be removed from the cavities for further examination in the reverse order, beginning with the heart.

The primary or long anterior incision to bare the thorax and to open the abdomen (Fig. 5) should extend from the larynx to the pubes, passing to the left of the umbilicus, so as not to cut the round ligament. In cutting, the handle of the knife is depressed so as to use the belly of the blade rather

than the point. An incision beginning as high as the chin is, unfortunately, rarely allowable. Over the sternum the cut should extend down to the bone; over the abdomen, however, only into the muscles, or in fat people through the muscles into the subperitoneal fat-tissue. To open the abdominal cavity, nick carefully through the peritoneum just below the sternum, introduce the first and second fingers of

the left hand, and while making strong upward and outward traction on the right abdominal flap extend the incision to the pubes. Some operators prefer to separate the fingers and to cut between them.

The abdominal flaps are rendered much less tense by cutting the pyramidales and recti muscles from below just above the pubis. Care must be taken not to injure the overlying skin. The abdominal cavity can now be examined, but more room will be obtained if the skin and the underlying muscles be first stripped back from the thorax to about 5 cm. outside of the costochondral line.

The operation is most easily and neatly done by lifting the skin directly away from the chest-wall or turning it forcibly out with the left hand, and then cutting the tense tissue close to the cartilages and ribs with long sweeps of the knife held almost flat. The operation begins over the lower border of the ribs and extends upward. In dissecting off the skin and muscles from the left side the right hand works underneath the left. The mammæ can easily be incised from the under side of the flap, and if necessary the axillary lymph-nodes can be reached by dissecting the skin farther out, especially over the clavicle. Before beginning the inspection of the peritoneal cavity it is important to examine first the surface of the incision into the abdomen, noting the thickness and color of the fat-tissue and the condition of the muscles.

Inspection of the Abdominal Cavity.—The character of any fluid present should be determined and its amount measured or estimated. The simplest way to remove it is to dip it up with a small cup or dish and pour it into a glass graduate for inspection and measurement. If the presence of gas within the peritoneal cavity is suspected, a small pouch should be formed in the first incision as soon as it has been made and water poured in. The first opening into the abdominal cavity should then be made with the point of a scalpel at the bottom of the water, through which the gas, if present, will escape in bubbles.

The various abdominal organs and their relations to each other are to be investigated in situ by sight and by touch.

As a rule, examine first the gastro-intestinal tract, including the appendix and the mesenteric lymph-nodes. Ulcerations of the intestine can often readily be made out through the walls. The examination of the spleen, liver, kidneys, and pelvic organs follows. The pancreas is easily reached by tearing through the omentum between the stomach and the colon, so as to open the lesser peritoneal cavity.

After the inspection of the abdominal organs the position of the diaphragm is to be ascertained on both sides in the costochondral line by measuring with the right hand passed palm upward underneath the ribs, and the left hand outside at the corresponding height to mark the position of ribs or intercostal spaces. On the right side the hand is to be passed up on the outside of the falciform ligament. Normally, the diaphragm stands at the fifth rib on the left side, and at the fourth rib or fourth interspace on the right.

Opening of the Thorax.-To open the thorax, cut through the cartilages close to the ribs from the second down (about 5 mm. distant) with a scalpel held nearly horizontal, so that as one cartilage is cut through the handle of the scalpel will strike the next below and prevent the blade from penetrating too far and injuring the lung. In young people the cartilages can be cut easily by one long stroke on each side, but care must be taken not to go too deep. If the intercostal muscles are not divided by the same operation, the sternum can be depressed by the left hand and the muscles severed by one pass of the knife on each side. The lower end of the sternum can now be elevated and freed from below upward from the diaphragm and pericardium until the first rib is reached. The cartilage of this rib is to be cut about 1 cm. farther out than the others, and from below upward toward the clavicle, with the handle of the knife beneath the elevated sternum and with the point and edge of the knife directed upward and a little outward. The sternum is then to be still further freed from the anterior mediastinal tissue until its upper end is reached. The sternoclavicular joint on the left side can now be easily opened from below by entering a scalpel just above the cartilage of

the first rib, and following the irregular line of the joint around the end of the clavicle, while at the same time drawing the sternum over to the right side of the body. The right sterno-clavicular articulation is to be opened by continuing the incision of the scalpel over the upper end of the sternum and into the second joint. The advantage of this method is that there is much less danger of wounding the large vessels at the base of the neck, and thus of mingling blood with any exudation which may happen to be present in the pleural cavities. If preferred, however, the articulations can be opened and the cartilages of the first ribs cut from above before freeing the sternum from the diaphragm. In this case enter a short, sharp, narrow-bladed scalpel held vertically, but loosely, into the left joint on its upper side, starting the incision just outside of the attachment of the sternal end of the sterno-mastoid muscle, and cut around the end of the clavicle by a series of short up-and-down strokes, allowing the blade to follow the irregular line of the joint. After cutting through the joint continue the incision outward and cut through the cartilage of the first rib.

If the cartilages are calcified, use the costotome and cut through the ribs, as more room can be gained in this way, and they are more easily cut than calcified cartilages. When for any reason it is not permitted to open the thorax, the organs within it can be obtained through the opening into the abdominal cavity by freeing the diaphragm from the ribs, and removing first the heart and then the lungs. The sternum should be inspected at the time of its removal. It is perhaps best to examine next, especially in children, the epiphyses of the ribs at the costochondral line for any evidence of thickening.

Inspection of the Pleural Cavities.—In the pleural cavities, as in the peritoneal cavity, the character and amount of any abnormal contents must be determined. If, from the clinical history or from any other reason, the presence of air in a pleural cavity is suspected, a pouch should be formed over the ribs by aid of the skin-flap and filled with water. The pleural cavity is then to be pierced with a scalpel

through the bottom of the pouch. Air, if present, will bubble up through the water.

Slight adhesions are best torn through or cut. If the lungs are firmly attached, it is best to strip off the costal layer of the pleura with the lung. This is most easily done by starting the anterior edge of the costal pleura with the handle of the scalpel, and working in first a finger and then the whole hand until the pleura is entirely free. In passing the hand into the pleural cavities protect the back of it, especially if the ribs have been cut through, by folding the skin-flap in over the edge of the ribs.

If desired, the lungs can be drawn forward, examined over their whole extent, even incised, and then replaced until the heart has been removed. In the connective tissue of the anterior mediastinum there is almost always a certain amount of emphysema due to the removal of the sternum. Emphysema due to laceration of lung-tissue is more marked in the upper half of the mediastinum, and usually extends up into the neck. The thymus gland attains its full development at the end of the second year, after which time it usually gradually disappears.

Opening of the Pericardium.-To open the pericardium, seize the sac near the middle with fingers or forceps, snip through the wall with knife or scissors, and with either instrument cut upward to where the pericardium is reflected over the large vessels, downward to the lower right border, and lastly to the apex. By gently raising the apex of the heart the amount of fluid in the pericardial cavity can be seen. The normal amount is about a teaspoonful, but it may be increased to 100 c.c. in cases where the death-agony is prolonged. Pericardial adhesions should be broken through with the fingers. If this is impossible, the heart must be incised through the pericardium.

External Inspection of the Heart.-Determine first the position, size, and shape of the heart, and the degree of distention of the different parts. The right ventricle and both auricles are usually distended with blood, which may be fluid as in death from suffocation or more or less coagu