Post-mortem pathology; a manual of post-mortem examinations and the interpretations to be drawn therefrom; a practical treatise for students and practitioners

Front matter

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Book

COPYRIGHT DEPOSIT

Preface To The Second Edition

To this edition have been added a chapter on the pathology of the bones and joints, a summary of the literature on legal medicine and the technic of post-mortem examinations, and twenty-seven new illustrations, including six in colors. The chapters on bacteriologic investigations, medicolegal suggestions, and the examination of the exterior of the body have been thoroughly revised, and much other matter has been rearranged and wholly or in part rewritten.

I am indebted to Dr. Adelaide W. Peckham, Professor of Bacteriology in the Woman's Medical College of Pennsylvania, for suggestions regarding Chapter XXIII, Bacteriologic Investigations, and to Dr. Ellen P. Corson-White for her assistance upon Chapter V, Examination of the Exterior of the Body, and upon the references contained in Chapter XXIX. Those who helped me in the preparation of the first edition of this work have again performed a similar service, for which I am grateful.

HENRY W. CATTELL.

3709 Spruce Street, Philadelphia, January 18, 1905.

Preface To The First Edition

This book has been written for those who ought to make autopsies but do not and for those of whom such investigations are required, as medical students, hospital interns, and coroner's physicians. While it would seem to be quite needless to urge upon a practitioner the importance of performing post-mortem examinations, it is a fact that extremely few are made outside of hospitals, and even there necropsies are usually conducted by the untrained resident or the substitute of the pathologist. It cannot be questioned, however, that the physician who improves his opportunities for pathological study *on the cadaver will be a better diagnostician and safer therapist, will have a more enduring reputation, and will receive a greater pecuniary return than he who neglects such means of investigating morbid processes.

While the author has mainly relied upon his personal experiences in the preparation of the subject-matter of this manual, he has freely used classifications and material derived from Orth's Pathologisch- Anatomische Diagnostik, Osler's Practice of Medicine, Nauwerck's Sections-Technik, and other publications mentioned in the foot-notes and in the text. He is, therefore, much indebted to these authorities, as well as to Dr. George Robinson and Mr. Louis Schmidt for most of the drawings, all of which were prepared under the writer's direction, to his friends and former students Drs. William S. Wads worth, Mary E. Lapham, E. D. Burkhard, and Edward Lodholz for suggestions in the preparation of the book, and to that excellent proof-reader Mr. T. Grow Taylor for seeing the work through the press.

HENRY W. CATTELL.

3709 Spruce Street, Philadelphia. March 31, 1903.

Contents

CHAPTER PAGE

I. General Considerations I

II. Order of Examination and Post-Mortem Records 13

Chapter I General Considerations

Historical. — The Code of Hammurabi, the Old Testament, and the ancient classics abound in references to violent death and the shedding of blood, but are silent up to the time of Herophilus (320—250 B.C.) as to any opening of the body for legal or pathologic purposes. It is known, however, that the Jewish priests examined the carcasses of animals killed for food to detect impurities, and the knowledge of anatomy displayed at an early date shows that human dissection must have been practised. In the Middle Ages postmortems were performed in cases of poisoning, Charles V. in 1530 empowering the judge to call in physicians as experts. In 1562 Pare made a judicial postmortem, and thus established a medicolegal status which has continued until the present time. The office of coroner is an old and important one. It was created during the reign of King Athelstan, 925 a.d., and its duties were clearly defined soon after the Norman conquest. From England the institution was brought to America by the colonists, where the first post-mortem examination appears to have been made in 1639 in a case of fracture of the skull, and the second in 1643, death being caused by a bullet wound. 1 The authority of the coroner to hold an inquest is not confined to the body of a person who may have died within his jurisdiction, but extends to all cadavers brought within his territory, no matter where death may have taken place. (Becker.) Massachusetts in 1877 abolished the office of coroner, substituting therefor medical examiners, and the New York legislature in 1904 passed a bill for a similar purpose, which was, however, returned to the Governor with a veto by the Mayor of New York City.

1 Hoadley, Proceedings Conn. Med. Soc, 1892, pp. 207-17, quoted by Steiner, Johns Hopkins Bull, Aug., 1903. See also Packard, Phila. Med. Jr., Feb. 17, 1902; Editorial, Jr. Amer. Med. Assoc., Oct. 28, 1893, p. 661.

Definition. — Postmortem, autopsy, and necropsy are synonymous terms applied to the systematic exposure and critical examination of the cadaver with the object of determining the cause of death or of studying morbid anatomy in any of its various aspects. Other synonyms employed are necroscopy, mortopsy, section, sectio cadaveris, sectio anatomica, and post (colloquial). A medicolegal postmortem differs from an ordinary postmortem only in the application of the information obtained to the furtherance of the ends of justice. The German word Obduction is correctly applied only to a medicolegal postmortem. The use of the word " autopsy," in the sense now generally accepted, was first made by v. Riihl, Crighton, and Bluhm, in an account by them of the examination of the body of the Empress Maria Feodorowna, of Russia. 1

Purpose. — As the object of a post-mortem examination is the acquisition of exact data, the method of procedure should be scientific and systematic. This is especially important in medicolegal cases, which frequently involve not only the reputation and liberty, but even the life of a human being. If the examination be conducted in a perfunctory or desultory way, some detail of the greatest importance may be overlooked or the information obtained may be so ill arranged as to be practically valueless for statistical or demonstrative purposes. In no other department of medical science are the faculties of observation and discrimination more vigorously called into play, and in none other are sound knowledge and accurate work so indispensable.

Opportunities for the study of normal structures offered by postmortems upon presumably healthy individuals killed by accident should not be neglected, as thorough familiarity with the appearance of the various organs and tissues in their normal condition is necessary in order that morbid changes or slight variations from health may be recognized. Such subjects also often afford favorable oportunities for the study of the earliest manifestations of disease, particularly in case of tumors and the infective granulomata. New anomalies also may be found, and these, as in the case of polydactylism, may be studied in order to support or disprove Mendel's and Galton's laws of inheritance. As the science of medicine advances, new discoveries

1 Sahb. med.-ch.ir. Ztg., 1829, vol. i, p. 107; Foster's Encyclopedic Med. Diet., p. 516, quoting from Kraus's Kritisch-etymologisches medicinisches Lexikon.

GENERAL CONSIDERATIONS 3

necessitate a constant revision of the statistics of even the most common diseases.

Autopsies present exceptional opportunities for reviewing the study of anatomy and also for acquiring dexterity in the practice of surgery. To this end, it is permissible in suitable cases to perform surgical operations that entail no visible disfigurement of the body. Some of the more recently devised surgical procedures, such as the decapsulization of the kidney, the mechanical irritation of the hepatic peritoneum, the transplantation of ovarian tissue, the Lorenz operation for congenital dislocation of the hip, Gersung's injection of paraffin for the correction of deformities, the formation of an anterior and posterior cusp in the cervical os to prevent conception without interference with the outflow of the menstrual fluid, etc., will at once suggest themselves as being worthy of practice upon the cadaver as opportunity occurs.

Permission. — When a postmortem is desired, the first step in every instance is to secure the legal right to make it. When not performed by order of a regularly appointed officer of the law, consent (preferably in writing) should be obtained from the next of kin to the deceased, or, in the absence of relatives, from the person in charge of the funeral. The feelings of friends and relatives must be fully respected : scientific zeal is no excuse for wounding them. In a suit for damages brought a few years ago against a Philadelphia hospital on account of a postmortem that had been made without the consent of the nearest relative, the judge severely deprecated the procedure, but held that no damages could be recovered in this instance, as the hospital was a charitable institution.

The method to be pursued in gaining permission will depend largely on the nature of the case, but the exercise of tact will nearly always overcome sentimental objections and secure consent except where religious scruples stand in the way. Thus, one resident in a hospital will obtain the opportunity of making an autopsy upon almost ever}- patient dying in the wards during his term of service, while another interne of the same institution will, for one reason or another, meet refusal in the great majority of his cases. The curiosity of relatives and friends may be aroused, or the humane plea of doing no harm to the dead but possibly much good to the living will often appeal to the better judgment of those from whom consent is to be obtained. The author recalls a case in which those interested expressed great satisfaction on learning that death was not due, as had been diagnosed during life, to consumption. An invitation to a member of the family to be present at the postmortem or a promise to make a death-mask (see page 289) will often secure the desired permission. The laity should be encouraged to ask for an autopsy. A carefully performed postmortem often secures ready consent to, or even a voluntary request for, others in the vicinity in which the physician resides. The blank forms which accompany insurance papers often contain the query, "Was an autopsy made?" and an affirmative answer greatly strengthens the holder's claim. Indeed, insurance companies should encourage the making of autopsies, as it is to their own pecuniary advantage so to do. Our Boards of Health, with their enormous power for good or evil, in some States have the legal right to compel the performance of postmortems, a prerogative that has already been advocated more warmly by the lay press than by the profession at large. The offer of a small sum of money will often secure permission to make a necropsy among the indigent foreigners who are so numerous in our large cities, but a threat to refer the case to the coroner unless permission is voluntarily granted should never be employed. Undertakers who oppose the making of autopsies should not be recommended.

The pecuniary value that dead bodies may have sometimes gives rise to legal contests. The Supreme Court of California has decided that one cannot dispose of his own corpse by will. A man bequeathed his body to the managers of a medical college, in the hospital of which he had been treated, to be used for scientific purposes. The man's relatives claimed the cadaver, and applied to the courts for an injunction restraining the medical college from using it. The kinsfolk won, the court holding that the custody of the corpse and the right of burial belong to the next of kin. 1 There are in America and in France several societies the members of which sign cards granting permission for the performance of postmortems on their bodies: it would, however, on account of the decision of the court just referred to, seem best to have the card endorsed by the legal heirs.

Yet even when permission has been given circumstances may prevent the performance of the autopsy. Thus, in the case of Phillips Brooks, who was a member of the American Anthropometric Society,

1 American Medicine, April 6, 1901.

GENERAL CONSIDERATIONS c

the prosector of the society, on reaching Boston, could not perform the postmortem, as, a public funeral being universally desired, the body had been placed in an hermetically sealed coffin, death being due to diphtheria.

In the case of Loesch vs. the Union Casualty and Surety Co., 1 the Supreme Court of Missouri held that the autopsy made without notice to the company was no bar to recovery. The physicians making the examination and the mother of the deceased, who tacitly assented to its performance, were in ignorance of the fact that there was a clause in the policy stating that if a postmortem was held without notice to the company in time to have its medical adviser present all claims under the policy should be forfeited. As soon as the error was discovered, which was in time for a re-examination, the company was notified.

There should be a law permitting post-mortem examinations of the bodies of all persons dying in charitable institutions. Such a rule exists in the hospitals in Germany, and this precedent for some time prevailed in the Philadelphia Hospital with practically no opposition, until a lawsuit, now pending, caused it to be abolished. In cadavers allotted to the anatomical board care should be taken not to destroy the arteries commonly used for injection. If in the course of an autopsy conditions are found which indicate foul play, as injuries or the presence of poison, the examination should be immediately suspended, and steps at once taken to have the coroner or other legal officer take charge of the case. If properly authorized by the coroner or the person who is legally acting in his stead, the examination may proceed in the manner prescribed for conducting medicolegal postmortems.

When portions of the body are desired for preservation or for future study, permission to remove them should be obtained from some one connected with the household, though not necessarily from the nearest relative, as in gaining consent for the performance of the autopsy; it is, of course, unnecessary to tell how much is to be taken away ! Should, however, the person authorizing the autopsy forbid the removal of any portion of the body from the house, no specimens should be taken. Consent can nearly always be obtained for the removal of small pieces of tissue for microscopic purposes, even

1 Jr. Amer. Med. Assoc, September 26, 1903.

when permission to take away larger specimens is refused. In the necropsy on the body of President McKinley, the bullet which produced the fatal wound was not found, because a member of the family objected, though without legal right so to do, to the further continuance of the search, and it was only with the greatest difficulty that consent was obtained to remove portions of the body for microscopic study. In France the law forbids the extraction of teeth without special administrative authorization. (Letulle. ) The careless handling of specimens removed at autopsies, especially those containing pathogenic organisms, and the culture of the more virulent bacteria in our laboratories are sources of danger to the public that will, no doubt evoke legislative restrictions in the near future. For the protection of their patients, residents on duty in the surgical and gynaecological wards of our hospitals should be forbidden to make autopsies, and they should not be tempted to break this rule by a request to assist at a postmortem, even though no one else be available to open the body.

Those Present. — To one who makes many autopsies a capable assistant and a trained attendant are invaluable. Anticipating what is wanted of them, they render prompt aid without being asked. In order to familiarize an assistant with one's method of work, it is a good plan, except in important cases, for the experienced pathologist to alternate with him, he himself often performing the duties of an assistant. Professional friends, especially those wdio saw the patient during life, should be invited to be present at the autopsy ; the scrutiny of critical eyes undoubtedly ensures more careful work. Besides, in medicolegal cases the responsibility of making an autopsy in which the evidence obtained may be sufficient to convict a person of the gravest of crimes is often too great to be borne alone. Before work is begun, the relatives and friends should be tactfully requested to leave the room. The nurse should be within calling distance, and the undertaker or his assistant should remain in the room, as he can often render valuable aid.

While those present are prone to give advice that is useless, the suggestions made by them are frequently of great value. Courtesy demands that a guest should not be too forward in offering advice, but should always be ready to render such assistance as the operator may need or request. The one making the autopsy is in command and is responsible for the success or failure of the work entrusted to

GENERAL CONSIDERATIONS j

him. Letulle lays great stress upon the prohibition of smoking during the performance of the postmortem.

Time. — The time allowed to elapse after death before making an autopsy depends upon the circumstances of the case, and may vary from a few minutes to several days or even months. The examination should never be deferred longer than is absolutely necessary, as the entire cadaver is soon invaded by bacteria, and nuclear figures and cellular elements quickly lose much of their value for microscopic study. But the feeling of warmth imparted to the hands of the operator while making a necropsy soon after death, especially where there is much elevation of the temperature of the cadaver, as in fatal cases of heat-exhaustion or atropine-poisoning, is so repugnant to one's sensibilities that sufficient time should always be allowed for the temperature of the corpse to fall to a point inconsistent with suspended animation. In Xew York State a postmortem must immediately follow an electrocution inflicted as punishment for crime ; it is popularly believed that in at least one case the criminal was not killed by the electric current. The suit brought in the case of Bishop, the so-called mind-reader and cataleptic, where the necropsy was made immediately after death, will also be recalled in this connection. The law in Germany is that at least twenty-four hours should elapse after death before the performance of the autopsy is begun.

The time required for the completion of a postmortem depends, of course, upon the conditions under which it is performed, upon the nature of the case, and upon the skill of the operator. In favorable cases the author has removed the brain in less than three minutes from the time of making the preliminary incision, and has made an entire postmortem examination, including the removal of the cord, in less than nineteen minutes. On the other hand, eight hours of uninterrupted work have been consumed by him in the performance of one autopsy. In a hospital the time usually required for a necropsy is about an hour and a half. Virchow considered that three hours' work was ordinarily sufficient to complete a medicolegal postmortem according to the Prussian regulations given in Chapter XXVII., and that in certain cases this time might be reduced by one-third. It is stated that Rokitansky x performed over thirty thousand autopsies,

1 Preface to the Sydenham Society's translation of Rokitansky's Pathologische Anatomie.

which would hardly allow an average of an hour for each. Kolisko, of Vienna, sometimes made five or six postmortems in a morning, and the author himself has more than once performed ten within twenty-four hours. Owing to lack of time, the surgeon or clinician may wish the necropsy to be made with more celerity than is consistent with thoroughness. As he often merely desires to ascertain a certain fact or to observe a single organ, he can generally be accommodated in a few minutes, and the examination afterwards completed in the routine manner. The performance of the autopsy may take but a short time in comparison with that required for the proper preparation and study of the tissues. Indeed, the collection and preservation of material for future investigation by the microscopist, chemist, experimentalist, and bacteriologist are often the most important part of the process, for an error made at this stage may be irremediable. As Virchow aptly said, " A postmortem does not admit of repetition, whereas in a clinical examination at the bedside any omission may ordinarily be rectified at a subsequent visit."

Place. — The place at which a post-mortem examination is to be made is rarely a matter of choice, especially in private practice, but it should always be where the best light is obtainable. Daylight from the north, such as is sought by artists, should be preferred. If the autopsy must be made after dark, a combination of the electric and Welsbach lights is the most satisfactory artificial illuminant. Orth suggests that a good substitute for daylight may be obtained by allowing the artificial light to pass through a glass flask containing water slightly colored with methylene blue. Such a flask may be used also as a condenser to concentrate the rays of light upon the surface under examination. In Manchester, England, where the days are so often dark, textile workers adopt various expedients to get true color values ; one of these consists in having the artificial light pass through specially colored glass. That one should accustom himself to the changes of color produced by different kinds of artificial light was well shown in one of the author's autopsies made by gaslight on a subject of poisoning by battery-fluid: the tissues stained with potassium bichromate presented an entirely different appearance when examined by daylight the next morning.

Time and labor will, of course, be saved by making the autopsy before the body is dressed for interment, and the undertaker should be directed not to embalm it until after the completion of the examina-

Fig. 2. — Body in a coffin prepared for a post-mortem examination. In this ease the board supporting the body is elevated by means of a soap-box.

Fig. 3.— Post-mortem table for a babe, constructed of chairs and a drawing-board; the marble slab from a wash-stand or bureau may be used for the same purpose.

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tion. The fact that the appearance of the exposed parts is improved by the loss of blood and by its gravitation into the larger cavities of the body as a result of the post-mortem section may be mentioned to him as an argument in favor of the procedure. Fortunately, the formalin injecting fluid now generally employed for embalming purposes does not interfere with the microscopic study of tissues as did the arsenical preparation formerly used. Indeed, one of the special methods for hardening the brain is based on its previous injection with formalin by means of a cannula introduced through the orbit or nasal cavities.

The amount of preparation necessary for an autopsy will depend somewhat on whether the examination is to be made (I.) in a private house or at an undertaker's establishment, or (II.) in a hospital or morgue.

I. In the former case a table on which to lay the cadaver is rarely available, and a substitute must be provided. There are in the market several portable operating tables 1 which may be used for this purpose, as the one shown in Fig. i. The postmortem may be performed while the body lies in the coffin, on the coffin-lid, or, still better, on the bottom of the inverted coffin, on the wooden slab usually found in the box, or on a door taken from its hinges and placed upon two kitchen chairs. The undertaker may have prepared the corpse for the autopsy, as seen in Fig. 2. For the body of a child the marble slab from the top of a bureau or wash-stand placed on the backs of chairs may be used. (Fig. 3.)

To facilitate the necessary manipulations, the cadaver must lie at a proper height. If placed too low, the stooping position required in making the autopsy is most fatiguing. A piece of oil-cloth, mackintosh, or old carpet should be placed under the table or its substitute, to prevent soiling the floor. In addition to the articles brought by the operator (see page 35), two buckets half filled with lukewarm water, an empty basin, and several newspapers should be provided.

Scrupulous cleanliness in the performance of an autopsy is of the greatest importance. The reasons for this are apparent. We owe it to our fellow-men to leave no malignant organisms in the place where the postmortem was performed. Besides, the pathologist can see bet-

1 Sherman, American Medicine, October 26, 1901. Illustration from International Clinics, vol. i., Twelfth Series, 1902.

ter and his sense of touch is finer if the organs, fingers, and rubber gloves are not besmeared.

If the operator be careful not to soil his own person, the surrounding objects will be more likely to escape contamination. For this reason, he may accustom himself in private work to make necropsies on non-contagious cases with but little protection to his clothing. In France the usual dress consists of a hospital blouse, overalls of homespun, an apron reaching to the feet, and a pair of sabots or wooden shoes. In our hospitals the regulation duck trousers, shirt-sleeves, bare arms, rubber gloves, and an apron are most frequently seen. There should be a bountiful supply of water, a basin for the hands, and a board on which to arrange the instruments. The parts under examination should be cleansed as occasion requires by a stream of water squeezed from a sponge, the sponge itself not being permitted to touch the tissues. Mucous and serous surfaces should be carefully inspected before washing.

In private work the laity are likely to estimate the skill of the pathologist by the neatness displayed in sewing up the body and the appearance of the room after the autopsy is completed. The greatest care should be exercised that no blood-stains be left behind. Incense or cascarilla may be burnt or ground coffee strewn on red-hot coals to remove the odor from the apartment, which should then be thoroughly aired.

II. In a hospital or morgue the facilities for making postmortems are much more complete. The room set apart for this purpose should be clean, well lighted, and secure against intrusion. The author remembers once having seen, much to his annoyance, a number of convalescents in the grounds of a hospital watching the performance of an autopsy through an open window. If practicable, the dead-house should communicate by an underground passage with all the wards of the hospital, and a covered or screened court for the undertaker's wagon should also be provided. A well-appointed mortuary room, like the one at the Ayer Clinical Laboratory of the Pennsylvania Hospital (Fig. 4), should have a refrigerator box with scales so arranged that bodies can be weighed within it. At the author's suggestion, the Fairbanks Scale Company fitted one of their scales to a Ridgeway refrigerator for this laboratory (Fig. 5), in such a way that the cadaver could be weighed while in the ice-chest and the result noted without opening the doors. (For structural plans see Figs. 6, 7, and 8.) The

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Fig. 6. — Working plans for preparing refrigerator with eight compartments for the storage of bodies preparatory to their removal for burial. Front view.

Fig. 7.— Ground plan for a truck a, guide ; b, track.

Fig. 8.— Cross-section.

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corpse should be weighed as soon as it is brought into the dead-house, as it will usually be found to lose weight after a time. Each box should have two doors, one opening into the post-mortem room, and the other into a waiting-room on the opposite side, through which the body may be viewed by friends and removed by the undertaker. This arrangement prevents the transmission of noises and odors. The waiting-room ought also to be such that religious services may be held in it, if desired.

The operating table should be strongly built, about seven feet long, two feet nine inches high, and three feet six inches wide. The top may be slate, soapstone, zinc, or copper ; its surface should slope gently towards a central perforated depression connected with a drain and a ventilating shaft operated by an electric fan, and should be provided with sunken grooves converging towards the centre. (Figs. 9 and 10.) The drains of the post-mortem room should not connect with those of the hospital, but empty directly into the main sewer. An ideal though expensive plan would be to sterilize the waste water. A scale of feet, inches, and fractional parts of an inch (or of centimetres) should be laid off on the top of the table, or, if this be of slate, upon a metal rule sunk into it in such a way that no edges are exposed. For class instruction, a revolving table is required, upon which by an ingenious fulcrum and lever attachment the body can be weighed. An extra iron table like those used in the dissecting-room may be provided, in case it is desired to conduct two autopsies at once. The making of several necropsies simultaneously was discontinued in one Philadelphia hospital owing to the fact that three livers were found in a body subsequently exhumed on account of suspected poisoning. Additional tables, upon which to place instruments, scales, plates, and other requisites, should also be at hand.

Ample illumination should be provided, preferably by a northern skylight for day and by a combination gas-light and electric-light fixture directly over the table (Figs. 11 and 12) for night work. Plenty of water, hot and cold, should be supplied by means of an overhead spigot with rubber tubing attached, so that by the use of a mixer a steady stream of water at any required temperature may at once be had wherever desired.