachian
tube and middle ear by the establishment of respiration) may be shown
by the examination of the middle-ear from the cranium. The ear-drum
must be examined to see if it is intact.
The _Béclard center of ossification_ in the lower epiphysis of the
femur is examined by opening the knee-joint, flexing the leg, and
then making parallel transverse cuts perpendicularly to the long
axis of the bone, until the greatest diameter of the center of
ossification is cut.
The eye-ball may be removed and examined for the pupillary membrane.
The eye is cut through a few millimetres back of the cornea, the
anterior segment is fixed in dilute chromic acid or alcohol and then
examined microscopically; or it can be examined in the fresh state,
the membrane being visible even to the naked eye.
Bacteriologic examinations should be made in the usual way, the
material being secured by sterile pipette, sterilized knife or
platinum loop, smears, etc. In the examination of a very fresh
cadaver the possibility of danger from infection with syphilis must
always be borne in mind.
II. POINTS TO BE NOTED IN THE SECTION OF THE NEW-BORN.
Aside from establishing the cause of death, the autopsy of the
new-born has for its aim the determination of the age of the infant,
its viability and whether it was born living or dead. Special
attention must therefore be paid to all points that may be of value
in settling these questions.
The _average length_ of a full-term new-born child is 50 cm. (42-58
cm.), boys being somewhat longer than girls; 58 cm. may be taken
as the maximal length, 48 cm. the minimal. Both length and weight
vary within wide limits. The length of the fetus in the first five
months of intra-uterine life corresponds approximately to the square
of the month. In the last five months the age of the fetus equals
approximately the length in centimetres divided by five. Viability
is usually regarded as beginning in the eighth month and with a
body-length of over 32 cm. The _average weight_ of the full-term
new-born is 3,200 grms., for boys 3,310 grms., girls 3,230 grms.;
maximum weight 5,500 grms., minimal 2,500. The weights for the
different months are: second month, 4 grms., third month 5-20 grms.,
fourth 120 grms., fifth 284 grms., sixth 434 grms., seventh 1,218
grms., eighth 1,549 grms., ninth 1,971 grms., tenth 2,334 grms.
Look for traces of _vernix cascosa_. The _skin_ of the
well-nourished, full-term, new-born is smooth, not wrinkled, white
or grayish-red rather than red in color (a slight icteric tint is so
common as to be regarded as normal), and showing the fine _lanugo
hair_ only on the shoulders. The _hair_ of the scalp averages 2-3
cm. in length. The _finger-nails_ are firm, horny and extend beyond
the finger-tips. The subcutaneous panniculus should be abundant. The
average length of the _umbilical cord_ is about 50 cm., and it is
inserted about the middle of the body or just below it. As a rule it
is thrown off on about the 5-6th day. The _cartilages of the nose and
ears_ are firm. In male infants the _testicles_ lie in the firm and
wrinkled scrotum (they begin to descend in the seventh month); in the
female the outer _labia_ usually meet, but occasionally the inner
ones are visible. In the seventh and eighth months the _clitoris_
rises above the greater labia. A small amount of blood-stained
discharge is often present in the vagina of the new-born. From the
_mammæ_ of both male and female new-born a whitish turbid fluid
(“Hexenmilch”) can usually be expressed. The _great fontanel_
is 2-2.5 cm. broad, while the posterior one is nearly closed.
The _pupillary membrane_ is absent after the eighth month. The
_ductus arteriosus_ remains open 4-5 days after birth; the _foramen
ovale_ is not completely closed until the second or third month of
extra-uterine life, although by the tenth day the opening is nearly
obliterated. The _center of ossification_ in the lower epiphysis of
the femur should be present and measure 2-9 mm. It is not present in
the eighth month and in a large proportion of cases begins to develop
in the ninth month. Only rarely is it absent in normal full-term
infants. It appears in the bluish-white cartilage as a lenticular
mass of red or reddish-brown color in which the blood-vessels can be
easily seen. It may be absent in congenital rachitis or syphilis, or
in the latter disease it may show the characteristic appearance of
osteochondritis syphilitica.
The head should be examined for the presence of the “_head-tumor_” or
“_caput succedaneum_,” the œdematous swelling of the scalp over the
parietal eminences. Minute hæmorrhages may be present in the tissues.
The tumor usually grows smaller or disappears within 12-48 hours. In
difficult labors a _hœmatoma neonatorum_ may be produced between the
periosteum and bone, usually over the right parietal eminence. It
appears as a circumscribed tumor which may increase after birth and
persists for a long time. As the result of a periostitis ossificans
a wall of bone may be formed about the extravasate, or it may be
encapsulated with small bony plates. After the absorption of the
extravasate the newly-formed bone may persist throughout life in the
form of a “crater-like” or “coral island” elevated circle of bone.
Infection of the hæmatoma not infrequently leads to the formation
of a subperiosteal abscess, purulent infiltration of the cranial
bone and purulent meningitis. The cranium should also be carefully
examined for other evidences of conditions due to the mechanism of
birth, such as the general shape of the head, condition of sutures,
movability of the cranial bones, depressions, over-lapping, etc., of
the cranial bones. Wounds of the scalp and face should be carefully
noted. The circumference of the _cranium_ is 34.5 cm., sagittal
diameter 10-13.5 cm., transverse 8-9.5 cm., diagonal 12-14 cm.
The _brain_ of the infant is normally rosy-red in color, rather
translucent, soft, almost jelly-like, and moist. Tearing of the
pial veins or meningeal arteries during delivery may produce fatal
meningeal hæmorrhages.
The _weights_ of the internal organs are: brain 380 grms., thymus
7-10 grms., heart 20.6 grms., lungs 58 grms., spleen 11.1 grms.,
kidneys together 23.6 grms., testicle 0.8 grm., liver 118 grms. The
_mature placenta_ weighs about 500 grms., and measures 15-20 cm. in
diameter, 3 cm. thick in the middle and 0.5-1 cm. thick at the edge.
In the examination of the abdomen the _color and appearance of the
peritoneum_, _position of abdominal organs_ and _height of diaphragm_
should be noted. Before respiration is established the diaphragm is
at the fourth rib; after respiration is begun it is about one rib
lower on both sides, usually a little lower on the left side than on
the right. The condition of the _umbilicus_ and _umbilical_ vessels
is of great importance (umbilical hæmorrhage, infection, insertion
of cord, line of demarcation, etc.). Note contents, size of lumen,
thickness and character of walls, appearance and moistness of intima.
In umbilical infection the process spreads through the sheaths of the
umbilical arteries rather than of the vein. The infected arteries
contain yellowish-brown purulent thrombi; and the tissues about them
show œdema, hæmorrhages, purulent infiltration or small abscesses.
The perpendicular position of the stomach, the relatively large size
of appendix to that of kidney and spleen, the lobulation of the
kidneys, and the relatively large size of liver and adrenals must be
borne in mind and not be regarded as pathologic. Examine _adrenals_
especially for occurrence of hæemorrhage, infarction and thrombosis.
Look for accessory adrenals (“adrenals of Marchand”) in broad
ligament and along the spermatic cords. Thrombi in the renal and
spermatic vessels are not rare in the new-born. Note occurrence and
degree of _uric-acid infarction of the kidneys_ (formerly supposed
to indicate that child was born alive). Meconium is present in the
large intestine of the child born at term; when prematurely born it
is found only in the small intestine. It is greenish in color and
contains cholesterin, crystals of calcium sulphate, bile-pigment,
desquamated epithelium and granular detritus.
In the examination of the thorax especial attention should be paid to
the _thymus_, noting its size, color, consistence and evidences of
pressure upon underlying structures, particularly upon the trachea.
In death from suffocation small petechiæ are often found in the
thymus and in the serous membranes. The _lungs_ rise up over the
edges of the pericardium and thymus when respiration has occurred,
and their color is a light rose. Areas of atelectasis are bluish. The
unexpanded lungs are brownish-red, firm in consistence and distinctly
lobulated. Air-containing lung floats in water and crepitates, and
gives off bubbles when cut beneath the water. Attempts at artificial
respiration may draw some air into the lungs. Gas-bubbles may be
produced by decomposition. In _white pneumonia_ the lung is pale,
grayish-white and airless. The _larynx_, _trachea_ and _bronchi_ are
to be examined for presence of mucus, amniotic fluid, meconium,
foreign substances, etc. The ligated stomach should also be tested as
to its floating power, and should be opened under water to determine
the presence of air or gas.
The determination of the exact cause of death in the new-born is
often very difficult or impossible. In many cases no adequate
lesions can be found to explain the occurrence of sudden death
in the first days or weeks after birth. Among the more frequent
causes of such deaths are congenital syphilis, asphyxia neonatorum
(cardiac syphilis, presence of amniotic fluid, etc., in respiratory
passages, congenital cardiac lesions, injury to brain, meningeal or
cerebral hæmorrhage, congenital marasmus, intra-uterine infections,
umbilical infections, enlarged thymus, “overlying,” poisoning,
congenital hæmophilia, melaena neonatorum, etc.), adrenal hæmorrhage,
malformations of gastro-intestinal tract, absence of common duct,
nephritis, pneumonia, etc. The most important congenital infections
are syphilis, gonorrhœa, tuberculosis, variola, typhoid, pyogenic
infection, tetanus, measles, scarlatina, influenza, meningitis,
malaria, recurrent fever, pneumococcus, colon bacillus and others,
mostly very rare. Congenital leukæmia has been observed. Numerous
cases of congenital neoplasm have been reported (hæmangioma,
lymphangioma, fibroma, lipoma, neurofibroma, papilloma of the
larynx, adenoma, carcinoma [liver, kidneys, stomach, intestine],
cystic tumors of liver, pancreas, kidneys and ovary, rhabdomyoma or
rhabdomyosarcoma of kidney, heart, etc., adenosarcoma of kidney,
dermoid cysts and various forms of teratomata).
Congenital syphilis is so common and such an important condition in
the new-born that especial search should always be made for evidence
of its presence. Smears of all the organs should be made in the cases
examined soon after death, and either stained or examined at once by
the dark-field method for the presence of the spirochæte. The most
common anatomic manifestations of congenital syphilis are pemphigus,
macules, papules, or maceration of the skin, white pneumonia, cardiac
dilatation due to interstitial myocarditis, interstitial hepatitis,
splenic enlargement and osteochondritis syphilitica. The long bones
should always be examined for the last-named condition; they should
be removed and cut longitudinally. In the boundary between epiphysis
and diaphysis the presence of a yellow, hard zone points to this
condition. The area of ossification is increased, irregular, and
is separated from the bone by the yellowish zone, which in its
earliest stages is soft and cellular, later sclerotic. The area of
proliferating cartilage is also increased and may contain medullary
spaces, showing as red lines. In rachitis the ossification-zone is
wholly or partly wanting, while the zone of proliferating cartilage
is broader and rich in red medullary spaces. In place of the
ossification-zone there may be present a layer of soft, grayish-white
osteoid tissue containing medullary spaces. No sharp line exists
between the different zones.
CHAPTER XIV.
THE MEDICOLEGAL AUTOPSY.
As has been stated above, every autopsy should be conducted as if it
were a medicolegal case, and autopsy-protocols should be so complete
and accurate that they may be accepted as evidence in any case in
which such testimony can be introduced. While the ordinary autopsy
may give satisfactory evidence as to the nature of the pathologic
processes found and the cause of death, the scope of a medicolegal
autopsy includes not only the cause and manner of death, but also the
identification of the body, the determination of the commission of a
crime, the manner in which the crime was performed, its motive and
the detection of the criminal. Under such conditions the prosector
must extend the field of his observations and conclusions to meet
the possibilities of the witness-stand. The general technique of the
medicolegal autopsy will vary but little from that of the ordinary,
and these variations will be given here, as follows:—
The medicolegal autopsy should always be performed in the presence
of two witnesses, one of whom should be a physician competent to
judge of the methods employed in the autopsy. The autopsy findings
should be dictated during the progress of the autopsy, and at
its close should be verified and signed in the presence of the
witnesses. No other spectators should be permitted in the room.
The examination should be made by daylight, and not until positive
signs of death appear. If the cadaver has been frozen it must
first be allowed to thaw out at room-temperature. The prosector
should, if possible, see and examine the body before it is removed
from the place where it is found, and he should carefully examine
the surroundings, clothes and external surface of the body for
possible clues. All known information concerning the circumstances
of the case, the personal history of the deceased, the occurrence
of any injury, previous illness, etc., should be in the hands of
the prosector. Undertaker’s manipulations, such as the injection
of embalming fluids, puncture of intestines, aspiration of
fluid-contents, etc., must not be permitted before the autopsy.
Especial attention should be given to the =identification= of the
body (measurements, weight, build, shape of head, deformities
or defects, color of hair and eyes, teeth, dental work,
thumb-markings, tattoo marks, birth-marks, scars, evidences of
previous diseases, occupation, clothing, etc.). In doubtful cases
the body should be photographed. Roentgen-ray pictures may also
be made. When only portions of a body are found the microscopic
examination alone may be able to throw light upon the case and
give positive evidence as to the sex, age, existence of certain
physical characteristics, birth-marks, scars, disease, etc. When
no conclusions can be reached a minute description of the remains
should be placed in the protocol. The approximate =time of death=
is to be determined with greater care in the medicolegal case
(temperature of body, rigor mortis, putrefaction, dissolution,
mummification, character of stomach-contents, changes in eye-balls,
etc.).
In the performance of the autopsy the greatest care should be taken
to avoid the production of artefacts. Hammer, chisel or wedge
should not be used; bones should be sawed through completely,
particularly in the case of the skull and spine. Especial care
should be exercised in the removal of brain and cord. Examine
vertebræ in all cases when cause of death is unknown. The
main-incision may begin at the chin. The mouth and pharynx should
be examined for foreign-bodies before the mouth- and neck-organs
are removed. These should be taken out _en masse_. Particularly in
young infants is the examination of the larynx of great importance.
Examine thoracic organs _in situ_ before removing them; then
remove in connection with neck-organs and examine on table. Ligate
cardiac end of œsophagus to prevent escape of stomach-contents.
Cut œsophagus above ligature. Open pulmonary artery before lungs
are sectioned. Examine abdominal organs _in situ_ before removing
them. Bullet- and stab-wounds should be accurately located,
traced, measured and course described. Recover missiles for use as
evidence. The origin and cause of hæmorrhage must be accurately
determined. Remove genital organs _en masse_ after examination
_in situ_. Examine particularly contents of vagina and anus; make
microscopic examination of same (semen, blood, foreign-bodies,
etc.). Do not put probe, knife or shears into cavity of uterus, but
open with a clean cut in the median posterior line. Examine ovaries
for presence of corpus luteum.
In cases of =suspected poisoning= especial attention should be
paid to the condition of the gastro-intestinal tract (position,
distention, odor, consistence, condition of blood-vessels, etc.).
A ligature should be placed about the cardiac end of the stomach
and another around the duodenum below the mouth of the common
duct, and both organs removed. They should then be opened outside
the body and the contents examined (amount, consistence, color,
composition, reaction, odor), and the latter then placed in
clean, sterilized glass or porcelain jars, which are sealed and
labeled. The mucosa of the organ is then carefully examined and
described, and the organ itself finally preserved in a sealed and
labeled jar. The small and large intestines and the œsophagus are
similarly ligatured, removed and examined, and with their contents
are preserved for chemic reaction by sealing them in separate
sterilized jars properly labeled. Blood from the heart and large
veins should be saved for spectroscopic and chemic examination.
The contents of the urinary bladder likewise are saved for chemic
analysis. Finally, portions of the brain, liver, kidney, intestine,
spleen and other organs and tissues are preserved in separate
vessels for chemic and microscopic examination. When possible an
expert chemist should be present at the autopsy and receive the
organs and contents directly from the pathologist. Especial care
must be taken that no contamination of the material can occur. The
manner of removal of the organs, the character and condition of the
instruments used, nature and condition of receptacles for material,
manner of sealing, use of preservatives, method of transportation
to the chemist, and other fine points of detail will all be
threshed over in court in the endeavor to discredit the testimony,
and the pathologist and chemist must be thoroughly prepared to meet
all questions of this nature. In certain cases the presence of a
poison may be told by the finding of a granular or crystalline
substance in the stomach or intestines (arsenic-poisoning), by the
color (green from aceto-arsenite of copper, yellow from potassium
chromate or iodin, purple from iodin, red from bromin) or by the
odor (bitter almonds, phosphorus, alcohol, chloroform, laudanum,
carbolic acid, lysol, garlic in arsenic poisoning). Excessive
acidity or alkalinity of the stomach contents is found in poisoning
with acids, alkalies or potassium cyanide. Portions of poisonous
plants, mushrooms, match-heads, etc., may be found in the stomach.
Certain pathologic conditions, as fatty degeneration of the liver,
cloudy swelling of the kidney, nephritis, malignant jaundice,
acute yellow atrophy of the liver, dysentery, and others may be
caused by such poisons as phosphorus, arsenic, mercuric chloride,
potassium chlorate, chloroform, etc. When such changes are found at
autopsy the pathologist must always carefully differentiate between
disease and poisoning. He must decide as to the actual occurrence
of poisoning, the source and nature of the poison, how and when
administered, amount of poison, number of poisons, primary and
secondary effects, attendant circumstances, accidental, suicidal
or criminal administration, motive, etc. Some poisons produce
no characteristic gross or microscopic changes in the organs or
tissues. In such cases no pathologic conditions sufficient to cause
death may be found, and when there is doubt a chemical examination
should be made. Other poisons produce more or less characteristic
changes, either by their local action, by selective action upon
certain organs, by excretion, or by acting upon the blood. The
effects will vary according to the amount of the poison, its
concentration, length of action, condition of gastro-intestinal
tract, rapidity of excretion, etc. The most important and common
poisons producing recognizable autopsy conditions are as follows:—
=Acids.= In _carbolic-acid_ poisoning there may be dry, brown,
leathery spots on the face about the lips; grayish-white eschars
on mucosa of lips, mouth, tongue, pharynx and œsophagus; œdema of
the glottis and pharyngeal submucosa; white or gray longitudinal
eschars in stomach and duodenum; leathery appearance of stomach
wall; cloudy swelling of kidneys, odor of phenol in urine, which
is dark in color; general passive hyperæmia. In _sulphuric-acid_
poisoning there may be brown, leathery and dry eschars on lips and
skin, grayish-white to black eschars in mucosa of mouth, stomach
and œsophagus; black, dry and brittle clots in the blood-vessels;
perforation of stomach; sloughing of mucosa; parenchymatous
nephritis. _Hydrochloric acid_ has little or no action on the skin;
on mucous membranes the action is similar to that of sulphuric
acid except that the drying of the eschars and blood-clots is less
marked. In _nitric-acid_ poisoning the eschars are yellowish;
hæmatin is not separated and dissolved, so that the brown black
eschars seen in sulphuric- and hydrochloric-acid poisoning are
not formed. _Oxalic acid_ causes a white or grayish escharotic
condition of the mouth, œsophagus and stomach; crystals of calcium
oxalate may be found in the blood-clots and in the kidney-tubules.
_Glacial acetic acid_ may produce a grayish-white escharotic
condition of the mucosa of the upper respiratory tract, and
pneumonia, when inhaled.
=Alcohol.= In concentrated solutions coagulates albumin and has
a corrosive action on mucous membranes. The ingestion of large
amounts causes asphyxia, gastro-enteritis, cloudy swelling of
ganglion cells of brain, and parenchymatous degeneration of kidney
and liver. Lungs, liver, brain and stomach may give an alcoholic
odor. In chronic alcoholism there may be chronic atrophic or
hypertrophic gastritis, atrophic cirrhosis, sclerosis of arteries,
miliary aneurisms of pial vessels, fatty degeneration of heart and
liver, and “hog-back kidney.”
=Alkalies.= Mucosa of mouth and œsophagus swollen and red, with
desquamation of epithelium; mucosa of stomach swollen, dark brown
and ecchymotic, with diphtheritic patches; croupous bronchitis
may result from aspiration of caustic soda or potash, and
bronchopneumonia from inhalation of ammonia. Stricture of the
œsophagus, due to contraction of scar-tissue, may occur when the
patient survives the immediate effects of the poison.
=Antimony.= In acute cases the mucosa of mouth, œsophagus and
stomach is inflamed, with erosions and ulcerations; in chronic
cases there is marked emaciation.
=Arsenic.= Mucosa of stomach œdematous, hyperæmic and ecchymotic;
over the hæmorrhages there may be grayish-white sloughs or
erosions. In these there may be found granules or crystals of the
poison. The glands of the mucosa show cloudy swelling and fatty
degeneration. Yellow sulphide of arsenic may be seen on the gastric
mucosa. The small intestine is filled with a rice-water-like
fluid, as in cholera, and the mucosa is congested, swollen
and hæmorrhagic; the lymphoid tissue may be swollen. There is
slight icterus, cloudy swelling of all organs and ecchymoses in
pericardium and pleura. In chronic poisoning with dilute solutions
characteristic gastro-intestinal changes are wanting. In cases of
suspected arsenic poisoning it is important to take portions of all
organs and tissues for chemical examination.
=Atropine.= Death from asphyxia, resembles heat-exhaustion.
=Chloral-hydrate.= Hyperæmia of lungs, brain and cord. Examine
urine.
=Chloroform.= Fatty degeneration of liver and heart. In delayed
poisoning the liver shows picture of acute yellow atrophy, with
marked icterus, widespread ecchymoses, cloudy swelling of kidneys
and fatty degeneration of heart. Lungs, brain and liver may or may
not give odor of chloroform.
=Ergot.= Sclerosis and contraction of arteries; gangrene of
endometrium; in chronic cases sclerosis of the posterior columns of
the cord.
=Formalin.= Corrosive action on mucosa of stomach; formic-acid in
urine.
=Hydrocyanic Acid and Potassium Cyanide.= The mucosa of stomach is
deep red, swollen, softened and sometimes translucent; soapy to the
touch; odor of bitter almonds or ammonia; blood is fluid, dark or
light cherry-red; red hypostasis.
=Illuminating-gas and Carbon-monoxide.= Blood fluid and cherry-red;
cadaver life-like; pink hypostasis; carbon-monoxide-hæmoglobin in
blood demonstrated by spectroscope. In poisoning by coal-gas the
changes are less marked because of the greater amount of carbon
dioxide present. Inhalation of smoke is shown by black, sooty
deposits upon the mucosa of the respiratory tract.
=Lead.= In acute cases severe gastro-enteritis; black fluid
in intestines; cloudy swelling of kidneys. In chronic cases
arteriosclerosis, fatty degeneration of muscles, liver, kidneys and
spleen; cirrhosis; blue line on gums.
=Mercury.= Mucosæ congested, ecchymotic or showing grayish-white
eschars; diphtheritic inflammation of pharynx, colon and vagina;
decalcification of bone; cloudy swelling and calcification of
kidney. In chronic cases ulcerative stomatitis.
=Nitrobenzol.= Cadaver cyanosed; blood and muscles brown; mucosa of
stomach hyperæmic and ecchymotic; odor of bitter almonds; brownish
methæmoglobin in collecting tubules of kidney.
=Opium and Morphine.= No characteristic findings. Condition of
pupils not conclusive.
=Phosphorus.= In very acute cases there may be few changes; odor of
phosphorus; cloudy swelling of heart, liver, kidneys and gastric
mucosa. In subacute cases there is icterus, hæmorrhage, marked
fatty degeneration of all organs; in chronic poisoning there is
universal fatty degeneration, and not rarely a necrosis of the
jaw-bone.
=Potassium Chlorate.= Hypostatic spots and blood are of chocolate
color; methæmoglobinæmia; hæmorrhagic nephritis.
=Ptomaines.= Gastro-enteritis, fatty degeneration; icterus, cloudy
swelling of kidneys.
=Strychnine.= Intense and persistent rigor mortis; blood fluid and
dark as in asphyxia. Urine should be saved for the frog-test.
Other causes of death requiring especial consideration in a
medicolegal examination are:—
=Abortion.= Determined by the finding of fœtal tissues, chorionic
villi, decidua, enlargement of uterus, formation of sinuses at
placental site, curetted surface, corpus luteum of pregnancy in
ovary, punctures or lacerations of uterus and cervix, effects of
corrosive fluids, infective endometritis, evidences of poisoning.
=Asphyxia.= Death due to lack of oxygen and excess of carbon dioxide,
produced by interference with respiration, choking, drowning,
hanging, paralysis of muscles of respiration, intoxication, etc.
When respiration is suddenly checked ecchymoses are usually found in
the pericardium, pleura, meninges, thymus, and rarely in peritoneum.
Lips, skin of face and neck, and finger-nails may be deeply cyanotic;
the blood is dark and fluid; passive congestion of lung is usually
present. In death caused by hanging or strangling there may be
fracture of the hyoid bone, thyroid cartilage or tracheal rings,
marks upon the skin, hæmorrhage, laceration of the intima of the
arteries, fracture or dislocation of the cervical vertebræ and injury
to the cord. In death from drowning the bronchi, lungs and stomach
may contain fluid, there is watery fluid in the pleural cavities,
maceration of skin, greater water-content in blood of right heart
than of left, with consequent raising of freezing point.
=Infanticide.= The points to be considered in determining the age and
viability of the child are given in Chapter XIII. The most important
causes of death in the new-born are also given in the same chapter.
=Electric Shock.= Burns of skin, “lightning figures,” signs of
asphyxia, laceration of internal organs.
=Burns and Scalds.= Extent of burn more important than depth of the
burn; death usually ensues if one-third of the surface is burned.
Burns show scorching, singeing or marks of the hot object; scalds
usually show some action of the hot fluid on the skin or mucous
membranes. Demonstration of carbon-monoxide in blood of internal
organs proves the inhalation of carbon monoxide. When exposed to
intense heat the soft parts of the body show marked shrinking.
=Heat or Cold.= No characteristic lesions in death from these causes.
Diagnosis must be made by exclusion and history of case.
=Starvation.= Marked disappearance of fat and atrophy of all organs,
stomach and small intestines empty, marked emaciation, blood anæmic,
concentrated when subject was deprived of water.
=Violence.= Wounds must be minutely described as to character,
degree of laceration, contusion, extravasation, damage to tissues,
direction of force, character of instrument, means and method of
infliction, path of projectile or stab-wound, etc. Postmortem changes
and injuries must be differentiated, as must be also antemortem and
postmortem lesions, primary and secondary effects of the injury,
effects of injury and pre-existing diseases. Intracranial hæmorrhages
must be carefully differentiated with respect to causation by
violence or disease. Effects of _contrecoup_ must be borne in mind.
The presence of other marks of trauma, the exclusion of disease, the
location of the clot, the age of the clot, the age of the patient,
etc., are some of the factors to be considered. In young people
without alcoholic history or syphilis intracerebral hæmorrhages
without signs of violence are rare. When associated with fractured
skull they are usually regarded as due to the trauma.
CHAPTER XV.
THE RESTORATION OF THE BODY.
When the autopsy is finished the body-cavities are cleansed and then
thoroughly dried. No blood, stomach- or intestinal-contents should be
left in the cadaver. All bleeding or dripping parts should be tightly
secured; the anus and vulva should be tightly stitched, and the penis
ligated. If necessary, the organs are then cleansed and returned to
the body, as nearly as possible to their normal positions, although
the brain, because of the difficulty of getting it back into the
skull-cap, is usually put into the thoracic cavity. When several
autopsies are done at the same time, care should be taken not to mix
the organs. The undertaker should always be aided in his work; and,
if he so desires, an embalming powder or fluid may now be sprinkled
or poured into the cavities.
The skull-cap must be securely fastened in its normal position, so
that no slipping can occur. If the body is not to be shipped any
distance the posterior interlocking joint will usually hold it firmly
in place if the scalp is drawn tightly together and closely stitched.
When the body is to be moved some distance, the skull-cap must be
more firmly fastened. This can be accomplished by drilling holes at
the sides of the saw-cut and fastening the skull-cap to the cranium
by means of copper wire, which must be tightly twisted and pressed
flat against the bone. When this is done in the temporal region the
wire is completely concealed by the temporal muscles when these are
drawn up with the scalp, or if these have been cut away pads of
cotton can be put in their place. The cranial fossæ and the skull-cap
may be filled with plaster-of-Paris; while this is still soft a piece
of wood may be pushed through into the foramen magnum and allowed to
project high enough above the saw-cut to hold the skull-cap on, when
it, filled with plaster, is put in position. With the setting of the
plaster the skull-cap is firmly held. A little ingenuity will suffice
to improvise various other methods of securing the skull-cap, by the
use of bandages, metal pins, etc. After the employment of Harke’s
method the halves of the skull must be brought together and securely
fastened at the base or in the occipital region. After resection of
the temporal bone for the examination of the auditory apparatus the
defect must be filled in with cotton or other substance, and the
lower jaw and external ear restored to their normal positions. After
examination of the orbit and the removal of the posterior half of
the eye-ball a wad of red- or black-stained cotton should be used to
fill out the eye so that it will have the same degree of fullness
that the other eye has. When the eye is enucleated a glass-eye may
be substituted and the lids fastened together by fine stitches made
on the conjunctival side. If it is desired to save the skull-cap an
artificial skull-cap may be molded from a square piece of pulp-board
of the thickness of 0.5 cm. in the case of the adult, somewhat
thinner for children. The pasteboard is soaked in warm water for
about fifteen minutes, and is then molded over the skull-cap. It is
then cut parallel with the edges of the saw-cuts so that the edge of
the board will extend about 1 to 1.5 centimetres over the edges of
the skull-cap to overlap the bones below the saw-cut. The cranial
cavity is then filled with plaster or cotton. The pasteboard is
removed from the skull-cap before it becomes too dry for its lower
edge to be adapted easily to the lower border of the saw-cut. Ridges
or folds are trimmed off with the knife and the surface made smooth.
It is then adjusted and firmly fastened in position by passing
several turns of strong twine around the lower border over-lapping
the cranial bones. The temporal muscles and the scalp-flaps are then
drawn up and tightly stitched. A close base-ball stitch should be
used to fasten the scalp-flaps, and a black thread should be used. If
the scalp has been stretched so that it is loose and baggy, a portion
of it may be cut out, so that when sewed together the flaps will fit
tightly. The hair must be freed from all bone-dust and blood-clots,
washed if necessary, then dried, and arranged in its former position
in such a manner as to hide the sutures.
The place of any bone that has been removed may be filled by a piece
of wood cut to the required proportions, and securely fastened
by wire or bolts, or plaster-of-Paris may be poured about it and
allowed to set. After removal of the spinal column or of portions
of it, there may be substituted a block of wood or an iron pipe of
suitable size, which may either be securely fastened above and below
by means of wire or bolts, or it may be held in place by imbedding
it in plaster-of-Paris. These expedients are not necessary after
the removal of the cord alone, but only when entire sections of the
spinal column are removed. When the cord is removed posteriorly the
skin-incision is tightly closed with a base-ball stitch, and then
covered with a strip of surgeon’s plaster or collodion to prevent
leakage of blood and serum after the body is turned over.
The thoracic and abdominal cavities are filled with dry bran,
saw-dust or finely-cut excelsior to fill out the normal contour, a
piece of old cloth or paper is laid over the whole, and the sternum
replaced. It is usually not necessary to fasten the latter, but if
desired the costal cartilages may be stitched together, or wired
when the needle cannot be pushed through the cartilage. When the
tongue and neck-organs have been removed, the lower jaw must be held
in position by fine stitches in the mucous membrane of the lips to
prevent the jaw from dropping and leaving the mouth open. The contour
of the neck may be restored by a pad of cotton.
The main-incision is then closed by a continuous base-ball stitch,
using a stout linen pack-thread and a rather large, slightly curved
needle. The first stitch begins in the middle-line about 1 cm. above
the beginning of the main-incision, the needle being introduced from
below through the incision, and the thread secured at its end by a
knot. The stitches are then made about 5-7 mm. apart, the needle
each time being pushed through the skin from the inside, so that it
comes through the skin about 5 mm. on either side of the incision,
alternately to the left and right. The thread is kept tightly pulled,
and as perfect coaptation as possible is secured. At the end of the
incision the thread is secured by a knot before it is cut. Collodion
or surgeon’s plaster may then be used to cover the entire incision.
All other skin-incisions are sewed up in the same manner. When
the testes and the body of the penis have been removed, it may be
necessary under certain conditions to restore the form of these parts
before the main-incision is closed. Cotton wads may be used for this
purpose.
When all incisions are finally closed the cadaver is carefully washed
and all blood-stains and discolorations removed. When formalin has
been used as an injection-fluid blood spilled upon the skin may
produce a brownish stain that is removed with difficulty. Corn-meal
or hand-sapolio may be used to remove such stains. After the cadaver
has been thoroughly washed, it is dried, and can then be turned over
to the undertaker.
CHAPTER XVI.
OTHER SOURCES OF PATHOLOGIC MATERIAL.
1. =Autopsies on Animals.= In the case of the small animals used
ordinarily for laboratory purposes, such as the mouse, rat,
guinea-pig, rabbit, cat and dog, the animal is put upon its back and
fastened to the autopsy-board either by small nails driven through
the extremities or by slip-knots of string or rope passed over the
latter. Autopsy board and holders designed especially for the purpose
can be obtained from makers of laboratory apparatus. A main-incision
is made in the anterior or median line from the chin to the
genitalia, and the skin stripped back from the thorax on each side
to expose the ribs. The thoracic cavity is then opened by cutting
the ribs with the bone-shears or bone-forceps, and the sternum and
cartilages are removed. The neck, thoracic and abdominal organs may
then be removed _en masse_ and examined outside the body, or the
organs may be removed singly and examined in succession, following in
general the same methods of procedure as in the autopsy on the human
body, adapting the methods given above to differences in anatomic
structure and size. For the opening of the skull and spinal canal the
bone-forceps alone may be used, or in the case of larger animals the
saw may be needed. Anatomic considerations should govern the method
of opening the skull. Directions for the performance of autopsies on
inoculated animals will be found in textbooks on bacteriology; and
veterinary methods of autopsies on the larger domestic animals are
given in textbooks on veterinary pathology. In all cases of autopsies
on animals full protocols should be kept, following the general order
of the autopsy, altered to suit the individual case.
2. =Surgical Operation.= A very large part of the material obtained
for pathologic examination is removed by the surgeon for diagnostic
purposes. The question of the surgical technique employed may be left
to the surgeon, but as far as the pathologic aim is concerned certain
principles should be followed, if the object of the examination is to
be secured. Unfortunately these principles are not recognized by the
great majority of practitioners, and pieces of tissue to be examined
are taken at haphazard from the surface or from necrotic areas, to
be run through by the pathologist, only to find that no diagnosis
is possible, either because the portion of tissue removed did not
extend deeply enough or is wholly necrotic. Great care and judgment
should be exercised in the choice of the portions to be removed for
diagnosis. The part removed must be characteristic of the condition
present. It is necessary not only to ascertain the character of
the pathologic change but also the nature of the reaction in the
surrounding tissue. A neoplasm may show the histologic structure
of an adenoma, but at its periphery may be found infiltrating the
neighboring tissues as an adenocarcinoma. If the piece of tissue
for examination is removed from the central part or surface of the
tumor, an incorrect diagnosis may be given. This is especially
true in the case of rectal and uterine polypi, papillomata of the
mouth and penis, horny warts, etc. The rule to be followed in all
cases is that the excised portion must be at the boundary-line of
the neoplasm or morbid process, and extending across it so as to
include both pathologic and surrounding normal tissues. The cut
must be deep enough to extend into living tissue, and in the case
of epithelial surfaces to go below the basement membrane. It should
be made at right angles to the surface. Necrotic, softened, or
degenerating portions should be avoided, unless a portion of this is
removed in addition for the purpose of ascertaining the nature of
the degenerative changes present. The scraping away of superficial
scabs, exudates, etc., should never be practiced for purposes of
diagnosis. Time is saved if a satisfactory excision be made the first
time, and to secure this the tissue must be living, the cut must be
deep enough, and the portion removed must fully represent the nature
of the condition present. When organs are removed, as in the case of
the appendix, uterus, tubes, ovaries, mamma, etc., several portions
of tissue representing different structures of the organ should be
secured for the examination.
Tumors and other pathologic specimens received from the surgeon
should be fully described as to _size_, _form_, _weight_,
_consistence_, _color_, _relation to surrounding tissues_
(encapsulated, well-defined borders, growth by infiltration or
expansion, zone of inflammation, etc.), _character of cut-surface_
(color, moisture, translucency, smooth or elevated, homogeneous,
character of cell-scraping, evidences of structure, etc.).
Accompanying all pathologic material sent to the pathologist should
be concise and accurate notes giving the name, sex, age, nationality,
occupation and status of the patient, anything in the individual
or family history bearing upon the condition, the source of the
specimen, its exact location and relations, manner of growth and
character of operation. The pathologist should have full data upon
which to construct his diagnosis. A very common idea among surgeons
is that the specimen alone should be sufficient for the pathologist,
and that other data are not necessary for the formation of his
opinion. Many other considerations than the mere histologic picture
presented by a specimen enter into the formulation of a pathologic
diagnosis, if it is to bring to the aid of the surgeon all that a
pathologist’s knowledge and experience can give. This is particularly
true when the pathologist, as is usually the case, is asked to give a
prognosis. Both in hospital service and in private surgical practice
it is best to have printed history forms to be filled out and to be
sent to the pathologist with each specimen.
Another factor seriously interfering with the efficiency of the
pathologist’s work is the failure of the surgeon to see that the
material removed for diagnosis is properly taken care of before it
reaches the pathologist. Tissues removed for examination should
never be allowed to dry. They should not be exposed to the air, but
should either be placed at once in a fixing fluid or covered with
damp cloth. Curettings should be placed for a moment upon a pad of
gauze to remove the excess of blood, and the fragments of tissue
are then picked up and put into the fixing solution. When sent by
mail or express fresh tissues should be wrapped in damp cloth and
then in rubber cloth; or if the distance is great they should be put
into fixing fluids. A sufficient quantity of the latter should be
used, or decomposition may take place before the specimen reaches
the pathologist. All material for bacteriologic examination should
be removed under proper precautions, put into sterilized vessels,
properly sealed and sent to the pathologist under proper precautions.
PART II.
THE TREATMENT OF THE MATERIAL.
=INTRODUCTION.= The material obtained by autopsy, surgical operation,
curettage, excision, spontaneous discharge, animal experimentation,
etc., may be examined microscopically in the fresh state, or prepared
for microscopic examination by methods of fixation, hardening and
imbedding. The methods necessary for such histologic studies of
pathologic material are given in the following pages, arranged as
far as possible in their logical order. Only those methods are
given that, in the light of the writer’s experience, yield the best
results, from the standpoints of economy of time, labor, and expense,
and perfection of result. The number of histologic methods contained
in the literature is so great that it is out of the question for
the student or practical worker to try out all of them. To give all
of these methods would create confusion. I have attempted to avoid
this by giving in full detail only those which in our laboratory
experience have yielded the best results. So many methods represent
but slight variations of some original method, and in the great
majority of cases these variations add so little or nothing of value
to the original method that in such cases the latter alone is given
in full, with references only to the variations of the method. The
individual equation plays such a large part in the judgment of
laboratory methods that allowance has been made for this when certain
variations or alterations in original methods have been strongly
recommended by expert laboratory workers.
The purpose of the microscopic examination is the revealment
of pathologic changes too small to be recognized by the naked
eye, and the securing of a diagnosis that cannot be made
macroscopically, as well as the confirmation of diagnoses based upon
the gross appearances. Aside from these more immediate practical
considerations, the microscopic examination of tissues is concerned
with the solution of etiologic and pathologic problems, and the
extension of our knowledge of disease. The aim of pathologic
technique is the fixation of tissues for microscopic examination
in such a manner that all of the morphologic and chemical elements
and constituents of the tissue are perfectly preserved, so that
with differential staining methods they are all brought out with
sufficient contrast to be readily and correctly identified. In a
certain number of methods this ideal is attained, and to Weigert,
more than to any other worker in the field of pathologic technique,
are we indebted for such ideal methods.
The choice of methods will depend upon the source and nature of the
material, the object of the examination, the time-element and the
degree of responsibility involved. The cellular elements of all
pathologic fluids, secretions and excretions should be examined
in the fresh state as well as in fixed preparations. For the
demonstration of various chemical and morphologic features that are
lost or altered by processes of fixation and imbedding, and when a
rapid diagnosis is required, the examination of the material in its
fresh state or by the freezing method is indicated. When the freezing
method cannot be employed because of the changes in cells and tissue
produced by it, when very thin or serial sections are desired, when a
rapid diagnosis is not required, and when a very careful and minute
study is desired, with the application of various staining methods,
then the material should be fixed, hardened and imbedded and cut
upon a microtome. Whatever method is chosen, it must be borne in
mind, particularly in practical diagnostic work, that the portions
chosen for microscopic examination must represent the characteristic
anatomic structures of the tissue or organ, that living tissue be
included, that the pathologic condition be represented both in its
fully-developed state and at the transition-border between it and the
healthy tissue, and that when sections are cut the block or tissue
must be so oriented as to give the most comprehensive view of the
tissue and the pathologic process. To accomplish this fully it is
often necessary to make a number of blocks representing different
areas of the material, and to cut these in different planes.
CHAPTER XVII.
THE LABORATORY OUTFIT.
For practical diagnostic work or for pathologic research various
instruments and utensils are necessary, although the expense of
fitting up a working pathologic laboratory is not as great as it
is often thought to be. The most expensive item, as well as the
most important, is the =microscope=. This should be of the best
make, and should be carefully selected and tested before the final
purchase. As a rule the German makes, Zeiss, Leitz, and others,
are to be preferred to the American instruments, in spite of the
higher cost due to the duty imposed. I have found the German
microscopes uniformly good and standing the wear and tear of a
teaching laboratory much better than the American-made stands. I have
never seen a poor Zeiss or Leitz objective, but cannot say the same
thing of other makes. On the other hand, I have seen some American
objectives that were as good as any German ones, but there are not
many such. If one is going to buy an American microscope it should
be bought on the same principle that one would buy a violin or a
piano, wholly on its individual merits; and these can be ascertained
only by having the instrument carefully examined and tested by an
expert. Most laboratory workers will agree that the Zeiss instruments
are the best; they are also the most expensive. For all practical
purposes a Leitz stand costing ninety to one hundred dollars is
quite good enough. A medium-sized continental stand, with rack and
pinion and micrometer screw for coarse and fine adjustment, a triple
nose-piece with dust-protector, Abbé condenser, iris diaphragm,
plane and concave mirrors, three objectives (low, high and 1/12
oil-immersion), and two eye-pieces, a low and a high, form a complete
outfit that answers all practical requirements. The new type of
stand with curved arm and large stage, permitting the examination of
all parts of a Petri dish or glass plate, and with the mechanism of
the fine adjustment protected from any strain when the instrument
is lifted by the arm is especially recommended. I have also found
the black-finish very practical. The entire outfit need not be
purchased at once; the stand with its accessories and a low power
may first be purchased, and the higher-power objectives obtained
later. One of the first luxuries is a movable adjustable stage. A
very good and relatively cheap one is made by the Spencer Lens Co.,
of Buffalo. If a Zeiss stand is purchased the objectives A, D, and
1/12 oil-immersion, and oculars 2 and 4 best meet the requirements.
Of the Zeiss apochromatic series, the objectives 16.0, 8.0, 4.0, and
oil-immersion 2.0 mm., apert. 1.30, and oculars 4, 6 and 8 are most
serviceable. The apochromatic objectives and the compensation-oculars
are expensive, and need not be used for ordinary work, but are
indispensable for photographic work. The Leitz objectives, 3, 6, or
7, and 1/12 oil-immersion, with oculars 2 and 4, and the equivalent
objectives of the Spencer Lens Co. or Bausch and Lomb will answer
all ordinary needs. For the purpose of microscopic measurements an
ocular micrometer is necessary. This may be obtained as a separate
eye-piece, or as a round piece of glass with measured divisions
marked upon it that may be put into an ocular. The value of the scale
must be determined for every lens and tube-length by estimating the
number of its parts covering one part of a stage-micrometer marked in
hundredths of a millimetre.
[Illustration: FIG. 50.—A satisfactory outfit for the working
laboratory. Continental stand, medium-sized, with large stage, three
objectives, etc.]
An instrument of any one of the above-mentioned makes, carefully
selected and tested, should last its owner a life-time if proper
care is taken of it. It should receive the same careful attention
accorded a good violin or piano. It should be protected from dust,
action of chemicals, heat, sunlight, and rough usage. When carried
it should be supported in such a way that its weight is not thrown
upon the thread of the adjusting screws. The adjustment, draw-tube
and iris diaphragm should be carefully oiled at intervals, using the
least possible amount of the best microtome oil. It is not necessary
here to enter into the construction and theory of the microscope,
as this knowledge has usually been obtained before the pathologic
laboratory is reached. Experience has shown me, however, that it is
always necessary to remind students, even those experienced for some
time in the use of the microscope, of certain fundamental principles
in the adaptation of microscopic technique to pathologic work. The
following rules are of value:—
1. Use a _low-power_ objective for all work except for the study of
bacteria, microparasites and finer cell-structures. The aim should
be to obtain as much of a bird’s-eye view of the “geography” of
the section as possible. Contrast plays a very important part in
pathologic diagnosis; and it is lost in high-power work, so far as
the relations of cells and tissue-elements and pathologic products
are concerned. The student almost invariably enters the pathologic
laboratory with a fixed “high-power habit,” and he is usually greatly
surprised to learn how much he misses with the high-power and how
much he can see with the low-power. A motto used many years in my
laboratory, “Low-power objective and high-power cortex,” is of
greater educational value than may appear at first sight. A slide
should be examined first with the naked-eye, as it is held against
a window or light; then it should be examined under the low power.
Rarely will it be necessary to use a high-power except for the
purposes mentioned above.
2. Weak eye-pieces should be used; strong ones darken the field
and tire the eyes. Only in the case of apochromatic lenses and
compensation oculars can the strong ones be used without darkening
the field too much.
3. In the use of higher powers see that the tube is drawn out to
the proper length, as indicated in the directions sent with the
instrument.
4. For pathologic work an Abbé condenser is essential. It should be
pushed up to its proper position beneath the stage, and the plane
mirror should be used with it, reflecting the light from a cloud if
possible. Daylight is always the best light. When this cannot be
obtained an incandescent or Welsbach lamp with ground-glass globe
can be used. The concave mirror should then be used. The yellowish
tint of artificial light may be avoided by the use of a piece of blue
glass placed beneath the condenser, or a vessel of copper sulphate
solution may be interposed. Especial lamps designed to meet the
requirements are offered by the trade.
5. The iris-diaphragm should be adjusted by the same hand that moves
the slide, usually the left one. With unstained preparations the
diaphragm should be nearly closed; when using the oil-immersion it
should be fully opened, as is also the case when stained preparations
are studied with the lower power. With higher magnification the
aperture is diminished somewhat, although color-effects are best
shown with open diaphragm. In the study of pigments the diaphragm
should be fully closed for a few moments to see if the pigment
shows any color by reflected light. It is then examined by open
diaphragm. In the study of sections the mirror and diaphragm should
be manipulated in various ways to bring out all of the detail of the
preparation, and should be adjusted to suit each preparation.
6. Objectives must never be screwed down until they strike the slide
or stage. The higher-powers are frequently ruined in this way. When
running the objective down always examine from the side to see that
there is no danger of its striking the stage. In the use of the
oil-immersion place the drop of oil upon the slide or cover-glass,
and lower the objective by turning the coarse adjustment until the
oil spreads out between the lens and the glass; then focus with
the fine adjustment until a well-defined field is obtained. The
oil-immersion lens should not be allowed to stand many consecutive
hours in the oil. The oil should be cleaned from the lens by wiping
the latter with lens-paper or a soft cloth; if the lens is sticky the
paper or cloth may be moistened with benzol. The lens itself should
never be _wet_ with benzol, xylol, alcohol or any cleaning-fluid,
because of the danger of softening the balsam in which the lenses are
imbedded.
7. Use the mechanical stage only for differential blood-counting, or
when the entire section is to be gone over carefully, or when certain
details are found with difficulty and it is desirable to mark them
for future reference. An immense amount of time is lost in the use
of the mechanical stage for ordinary work. By moving the slide with
the fingers of the left hand resting upon the stage an entire section
may be gone over in a few seconds without missing any part of it;
to accomplish the same thing with the mechanical stage requires much
more time.
It is an excellent plan for the student to purchase his microscope
when entering the medical school and to use his own instrument
throughout his course. It is the one instrument without which no
physician can afford to enter practice; and the student who uses his
own microscope before graduation will continue to use it afterward.
The microscope obtained, the remaining expenditure necessary for
the fitting-up of a practical working laboratory of clinical and
pathologic diagnosis need not be very great if one’s financial
condition does not warrant spending with a free hand. It is possible
with a little labor and ingenuity to make at home, or to show the
local tinsmith how to make, a large part of the necessary apparatus,
such as sterilizers, paraffin-ovens, drying ovens, thermo-regulators,
etc., at a slight cost. Students of mine have made these things out
of old tin cans and glass tubing; one student at a cost of less than
three dollars constructed a microtome on which practical working
sections could be cut. For the celloidin method no apparatus except
the microtome is necessary, as the process of imbedding is carried
on in bottles or dishes. These points are mentioned to offset the
prevalent idea that a large expenditure is a necessity in installing
a practical working laboratory.
In a large diagnostic laboratory, or in one intended for teaching and
investigation, there are numerous accessories necessary to modern
microscopic technique. For the observation of living objects a _warm
stage_ is needed. The simple electrical apparatus devised by Ross is
the most convenient form, as it can be slipped on and off the slide
without changing the focus. It can be attached to any electric light
circuit and requires no attention.
For drawing from the microscope the improved form of the _camera
lucida_, or the latest model of the _Edinger drawing-apparatus_ are
recommended. Both of these instruments have recently been greatly
improved. The _Zeiss microphotographic apparatus_ is by far the
best for microphotographic work. For the _polarization-microscope_,
_microspectroscope_, and the complicated and expensive _ultra-violet_
and _dark-field_ apparatus the worker is referred to the Zeiss
catalogues. A simple and practical _dark-field_ method for the
illumination of bacteria, spirochætes and ultramicroscopic particles
suspended in fluids requires only a strong illumination and the use
of a _Zeiss_, _Leitz_, or _Reichert dark-field condenser_; or the
very simple “India-ink” method may be used for the demonstration of
spirochætes. (See Staining of Spirochætes.) Especial instruments
for easily finding a certain field are obtainable, and are of great
convenience in marking slides for photographic purposes.
[Illustration: FIG. 51.—A good practical microtome for paraffin and
celloidin work. Well-adapted to needs of students and beginners.]
Next to the microscope the most important instrument in pathologic
work is the =microtome=. One that can be used for either celloidin or
paraffin work, and that can also be utilized as a freezing microtome,
should be selected in private work, when economy is desired. The
majority can be used for either paraffin or celloidin, and one of the
Becker models can be easily attached to the carbonic acid holder for
the cutting of frozen material. The Bardeen freezing microtome is
relatively inexpensive, very satisfactory, and can be easily attached
to the carbonic acid tanks. It can be recommended for freezing work.
The “slide” type, either that in which the knife-holder is moved by
the hand directly or by a crank turned by the hand, is advised for
ordinary diagnostic work. For students and beginners the crank is of
great advantage, as the knife is securely held and cannot jump. The
best microtomes are made by Schanze of Leipzig, Jung of Heidelberg,
Becker of Göttingen, the Cambridge Scientific Co., the International
Instrument Co., and the Bausch & Lomb Co. For either celloidin or
paraffin work the medium or large Schanze slide-microtome or the
Minot’s precision microtome are recommended; for cutting serial
sections in paraffin the latest modification of the Minot automatic
rotary microtome is especially adapted. The best =microtome knives=
are made by Walb of Heidelberg. A long, heavy knife is to be
preferred to a light one. For the freezing microtome a knife of the
type of the blade of a carpenter’s plane set in a wooden handle
should be used, Hones and strops of the best quality are necessary.
=Paraffin-ovens= and =drying-ovens= of suitable size, and constructed
preferably of copper, are necessary for paraffin work. The
water-space about the oven should be sufficiently large, and the
temperature should be controlled by a thermo-regulator. Various
models are offered in the trade, but they can be made more cheaply
by the local tinsmith. The thermo-regulator can also be home-made by
anyone who has the necessary training in glass-blowing usually given
in courses in bacteriology.
=Various instruments= and =utensils=, such as _razors_,
_double-bladed knives_, _forceps_, _spatulas_, _section-lifters_,
_needles_, _scalpels_, _scissors_, _glass rods_ and _tubing_,
_test-tubes_, _graduates_, _flasks_, _funnels_, _bottles_,
_staining dishes_, _reagent bottles_, _rubber tubing_,
_water-bath_, _tripods_, _centrifuge_, _Bunsen burners_, _asbestos
pads_, _gauze_, _filter-papers_, _absorbent paper_, _labels_,
_oil_ and _wax colored pencils_, _slides_, _cover-glasses_,
_slide-boxes_, _camel’s-hair brushes_, _glass droppers_, _platinum
wire_, etc., are required for the pathologic laboratory, and can
be chosen to suit the individual needs. The solid watch glasses
make very good small staining dishes; the enamelled trays and
glass dishes used in photographic work are especially adapted
to the plate-method, particularly the size used for the 4 × 5
plate. Tea-strainers or small sieves can be used for staining
a large number of celloidin sections; and there are different
types of staining-dishes designed for the staining of slide- and
cover-glass preparations in number. Slides should be of the best
quality, colorless and with ground edges, and of medium thickness.
Cover-glasses should be square or oblong, round covers having but
little use in pathology. For ordinary work the No. 2 square, ¾
inch, is recommended; for work with the higher-power dry objectives
a thinner cover must be used. Slides and covers may be cleaned by
placing them in a solution of equal parts of one per cent sulphuric
and chromic acids and then rinsing in distilled water. A good
cleaning fluid is also made of one part acetic acid to three of
80 per cent alcohol. To clean old mounts melt the balsam by heat
or dissolve in turpentine, separate slides and covers, boil in
ten per cent lysol for half an hour, or for ten minutes in the
sulphuric-chromic-acid mixture, rinse thoroughly, dry with cloth
having no lint.
The laboratory should be supplied with running water, a sink
large enough for washing out specimens, numerous stop-cocks, and
a drip-board. Distilled water in abundance must be available. The
laboratory-table should have an alcohol- and xylol-proof finish,
black on the whole being the most practical color. A portion of the
table should be covered with glass beneath which there is laid a
sheet of white paper.
CHAPTER XVIII.
THE EXAMINATION OF FRESH MATERIAL.
I. METHODS OF EXAMINATION.
Pathologic material is examined in the fresh state when it is desired
to make a diagnosis in the shortest time possible, or when the
processes of fixation and hardening produce such alterations in the
morphology and chemic constitution of the cells that these features
can be recognized only in the unfixed, fresh state. So far as the
saving of time is concerned it is possible to take material removed
during an operation, examine it in the fresh state, and return a
diagnosis to the surgeon, while the patient is still on the table
under the influence of the anæsthetic. It is not possible to do this
with all tissues or with all pathologic conditions; but, when it can
be done, the advantages of such a rapid diagnosis, in the saving of
time, labor, expense and danger to the patient, are obvious. The best
idea of the cell is also gained by its study in a fresh condition.
Vital phenomena and certain morphologic features, as cilia, can be
observed only in fresh material. Many of the chemic constituents
of cells (glycogen, fat, mucin, pseudomucin, albumin-granules,
cholesterin, etc.) are either lost, or are so changed by processes
of fixation or hardening that they can no longer be recognized. The
majority of specific chemic tests can be made in fresh tissues only.
Moderate and slight degrees of fatty degeneration and cloudy swelling
are easily recognized in the fresh state; in fixed and hardened
preparations they may not be recognized at all. Particularly in the
case of the heart-muscle is it necessary to make an examination
of the fresh material when the diagnosis of these conditions is
concerned. Further, a greater or less degree of shrinking is caused
by many of the agents used in fixing and hardening, and this is
avoided by the examination of the fresh material. In the case of
pathologic fluids (sputum, urine, féces, etc.) an examination of
the sediment in the fresh state should always be made as a matter
of routine. The formed elements of these fluids are best determined
by this means. In the case of tissues, a diagnosis made by means of
scrapings, smears, teased bits of tissue, frozen sections, etc.,
should always be controlled by the examination of fixed and hardened
material.
In the examination of fresh material the following methods are
employed: _Sedimentation_, _smears_, _scraping_, _crushing_,
_teasing_, _maceration_, _sections_, _shaking or penciling_,
_digestion_, _intravital staining_, injection, _the warm stage_ _and_
“_cultivation_.”
1. =Sedimentation.= The formed elements of pathologic fluids (urine,
sputum, pus, blood, exudates, transudates, cyst-contents, etc.) are
examined by collecting the sediment of such fluids from the bottom
of a sedimenting glass or bottle, by means of a capillary pipette
controlled by the finger. While the sediment is passing up into the
tube the pipette should be moved about the bottom of the vessel so as
to get some of the sediment from all parts. When the fluid is rich in
cellular elements sedimentation is not necessary; a drop of the fluid
is placed upon the slide; if too thick it is diluted with physiologic
salt-solution or serum. If poor in cellular elements the fluid must
be centrifugalized by means of a water- or electric-centrifuge; and
a drop of the sediment in the centrifuge tube is then removed by the
pipette and placed upon the slide, and covered with a cover-glass.
To facilitate the low-power examination of such sediments parallel
streaks upon the slide may be made across its entire length, and
examined without the use of cover-glasses. To apply the various
reagents mentioned below it becomes necessary to use a cover-glass as
directed.
2. =Smears.= A clean fresh cut is made into the organ or tissue, and
a clean slide or cover-glass is drawn across the surface. Without
permitting the smear to dry a drop of salt-solution or any desired
reagent is put upon it, and it is then examined. This method is
especially applicable to the study of the cells of the spleen,
bone-marrow, lymphnodes, etc. Permanent balsam-mounts may be made
of such smears by fixing with heat or alcohol and ether, staining,
drying and mounting.
3. =Scraping.= A fresh cut is made into the organ or tissue, and
the excess of blood absorbed by a pad of absorbent paper devoid of
lint. A clean scalpel held at an angle of 45° is then drawn with
some force back and forth over the cut-surface until its blade
collects a sufficient amount of “tissue-juice” made up of the cells
of the tissue. This is then put upon a slide, and covered with
salt-solution or any desired reagent, and is then examined. This
method is used especially for cellular infiltrations, soft tumors,
and parenchymatous organs (spleen, lymphnodes, bone-marrow, liver,
etc.), and for the inner wall of cysts (echinococcus-cysts, cysts
lined with ciliated epithelium).
4. =Crushing.= A small bit of the tissue is cut out with the scissors
or scalpel, and placed upon the slide. A cover-glass is then placed
upon it and pressed down so firmly that the bit of tissue is spread
out in a thin film or layer beneath the cover-glass. Reagents are
introduced beneath the cover-glass, as desired. (See below.) This
method is used in the examination of the lung, kidneys and brain for
fatty embolism, and of the brain and spinal-cord for “fat-granule”
cells, pigment, calcified ganglion-cells, Negri bodies, etc. It is
also frequently used in the bacteriologic examination of tissues
(crushing of tubercles, etc.).
5. =Teasing.= A small bit of the tissue is cut out and placed
upon the slide or in a staining-dish and covered with physiologic
salt-solution. It is then teased with fine needles until divided
into its ultimate elements. Hard tumors (mature connective-tissue
tumors, fibrosarcomata, etc.), muscle (examination for trichina),
nerve-trunks, etc., are best examined in this way.
6. =Maceration.= In the case of some tissues the ultimate histologic
elements are so firmly held together that they cannot be separated
without the aid of a _macerating-_ or _dissociation-fluid_. (See
below.) =Digestion= is also used for the same end. The tissue should
be as fresh as possible and cut into small bits, which are placed
in the maceration-fluid in watch-glasses or staining-dishes for
twenty-four hours or longer. The macerated bits are then teased
until the finest elements are separated. In the case of very minute
elements the teasing may be carried on under a hand-lens or the
stereoscopic binocular microscope. During the process of maceration
all parts of the macerating tissue must be kept covered with the
macerating-fluid, or the uncovered portions will become hardened.
7. =Section-cutting.= Sections of fresh tissue may be made with
the _curved shears_, _simple razor_, _double-bladed razor_ and the
_freezing-microtome_.
_a._ _Curved Shears._ The tissue is put upon a stretch, and from the
surface a thin, flat section is cut out with the scissors. With care
a fairly thin section may be obtained in this way. It may be examined
by pressing it upon a slide beneath a cover-glass, or it may be
treated as a frozen section.
_b._ _Simple Razor._ As a part of their required laboratory training
medical students should learn how to make working sections with a
simple razor. Such a technical knowledge is sure to be of practical
use at some time or other. With a little practice sections
sufficiently thin for ordinary diagnostic work can be cut. If the
piece of tissue is large it may be held in the hand; but when small
or soft it may be placed in a matrix of hardened liver, pith,
potato, apple, firm lard or butter, paraffin, etc., and cut at the
same time with the latter. Both blade and tissue should be wet with
physiologic salt-solution. The blade, which must be very sharp,
should be _drawn_ through the tissue by a shoulder movement, with the
wrist-joint fixed. As the sections are cut they are floated off of
the razor-blade into physiologic salt-solution, and thence treated as
desired.
_c._ _Double-bladed Knife._ This consists of two parallel blades
arranged so that the space between them can be changed by means
of screws. For firm material the blades should be close together;
for soft material farther apart. The blades should be dipped into
physiologic salt-solution to fill up the space between the blades.
The instrument is then drawn through the tissue, and the section
between the blades floated out in salt-solution. Some workers use
this double-bladed knife to make a perpendicular cut into the tissue,
then turning it to either side to cut the lower edge of the section
and removing the blades with the section between them. Both the
single- and the double-bladed razors require practice for successful
section-cutting. Further, it must be borne in mind that sections of
fresh tissue obtained by these methods are unsuited for complicated
staining methods and can be used only for the simplest staining
processes. Nevertheless, in a fairly large proportion of pathologic
conditions it is possible to secure a diagnosis by these methods.
_d._ _Freezing Microtome._ Much more satisfactory sections can
be obtained by freezing the fresh tissue and cutting it upon the
=freezing microtome=. Various types of these instruments are in
the market. The freezing is accomplished by the use of _ether_,
_ethyl-chloride_ or _fluid carbonic acid gas_. The ether and
ethyl-chloride freezing-microtomes consist essentially of a metal
plate or hollow box on which the tissue rests and against the
under-surface of which a spray of ether or ethyl-chloride is forced
by means of a rubber bulb connected with a supply of the freezing
agent in a bottle. Such freezing attachments can be attached to any
microtome, but special instruments as Jung’s “student’s freezing
microtome,” Cathcart’s, Bausch and Lomb’s or Becker’s ether-freezing
microtome can be recommended for this purpose. (See Fig. 52.) The
tissue to be frozen must be of small size and not more than 3-4 mm.
thick. It is placed upon the freezing plate in a drop of water, white
of egg or thick gum-arabic, and pressed firmly against the plate. The
spray must not be too constant or strong, but should be given with
regular pauses of about a second to allow the ether to evaporate. The
tissue must be firmly frozen, but not so hard that it crumbles. It is
usually difficult to freeze the upper part of the tissue hard enough
to give good sections, and this half-frozen tissue must be trimmed
off with the knife until good sections are secured. As the sections
are cut they are removed from the knife-blade with the finger and
put into physiologic salt-solution that has been recently boiled to
drive off the air, so that, in thawing, there may be no formation
of air-bubbles in the tissue to cause artefacts. If put into strong
alcohol diffusion-currents may damage the tissue; a succession of
graded solutions should, therefore, be used if the sections are to be
fixed and hardened. The further treatment of frozen sections is given
below. The relative slowness of the method of freezing, its greater
cost, the necessity of the frequent replacement of the rubber bulbs
and tubing, and the greater amount of trouble required by the use of
ether or ethyl-chloride are disadvantages that can be avoided by the
use of the carbonic acid freezing microtome. Where much work is done
by the freezing method the use of the latter is advised.
[Illustration: FIG. 52.—Type of freezing-microtome, for the use of
ether or ethyl-chloride. Cathcart model.]
[Illustration: FIG. 53.—Carbonic-acid freezing-microtome. Becker
model.]
[Illustration: FIG. 54.—Bardeen freezing-microtome attached to
carbonic-acid gas-cylinder.]
The _carbonic acid outfit_ consists of a microtome arranged so that
it can be connected with a cylinder of compressed carbonic acid
gas, as shown in the Aschoff-Becker or Bardeen models. (Figs 53 and
54.) The cylinders or drums containing a charge of 15-30 lbs. of
the liquid carbonic-acid are furnished by the trade at reasonable
rates. It is not necessary to buy the drums, as they are replaced
by full ones as needed. They are provided with valves and can be
fastened in an upright position or laid flat upon a table, in any
way convenient for the attachment to the microtome. Connection is
made between the valve of the cylinder and the object-holder of the
microtome by means of strong rubber tubing which should be securely
wired at both ends, or by a flexible metallic tube. The latter is
preferable, as the rubber-tubing often bursts, or is so stretched
by the pressure of the gas that it must be frequently replaced.
Object-holders with flexible metallic tube attachment for use in an
ordinary microtome are supplied by Bausch and Lomb and other firms.
My personal experience makes me prefer the Bardeen freezing microtome
(see Fig. 54) to all others. It is cheap and can be easily attached
to the valve of the gas-cylinder, which is fastened horizontally
to the table-top, as it has a screw-thread fitted to the uniform
thread of the drum-valve. The object-holder can be raised or lowered
between the glass-tracks on which the knife runs, so that sections
of a definite thickness can be obtained. The most satisfactory knife
is that of the type of a plane-bit set in a wooden handle. (See Fig.
55.) It must be well honed and stropped. The tissue, which should
not be more than 5 mm. thick, is placed upon the object-holder in a
drop of water, albumin fixative, or saturated solution of gum-arabic,
and pressed firmly against the plate as the gas is turned on slowly
and evenly. Freezing is usually accomplished in one-half to one
minute. The best results are obtained by turning the gas on for about
15-20 seconds, then turning it off for several seconds; the tissue
will continue to freeze; if not hard enough the gas is turned on
again for 15 seconds and then turned off. If necessary this may be
repeated until the tissue is properly frozen. The interruption of the
gas-flow prevents over-freezing and thereby lessens the amount of
change in the cells. When sufficiently frozen the gas is then turned
off; the knife, with bevel-edge down, is held in the right hand with
its handle between the palm and the ball of the thumb with the back
of the hand uppermost; and the edge of the knife set at an angle of
45° to the tracks, along which it is rapidly pushed back and forth,
shaving the sections from the frozen tissue as the latter is pushed
up above the level of the tracks by means of the micrometer screw
turned with the left hand. The screw should have been adjusted at the
proper height before freezing, so that no time is lost in getting
the object-holder up to the height for cutting. By holding the elbow
and fore-arm closely against the body and pushing from the elbow
with wrist-joint fixed the shaving of sections can be accomplished
very quickly, so that with one freezing several hundred sections can
be obtained. The microtome-screw should not be turned by the left
hand until the knife on its return has cleared the tissue. A little
practice in co-ordinating movements is necessary for expert work. The
sections should be allowed to collect upon the knife-blade until a
large number have been cut; they are then swept off the blade by the
finger into cold freshly-boiled physiologic salt-solution. Sections
of tissue that have been previously fixed can be put into 60 per cent
alcohol, where the sections will unroll and straighten out perfectly
flat. When the method of freezing by alternately turning on and off
the gas, as given above, is followed, and the amount of freezing in
the interval noted, there is no danger of over-freezing, and the
breaking and crumbling of sections, with the production of marked
artefacts, is avoided. When over-freezing has occurred the block may
be partly thawed out by the finger. But _over-freezing_, as well as
_repeated freezing and thawing_, may cause so much damage to fresh
tissue that a diagnosis cannot be obtained from the frozen sections.
After thawing out in the physiologic salt-solution the sections
of fresh tissue obtained by freezing are treated according to the
methods given in the next section of this chapter.
[Illustration: FIG. 55.—Knife for Bardeen freezing-microtome.]
It must be emphasized here that the process of freezing is an
active one, and alters the relation of cell-structures. With many
fresh tissues the changes resulting from the freezing are so great
that no diagnosis can be made. It seems necessary here to warn
against the routine employment of the rapid method of freezing and
staining fresh tissues in the diagnosis of material obtained by
surgical operation. It has become a fad with some surgeons to make
a pathologic diagnosis by the freezing method while the patient is
on the table. Consequently, as the result of diagnoses made by the
rapid freezing and staining method, many mistakes are made, even
by supposed experts in this line. Particularly in the diagnosis of
sarcoma is it easy to make mistakes because of the altered aspect
of the cells caused by freezing. Normal lymphnodes, tonsils and
inflammatory infiltrations may look like spindle-cell sarcoma in
the sections prepared by the rapid freezing and staining method;
and the exact nature of many other pathologic conditions cannot
be accurately determined from such sections. On the other hand, a
certain number of pathologic conditions can always be recognized in
sections obtained in this way, and this fact justifies the employment
of the method when properly controlled. _In all cases in which the
pathologic condition is not clearly evident in sections obtained
by the rapid freezing and staining method no diagnosis should be
given._ In such cases the tissue should be fixed and then cut upon
the freezing-microtome, or imbedded in celloidin or paraffin and then
cut. Even when the patient is upon the table the tissue removed can
be put into a 10 per cent formol solution for a few minutes and then
frozen directly in gum without washing out the formalin. The longer
the time that can be used for this short preliminary fixation the
better the sections will be and the less the production of artefacts
by the freezing. The process of fixation can be hastened by warming
the fixing-fluid. I advise this short fixation before freezing in
all cases of operative diagnostic work when the diagnosis is wanted
as soon as possible. For all other work with the freezing microtome,
when the question of time is not so important, fixation with
formol for 12-24 hours should be carried out. This combination of
formol-fixation and the freezing method permits the early diagnosis
of autopsy and operation material, makes possible the demonstration
of fat and other substances altered or dissolved out by the imbedding
methods, and is a convenient way of selecting tissues, requiring more
complicated staining processes. (See also Page 239.) The further
treatment of sections of fresh tissue obtained by freezing will be
found in the second section of this chapter.
8. =Penciling or Shaking.= For the demonstration of the stroma or
reticulum either fresh or fixed sections may be placed upon a slide
in an abundance of fluid and gently penciled with a fine, blunt
camel’s hair brush until the fluid becomes cloudy. The cloudy fluid
is washed away and replaced by fresh as long as cells are given
off. The same results may be obtained by shaking the sections in a
test-tube until the cells are shaken out of the stroma. The removal
of the cells from the section is shown by its greater transparency.
One of the practical applications of these methods in diagnostic work
is the differentiation between alveolar round-cell sarcomata and
carcinomata.
9. =Digestion.= For the demonstration of stroma, parasites, etc., the
tissues may be digested with gastric or pancreatic ferments until the
required elements are freed. A freshly prepared pepsin in 0.2 per
cent HCl in the incubator for 3-5 hours will digest fibrin in fresh
clots. Sections of fixed tissues may be imbedded in paraffin, cut,
and digested on the slide with Grübler’s pancreatin according to the
method of Flint.
10. =Intravital and Supravital Staining.= Various methods have been
advised for the intravital staining of cell-granules. Intravenous or
intraperitoneal injections of methylene blue, alum carmine, neutral
red and other stains will produce intracellular granule-staining in
various organs of experimental animals. In the study of low forms
of animal life staining solutions may be injected, or the animal or
its parts may be examined in staining fluids. Human material can be
examined by this method immediately after being removed from the body
by operation or within 1-2 hours after death. (For details of these
methods see article on _“Färbungen, intravitale_,” _Encyklopädie der
mikroskopischen Technik_.)
11. =Injection.= Injections for the demonstration of blood-vessels,
lymphatics, ducts of glands, etc., are rarely used in pathologic
work. The organs to be injected must be fresh, warm from the
body, if possible. The vessels should be washed out by a freshly
filtered 8 per cent sodium nitrate or sodium sulphate solution,
followed by physiologic salt-solution. A cannula is introduced into
a main vessel, tightly secured, and then connected with a syringe
or a gravity injection-apparatus giving a constant pressure. The
injection-mass is then injected under a low pressure. In the case of
injections into lymphatic vessels the cannula should be introduced
into the largest lymphatics at the periphery of the blood-vessels
where larger lymph-vessels are more easily found. Injections are
made with either cold or warm solutions; the latter are preferable
but require that the organ to be injected be warmed by immersing
it in water at a temperature of 40°C. The injection fluid must
be of the same temperature. After the warm injection is given
the organ is put into ice-cold 10 per cent formol solution until
fixed and then after-hardened, imbedded and stained as desired.
After the use of cold injections the tissues are fixed in 10 per
cent formol, alcohol, or any other desired solution, and treated
according to the end sought. Nuclear and diffuse stains contrasting
with the color of the injection mass should be used. The process
of injection requires great care; the pressure must be carefully
regulated to prevent extravasations, and the injection-fluid must
be free from air-bubbles. The injection is continued until the
organ appears diffusely stained. Blood-vessels are fixed in their
natural blood-injection by such agents as formol and chromic acid,
so that stains acting upon the red blood cells cause the veins and
capillaries to appear as if they had been injected.
The following injection masses are advised:—
1. =Cold Injection Mass (Beale’s Glycerin Carmine):—=
Dissolve 0.3 grm. of carmine in a small quantity of water
containing 5 drops of ammonia; add 15 cc. of glycerin and shake;
add drop by drop 15 cc. of glycerin containing 8-10 drops of
glacial acetic acid. Then add further glycerin 15 cc., alcohol 8
cc., and water 24 cc.
2. =Warm Injection Mass (Thiersch’s Berlin-blue Gelatin):—=
(_a_) Dissolve 1 part of gelatin in 2 parts of water by allowing it
to soak 24 hours, and then warming. Filter through flannel.
(_b_) Saturated water solution of ferrous sulphate.
(_c_) Saturated water solution of red ferricyanide of potassium.
(_d_) Saturated water solution of oxalic acid.
Make a solution (_1_) by adding 30 cc. of _a_ to 12 cc. of _b_, and
a solution (_2_) by adding 24 cc. of _c_ to 60 cc. of _a_; both
mixtures to be made at a temperature of 30°C. At same temperature
add 24 cc. of _d_ to solution _2_, and then solution _1_, stirring
constantly so that Berlin blue is precipitated. Heat on a
water-bath to 90°C.; filter through flannel.
3. =Fischer’s Milk-Method.= The vessels are flushed with 8 per cent
sodium nitrate or sulphate solution, and then injected with milk.
When sufficiently injected the tissue is hardened for 24 hours in a
solution of water, 1,000 cc., formalin (40 per cent formaldehyde)
75 cc., and glacial acetic acid 15 cc. Freeze, cut and stain with
Sudan III or Scharlach R.; the course of the vessels is outlined by
the fat-globules.
4. =Silbermann’s= method of injecting indigo-carmine, eosin or
phlosin-red into the circulating blood has been used for the
demonstration of capillary thrombi, the latter remaining free from
the pigment.
12. =Warm Stage.= For the study of vital phenomena in the living
cell _Ross’s electrical warmer_ is recommended. It can be slipped on
and off the slide without changing the focus, and is managed without
any difficulty. It keeps the centre of the slide at a temperature of
37°C. Reagents can be applied as desired. Deetjen’s agar may be used
as a medium for the preservation of living cells. (See Methods of
Blood-Examination.) Various forms of warm and moist chambers used in
experimental embryological work can also be utilized in experimental
pathology.
13. =Tissue-cultivation.= The embryologic methods of growing tissues
in lymph and blood-plasma as developed by Harrison, Burrows and
Carrel have been applied in pathologic work to the experimental
study of repair and regeneration, grafting, transplantation and
tumor-transplantation. (For methods see _Harrison_, Journal of Exper.
Zoology, 1910; _Burrows_, Jour. of Amer. Med. Assoc., 1910; _Carrel_,
Jour. of Amer. Med. Assoc., 1910.)
II. REAGENTS USED IN THE EXAMINATION OF FRESH TISSUES.
In the examination of fresh tissue it is often desirable to use
certain reagents for the purpose of making chemical tests or to bring
out some structures more prominently than others. To introduce these
reagents beneath the cover-glass in such a way as to get the desired
effect without disturbing given fields requires some practice with a
very simple technical method. The preparation is first examined in
salt-solution, and the cover-glass adjusted so that it has a slight
rim of fluid about its edge, but not enough to make it float. The
reagent to be applied is dropped with a glass-dropper at one side
of the cover-glass, while at the other the salt-solution is removed
slowly by a piece of absorbent paper. The changes produced in the
tissue-elements during the progress of the reagent can be observed
under low or high powers. Care must be taken to change the fluids so
slowly that isolated cells will not be washed away.
1. =Physiologic or Indifferent Fluids.= Serous exudates,
blood-serum, hydrocele fluid, etc.; artificial serum made by a
mixture of 9 parts physiologic salt-solution with 1 part white of
egg; or physiologic salt-solution (0.9 per cent for warm-blooded
animals, 0.6 per cent for cold-blooded).
2. =Maceration Fluids.= 33 per cent alcohol (24 hours); chromic
acid 1:5000 (24 hours); potassium bichromate 0.1-0.2 per cent
solution (2-4 days for nervous tissue); 0.1 per cent osmic acid
(12-24 hours); 33 per cent potassium hydroxide (¼-1 hour, for
muscle, tissue must be examined in the solution, as the cells
dissolve when water is added); Arnold’s iodine solution (10 parts
of a 10 per cent potassium iodide solution to which are added 5-10
drops of a solution containing 5 grms. of iodine and 10 grms. of
potassium iodide in 100 cc. of water. Macerate one or more days.
If solution becomes discolored add more of the second solution);
very dilute formol solutions (1 cc. to 500 cc. physiologic
salt-solution); Müller’s fluid (2-3 days, good for nervous tissue).
3. =Glycerin.= Used without diluting as a _clearing agent_,
particularly when pigment is present; and as a _mounting medium_
for stained preparations that cannot be put into alcohol.
4. =Potassium Acetate.= Saturated water solution for clearing
and mounting fresh preparations. Does not clear as strongly as
glycerin, hence is better adapted for the examination of fresh
tissues.
5. =Acetic Acid.= 1-2-5 per cent solutions are usually employed.
Clears the protoplasm and causes the nucleus to shrink slightly
and to stand out more distinctly. It differentiates fatty and
albuminous granules, dissolving the latter; and is useful in the
demonstration of elastic tissue fibres, sharply outlining these
against the connective-tissue which swells and becomes clear.
6. =Acetic Acid Fuchsin.= A few drops of fuchsin are added to a 2
per cent solution of acetic acid. With this solution the nuclei are
not only brought out more sharply but they are stained red.
7. =Lugol’s Solution.= Dilute Lugol’s solution to a pale yellow
color. It brings out the contours of cell and nucleus, and has a
specific reaction with glycogen and amyloid, giving both a brown
color. Since glycogen is dissolved out in water-solutions tests
for glycogen in fresh tissues should be made with iodine-glycerin
or iodine-gum (Lugol’s one part, gum arabic 100 parts). Smears or
cover-glass preparations may be placed in covered dishes containing
a few crystals of iodine.
8. =Potassium and Sodium Hydroxides.= In solutions of 1-3 per cent
all tissue-structures swell and dissolve or become unrecognizable
except elastic fibres, fat, pigment, amyloid, bacteria, yeasts
and moulds. Used especially for examination of skin-scrapings or
pus for presence of blastomyces and various forms of parasitic
moulds (barber’s itch, ringworm, tinea, etc.). Solutions of 33 per
cent clear the tissues but do not destroy the cells. Useful for
maceration. When diluted the cells are destroyed.
9. =Mineral Acids.= HCl or H_{2}SO_{4} (3-5 per cent). Used to
dissolve areas of calcification. Calcium dissolves with liberation
of CO_{2}; the phosphates dissolve without gas-formation, but with
H_{2}SO_{4} form crystals of calcium sulphate. Sulphuric acid is
also used as a test for cholesterin (red or violet coloration), and
with iodine as a test for amyloid.
10. =Osmic Acid.= In a 1 per cent solution this is used to test for
the presence of fat (oleates), the fat-droplets become black or
brown.
11. =Sudan III or Scharlach R.= Alcoholic solutions of these dyes
are used for the demonstration of fat in fresh tissues. They stain
fat orange to scarlet. (For method see Staining of Fat.)
12. =Alcohol and Ether.= Used to dissolve fat-granules and to
differentiate between these and albuminous granules.
13. =Stains.= Fuchsin, methylene blue, methylene green in 1 per
cent solutions in physiologic salt-solution and acetic-acid-fuchsin
are the best stains used for the examination of fresh-tissues
beneath the cover-glass. They are drawn under the cover-glass
according to the method given above.
For the rapid staining of sections of fresh tissue cut by freezing
a section is floated from the salt-solution onto a slide, which is
then carefully lifted from the salt-solution and the excess of the
latter removed. Several drops of methylene blue, carbol-thionin
or carbol-kresyl-echt-violett are run upon the section with the
glass-dropper, and allowed to remain for 15-30 seconds. The stain
is then washed off with salt-solution, a cover-slip put on and the
section examined in the salt-solution. Thionin has been especially
recommended (Wood, Strouse and others) for the rapid staining of
frozen sections; but I prefer to use carbol-kresyl-echt-violett
(kresyl-echt-violett 1 grm., 5 per cent aqueous solution of phenol
80 cc., 95 per cent alcohol 20 cc.). This gives a very good
differentiation in the section examined in water, and the picture
is clearer than with thionin; the specific staining-reactions with
mucin, amyloid, mast-cells, etc., are also more marked than with
the latter stain. Such sections are not as clear as dehydrated
and cleared sections and their possibilities of diagnosis are
correspondingly limited, even in the hands of an expert with
sections of this kind.
To make permanent balsam-mounts of the frozen unfixed sections
the latter must be fixed in formol or alcohol, or by heat (hot
water). The sections may be placed in 4 per cent formol for
several minutes, then into 80 per cent alcohol, then stained,
washed, dehydrated in absolute alcohol, cleared in carbol-xylol
and finally mounted in balsam. Hæmatoxylin and eosin may be used
for the staining. Fresh sections may also be fixed in hot water,
stained in hæmatoxylin, dehydrated in alcohol and cleared in
xylol. To save time the sections may be fixed on the slide for a
few minutes in alcohol, care being taken to prevent the sections
from rolling up by dropping the alcohol onto the middle of the
section after it has been carefully flattened out on the slide.
The section may then be stained with hæmatoxylin, borax-carmine
or other stains, dehydrated, cleared and mounted in balsam. After
fixing with alcohol on the slide the section may be attached to the
slide by blotting it with absorbent paper, then covering section
with absolute alcohol, draining this off after a few seconds and
then running over the section a thin solution of celloidin, which
is allowed to drain off, leaving a very thin film over the section
and slide. The latter is then immersed in water for a few seconds,
and the celloidin-film on setting holds the section to the slide,
provided the celloidin has been of proper consistence. The section
can now be stained, washed, dehydrated, cleared in origanum and
mounted in balsam. When mounted the thin film of celloidin is
invisible (Wright’s method).
I have originated a much better method which is in use in my
laboratory, and can be applied to the staining of frozen sections
of fresh tissues in large numbers for class use. The sections are
floated from the salt-solution on to a warm solution of New Orleans
baking molasses diluted ten times, or a dilute sugar-dextrin
solution, and thence are floated on to a clean glass plate and
arranged in rows. The plate is drained, and then without drying is
immersed in absolute alcohol for 15-30 seconds; it is then flooded
with a thin celloidin, drained, the celloidin film allowed to set,
and the plate then put into warm water, where the celloidin sheet
floats off, carrying the sections, which can now be cut out and
treated as single celloidin sections, or the whole sheet can be
carried through the staining, dehydrating and clearing solutions to
be cut up into single sections before mounting.
CHAPTER XIX.
THE PRESERVATION OF MACROSCOPIC PREPARATIONS.
For preserving gross objects for museum specimens alcohol or formol
may be employed. The former bleaches the tissues so that ultimately
they are almost destitute of color. Formol in a 5 per cent solution
gives better color-effects than alcohol, as the blood-containing
parts remain darker. The fluid also remains clear and the tissues
are firm. When alcohol is used the fluid must be frequently changed,
as it becomes turbid and yellowish, and the tissues finally become
soft and lose their form. The best methods of preserving the natural
color are found in the various modifications of the =Kaiserling
method=. The organs or tissues are placed first in a formol solution
until they are just hardened, the formol changing the oxyhæmoglobin
into acid hæmatin. They are then transferred to alcohol to bring
back the natural color, which is accomplished by the change of the
acid hæmatin to an alkali hæmatin, which has a color very closely
resembling that of oxyhæmoglobin, so that the natural color is
approximately reproduced. The method is carried out as follows:—
Sol. I.—Formalin 200 cc.
Water 1,000 cc.
Potassium nitrate 15 grms.
Potassium acetate 30 grms.
The tissues are left in this solution, in the dark, for one to
several days, being watched carefully to see that they are not
over-hardened.
Sol. II.—80 per cent alcohol for 1-6 hours and then 95 per cent
until the color is fully restored (2-24 hours). Watch carefully and
remove as soon as best color effect is reached, and preserve in—
Sol. III.—Glycerin 400 cc.
Water 2,000 cc.
Potassium acetate 200 grms.
The specimens must be kept in air-tight jars, and crystals of
thymol added to prevent growth of moulds. This is sometimes very
difficult, and it becomes necessary to change the discolored fluid
for clear. I have found the rectangular museum jars best adapted
for the preservation of Kaiserling specimens. I use a wooden top
which fits over a thick piece of felt cut just the size of the
jar, which in turn fits over a piece of dental rubber cut to fit
the jar. The jar is placed upon a wooden bottom which has upright
steel rods at the corners, that pass through holes in the wooden
top, and have a screw-thread so that they can be fitted with
screws, which when screwed down hold the wooden top, felt and
rubber sheeting tightly in place, making the jar air-tight, but
giving a top easily removable. Very beautiful specimens can be
secured by the Kaiserling method, and they can be kept for several
years, but sooner or later the color-effect is lost. Light, heat
and exposure to the air cause a loss of color.
Some workers prefer the following in place of Sol. I:—
Hot water 2,000 cc.
Sodium sulphate 40 grms.
Magnesium sulphate 40 grms.
Sodium chloride 20 grms.
When salts are dissolved and solution cool add 200 cc. of formalin.
Melnikow-Raswedenkow Method:—
Sol. I.—Water 100 parts
Formol 10 parts
Sodium acetate 3 parts
Potassium chlorate 0.5 part
Leave in this 1-2-3-4-5 days, according to size of specimen. Large
organs must have solution injected into vessels.
Sol. II.—95 per cent alcohol, until color is restored.
Sol. III.—Preserve in: Water 100 parts
Glycerin 60 parts
Potassium acetate 30 parts
Pick’s Method:—
Sol. I.—Water 1,000 cc.
Formol 50 cc.
Carlsbad salts 50 grms.
Then transfer to 80 and 95 per cent alcohols, as for Kaiserling,
and preserve in water 9,000 cc., glycerin 5,400 cc., sodium acetate
2,700 grms.
=Westenhoeffer’s method= of preserving uric-acid: formol vapor 4-24
hours, then 80-90 per cent alcohol containing mercuric oxide, and
preserve in glycerin to which some mercuric oxide covered by cotton
or absorbent paper has been added.
=Claudius’s Method.= The specimen is placed on a grating in a
closed vessel containing a concentrated solution of ammonium
sulphate, an abundance of the crystals being left on the bottom of
the vessel. Carbonic acid or illuminating gas is passed through the
ammonium sulphate solution for 48-72 hours, and the specimens are
then preserved in the same solution. My experience with this method
has not been satisfactory.
=Gelatin method= of mounting Kaiserling preparations: Soak washed
Gold Label gelatin in distilled water for 12-24 hours. Take equal
parts of water-logged gelatin and glycerin and dissolve by heating
in a double boiler, stirring, for 15-20 minutes. Cool to 40°C.
Then clarify with white of egg (well-whipped whites of three eggs
to half a gallon of jelly: stir well; steam for ½ hour) and filter
through cotton-wool. Add to jelly a few drops of a weak aqueous
solution of crystal violet to remove yellow color (_Bruère and
Kaufmann_). To prevent growth of bacteria a small percentage of
formol or crystal of phenol may be added. Kaiserling specimens are
placed in glass dishes in the melted jelly, and covered with it.
When set the dishes containing the mounted specimens may be covered
with glass-plates and fastened to these by balsam or cement. I use
a deep Petri dish, filling it about two-thirds full with the jelly;
over this I pour melted paraffin of a very low melting point so as
not to melt the jelly. When the layer of soft paraffin is hard, a
thick layer of paraffin of a 52° melting-point is poured over it,
and the dish filled even. When the hard paraffin is set, it is
varnished with shellac. Liquefaction of the gelatin by bacteria or
enzymes constitutes the great drawback to this method.
CHAPTER XX.
THE FIXATION AND HARDENING OF TISSUES.
=GENERAL CONSIDERATIONS.= For the examination of material that may
be injured by freezing, or when very thin sections are required for
complicated staining procedures, it becomes necessary to prepare the
tissue by _fixation_ and _hardening_, so that it can be _imbedded_
in some medium permitting the _cutting_ on the microtome of as thin
sections as may be desired. Fixation is that process by which the
appearances of the tissue are preserved as they were when it was
taken for examination; hence in order to obtain pictures resembling
as closely as possible those of the living tissue the material
should be _fixed_ immediately upon its removal from the living body
by operation, or as soon as possible after death when obtained by
autopsy. _Fixing agents_ act by coagulating the cell albumins, in
this way “setting” or “fixing” the constituents of the cell so that
further change is stopped. Fixation, therefore, _hardens_ the cell,
and all fixatives are also hardening agents. A practical distinction
between fixing and hardening is made, however, resting upon the fact
that not all fixatives harden the tissue so completely that the
proper consistence for the cutting of thin sections is attained. To
achieve this the tissue must be dehydrated. Alcohol and acetone are
the only reagents fixing and hardening perfectly at the same time, as
they remove the water from the tissue; for all other fixing agents
an _after-hardening_ in alcohol is necessary. In the case of such
reagents the division of the process into a _primary fixation_ and
a _second hardening_ stage has been the cause of the divergence in
meaning of the two terms.
The best fixing agents are those that kill the cells at once, but
cause a slow coagulation with little or no shrinking. They must
penetrate and diffuse through the tissues rapidly so that the deepest
cells are quickly reached. Acid media, especially those containing
small percentages of acetic acid, are therefore better than alkaline
solutions. The tissue-elements, particularly the nuclei, must
be preserved as perfectly as possible so that they will not be
affected by further procedures of microscopic technique. The chemic
properties of physiologic and pathologic substances must likewise be
preserved. The preservation of karyokinetic figures is a criterion
of good fixation. In pathologic work it is also desirable that the
fixing agent should preserve the red blood cells, and permit of the
staining of bacteria in sections. Since fixing media are more or less
selective in their action, it follows that there is no one fixative
that gives equally good results in all cases. Especial fixing
reagents must be used for the demonstration of certain substances
(fat, etc.), or for the use of certain staining methods. Some
stains cannot be used at all after certain fixing agents have been
employed. For general use that fixing agent having the widest range
of usefulness should be employed; and for this reason fixing media
composed of several fixing agents are often employed in preference to
the use of a single one.
GENERAL RULES FOR FIXING AND HARDENING.
The tissue should be put into the fixing fluid as soon as possible
after its removal from the body. It must not be allowed to dry. There
should be an abundance of the fixing solution, 25-50 times the volume
of the object to be fixed. The tissue should never be put into a
dry vessel and the fixing fluid poured upon it; the vessel should
first be filled with the fixing solution and the tissue then dropped
into the latter. A slight agitation of the fluid will prevent the
sticking of the tissue to the bottom or sides of the vessel. The
size of the pieces must be adapted to the penetrating power of the
fixing reagent, but as a rule the pieces should not be more than 2-3
cms. in thickness, and for some reagents 0.5 cm. is as thick as they
can safely be. The reagents used should be changed when they become
cloudy or discolored. The used solution may be filtered and used
again, but some reagents can be used but once. Alcohol may be saved
for redistillation. In the case of some reagents (mercuric chloride,
chromic acid, osmic acid, etc.), the time limits of the fixation
should not be exceeded, as over-fixation will ruin the staining-power
of the tissues. Alcohol is practically the only solution in which
tissues may be left indefinitely, but even with it there are certain
limitations. As a general rule the time required for fixation may
be shortened by keeping the reagents at incubator-temperature. As
the different fixing reagents vary so greatly as to their especial
advantages and disadvantages these will be considered separately.
Only the best and most commonly used methods are here included.
1. =ACETONE.= A water-free acetone is employed by placing pure
dried white copper sulphate in the bottom of the bottle or vessel
in which the fixation-process is carried on. Several layers
of filter-paper are put over the copper sulphate to keep the
tissues from touching it, and the acetone is then poured into the
vessel. As soon as the copper-sulphate becomes blue it must be
again fused. It is only by this method of constant dehydration
that acetone can be employed to any advantage as a fixing agent;
if fused copper sulphate is not employed the amount of acetone
necessary to fix well is so great that the method becomes too
troublesome and expensive to be recommended. But with the simple
copper-sulphate method of constant dehydration acetone becomes the
cheapest, most rapid and one of the best fixing reagents. The use
of alcohol is avoided, and the period of infiltration in xylol
and in paraffin shortened. For very quick work the entire process
of fixation, hardening and dehydration may be achieved by the use
of acetone alone, small pieces of tissue being fixed ½-2 hours
in acetone and then transferred directly to soft paraffin. For
ordinary work pieces of tissue 0.5 cm. thick are put into acetone
over fused copper sulphate for 20-60 minutes. A judgment of the
degree of fixation can be obtained by pressing the tissue lightly
between the fingers; if it is of uniform consistence, and does
not give as if the inner portions were softer than the surface,
the fixation is complete. From the acetone the tissues may be
brought directly into xylol for 5-10 minutes, until they obtain a
cloudy transparency, thence into paraffin for 15-30 minutes and
then blocked. The whole process of fixation, imbedding, cutting
and staining can be carried out in 30 minutes. Acetone may be
combined with formol, alcohol or any of the other fixing agents,
but when it is desired to use any one of these for some especial
purpose it is better to fix first with the desired reagent and
then to use acetone for the dehydration-process alone, instead of
alcohol. We have found that formol-fixation followed by acetone
dehydration gives excellent results for general pathologic work.
=Formol-acetone= (acetone 100 cc., formol 10 cc.) may be found to
have advantages. The quick fixation in water-free acetone causes
less contraction than fixation with absolute alcohol; fixation with
graded acetone-solutions causes practically none.
=Advantages.= It is the cheapest and quickest method. It penetrates
well and causes little contraction of the tissues, shortens the
time in xylol and paraffin and makes more easy the cutting of dense
fibrous structures. Cell-division figures are as well preserved as
by alcohol fixation, and the staining of bacteria in the tissues
can be carried out as well after acetone-fixation as after alcohol.
It preserves lecithin, hence can be used for the fixation of
nerve-tissues. When combined with formol (formol-acetone) the red
blood-cells are well-preserved and take a brilliant eosin stain.
=Disadvantages.= The disadvantages are practically the same as with
alcohol fixation but not so marked. Fat is dissolved, cell-division
figures are not so well-preserved as with mercuric chloride and
Flemming’s solution, and the blood-cells not so well preserved as
with formol and mercuric chloride.
2. =ALCOHOL.= Absolute, 95-96 per cent alcohol, or graded alcohols
(70, 95 per cent. and absolute) may be used for fixation. For
this purpose the stronger alcohols are preferable, as the weaker
solutions do not fix quickly enough. On the whole the use of 95-96
per cent is to be advised. The pieces of tissue must not be thick.
Plenty of alcohol should be used and it should be changed several
times during the process of fixation, which for larger pieces
requires several days. For the last change absolute should be used.
Very small bits such as uterine curettings can be fixed in one
hour, by using three changes of absolute alcohol. Since alcohol
both fixes and hardens it has been generally used, but it is a
relatively poor fixative. For after-hardening it is indispensable.
Absolute alcohol may be made from 96 per cent by the use of fused
copper sulphate. To test the strength of alcohol mix a few drops
with pure water-free xylol; if no sediment appears when viewed
against a dark background the alcohol is absolute or practically
so. Many of the disadvantages of alcohol fixation can be obviated
by the use of =formol-alcohol= (95 per cent alcohol 100 cc.,
formalin 10 cc.).
=Advantages.= Cheapness, quickness, and ease of method. Can be used
for quick diagnostic work. Penetrates well, and can be used for
large pieces of tissue. Preserves glycogen, is especially good for
the staining of bacteria in sections, and the majority of stains
work well with alcohol-fixation.
=Disadvantages.= Causes much shrinking and loss of finer details;
preserves cell-division figures not at all or poorly; destroys
the red blood cells; dissolves fat and other chemic products:
does not permit of the use of certain specific staining methods
(nerve-tissues); causes excessive hardness of fibrous and elastic
tissues and makes cutting difficult.
3. =CHROMIC ACID AND SALTS.= Chromic acid is rarely used alone in
pathologic work, but is a constituent of Flemming’s solution (see
below). Its salts are employed in the form of:—
A. =Müller’s Fluid= (Potassium bichromate 25.0 grms., sodium
sulphate 10.0 grms., water 1,000.0 cc.) This was formerly the
favorite fixing solution, but is now used chiefly for the eye
and nervous tissues, either alone, or after formol fixation,
or mixed with formol. Large pieces may be used, even an entire
brain, but the process requires months or even a year for the
best results. Even small pieces take several weeks. The process
may be hastened in the incubator. The solution should be changed
whenever it becomes cloudy. When fixation is complete the fixed and
hardened tissue may be cut directly on the freezing-microtome or
after-hardened and dehydrated in alcohol or acetone when it is to
be imbedded. The dehydration in alcohol should be carried out in
the dark and without previous washing of the tissue in the case of
nervous tissue. Greenish or brownish chrome precipitates appear if
the dehydration takes place in the light; but for ordinary material
this precipitate can be avoided by washing the fixed material in
running water for 24 hours before transferring to alcohol. Moulds
grow luxuriantly in Müller’s fluid, but may be inhibited by the use
of pieces of camphor, thymol, etc.
=Advantages.= Cheap, penetrates well, causes little shrinking,
permits special nerve-stains, preserves red blood-cells, gives
beautiful results with ordinary stains, preserves fat.
=Disadvantages.= Slowness; does not preserve division-figures;
does not permit of staining for bacteria; does not give good
results with many special staining methods (fibrin, elastic tissue,
reticulum, etc.).
B. =Erlitzky’s Fluid= (Potassium bichromate 25.0 grms., copper
sulphate 5.0 grms., water 1,000.0 cc.). Used for fixation of
nervous tissue. The formation of pigment precipitates may lead to
misinterpretation: the artefacts may be removed by hot water or
dilute acetic acid.
C. =Orth’s Fluid= (Müller’s fluid 100 cc., formol 10 cc. Make
fresh before using, as the mixture precipitates on standing.).
Fix for 3-12 hours in the incubator, or for 24-48 hours at room
temperature. Wash in running water for 12-24 hours; cut on the
freezing microtome, or after-harden in acetone or alcohol and imbed.
=Advantages.= Combines the good features of Müller’s and formol
fixations, and obviates some of the disadvantages. It is a good
general fixing solution.
3. =FORMOL OR FORMALIN= (40 per cent solution of formaldehyde
gas). Used in a _ten per cent solution_ (water or physiologic salt
solution nine parts, formalin one part), often incorrectly called 4
per cent formol or formalin, the mistake arising from the confusion
with 4 per cent formaldehyde gas. For nerve-tissues it is better to
dilute the formol with physiologic salt-solution than with water.
Fix for 3-4-12 hours according to size of tissue. As it penetrates
well large pieces can be used. Wash in water before after-hardening
in alcohol, if tissue is to be employed for general work, otherwise
it can be transferred directly to the alcohol without washing.
Tissues can be kept in formol for some weeks, but after that time
the staining-power is slowly affected, and the finer structures
suffer.
=Advantages.= Probably the best fixing reagent for general
pathologic work. It is cheap; easily made and kept in solutions
of proper strength for fixing; hardens while it fixes; does not
require after-washing; penetrates well; causes little shrinking;
permits freezing directly from the fixing solution; preserves fat;
permits the use of after-hardening with bichromate solutions for
especial nerve-stains: preserves the red blood-cells: gives good
results with nearly all stains, and differentiates bile-pigment
from hæmatoidin. It is the best fixing reagent when tissues are to
be sent some distance, as over-fixation occurs only after several
weeks or even months.
=Disadvantages.= Affects many people unpleasantly, causing coryza,
eczema of the hands and arms, and affections of the finger-nails,
so that workers having acquired this idiosyncrasy cannot expose
themselves to formol vapor; it dissolves glycogen and uric acid;
does not fix cell-division figures as well as mercuric chloride
or Flemming’s solution; causes the precipitation of diffuse
hæmoglobin in the form of brown or black pigment-granules that
may be taken for melanin, malaria pigment or hæmosiderin; causes
a pseudo-ochronosis of cartilages; and, unless thoroughly washed
from the tissues before after-hardening in alcohol, it makes
carmine-staining difficult or unsatisfactory and affects also the
specific staining-reactions for amyloid and mucin; it is not as
good as alcohol or mercuric-chloride when the sections are to be
stained for bacteria. In spite of these disadvantages it can be
recommended as the best general fixing reagent.
For =Orth’s fluid=, =formol-acetone= and =formol-alcohol= see above.
4. =FREEZING AND DRYING.= The fresh tissue is frozen and dehydrated
in a vacuum over sulphuric acid, at a temperature of 20-30°C.; when
completely dried it is imbedded directly in paraffin. This method
has been especially recommended by Altmann on the ground that the
tissues are simply deprived of water without any change in volume.
5. =HEAT.= Physiologic salt-solution is heated to 80°C. Thin pieces
of tissue are placed in the hot water for two minutes, and then
after-hardened in alcohol. For larger pieces of œdematous tissues,
cysts, etc., that cannot be cut into thin pieces, the salt-solution
should be brought to 100°C and the tissues boiled for several
minutes. This method is advised particularly for the coagulation of
albumin in cysts, œdematous tissues, for the study of renal casts,
etc.
6. =MERCURIC CHLORIDE.= This is used most commonly in the form
of =a concentrated water solution= (mercuric chloride 7.5 grms.,
sodium chloride 0.5 grm., glacial acetic acid 5 cc., water 100.0
cc.), or as =Zenker’s solution= (mercuric chloride 5.0 grms.,
sodium sulphate 1.0 grm., potassium bichromate 2.5 grms., water 100
cc.; dissolve by heating, add 5 cc. glacial acetic acid just before
using. The use of a 5 per cent formol solution instead of acetic
acid is recommended). The pieces of tissue should not be thicker
than 5 mm. Fix 6-24 hours, then wash 24 hours in running water,
and after-harden in alcohol. Should the sections show mercuric
precipitates they should be treated with Lugol’s solution for 30-60
minutes, then washed in a dilute solution of lithium carbonate and
thoroughly washed out in water and alcohol. Much better stains can
be obtained by this treatment of the sections with Lugol’s. The
use of iodine in the alcohol during the process of after-hardening
is not advisable because of the action of the iodine upon the
albuminates of mercury. A 5 per cent solution of =sublamine= in
distilled water has recently been recommended by _Klingmüller_
and _Veiel_. Fix 1-3 hours, wash and after-harden in alcohol.
Precipitates are not formed, and good staining-results are obtained.
=Advantages.= The mercuric chloride solutions preserve well the red
blood-cells, mitotic figures and finer details of cell-structure,
and permit the staining of bacteria and animal parasites in
the sections. Certain especial staining methods (Mallory’s
reticulum-stain, etc.) can be used only after mercuric chloride
fixation, while many others (Heidenhain’s iron-hæmatoxylin,
Biondi-Heidenhain triple stain, etc.) give best results after
this fixation. For ordinary work the saturated mercuric chloride
solution is preferable to Zenker’s, as the latter does not give
good results with the commonly-used hæmatoxylin stains.
=Disadvantages.= More troublesome and expensive; require thorough
washing and subsequent removal of precipitates, and affect
(Zenker’s particularly) certain stains.
7. =OSMIC ACID.= Osmic acid is used alone in a 1 per cent solution,
or in such combinations as =Flemming’s solution= (chromic acid 1
per cent. sol. 15 cc., 1 per cent osmic acid 4 cc., glacial acetic
acid 1 cc.), =Hermann’s solution= (same as Flemming’s, with 15
cc. of a 1 per cent platinic chloride substituted for the chromic
acid), =Altmann’s solution= (5 per cent potassium bichromate
solution 50 cc., 2 per cent osmic acid solution 50 cc.), =Marchi’s
solution= (Müller’s fluid 2 parts, 1 per cent osmic acid solution
1 part), and that of =Pianese= (1 per cent sodium-chloroplatinate
15 cc., 2 per cent osmic acid 5 cc., ¼ per cent chromic acid
5 cc., formic acid 1 drop). The pieces of tissue must be very
thin, as osmic acid penetrates very slightly. Fix 6-24 hours in
the dark, and wash thoroughly in running water, and after-harden
in graded alcohols. These solutions have but limited use in
pathology, and are used chiefly for the study of fat (oleates) and
mitotic figures. Flemming’s and Hermann’s solutions are the best
for the study of mitotic figures, the latter bringing out plasma
details more clearly. Marchi’s fluid is used especially for the
study of nerve-degeneration, and Altmann’s for the demonstration
of Altmann’s granules. The method of Pianese is used for the
demonstration of cell-inclusions. The osmic-acid mixtures are all
expensive, penetrate poorly, cause precipitates, and affect greatly
the staining-power of the tissues, so that it becomes necessary
to use certain stains (safranin, carbol fuchsin, aniline gentian
violet, etc.) as counterstains.
8. =PICRIC ACID.= A saturated water solution of picric acid is
usually employed. Fix 12-24 hours, and wash in alcohol, not water,
and after-harden in graded alcohols. Preserves mitotic figures,
fine details of cell-structure, and is very good for bone and
calcified tissues, as it decalcifies and fixes at the same time.
Numerous modifications and combinations of the above methods
have been proposed such as _Flemming’s chrom-acetic solution_,
_Rawitz’s chromic-picric-nitric fluid_, _Rabl’s chrom-formic
mixture_, _Burckhardt’s chrom-osmic-nitric solution_, _Merkel’s
fluid (chromic acid-platinic chloride)_, _Carnoy’s mixture (glacial
acetic acid 1_, _absolute alcohol 6_, _chloroform 3_), and many
others. They have a limited use in pathologic work.
In the judgment of a section as to its fixation the following points
may be of service: in alcohol fixation the red blood cells are
haemolyzed, and there is much shrinking; with formol fixation the red
cells stain copper-red with eosin; in mercuric chloride fixations the
red cells stain rose-red with eosin, and pigment precipitates are
present; in bichromate fixation the red cells preserve their natural
color, and fat cells show a brownish color; osmic-acid fixation is
shown by the black color of the oleates, and the failure of the
tissue to stain by ordinary stains.
CHAPTER XXI.
DECALCIFICATION.
Bone and tissue containing deposits of lime must be decalcified
before they can be sectioned on the microtome. The decalcification
should be carried out after fixation and before the after-hardening
in alcohol. Some reagents may combine decalcification with fixation,
but this is satisfactory only when the amount of lime-salts is
relatively small. Fresh tissues should not be put into any of the
stronger acid decalcifying fluids, as they alter unfixed cells so
that the staining-power is lost and the fine histologic details
destroyed. The fixed tissue cut into small pieces is put into the
decalcifying reagent, which is used in large amount and must be
frequently changed. It is left in the decalcifying fluid until the
calcium salts are removed, as shown by tests with needle or scalpel.
The tissue must not be left in the fluid after decalcification is
attained, as the staining-power is affected by all decalcifying
reagents; it is therefore necessary to make frequent tests in
order to judge of the progress of the decalcifying process. After
decalcification the tissue should be washed in running water for 24
hours, and then after-hardened in alcohol. Alkaline solutions may
be used to remove the acid before washing. Sections of decalcified
tissue always stain slowly, and it is advisable to remove any acid
remaining in the tissues by soaking the sections in a saturated water
solution of lithium carbonate before staining. Numerous formulæ for
decalcifying fluids have been recommended; a few of the best methods
only are given here.
1. =Combined Fixation and Decalcification.= Picric acid or Müller’s
fluid may be used for this purpose when the amount of lime-salts
contained in the tissues is very small. The process is slow.
2. =Trichloracetic Acid.= Fix tissues in 10% formalin and decalcify
in trichloracetic acid 90 cc., formol (40 per cent formaldehyde) 10
cc. Change frequently. Decalcification is rapid, the tissue is but
little changed and the staining-power not affected.
3. =Concentrated Sulphurous Acid.= Fix in 10 per cent formol;
decalcify in concentrated sulphurous acid for 24 hours or longer if
necessary. Wash thoroughly in alkaline water. This is a very good and
rapid method; the staining-power is but little affected.
4. =Haug’s Solution.= (Pure nitric acid 3-9 cc., absolute alcohol 70
cc., sodium chloride 0.25 grm., water 30 cc.). For tissues fixed in
mercuric chloride.
5. =Phloroglucin.= (Phloroglucin 1 grm., pure nitric acid 10 cc.,
distilled water 50 cc.). The solution must be carefully dissolved
over the flame in a hood. Decalcification is rapid, and the tissue is
protected from the acid by the phloroglucin.
6. =Ebner’s Fluid.= (Hydrochloric acid 5 cc., sodium sulphate 5
grms., alcohol 500 cc., water 1,000 cc.).
7. =Schaffer’s Method.= Imbed the fixed and hardened tissue in
celloidin, harden the celloidin preparation in 85 per cent alcohol,
then place celloidin block in a 3-5 per cent water solution of pure
nitric acid and agitate in Thoma’s water wheel, for 12 hours, or
longer according to the size of the piece. Transfer block to a 5
per cent solution of lithium carbonate or sodium sulphate for 12-24
hours, changing solution several times, wash in running water for 48
hours, dehydrate in graded alcohols up to 85 per cent, and cut.
CHAPTER XXII.
IMBEDDING.
The most perfect methods of fixation and hardening do not permit
the cutting of fine sections on a microtome without the freezing of
the tissue, or its =infiltration= and =imbedding= in some substance
which surrounds it with a protective coating, and preserves and
holds together its structural elements in their relative positions.
For the cutting of very thin sections, or for the preparation of
serial sections, it is absolutely necessary to employ the process of
imbedding. At the present time =paraffin= and =celloidin= are the two
substances in general use for this purpose. While each one of these
possesses certain advantages over the other, and we find consequently
one laboratory worker preferring celloidin and another paraffin for
general work, a long and varied experience makes me believe that for
a teaching laboratory and for diagnostic work when much material is
examined, the paraffin method answers all purposes much better than
the celloidin, and that the latter need be employed only in very
exceptional cases. Since paraffin sections can be transferred into
celloidin by the molasses- or dextrin-fixative method, thus enabling
the use of staining-methods that require celloidin sections, very few
advantages are left in the favor of celloidin as an imbedding agent.
The paraffin method requires a more expensive outfit to start with in
the form of a paraffin oven and thermo-regulator, but otherwise the
two methods cost about the same. The paraffin method requires more
careful attention than the celloidin. As a rule thinner sections can
be obtained in paraffin than in celloidin, and for the preparation
of serial sections the paraffin method is the only method. Paraffin
blocks can be labeled and filed away, and kept indefinitely without
any loss of staining-power. With careful attention paid to the
different steps of the imbedding process practically everything that
can be cut in celloidin can be cut in paraffin. For very large pieces
a slow imbedding in celloidin is, however, preferred by most workers.
Hard and brittle tissues are as a rule more easily cut in celloidin.
For the staining of bacteria in sections paraffin imbedding is
necessary. Both methods should be learned and practiced with equal
facility; a working knowledge of both is essential in pathologic
investigation and diagnosis.
1. =CELLOIDIN IMBEDDING.= The granular form of Schering’s celloidin
is the best preparation to use, although good results can be obtained
by using a cheaper well-washed gun-cotton. In purchasing the latter
care should be taken to secure a sample that dissolves easily in
alcohol and ether, and does not give off yellow fumes when exposed
to the light. Schering’s granular celloidin keeps well, and forms
on solution a firm, tough, transparent imbedding mass, so that thin
sections are obtainable without difficulty. When kept long in stock
celloidin becomes hard and dissolves more slowly. For use three
solutions are made, thick (10 per cent), thin (2 per cent), and
medium (5 per cent). The celloidin granules or shavings are put into
a wide-mouthed bottle having a tight stopper, and are covered with
absolute alcohol and well shaken, and left for 24 hours. An equal
quantity of pure ether is then added, the mixture is well stirred
and allowed to stand for another 24 hours, when it is again stirred
and evenly mixed, and is then ready for use. When gun-cotton is used
it is torn into fine shreds and added to a mixture of equal parts of
absolute alcohol and pure ether and shaken until sufficient has been
added to give the solution the desired strength.
Slow Celloidin Method.
1. Absolute alcohol 24 hours.
2. Equal parts absolute alcohol and ether 24 hours.
3. Thin celloidin for 1-3 days.
4. Medium celloidin for 1-3 days.
5. Thick celloidin for 1-3 days.
6. Block.
The tissue is blocked by removing it from the thick celloidin on a
section-lifter and placing it on a block of vulcanized fiber or wood
with enough of the thick celloidin about it to form a good matrix.
The preparation is then allowed to evaporate in the air until the
surface of the celloidin becomes firm (does not stick to the finger).
The block is then placed in 80 per cent alcohol or pure chloroform
until hard enough for cutting (1-24 hours). Cork should not be used
for blocking, nor should wood unless the tannin has been removed by
long treatment with alcohol-ether. The celloidin will adhere more
firmly to the fiber block if the latter is dry, and if there is a
sufficient layer of celloidin between the tissue and the block. The
imbedded tissues may be preserved in 80 per cent alcohol for a long
time, but gradually lose their staining power. They may also be kept
dry by coating them with melted paraffin. The blocks when preserved
in alcohol may be marked with an indelible pencil.
For imbedding large pieces of tissue in celloidin a glass dish may be
filled with thick celloidin and the infiltrated tissue placed in it
with cutting surface down. The celloidin is then allowed to evaporate
slowly under a glass cover, and fresh celloidin may be added as
shrinkage occurs. When well-hardened the celloidin is cut out of the
dish and the block trimmed to the proper proportions, and attached
directly to the object-holder of the microtome or to a block of wood
by a few drops of thick celloidin, allowing it to dry for a minute or
so and then immersing in 80 per cent alcohol. The block may be cut on
the freezing microtome by soaking the hardened celloidin in water to
remove the alcohol (when block sinks), then coating it with saturated
gum arabic solution, and freezing.
Rapid Celloidin Method.
I have used the following method in my laboratory for a number of
years as a regular procedure in practical diagnostic work, and the
results have been uniformly good.
1. Fresh tissue cut thin, or uterine curettings, in absolute
alcohol 1½ hours, three changes of fresh absolute during this time.
2. Alcohol-ether 1 hour.
3. Thin celloidin at incubator temperature 12 hours (over night).
4. Medium celloidin 1 hour.
5. Block from medium celloidin, evaporating celloidin by blowing,
and building up matrix by adding successive layers of celloidin.
6. 80 per cent alcohol 1-3 hours.
7. Cut.
The quick celloidin methods recommended in the literature (Kaufmann,
Stepanow, Scholz and others) require more time, and do not give
better results. Material received from operative clinics late in the
afternoon can be sectioned and stained usually by ten o’clock the
next morning.
2. =PARAFFIN IMBEDDING.= A paraffin of a melting-point sufficiently
high enough to withstand summer heat is advisable; a 52°C. paraffin
answers for this latitude. The use of softer paraffins is not
necessary. The paraffin-oven should be regulated at a constant
temperature of 54-55°C. Over-heating of the tissue while in the
oven must be carefully safeguarded, so that in the management of a
paraffin-oven the care of the thermo-regulator is the most important
thing.
Slow Paraffin Method.
1. Thorough dehydration in absolute alcohol 12-24 hours.
2. Aniline oil to remove alcohol, until tissue becomes transparent
or sinks.
3. 1st. Xylol, ½ hour, to remove aniline oil.
4. 2nd. Xylol, 1-2 hours, until translucent.
5. 1st. Paraffin, 52°C. in oven, 1 hour, to remove xylol.
6. 2nd. Paraffin, 52°C. in oven, 1-12 hours.
7. Block.
The use of xylol-paraffin is not necessary. For blocking staining
dishes, watch-glasses, glass salt-cellars, paper-boxes, metal
frames., etc., may be used. A thin smear of tincture of green soap
or glycerin is rubbed over the inside of the imbedding box, and
it is nearly filled with fresh melted paraffin. With warm forceps
the tissue is taken out of the bottle of second paraffin in the
oven, and arranged in the melted paraffin in the imbedding dish
in the proper position for cutting. Care must be taken that the
melted paraffin is not hot enough to “burn” the tissue, else its
staining-power may be affected. The surface of the paraffin is
then cooled by blowing upon it, and as soon as a film appears upon
the surface, the dish is carefully immersed in cold water, so that
the paraffin may set quickly. When cool the paraffin-block should
slip out of the dish and float to the surface. It is then trimmed
to the desired shape, leaving a good matrix of paraffin around the
tissue. The paraffin-block is then fastened to a wooden block or
to the object-holder of the microtome by means of melted paraffin
(a hot knife is drawn along the under-surface of the block and the
latter immediately pressed upon the wooden block or object-holder).
Chloroform, cedar oil, benzene, carbon bisulphide, etc., may be used
instead of xylol, and each one possesses certain advantages for
certain purposes. Benzene is advisable for osmic-acid preparations.
Rapid Paraffin Method.
The above method can be greatly shortened for uterine curettings,
thin bits of tissue, etc., if the various steps are closely watched,
and if the entire process is carried on in the oven. The whole
process may be carried out in 1-3 hours, a very great advantage over
the quick celloidin method. A simpler and cheaper method is that
recommended by _Heller_, _Henke_ and _Brunk_, as follows:—
Acetone Method.
1. Small bits of fresh tissue, or tissue fixed in formol, in
water-free acetone over copper sulphate for ½-1½ hours.
2. Transfer tissue directly to fluid paraffin in the oven for ½-1½
hours; the acetone evaporates, and the tissue is infiltrated with
paraffin; or put into xylol 5-10 minutes, then in paraffin 15-20
minutes.
3. Block.
By this method the entire process of fixing, hardening, imbedding,
cutting and staining can be carried out in half an hour, and by it
the freezing-microtome can be dispensed with in a large part of quick
diagnostic work.
Pyridin Method.
1. Fix in formol.
2. Dehydrate and clear in pyridin.
3. Paraffin.
This method requires a longer time than the acetone method, and is
not so good.
Combinations of celloidin and paraffin may be employed by imbedding
first in celloidin, transferring block to origanum oil, then xylol
and finally paraffin. Formol-agar has been recommended by _Bolton_
and _Harris_ for simultaneous fixation and imbedding. It offers no
especial advantages. _Wright_ uses formol-gelatin for imbedding
tissues for sectioning on the freezing microtome. The bits of tissue
are placed in warm 20 per cent pure gelatin; this is allowed to set,
and the block placed in 10 per cent formol for 24 hours; it is then
frozen and cut. Soap-gelatin, glycerin-gelatin, gum-glycerin, etc.,
are now rarely used for imbedding.
NOTE:—When a number of pieces of tissue are blocked at the same
time, either in celloidin or paraffin, they may be tagged with paper
labels fastened to the tissue with a drop of gum tragacanth or gum
arabic. As the gum is not soluble in any of the infiltrating and
imbedding media the labels remain attached until the block is ready
for cutting.
CHAPTER XXIII.
SECTION-CUTTING.
Fixed and hardened tissues may be sectioned on a microtome without
freezing or imbedding, or they may be cut on a freezing-microtome;
or, having been imbedded in either celloidin or paraffin, they may be
sectioned on any form of microtome suited to the purpose desired. The
choice of the microtome depends, therefore, upon the character of the
work. For ordinary purposes the small sliding microtomes furnished
with a crank are preferable, as they are more easily kept in order
and can be used for rapid cutting. For serial paraffin sections
the Minot automatic rotary microtome is advised. Especial types
of microtomes can be obtained for the cutting of large sections,
particularly for brain-sections. The Bardeen freezing-microtome
I have already recommended as the most practical instrument for
freezing work. In all cases it is absolutely necessary that the
instruments be in good order and that they work with precision. The
microtome knife must be carefully honed and stropped. A heavy, rigid,
biconcave knife-blade should be used, and a good hone and strop
are absolute necessities. In honing, the knife is drawn from heel
to toe with cutting edge forward; while, in stropping, the motion
is reversed, the back of the knife being forward, and the motion
from toe to heel. The knife during the honing should be fitted in a
knife-holder, and the back of the blade protected from the hone by a
knife-back. The knife-blade must be kept free from grease and dirt,
and nothing must be permitted to touch its edge. When many sections
are cut at one sitting frequent stropping is necessary. When the
cutting is finished the knife should be removed from the microtome,
carefully cleaned and dried, and placed in its box. The slide and
other bearings of the microtome should be well-oiled with the best
microtome oil, and kept free from dust.
1. =Cutting of Fixed Tissues Without Imbedding or Freezing.= It
occasionally becomes necessary in pathologic work to cut tissues
directly upon the microtome without freezing or imbedding. This can
be done satisfactorily in the case of very firm substances, such
as amyloid liver and spleen, etc. The sectioning is done in the
wet, using 80 per cent alcohol, as in celloidin cutting. A large
celloidin knife should be used, and the blade should be flooded in
alcohol. A large piece of the tissue, or, better, several pieces,
are clamped in the object holder with only a small layer of tissue
above the holder. The knife-blade is placed at the least possible
angle to the pieces of tissue. To obtain sections of 15-20 microns in
thickness the object-holder is raised each time about 25-30 microns.
The sections will vary in thickness, some thin, others very thick.
2. =Sectioning of Frozen Fixed Tissues.= Tissues fixed in formol,
Müller’s fluid or Orth’s fluid may be frozen directly on the
freezing-microtome without previous washing. For other fixations
previous washing is necessary. Tissues in alcohol must have the
alcohol thoroughly washed out before freezing. Celloidin blocks may
also be cut by freezing after the removal of alcohol. The fixed
tissues cut to the proper size are placed on the object-holder of the
freezing-microtome in a drop of saturated gum-arabic and the freezing
carried out as directed above. (See Page 214.) As the freezing
causes little or no damage to fixed tissue, the frozen sections may
be transferred directly to alcohol, or floated out on the dilute
molasses or sugar-dextrin solution, and stained separately or in
sheets, according to the directions given in the next chapter.
3. =Sectioning of Celloidin Blocks.= The celloidin blocks are
fastened in the object-holder of the microtome, and the knife-blade
(a longer and broader one than for paraffin-sectioning is advisable)
set nearly parallel with the longitudinal axis of the microtome,
so that the cutting-edge, striking the block at a very slight
angle, will be utilized for the greater part of its length in
cutting entirely across the surface of the block. Both object and
knife-blade must be kept constantly wet with 80 per cent alcohol;
a broad camel’s-hair brush or a drip-bottle can be used for this
purpose. The sections, as they are cut, are transferred from the
knife to 80 per cent alcohol by sweeping the finger or brush from
above toward the edge of the blade. Care must be taken not to strike
the brush against the edge of the blade, and this can be avoided by
using the brush always with a downward stroke. As the sections are
cut they are guided onto the knife-blade by means of a fine-pointed
camel’s-hair brush, if the sections show any tendency to curl. They
should be smoothed out at once on the knife, and then transferred to
the dish of 80 per cent alcohol. Sections 7-10µ thick are easily cut
in celloidin, if the process of imbedding has been carefully carried
out.
To prepare _serial-sections_ from celloidin blocks the sections as
they are cut must be arranged in their order on the knife-blade and
thence transferred in this order to a slide or glass-plate, to which
they are either fastened so that they cannot become loose during
the staining process, or they are fastened together by a film of
celloidin and stained in one piece. To fasten the celloidin sections
to the slide _Mallory_ and _Wright_ suggest the cutting of the block
in 95 per cent alcohol, and the arrangement of the sections in their
order on the knife, whence they are drawn on to a dry, clean and
numbered slide. Ether vapor from a half-full bottle of ether is
then poured over the slide, slowly, to flatten out the sections and
fasten down the frilled edges. The slides are then transferred to
80 per cent alcohol to harden the celloidin, and they are kept in
this solution until ready for staining. Celloidin sections may also
be fastened to the slide by albumin glycerin (equal parts white of
egg and glycerin with a crystal of phenol or thymol). The celloidin
sections, as they are cut, may be transferred to a dry gelatinized
slide or plate (16 grms. gelatin in 300 cc. warm water), and are
then covered with a thin celloidin; the slide is then placed in
water at 50°C., the gelatin dissolves and the celloidin film floats
off; the latter is then stained as one section. Serial sections of
celloidin-blocks may also be arranged upon slides or plates covered
with a coating of the _Schmorl-Obregia_ sugar-dextrin solution or
diluted New Orleans black molasses; the slide or plate is flooded
with absolute alcohol; drained; a thin celloidin is then poured over
it; it is immersed in warm water and the celloidin-sheet containing
the sections is liberated, and is then stained as a whole or cut
into strips as desired. The molasses method is the cheapest and
simplest method, and much to be preferred to the Weigert closet-paper
method, by which the sections are arranged upon a strip of moist
closet-paper which is either held upon the slide or kept upon a
piece of blotting-paper wet with 80 per cent alcohol. A slide or
glass-plate is covered with a thin layer of celloidin and the strip
of paper containing the sections is laid upon the celloidin surface,
the sections down, so that these stick to the slide as the paper is
carefully peeled off. The preparation is dried with filter-paper and
a thin layer of celloidin poured over the slide and sections. The
celloidin is then hardened in 80 per cent alcohol and the sections
stained on the slide; or the celloidin film is removed by immersion
in warm water, and then treated as one section. Celloidin films may
be marked with a brush dipped in a water solution of methylene-blue.
This should be done as soon as they are made. _Langhans’ method_
is advised for the remounting of serial sections from tissues
stained in bulk and imbedded in celloidin. The sections are cut in
origanum-alcohol (1 part absolute alcohol to 3 parts origanum oil)
and placed on a slide in a layer of origanum oil, blotted and mounted
in balsam. Should sections become milky in the oil, renew the latter
until they are cleared.
4. =Sectioning of Paraffin Blocks.= The paraffin block trimmed to
the proper proportions, leaving a rim of paraffin about 2-3 mm. wide
all about the tissue, is fastened to the wooden block by melting the
under side of the paraffin by drawing a hot knife across it, and then
immediately pressing the block upon the wood. The wooden block is
then clamped into the object-holder. If desired the paraffin block
can be fixed directly to the metal plate of the object-holder in the
same manner. The block is raised until the level of the edge of the
knife is reached. The knife is placed transversely or at a slight
angle, and the cutting done with a relatively small portion of the
edge. The paraffin block may be breathed upon to warm slightly the
upper layer when a hard paraffin is used, and the knife is then drawn
carefully through the block, guiding the section onto the knife-blade
by means of a fine-pointed camel’s-hair brush held in the left hand.
It is preferable, I think, to have a wider rim of paraffin at one
corner of the block and to place the block with that corner at a
slight angle to the knife, so that the edge of the blade will first
engage the block at that point. The tip of the camel’s-hair brush
moistened in water catches the corner of the section as the knife
begins to cut, and pushes it over onto the blade, thus holding the
section flat and preventing curling. When entirely cut through, the
section is removed from the knife by the brush, still holding it at
the corner first touched, or if necessary it is again moistened and
applied to the upper side of the section, lifting the latter off
the knife. The block is trimmed down to the proper level by cutting
thick sections first, then sections of the desired thickness when
the level of the entire block is reached. The sections are then
transferred, with their shiny side down, just as they come off the
knife, to a slide, sheet of paper, warm water, warm molasses or
sugar-dextrin solution, or 70 per cent alcohol, and treated further
according to the directions given in the next chapter. The presence
of ridges on the cut surface of the block is an indication that the
knife needs stropping. The knife must cut the paraffin, not scrape
it. Crumbling of the paraffin is the result of imperfect infiltration
during the imbedding process; water, alcohol, aniline oil or xylol
may be left in the tissue, the paraffin may contain oil, or the
cooling process may have been delayed. Curling of the sections can
be prevented by using a sharp knife and slightly warming the surface
of the block by breathing upon the block, use of a warm knife or
spatula, heat-focus, etc. For ordinary work paraffin sections 5-7µ
thick are easily obtained; for especial work 1-2µ sections may be
obtained by especial care in imbedding, using graded paraffins and
finally imbedding in a 56°C. paraffin. The pieces of tissue should
be small, and the sections may be cut with a knife wet with water or
alcohol. _Serial paraffin sections_ are easily obtained; in fact,
paraffin imbedding is by far the best method for serial cutting. To
cut ribbons of sections upon the ordinary slide microtome the block
must be clamped into the object-holder so that the edge of the block
facing the knife, as well as the opposite side of the block, is
parallel with the knife-edge. The knife should be placed at right
angles to the microtome. If the paraffin has the right consistency
the edges of the sections as they are cut will adhere, and a ribbon
of serial sections will be pushed up over the knife. This ribbon
can be cut into pieces of the desired length and mounted according
to the directions given in the next chapter. The Minot automatic
rotary microtome is especially well adapted for the cutting of ribbon
sections. Failure of sections to adhere to each other is usually
the result of too hard consistence of the paraffin, and this can be
remedied by warming slightly, according to the method given above. If
the paraffin is too soft the sections fold together. The block may be
cooled in ice-water, or the sections may be cut with a cooled knife.
Paraffin knives so constructed that they may be cooled by a stream
of ice-water are supplied by dealers in microtomes. The conditions
essential for successful paraffin cutting are perfect infiltration
and imbedding, sharp clean knives and a certain degree of skill in
manipulation that can only be secured by practice.
CHAPTER XXIV.
THE PREPARATION OF MOUNTED SECTIONS.
Sections of fresh material, unimbedded or imbedded tissues must be
treated by a series of processes before they are finally permanently
mounted and ready for use. These processes in general are:
=preparation for staining=, =staining=, =differentiation=, =washing=,
=dehydration=, =clearing= and =mounting=. The general procedure will
be modified to some extent by the character of the tissue, manner
of preparation (fixed or unfixed, imbedded or unimbedded, unstained
or stained), character of stain (affected by alcohol, xylol, etc.),
and the mounting agent (glycerin, balsam, damar, colophonium). Two
or more of these steps may be combined in one; the same agent may
differentiate, dehydrate and clear. Several stains may be combined in
one solution, or it may be necessary to use them in succession. The
very greatest variation is possible in pathologic technique; in fact,
practically every laboratory worker modifies methods according to the
light of his individual experience. The really important thing is
to be master of the method, and not allow the method to control the
situation. One of the greatest attractions about laboratory work is
the infinite possibility of variation and improvement of methods and
the invention of new ones.
I. PREPARATION FOR STAINING.
a. =Frozen Sections of Fresh Tissue.= Frozen sections of fresh
tissues, as well as those obtained by the single or double razor,
may be stained by floating the section on a slide, staining it
directly (carbol-kresyl-echt-violett or carbol-thionin), examining
in the stain or washing, dehydrating, clearing and mounting; or the
section may be fixed to the slide with molasses or sugar-dextrin
solution, covered with a celloidin-film, and treated according to
the methods followed for paraffin or celloidin sections. Sections
of fresh tissue may be fixed in formol or alcohol, and then treated
by the same methods as celloidin sections. (See also Page 220.)
b. =Sections of Unimbedded Tissues.= These may be handled for
staining in the same way as paraffin, celloidin or fresh-tissue
sections, either when sectioned directly or after freezing. The
sections may be stained directly, on the slide, cover-slip, or in
the staining solution, or they may be transferred into celloidin
sheets by the same methods employed in the preparation of paraffin
sections.
c. =Celloidin Sections.= These may be transferred from water or
alcohol directly to the stain. It is not necessary to remove the
celloidin. If not stained soon after cutting they should be
preserved in 95 per cent alcohol. Celloidin sections may be stained
on the slide by simply blotting the section firmly on the slide,
without permitting it to become dry, and manipulating it carefully
through the various solutions; or the section may be fixed to the
slide by the use of 95 per cent alcohol, ether-vapor and fixation
in 80 per cent alcohol; or the section may be fixed to the slide
by the methods given above under the cutting of serial sections
of celloidin blocks. The most common method of preparation of
celloidin sections for staining is to transfer the sections from
alcohol into water to straighten them out, and then to transfer on
the spatula into the stain. For the treatment of serial celloidin
sections see above.
d. =Paraffin Sections.= Paraffin sections may be stained directly
_without removing the paraffin_. This is especially advisable in
the staining of tubercle-bacilli and in other cases where the use
of alcohol is to be avoided. For many stains this method cannot be
used. The sections as they are cut are floated directly into the
warm stain, on which they flatten out, and are then transferred to
the other solutions on the section-lifter, finally dried on the
slide, in the incubator or over the flame, cleared in xylol and
mounted in balsam. Paraffin sections may also be stained without
removing the paraffin by being transferred directly from the
knife on to 80 per cent alcohol, stained, washed, dehydrated in
absolute alcohol or by drying, cleared and mounted. The section is
transferred from one solution to another on the slide or spatula.
The paraffin is removed during the clearing in xylol in both of
these methods. The treatment with xylol must be on the slide, else
the section may go to pieces. The staining of the section in the
paraffin usually takes more time than staining after the paraffin
has been removed, but the process can be hastened by heating the
stain.
_Slide and Cover-slip Preparations._ Paraffin sections may be
affixed to a slide smeared with a thin film of albumin-glycerin
(equal parts of filtered beaten white of egg and glycerin, with
crystal of phenol or thymol, or 1 grm. of sodium salicylate to
100 grms. of the mixture as a preservative). A drop of fixative
is placed upon a clean slide, and is rubbed over the slide in a
fine film with the back of the finger. The dry paraffin section
with glossy side down is placed upon the smeared slide, flattened
with a brush and then pressed firmly against the slide with the
ball of the thumb. The albumin-fixative is then coagulated in
the incubator or over the flame; the paraffin is melted over the
flame without over-heating the section and the slide covered at
once with xylol to remove the paraffin. It is then put into 95
per cent alcohol, thence into the stain; and after staining, the
section is washed, dehydrated, cleared and mounted. _Cover-glass_
preparations of paraffin sections are made by floating the
sections with glossy side downward on warm water (just below the
melting-point of the paraffin) until they straighten out and are
perfectly flat. They are then floated on to cover-slips covered
with a thin film of albumin-glycerin, the albumin having previously
been coagulated by passing the smeared cover-slips through the
flame quickly so that they do not scorch or burn. The cover-slips
with the adherent sections are then placed in the incubator for 12
hours. The paraffin is then removed by xylol, the xylol is washed
out in 95 per cent alcohol, and the cover-slips are then carried
through the processes of staining, washing, dehydration, clearing
and mounting. The cover-slips must be handled with forceps and
the section side should always be uppermost. Slides covered with
a film of albumin-glycerin may be used instead of cover-slips.
The albumin-glycerin film may be omitted, and the sections with
glossy side down floated in warm water on to clean covers or
slides; the water is drained off and the slides or covers are put
in the incubator for 12 hours. Sections adhere fairly well by this
method (_capillary attraction method_). Bubbles are removed by
careful heating. Serial ribbons of the size desired can be floated
and mounted on slides by the albumin-glycerin or the capillary
attraction method.
By far the best method of preparing paraffin sections for staining
is the _molasses plate method_, a modification, originating in
my laboratory, of the _Schmorl-Obregia_ sugar-dextrin method.
When many sections are to be stained at once it is the most
convenient method and gives uniform results. In the preparation
of sections for class-work it has no equal. It can be used also
for giving out unstained sections. When many sections must be
stained in diagnostic work the method saves much time and labor.
Fifty sections can be stained as easily as one. It combines all
the advantages of the celloidin and paraffin methods, as does the
_Schmorl-Obregia_ sugar-dextrin method, but is much cheaper than
the latter.
_Schmorl_ advised the use of a sugar-dextrin solution (cane sugar
solution [1:1] 300 cc., 80 per cent alcohol 200 cc., yellow
dextrin solution [1:1] 100 cc.) to be run over a perfectly clean
glass plate or slide until the entire surface is covered with an
even layer. The paraffin sections as they are cut are arranged in
order on the wet plate, and when the plate is full, it is heated
sufficiently to flatten and smooth the sections. The plate is then
placed in an incubator for 3-12 hours to harden and dry. When dry
it is immersed in xylol to take out the paraffin, then treated
with absolute alcohol for 10-15 minutes, the alcohol drained off,
and the plate covered with a thin layer of celloidin (celloidin or
photoxylin 10, absolute alcohol 100, ether 100). As soon as the
celloidin sets (1-2 minutes) the plate is immersed in warm water
and the celloidin film containing the sections is detached. It
can now be carried through the staining, washing, dehydrating and
clearing solutions as one section, and in the clearing solution cut
into strips or single sections, as desired, for mounting. _Huber
and Snow_ improved the method greatly by floating the paraffin
sections directly on to warm dilute sugar-dextrin (a 10 per cent
solution of Schmorl’s stock-solution will suffice), and plating
the sections directly from the latter. This method of using the
dilute solution is less expensive, much cleaner, and saves time
in drying in the incubator. The results are in every way better
than with the Schmorl solution in full strength. The formation of
bubbles and crystals is almost wholly prevented, and less dust is
caught on the plate. In my laboratory we have modified the method
still further by using a 10 per cent solution of New Orleans black
(or baking) molasses instead of the more expensive sugar-dextrin
solution. As the molasses costs but 20 cents a gallon, a gallon of
the dilute solution costing 2 cents can be used indefinitely if
fermentation be prevented by a crystal of phenol or thymol. The
paraffin sections are floated on to this dilute molasses solution
warmed sufficiently to smooth out the sections; 4 × 5 glass plates
(old negatives) thoroughly cleaned and kept in alcohol are immersed
in the warm molasses solution and the sections arranged on them as
desired, lifting out of the solution that part of the plate covered
with sections as they are drawn upon it. As soon as the plate is
covered it is drained, and is then flooded with absolute alcohol.
After 1-2 minutes the alcohol is drained off and the plate flooded
with thin celloidin, which is allowed to set for a minute or so,
and the plate then immersed in warm water in which the celloidin
film containing the paraffin sections is detached. This film is
then handled by catching it at the two corners of one end with
the fingers, or better still by a pair of forceps held in each
hand. The film is put first into xylol to remove the paraffin,
then into 95 per cent alcohol, then into water and thence into the
staining solution. After staining the film is washed, dehydrated
and cleared, and in the clearing solution is cut into strips or
single sections by means of the wheel-shaped paper-cutter used by
paper-hangers. The pieces are then mounted. A dilute sugar-dextrin
solution can be used instead of the molasses-solution, but the
latter is much cheaper and does just as well. Aside from this
advantage our method of transferring the paraffin-sections into the
celloidin film without first removing the paraffin saves a great
deal of time, as it is not necessary to wait for the plates to dry
in the incubator. The same method can be applied to the staining
of single paraffin sections on the slide. The conversion of the
paraffin section into a celloidin preparation without any loss of
time for drying is so quickly and easily carried out that I advise
it above all others. The same method may also be applied to the
staining of fresh and fixed tissues cut on the freezing microtome
or sectioned without imbedding. The success of the plate-method
will depend largely upon the state of the glass-plates when put
into the molasses solution. They must be perfectly clean or the
celloidin sheet will not separate well. It is best to keep them
in alcohol until they are needed. The celloidin must be of the
right consistency, the layer must be thin, and cover the entire
plate uniformly. It must not be allowed to harden too much before
immersion in water or it will be tough and will shrink. Handling
of the celloidin-sheets with the bare hands is not advisable
because of the large number of epithelial cells adhering to the
celloidin. The sheets are easily changed from one solution to
another by catching them with forceps; the use of a glass-plate
to transfer them is not necessary. When it is desired to preserve
sections for future staining the celloidin sheet containing the
paraffin-sections can be kept in 80 per cent alcohol indefinitely.
NOTE:—If the glass-plate is numbered with a blue wax-pencil
after the paraffin sections are floated on, the marking will be
transferred to the celloidin sheet, and the latter will retain the
marking through all solutions.
II. STAINING AND DIFFERENTIATION.
Staining is necessary to bring out clearly the constituent elements
of the tissues and their relations with each other, and for the
demonstration of histologic structures or chemical substances that
would otherwise be nearly or wholly invisible. The technique of
staining depends upon the fact that stains or dyes possess certain
affinities for the tissue-elements or for certain simple or complex
substances present in the tissues (_microchemic reactions_). These
affinities vary greatly with the dye. Some dyes have an affinity
only for single constituents of the tissue (_elective_ or _specific
stains_); others have an especial affinity for the nucleus (_nuclear
stains_), others stain all the tissue-constituents diffusely
(_diffuse_ or _protoplasmic stains_). There are but few pure elective
stains for single tissue-elements; the majority of stains will stain
more than one of the tissue elements, but may show an especial
affinity for certain ones. As a result of these variations in the
affinities of dyes for the constituents of the tissues it becomes
possible to manipulate the dyes or to combine them in such a way
that a specific differentiation of many tissue-elements is possible
through the use of _different methods of staining_. These methods are
based in part upon the use of different mordants, the employment of
several stains in combination or in succession, the mixture of stains
to form a new staining compound, the phenomenon of _metachromasia_,
the differentiation of certain tissue-elements by the removal of
the stain from the structures for which it possesses a weaker
affinity, and by the employment of different microchemic reactions.
The two most commonly employed methods are the _progressive_, in
which the stain is allowed to act until the affinities of certain
tissue-elements have been satisfied when the staining process
is interrupted; and the _regressive_, in which the tissue is
over-stained, and the dye withdrawn from the tissue-elements for
which it possesses the weakest affinities leaving the other elements
stained. This latter process is usually called “_differentiation_,”
and the chief substances used for such differentiating are dilute
acid, acid alcohol, acid stains, aniline oil, aniline-xylol and
alcohol. Some workers use the regressive method for such simple
stains as hæmatoxylin, overstaining, and then differentiating with
acid alcohol before counterstaining with eosin. The results obtained
in this way are much less satisfactory than is possible with the
progressive method.
Tissues may be stained in the body during life (_intravital
staining_), or immediately after removal from the body (_supravital
or survival staining_), either before or after sectioning. (See Page
217.) Fixed tissues may be stained in bulk or in sections.
Staining Tissues in Bulk.
This method is not often used in pathologic work. The fixed and
hardened tissue is cut into small pieces, placed in the staining
solution for several days, washed thoroughly, dehydrated in
alcohol, imbedded, cut, and mounted without further staining.
Alcoholic solutions penetrate best; hæmatoxylin, hæmalum, carmine
and alcoholic solutions of the aniline stains may be used.
_Metallic impregnation_ (gold or silver salts) of fresh or fixed
tissues is but little used in pathology. (See Staining of Nervous
System, and Spirochætes.)
Staining of Sections.
=Celloidin sections= are lifted from water or alcohol into the
stain by the needle or section-lifter. The use of the latter
is advised, as by it the section can be floated flat on to the
staining solution. When many celloidin sections are to be stained
at once they can be stained in small tea-strainers and transferred
in these from one solution to another. =Paraffin sections= may be
floated directly on to the stain without removing the paraffin; or
they may be stained on the slide or cover-glass after removing the
paraffin, the stain being dropped on to the section, or the slide
or cover-slip is immersed in the stain. Special staining-dishes
for the staining of paraffin sections on slides and covers can be
obtained. Paraffin sections transferred to celloidin sheets by the
plate method can be put into the staining-solution while on the
glass-plate, or the films can be detached and transferred from one
solution to another by means of forceps. This is the easier way,
and it is not necessary to touch the films with the fingers.
General Rules for Staining.
1. The stain should be filtered just before being used, in order
to remove precipitates, moulds, etc. Unless they have been diluted
most of them can be used over and over again, hence after using
they should be filtered back into the stock bottle.
2. A liberal amount of stain should be used. Slides and cover-slips
are given enough stain to cover completely the section, when
the staining is done on the slide, or they may be immersed in
staining-dishes. Plates and celloidin sheets should be stained in
large trays. Sections and celloidin films should be flat without
folds or wrinkles, and they should not touch one another when
several are stained at the same time. Transference of the section
from water or dilute alcoholic solutions to dilute or stronger
alcohol respectively for a moment and then back again will usually
straighten out curled or wrinkled celloidin sections.
3. Stain until the section is properly stained. Control this by
removing it from the staining-solution and examining it in water on
a glass-slide without a cover-slip, using the low-power. Sections
will always appear more deeply-stained when cleared than when
examined in water, hence due allowance should be made. Celloidin
sheets can be examined on glass-plates. The time-limits given in
staining methods are only approximate; no absolute rules can be
laid down as to the length of time necessary to obtain a good
stain. The methods of fixation and hardening, age of the tissue,
age of the stain, etc., affect the staining power. Some stains
lose their staining-power after a time; others require a period of
ripening before they yield the best results. As a rule staining
may be intensified or hastened by staining in the incubator or at
a higher temperature, by concentrating the stain, or by the use of
such substances as aniline oil. When differentiation is necessary
the process should also be controlled by frequent examination of
the section, as above for staining. Usually the section can be
examined in the differentiating fluid.
III. WASHING.
Thorough washing after staining is necessary after nearly all
stains. The washing should usually be done by soaking the sections
in several changes of distilled water, although tap-water, alcohol,
alum-water, and other solutions may be used to intensify the
staining effects. When this is done a final washing in distilled
water or alcohol is usually necessary. Differentiating fluids
should always be thoroughly removed from the section before
mounting. Sections should not be allowed to lie in wash-water that
is colored by the stain; as soon as the wash-water becomes colored
it should be replaced by fresh. When sections are left lying in
the wash-water for some time the vessel containing them should be
covered to prevent the settling of dust on the sections, as it is
practically impossible to remove from the latter dust or other
precipitates that may become attached to them. Some stains give
better results after long washing; others are easily washed out if
the sections are left standing in the wash-water. The time-limits
of washing will depend upon the character of the stain employed.
IV. DEHYDRATION.
Dehydration of the sections is usually produced by passing them
through two alcohols, 80 per cent and absolute, or 80 per cent and
95 per cent. For certain clearing reagents (xylol) it is necessary
to use absolute alcohol. When carbol-xylol is used as a clearing
reagent absolute alcohol is not necessary, and 95 per cent can
be used instead for the second dehydrating solution. Usually a
minute in each alcohol is sufficient for the dehydration of single
sections. If dehydration with alcohol is not desirable because of
its action on the stain it is possible to dehydrate and clear in
xylol by repeatedly blotting the section with absorbent paper,
covering the section several times with xylol and then blotting.
The section should never be allowed to become perfectly dry.
Dehydration with alcohol may also be avoided by staining paraffin
sections without removing the paraffin, drying in the incubator
or over the flame, removing the paraffin in xylol, and mounting.
Imperfect dehydration is shown by the presence of white spots or a
milky cloud in the section when it is put into the clearing fluid.
V. CLEARING.
After dehydration, sections must be cleared in some solvent of
balsam before they can be mounted in the latter medium. When 95
per cent alcohol has been used for the final dehydration the
sections may be completely dehydrated and cleared at the same
time by the use of carbol-xylol (xylol, 3 parts; melted crystals
of carbolic acid, 1 part; add melted carbolic acid to the xylol
to prevent formation of crystals). The sections (on the slide
or cover-slips, in celloidin sections or films) are transferred
from the alcohol, draining or blotting off excess of the latter,
into the carbol-xylol, and left until perfectly clear. This can
be most easily determined by viewing the sections against a dark
background. Carbol-xylol cannot be used for sections treated with
aniline stains. These are dehydrated in 95 per cent alcohol, and
the final dehydration and clearing accomplished by repeatedly
placing xylol upon the slide and blotting it out until the sections
are transparent. Turpentine, chloroform, benzine, toluol, the
oils of bergamot, cloves, thyme, lavender, origanum cretici, and
cedarwood, aniline oil, and various mixtures of these oils are
also used as clearing agents. The majority of these will clear
from 95 per cent alcohol, but not so readily as carbol-xylol; they
have individual disadvantages of taking out the eosin, affecting
aniline colors, dissolving celloidin, making sections brittle,
slow action, clinging odor, etc. Chloroform and benzine may be
used for clearing osmic-acid preparations; oil of turpentine is
also good for clearing sections stained with kresyl-echt-violett,
and Wright’s blood-slain. With but few exceptions carbol-xylol
and xylol meet all requirements better than any other clearing
reagents. There is but one disadvantage in the case of
carbol-xylol; some of the phenols in the market cause a fading of
eosin and hæmatoxylin stains. _DeWitt_ has shown that this fault
can be corrected by redistillation, stopping the distillation as
soon as the temperature begins to rise above the constant boiling
point of the phenol; or the carbol-xylol that fades the stains can
also be corrected by supersaturating it with a mixture of sodium
bicarbonate one part, and sodium-potassium tartrate two parts.
Sections kept in xylol or carbol-xylol should be protected from
dust and evaporation; it is not a good plan to keep them in these
solutions for more than 24 hours.
VI. MOUNTING.
Permanent mounts are made in glycerin, potassium acetate, lævulose,
glycerin gelatin, balsam, damar or colophonium. For celloidin and
paraffin sections a solution of =Canada balsam= in xylol is most
commonly used for mounting. Celloidin sections (celloidin films are
best cut into strips and single sections when in the carbol-xylol;
the wheel-shaped paper-cutter used by paper-hangers is the best
instrument for this purpose) are lifted onto the slide from the
clearing-fluid; folds or wrinkles in the celloidin are straightened
or removed by cutting the celloidin at right angles to the section
in order to relieve the tension, and the section is then blotted
firmly against the slide by means of a pad of absorbent paper.
The greatest care should be taken to prevent wrinkling, folding
or turning over of the edge of the section. As soon as the pad
is removed a drop of balsam is placed upon the section and the
cover-glass put over it. There should be just enough balsam used to
fill the space between cover-slip and slide, so that air-bubbles
are not formed. The balsam must not be so thin that the cover-glass
will float about on the liquid, or so thick that it does not spread
well. In the latter case warming the slide may cause it to spread
more readily, but care must be taken not to injure the stain by
over-heating. Paraffin sections on the slide are similarly blotted
and covered with balsam and cover-glass; those on cover-slips are
blotted between folds of absorbent paper and immediately placed
with section-side downward upon a drop of balsam that has been put
upon the slide.
=Xylol-damar= may be used in place of Canada balsam; it is cheaper
and colorless, but it tends to become cloudy. =Colophonium= is
the cheapest of the three and has but little color; it is highly
recommended by many workers. In a xylol-solution it may be used for
aniline stains; a chloroform solution is advisable for the mounting
of osmic-acid preparations; while a solution in turpentine and
shellac is recommended for Weigert’s neuroglia method, Wright’s
blood-stain, and other special staining methods.
=Glycerin=, =potassium acetate=, =laevulose= and =glycerin-gelatin=
are used for the preservation of amyloid-, mucin- and fat-stains,
as well as for other preparations that do not permit the use of
alcohol and xylol. =Glycerin-gelatin= is probably the best medium
for this purpose. It is made according to _Kaiser_ by soaking 7
grms. of gelatin for 2 hours in 42 cc. distilled water, then adding
50 grms. glycerin and 1 grm. carbolic acid; the mixture is warmed
10-15 minutes, stirring constantly, and filtered while hot. It is
also made by taking water, 200 cc.; gelatin, 20 grms.; powdered
white shellac, 2 grms.; Farrant’s solution (gum arabic, glycerin,
solutio acidi arsenicosi conc., _aa._ 30.0 grms.), dissolve by
warming, and filter while warm. To mount in this medium the section
is placed on the slide, and blotted with absorbent paper. A drop
of warm glycerin-gelatin is then placed on it and the cover-slip
affixed. The drop spreads evenly beneath the cover-glass and
becomes solid as it cools. Mounts in glycerin, glycerin-gelatin,
potassium acetate and laevulose must be cemented around the borders
of the cover-slip with asphalt, wax, paraffin, gold size, etc.,
using a brush or glass rod for this purpose.
VII. SUMMARY OF METHODS OF PREPARATION OF CELLOIDIN SECTIONS.
1. Fixation of the tissues in alcohol, formol, etc.
2. Wash 24 hours, when necessary.
3. After-harden in 80 and 95 per cent alcohols for 1 to several days.
4. Complete dehydration in absolute alcohol for 24 hours.
5. Equal parts of pure ether and absolute alcohol, 24 hours.
6. Thin celloidin, 1-3 days.
7. Thick celloidin, 1-3 days.
8. Block. Harden block in 80 per cent alcohol.
9. Cut; keep sections in 80 per cent alcohol.
10. Stain; differentiate.
11. Wash thoroughly.
12. Dehydrate in 80 and 95 per cent alcohols.
13. Final dehydration and clearing in carbol-xylol.
14. Place on slide and blot with absorbent paper.
15. Mount in xylol-balsam or xylol-colophonium.
VIII. SUMMARY OF METHODS OF PREPARATION OF PARAFFIN SECTIONS.
1. Fixation of the tissue in alcohol, formol, etc.
2. Wash 24 hours, when necessary.
3. After-harden in 80 and 95 per cent alcohol for 1 to several days.
4. Complete the dehydration in absolute alcohol for 24 hours.
5. Aniline-oil until tissue becomes transparent.
6. 1st. Xylol, ½ hour, to remove aniline oil.
7. 2nd. Xylol, 1-2 hours, until translucent.
8. 1st. Paraffin (52°C.), ½ hour in oven, to remove xylol.
9. 2nd. Paraffin (52°C.), 1-12 hours in oven, until infiltrated.
10. Imbed and block; cool quickly.
11. Cut sections; mount on slides or covers.
12. Remove paraffin in xylol.
13. Remove xylol in absolute alcohol.
14. 80 per cent alcohol, for a few minutes.
15. Stain; differentiate; wash.
16. Dehydrate in 80 and 95 per cent alcohols.
17. Clear in carbol-xylol.
18. Mount in Canada-balsam or colophonium.
IX. ARTEFACTS IN MOUNTED SECTIONS.
A mounted section, after passing through the various stages indicated
above, must of necessity present some appearances that are the result
of the technical methods employed. The number and degree of such
artefacts will depend upon the character of the methods employed
and the care exercised in their performance. The trained observer
ignores the presence of artefacts as having nothing at all to do
with the significance of the section itself; but to the beginner in
microscopic work they often appear to be the most important thing
in the preparation, and are given a pathologic interpretation. How
frequently do we see students, undergraduates and postgraduates, take
up a section and pick out a fold, wrinkle, tear, staining-defect,
precipitate, dirt, etc., as pathologic features! It is necessary,
therefore, for the student to acquaint himself with the nature of
artefacts so that he may ignore them and not give them an incorrect
interpretation. The most important artefacts are as follows:—
1. =Artefacts due to fixation= (mercuric, chromic, osmic, etc.,
precipitates; alterations in blood-pigment due to formol; loosening
of cells from basement membrane due to contraction [kidney tubules,
etc.: loosened endothelium in blood-vessels, particularly confusing
to students]; destruction of red blood cells, as in alcohol
fixation; poor staining due to over-fixation).
2. =Artefacts due to hardening= (contraction, desquamation of
cells, etc.).
3. =Artefacts due to imbedding and cutting= (tears, holes,
ragged edges, irregular thickness, knife-streaks, compression of
soft structures, dislocation and tearing-out of firm tissues or
material, wrinkles, folds, etc.).
4. =Artefacts due to poor staining= (uneven, spotted or streaked
staining, overstaining, understaining, poor differentiation,
precipitates, insufficient washing, fading, poor contrasts,
defective staining due to presence of paraffin, dextrin, etc., in
section).
5. =Artefacts due to poor mounting= (imperfect dehydration and
clearing, cloudiness, milkiness or opacity of section; folds;
wrinkles; turned-over edges; tears in section caused by striking it
with balsam-dropper or needle; air-bubbles; lack of balsam).
6. =Dirt and foreign-material= (opaque and translucent dirt, above
or below section; coloring-matter in balsam; ink; pigment from
pencil; cotton-, silk, wool-, linen-, vegetable and paper-fibres,
hairs, desquamated squamous epithelium, portions of insects, etc.)
CHAPTER XXV.
STAINS AND STAINING METHODS.—NUCLEAR AND PROTOPLASMIC STAINS.
=THEORIES OF STAINING.= The exact nature of the process of staining
has not yet been determined. Various theories have been advanced,
explaining the affinity of the tissues for certain dyes, on the
ground of a chemical, mechanical or chemicophysical action. The
chemical theory assumes the formation of an insoluble compound
through the chemical combination of tissue and stain; the physical
theory is based upon the assumption that the process is purely
physical or mechanical, while the chemicophysical theory holds that
it is neither purely physical nor purely chemical. The process is
not controlled by the molecular weights alone of the substances
concerned, but does depend upon the conditions controlling the
formation of solutions in general. Therefore, the theory most widely
accepted at the present time is the solution-theory, which assumes
that the staining-process is a solution of the dye in the tissue,
and that the stained tissue-element is a fixed solution of the stain
in its substance. This solution of the dye in the tissues may be a
direct action between the two (direct or substantive stains); or it
may be brought about only by the interaction of a third substance
(indirect or adjective stains). The third substance is called a
_mordant_, and the combination of the dye with the mordant is known
as a _lake_. The mordant may be added to the stain or to the tissue,
either before or at the time of staining. Many of the fixing-fluids
are mordants, particularly those containing chromic acid or its
salts. Alum, iron, and many of the metals are the most commonly used
mordants. In a general way acid mordants are used for basic colors,
and basic mordants with acid colors.
The =stains= most commonly used in pathologic work are:—
1. =Natural Dyes=:—Hæmatoxylin and Carmine.
2. =Aniline Dyes=:—_a, Acid._—Eosin, erythrosin, acid fuchsin,
orange G, picric acid, sudan III, and scarlet R (Fett-ponceau).
_b, Basic._—Methylene blue, methylene violet, thionin, toluidin
blue, kresyl-echt-violett, methyl violet, gentian violet, crystal
violet, basic fuchsin, dahlia, aniline blue, methyl green, iodine
green, safranin, Bismarck brown, and vesuvin.
In a general way it may be said that basic stains are nuclear
stains, and acid stains are protoplasmic. Neutral stains are
usually diffuse stains; when formed by the combination of acid and
basic dyes they usually act as selective stains for some especial
tissue-element or cell-constituent. =Metachromasia=, in its
narrowest sense, is the term applied to that staining-phenomenon,
in which a single-chemical entity gives different colors to
different tissue-elements. In this sense iodine, in its action
upon glycogen and amyloid, is a true metachromatic substance.
The majority of the so-called metachromatic stains, however,
do not possess true metachromasia, since their metachromatic
powers are dependent upon a mixture of two or more dye-stuffs in
the one compound. The most important stains of this class are
gentian violet, methyl violet, crystal violet, dahlia, thionin,
toluidin-blue, polychrome methylene blue, methylene azure, and
kresyl-echt-violett. The chief _chromotropic_ substances are
amyloid, mucin, mast-cell granules and cartilage. Metachromatic
reactions are at their best usually when examined in water; they
are affected by alcohol and usually destroyed by carbol-xylol.
Sections stained by metachromatic stains should be quickly
dehydrated by absolute alcohol and blotting, and cleared in xylol,
when mounted in balsam.
I. NUCLEAR STAINS.
1. =Haematoxylin= (C_{16}H_{14}O_{6}) is an ether extract of the
wood of _Hæmatoxylon campechianum_, a tree found in the West Indies
and Central America. In itself not a dye, it becomes one of the
most valuable when oxidized to hæmatein (C_{16}H_{12}O_{6}), and
combined with alum, iron or other mordants to form a lake. It then
stains nuclei a deep violet-blue or black color that is practically
permanent. Mucin, lime-salts, bacteria, and colonies of actinomyces
are also stained varying shades of blue. If the staining process
is prolonged the entire tissue, as well as celloidin, becomes more
or less heavily stained blue. A pure nuclear stain is obtained by
interrupting the stain at the right time (examine in water); or if
the sections are over-stained they may be differentiated in acid
alcohol (1 per cent hydrochloric acid in 70 per cent alcohol).
Hæmatoxylin stains well after all fixing-solutions except osmic
acid; some of its staining-formulæ stain slowly after fixation in
Zenker’s fluid. On the whole, it is by far the best general nuclear
stain for laboratory and diagnostic work. It is employed in numerous
staining formulæ, the most useful of which are given here. These
formulæ differ chiefly in the time of staining, “ripening” of the
stain (oxidation of hæmatein), intensity of stain, necessity of
differentiation, etc.
a. =Böhmer’s Alum-haematoxylin.=
Dissolve 5 grms. of hæmatoxylin crystals in 50 cc. of absolute
alcohol; add this drop by drop, while stirring, to 1,000 cc. of a 1
per cent solution of potassium alum. Expose in open vessel to air
and light for 1-2 weeks. Filter before using.
b. =Hansen’s Haematoxylin.=
To 200 cc. of alum-hæmatoxylin solution brought to the
boiling-point add 2 cc. of a concentrated solution of potassium
permanganate. Cool quickly; filter when cold. Can be used at once
without further ripening. It tends to stain diffusely.
c. =Delafield’s Haematoxylin.=
To 400 cc. of a saturated solution of ammonia alum add a solution
of 4 grms. of hæmatoxylin in 25 cc. of absolute alcohol. Expose
mixture to air and light for 3-4 days; filter; then add 100 cc. of
glycerin and 100 cc. of 95 per cent alcohol, and filter. Expose to
light until solution is dark enough, then keep in tightly-stoppered
bottle. It is a strong stain, and may be diluted with distilled
water when desired. The solution keeps well.
d. =Ehrlich’s Acid-haematoxylin.=
Dissolve 2 grms. of hæmatoxylin in 100 cc. of absolute alcohol.
Add this to a saturated solution of potassium alum in water 100
cc., glycerin 100 cc., and glacial acetic acid 10 cc. Allow mixture
to stand for a week exposed to air and light; then filter. Keep
in well-stoppered brown bottles. The solution stains best when it
is six months old, and may be kept for several years. It does not
overstain, and on the whole is more useful than Böhmer’s, Hansen’s
or Delafield’s.
e. =Mayer’s Haemalum.=
Dissolve 1 grm. of hæmatein in 50 cc. of 90 per cent alcohol and
warm. Add this solution to a solution of 50 grms. of potassium alum
in 1,000 cc. of distilled water dissolved by heating. Mix warm,
cool, and filter. With hæmatein no ripening is required, and the
solution can be used at once. Hæmalum is a more precise nuclear
stain, but stains more slowly than the formulæ given above.
It may be prepared directly from hæmatoxylin crystals by dissolving
1 grm. of hæmatoxylin in boiling water; add water up to 1 litre,
and cool. Add 0.2 grm. sodium iodate and 50 grms. potassium alum,
dissolving at room temperature; 50 grms. chloral hydrate and 1 grm.
citric acid may be added to make solution keep better.
f. =Mayer’s Acid-haemalum.=
Add 2 cc. glacial acetic acid to 100 cc. of hæmalum solution. It
stains the nuclei more precisely than hæmalum.
g. =Weigert’s Iron-haematoxylin.=
Dissolve 1 grm. of hæmatoxylin in 100 cc. of 96 per cent alcohol.
Allow to ripen several days, but this solution should not be kept
longer than six months. Make a second solution of 4 cc. of liq.
ferri. sesquichlor. (German Pharmak. IV, sp. gr. 1,124), 1 cc. of
concentrated hydrochloric acid and 100 cc. of water. Mix equal
parts of each solution just before staining. The mixture stains
well for 5-8 days, so that a quantity of stain sufficient for this
time only should be made up. The two stock solutions are easily
made and keep well. The nuclei stain quickly and deeply, and
differentiation and long washing are unnecessary when hydrochloric
acid is included in the second solution, as given above.
After-staining with eosin, picric acid or the Van Gieson’s mixture
gives better results with Wiegert’s iron-hæmatoxylin than with any
other hæmatoxylin.
Method of Staining with Haematoxylin.
1. Stain 1-15 minutes, controlling progress of stain by examination
of section in water, on slide, using low-power.
2. If sections are over-stained, differentiate in ½-1 per cent
potassium-alum or in acid alcohol.
3. Wash thoroughly in tap water, until a good blue is obtained.
Exposure to ammonia vapor or washing for a few seconds in
lithium-carbonate solution will hasten the development of the blue
color. If these reagents are used the section should afterwards be
thoroughly washed in water.
(Stain with a plasma stain, if contrast is desired.)
4. Dehydrate in 80 and 95 per cent alcohols.
5. Clear in carbol-xylol.
6. Mount in balsam.
Over-ripened hæmatoxylins may stain reddish or even brownish,
and too diffusely. In such cases the celloidin will be deeply
stained. The addition of alum-water to the stain may counteract the
fault. Alum-hæmatoxylins must always be filtered before using, as
precipitates are constantly formed as the result of oxidation.
2. =Carmine.= Carmine is the coloring matter of cochineal, the
dried bodies of the female _coccus cacti_, and is obtained
chiefly from Honduras. The coloring principle is carminic acid
(C_{2}H_{22}O_{12}). When combined with alum, borax, lithium,
etc., carmine gives a good, permanent nuclear stain, varying from
reddish violet to deep scarlet. It is used chiefly in pathology to
give a contrasting nuclear stain to the various pigments, and when
specific blue stains have been used for fibrin, mucin, bacteria,
elastic tissue, etc., or when a blue injection-mass has been used.
Alum-carmine is the most precise nuclear stain. Differentiation
with acid-alcohol is necessary after staining with borax- or
lithium-carmine. Lithium-carmine is on the whole the best of the
three for use as a contrast-color to the various pigments.
a. =Alum Carmine.=
Carmine ½-1 grm., 1-5 per cent alum solution 100 cc.; boil 20
minutes; cool; filter. Add crystal of thymol as preservative.
1. Stain 15 minutes to several hours.
2. Wash thoroughly in distilled water.
3. Dehydrate in 80 and 95 per cent alcohols; clear in carbol-xylol:
mount in balsam. Nuclei are a light reddish violet; the plasma is
slightly stained (muscle) or not at all.
b. =Lithium Carmine.=
2-5 grms. of carmine to 100 cc. of a cold saturated water solution
of lithium carbonate; filter.
1. Stain 1-3 minutes; transfer directly to acid alcohol (1 cc.
of hydrochloric acid to 100 cc. of 70 per cent alcohol) without
putting section into water; differentiate ¼-6 hours, until nuclei
alone retain the color. Control differentiation by examination on
the slide in acid alcohol.
2. Wash thoroughly in water.
(Use plasma stain, as picric acid, if desired.)
3. Deyhdrate in 80 and 95 per cent alcohols; clear in carbol-xylol;
mount in balsam.
c. =Borax Carmine.=
Dissolve by boiling 0.5-0.75 grm. carmine and 1-2 grms. of borax in
100 cc. of water. To the hot solution add 5 cc. of a O.5 per cent
acetic acid until solution is deep red. After 24 hours filter and
add crystal of thymol.
Stain and differentiate as with lithium-carmine, but leave the
sections somewhat longer in the stain (15 minutes).
3. =Basic Aniline Stains.= The basic aniline stains are used as
general stains for bacteria in sections, and at the same time stain
the nuclei. Methylene blue and fuchsin are employed especially for
this purpose. The metachromatic dyes (thionin, kresyl-echt-violett,
etc.) are also used as nuclear stains in combination with their
metachromatic reactions with mucin, amyloid, mast-cells, etc.
Methylene blue is used in the study of the blood-forming organs,
cell-inclusions, parasites in the tissues, etc. Safranin and fuchsin
are used for staining mitotic figures. (See Staining of Mitoses.)
Bismarck brown is employed sometimes in preparing sections for
microphotography. Methyl green is an intense chromatin stain and
is used in various combinations. Since these dyes are not very
permanent, and are easily washed out in dehydrating and clearing
fluids, as well as “running” in balsam mounts, they are rarely
employed as pure nuclear stains in pathologic work.
When the basic-aniline stains are used a saturated water or
concentrated alcoholic solution (1½-2 per cent in 40 per cent
alcohol) may be employed as stock-solution and diluted 1:5 or
1:10, as desired. The sections are stained 3-5 minutes, then
differentiated in absolute alcohol, cleared in xylol, and mounted
in balsam. Methylene-blue is used by some workers as a nuclear
stain contrasted with eosin for tissues fixed in Zenker’s
solution, giving better effects with this fixation than the
hæmatoxylins. =Unna’s alkaline methylene-blue formula= is employed
(methylene-blue 1 grm., carbonate of potassium 1 grm., water 100
cc.). Dilute 1:10 or 1:5 for staining. Stain 10-15 minutes, wash
quickly in water, differentiate in 95 per cent alcohol; dehydrate
in absolute, clear in xylol, mount in balsam. When celloidin
sections are used, 95 per cent alcohol may be used for dehydrating,
blotting on the slide with several changes of xylol.
The =nucleolus= has an affinity for the acid stains. With the
modifications of the Romanowsky methylene-blue-eosin methods the
nucleolus stains red, the nucleus blue.
II. DIFFUSE OR PLASMA STAINS.
The most commonly used diffuse stains are eosin, erythrosin, acid
fuchsin, orange G, and picric acid. They are practically never
used alone, but are employed as contrast-stains to the nuclear
stains. Eosin, orange G, acid fuchsin and picric acid may be used
as counterstains for hæmatoxylin; picric acid is used as the best
contrast to the carmines, while eosin and orange G are employed as
counterstains for methylene blue. The combination of hæmatoxylin and
eosin is by far the best general staining method for laboratory and
diagnostic work, except for tissues fixed in Zenker’s solution; for
these the combination of methylene blue and eosin is preferable.
Ammonia carmine is sometimes used as a diffuse stain for bone and
the central nervous system. The majority of the diffuse stains wash
out easily in water, alcohol and xylol, hence sections thus stained
should not be allowed to remain too long in these fluids.
a. =Eosin.= Two forms of eosin are obtainable, one soluble in
water, the other in alcohol. Saturated solutions of both kinds
should be kept as stock solutions and diluted as occasion demands.
For use after hæmatoxylin a ½ per cent solution is advisable; with
Zenker’s fixation a more dilute solution may be used, as tissues
so fixed stain intensely in eosin. If used as a contrast-stain to
methylene-blue, eosin is used first in a 5 or 10 per cent solution,
as the basic nuclear stain takes out some of it. Some workers
express a preference for the aqueous solution of eosin, others for
the alcoholic; the alcoholic solution stains more uniformly and
with less differentiation than the other. Eosin is particularly
good as a contrast-stain for tissues containing red blood cells
when fixed in formol, mercuric chloride or Zenker’s.
b. =Orange G.= Used in a 1 per cent water solution. Requires longer
time for staining than eosin.
c. =Acid Fuchsin.= A saturated water solution is kept in stock and
diluted as needed. Must be used in weaker solutions than eosin, as
it more quickly overstains, and cannot be washed out so well.
d. =Picric Acid.= Keep in stock either a saturated water or
saturated alcoholic solution, and dilute as needed. As it washes
out more readily than eosin, the staining solution should
be stronger than for the latter, and the sections somewhat
over-stained to allow for some loss of stain. Picric acid gives a
brownish tint to nuclei stained with hæmatoxylin or carmine, and
will take out the stains completely, if allowed to act too long.
e. =Ammonia Carmine.= One grm. of carmine is dissolved, without
heating, in 50 cc. of distilled water and 5 cc. of strong ammonia
water. The fluid is then exposed in an open dish until the odor of
ammonia is lost; it is then filtered. When ready for use dilute by
filtering 1-2 drops into 20 cc. of distilled water.
III. COMBINED NUCLEAR AND DIFFUSE STAINS.
The diffuse or plasma stains may be combined with the nuclear in one
staining solution, or used in succession. The latter method gives
better results. The nuclei are stained first, the diffuse stain being
used after the washing-out following the use of the nuclear stain,
except in the methylene-blue and eosin method in which to obtain the
best results it is necessary to stain with the eosin first. Nuclear
hæmatoxylin may also be followed by a combination of plasma stains,
as in the Van Gieson’s mixture of picric acid and acid fuchsin,
Delépine’s mixture of rubin and orange, White’s erythrosin and picric
acid mixture, etc. In these mixtures the different affinities of the
plasma-stains give rise to differential or selective staining effects.
a. =Haematoxylin and Eosin.=
1. Stain in any one of the hæmatoxylins.
2. Wash thoroughly.
3. Stain in dilute water or alcoholic eosin until section is
bright rose-red.
4. Differentiate eosin-staining, as desired, by rapid or slow
washing in water.
5. Dehydrate quickly in 80 and 95 per cent alcohols.
6. Clear quickly in carbol-xylol. (If carbol-xylol takes
out eosin too rapidly add some of the dry eosin stain to
it. Hæmatoxylin-stained sections can be placed in such
eosin-carbol-xylol and will take up the eosin beautifully.)
7. Mount in balsam.
Hæmatoxylin and eosin can also be combined in one stain, but the
results are not as good as those obtained by successive staining.
b. =Haematoxylin and Picric Acid.=
1. Stain with Weigert’s iron-hæmatoxylin, or overstain with any
other hæmatoxylin.
2. Wash thoroughly.
3. Stain in saturated water solution of picric acid, diluted
one-half, until sections are a bright yellow. If left too long
in the stain, the hæmatoxylin will become brown or may be wholly
lost.
4. Wash, dehydrate and clear quickly, as for eosin. (Dry picric
acid may be added to the carbol-xylol.)
5. Mount in balsam.
c. =Haematoxylin and Acid Fuchsin.=
Stain with hæmatoxylin, and after washing use a 1 per cent water
solution of acid fuchsin, until section is sufficiently red; wash;
dehydrate; clear; mount.
d. =Haematoxylin and Orange G.=
Stain with hæmatoxylin, and after washing use a 1 per cent water
solution of orange G, staining ¼-3 hours. Treat otherwise as for
eosin-staining.
e. =Carmine and Picric Acid.=
Stain with borax- or lithium-carmine; differentiate in acid alcohol
and wash thoroughly. Then counterstain with picric acid, as for
hæmatoxylin and picric acid. Carmine and picric acid may also be
combined in one stain, as picro-carmine, but this is rarely used at
the present.
f. =Eosin and Methylene-blue.=
(For tissues fixed in mercuric chloride or Zenker’s.)
1. Stain in a 5-10 per cent aqueous eosin for 20 minutes or
longer, until a deep eosin-stain is obtained.
2. Wash out excess of eosin in water.
3. Stain in Unna’s alkaline methylene-blue, diluted 1-4 or 5 with
water, 10-15 minutes.
4. Wash in water.
5. Differentiate in 95 per cent alcohol, keeping the section
in constant motion to obtain a uniform decolorization. Control
process under microscope. _Wolbach_ advises the use of a
0.75-1.5 per cent solution of colophonium in methyl alcohol as
a differentiating medium instead of 95 per cent alcohol. For
tissues fixed in formol or alcohol a 10 per cent solution should
be used.
6. When the background is pink, dehydrate quickly with absolute
alcohol, or in 95 per cent by blotting on slide with xylol, until
clear.
7. Clear in xylol.
8. Mount in balsam.
g. =Van Gieson’s Method.=
1. Stain in Weigert’s iron-hæmatoxylin, or overstain if any other
hæmatoxylin is used. (Weigert’s gives the best results, as it
does not decolorize so readily.)
2. Wash thoroughly.
3. Stain in Van Gieson’s mixture (acid fuchsin 1.5 grms.,
saturated water solution of picric acid [0.6 per cent] 150 cc.
This mixture keeps well. Add 1 cc. of this stock solution to 10
cc. of saturated water solution of picric acid. Stain in this for
10 seconds).
4. Wash quickly; dehydrate in alcohol; clear in xylol or
carbol-xylol; mount in balsam.
I have obtained the best results by making the Van Gieson’s mixture
by taking an ordinary small staining-dish nearly full of saturated
water solution of picric acid, and adding to this, drop by drop,
sufficient saturated water solution of acid fuchsin to make the
solution just dark enough so that the finger cannot be seen through
the staining-dish. The hæmatoxylin-stained section is put into this
mixture for a few seconds, until it appears to become lighter. The
section is then washed in 95 per cent alcohol, dehydrated, cleared
and mounted.
The Van Gieson method is extremely valuable in pathologic work,
because of its varied differential reactions. The nuclei are brown
or black, protoplasm is ochre-yellow, connective-tissue light
red, voluntary and involuntary muscle yellow, axis-cylinders red,
connective-tissue hyalin deep rose-red, epithelial hyalin yellow,
orange or brownish, amyloid yellow or brownish pink, mucin yellow
or brownish, fibrin yellow or brown, necrotic areas yellow or
brownish, lime-salts brown to brownish blue or violet.
Combinations of rubin and orange (Delépine) and erythrosin and
picric acid (Powell White) are also advised as differential
combination stains, but are not so useful as Van Gieson’s. Other
combination methods are to be found in the various modifications of
the Ehrlich triple stain.
CHAPTER XXVI.
SPECIAL STAINING METHODS FOR DEMONSTRATION OF PATHOLOGIC CONDITIONS
IN CELLS OR TISSUES.
=I. AMYLOID.= The best selective staining of amyloid is obtained
with relatively fresh tissues; long preservation in alcohol or
formol tends to weaken the reactions. Probably the best effects are
obtained by formol-fixation for 24 hours, and sectioning on the
freezing-microtome. Good results may be produced, however, after
any of the ordinary fixing and hardening methods by cutting the
sections on the freezing-microtome, without imbedding, or imbedding
in paraffin. The metachromatic reactions are not satisfactory with
celloidin sections. With hæmatoxylin and eosin the amyloid substance
stains a light red or bluish-pink; Van Gieson’s stains it a yellow
or brownish-pink color, giving it practically the same color that it
does epithelial hyalin. The different tissue-relations of the two
substances serve to distinguish them. The most important specific
amyloid stains are:—
1. =Iodine.=
1. Stain in Lugol’s solution 5-10 minutes.
2. Dehydrate in absolute alcohol 4 parts, tincture of iodine 1
part.
3. Clear and mount in origanum oil. Seal preparation with
paraffin, gold size or shellac.
The iodine reaction is also applied to fresh tissues by pouring
Lugol’s solution over a freshly cut surface, and is a good gross
test for amyloid. In both microscopic and macroscopic preparations
iodine gives a mahogany brown color to amyloid; other tissue is
yellow. The iodine reaction may be intensified by placing the
sections in a 1 per cent sulphuric acid; the brown color may be
changed to blue, violet or green.
2. =Methyl Violet.=
1. Stain in 0.5 per cent methyl-violet solution ½ to several
minutes. Examine in water.
2. Wash in water.
3. Differentiate in 2 per cent acetic or dilute hydrochloric acid
1-2 minutes.
4. Wash thoroughly in water.
5. Mount in lævulose or glycerin-gelatin. Amyloid ruby red;
tissue blue-violet.
3. =Gentian Violet.=
Use same method as for methyl violet. The same color-effects are
produced.
4. =Methyl Green.=
Use methyl green in the same way as methyl violet. Amyloid sky-blue
or violet; tissue is green.
5. =Iodine Green.=
1. Stain for 24 hours in a ⅓ per cent water solution of iodine
green.
2. Wash in water.
3. Mount in lævulose, glycerin or glycerin-gelatin. Amyloid red
violet; tissue green.
6. =Birch-Hirschfeld’s Method.=
1. Stain in a 2 per cent alcoholic solution of Bismarck brown for
5 minutes.
2. Wash in absolute alcohol.
3. Wash in water.
4. Stain in a 2 per cent water solution of methyl-violet (or a 20
per cent gentian violet) for 5 minutes.
5. Differentiate in 1 per cent acetic acid until the non-amyloid
parts are brown.
6. Wash thoroughly in water.
7. Mount in lævulose, glycerin or glycerin-gelatin. Nuclei are
brown; amyloid ruby red.
7. =Green’s Method.=
To a few cc. of hæmalum in a watch-glass add a saturated solution
of methyl-violet, drop by drop, until the mixture shows a faint
purple-red tinge at the edge of the glass.
1. Stain sections 15-30 minutes.
2. Differentiate in acid alcohol until the purple begins to fade.
3. Wash thoroughly in water.
4. Mount in glycerin. (Sections may be blotted and dehydrated in
pure liquid paraffin; the latter is then removed by blotting with
xylol, and then mount in pure white vaseline.)
Nuclei are blue, amyloid ruby-red.
8. =Kresyl-echt-violett (Morse’s Method).=
Kresyl-echt-violett (R. extra) 1 grm., 5 per cent carbolic acid
80 cc., alcohol 20 cc. Mix, stirring well; filter. Solution keeps
well, and can be diluted as desired without precipitating.
1. Stain 1-5 minutes.
2. Wash thoroughly in distilled water, differentiating, if necessary.
3. Blot with filter paper.
4. Dehydrate in absolute alcohol as quickly as possible.
5. Clear in turpentine. Blot nearly dry before mounting.
6. Mount in balsam.
Formol, mercuric chloride and Zenker’s all give good results.
Paraffin imbedding, with staining of sections on the cover-glass
(albumin-fixative method), is the best method of staining for
permanent mounts, although good preparations can be obtained by
the use of the freezing-microtome. Carbol-xylol cannot be used for
clearing. Nuclei are blue, protoplasm pale blue, amyloid ruby-red.
As a specific reaction for amyloid and mucin this method has been
used in my laboratory for the last ten years in preference to any
other. The stains are permanent if not exposed to the action of
light.
=Thionin=, =toluidin-blue=, =polychrome-methylene-blue=, and other
metachromatic dyes are also used to give similar reactions with
amyloid, but are not as satisfactory as the kresyl-echt-violett
method. Amyloid may also be stained with =scarlet R= or =sudan
III=, according to the method of Herxheimer, but the results are
rarely satisfactory.
=II. ATROPHY.= Good pictures of atrophic tissues are obtained
with formol-Müller’s, mercuric chloride or Zenker’s fixation, and
staining with Van Gieson’s, to bring out the stroma which is usually
relatively or absolutely increased. In the case of pigment-atrophy
the sections should be very thin and stained with alum- or
lithium-carmine.
=III. CALCIFICATION.= Deposits of lime-salts appear in fresh tissue
as gritty, refractive areas that are bright and shining by reflected
light, and dark by transmitted. They are soluble in acids, solution
of the carbonate being accompanied by the formation of bubbles of
carbonic acid gas. Hæmalum and the alum-hæmatoxylins show a specific
reaction with the phosphates and carbonates of lime, giving them a
deep blue or reddish-violet stain. Fresh calcification usually stains
diffusely blue; older deposits are deep-blue about the borders of the
deposits, lighter or unstained in the center of the mass. Tissues
containing much calcium must be decalcified before imbedding. If
the process of decalcification is not carried too far the specific
staining reaction is not lost.
v. Kossa’s Silver Method for Calcium Phosphate.
1. Fix in alcohol or formol; imbed; cut.
2. Place section in 1-5 per cent silver nitrate solution, and
expose to daylight 5 minutes to 1 hour.
3. Wash in distilled water.
4. Transfer section to a 5 per cent solution of sodium
hyposulphite, to remove excess of silver nitrate.
5. Wash thoroughly in water.
6. Dehydrate in absolute alcohol.
7. Clear in xylol; mount in balsam.
Calcareous deposit black, as the result of the formation of
phosphate of silver and its reduction by the action of light. Alum
carmine may be used as a nuclear stain before the sections are
treated with silver nitrate, or safranin may be used after the
sodium sulphite has been washed out.
=IV. CELL GRANULES AND CELL INCLUSIONS.= The granules and
cell-inclusions here included fall within the class of special
protoplasmic structures found particularly in neoplasms and inflamed
tissues, and which have been supposed to be parasites. For the
staining of other cell-granules see Blood and Blood-forming organs.
1. =Altmann’s Granules.=
1. Fix small, thin pieces of fresh tissue in equal parts of 5
per cent potassium bichromate and 2 per cent perosmic acid for
24 hours. Wash in running water for several hours. After-harden
in alcohol, and imbed in paraffin. Cut very thin and mount on
cover-glass; remove paraffin.
2. Stain in aniline-water-acid-fuchsin (acid fuchsin 20 grms.,
aniline water 100 cc.), warming until vapor is given off.
3. When cool remove the fuchsin with a mixture of 1 part
saturated alcoholic picric acid and 2 parts of water.
4. Renew the picric acid solution and warm on the paraffin oven
for 30-60 seconds.
5. Dehydrate in alcohol; clear in xylol; mount in balsam.
Protoplasm yellow: Altmann’s granules red: fat black.
2. =Russell’s Bodies.=
1. Fix and harden in Müller’s; wash; after-harden in alcohol;
imbed in paraffin; mount on cover-glass.
2. Stain sections in a saturated solution of fuchsin in 2 per
cent carbolic acid 10 minutes or longer.
3. Wash in water.
4. Wash in absolute alcohol for 30 seconds.
5. Counterstain in iodine green (1 grm. in 100 cc. of a 2 per
cent carbolic acid) for 5 minutes.
6. Dehydrate quickly in absolute alcohol.
7. Clear in xylol; mount in balsam.
Nuclei are green; Russell’s fuchsin-bodies light-red; Altmann’s
granules light-red.
3. =Pianese’s Method.=
1. Fix in Pianese’s solution (see methods of fixation) 6 hours;
wash in running water for 12 hours; after-harden in graded
alcohols; imbed in paraffin; mount on cover-glass.
2. Stain 30 minutes in a staining mixture consisting of malachite
green 0.5 grm., acid fuchsin 0.1 grm., Martius yellow 0.01 grm.,
distilled water 150 cc., 96 per cent alcohol 50 cc.
3. Dehydrate in absolute alcohol; clear in xylol; balsam.
Nuclei are green; protoplasm reddish; cell-inclusions light-red.
4. =Method for Staining “Plimmer’s Bodies.”=
1. Fix in Hermann’s fluid for 12-24 hours. Imbed in paraffin.
Mount sections on cover or slide.
2. Transfer sections to hydrogen peroxide for 15-30 seconds.
3. Wash in water.
4. Transfer to a 4 per cent ferric alum solution for 2 hours.
5. Wash in water.
6. Stain in 0.5 per cent watery hæmatoxylin solution for 30
minutes. Differentiate in the ferric alum solution until the
nuclei are dark and protoplasm colorless; control under the
microscope.
7. Wash in water 3-6 hours.
8. Counterstain in 1 per cent solution of Ehrlich’s neutral red
until section is yellow-red.
Nuclei blue-black; cell-inclusions yellow- to copper-red.
=V. CHOLESTERIN.= Cholesterin is soluble in absolute alcohol, xylol,
ether and glacial acetic. It occurs in the tissues in characteristic
rhombic plates often showing a square notch in one corner. In
sections from which the cholesterin has been dissolved its presence
may be told by the appearance of “cholesterin-clefts” in the tissue,
or often in the protoplasm of large foreign-body giant-cells
(“cholesterin-giant-cells”). With concentrated sulphuric acid,
sections or material containing cholesterin become yellow and then
rose-pink. Lugol’s gives it a brown color which turns blue-violet
after the addition of sulphuric acid, and exhibits a play of colors,
blue, green, to red.
=VI. CLOUDY SWELLING.= This is best seen in the fresh state in cells
obtained by scraping or teasing, or by the examination of frozen
sections. Osmic acid, sudan III, scarlet R. ether, alcohol and acetic
acid may be used to differentiate from fatty degeneration. The
ordinary fixing and staining methods give good pictures, except for
slight degrees of the change. These are sometimes wholly lost as the
result of the contraction due to the fixation.
=VII. COLLOID.= (See Epithelial Hyalin.)
=VIII. CORNIFICATION.= Horn takes the plasma stains (eosin,
picric acid, etc.). Van Gieson’s makes a good differential
stain. With Gram’s method horn stains deep blue, and with the
Ehrlich-Biondi-Heidenhain method it stains red. After fixation
in Flemming’s it may be stained with safranin or gentian-violet.
=Keratohyalin= occurs as fine granules in the cells of the stratum
granulosum. They stain by hæmatoxylin, carmine and Gram’s method, or
may be demonstrated by means of special stains. =Eleidin= stains with
carmine and the fat-stains, but not with hæmatoxylin.
1. =Buzzi’s Method of Staining Eleidin and Keratohyalin.=
1. Harden, imbed, cut.
2. Stain in Congo red (2-3 drops of a 1 per cent water solution
added to small basin of water) for 2-3 minutes.
3. Wash thoroughly in water.
4. Stain in hæmatoxylin, and wash.
5. Dehydrate in absolute alcohol; xylol; balsam.
Keratohyalin blue, eleidin red.
2. =Fick’s Method of Staining Keratohyalin and Keratin.=
1. Harden in alcohol, imbed, cut.
2. Stain in saturated water solution of kresyl-echt-violett for
3-4 minutes.
3. Wash thoroughly in water.
4. Differentiate in 95 per cent alcohol until connective-tissue
is colorless.
5. Dehydrate in absolute alcohol; xylol; balsam.
Keratohyalin red, keratin dark violet; nuclei blue-violet, plasma
light blue-violet.
=IX. FAT.= When alcohol has been used in the preparation of the
tissue, the fat-contents of the latter are dissolved out, and their
presence can alone be told by the presence of vacuoles. When osmic
acid is used as a fixing agent the oleates and oleic acid are
blackened. The tissue should then be washed in running water and
cut upon the freezing-microtome, or it may be imbedded in celloidin
or paraffin if this is done as quickly as possible to prevent the
loss of the fat. Chloroform or benzene should be used in place of
xylol, as the last-named dissolves out the fat. Safranin should
be used as a stain after fixation with any fluid containing osmic
acid. Frozen sections are to be mounted in glycerin-gelatin; when
balsam is used it should be warm melted Canada balsam without xylol.
Formol fixation preserves fat, and tissues so fixed may be cut on
the freezing-microtome and the sections stained with osmic acid,
sudan III or scharlach R, with nuclear counterstaining when desired.
For the demonstration of fat-embolism, fatty degeneration or fatty
infiltration the following methods are advised:—
1. =Staining of Fat with Osmic Acid.=
1. Fix in formol for 24 hours.
2. Wash; freeze; cut.
3. Place sections in 1 per cent osmic acid, Flemming’s or Marchi’s
fluid for 1-24 hours.
4. Wash in water, changing frequently.
5. 80 per cent alcohol ½-2 hours.
6. Wash in water.
7. Place section flat on slide; blot; add a drop of warmed
glycerin-gelatin; cover quickly. Ringing or sealing is not
necessary.
Or, to mount section in balsam:—
After 6, counterstain with hæmatoxylin or safranin; wash again;
dehydrate quickly with absolute alcohol; clear in pure benzene;
mount in pure melted Canada balsam (containing no xylol).
2. =Staining of Fat with Sudan III or Scharlach R.=
Staining-solutions of these dyes may be made, as follows:—
_a._ Dissolve stain in 70-80 per cent boiling alcohol, keep in
the incubator over night, and use warm.
_b._ Make a solution of absolute alcohol 70 cc., 10 per cent
caustic soda solution 20 cc., water 100 cc. Saturate this with
the stain, slightly heating.
_c._ Make a mixture of 70 per cent alcohol 50 cc. and pure
acetone 50 cc.; saturate this with the stain.
All solutions of these dyes should be filtered before using,
and should be kept covered to avoid evaporation and subsequent
precipitation.
1. Formalin fixation 24 hours; cut on freezing-microtome.
2. Place sections in 70 per cent alcohol.
3. Stain in the simple solution 20-30 minutes; in the acetone or
alkaline alcoholic solutions 2-3 minutes.
4. Wash in 50-70 per cent alcohol, differentiating as needed.
5. Transfer to water; thence to slide; blot, and mount in
glycerin gelatin.
When a nuclear counterstain is desired, put the sections in water
after 4; then stain in hæmatoxylin; differentiate quickly in acid
alcohol; wash in water; place in weak ammonia or lithium-carbonate
solution; wash in water; transfer to slide; blot; mount in glycerin
gelatin.
Sudan III and scarlet R stain the smallest particles of fat
yellowish-red to deep scarlet; scarlet R on the whole gives the
best results. The contrast with the blue nuclei when stained with
hæmatoxylin gives beautiful preparations.
3. =Staining of Fat with Indophenol.=
Stain sections with lithium-carmine; wash; then stain 20 minutes
in a saturated solution of indophenol in 70 per cent alcohol. Fat
blue; nuclei red.
4. =Staining of Fatty Acids and Soaps.=
_a. Benda’s Method._ Fix in 10 per cent formol. Transfer tissue
to Weigert’s copper-fluorchrom mordant (neutral copper acetate 5
grms., fluorchrom 2.5 grms., water 100 cc.; boil and add 5 cc. of
36 per cent acetic acid) in the incubator for 2-4 days. Cut on the
freezing-microtome. Stain sections in sudan III or scharlach R,
and then in hæmatoxylin. Nuclei are blue, normal fat red, necrosed
fat green due to formation of fatty acid copper salt. Soaps give
the same reaction when converted into insoluble salts by fixing in
formol saturated with calcium salicylate. Through comparison of
tissue hardened in this way with another portion fixed in formol
alone soaps and fatty acids may be differentiated.
_b. Smith’s Method._ Stain in concentrated water solution of Nile
blue sulphate for 10 minutes. Fat stains red, nuclei dark blue,
protoplasm light blue, fatty acids dark-blue. Differentiate in 1
per cent acetic acid; wash in water; mount in glycerin-gelatin.
=X. FIBRIN.= Fibrin stains with the acid aniline dyes, except
in areas of necrosis containing diffused chromatin, under which
conditions it stains deep blue with hæmatoxylin. In Van Gieson’s
mixture it stains yellow or brownish; in Mallory’s reticulum stain
it stains red, and with Mallory’s chloride of iron hæmatoxylin
it is grayish to dark blue. The best selective method by far is
Weigert’s, and it is the only really practical method giving a good
differentiation.
1. =Weigert’s Fibrin Stain.=
I have obtained the best results by making this stain as follows:
10 cc. of aniline oil and 100 cc. of water are shaken together
violently for several minutes, and then filtered through a moist
filter. The filtrate must contain no drops of aniline. Add to the
filtrate sufficient dry gentian-violet or methyl-violet to produce
a metallic shimmer on the surface of the solution after the dye is
dissolved by shaking. The solution will keep for several months.
Weigert advised the use of two stock solutions, I (absolute
alcohol 33 cc., aniline oil 9 cc., methyl violet in excess) and II
(saturated water solution of methyl violet). These solutions will
keep for years. When ready to use stain take 3 cc. of Sol. I and 27
cc. of Sol. II. This staining mixture will keep for about 2 weeks.
1. Fix in alcohol, formol, acetone, mercuric chloride or
Müller’s. Imbed in celloidin or paraffin; the latter preferably.
Mount sections on cover-glass with albumin fixative. Celloidin
sections must be fastened to slide by thin film of celloidin
to prevent shrinkage. Sections fixed in chromic mixtures (and
sometimes after formol fixation) must be oxidized in potassium
permanganate and then reduced in oxalic acid to give good
results. (Transfer sections to a 1 per cent solution of potassium
permanganate to which 2 volumes of water have been added; oxidize
for 10 minutes; then wash in water, and reduce for several hours
in a 5 per cent water oxalic acid solution.)
2. Wash in water.
3. Stain in lithium carmine; differentiate in acid alcohol; wash
thoroughly in water.
4. Stain on the slide or cover-glass in the aniline-methyl-violet
(or gentian-violet) solution for 10 minutes. Wash off stain with
physiologic salt solution.
5. Blot section with absorbent paper.
6. Cover section with Lugol’s (300-2-1) or a 5 per cent watery
potassium iodide saturated with iodine. Leave on section for 1-5
minutes.
7. Blot off iodine.
8. Differentiate in aniline xylol (equal parts of xylol and
aniline oil) until the nuclei become red.
9. Wash in xylol, blotting with absorbent paper. Repeat until
section is transparent; then mount in balsam. All aniline oil
must be removed before using the balsam.
Nuclei are red; fibrin deep blue; bacteria, mucin, keratin and
Altmann’s granules also blue. The differentiation must be carefully
controlled under the microscope, and should be stopped before the
finest threads of fibrin begin to be decolorized.
=XI. GLYCOGEN.= Glycogen is soluble in water; and fixation and
hardening must be carried out with absolute alcohol to prevent
the solution of the glycogen. Tissue must be fixed immediately
after death, as glycogen is quickly broken up. Its reaction with
iodine is similar to that of amyloid, but it does not give the
iodine-sulphuric-acid reaction that the latter substance does.
1. =Best’s Iodine Method.=
1. Fix and harden in absolute alcohol; imbed in paraffin; cut.
2. Stain somewhat deeply with hæmatoxylin.
3. Wash in water.
4. Stain in iodine 1, potassium iodide 2, water 100.
5. Dehydrate in iodine 2, absolute alcohol 100.
6. Differentiate in origanum oil, 1-2 hours.
7. Wash thoroughly with xylol.
8. Arrange on slide and dry in air.
9. Mount in pure melted balsam (no xylol).
Nuclei are blue, glycogen brown.
2. =Best’s Carmine Method for Glycogen.=
1. Fix in absolute alcohol; imbed in celloidin; cut.
2. Stain in hæmatoxylin; differentiate in acid alcohol.
3. Wash in water.
4. Stain in filtered carmine mixture (carmine 1 grm., ammonium
chlorate 2 grms., lithium carbonate O.5 grm., water 50 cc.; bring
to boiling point, and when cool, add 20 cc. of strong liquid
ammonia. Keep in dark; can be used after 2-3 days and gives good
results up to 14 days) 2 parts, strong ammonia 3 parts, methyl
alcohol 6 parts. Make fresh each time it is used, as it soon
precipitates; do not filter; stain few sections at a time ¾-1
hour.
5. Differentiate 1-2 minutes in a mixture of absolute alcohol 4
parts, methyl alcohol 2 parts, water 5 parts.
6. Wash in 80 per cent alcohol.
7. Dehydrate in absolute alcohol.
8. Clear in xylol; mount in balsam.
Glycogen is stained red; nuclei blue; dense connective-tissue,
mast-cell granules, protoplasm of gastric glands, etc., red; but
these can all be distinguished morphologically from glycogen. This
is by far the best method for the staining of glycogen.
=XII. HYALIN.= Epithelial hyalin (colloid) stains red or violet
with hæmatoxylin and eosin; it takes the other acid dyes and stains
to some degree with basic aniline stains. Van Gieson’s stains it a
yellow, orange or brownish-pink. Kresyl-echt-violett gives it a deep
indigo-blue color or a more green robin-egg blue. _Connective-tissue
hyalin_ stains deep brilliant red with Van Gieson’s; this is the best
method for differentiating connective-tissue hyalin from amyloid or
epithelial hyalin. Russell’s method also stains hyalin red.
=XIII. HYDROPIC DEGENERATION.= Fix by heat or formol-alcohol. Imbed
in celloidin; stain with hæmatoxylin and eosin.
=XIV. HYPERTROPHY.= Fix in Müller’s or mercuric chloride for simple
staining; for study of nuclei fix in Flemming’s and stain with
safranin.
=XV. INFLAMMATION.= The process of inflammation may be studied to
advantage in the mesentery, web or tongue of the curarized living
frog, by stretching these parts over a cork-ring attached to a
glass plate on which the animal rests. The exposed tissues must be
kept moist with physiologic salt solution. Heat, chemicals or other
irritants may be employed to produce the inflammatory reaction.
For the study of the inflammatory process in sections the ordinary
fixations may be employed, but for the study of the nuclei, mitotic
figures and cell-granulations fixation in Flemming’s, Zenker’s, etc.,
is advised. Safranin, methylene blue and eosin, the various stains
used in the study of blood-cells, etc., may be used.
1. =Staining of Mast-cells.=
_a. Kresyl-echt-violett_ used as for amyloid or mucin is the best
stain for mast-cells. The cell-granules stain bright rose-red.
_b. Ehrlich’s Dahlia Method._
1. Harden in absolute alcohol; imbed; cut.
2. Stain with saturated water solution of dahlia.
3. Wash in water.
4. Dehydrate in absolute alcohol.
5. Clear in xylol; mount in balsam.
_c. Unna’s Method for Mast and Plasma Cells._
1. Harden in absolute alcohol; imbed; cut.
2. Stain in Unna’s polychrome methylene blue ¼-12 hours.
3. Wash in water.
4. Differentiate in Unna’s glycerin-ether mixture (Grübler) 15
seconds to several minutes.
5. Wash carefully in water.
6. Dehydrate in absolute alcohol; clear in xylol; mount in balsam.
Mast cell granules are red; plasma cell granules blue.
_d._ Various modifications of the _Romanowsky method_ stain mast-
and plasma-cells very well.
=XVI. IODINE.= For the demonstration of iodine in tissues the
following method has been advised by =Justus=. The experience of
other workers with it has not been satisfactory.
1. Harden in absolute alcohol; imbed in celloidin; cut.
2. Soak in water to remove alcohol.
3. Put section in wide-mouthed, stoppered bottle in freshly
prepared green chlorine-water for 1-2 minutes.
4. Transfer section on a glass needle to a vessel containing 500
cc. water and 1 cc. of a 1 per cent solution of silver nitrate for
2-3 hours. The section is colored yellow-green, and a precipitate
of silver chloride appears.
5. Transfer section to a warm saturated solution of sodium chloride
until it becomes light.
6. Wash in distilled water.
7. Transfer to a concentrated solution of mercuric chloride.
8. Examine in pure glycerin.
Iodine should be red.
=XVII. MITOTIC FIGURES.= Various histologic methods devised for the
study of mitoses can be applied to the demonstration of these in
neoplasms, inflammation and regeneration. Flemming’s solution or
mercuric chloride fixation gives best results, although formol, or
even absolute alcohol, when used quickly and carefully gives fair
results if tissue is very fresh.
1. =Flemming’s Solution and Safranin.=
1. Fix small pieces of fresh tissue in Flemming’s, in the dark,
for 24 hours; wash 24 hours; after-harden in graded alcohols;
imbed and cut.
2. Stain in 1 per cent water solution or saturated aniline water
solution of safranin, or 1 per cent water methyl violet for 12-24
hours, or carbol-fuchsin for one hour.
3. Differentiate quickly in a 0.5-0.0001 HCl in 70 per cent
alcohol and then in absolute alcohol until stain no longer comes
away in clouds and nuclei have right shade.
4. Clear in xylol; mount in balsam.
Fat is black; mitoses stand out sharply; tubercle-bacilli may be
stained black or red.
2. Fixation in mercuric-chloride may be followed by
=Ehrlich-Biondi-Heidenhain’s stain= (saturated aqueous orange 100
cc., saturated aqueous acid fuchsin 20 cc., saturated aqueous
methyl green 50 cc.) 12 grms. of Grübler’s prepared stain dissolved
in 100 cc. of distilled water, for stock solution. For staining
take 1 cc. of stock solution, water 30 cc., ½ per cent watery acid
fuchsin 3 cc., and 2 per cent acetic 5-6 drops. Stain 2-24 hours;
wash in 90 per cent alcohol; dehydrate in absolute; clear in xylol;
balsam.
Resting nuclei are bluish; mitoses and fragments of leukocyte
nuclei dark green; red blood cells orange red; protoplasm and
connective-tissue fuchsin red.
3. =Benda’s Iron-Haematoxylin Method.=
1. Fix in osmic acid, mercuric chloride or other fixative.
2. Stain sections by placing them in liq. ferri. sulfur. oxyd.
(Germ. Pharm.) diluted with double its volume of water, for 24
hours; wash carefully in distilled water and then in tap water;
stain in 1 per cent watery hæmatoxylin until section is black.
Wash in water. Differentiate in 10-30 per cent acetic acid, or in
liq. ferri. sulfur. oxyd. diluted with distilled water 1-20. A 10
per cent solution of ferric sulphate may be used instead of the
persulphate.
4. =Heidenhain’s Iron-Haematoxylin.=
1. Imbed in paraffin after fixation in mercuric chloride.
2. Immerse section in a 1.5 per cent solution of iron-alum
sulphate (violet-colored salt) or iron-ammonium sulphate for ½-3
hours.
3. Wash in water.
4. Stain in 0.5 per cent watery hæmatoxylin or hæmatein for 12-18
hours.
5. Wash in water.
6. Differentiate in the iron-alum or iron-ammonium solution until
the section becomes deep blue (control under microscope) and
nuclear structures stand out distinctly.
7. Wash in running water for 15 minutes.
8. Absolute alcohol; xylol; balsam.
Instead of the watery hæmatoxylin solution a mixture of hæmatoxylin
1 grm., alcohol 10 cc., and water 90 cc. may be used. Keep four
weeks before using. Stain 24-36 hours. For contrast staining a
weak solution of Bordeaux red may be used before the iron-alum and
hæmatoxylin, staining 24 hours.
=XVIII. MUCIN.= Mucin stains a deep blue or reddish-violet with
an over-ripe hæmatoxylin. When counterstained with picric acid
very beautiful preparations can be obtained. Mucin also gives
a metachromatic reaction with kresyl-echt-violett, thionin,
toluidin-blue and polychrome methylene-blue, staining red with these
stains. Water or carbolic-acid solutions of these stains may be used;
dehydrate in absolute alcohol, clear in xylol, and mount in balsam.
In my opinion =Morse’s Carbol-kresyl-echt-violett= method as given
above for amyloid is the best of these metachromatic reactions.
Muchæmatein and mucicarmin give the most delicate reactions.
1. =Mayer’s Muchaematein.=
1. Absolute alcohol fixation is preferable.
2. Stain sections in Mayer’s solution (hæmatein O.2 grm. mixed
with a few drops of glycerin, O.1 grm. of aluminum chloride, 40
cc. of glycerin, 60 cc. of water) for 5-10 minutes.
3. Wash in water.
4. Dehydrate in absolute alcohol; xylol; balsam.
Carmine may be used for counterstaining; mucin is blue. Should the
mucin swell in the stain replace water and glycerin with 100 cc. of
70 per cent alcohol and 1-2 drops of nitric acid.
2. =Mayer’s Mucicarmin.=
Make staining solution by mixing 1 grm. carmine, O.5 grm. aluminum
chloride, 2 cc. water and 100 cc. of 50 per cent alcohol, heating
over the flame for 2-3 minutes until mixture darkens. Let stand 24
hours and filter. The stock solution may be diluted 1-10. Stain
10 minutes. If it does not stain well add 0.5-1 grm. of aluminum
chloride. Mucin alone should be stained red. Counterstain with
hæmatoxylin.
=XIX. MYELIN.= This appears in the form of doubly refractive
granules, that stain with less intensity with the fat dyes, but may
be differentiated from fat in that it loses the power of reducing
osmic acid after being mordanted for eight days or more in bichromate
solutions, while fat does not.
=XX. NECROSIS.= Hæmatoxylin and eosin, and Van Gieson’s give good
pictures. Use Weigert’s fibrin stain for coagulation-necrosis, and
Benda’s method for the demonstration of fatty acids for the staining
of fat-necrosis. Recent necrotic areas stain diffusely blue with
hæmatoxylin; older areas may take the plasma stains alone. Use
various methods for the demonstration of micro-organisms in the
necrotic areas.
=XXI. NEOPLASMS.= Use hæmatoxylin and eosin, and Van Gieson’s for
ordinary diagnosis. To differentiate sarcoma and carcinoma use Van
Gieson’s, Mallory’s or other reticulum stains. For the study of
cell-inclusions use Altmann’s, Russell’s, Plimmer’s and Pianese’s
methods. Special fixation or Zenker’s is necessary. Methylene-blue
and eosin after Zenker’s give excellent pictures. For the
demonstration of mitoses the methods given above should be employed.
=XXII. PIGMENT.= Use the carmines for contrasting melanin,
hæmofuscin, lipochromes, hæmatoidin, hæmosiderin, bilirubin and all
yellow, brown, blue, black, etc., extrinsic pigments. In tissue
fixed in mercuric chloride or formol bilirubin is green, and can
thus be differentiated from hæmatoidin. The lipochromes give weak
fat-reactions, and this is used to distinguish them from other
yellow or brown pigments. Alcohol fixation is the best for pigment
study, although the other fixing solutions may be used. Formol
sometimes produces pseudo-pigments by its action upon hæmoglobin.
The iron-reactions are obtained best in sections cut on the
freezing-microtome, although both paraffin and celloidin imbedding
may be used. In testing for iron glass needles should be used and all
traces of iron should be removed from staining-dishes, slides, etc.,
by treating with hydrochloric acid, distilled water and alcohol.
1. =Potassium Ferrocyanid Test for Iron.=
1. Stain sections in lithium carmine for several hours.
2. Differentiate in acid alcohol, stopping short of the desired
complete differentiation of the nuclei.
3. Wash in water.
4. Saturated solution of potassium ferrocyanid 1-3 hours.
5. Acid alcohol until iron-pigment becomes blue (½-12 hours).
Complete differentiation of nuclei.
6. Wash in water.
7. Dehydrate in absolute alcohol.
8. Clear in xylol; mount in balsam.
Hæmosiderin is blue (Berlin blue); nuclei are red. Lithium carmine
may be used after the iron-test, if desired.
2. =Ammonium Sulphide Test for Iron.=
1. Fix in alcohol; imbed; cut.
2. Treat sections with yellow ammonium sulphide for 5-60 minutes.
3. Wash quickly in water.
4. Dehydrate in absolute alcohol.
5. Clear in xylol; mount in balsam.
Stain with lithium carmine either before or after the reaction with
ammonium sulphide. Iron is grayish-black to black.
3. =Combined or Masked Iron.=
1. Treat tissues with Bunge’s fluid (95 per cent alcohol 95 cc., 25
per cent hydrochloric acid 10 cc.) for 1-2 hours at 50-60°C., until
inorganic iron is all removed.
2. Place tissues in acid alcohol (sulphuric acid 4 cc. in 100 cc.
alcohol 95 per cent.)
5. Wash sections in acid alcohol, then pure alcohol, and finally in
distilled water.
6. Transfer to ammonium sulphide (5-60 minutes) or to potassium
ferrocyanid and O.5 HCl for 5 minutes.
7. Wash in water.
8. Counterstain in eosin or safranin; wash; dehydrate in absolute
alcohol; clear in cedar-oil; mount in benzene balsam. Keep
preparations in the dark.
4. =Staining of Chromophilic Cells.=
1. Fix in a chromic solution. In this the chromophilic cells become
yellow or brown.
2. Stain in polychrome methylene blue; the cells become grass-green
in color.
5. =Tests for Silver, Lead and Mercury.=
Use ammonium sulphide as for iron. Black sulphides are formed.
6. =Test for Copper.=
Treat with potassium ferrocyanid and hydrochloric acid; copper
gives a dark yellow-brown coloration.
=XXIII. PSEUDOMUCIN.= It is not precipitated by acetic acid. It has a
greater affinity for the diffuse stains than mucin, and gives weaker
metachromatic reactions.
=XXIV. REGENERATION AND REPAIR.= For the staining of mitoses, cell
granules and cell-inclusions see methods given above. See also
methods for staining of epithelium, reticulum, neuroglia, etc.
XXV. URIC ACID AND PURIN BASES:—
1. =Courmont and Andre’s Method.=
1. Fix in absolute alcohol; imbed; cut.
2. Treat sections with 1/100 ammonia solution or very weak sodium
hyposulphite solution.
3. Transfer to 1/100 silver nitrate solution.
4. Wash.
5. Develop with a photographic developer.
6. Wash in water; stain with hæmalum and eosin; dehydrate; clear
in xylol; balsam.
Uric acid and xanthin or purin bases appear as black granules.
CHAPTER XXVII.
THE STAINING OF PATHOGENIC MICRO-ORGANISMS IN TISSUES
Rapid fixation and hardening are requisites for the successful
staining of micro-organisms in sections. Alcohol, Zenker’s, mercuric
chloride and formol give best results; Müller’s because of its
slow action is not good, although formol-Müller’s may be used
because of the more rapid fixation with this fluid. In the case
of formalin-fixation staining with Weigert-Gram’s method may not
give good results unless the sections are oxidized in potassium
permanganate solution and then reduced in oxalic acid. (See Staining
of Fibrin.) Preservation of the tissue for a long time in alcohol
impairs the staining power of micro-organisms contained within it.
The tissue should be imbedded preferably in paraffin, as very thin
sections must be obtained. The freezing-microtome may be employed
and the thinnest sections selected for staining. Celloidin stains
very heavily with the aniline dyes and retains the color, so that
bacteria in celloidin sections do not stand out very distinctly.
On the whole paraffin sections, floated on slide or cover, and
fastened by albumin-fixative, give the best results, though for
the micro-organisms stained in carbol-fuchsin and decolorized in
nitric acid it is best to float the sections directly onto the
warm stain without removing the paraffin, and mount without the
use of alcohol. This method may be employed for all stains that
are taken out by alcohol. The stains used for film preparations
are as a rule applicable to sections. The basic aniline dyes,
particularly methylene-blue, fuchsin, methyl or gentian violet,
kresyl-echt-violett, thionin, and Bismarck brown, either in saturated
alcoholic solutions or dilutions of such, or in combination with
alkalies, aniline oil or phenol, are usually employed. The various
modifications of the Romanowsky method are very useful. The time
required for staining in sections is usually much longer than for
films; but the staining can often be accelerated or strengthened by
warming over the flame or in the incubator. Contrast staining of the
nuclei with lithium-carmine or Bismarck brown is advisable after the
use of staining methods in which the nuclei are decolorized. Xylol or
origanum oil should be used for clearing.
I. THE STAINING OF BACTERIA IN TISSUES.
According to their staining-reactions bacteria may be very
conveniently grouped in three classes: 1, _Staining with
Gram-Weigert’s method_; 2, _Not staining with Gram-Weigert’s_; 3,
_Staining with the tubercle-bacillus method_ (_acid-resisting_).
1. BACTERIA STAINING BY THE GRAM-WEIGERT METHOD.
Weigert’s modification of Gram’s method, as given above for the
staining of fibrin, is the best for the staining of bacteria
that stain by this method. (See Fibrin, Chapter XXVI.) The
differentiation with aniline-xylol is slower and safer than
with alcohol. Acetone-xylol (1:5) has been recommended in
place of aniline-xylol. Wolbach recommends the use of a 5-10
per cent colophonium-alcohol for differentiation. Contrast
staining with watery Bismarck brown, dilute carbol-fuchsin or
eosin may be carried out if desired. The aniline-xylol may
be saturated with eosin and the section stained during the
differentiation. _Carbol-gentian-violet_ may be used instead of
aniline-gentian-violet; it keeps much better than the latter.
Staining by Gram’s Method (Gram-positive).
Staphylococcus pyogenes aureus.
Staphylococcus pyogenes albus.
Staphylococcus pyogenes citreus.
Streptococcus pyogenes.
Micrococcus tetragenus.
Diplococcus pneumoniæ.
Bacillus aërogenes capsulatus.
Bacillus of diphtheria.
Bacillus of anthrax.
Bacillus of leprosy.
Bacillus of tetanus.
Bacillus of tuberculosis.
Bacillus of rhinoscleroma.
Bacillus of mouse septicæmia.
Bacillus of swine erysipelas.
Oïdium albicans.
Mycelium of actinomyces.
2. BACTERIA NOT STAINING BY GRAM’S METHOD.
For the bacteria belonging to this class Löffler’s methylene-blue,
carbol methylene-blue, a watery solution of methylene-blue or
gentian-violet, Leishman’s or Wright’s modification of Romanowsky’s
methylene-blue eosin method (see page 290), Unna’s alkaline
methylene-blue solution preceded by eosin after Zenker’s fixation
(see page 260), aniline gentian-violet, Zieler’s method and
carbol fuchsin are most commonly used as stains. Wolbach advises
the use of a 5-10 per cent acetone-colophonium solution for the
differentiation of Gram-negative bacteria in tissue fixed in formol.
1. =Löffler’s Methylene-blue.=
1. Saturated alcoholic solution of methylene-blue 30 cc.;
potassium hydrate solution (1 in 10,000) 100 cc.
2. Stain 5 minutes to 24 hours.
3. Wash in water.
4. Differentiate in 1 per cent acetic acid, 10-30 seconds.
5. Wash in 90 per cent alcohol, 2-5 minutes; dehydrate in
absolute alcohol; clear in xylol; mount in balsam.
2. =Gentian-violet.=
1. Stain sections in a 2 per cent watery gentian-violet for 5-20
minutes.
2. Wash in water.
3. Decolorize in 70 per cent alcohol until stain ceases to come
away.
4. Dehydrate in absolute alcohol; clear in xylol; balsam.
3. =Zieler’s Method.=
1. Fix in Orth’s solution, or any fixing solution except those
containing osmic acid; imbed in paraffin or celloidin.
2. Stain in Pranter’s solution (orcein D 0.1 grm., hydrochloric
acid 2.0 cc., 70 per cent alcohol 100 cc.) for 8-24 hours.
3. Wash rapidly in 70 per cent alcohol.
4. Wash in water.
5. Stain in polychrome methylene-blue 10 minutes to several hours.
6. Wash in distilled water.
7. Differentiate in glycerin ether until no more clouds of color
come away and section is light blue.
8. Wash in distilled water.
9. 70 per cent alcohol for a few seconds; absolute 5-10 minutes;
xylol; balsam.
Protoplasm is gray-brown; bacteria dark-blue; background colorless.
Zieler’s method is especially good for the staining of the
glanders, typhoid and chancroid bacilli and the gonococcus.
For Unna’s methylene-blue eosin and the modifications of the
Romanowsky method see Pages 260 and 290 respectively. Pappenheim’s
methyl-green-pyronin method is also recommended for the staining in
sections of Gram-negative bacteria.
Not Staining by Gram’s (Gram-negative).
Gonococcus.
Micrococcus melitensis.
Meningococcus (in sections).
Bacillus of bubonic plague.
Bacillus of chancroid.
Bacillus coli communis.
Bacillus dysenteriæ.
Bacillus of epidemic conjunctivitis (Koch-Weeks).
Bacillus of influenza.
Bacillus mallei.
Bacillus pneumoniæ.
Bacillus proteus.
Bacillus of malignant œdema.
Bacillus pyocyaneus.
Bacillus of typhoid fever.
Bacillus of fowl cholera.
Bacillus of rabbit septicæmia.
Bacillus of swine plague.
Spirillum of Asiatic cholera.
Spirochæte pallida.
3. BACTERIA STAINING BY THE TUBERCLE-BACILLUS METHOD.
(ZIEHL-NEELSEN.)
1. Tubercle-bacillus.
2. Lepra-bacillus.
3. Smegma-bacillus.
4. Lustgarten’s bacillus.
1. Stain sections by floating thin paraffin sections directly on
to warm carbol-fuchsin (fuchsin 1 grm., absolute alcohol 10 cc.,
cryst. carbolic acid, 5 grms., water 100 cc.) for 1-3 minutes.
2. Transfer on spatula to water, agitating so as to wash off excess
of stain.
3. Transfer section to 30 per cent nitric acid and water
alternately, until section has a pale lilac tint.
4. Wash in water.
5. Float on warm watery methylene-blue for 1 minute.
6. Wash in water.
7. Float section on slide; dry over flame or in oven; melt over
flame, and put section at once into xylol to remove paraffin.
8. Balsam.
Various staining-methods have been recommended for the staining of
the most important pathogenic bacteria in tissues. The most useful of
these methods are here given:—
_a. Cocci._
1. =Pyogenic Cocci.= Stain by Gram-Weigert’s, contrast with
Bismarck brown or lithium-carmine.
2. =Pneumococcus.= Stains with ordinary water solutions,
carbol-fuchsin and Gram-Weigert’s. The staining of the capsule in
sections is not very satisfactory.
3. =Gonococcus.= Gram-negative. Stains in sections with Zieler’s
method, Löffler’s methylene-blue, or dilute carbol-fuchsin with
differentiation in alcohol.
4. =Micrococcus Catarrhalis.= Stains like the gonococcus.
5. =Diplococcus Intracellularis Meningitidis.= Smear preparations
often Gram-positive, in sections usually Gram-negative. Use same
stains as for gonococcus.
6. =Micrococcus Tetragenus.= Stain with Gram’s or watery solutions
of basic aniline dyes.
_b. Bacilli._
1. =Anthrax-bacillus.= Stain with Gram-Weigert’s and contrast with
Bismarck brown or lithium-carmine. Stains also with strong watery
gentian-violet solution, with differentiation in strong alcohol.
2. =Bacillus of Malignant Oedema.= Gram-negative. Stain with watery
solution or gentian-violet.
3. =Bacillus of Tetanus.= Gram-positive. Stains with watery
solutions of basic aniline dyes.
4. =Bacillus Aërogenes Capsulatus.= Gram-positive. Stains with
other aniline stains.
5. =Bacillus Pyocyaneus.= Stains with Gram’s and other aniline dyes.
6. =Bacillus of Influenza.= Gram-negative. Fix tissue in alcohol.
Stain with dilute carbol-fuchsin and differentiate in dilute acetic
acid.
7. =Koch-Week’s Bacillus.= Gram-negative.
8. =Bacillus of Bubonic Plague.= Gram-negative. Stain by
_Gaffky’s method_ (Fix in alcohol or a mixture of glacial acetic
acid 10.0, chloroform 30.0, and 96 per cent alcohol 60.0, imbed
in paraffin, stain 2-3 hours in weak watery methylene-blue,
dehydrate quickly in absolute alcohol, xylol, balsam). It may
also be stained by 24 hours in concentrated solution of fuchsin
in glycerin, rapid differentiation in weak acetic; alcohol;
xylol; balsam. Alcohol or mercuric chloride fixation should be
used, as formol fixation does not give good staining.
9. =Typhoid Bacillus.= Löffler’s methylene-blue or carbol-fuchsin,
staining 24 hours, decolorizing in dilute acetic and washing
rapidly in alcohol. Zieler’s method may also be used. It is
Gram-negative.
10. =Paratyphoid Bacillus.= Stains like the typhoid bacillus.
11. =Colon Bacillus.= Gram-negative. May be stained with Löffler’s
methylene-blue or carbol-fuchsin.
12. =Diphtheria Bacillus.= May be stained in sections of
diphtheritic membranes with Löffler’s methylene-blue, watery
aniline stains, or with Gram’s if the decolorization is not carried
too far.
13. =Bacillus of Chancroid.= Gram-negative. Stain according to
_Unna’s method_:—
1. Fix in alcohol.
2. Stain 5-10 minutes in a mixture of a solution of
methylene-blue 1 grm., potassium carbonate 1 grm., alcohol 20
cc., water 100 cc., and a solution of methylene-blue 1 grm.,
borax 1 grm., water 100 cc.
3. Place sections on slide; blot.
4. Decolorize in Unna’s glycerin-ether mixture.
5. Dry; dehydrate in alcohol.
6. Xylol; balsam.
14. =Bacillus of Glanders.= Gram-negative. Stain with Zieler’s
method or with Löffler’s methylene-blue, differentiating in weak
acetic.
_Noniewicz’s Method._
1. Stain with Löffler’s methylene-blue 2-5 minutes.
2. Wash in water.
3. Differentiate for about 5 seconds in a mixture of ½ per cent
acetic acid 75 cc., ½ per cent watery solution tropaeolin 25 cc.
4. Wash in water; dry by blotting; xylol; balsam.
Bacilli deep-blue; tissues light-blue.
15. =Bacillus of Rhinoscleroma.= Gram-positive. Fix in alcohol for
_Wolkowitsch’s method_:—
1. Stain in aniline gentian-violet 24-48 hours.
2. Wash in water.
3. Treat with Lugol’s 1-4 minutes.
4. Decolorize in absolute alcohol.
5. Remove more color by oil of cloves.
6. Xylol; balsam.
In tissues fixed in osmic acid and then stained in hæmatoxylin
the bacilli are dark blue with light blue capsules. The hyaline
substance of rhinoscleroma stains with basic stains.
16. =Friedländer’s Bacillus.= Gram-negative. Stains with ordinary
aniline dyes. For staining the capsules the following method is
advised:—
1. Stain for 24 hours in the incubator in a mixture of a
concentrated alcoholic solution of gentian-violet 50 cc., glacial
acetic acid 10 cc., and distilled water 100 cc.
2. Wash in a 1 per cent acetic acid solution.
3. Alcohol; xylol; balsam.
Bacilli deep-blue; capsules light-blue.
17. =Tubercle-bacillus.= Gram-positive. Stain in sections on
warm carbol-fuchsin without removing paraffin, as given above.
Alcohol and mercuric chloride fixation give best results.
Aniline-gentian-violet may also be used, staining with a warm
solution for 15-30 minutes, and decolorizing in 20 per cent nitric
acid followed by 70 per cent alcohol, counterstaining in Bismarck
brown, dehydrating in alcohol, clearing in xylol and mounting in
balsam. The Weigert-Gram method may be used for the demonstration
of the branched or streptothrix forms of the tubercle bacillus. For
celloidin sections _Mallory and Wright_ advise the following:—
1. Stain rather lightly in alum-hæmatoxylin.
2. Wash in water.
3. Dehydrate in 95 per cent alcohol.
4. Attach sections to slide by ether-vapor method.
5. Stain in steaming carbol-fuchsin 2-5 minutes.
6. Wash in water.
7. Acid alcohol ½-1 minute.
8. Wash thoroughly in several changes of water to remove acid
completely and to bring back blue color to nuclei.
9. 95 per cent alcohol to remove fuchsin.
10. Aniline-oil, followed by xylol, blotting.
11. Xylol; balsam.
Celloidin is colorless, nuclei blue, tissue colorless,
tubercle-bacilli red. Orange G may be used as a diffuse stain.
18. =Lepra Bacillus.= Gram-positive. Stain paraffin sections on
warm carbol-fuchsin, as for the tubercle-bacillus. To differentiate
from the tubercle-bacillus, stain 6-7 minutes in a dilute alcoholic
solution of fuchsin, and decolorize in acid alcohol (nitric acid 1,
alcohol 10). Lepra-bacilli stain; tubercle-bacilli do not.
_c. Trichomycetes._
1. =Actinomyces.= Alcohol and formol fixation are best. Good
preparations can be obtained with hæmatoxylin and eosin, Van
Gieson’s or Weigert-Gram’s. The special staining methods advised
give no better results than these simpler stains. Differential
staining of clubs and mycelium may be obtained by _Mallory’s
method_:—
1. Stain lightly in alum-cochineal. (Powdered cochineal 6 grms.,
ammonia alum 6 grms., water 100 cc. Boil half an hour, add water
lost by evaporation, filter, add crystals of thymol.)
2. Saturated watery eosin 10 minutes.
3. Wash in water.
4. Stain in aniline gentian-violet 2-5 minutes.
5. Wash in physiologic saline solution.
6. Transfer sections to Lugol’s for 1 minute.
7. Pass rapidly through water.
8. Dry thoroughly between folds of filter-paper.
9. Cover section with aniline-oil until clear.
10. Xylol; balsam.
Clubs pink; mycelium blue.
2. =Nocardia, Cladothrix, Streptothrix and Leptothrix.= Löffler’s
methylene-blue and carbol-fuchsin give good results. The Nocardiæ
are acid-fast with dilute acids. They give good preparations with
Weigert’s fibrin stain and lithium-carmine.
_d. Vibrios._
1. =Cholera Vibrios.= Gram-negative. Sections may be stained with
fuchsin or methylene-blue.
_e. Spirilla and Spirochætes._
1. =Spirillum of Recurrent Fever.= Stain in sections with
Levaditi’s silver-method, or with Nikiforoff’s method:—
1. Fix for 24 hours in equal parts of a 5 per cent water solution
of potassium bichromate and a saturated solution of mercuric
chloride in 0.6 per cent sodium chloride.
2. After-harden in graded alcohols in the incubator.
3. Imbed in paraffin.
4. Stain 24 hours in a mixture of alcoholic 1 per cent solution
of tropæolin 5 cc., concentrated watery methylene-blue solution
10 cc., caustic potash solution (1:1000) 2 drops.
5. Wash in water.
6. Dip several times in a mixture of equal parts of absolute
alcohol and ether.
7. Oil of bergamot; xylol; balsam.
The spirillum of _African relapsing fever_ stains with the same
stains as the spirillum Obermeieri. The _spirochætes of Vincent’s
angina_ and _fowl-spirillosis_, and the _spirochæte refringens_
stain with watery aniline dyes and with Giemsa’s stain; in section
they are stained by the Levaditi method.
2. =Spirochaeta Pallida (Treponema Pallidum).= This organism is
best examined in the living condition by means of the dark-field
illumination (dark-field condenser). A very simple method of
dark-field illumination consists of the use of India ink. The
suspected discharge or serum is placed on a slide and an equal
quantity of ink (Gunther’s or Higgin’s) added. The serum and ink
are rapidly mixed and spread over the slide to dry in a pale brown
smear. The oil for the immersion is placed directly on the smear.
The spirochætes appear as white spirals against a brownish-black
field. The best results are obtained with serum; the presence
of mucus or fibrin interferes with the clearness of the picture
obtained.
Smears of serum from syphilitic lesions may be dried in the air and
fixed in absolute alcohol or equal parts of absolute alcohol and
ether for 15-20 minutes. They may then be stained by Giemsa’s (old
formula) stain (azur II-eosin 3 grms., azur II 0.8 grm., glycerin
[Merck’s chemically pure] 250 grms., methyl-alcohol [Kahlbaum I]
250 grms.). This solution can be obtained from Grübler. Ten drops
of the stain are mixed with 10 cc. of distilled water immediately
before the staining. The fixed preparation is covered with the
diluted staining fluid and warmed over the flame until a slight
steam arises. It is then allowed to cool for about 15 seconds, when
the stain is poured off and replaced by fresh, and the process
repeated four or five times, when the preparation is washed,
dried and mounted in balsam. Spirochætes are dark red. Slide or
cover-glass and forceps must be absolutely clean. Smears may also
be fixed and stained by _Wright’s blood-stain_.
For the demonstration of the treponema in sections the method of
_Levaditi_ gives the most satisfactory results:—
1. Fix thin pieces of tissue 24 hours or longer in 10 per cent
formol. (Formol-Müller’s and alcohol-fixation may also be used.)
2. 24 hours in 96 per cent alcohol.
3. Transfer to distilled water until tissue sinks.
4. Impregnation for 3 days in incubator, in a 1.5-3 per cent
silver nitrate solution.
5. Wash for a short time in water.
6. Reduce for 48 hours, in the dark, at room-temperature, in
pyrogallic acid 4 grms., 40 per cent formol 5 cc., distilled
water 100 cc.
7. Wash in water. Cut on freezing-microtome, or imbed in
celloidin or paraffin. Toluidin-blue or safranin may be used as a
contrast-stain.
The spirochætes are dark brown to black. Silver precipitates occur
chiefly in the outer portions of the tissue. The reticulum is
brown; other parts of the tissue are yellowish. Levaditi’s more
recent modification of this method does not give so good results as
the original.
_Schmorl’s Staining of Sections with Giemsa’s Stain._
1. Fix in 10 per cent formol. Cut very thin sections on
freezing-microtome.
2. Place the sections in a staining dish containing a measured
amount of distilled water. To each cc. of water add one drop
of Giemsa’s stain. Use clean glass-needles to manipulate the
sections. After 1 hour transfer sections to a fresh solution, in
which they are left 5-12-24 hours.
3. Wash quickly in a concentrated solution of potassium alum,
then quickly in water.
4. Mount in glycerin-gelatin; or dry on the slide until nearly
perfectly dry, then xylol, and balsam, or cedar oil. Alcohol must
not be used.
II. THE STAINING OF PATHOGENIC YEASTS AND MOULDS IN SECTIONS.
1. =Blastomycetes.= The parasites of blastomycetic dermatitis
can be demonstrated unstained in pus treated with a weak sodium
hydroxide. In sections they are easily found after treatment
with ordinary staining methods. The various modifications of the
Romanowsky method, or other methylene-blue-eosin staining, give
better staining of the parasite than can be obtained by hæmatoxylin
and eosin.
2. =Oïdium Albicans.= Staining with Weigert-Gram’s and
lithium-carmine gives beautiful preparations.
3. =Moulds.= These are best examined in the unstained condition,
by treating the material with equal parts of alcohol and ether,
followed by a 3 per cent potassium hydroxide solution. The
organisms and spores are brought out distinctly. Löffler’s
methylene-blue may be used for staining. In the case of sections
stain 1-2 hours and contrast with eosin. For the examination of
hairs or horny scales for fungi, _Unna’s method_ may be used:—
1. Add glacial acetic acid to hair or epidermis; make cover-glass
preparations, drying by heat.
2. Ether and alcohol equal parts.
3. Stain in borax 1 grm., methylene-blue 1 grm., water 100 cc.,
½-5 minutes.
4. Wash in water; dry; balsam.
If the horny elements are too deeply stained, decolorize in 1 per
cent acetic for 10 seconds, or in 1 per cent oxalic, citric, or
arsenious acid for 1 minute.
III. THE STAINING OF ANIMAL PARASITES.
1. =Amoeba Coli.= Examine fresh material from fæces, abscesses or
cultures, in physiologic saline solution, on a warm stage. Stain
under the cover with methylene-blue and carmine. Make permanent
mounts by removing excess of stain and running in 50 per cent
glycerin. In fixed preparations the nuclei of the amoebæ do not
stain with ordinary nuclear stains. _Mallory’s method_ may be used:—
1. Fix in alcohol.
2. Stain sections in a saturated aqueous solution of thionin 3-5
minutes.
3. Differentiate in a 2 per cent aqueous solution of oxalic acid
for ½-1 minute.
4. Wash in water; dehydrate in absolute alcohol; clear in xylol;
mount in xylol-balsam.
Nuclei of the amœbæ and granules of the mast-cells are
brownish-red; nuclei of cells blue.
2. =Trichomonas vaginalis and intestinalis=; =Cercomonas coli=;
=Megastoma entericum=; =Balantidium coli=; =Pyrosoma bigeminum=;
=Trypanosoma=; =Leishman-Donovan bodies=, and allied forms are
best stained with the modifications of Romanowsky’s stain; the
chromatin is red-violet (macro-nucleus red, micro-nucleus black,
flagellum red, protoplasm blue, basophilic granules black). For
staining in sections mercuric chloride or Zenker’s fixation
followed by staining with polychrome methylene-blue, Giemsa’s or
the modifications of the Romanowsky method may be employed.
3. =Plasmodium Malariae.= For films make medium smears (not too
thin); fix with equal parts of absolute alcohol and ether for ½-1
hour; or fix and stain in the same solution (Leishman-Romanowsky,
Wright’s stain, etc.). For single staining methylene-blue,
carbol-thionin, etc., may be employed; for double staining
eosin and methylene-blue. Ehrlich’s tri-acid, or any of the
eosin-methylene-blue combinations may be used (particularly the
Leishman-Romanowsky or Wright’s). With the Romanowsky methods the
body of malarial organism is stained blue, the chromatin varying
shades of lilac, red, purplish-red or almost black. When the blood
contains but few parasites 1 cc. may be drawn, mixed with 20 cc.
of distilled water and centrifugated. Smears are then made of the
sediment. For the staining of the plasmodium in imbedded tissues
the following method is recommended by _Bignami_. The tissue should
be fixed in formol or mercuric chloride, preferably a mixture of
mercuric chloride 1 grm., sodium chloride 0.75 grm., acetic acid
0.75 grm., water 200 cc. Fix for 2 hours; after-harden in alcohol
and iodine-alcohol, changing the alcohol each day for seven days.
Dehydrate in absolute alcohol, and imbed in celloidin or paraffin.
Stain in a saturated watery solution of magenta or in a mixture
of equal parts of saturated alcoholic mixtures of magenta and
orange G. Good results may, however, be obtained with Löffler’s
methylene-blue. Clear in xylol; mount in balsam.
4. =Coccidia and Sarcosporidia.= The ordinary fixations give good
results. Imbed in paraffin or celloidin. Weigert’s iron-hæmatoxylin
and Van Gieson’s give as good pictures as any of the special
methods advised.
5. =Negri Bodies of Rabies.= Examine in smears or make sections.
Take portions of gray brain-substance from the cortex in the
region of the fissure of Rolando (in the dog from around the
crucial sulcus), from the hippocampus, and from the cerebellum.
Smear cover or slide by taking a thin slice of the gray matter
and compressing it between two slides, or cover and slide, or by
drawing the cover across the cut surface in order to get some
of the cells. Dry in the air; stain with watery methylene-blue;
wash; stain with watery acid fuchsin; wash in water; blot dry;
mount in balsam. Negri bodies fuchsin-red (about size of red
blood cells); everything else blue. When dried in the air and
then fixed in methyl alcohol for 5 minutes the smears may be
stained by Giemsa’s method. For the demonstration of the bodies
in sections fix in Zenker’s, imbed in paraffin, and stain by the
eosin-methylene-blue method. The bodies take the eosin stain.
Formol fixation, freezing-microtome and Romanowsky stain give
quick results. _Mann’s method_ for the staining of Negri bodies in
sections is strongly recommended by many workers. Fix material in
mercuric chloride or Mann’s fluid (1 grm. picric acid and 2 grms.
tannin dissolved in 100 cc. concentrated water solution of mercuric
chloride) for 24 hours; wash thoroughly in running water; imbed in
paraffin. Stain in Mann’s mixture (1 per cent aqueous methyl-blue
[not methylene-blue] 35 parts, 1 per cent aqueous eosin 35 parts)
for 24 hours; wash in water; rinse in absolute alcohol; place in
alkaline alcohol (absolute alcohol 50 cc., 4 drops of a 1 per cent
solution of sodium hydroxide) for 15-20 seconds until sections
become reddish; wash quickly in alcohol; wash about 2 minutes in
water until superfluous color is removed; place in weak acidulated
water (acetic acid) 1-2 minutes until sections are blue; quick
dehydration in alcohol; xylol; balsam. Cells are blue, nucleoli and
blood-vessels red; Negri bodies bright red. For quick diagnosis use
acetone fixation and imbedding, stain in Mann’s fluid 2-4 minutes,
and proceed as in the Mann’s method. While these bodies possess
a great diagnostic importance for rabies, their exact nature
must still be regarded as unsettled; they are most probably not
parasites.
6. =Vaccine Bodies.= Fix in Flemming’s, mercuric chloride or
Zenker’s; imbed in celloidin or paraffin. Stain with Heidenhain’s
iron-hæmatoxylin (bodies black) or Biondi-Heidenhain mixture
(bodies blue, nuclei of leukocytes and mitoses green, nuclei
of epithelium and connective-tissue blue, protoplasm and
connective-tissue red). These bodies are probably not parasites,
but may be products of cell-degeneration.
7. =Vermes.= The _heads_, _proglottides_ and _ova_ are best
examined in the fresh state, in physiologic saline or glycerin.
Acetic acid may be used to bring out details. Berlin-blue or
methylene-blue may be injected through the genital pore for the
demonstration of the excretory and genital organs. _Scolices_
and _hooklets_ of _echinococcus_ may be obtained by scraping
the cyst-wall; examine in glycerin. Permanent preparations of
_cestodes_, _nematodes_ and _trematodes_ may be made by fixing
in mercuric chloride, formol or Flemming’s, after-hardening in
alcohol, staining in orange G, borax carmine, alum hæmatoxylin,
hæmatoxylin and eosin etc., mounting in glycerin gelatin; or
dehydrating, clearing in xylol and mounting in balsam. For sections
imbed in paraffin or celloidin. _Trichinæ_ may be studied by
teasing the fresh muscle; by digesting with pepsin and hydrochloric
acid and examining the freed trichinæ on a warm stage; or by
imbedding in paraffin or celloidin and staining with hæmatoxylin
and eosin. Permanent mounts of the embryos of _filaria_ may be
made by fixing cover-glass preparations of blood or chylous fluid
by heat or mercuric chloride, and staining for a few seconds with
Löffler’s or a 2 per cent aqueous thionin.
CHAPTER XXVIII.
THE STAINING OF SPECIAL ORGANS AND TISSUES.
I. BLOOD AND BLOOD-FORMING ORGANS.
The =blood= may be examined by means of _films_, _stained_ or
_unstained_, or by _sections_, _celloidin_ or _paraffin_.
_A. FILMS._ The blood may be obtained from the pulp of the ring
finger, from the skin over the knuckles, or from the posterior aspect
of the lobe of the ear. The place selected should be carefully
cleansed with water, soap and 1/1000 mercuric chloride solution, and
finally with alcohol and ether. A puncture is made with a sterilized
triangular needle or knife, or a stub-pen with one point broken
off. The last-named makes a most useful and inexpensive instrument
for this purpose. The puncture should be made by a quick and deep
stab, so that sufficient blood can be obtained from one stab-wound.
Pressure should not be employed to force blood from the wound.
Bleeding may be encouraged by letting the arm hang down, or by
applying pressure in the furrow of the terminal joint of the finger.
The first drop of blood should be wiped away with a clean towel.
When the second drop reaches the size of a pin-head touch it with
the under side of a perfectly clean cover-glass, held by forceps,
not by the fingers; place this cover-glass immediately upon another
clean cover, so that the blood will spread out between the two covers
in a thin film. The covers are then separated by sliding them apart
without pressing or squeezing; place covers with film side upward,
and dry in the air. The films should not be touched with the hands;
forceps alone should be used to handle them. If the blood does not
dry as quickly as it is spread the film will be too thick. Films
may be made upon slides in the same way, or the drop of blood may
be caught upon the edge of a clean cover, slide or “spreader” and
then drawn rapidly across a slide. The dried film may be marked
by scratching with a needle-point the number and date on the film
itself. Blood-films may be fixed _without drying_ by exposure to the
vapor of formol or osmic acid for several seconds and then dropping
into absolute alcohol. Formol alcohol, saturated mercuric chloride
solution or Flemming’s solution may also be used for the fixation of
wet films, fixing for 5-10 minutes, and washing thoroughly after
each of the last two solutions. The _dried film_ may be fixed by
exposure to heat (110-115°C.) for 5-10 minutes for Ehrlich’s triple
stain, and for 2 hours for the methylene-blue-eosin methods; 30-60
seconds at a temperature of 120°C. may suffice; the film should be
brought at once into the required temperature. Heat-fixed films are
improved by dipping them for a few minutes in mercuric chloride
solution and then washing well before staining. _Acetone-free methyl
alcohol_ (1-2 minutes), _absolute alcohol and ether in equal parts_
(½-12 hours), _formol-alcohol_ (1-2 minutes), _alcoholic mercuric
chloride_ (absolute alcohol 25 cc., ether 25 cc., 5 drops of a 2
grms. mercuric chloride solution in 10 cc. of absolute alcohol)
for 2-5 minutes, and _formol-vapor_ are the chief solutions used
for fixing the air-dried film. For ordinary work methyl alcohol,
formol alcohol, and the absolute-alcohol and ether mixture give good
results; heat fixation brings out the granules well, and mercuric
chloride is a good fixative for the leukocytes. The combination of
fixation and staining, as in Leishman’s or Wright’s modification of
the Romanowsky method, is also recommended for general work.
For the _staining of blood-films_ an almost endless variety of
staining-methods can be found in the literature. Many of these
represent slight deviations in the method of making the stain or in
its application, such deviations marking stages of improvement in the
development of the method. It is not necessary, therefore, to give
all of these methods, but to consider only the latest modifications
of value. In a general way _blood-stains_ may be divided into five
classes:—
1. =HAEMATOXYLIN AND EOSIN.=
Fix in equal parts of absolute alcohol and ether for at least
30 minutes; stain with hæmalum and eosin, or Ehrlich’s acid
hæmatoxylin and eosin. By adding O.5 grm. of eosin to the formula
for Ehrlich’s acid hæmatoxylin a combination stain can be made that
is very good for blood-films fixed by heat or absolute alcohol and
ether. Stain 2-24 hours, wash, dry and mount in xylol balsam.
2. =EOSIN AND METHYLENE-BLUE.=
Fix by formol (dried film over 40 per cent formol for 1 minute);
absolute alcohol for 1 minute; stain 5 minutes in a 1 per cent
watery eosin; then without removing eosin place in watery
methylene-blue for 2 minutes; wash quickly; dry in air; balsam.
3. =MIXTURES OF EOSIN AND METHYLENE-BLUE.=
The numerous mixtures of methylene-blue and eosin are not very
stable, can be kept for a few days only, and give varying results.
_Jenner_ improved this method of staining greatly by collecting the
precipitate formed by the addition of eosin to methylene-blue, and
dissolving it in pure methyl alcohol, thus giving a solution that
fixes and stains at the same time. The _May-Grünwald_ method is
practically the same.
Jenner’s Method.
a. Water-soluble eosin, 1.25 grms.
Distilled water, 100 cc.
b. Medicinal methylene-blue, 1 grm.
Distilled water, 100 cc.
Mix equal parts of _a_ and _b_ in an open basin, stirring with
a glass rod. Let stand for 24 hours; filter; dry the residue at
50°C. Wash residue thoroughly with distilled water and again dry
thoroughly. Take 0.5 grm. of the dried powder and dissolve in 100
cc. of pure methyl alcohol. Filter. Solution keeps well.
1. Make blood-film. Dry in air. Do not fix.
2. Cover film with stain, keeping under watch-glass to prevent
evaporation Stain 2 minutes.
3. Wash in distilled water until the film has a pink color. Dry
in air. Mount in xylol-balsam.
Neutrophile granules are red, eosinophile rose red, basophile
granules violet, red blood cells and central portion of
blood-platelets are terra-cotta, leukocyte nuclei and granules in
red blood cells are blue, protoplasm of nuclei and outer portion of
platelets light blue.
4. =MODIFICATIONS OF THE ROMANOWSKY METHOD.=
A large group of stains has resulted from various applications
of the Romanowsky idea of uniting equimolecular proportions of
methylene-blue and eosin, and the solution of the dyes so obtained
in some suitable solvent. These dyes consist of mixtures of
methylene violet, methylene azure, eosinate of methylene blue,
etc., and can be obtained from Grübler and Co. under various names,
such as _Azur-blau_, _Bleu Borrel_, _Giemsa’s stain_, _Leishman’s
stain_, etc. _Hastings_, _Leishman_, _Wright_ and others have
combined the Romanowsky method with that of Jenner by dissolving
the new dyes obtained by their various modifications in pure methyl
alcohol, so as to form a solution that will fix and stain at the
same time. _Hastings’ stain_ is a modification of _Nocht’s stain_;
_Wright’s stain_ is a modification of the _Leishman-Romanowsky_
method. The revised directions given by _Wright_ for making and
using his stain are here given. Wright’s method and the Giemsa
stain possess all of the staining advantages afforded by the
variations of the Romanowsky method, and are alone given here. The
former is recommended for blood-work, the latter for the staining
of protozoa.
Wright’s Blood-stain.
To a 0.5 per cent aqueous solution of sodium bicarbonate add
methylene-blue (B.X or medicinal) in the proportion of 1 grm. of
the dye to each 100 cc. of the solution. Heat the mixture in a
steam sterilizer at 100°C. for one full hour, counting the time
after the sterilizer has become thoroughly heated. The mixture
should be placed in a flask of such size and shape that the
fluid will not be more than 6 cm. deep. After heating, allow the
mixture to cool, placing the flask in cold water if desired, and
then filter it to remove the precipitate. When cold the fluid
should have a deep purple-red color when viewed in a thin layer by
transmitted yellowish artificial light. It does not show this color
while warm.
To each 100 cc. of the filtered mixture add 500 cc. of a 0.1 per
cent aqueous solution of yellow water-soluble eosin, and mix
thoroughly. Collect on a filter the abundant precipitate which
immediately appears. When the precipitate is dry, dissolve it in
pure methyl alcohol (Merck’s) in the proportion of 0.1 grm. to 60
cc. of the alcohol. To facilitate solution the precipitate is to be
rubbed up in a porcelain dish or mortar with a spatula or pestle.
This alcoholic solution is the staining solution. It should be
kept in a tightly-stoppered bottle. Should it become concentrated
through evaporation methyl alcohol in proper quantity should be
added.
1. Cover film with a given quantity of staining fluid by means of
a medicine dropper.
2. After 1 minute add to the staining fluid on the film the same
quantity of distilled water by means of the medicine dropper,
and allow the mixture to remain for 2-3 minutes according to the
intensity of the stain desired. A longer period of staining may
produce a precipitate. Eosinophile granules show best after short
staining. The quantity of diluted stain on the preparation should
not be so great that some of it runs off.
3. Wash the preparation in water for 30 seconds or until the
thinner portions of the film become yellow or pink in color.
4. Dry, and mount in balsam.
Films more than a few hours old do not stain as well as fresh ones.
The _red cells_ are orange or pink in color. Polychromatophilia
and punctate basophilia or granular degeneration are well shown.
Nucleated reds have deep-blue nuclei, and their cytoplasm is
usually bluish. The _lymphocytes_ have dark purplish-blue nuclei
and cytoplasm of a robin’s-egg blue, in which a few dark-blue
or purplish granules are sometimes present. The nuclei of the
_polynuclear neutrophilic leukocytes_ are dark-blue or dark
lilac-colored, the granules reddish-lilac. The _eosinophiles_ have
blue or dark lilac nuclei, a blue cytoplasm and eosin-red granules.
The _large mononuclear leukocytes_ have a dark lilac or blue
nucleus, cytoplasm pale blue or blue with dark-lilac or deep purple
granules. Mast-cells have purplish or dark-blue nuclei, bluish
protoplasm and coarse dark purple or black granules. _Myelocytes_
have dark blue or lilac nuclei, blue cytoplasm, and dark-lilac
or reddish-lilac granules. _Blood platelets_ are blue with small
violet or purplish granules in their central portions. _Malarial
parasites_ have a blue body and lilac or red chromatin. _Spirochæte
pallida_ is pale blue.
Giemsa’s Method.
_a_, One per cent water solution of azur-blau; _b_, one per cent
watery solution of eosin. For staining take 1 cc. of _b_, add 10
cc. of water, and then 1 cc. of the azur-blau solution. Stain 10
minutes to 1 hour.
Giemsa’s Old Method.
Azur II—Eosin 3.0 grm.
Azur II 0.8 grm.
Glycerin (Merck’s pure) 250.0 cc.
Methyl-alcohol (Kahlbaum I) 250.0 cc.
To 1 cc. of distilled water in a small, perfectly clean graduate
add 1 drop of the stain, shaking very gently. Make very thin
film; dry in air; fix 15-20 minutes in absolute alcohol. Cover
preparation with a thin layer of the freshly diluted stain for
10-15 minutes, renewing stain at end of 10 minutes. Wash in a
stream of water. Differentiate over-stained preparations in
distilled water. Dry with absorbent paper; mount in balsam. Stains
the _spirochæte pallida_ and _malarial organisms_. The Giemsa
solution may be obtained from Grübler. A more intense staining can
be obtained by adding to the water used for diluting the stain 1-2
drops of a 0.1 per cent solution of potassium carbonate.
5. SPECIAL ELECTIVE STAINS FOR THE BLOOD.
1. =Ehrlich’s Triple Stain.=
Saturated watery solution of Orange G 120 cc.
Saturated watery solution of acid fuchsin 80 cc.
Saturated watery solution of methyl green 100 cc.
Glycerin 50 cc.
Distilled water 300 cc.
Absolute alcohol 180 cc.
Mix gradually; allow to stand for several months; do not shake or
filter. Remove stain with pipette. Fix by heat, or pure methyl
alcohol for 5 minutes. Stain 5-10 minutes; wash thoroughly, dry
and mount in balsam. Neutrophile granules violet; eosinophile,
a bright red; nuclei of the neutrophilic and eosinophilic cells
greenish-blue; nuclei of the lymphocytes deep-blue; nuclei of the
large mononuclears pale blue; those of red cells intense blue; red
cells copper red. The Aronson-Philipp modification is more variable
and less satisfactory.
Pappenheim’s Stain for Lymphocytes.
3-4 parts of polychrome methylene-blue or methyl green to 1-2 parts
of pyronin. Fix in absolute alcohol. Nuclei blue-green; protoplasm
bright red.
Staining of Blood-platelets.
The blood-platelets may be examined in the fresh state by coating
a cover-slip with Deetjen’s agar-solution (boil 5 grms. agar-agar
in 500 cc. distilled water, filter hot, and to each 100 cc. of the
filtrate add 0.6 grm. sodium chloride, 6-8 cc. of a 10 per cent
solution of sodium phosphate and 5 cc. of a 10 per cent solution
of sodium diphosphate). Place drop of blood on this coating and
examine on warm stage. For permanent stained preparations bleed
into a fixing and staining fluid (equal parts alcohol and ether and
Romanowsky’s stain) or use Wright’s stain.
Bremer’s Diabetic Reaction.
Take a clean cover-glass, smear one-half with normal blood, the
other half with diabetic blood. Fix for 2 hours at 120°C., or in
equal parts of absolute alcohol and ether at 60°C. for 4 minutes.
Stain in a 10 per cent watery methylene-blue for 2 minutes, wash
off the stain in water, and stain for 10 seconds in a ⅛ per cent
watery eosin. Wash, dry and mount in balsam. In diabetic blood the
red cells are green; in normal blood red. While this reaction is
constant in diabetic blood it also occurs in leukæmia, Hodgkin’s
disease, exophthalmic goitre and multiple neuritis. A 1 per cent
solution of _Biebrich scarlet_ stains diabetic blood intensely,
normal blood but slightly. On the other hand, a _1 per cent
methylene-blue_ and a _1 per cent Congo red_ stain normal blood
intensely and diabetic blood slightly.
Staining of Glycogen in Leukocytes.
To a solution of Lugol’s (100:3:1) add sufficient gum arabic to
make a syrupy mixture. Keep tightly corked. Place a drop of this
solution upon an air-dried film. After 1 minute dry with blotting
paper. Examine with oil immersion. A positive reaction is shown
by the presence of a diffuse brown or reddish-brown coloration or
granules in the cell-body of the polymorphonuclear leukocytes.
Staining of Fat in Blood.
Stain in solutions of scharlach R or sudan III in 70 per cent
alcohol.
Staining of Blood-parasites.
The _malarial parasites_, _trypanosomes_, _Leishman-Donovan
bodies_, _sporidia_, _piroplasma bigeminum_, _spirilla_ and
_spirochætes_ and the _filaria_ may all be stained with Wright’s
or Giemsa’s modification of the Romanowsky method, or by any of
the modifications of this method. (See also Staining of Animal
Parasites.)
_B. SECTIONS._ The blood is allowed to drop directly into
Flemming’s solution and allowed to stand for 24 hours. It is then
washed in water by repeated decanting, or the coagulum may be
placed in a bottle covered with muslin, and then exposed to running
water. It is after-hardened in alcohol and imbedded in paraffin.
Safranin should be used to stain the sections. This method is
especially good for the demonstration of mitoses in the blood-cells.
Bone-marrow.
Prepare films and fix and stain, as for blood films. For sections,
fix the marrow in formol-Müller’s, mercuric chloride, Zenker’s,
etc.; imbed in paraffin; cut very thin sections; stain with
Ehrlich’s triple stain or Wright’s modification of Leishman’s
stain. To distinguish the young forms of erythrocytes and
leukocytes _Trambusi_ fixes in Flemming’s, stains the sections
in a 1 per cent thionin solution in aniline-water (4:100),
differentiates in acid-alcohol, and then brings the sections into
a watery eosin and finally an alcoholic eosin, and mounts in
xylol-balsam.
Spleen and Lymphnodes.
Fresh material may be obtained by means of a trocar, and may be
examined in the fresh state, or films may be prepared, fixed
and stained, as for blood-smears. Sections of fixed tissues may
be obtained by the use of the same fixing and staining methods
employed in the study of the blood or bone-marrow. For the study
of the reticulum Mallory’s reticulum stain or the digestion-method
may be used. In ordinary work formol-fixation followed by
eosin-staining is of great value in distinguishing hæmolymphnodes
and lymphatic glands.
II. BONE.
For ordinary work decalcification is necessary except for those
pathologic conditions in which the lime-salts have been lost (see
Chapter XXI). Imbed in celloidin preferably. When decalcification
has been carried out place sections in an alkaline solution before
staining, and stain for a longer period than usual. Methylene-blue
and eosin stain osteoblasts and osteoclasts very well. Van
Gieson’s is an especially useful stain for ordinary work; osteoid
tissue is red, calcified areas yellow. Sections of bone without
decalcification can be prepared by fixing, hardening and staining
in bulk; the bone is then sawn in the dried condition, and the
sections ground down to the required thickness. _Schmorl’s_ methods
for the preparation of bone-sections have practically superseded
all other staining methods.
Schmorl’s Thionin-picric-acid Method.
1. Fix in formol or formol-Müller’s preferably.
2. Decalcify in formol-nitric acid or Ebner’s alcoholic HCl acid
solution.
3. Wash thoroughly in water. After-harden in increasing strengths
of alcohol; freeze or imbed in celloidin (not paraffin); cut.
4. Transfer sections to water for 10 minutes.
5. Stain sections, well spread out, for 5-10 minutes in a
solution of 2 cc. of a saturated solution of thionin in 50 per
cent alcohol and 10 cc. of water, to which 1-2 drops of ammonia
are added.
6. Wash in water.
7. Stain ½-1 minute in hot saturated and cold filtered
watery-solution of picric acid.
8. Wash in water.
9. Differentiate in 70 per cent alcohol until the color ceases to
come away in blue-green clouds, 5-10 minutes or more.
10. Dehydrate in 96 per cent alcohol.
11. Clear in phenol xylol; xylol; balsam.
Lacunæ and canaliculi dark brown to black; bone cells red;
ground substance yellow or brownish yellow. Calcified areas take
a darker yellow than non-calcified. This method consists in an
impregnation with a fine precipitate rather than a staining. Should
the precipitate be too heavy in portions of the section it may be
removed by thorough washing between 9 and 10.
Schmorl’s Thionin and Phosphotungstic or Phosphomolybdic Acid
Method.
1. Fix thin pieces of fresh bone in formol, then in Müller’s for
6-8 weeks, or 3-4 weeks in the incubator. Fixation is best at
37°C.
2. Decalcify in Ebner’s hydrochloric acid solution. Wash
thoroughly. After-harden in alcohol. Imbed in celloidin or
paraffin. Cut very thin sections.
3. Water for 10 minutes.
4. Stain in the alkaline-thionin solution, as in previous method,
for 3 minutes.
5. Wash in water.
6. With glass needles transfer sections to a saturated watery
solution of phosphotungstic or phosphomolybdic acid for a few
seconds.
7. Wash 5-10 minutes, until section is sky-blue in color.
8. Fix the stain for 3-5 minutes in ammonia 1 part, water 10
parts.
9. Transfer directly to 90 per cent alcohol; change twice.
10. Dehydrate; clear in carbol-xylol; balsam.
If the ground-substance is too dark differentiate in acid alcohol
before dehydrating, and then wash thoroughly before beginning the
dehydration.
Outlines of lacunæ and canaliculi are dark blue; ground-substance a
light or greenish blue; cellular elements a diffuse blue. Schmorl
advises this method for growing bone; in rickets the well-ossified
areas alone stain well. Both of the Schmorl methods can be used for
the study of =teeth= as well.
Staining of Sharpey’s Fibres (v. Kölliker).
1. Harden, decalcify, imbed, cut.
2. Place section in strong acetic acid until it becomes
transparent.
3. Stain in a saturated watery solution of indigo carmine for
15-16 seconds.
4. Wash in water; mount in glycerin.
Fibres red; ground-substance blue.
III. CARTILAGE.
Cartilage stains deeply with hæmatoxylin; with Weigert’s fibrin
stain it holds the blue; with thionin and polychrome methylene-blue
stains for mucin cartilage stains metachromatically red.
IV. CONNECTIVE TISSUES.
_a._ =Connective-tissue Fibrils.= The demonstration of
connective-tissue fibrillæ or reticulum is of great importance in
the differential diagnosis of sarcoma and carcinoma. _Van Gieson’s_
method is the best stain for the coarser fibrils, but does not
bring out the finer reticulum as well as Mallory’s aniline-blue
method.
1. =Mallory’s Reticulum Stain.=
1. Fix in mercuric chloride or Zenker’s. After-harden in alcohol;
imbed in celloidin or paraffin; cut.
2. Stain in 1/10 aqueous acid fuchsin 5-10 minutes.
3. Transfer directly to the following solution and stain for 20
minutes or longer:—
Aniline-blue, water-soluble (Grübler) 0.5 grm.
Orange G (Grübler) 2.0 grms.
1 per cent aqueous solution of phosphomolybdic acid 100 cc.
4. Wash and dehydrate in several changes of 95 per cent alcohol;
dry with absorbent paper.
5. Clear in xylol or origanum oil.
6. Mount in balsam.
Fibrils and reticulum of connective tissue, amyloid, mucin
and connective-tissue hyalin are blue; nuclei, protoplasm,
fibroglia fibres, axis cylinders, neuroglia fibres and fibrin
are red; elastic fibres are pink or yellow; red blood-cells and
myelin-sheaths are yellow.
2. =Mall’s Method for Reticulum.=
1. Digest frozen sections of fresh tissue for 24 hours in a
solution of Parke, Davis and Co.’s pancreatin 5 grms., soda
bicarbonate 10 grms., water 100 cc.
2. Wash carefully in water.
3. Place section in test-tube half-full of water and shake
thoroughly to remove cells.
4. Spread out on slide and allow to dry.
5. Allow a few drops of the following solution to dry on
slide:—picric acid 10 grms., absolute alcohol 33 cc., water 300
cc.
6. Stain for 30 minutes in the following mixture: acid fuchsin 10
grms., absolute alcohol 33 cc., water 66 cc.
7. Wash in the picric acid solution for a second.
8. Dehydrate in absolute alcohol; xylol; balsam.
3. =Unna’s Method for Collagen.=
1. Harden in absolute alcohol; imbed; cut.
2. Stain 5-15 minutes in polychrome methylene-blue.
3. Wash in water.
4. Differentiate in 1 per cent neutral orcein in absolute
alcohol, 15 minutes.
5. Dehydrate in absolute alcohol.
6. Clear in xylol; mount in balsam.
Nuclei dark blue; protoplasm light blue; collagen dark red;
plasma-cell granules greenish-blue; mast-cell granules red.
4. =Mallory’s Fibroglia Method.=
1. Fix thin, small, fresh pieces of tissue in Zenker’s fluid;
harden in alcohol; imbed in celloidin or paraffin; cut.
2. Stain sections in 1 per cent aqueous acid fuchsin for 12 hours
in the cold, or 20-30 minutes at 50-56°C.
3. Wash in water for 5 seconds.
4. Differentiate in 0.25 per cent aqueous potassium permanganate
solution 10-20 seconds.
5. Wash in water for 5 seconds.
6. Dehydrate in alcohol; clear in xylol or origanum; mount in
balsam.
Fibroglia fibrils and cell-nuclei intensely red; contractile
elements of striped muscle, smooth muscle, neuroglia fibres,
cuticular surfaces of epithelial cells and fibrin are also red;
connective-tissue fibres brownish-yellow or colorless; elastic
fibres, unless degenerated, bright yellow.
_b._ =Elastic Fibres.= Weigert’s method is so superior to the Unna
orcein-stain that it alone is given here. It is our best elective
stain: gives permanent preparations, and is in every way practical.
The stain keeps well.
Weigert’s Method for Staining Elastic Fibres.
_Preparation._ Boil in a porcelain dish resorcin 4 grms., fuchsin
(Grübler) 2 grms., and water 200 cc. After the mixture has
boiled a few seconds add 25 cc. of liquor-ferri sesquichlor.,
Pharm. Germ. III. Stir well and boil for 5 minutes. When cool,
filter. Carefully loosen the filter from the funnel, transfer it
to the same porcelain dish which still contains a small amount
of sediment, and add 200 cc. of 94 per cent alcohol. Boil and
stir carefully. Remove the filter-paper when all the sediment is
dissolved. Cool, filter; make up the filtrate to 200 cc. with 94
per cent alcohol, and to these 200 cc. add 8 cc. of hydrochloric
acid. Resorcin-fuchsin may be obtained from Grübler, but the
freshly-prepared stain gives better results.
1. Fix in any ordinary solution; imbed; cut.
2. Stain with lithium-carmine and differentiate in acid alcohol;
wash thoroughly.
3. Stain in the resorcin-fuchsin mixture for 20-60 minutes.
4. Wash rapidly in acid alcohol.
5. Dehydrate and differentiate in absolute alcohol until section
is red.
6. Clear in xylol; balsam.
Nuclei are red; elastic fibres blue-black. Should the stain when
old give a diffuse staining differentiate for a longer time in acid
alcohol.
_c._ =Fat Tissue.= Use same methods as advised for the
demonstration of fatty degeneration and infiltration (osmic acid,
scharlach R, sudan III).
V. EAR.
Remove temporal bone; fix in formol-Müller’s; decalcify in
trichloracetic acid; wash; after-harden in alcohol; imbed in
celloidin. For nerve-endings use Golgi’s and methylene-blue methods.
VI. EYE.
Fix in Müller’s, formol-Müller’s, Zenker’s, formol, Flemming’s
or Marchi’s solution. Aid fixation by incisions into sclera. The
eye should not be left in formol for more than 3 days. Section as
desired; imbed larger pieces in celloidin, small ones in paraffin.
Use alum-carmine, iron-hæmatoxylin, Van Gieson’s, Weigert’s
elastic stain, Levaditi’s silver-method, Golgi’s nerve-stain,
methylene-blue method, etc., according to the object of the
investigation.
VII. LIVER.
For the demonstration of the bile-capillaries _Weigert’s neuroglia
method_ gives the best results. (See Page 300.) This method may be
used with sections cut on the freezing-microtome after fixation
in formol. Such sections are placed in a ½ per cent solution of
chromic acid for 1 hour, transferred to the neuroglia mordant for
5-6 hours, washed well with water, and then treated as for the
neuroglia method. Van Gieson’s method may also be used for frozen
sections of formol-fixed tissue. The walls of the capillaries show
as fuchsin-colored streaks.
VIII. MUSCLE.
Van Gieson’s is the best general stain for both striped and
unstriped muscle, as it differentiates the muscle perfectly from
the connective-tissue. Mallory’s reticulum stain may also be
used for the same purpose. For the study of myoglia fibrils the
tissue must be fixed within a few minutes after its removal from
the living body. Autopsy material cannot be used. These fibrils
can be demonstrated by Mallory’s fibroglia stain, or by Mallory’s
phosphotungstic-acid hæmatoxylin stain for neuroglia. (See below.)
IX. NERVOUS SYSTEM.
It is impossible in a book on general pathologic technic to consider
all of the numerous staining methods that have been devised for
the study of the nervous system. I have attempted, therefore, to
pick out the best selective methods for the staining of the more
important nervous structures, so as to cover adequately the general
held of nervous pathology. Formol has now replaced Müller’s for the
preliminary fixation of nervous tissue, because of its quick action,
and because after its use chromic acid may be employed to mordant the
tissue, when it is desired to use certain staining methods requiring
such mordanting. _Celloidin imbedding_ is preferable, although
paraffin may be used for general work. _General stains_, such as
_hæmatoxylin and eosin_, and _Van Gieson’s_ are used for general
impressions.
1. =METHODS FOR STAINING GANGLION CELLS.=
A. Lenhossék’s Method.
1. Fix in equal parts of saturated watery picric acid and
mercuric chloride (Rabl’s mixture); after-harden in absolute
alcohol; imbed in paraffin; cut.
2. Stain in saturated watery solution of toluidin blue, or
thionin blue, for 12 hours.
3. Wash rapidly in water.
4. Differentiate carefully in absolute alcohol, or in
aniline-alcohol (1-10).
5. Carbol xylol; xylol (quickly); balsam.
Nissl’s granules are blue. This method is easy, and the best for
general work.
B. Nissl’s Method.
1. Fix in 96 per cent alcohol for 2-5 days; mount tissue in
gum arabic on block; harden in 96 per cent alcohol; cut; place
sections in 96 per cent alcohol.
2. Stain in methylene-blue soap mixture (methylene-blue B 3.75
grms., Venetian soap shavings 1.75 grms., water 1,000 cc. Shake
well. Keep 3 months before using. Shake and filter before
using.), warming, until bubbles arise.
3. Differentiate in aniline alcohol (aniline oil 10 parts, 96 per
cent alcohol 90 parts) very rapidly.
4. Arrange section on slide; dry with blotting-paper; cover with
cajuput oil.
5. Blot; wash off oil with benzene.
6. Remove benzene; mount the wet section in xylol colophonium,
slightly warming; press on cover, and remove excess of
colophonium.
Nuclei of ganglion cells light blue: granules dark blue. Toluidin
blue, thionin, dahlia, Bismarck brown or neutral red may be used
instead of methylene-blue, and often give better results.
2. METHODS FOR STAINING MYELIN SHEATHS.
A. Weigert’s Method.
1. Fix in formol 2-3 days.
2. Primary mordant (potassium bichromate 5 grms., fluorchrom 2.5
grms., water 100 cc.: boil and filter) 4-6 days.
3. Without washing after-harden in graded alcohols, in the dark.
4. Imbed in celloidin.
5. Secondary mordant (neutral copper acetate 5 grms., fluorchrom
2.5 grms., water 100 cc., boil and add 36 per cent acetic 5 cc.)
for 1 day at 37°C.
6. Transfer to 70-80 per cent alcohol.
7. Cut.
8. Stain in Weigert’s iron-hæmatoxylin, 24 hours.
9. Wash in water, 30 minutes or longer.
10. Differentiate in borax-potassium ferricyanide (potassium
ferricyanide 2.5 grms., borax 2 grms., water 100 cc.) until the
gray substance appears yellow to white. Control under microscope.
11. Wash thoroughly in water.
12. Dehydrate in absolute alcohol; clear in xylol; mount in
balsam.
Myelinated fibres, blue-black, upon a colorless or light yellow
background; red blood cells may be blue-black. Weigert’s method is
better than any of the numerous modifications.
B. Orr’s Osmic-Acid Method.
1. Place fresh tissue from cerebral cortex or cord, not more than
⅛ inch in thickness, in 1 per cent acetic, 2 cc., and 2 per cent
osmic acid 8 cc., for 48 hours. If mixture is darkened at end of
24 hours, renew.
2. Transfer to 10 per cent formol for 3 days, in order to
complete reduction and hardening.
3. Imbed in celloidin or paraffin; cut.
4. Remove paraffin; alcohol; water; differentiate in ⅛-1/12 per
cent potassium permanganate.
5. Transfer to a 1 per cent oxalic acid solution, until sections
become yellowish-green.
6. Wash; dehydrate; xylol; balsam.
Nerves and fat black: tissue yellowish-green. A very reliable
method.
3. STAINING OF AXIS CYLINDERS.
Stain with Van Gieson’s (red), Mallory’s aniline blue method (red),
lithium carmine (red), or
Williamson’s Modification of Bielschowsky’s Method.
1. Fix in Müller’s; imbed; cut.
2. Place sections in 10 cc. of tap water containing a few drops
of formalin, 5 minutes.
3. Wash in water.
4. Place in the following silver bath 5-10 minutes: 3 drops of
liq. ammoniæ (B.P.) are dropped into a test tube. Add 10 per
cent silver nitrate solution, drop by drop, until a brownish
precipitate is formed. Dissolve the latter by adding ammonia,
drop by drop, until the fluid is quite clear. Add tap water up to
10 cc.
5. Wash thoroughly in water.
6. Transfer to the dilute formol solution until sections become
grayish-black (1-3 minutes).
7. Place in the following solution for a few minutes: To 10 cc.
of water add 2 drops of 1 per cent watery solution of chloride of
gold, a few drops of saturated borax solution, and a few drops of
a 10 per cent solution of potassium carbonate.
8. Transfer to a 10 per cent aqueous solution of sodium
hyposulphite for a few minutes.
9. Wash in water; dehydrate in alcohol; clear in oil of cajuput;
xylol; balsam.
Axis-cylinders, intracellular fibrils and Golgi’s network are
stained.
4. =STAINING OF NEURO-FIBRILLAR STRUCTURES.=
These are stained by Bielschowsky’s method, and by acid fuchsin
after fixation with osmic acid. The special methods (Apathy’s
gold method, Bethe’s molybdic method, the silver methods of
Ramen y Cajal and Robertson) have little practical application
in pathologic work, and are used chiefly in the study of normal
histology.
5. =THE STAINING OF NEUROGLIA.=
A. Weigert’s Method.
1. Fix small pieces of fresh tissue in 10 per cent formol for 24
hours.
2. Mordant. 8 days at room temperature (4 days at 37°C.) in
copper acetate 5 grms., fluorchrom 2.5 grms., acetic acid 5 cc.,
water 100 cc.
Or, harden and mordant at the same time in 9 parts of the copper
mordant, and 1 part of commercial formol for 8 days, changing on
the second day, and once again later.
3. Wash in water: after-harden in alcohol; imbed in celloidin;
cut.
4. Place sections in ⅓ per cent aqueous solution of potassium
permanganate.
5. Wash in two changes of water.
6. Place in the following reducing mixture, 2-4 hours: Chromogen
5 grms., formic acid (sp. gr. 1.2) 5 cc., water 100 cc.; filter;
to 90 cc. add 10 cc. of 10 per cent sodium sulphite solution just
before using.
7. Wash twice in water.
8. Place sections in 5 per cent carefully filtered aqueous
chromogen solution 10-12 hours. (The glia fibres become darker,
and a yellowish contrast is obtained for the ganglion and
ependymal cells and thicker axis cylinders. Connective-tissue is
stained red.)
9. Wash in water.
10. Place section on a slide freshly cleaned with alcohol; dry
with filter paper; stain in the following mixture for about 30
seconds: Saturated solution of methyl violet in 70-80 per cent
alcohol 100 cc., oxalic acid 5 per cent solution, 5 cc.
11. Remove excess of stain; dry with filter paper; cover slide
with saturated solution of iodine in 5 per cent potassium-iodide
solution, 30 seconds.
12. Remove iodine solution; dry with filter paper; differentiate
in a mixture of equal parts aniline oil and xylol until no more
heavy clouds of stain are given off. Control under microscope.
13. Dry section with filter-paper; add xylol; blot; repeat three
times.
14. Mount in balsam or turpentine colophonium.
Neuroglia fibres and nuclei, blue; connective-tissue, blue-violet;
thicker myelin sheaths, ganglion and ependymal cells, yellowish.
This is the best method, none of the modifications giving as good
results. No method, however, will stain every neuroglia-fibre.
B. Mallory’s Neuroglia Method.
1. Fix small pieces in 10 per cent formol, 4 days.
2. After-harden in saturated watery picric solution 4-8 days:
or combine 1 and 2 by using formol 10 cc. with 90 cc. saturated
picric acid solution.
3. Place in a 5 per cent aqueous solution of ammonium bichromate,
4-7 days at 37°C., changing solution 011 second day; or 3-4 weeks
at room-temperature.
4. Without washing, harden in alcohol; imbed in celloidin or
paraffin; cut.
5. Place sections in ¼ per cent aqueous solution of potassium
permanganate, 15-30 minutes.
6. Wash in water.
7. Immerse in 5 per cent aqueous oxalic acid, 5-30 minutes.
8. Wash in several changes of water.
9. Stain in following solution, 1-several days: Hæmatoxylin 0.1
grm., 10 per cent phosphotungstic acid 20 cc., hydrogen peroxide
0.2 cc., water 80 cc.
10. Wash rapidly in water.
11. Differentiate in freshly prepared 30 per cent alcoholic
solution of ferric chloride, 5-20 minutes.
12. Wash in water.
13. Dehydrate in 95 per cent and absolute alcohol or blot with
xylol.
14. Clear in xylol; balsam.
When Zenker’s fixation is used, omit 2 and 3, and after cutting
sections treat with Lugol’s to remove mercury and then with 95 per
cent alcohol to wash out iodine; then wash in water and proceed
with 5.
Neuroglia, nuclei and fibrin, dark-blue; all else is pale yellow or
gray. If the differentiation in 11 is omitted, the axis-cylinders
and ganglion-cells are rose-pink; the connective-tissues, dark
red-pink.
6. =COMBINED STAINING OF SEVERAL NERVOUS STRUCTURES.=
Various methods of impregnation with silver, gold or lead are used
in histologic work, the Golgi methods and their modifications in
particular. They have but little application in pathologic work,
and for that reason are omitted here, as is also a consideration of
Ehrlich’s vital methylene-blue method and its modifications. Full
details of these methods can be found in laboratory textbooks on
histology.
7. =METHODS FOR THE DEMONSTRATION OF NERVE-DEGENERATION.=
A. Marchi’s Method.
1. Harden small fresh pieces of tissue in Müller’s fluid for at
least 8 days. Handle tissue very carefully to prevent mechanical
injury. The tissue may be placed first in formol, and then later
transferred to Müller’s fluid.
2. Place in freshly prepared Marchi’s fluid (Müller’s fluid 2
parts, 1 per cent osmic acid solution 1 part) for about 8 days in
the incubator at 37°C. The brain requires a longer time. When the
mixture loses the osmic acid smell renew it.
3. Wash in running water, 24 hours.
4. Harden in graded alcohols.
5. Imbed in celloidin; cut; dehydrate; clear; mount.
Degenerated nervous tissue (fat) is black: all else brownish gray.
Contrast stain in Van Gieson’s, lithium carmine, etc. This method
is good for the demonstration of early degenerations.
B. Donaggio’s Methods for Early Degeneration.
Method I—
1. Fix in Müller’s fluid or in 4 per cent potassium-bichromate
solution. The tissue may remain in the fluid for any length of
time.
2. Transfer directly, without washing, to alcohol. Dehydrate;
imbed in celloidin; cut sections 20-30 microns. Place sections in
distilled water for a few seconds.
3. Transfer to the following mixture for 10-20 minutes: To 20 per
cent solution of ammoniated chloride of tin add an equal amount
of 1 per cent aqueous hæmatoxylin. Allow to stand for five days.
Keep in the dark, and in a cool place.
4. Wash rapidly in distilled water.
5. Differentiate in Pal’s solution (oxalic acid 0.5 grm.,
potassium sulphite 0.5 grm., water 100 cc.) until the normal
fibres are entirely decolorized.
6. Dehydrate; xylol; neutral balsam.
Degenerated fibres blue; normal, decolorized.
Method II—
1. Fix in Müller’s fluid: imbed as in Method I.
2. Place sections in 0.5-1 per cent aqueous hæmatoxylin solution,
10-20 minutes.
3. Transfer directly to a saturated aqueous solution of neutral
acetate of copper, 30 minutes. Renew copper solution once.
4. Decolorize as in Method I.
5. Wash rapidly in distilled water.
6. Dehydrate in graded alcohols; xylol; balsam.
Degenerated fibres black; normal fibres unstained, except for a
narrow circle at periphery.
Method III—
1. Fix and imbed as in Method I.
2. Stain in 0.5-1 per cent aqueous hæmaloxylin solution, 10-20
minutes.
3. Transfer directly to 10-20 per cent solution of perchloride of
iron. The section becomes black. After a few seconds they lose
their color. If washed in water, they regain their color.
4. Without washing, differentiate in acid alcohol (0.75 cc. HCl
in 100 cc. alcohol).
5. Dehydrate in absolute alcohol; xylol; balsam.
Degenerated fibres appear as small black streaks or circular areas.
C. Staining of Fat-granule Cells.
Fix in Flemming’s or Marchi’s mixtures; or in formol, staining with
sudan III or scharlach R. The tissues may be examined also in the
fresh condition.
D. Old Degenerations.
Use Weigert’s myelin method to show absence of myelinated fibres.
Van Gieson’s method stains the neuroglia of degenerated areas a
deep red; it is very useful combined with Weigert’s myelin stain.
Weigert’s neuroglia stain may be used to demonstrate the relative
parts played by neuroglia and connective-tissue in the formation
of sclerotic patches. When Weigert’s iron-hæmatoxylin is used
with Van Gieson’s the neuroglia remains unstained, while the
connective-tissue stains red. With other hæmatoxylins the neuroglia
cannot be sharply differentiated from connective-tissue when
stained with Van Gieson’s.
8. =PERIPHERAL NERVES.=
Use any of the above methods for the staining of myelin sheaths,
ganglion cells, axis cylinders, etc. Van Gieson’s is good for the
demonstration of connective-tissue increase. For the demonstration
of peripheral fibrils and nerve-endings consult textbooks on
histology for Golgi methods, Ehrlich’s vital methylene-blue method,
and the modifications of May, Drasch, and others.
Platner’s Method.
1. Harden in 25 per cent solution of liq. ferri sesquichlor., 1-5
days.
2. Wash in water, until the addition of KCNS to the water yields
no reaction.
3. Place in 75 per cent alcohol containing an excess of
di-nitroresorcin, 2-30 days, according to the size of the piece
of tissue.
4. Dehydrate in absolute alcohol.
5. Imbed; cut; dehydrate; clear; mount.
Axis cylinders, emerald green. A good method for the rapid
demonstration of pathological processes connected with the
peripheral nerves.
9. =CHROMAFFINIC TISSUES.=
Wiesel’s Method.
1. Fix 1-4 days in 10 parts of a 5 per cent potassium bichromate
solution, 20 parts of 10 per cent formol, 20 parts distilled
water.
2. 1-2 days in 5 per cent potassium bichromate.
3. Wash thoroughly in running water, 24 hours; harden in graded
alcohols; imbed in paraffin.
4. Stain sections in a 1 per cent aqueous toluidin-blue or
water-blue solution.
5. 5 minutes in tap-water.
6. Stain 20 minutes in a 1 per cent watery safranin solution.
7. 96 per cent, and then absolute alcohol, until the blue color
appears.
8. Xylol; balsam.
Chromaffinic cells green; other cells light blue, nuclei red.
X. SKIN.
Skin should be fixed in formol-Müller’s or formol, and should
not be left too long in alcohol or xylol. Imbed in celloidin
preferably. For general use the ordinary stains suffice; for the
study of pigment stain with alum or lithium-carmine. Use Weigert’s
elastic-tissue stain for the demonstration of elastic fibrils.
The intercellular bridges may be demonstrated by Van Gieson’s
(remaining unstained), or by various special staining methods.
Herxheimer’s Method for Epithelial Fibrillae.
1. Harden; imbed; cut.
2. Stain in a saturated watery solution of kresyl-echt-violett.
3. Dehydrate in absolute alcohol; clear in clove oil; balsam.
CHAPTER XXIX.
MICROSCOPIC EXAMINATIONS FOR MEDICOLEGAL PURPOSES.
1. =BLOOD.= Fresh spots should be scraped off and examined in
physiologic salt solution. Older spots are scraped off when possible,
or if the spots are on clothing or other fabrics, a piece of the
stained portion is cut out, and the scraping or piece of material
is placed on a slide in a macerating fluid (30 per cent caustic
potash; glycerin 3 parts and concentrated sulphuric acid 1 part; 15
per cent tartaric acid; equal parts alcohol and ether; or Pacini’s
fluid [mercuric chloride 1 grm., sodium chloride 2.0 grm., glycerin
100 cc., water 300 cc.]). Even in very old clots or stains some red
cells may retain their characteristic form. The process of maceration
should be observed directly under the microscope, as the macerating
fluid gradually changes the cells after they become loosened.
_Schmorl_ advises the following method:—
Moisten a small piece of the fabric in water and stain with
hæmatoxylin. Differentiate in acid alcohol, wash thoroughly in water,
stain with 1/1000 watery eosin solution, wash in water (3-6 hours),
place in alcohol, and then again in water. Tease with great care
into fine threads on the slide, and examine the isolated fibres in a
drop of glycerin. The red corpuscles are easily recognized; and the
nuclei of the white cells or of the red cells of birds and amphibia
stand out distinctly. Permanent mounts may be made by passing the
specimen through alcohol, xylol, and mounting in balsam. A portion of
the stained fabric may be imbedded in celloidin, sections cut, and
stained with hæmatoxylin and eosin.
The =red cells= may be measured by the ocular micrometer. Those
of man are somewhat larger than those of other mammals, but the
difference in size is so slight that an absolute determination of
the source of the blood is not possible from the consideration of
size alone. Human corpuscles measure 0.0077 mm. in diameter; the
nearest in size are the corpuscles of the dog, rabbit, hog, cow,
horse, cat and sheep, in the order given, those of the sheep being
smaller. The measurements of a large number of corpuscles must be
taken if the question of size is to be considered. When red cells
cannot be found the stains must be tested for the presence of blood
=pigment= (_Teichmann’s hæmin crystals_). A small piece of the
scraping or stained fabric is placed upon a slide in glacial acetic
acid; the fluid is expressed; and a small crystal of sodium chloride
or sodium iodide is added to the fluid. Cover with cover-glass and
heat gently until bubbles are given off, and continue carefully
until the acetic acid has evaporated. The slower the evaporation
the larger the crystals will be. Examine with a ⅙ inch or No. 7
objective. The hæmin crystals are brown or claret-colored, of the
shape of rhombic plates single or superimposed. They are insoluble
in water, alcohol and ether; dissolve slowly in ammonia, dilute
sulphuric and nitric acids, and easily in caustic potash. The form of
the crystal and the color determines the diagnosis of the presence
of blood, but does not distinguish between human and animal blood.
Old stains should be treated with acetic acid 12-24 hours before
attempting to obtain the crystals. Contamination of the fabric with
fat interferes with the reaction; the fat should be removed first
with ether. If the suspected stain occurs on iron, steel, sand, clay
or coal, the crystals usually cannot be obtained. Decomposition may
also interfere with the reaction. In such cases a solution of the
stain in a saturated solution of borax should be made and submitted
to spectroscopic examination. The presence of blood-pigment on any
substance can be demonstrated by means of the =spectroscope= or
=microspectroscope=. Within recent years the =biologic= test for
blood and albumins has been turned to medicolegal uses, in the
differential diagnosis of human and animal blood or albumins. This
test rests upon the principle that in the serum of an animal treated
with human blood or albumin there are developed antibodies having a
strong specific hæmolytic or precipitating action upon human blood or
albumin.
2. =Semen.= Suspected seminal stains may be tested first by the
=Florence sperm reaction=. A portion of the material is mixed on the
slide with a drop of an iodine solution (1.65 iodine, 2.54 potassium
iodide, 30 water). Cover and examine with low power. The formation of
characteristic long rhombic, brown or violet crystals is evidence of
the presence of semen. The reaction is hindered by decomposition. The
=spermatozoa= may also be demonstrated in seminal stains by soaking
the fabric, carefully flattened out, in a watch-glass containing
dilute hydrochloric acid (1 drop to 40 cc. distilled water), for 5
minutes to 5 hours, according to the age of the stain. The fabric
is then removed and gently rubbed on a slide; the smear is covered
with a No. 1 cover-slip, and examined with the oil immersion or the
highest dry objectives. The smear may be stained by adding neutral
red solution to the macerating fluid, or by drying the smear in
the air, fixing in the flame, and staining with hæmatoxylin and
eosin, neutral carmine or fuchsin. The staining and macerating
solutions may be combined in one. The piece of fabric containing the
suspected seminal stain is soaked in a mixture of methyl green 1
grm., hydrochloric acid 15 drops, distilled water 350 cc., for 1-6
hours. It is then removed with the forceps and smeared on the slide,
examined in the moist state, or dried, fixed and mounted. The head is
stained an intense green.
3. =Decidua and Foetal Tissues.= Clots, curettings and discharges
may be examined in the fresh state by teasing; or the material
may be fixed in formol, formol-Müller’s or mercuric chloride. The
characteristic structures of the decidual cells, chorionic villi and
other fœtal tissues are easily recognized and the presence of any
one of these determines the occurrence of pregnancy, abortion or
child-birth.
4. =Hair.= The most important medicolegal question concerning hair is
the differential diagnosis between animal and human. The following
points must be considered:—
_1._ The cells of the outer layer (cuticle) of the hair are much
larger in the majority of animals than in man, and are much more
distinctly seen. The cuticle is much more dentate or serrate in the
hair of animals than in that of man.
_2._ The cortical layer in human hair is much thicker than in animal
hairs, as compared to the thickness of the medulla; in animal hair
the medulla is thicker than the cortical layer.
_3._ The cellular structure of the medullary substance is indistinct
in human hair; in animal hair it is very prominent. In human hair
the medulla is often absent, especially in certain portions of the
hair, while in animals it is rarely absent, and then only in sharply
localized portions. The hair should always be examined throughout its
entire length.
Hairs of the beard are usually thickest (0.14-0.15 mm. in diameter),
then follow in order of size the pubic hairs of the female, the hairs
of the eye-lids, male pubis, male head, and female head (0.06 mm. in
diameter). There are, however, marked individual differences, and
the hair of infants is much finer than that of older children and
adults. The hairs of the new-born are pointed, as are also the hairs
of adults that are protected from cutting, rubbing, maceration, etc.
Cut hairs are at first blunt; later more rounded. Hairs that have
been torn out usually show a bulbous end with the remains of the
hair-follicle; fallen hairs have a closed, smooth, atrophic root.
When the question arises as to the definite individual from whom
certain hairs may have come a very careful comparison of the given
hairs with those of the individual concerned must be carried out, as
to color, size, thickness of different layers, shape and size of the
transverse section, etc. Paraffin imbedding should be employed for
this purpose.
CHAPTER XXX.
THE STUDY OF MOUNTED PREPARATIONS.
1. =Preparation.= Analyze the method of preparation of the specimen,
noting-methods of fixation, hardening, imbedding, injection,
impregnation, staining, etc. Note the reaction of nucleus,
protoplasm, red blood-cells and connective-tissue to the stain. Look
for special staining reactions (hyalin. amyloid, mucin, etc.) and
metachromasia.
2. =Histology.= Look for histologic landmarks by which the organ, or
part of the body, from which the specimen is taken can be recognized.
If such landmarks cannot be found, analyze the section, element
by element, until its histologic features are fully noted and
recognized. Answer the question, “From what part of the body does the
tissue come?” Carry the differential diagnosis as far as possible,
with regard to sex, age, side of the body or organ (for example, in
the heart decide as to auricle or ventricle, left ventricle or right,
etc.).
3. =Pathology.= Study next the deviations from the normal. Answer
these questions: “Is the tissue normal?” “If not, in what respects
does it differ from the normal?” Study pathologic conditions with
the low power first, then use the high power for the finer details.
Consider the histologic features of the organ (capsule, stroma,
parenchyma, ducts, etc.) with respect to pathologic changes.
4. =Diagnosis.= After the pathologic changes have been fully studied,
the diagnosis should be formulated. If the pathologic changes found
can be correlated as factors in some specific conditions they should
not be considered separately, but the specific condition itself
would constitute the diagnosis. When the pathologic conditions
have no definite relation to each other they should be classified
separately. If a section of kidney shows cloudy swelling, congestion,
œdema, small-celled infiltration, hæmorrhage and casts, these
different conditions would all be included in the diagnosis of an
acute parenchymatous degenerative nephritis. If the general picture
corresponds to that of tuberculosis, syphilis, neoplasm, etc., the
various associated changes need not be considered alone, but the
broad and comprehensive diagnosis should be expressed in as concise
terms as possible.
Written descriptions of microscopic appearances should be so
full and clear that it is possible to make a diagnosis from the
word-picture. A full and adequate analysis of the preparation set
forth in concise and clear language is of more objective value
than the bare diagnosis. Reproductions by means of drawings are
also of great value in assisting the memory or in communicating
the results of the observation to others. A technique sufficient
for ordinary purposes may soon be obtained. Color work is usually
easiest, since the majority of sections are stained in color. The
camera lucida or Edinger’s drawing apparatus may be of great service
in the enlargement and placing of the various elements of the
section; with these instruments but little practice is necessary to
produce rapid and accurate representations. The close inspection
of the preparation during the drawing often reveals features that
previously had escaped attention. Many workers object to drawings
on the ground of subjectivity, but the same criticism applies even
more to word-descriptions. Especial attention must, however, be paid
to this danger, both in the case of drawings and word-descriptions.
In the case of scientific work the written description is best
backed up by photographs, rather than by drawings. Microphotography
has the very great advantage of being purely objective, although
dishonest photographs are possible. There are, however, certain
limitations to microphotography. Differential details are lost in
sections; all parts of the section cannot be fairly represented;
and focal and color limitations are great disadvantages. I believe,
however, that for pure scientific work word-descriptions should be
accompanied by objective microphotographs instead of drawings. The
microphotographic outfit of Zeiss has already been recommended as the
best. It is impossible to take up the subject of microphotographic
technique in this book. The reader is referred to the chapter on
“Microphotography” in Aschoff and Gaylord’s Atlas, and to the works
of Cresbie, Bagshaw, Kaiserling, Neuhauss, and others. (See article
on “_Mikrophotographic_” in the _Enzyklopädie der mikroscopischen
Tecknik_.)
INDEX.
A.
Abdomen:
Inspection of, 45
Section of, 140
Abdominal cavity, pathology of, 102
Abdominal organs, pathology of, 104
Abortion, death from, 191
Acetic acid fuchsin, 220
Acetone, 226, 237
Acetone-colophonium, 278
Acetone-xylol, 278
Acids:
Acetic, 220
Chromic, 228
Fatty, 268
Mineral, 220
Osmic, 220, 230, 267, 299
Picric, 231, 258
Poisoning with, 189
Acid fuchsin, 258
Acid stains, 253
Adrenals, examination of, 145, 146
Left, 145, 155
Right, 146, 155
Special pathology of, 155
African relapsing fever, 284
Agar-formol, 237
Age of new-born, 182
Alcohol, 220, 227
Alcohol poisoning, 189
Alkalies, poisoning with, 190
Alum carmine, 256
Alum cochineal, 283
Alum hæmatoxylin, 254
Altmann’s granules, 230, 265
Ammonium sulphide test, 275
Amœba coli, 285
Amyloid, staining of, 262
Aniline dyes, 253
Aniline-xylol, 270, 278
Animal parasites, 285
Anomalies, 45
Antimony, poisoning with, 190
Antrums, examination of, 86
Aorta, 120, 130
Abdominal, 158
Apathy’s method, 300
Aronson-Philipp stain, 292
Arsenic, poisoning with, 190
Artefacts, 251
Asphyxia, death from, 191
Atrophy, 264
Atropine, poisoning with, 190
Autopsy:
General considerations, 3
Heller’s method, 30
Importance of, 3
Instruments, 9
Legal aspects of, 5
Letulle’s method for, 30
Medicolegal, 187
of new-born, 177
in animals, 196
Order of, 24
Permit for, 8
Preparation for, 15
Technique, 20
Time of, 42
Axis-cylinders, staining, 299
Azur-blau, 290
B.
Back, inspection of, 45
Bacteria:
Acid fast, 280
Actinomyces, 278, 283
Bacillus:
Aërogenes capsulatus, 278, 281
of anthrax, 278, 280
of bubonic plague, 279, 281
of chancroid (Ducrez-Unna), 279, 281
Coli communis, 279, 281
Diphtheriæ, 278, 281
Dysenteriæ, 279
of epidemic conjunctivitis, 279, 281
of fowl cholera, 279
of Friedländer, 282
of glanders, 279, 281
of influenza, 279, 281
of Koch-Weeks, 270, 281
of leprosy, 278, 280, 283
of Lustgarten, 280
Mallei, 279, 281
of malignant œdema, 279, 280
of mouse septicæmia, 278
Paratyphoid, 281
Pestis, 279, 281
Pneumoniæ, 279, 282
Proteus, 279
Pyocyaneus, 279, 281
of rabbit septicæmia, 279
Rhinoscleroma, 278, 282
Smegma, 280
of swine erysipelas, 278
of swine plague, 279
of tetanus, 278, 281
Tuberculosis, 278, 280, 282
of typhoid fever, 279, 281
Cladothrix, 283
Diplococcus pneumoniæ, 278, 280
Gonococcus, 279, 280
Gram-negative, 278
Gram-positive, 278
Leptothrix, 283
Meningococcus, 279, 280
Micrococcus:
Catarrhalis, 280
Melitensis, 279
Tetragenus, 278, 280
Nocardia, 283
Oïdium Albicans, 278, 285
Spirilla and spirochaetes, 283
Spirillum:
of Asiatic cholera, 279
Obermeieri, 284
of recurrent fever, 283
of Vincent’s angina, 284
Spirochæte:
of African relapsing fever, 284
of fowl-spirillosis, 284
Pallida, 279, 284
Refringens, 284
Staphylococcus:
Pyogenes albus, 278, 280
Pyogenes aureus, 278, 280
Pyogenes citreus, 278, 280
Streptococcus pyogenes, 278, 280
Vibrios:
Staining of, 283
of cholera, 283
Balantidium coli, 286
Basic stains, 253
Basic aniline dyes, 257
Beale’s glycerin carmine, 218
Béclard’s center, 181
Benda’s method, 268
Iron hæmatoxylin, 273
Beneke’s method, 147
Best’s glycogen methods, 270
Bethe’s method, 300
Biebrich scarlet, 293
Bielschowsky’s method, 299, 300
Bignami’s method, 286
Bile capillaries, demonstration of, 297
Bile passages, 151
Birch-Hirschfeld’s method, 263
Bismarck brown, 257
Bladder, urinary, 161, 163, 165, 169
Blastomycetes, 285
Bleu Borrel, 290
Blood:
Biologic test for, 306
Examination of, 288
Fat in, 293
Films, 288
Fixing of, 288
Medicolegal examination of, 305
Parasites of, 293
Sections, 293
Size of red cells, 305
Staining of, 289
Blood-content, 39
Blood platelets, 292
Blood vessels, peripheral, 174, 176
Body, heat of, 50
Böhmer’s hæmatoxylin, 254
Bone marrow:
Examination of, 173
Special pathology of, 174
Staining of, 293
Staining methods, 294
Bones:
Examination of, 173
Special pathology of, 174
Borax carmine, 257
Bordeaux red, 273
Brain:
Basal vessels, 89
Removal of, 69
Section of, 70
Section in skull, 76
Section, Déjerine method, 77
Section, Meynert method, 77
Section, Pitres method, 75
Section, Virchow method, 70
Special pathology of, 93
Bremer’s reaction, 292
Broad ligament, 165, 172
Bronchi, 118, 120, 128
Bunge’s fluid, 275
Burckhardt’s fluid, 231
Burns, death from, 192
Buzzi’s method, 267
C.
Cadaver:
Age of, 42
Build of, 44
External examination of, 41
Facies of, 44
Head of, 44
Identification of, 41, 187
Legal status of, 5
Nationality of, 42
Nutrition of, 44
Occupation of, 42
Orifices of, 52
Palpation of, 52
Percussion of, 52
Restoration of, 193
Sex of, 41
Status of, 42
Calcification, 220, 264
Canada balsam, 250
Carotids, 134, 139
Carbol-kresyl-echt-violett, 220, 263
Carbol-xylol, 249
Carbon-monoxide poisoning, 190
Carmine, 256
Carmine, ammonia, 258
Carmine and picric acid, 260
Carnoy’s fluid, 231
Cartilage:
Béclard’s center, 181
Costal, 99, 105
Staining of, 295
Cell granules, 265
Cell inclusions, 265
Cellodin, 234, 235, 239, 240, 243, 245, 247, 251
Cercomonas, 286
Cerebellum:
Examination of, 92
Pathology of, 92
Section of, 74
Cerebrum:
Examination of, 90
Section of, 70
Size, 90
Weight, 90
Cestodes, 287
Chancroid, bacillus of, 281
Chisel, 12
Brunetti, 15, 56
Curved, 55
Esquirol, 55
Straight, 55
Tomahawk, 55
Cholera, vibrio of, 283
Cholesterin, 266
Chorioid plexus, 92
Chloral hydrate, poisoning with, 190
Chloroform, poisoning with, 190
Chromaffinic tissues, 304
Chromic acid, 228
Chromogen, 300
Chromophilic cells, 276
Claudius’ method, 223
Clearing, 249
Clearing fluids, 249
Cloudy swelling, 266
Cocci, staining of, 278, 279, 280
Coccidia, 286
Cold, death from, 192
Collagen, staining of, 296
Colloid, 266
Colophonium, 250, 278
Color:
of hair, 48
of organs, 35
Congo red, 293
Connective tissue, staining of, 295
Consistence, 36
Copper, test for, 276
Cord, spinal:
Examination of, 53, 61
Pathology of, 61, 62
Removal of, 57, 59
Size, 61
Weight, 61
Cornification, 266
Courmont and Andre’s method, 276
Cover-glass preparations, 244
Cowper’s gland, 161
Cranium:
Examination of, 64
Examination of base, 78, 93
Crushing, 210
Crystal-violet, 224
Cut surface, 38
D.
Dahlia, 271
Damar, 250
Dark field, 205, 284
Condenser, 284
Death:
Apparent, 43
Icard’s test for, 43
Larcher’s sign of, 43
Magnus’ sign of, 44
Positive signs of, 42
Ripault’s test for, 43
Tests for, 43
Time of, 42
Decalcification, methods of, 232
Combined with fixation, 232
Ebner’s fluid, 233
Haug’s solution, 233
Phloroglucin, 233
Schaffer’s, 233
Sulphurous acid, 232
Trichloracetic acid, 232
Decidua, demonstration of, 307
Deetjen’s agar solution, 292
Deformities, 45
Dehydration, 249
Déjerine method, 77
Delafield’s hæmatoxylin, 255
Delépine’s method, 261
Diaphragm, 98, 104, 148, 159
Differentiation, 246, 247
Diffuse stains, 258
Diffusion spots, 51
Digestion, 210, 217, 296
Diplococcus pneumoniæ, 278, 280
Dissociation fluids, 219
Donaggio’s methods, 302
Dorsal incision, 60
Drawing, 310
Duodenum, 143, 150
Dura:
Basal, 93
of brain, 88
of cord, 60
E.
Ear, 81, 82, 83, 94
Examination of, 81, 82, 83, 94
Politzer method of examining, 85
Microscopic examination of, 297
Edinger drawing apparatus, 310
Ehrlich:
Acid hæmatoxylin, 255
Dahlia method, 271
Triple stain, 261, 292
Ehrlich-Biondi-Heidenhain stain, 273
Ejaculatory ducts, 161
Elastic fibres:
Orcein stain for, 296
Resorcin-fuchsin, 296
Staining of, 296
Weigert’s method, 296
Electricity, death from, 192
Eleidin, 266, 267
Eosin, 258, 259, 260
Epithelial fibres, 304
Ergot, poisoning with, 190
Erlitzky’s fluid, 228
Ether, 220
Eustachian tube, 83, 84, 85
Eyes, 45, 94
Microscopic examination of, 297
Pathology of, 94
F.
Face, 86
Facies, 44
Fat, in blood, 293
Indophenol stain for, 268
Osmic acid stain for, 267
Scarlet R stain for, 268
Scharlach R stain for, 268
Staining of, 267
Sudan III stain for, 268
Fat-granule cells, 303
Fat tissue, staining of, 297
Fatty acids, 268
Fett Ponceau, 220
Fibres, elastic, 296
Epithelial, 304
Sharpey’s, 295
Fibrin:
Staining of, 269
Weigert’s method of staining, 269
Fibroglia, 296
Mallory’s stain for, 296
Filaria, staining of, 287
Films, blood, 288
Fisher’s milk injection, 218
Fixation, 225, 288
Fixation and hardening, 225
Acetone method, 226
Alcohol, 227
Altmann’s solution, 230
Burckhardt’s fluid, 231
Carnoy’s fluid, 231
Chromic acid and salts, 228
Combined with decalcification, 232
Determination of method, 231
Erlitzky’s fluid, 228
Flemming’s solution, 230
Flemming’s chroma-cetic solution, 231
Formalin, 229
Formol, 229
Formol-acetone, 227
Formol-alcohol, 228
Freezing and drying, 229
Heat, 229
Hermann’s solution, 230
Marchi’s solution, 230
Mercuric chloride solution, 230
Merkel’s fluid, 231
Orth’s fluid, 228
Osmic acid, 230
Pianese’s solution, 230
Picric acid solution, 230
Rabl’s fluid, 231
Rawitz’s fluid, 231
Rules for, 226
Sublamine, 230
Zenker’s solution, 230
Flemming’s solution, 230
Flemming’s solution and safranin, 272
Fluids:
Burckhardt, 231
Carnoy, 231
Dissociation, 219
Ebner, 233
Erlitzky’s, 228
Indifferent, 219
Maceration, 219
Merkel, 231
Müller’s, 228
Orth, 228
Pacini, 305
Physiologic, 219
Rabl, 231
Rawitz, 231
Fluorchrom, 299
Florence sperm reaction, 300
Fœtal tissues, demonstration of, 307
Formalin, 229
Formol, 229
Formol-agar, 237
Formol-alcohol, 228
Formol-gelatin, 237
Fowl-spirillosis, 284
Freezing, 211
Freezing and drying, 229
Freezing microtome, 211, 214, 216
Fresh material, examination of, 208
Staining of, 220, 243
Treatment of, 221
Fuchsin, 257
G.
Gaffky’s method, 281
Gall bladder, 145, 155
Ganglia:
Cerebral, 92
Spinal, 60
Sympathetic, 148, 158
Ganglion cells, staining of, 298
Gelatin preparations, 223
Gentian violet, 263, 279
Giemsa’s method, 291
Stain, 284, 290, 291
Glycerin, 219, 250
Glycerin-gelatin, 250
Glycogen:
Best’s method for, 270
in leucocytes, 293
Staining of, 270
Golgi’s network, 300
Gonococcus, 279, 280
Gram-positive bacteria, 278
Gram-negative bacteria, 278
Gram-Weigert stain, 269
Granules:
Altmann’s, 230, 265
Basophile, 290, 291, 292
Cell:
Plasma, 271, 272
Mast, 271, 272
Eosinophile, 290, 291, 292
Neutrophile, 290, 291, 292
Nissl’s, 298
Green’s method, 263
H.
Hæmalum, 255
Mayer’s, 255
Mayer’s acid, 255
Staining with, 256
Hæmatoxylin, 234
Alum, 254
and acid fuchsin, 259
and eosin, 259
and orange G, 259
and picric acid, 259
Benda’s iron, 273
Böhmer’s, 254
Delafield’s, 255
Ehrlich’s acid, 255
Hansen’s, 255
Heidenhain’s iron, 273
Weigert’s iron, 255
Hæmolymphnodes, 148, 158
Hæmosiderin, 275
Hair, 48
Medicolegal examination of, 307
Hansen’s hæmatoxylin, 255
Hardening, methods of, 225
Harke’s method, 85
Hasting’s stain, 290
Haug’s solution, 233
Head, 44
Examination of, 63
Inspection of, 44
Heart:
Left, 125
Nauwerck’s method of opening, 114
Orifices and valves of, 125
Prausnitz’s method of opening, 116
Right, 124
Section of, 107
Size and weight of, 123
Special pathology of, 126
Vessels of, 125
Virchow’s method of opening, 113
Heat, death from, 192
fixation by, 229
Heidenhain’s iron hæmatoxylin, 273
Heller’s method, 30
Hermann’s solution, 230
Herxheimer’s method, 304
Hey saw, 14, 85
Histologic features, 39
Huber and Snow’s plate method, 245
Hyalin, staining of, 271
Hydrocyanic acid, poisoning with, 190
Hydropic degeneration, 271
Hydroxides, potassium and sodium, 220
Hypertrophy, 271
Hypophysis, 80, 92
Hypostasis, 50
I.
Icard’s test, 43
Identification of cadaver, 41, 187
Iliacs, 158
Iliopsoas muscle, 148, 159
Illuminating gas, poisoning with, 190
Imbedding, methods of, 234
Acetone, 237
Celloidin, 234, 235
Formol-agar, 237
Formol-gelatin, 237
Paraffin, 234, 236
Pyridin, 237
Incision, main, 96
India ink method, 284
Indophenol, 268
Infanticide, 191
Infiltration, 234
Inflammation, 271
Injection, methods of, 217
Beale’s glycerin carmine, 218
Fisher’s milk, 218
Silbermann’s, 218
Thiersch’s Berlin blue gelatin, 218
Instruments, autopsy, 9
Intestines, 141, 150
Iodine-glycerin, 220
Iodine, test for, 272
Iodine green, 263
Iodine test for amyloid, 262
Iron:
Ammonium sulphide test, 275
Combined or masked, 275
Potassium ferrocyanide test, 275
Tests for, 275
J.
Joints, 174, 176
Jugulars, 133, 139
Justus’ test, 272
K.
Kaiserling’s method, 222
Keratin, 267
Keratohyalin, 266, 267
Kidney:
Left, 145, 155
Removal of, 145-147
Right, 146, 155
v. Kölliker’s method, 295
v. Kossa’s silver method, 264
Kresyl-echt-violett, 263, 273
L.
Laboratory, outfit, 201
Utensils, 207
Lævulose, 250
Lake, 253
Langhans’ method, 240
Larcher’s sign, 43
Larynx, section of, 133
Pathology of, 136
Lead, poisoning with, 190
Test for, 276
Legal aspects of autopsy, 5
Leishman-Donovan bodies, 286
Leishman’s stain, 290
v. Lenhossék’s method, 298
Leptothrix, 283
Letulle’s method, 30
Leukocytes, staining of, 291
Levaditi’s method, 284
Ligaments, broad, 165, 172
Uterine, 172
Lithium carmine, 257
Liver, pathology of, 153
Section of, 144
Staining of, 297
Location of organs, 34
Luer’s rhachiotome, 14, 55
Lugol’s solution, 220
Lungs, section of, 116
Pathology of, 126, 127
Lustgarten’s bacillus, 280
Lymphatics, 158
Uterine, 172
Lymphnodes:
Bronchial, 118, 120, 129
Cervical, 134, 138
Mesenteric, 145, 155
Microscopic examination, 293
Pelvic, 165
Portal, 145
Regional, 174, 176
Retroperitoneal, 148
Lymphocytes, staining of, 292
M.
Maceration, 210
Fluids, 219
Macroscopic preparations, 222
Magnus’ sign, 44
Malarial organisms, 286, 291, 292
Mallory’s method for actinomyces, 283
for amœba, 285
for fibroglia, 296
for neuroglia, 301
for reticulum, 295
Mallory-Wright method:
Serial sections, 240
Tubercle-stain, 282
Mall’s digestion-method, 296
Mamma, 99, 105
Mann’s method, 287
Marchi’s fluid, 230
Method, 302
Marking of plates, 246
Mast cells, staining of, 271
Material, examination of fresh, 208
Treatment of, 199
Mayer’s acid-hæmalum, 255
Hæmalum, 255
Mediastinum, anterior, 121
Medicolegal examination, 305
Medulla, 75, 92
Megastoma entericum, 286
Melnikow-Raswedenkow, 223
Meninges of cord, 60, 61
Basal, 89, 93
Inner, 61, 89
Vessels of, 88
Meningococcus, 279, 280
Mercuric chloride fixation, 230
Mercury, test for, 276
Merkel’s fluid, 231
Mesenteric lymphnodes, 145, 155
Mesentery, 145, 155
Metachromasia, 247, 254
Methods:
Apathy’s, 300
Benda’s, 268
Best’s, 270
Bethe’s, 300
Bielschowsky’s, 299, 300
Bignami’s, 286
Birch-Hirschfeld’s, 263
Buzzi’s, 267
Claudius’, 223
Courmont and Andre’s, 276
Delépine’s, 261
Donaggio’s, 302
Ehrlich’s dahlia, 271
Ehrlich’s triple stain, 261, 292
Fick’s, 267
Gaffky’s, 281
Giemsa’s, 284, 291
Golgi’s, 300
Green’s, 263
Herxheimer’s, 304
Huber and Snow’s, 245
India-ink, 284
Jenner’s, 290
Kaiserling’s, 222
v. Kölliker’s, 295
v. Kossa’s, 264
Langhans’, 240
v. Lenhossék’s, 298
Levaditi’s, 284
Mallory’s, 240, 285, 295, 296, 301
Mallory and Wright’s, 240, 282
Mann’s, 287
Marchi’s, 302
Melnikow-Raswedenkow, 222
Meynert’s, 77
Molasses plate, 245
Morse’s, 263
Nikiforoff’s, 283
Nissl’s, 298
Noniewicz’s, 281
Pappenheim’s, 279, 292
Pianese’s, 265
Pick’s, 223
Platner’s, 303
Politzer’s, 85
Ramon j Cajal, 300
Romanowsky, 272, 286, 290
Schaffer’s, 233
Schmorl’s, 294
Schmorl-Giemsa, 284
Schmorl-Obregia, 240, 245
Silbermann’s, 218
Smith’s, 269
Strouse’s, 220
Trambusi’s, 293
Unna’s chancroid, 281
Collagen, 296
Fungi, 285
Mast cell, 271
Van Gieson’s, 260
Warthin’s plate, 221, 245
Weigert’s, elastic tissue, 296
Fibrin, 269
Gram, 269, 278
Myelin sheath, 299
Neuroglia, 300
Westenhoeffer’s, 223
White’s, 261
Wiesel’s, 304
Williamson-Bielschowsky, 299
Wolkowitsch’s, 282
Wood’s, 220
Wright’s blood, 284, 290
Ziehl-Neelsen, 280
Zieler’s, 279
Methods of staining, 246
Methyl blue, 287
Methylene blue, 257, 260, 289
Methyl green, 257, 263
Methyl green-pyronin, 279, 292
Methyl violet, 262
Meynert’s method, 77
Micrococcus, catarrhalis, 280
Melitensis, 279
Tetragenus, 278, 280
Micro-organisms, pathogenic, 277
Microscope, accessories, 201-205
Choice of, 201
Polarization, 205
Use of, 203
Microspectroscope, 205, 306
Microtome, choice of, 206
Freezing, 206
Knives, 206, 211
Milk-injection, 218
Mineral acids, 220
Mitotic figures, 272
Molasses method, 221, 245
Mordant, 253
Morse’s method, 263
Moulds, pathogenic, 220, 285
Mounted preparations, drawing of, 310
Photographing of, 310
Study of, 309
Mounting, 243, 250, 251
Mouth, 135
Muchæmatin, 274
Mucin, 273
Mucicarmin, 274
Mucous membranes, 49
Müller’s fluid, 228
Muscles, 49, 102, 148, 159, 297
Myelin, 274
Myelin-sheath staining, 299
Myoglia, 297
N.
Nails, 49
Natural dyes, 253
Neck, 45
Neck organs, pathology of, 135
Removal of, 131
Section in situ, 134
Necrosis, 274
Negri bodies, 286
Nematodes, 287
Neoplasms, 274
Nerve-degeneration, 302, 303
Nerves, cranial, 93
Inferior laryngeal, 134, 139
Peripheral, 174, 176, 303
Superior laryngeal, 134, 139
Nervous tissue, staining of, 298
Neurofibrillar structures, 300
Neuroglia, staining of, 300, 301
New-born:
Age of, 182
Autopsy of, 177, 182
Cause of death, 185
Organs of, 183
Size of, 182
Nikiforoff’s method, 283
Nissl’s granules, 298
Method, 298
Nitrobenzol, poisoning with, 191
Nocardia, 283
Nocht’s stain, 290
Noniewicz’s method, 281
Nose, pathology of, 95, 136
Section of, 85
Nuclear stains, 246, 254
Nucleolus, staining of, 258
O.
Occupation, 42
Odor, 37
Oedema, 50
Oesophagus, pathology of, 130, 136
Section of, 120, 133
Oïdium albicans, 278, 285
Omentum, 104
Opium, poisoning with, 191
Orange G, 258, 259
Orbit, examination of, 81
Orcein, 279, 296
Organs, abdominal, 104
of new-born, 183
of special sense, 174, 176
Thoracic, 121
Orifices, 52
Orr’s osmic-acid method, 299
Orth’s fluid, 228
Osmic acid, 220, 230, 267
Ovary, pathology of, 172
Section of, 165
P.
Pacchionian bodies, 88
Pacini’s fluid, 305
Palate, 133, 135
Palpation, 52
Pal’s solution, 302
Pancreas, 144, 152
Panniculus, 50, 102
Pappenheim’s method, 279, 292
Paraffin, imbedding in, 234, 236
Mounting of sections, 251
Ovens, 207
Preparation of sections, 244, 245, 246
Sections, 241
Serial sections, 242
Staining of sections, 247
Parametrium, 165
Parasites, animal, 285
Parathyroids, 134, 138
Parotid, 86, 134, 138
Parovarium, 165
Pathogenic, bacteria, 277
Moulds, 220, 285
Yeasts, 285
Peduncles, 92
Pelvis, examination of female, 163
Examination of male, 160
Penciling, 216
Penis, 163, 166
Percussion of cadaver, 52
Pericardium, 106, 122
Peripheral nerves, 174, 176, 303
Peritoneum, 148
Pharynx, 133, 135
Phosphomolybdic acid, 294
Phosphorus, poisoning with, 190
Phosphotungstic acid, 294
Pianese’s method, 265
Solution, 230
Pick’s method, 223
Picric acid, 231, 258, 259, 260
Picrocarmine, 260
Pigment, 274
Pineal gland, 92
Pitre’s method, 75
Plasmodium malariæ, 286, 291, 292
Plate method, 245, 246
Platner’s method, 303
Plimmer’s bodies, 266
Poisoning:
Acids, 189
Alcohol, 189
Alkalies, 190
Antimony, 190
Arsenic, 190
Atropine, 190
Carbon monoxide, 190
Chloral hydrate, 190
Chloroform, 190
Ergot, 190
Formalin, 190
Hydrocyanic acid, 190
Illuminating gas, 190
Lead, 190
Mercury, 190
Morphine, 191
Nitrobenzol, 191
Opium, 191
Phosphorus, 191
Potassium chlorate, 191
Potassium cyanide, 190
Ptomaine, 191
Strychnine, 191
Suspected, 188
Polarization microscope, 205
Politzer’s method, 85
Polychrome methylene blue, 264
Pons, 92
Portal vein, 145, 155
Potassium acetate, 219, 250
Potassium ferrocyanide, 275
Progressive staining, 247
Prostate, 161, 163, 168
Protocol, 33
Pseudomucin, 276
Purin bodies, 276
Putrefaction, 51
Pyridin, 237
Pyronin, 279, 292
Pyrosoma bigeminum, 286
R.
Rabl’s fluid, 231
Rawitz’s fluid, 231
Reagents for fresh tissue, 219
Rectum, 161, 163, 165, 167, 169
Regeneration, 276
Regressive staining, 247
Repair, 276
Resorcin-fuchsin, 296
Reticulum, 295, 296
Rhachiotome of Amussat, 55
of Luer, 14, 55
Rigor mortis, 49
Ripault’s test, 43
Romanowsky method, 272, 286, 290
Ross’ electrical warmer, 218
Russell’s bodies, 265
S.
Sarcosporidia, 286
Scalp, 87
Scalds, death from, 192
Scars, 46
Schmorl’s bone methods, 295
Schmorl-Obregia method, 240, 245
Schmorl’s method of examining blood, 305
Scraping, 209
Scrotum, 167
Section cutting, 210, 238
of celloidin blocks, 239
of frozen tissue, 239
of paraffin blocks, 241
serial of celloidin, 240
serial of paraffin, 242
without imbedding, 238
Sedimentation, 209
Semen, tests for, 306
Seminal vesicles, 161, 163, 168
Sex, 41
Shaking, 216
Shape of organs, 35
Sharpey’s fibres, 295
Silbermann’s method, 218
Silver, test for, 276
Sinus, basal, 93
Longitudinal, 88
Size of organs, 34
Skin, 46
Staining of, 304
Skull:
Base of, 78, 93
Pathology of, 87
Periosteum of, 87
Removal of cap, 63
Smears, 209
Soap, Venetian, 298
Soaps, staining of, 268
Sperm-reaction, 306
Spermatozoa, 306
Spinal cord, 53, 57, 59, 61
Ganglia, 60
Spirillum, Obermeieri, 283, 284
of African relapsing fever, 284
of fowls, 284
of recurrent fever, 283
of Vincent’s angina, 284
Staining of, 283
Spirochæte:
Pallida, 284, 292
Refringens, 284
Staining of, 283
Spleen, 140, 148, 293
Stage, mechanical, 204
Warm, 205, 218
Staining, 246, 247, 253
General rules for, 248
Huber and Snow’s method, 245
In bulk, 247
Intravital, 217
Methods, 246, 247, 253
of bacteria in tissue, 277
of blood, 288
of celloidin sections, 243, 247
of cover-glass preparations, 244
of fresh tissue, 220, 243, 247
of leukocytes, 291
of paraffin sections, 243, 247
of unimbedded tissue, 243, 247
on slide, 244
Plate method, 245
Preparation for, 243
Progressive, 247
Regressive, 247
Schmorl and Obregia method, 245
Strouse’s method, 220
Supravital, 217
Theories, 253
Warthin’s molasses method, 245
Wood’s method, 220
Stains:
Acid, 253
Acid fuchsin, 258
Alum carmine, 256
Alum cochineal, 283
Ammonia carmine, 258
Aniline, 253
Aniline blue, 295
Aniline-gentian-violet, 269, 282
Aronson-Philipp, 292
Azur Blau, 290
Basic, 253
Basic aniline, 257
Benda’s, 268
Benda’s iron hæmatoxylin, 273
Best’s glycogen, 270
Biebrich scarlet, 293
Birch-Hirschfeld, 263
Bismarck brown, 257
Bleu Borrel, 290
Borax carmine, 257
Bordeaux red, 273
Carbol-fuchsin, 280
Carbol-kresyl-echt-violett, 220
Carbol-thionin, 220, 286
Carmine, 256
Carmine and picric acid, 260
Combined, 259
Congo red, 267, 293
Crystal violet, 224
Dahlia, 271
Delépine’s, 261
Diffuse, 246, 258
Eosin, 258
Eosin and methylene blue, 260
Ehrlich-Biondi-Heidenhain, 273
Ehrlich’s dahlia method, 271
Ehrlich’s triple, 261, 292
Erythrosin, 253, 259, 261
Fett Ponceau, 220
Fuchsin, 257
Gentian violet, 263, 279
Giemsa’s, 284, 290, 291
Gram-Weigert, 269
Green’s, 263
Hæmatoxylin, 254
Alum, 254
Böhmer’s, 254
Delafield’s, 255
Ehrlich’s acid, 255
Hansen’s, 255
Weigert’s iron, 255
Hæmatoxylin and acid fuchsin, 259
Hæmatoxylin and eosin, 259
Hæmatoxylin and orange G, 259
Hæmatoxylin and picric acid, 259
Hasting’s, 290
Heidenhain’s iron, 273
Indigo carmine, 295
Indophenol, 268
Iodine green, 220, 263, 265
Jenner’s, 290
Kresyl-echt-violett, 263, 271, 273
Leishman’s, 290
Lithium carmine, 257
Löffler’s methylene blue, 278
Magenta, 286
Malachite green, 265
Mallory’s fibroglia, 296
Mallory’s neuroglia, 301
Mallory’s reticulum, 295
Martius yellow, 265
Mayer’s acid hæmalum, 255
Mayer’s hæmalum, 255
Methyl blue, 287
Methyl green, 257, 263
Methyl green-pyronin, 279, 292
Methyl violet, 262
Methylene azure, 254
Methylene blue, 257, 260, 289
Alkaline, 257, 278
Morse’s, 263, 273
Muchæmatin, 274
Mucicarmin, 274
Natural dyes, 253
Neutral red, 217, 266
Nile blue, 269
Nocht’s, 290
Nuclear, 246, 254
Orange G, 258, 259
Orcein, 279, 296
Pappenheim’s, 279, 292
Phlosin-red, 218
Picric acid, 258
Picrocarmin, 260
Polychrome methylene blue, 264, 271, 276
Pranter’s, 279
Protoplasmic, 246, 258
Resorcin fuchsin, 296
Romanowsky’s, 272, 286, 290
Rubin, 259, 261
Safranin, 272
Scarlet R, 220, 264, 268
Scharlach R, 220, 264, 268
Schmorl’s, for bone, 294
Schmorl-Giemsa, 284
Selective, 246
Smith’s, 269
Specific, 246
Sudan III, 220, 264, 268
Thionin, 220, 254, 264, 273
Thionin and phosphotungstic acid, 294
Thionin and phosphomolybdic acid, 294
Thionin-picric acid, 294
Toluidin blue, 253, 264
Unna’s mast cell, 271
Unna’s methylene blue, 257, 271, 276
Unna’s orcein, 296
Van Gieson’s, 260
Vesuvin, 253
Water blue, 304
Weigert’s elastic tissue, 296
Weigert’s fibrin, 269
Weigert’s neuroglia, 297, 300
White’s, 261
Wright’s, 284, 290
Ziehl-Neelsen, 280
Zieler’s, 279
Staphylococcus, 278, 280
Starvation, death from, 192
Status of cadaver, 42
Sternum, 105
Stomach, 144, 151
Streptococcus, 278, 280
Sublamine, 230
Sublingual gland, 134, 138
Submaxillary gland, 134, 138
Sulphurous acid, 232
Supreme Court decisions, 6, 7
Surgical operation, material from, 196
Surgical material, care of, 198
Description of, 197
Removal of, 196
Surgical wounds, 46
Sympathetic, abdominal, 148, 158
Cervical, 134, 139
Peripheral, 174, 176
T.
Teasing, 210
Technique, autopsy, 20
Teeth, inspection of, 49
Microscopic examination, 295
Teichmann’s crystals, 301
Testicles, 161, 162, 167
Tests, to determine death, 43
Icard’s, 43
Ripault’s, 43
Tetanus bacillus, 278, 281
Thiersch’s Berlin-blue gelatin, 218
Thionin, 220, 254, 264, 294
Thoracic cavity, 106, 121
Duct, 120, 130, 134
Great vessels of, 129
Vertebræ, 120, 130
Thorax, 45, 121
Thymus, 106, 121, 184
Thyroid, 134, 137
Time of death, 42
Tissue, cultivation of, 219
Tongue, 133, 135
Tonsils, 133, 135
Trachea, 133, 136
Trambusi’s method, 293
Trauma, signs of, 46
Trematodes, 287
Treponema pallidum, 284
Trichina, 287
Trichloracetic acid, 232
Trichomonas, 286
Trichomycetes, 283
Trypanosoma, 286
Tubercle-bacillus, 278, 280, 282
Tubes, 165, 171
Typhoid-fever bacillus, 279, 281
U.
Unimbedded tissue, 243
Unna’s alkaline methylene blue, 257
Chancroid bacillus, 281
Collagen stain, 296
Glycerin-ether, 271
Mast cell stain, 271
Orcein stain, 296
Polychrome methylene blue, 271, 276
Stain for fungi, 285
Ureters, 158, 161
Urethra, 161, 165, 168, 169
Uric acid, 233, 276
Uterus, 165, 170
Uvula, 133, 135
V.
Vaccine bodies, 287
Vagina, 165, 169
Vagus, 134, 139
Van Gieson’s stain, 260
Vena cava, 158
Ventricles, 72, 91
Venetian soap, 298
Vermes, 287
Vertebræ, 60, 62, 139, 148, 159
Vessels, basal, 89
Meningeal, 88
Peripheral, 174, 176
Uterine, 172
Vesuvin, 253
Vibrios, 283
Vincent’s angina, 284
Violence, death from, 192
Virchow method, 70
Viscera, hollow, 34, 40
Vulva, 169
W.
Warthin’s molasses method, 245
Washing, 248
Weigert’s copper-fluorochrom, 268
Elastic tissue stain, 296
Fibrin stain, 269
Gram method, 269
Iron-hæmatoxylin, 255
Myelin-sheath stain, 299
Neuroglia, 297, 300
Weight, of organs, 34
Westenhoeffer’s method, 223
White’s method, 261
Wiesel’s method, 304
Williamson-Bielschowsky method, 299
Wright’s blood-stain, 284, 290
X.
Xylol, 249, 250
Acetone, 278
Aniline, 270, 278
Xylol-balsam, 250
Xylol-damar, 250
Y.
Yeasts, pathogenic, 285
Z.
Zenker’s solution, 230
Ziehl-Neelsen method, 280
Zieler’s method, 279
Transcriber’s Notes
pg 159 Changed: gangrenous inflammations, tuberculosis, atinomycosis
to: gangrenous inflammations, tuberculosis, actinomycosis
pg 193 Changed: A little ingenunity will suffice
to: A little ingenuity will suffice
pg 254 Changed: one of the most valuable when odidized
to: one of the most valuable when oxidized
pg 259 Changed: Stain with hæmaotxylin, and after washing
to: Stain with hæmatoxylin, and after washing
pg 295 Changed: Cartilage stains deeply with hæmatoxlyin
to: Cartilage stains deeply with hæmatoxylin
pg 303 Changed: stains the neroglia of degenerated areas
to: stains the neuroglia of degenerated areas
Errata changes have been made in text.
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