downward by the knife held transverse and flat, so as to avoid injuring the esophagus and aorta.

The procedure is the same for both lungs. Once in a great while the apex of a lung will be found so firmly adherent by dense scar-tissue that it can be freed only by using the knife.

The primary or main incision into a lung is a long, deep

FIG. 7.-Method of incising the lung (Nauwerck).

cut from the apex to the base and from the convex surface to the root, slitting the primary bronchus, and thus not cutting it off from its branches to the upper and lower lobes (Fig. 7). To incise the left lung, place it with its inner or median surface and root downward on a board and with its base toward the operator. The left thumb steadies the lower lobe; the first finger reaches between the two lobes almost to the primary bronchus; and the rest of the fingers should hold the upper lobe.

The right lung is most easily incised by placing it in the same position, but with the apex toward the operator; in other words, always place the anterior edge of a lung beneath the palm of the hand. Some prefer to place each lung on its lower or diaphragmatic surface for incision. The right middle lobe is incised separately by a cut extending transversely in its greatest diameter.

The bronchi and blood-vessels should be opened up for some distance with small probe-pointed scissors-as a rule from the surface of the section-cutting through the overlying lung-tissue. In some cases, however, it is best to open up both the blood-vessels and the bronchi from the outside of the lung before incising it. The order to follow is vein first, then artery, and finally the bronchus.

Secondary cuts into the lung are to be made parallel to the main incision.

The bronchial lymph-nodes should be incised from the outside of the lung.

Organs of the Neck.-The operation of the removal of the organs of the neck is greatly facilitated if it is possible to continue the primary skin-incision up to the chin. In other cases dissect the skin from the larynx and muscles of the neck as far up as possible. In like manner free the muscles, esophagus, and trachea from their attachments laterally and posteriorly. Then allow the head to drop well back over the end of the table, and pass a long, slender-bladed knife up between the skin and the larynx, just behind the symphysis of the lower jaw, until the point of the knife appears beneath the tip of the tongue. From this point the knife is carried with a sawing motion down first one ramus of the jaw and then the other, dividing laterally the glossal muscles as far back as the posterior pharynx. The knife is next carried up behind the esophagus, and the posterior wall of the pharynx divided as high as possible. Pass the left hand up inside of the neck and draw down the tongue. Then cut the attachments of the soft to the hard palate, carrying the knife well out so as not to injure the tonsils. Any remaining attachments are usually easily severed by

pressing the tongue first to one side and then to the other, and cutting close to the roof of the pharynx.

Each lobe of the thyroid gland is to be incised in its greatest diameter.

Next cut through the middle of the uvula and examine all of the pharynx removed. Incise the tonsils vertically. The esophagus is to be slit in the median line posteriorly; if it is normal, the larynx and trachea are then slit in the posterior median line also, thus splitting the esophagus in two.

The Abdominal Cavity.-The order of removal of the abdominal organs varies with different operators, and under varying circumstances with the same operator. The gastro-intestinal tract, including the liver and pancreas, may be removed before or after the genito-urinary tract. The spleen as an organ by itself is often the first to be removed. The early removal of the liver is occasionally advantageous for the sake of the additional space obtained for the examination of the other organs. It is well to practise the different methods of procedure, so that in a difficult case the best may be selected, because the examination of the abdominal cavity, especially in cases of extensive disease with numerous adhesions, is often one of the hardest tasks in postmortem technique. As a rule, it is best to follow the usual order as long as possible, gradually removing the more or less normal or uninvolved organs. Occasionally it may be advisable to remove the organs en bloc, so as to be able to approach the problem from all sides.

In all cases of acute peritonitis it is best before removing any organ to search for the source of the infection, paying particular attention to the vermiform appendix, to the gastrointestinal tract, and, in females, to the pelvic organs.

The order of removal of the abdominal organs adopted in this book for the majority of cases is that which seems the simplest and most natural-namely, to remove first the spleen as an organ essentially by itself; secondly, the gastrointestinal tract, including the pancreas and liver, which forms the upper layer; thirdly, the genito-urinary tract or middle layer, leaving the circulatory tract, the lowest layer, to be opened and inspected in situ. If, however, it proves neces

sary to open a part of the gastro-intestinal tract in situ, it will be neater perhaps to remove the kidneys and spleen first. Occasionally at private autopsies it may be unnecessary to examine the intestinal tract; under these circumstances it is important to be able to get at the different organs without taking out the intestines.

The Spleen. As a rule, the spleen can easily be drawn forward from its bed behind the fundus of the stomach, beneath the diaphragm, and lifted on to the lower edge of the ribs on the left side without cutting its vessels. The organ is then to be incised in its greatest diameter while thus firmly fixed between the left hand and the ribs; or the vessels may be cut close to the hilus and the spleen incised after being placed on a board.

In cases of adhesion to the diaphragm the spleen must be handled carefully while the fibrous attachments are torn or cut through, for the capsule is easily ruptured. Occasionally it is advisable to cut out with the spleen the portion of diaphragm attached to it.

The important anatomical structures to be noted in the macroscopic examination are the capsule, trabeculæ, bloodvessels, lymph-nodules, and pulp. The weight of the spleen, according to Orth, varies from 150 to 250 grams. The average weight is put at 171 grams. The spleen measures 12 X 7.5 X 3 cm.

The Gastro-intestinal Tract.-The first step is to examine externally, more or less carefully according to the clinical symptoms, the whole tract from the stomach to the rectum, if it has not already been done at the primary inspection of the peritoneal cavity. The main points to notice are distention or contraction of the intestines, injection of the blood-vessels, thickening of the wall, especially in the lower part of the ileum, adhesions, exudations, etc. Inspect the mesentery, its length, the amount of fat, and the size of the lymph-nodes; incise the latter to determine color and consistency. Examine the mesenteric vessels if any evidence of infarction of the intestine is noticed. The portal vein and its branches should be opened up in situ, in all cases of ab

scess of the liver or of secondary deposits in it of malignant growths, before the gastro-intestinal tract is removed. As a rule, it is not necessary to open any part of the gastro-intestinal tract in situ. The operation can be performed much more neatly at the sink. The duodenum is often opened for the sake of investigating the flow of bile from the gall-duct, but except in cases of jaundice the operation must be looked upon largely as a physiological experiment.

Free the omentum from the transverse colon by putting it on the stretch and dividing it with the knife close to the colon. Then begin the removal of the large intestine by drawing the sigmoid flexure forcibly forward and cutting the mesocolon close to the gut, first down to the rectum, then upward to the transverse colon. Free the latter by dividing the two folds of the lesser omentum, if not already cut through, which unite it to the stomach. The ascending colon is to be freed in the same manner as the descending portion. Care should be taken not to injure the appendix. If the lower part of the sigmoid flexure be now stripped upward a short distance with the fingers, so as to force the intestinal contents out of the way, the gut can be divided just above the rectum without fear of the feces escaping.

Place the freed intestine in a pan or pail, and as the small intestine is divided from its mesentery deposit it in the same receptacle. To remove the small intestine, begin at the cecum, and, while lifting the ileum with the left hand strongly enough to keep the mesentery constantly tense, cut the latter close to the intestine by playing the knife easily backward and forward across it with a fiddle-bow movement. Continue the operation until the duodenum is reached. The mesentery can now be dissected from the duodenum and removed, or the mesentery, duodenum, pancreas, and stomach can be removed in continuity with the intestine by carefully dissecting them off the underlying structures. The operation is perhaps more easily accomplished by freeing the organs from below upward. First cut down through the diaphragm and free it around the esophagus. Then separate the stomach from the liver by means of the thumb and fingers