which exposes the cavities of the body, for which purpose a rather broad but short and stout knife is used, fitted into a thick and broad handle; second, incisions into the viscera themselves. For the purpose of avoiding a number of short cuts, which should never be made, a knife should be used as long as an ordinary amputating-knife, but with broader blade, for making sections of the brain and the larger viscera at one sweep. The object in making these sections of the viscera in this manner is to expose a broad and even surface for examination without tearing the tissues, and this can only be done with a long and rather broad knife. For finer dissections an ordinary scalpel may be used. The blade of the first knife should be about three and a half inches long by one inch in breadth, with a handle four inches in length. The long-section knife should have a length of eight and a half inches, a breadth of one and a quarter inches. Other instruments which are of use in the autopsy are a saw, a hammer with hooked handle for removing the calvarium, a saw slightly curved for exposing the spinal cord, a costotome for dividing the ribs when ossified, and an enterotome for slitting the intestines or trachea. A few probes of different lengths, the chain and hooks of the dissecting-room, and a blow-pipe complete the necessary appliances of the post-mortem table. A brass gauge marked in millimeters is sometimes used for the purpose of making such measurements as the thickness of the ventricular walls, etc. A pair of small scissors having one blade pointed, the other probe-pointed, is often of use in laying open a small duct like the common bile-duct, but the necessity for such an examination seldom occurs to the medical jurist. Where the weight of the viscera is likely to be of importance, a pair of scales is a necessity. For the purpose of estimating the amount of fluid found in a large cavity, such as the chest, a large sponge is useful with which to remove the fluid, which is afterward expressed into a vessel of suitable size and measured in a graduate provided for the purpose.

Usually no autopsy ought to be performed earlier than twelve hours after death, except in cases where death has resulted from violence, and the German regulations do not permit an autopsy until twenty-four hours after. Even in cases of death by violence it is questionable whether an earlier examination is advisable, for it is possible to make the external examination as early as necessary, deferring the autopsy proper to the usual time after death. The Bishop case will no doubt occur to the reader as an instance where neglect of this precaution was the cause of great annoyance to the examiners, who were even indicted for their precipitation in hastening the autopsy. Yet it was because of their fear that post-mortem changes would obscure the peculiar condition which they sought in the nervous system, that they hurried the autopsy, with most unpleasant results to themselves. However desirable an early examination may be, considerations of humanity and obvious expediency will induce the examiner to defer the dissection until the lapse of at least twelve hours and possibly a full day after death. It is essential that an autopsy should not be held by artificial light. Differences in color, particularly such as denote the existence of pathological changes in the nervous system, are not easily appreciated except by daylight. Frozen bodies should be thawed out in a warm room, but the thawing process ought never to be hastened by artificial means.

In corpses other than those of new-born infants, the order in which

the examination should be made is as follows: first, the brain and cranial cavity; second, the vertebral column and spinal cord; third, the thorax; and lastly, the abdomen. The skull is to be exposed by an incision through the scalp made from ear to ear, over the vertex. The two flaps are then reflected anteriorly and posteriorly sufficiently to give room to saw through the calvarium. Any ecchymoses not before visible are now to be noted, and the surface of the cranial vault examined for fractures. If found, they should be traced throughout their whole extent, especially when, as is often the case, they extend into the base. In this situation they can be more conveniently followed after the calvarium has been removed. For this purpose usually it is directed that the saw-cut be made in a perfectly circular manner around the skull. There is one disadvantage connected with this method, which is, that when the calvarium is replaced, as the cut surfaces are horizontal, it is easy for them to glide apart. Thus an unsightly ridge or depression may be left over the forehead, marking the edge of the sawn bone, after the soft parts have been drawn together and the body prepared for burial. As it is desirable to conceal all traces of the autopsy subsequently, when possible, a modification of the usual method of applying the saw is here suggested. Instead of the circular cut around the cranium, two saw-cuts are made, one on each side of the skull, commencing anteriorly in the median line just above the superciliary ridge, running backward and terminating one inch above the external auditory meatus. Commencing a little below the "lambda," two other similarly oblique cuts are made, which join the first at their termination. The calvarium may now be removed. The dura should be cut through if adherent. The calvarium should never be violently torn off, for fear of injuring the brain. It will be seen that when replaced the obliquity of the saw-cuts prevents the calvarium from sliding in either direction. An ingenious method of still further securing the calvarium when replaced is practiced at the Methodist Episcopal Hospital of Brooklyn. In each of the anterior cuts, a little in front of their termination, a second saw-cut two inches long is made, parallel to the zygoma. Into these short cuts a two-inch roller is passed directly through the skull from side to side. The calvarium is then replaced and the ends of the roller bought together over the vertex and pinned. This renders it impossible for the calvarium to be subsequently moved. The temporal fascia should also be sutured before the scalp is replaced. (Fig. 1.)

After the removal of the calvarium its interior is to be examined with regard to the condition of the internal table, extensive shattering of which may exist without corresponding injuries of the external table. The dura mater is then to be inspected and its condition noted. Extra-dural clots are to be turned out into a graduate and measured—which is more exact than to make the usual loose statements, "a quantity of clotted blood," "a large clot." The meningeal arteries are to be carefully examined, especially where extra-dural clot exists, as they are frequently the seat of the hemorrhage. The longitudinal sinus may then be slit up and examined, after which the dura is to be divided and the arachnoid and pia inspected. Particular attention is to be given to the membranes with reference to the existence of such conditions as lepto- or pachymeningitis. The explanation of many an act of violence may often be found in just such pathological changes. The vascularity of the membranes is also to be noted. After this the brain is to be removed, the

section of the cord being made by a long knife, as low down as possible, to secure the whole of the medulla for examination with the brain. The base of the skull is now accessible for examination after removal of the dura which lines it. The sinuses of the base can also be inspected.

Bandage

Fig. 1.

The brain should then be weighed. The circle of Willis is then to be examined for miliary aneurism, emboli, etc., and also the middle cerebrals, so frequently the seat of disease. In cases of suspected poisoning by narcotics, particular attention is to be given to the state of the membranes, the sinuses, and the intra-cerebral circulation. In poisoning by opium the veins are said by some to show a slightly deeper color than the arteries. This seems doubtful in view of the imperfect aëration of the blood which occurs in these cases. At any rate, this disappears after exposure to the air, as both veins and arteries soon take up oxygen and become of uniform color. In estimating the amount of congestion present in the vessels of the central nervous system, it is never to be forgotten that the injection of an embalming fluid, particularly where a vein has not been opened and the vascular system washed out previous to the injection of the preservative fluid, is perfectly competent to produce an appearance which it is difficult to distinguish from the extreme congestion of narcotic poisoning or other pathological congestions. There will be found the same arborescence, the same punctate appearance

of the white matter on section, the same turgescence of the choroid plexuses. The coloration of arteries and veins will be uniform, however. In the Harris case the defense, singularly enough, overlooked this obvious point, for the body of Mrs. Harris had been embalmed previous to burial. In this connection it is also of some importance to remember that undertakers use for this purpose a small force-pump, and that as the fluid is forced through the vessels it takes up the coloring matter of the blood and produces the appearance above referred to. The writer has verified this statement many times in the dissecting-room. The more dependent portions of the brain are also apt to have a congested appearance even when no injection has been made, simply from the gravitation of fluids. The fact that the congested appearance is restricted to the more dependent parts will prevent this condition from being mistaken for true congestion.

The dissection of the brain is next in order. To make proper sections here, it is imperative that the knife used should be as keen as possible. The cut through the hemisphere should be made with a quick drawing motion with the minimum of pressure, otherwise the soft nervous tissue will certainly be torn as the knife drags and tears its way through. It has been recommended by Virchow that the incisions should commence from within and terminate at the pia mater, which is not, however, divided, but serves as a binding to keep the various sections together in proper serial order. In this manner the relations of the divided structures are preserved, and it is possible to reëxamine them in their natural order, if desirable. With regard to the thickness and number of the sections necessary, it may be observed that in cases where it is likely that the condition of the brain will form an important part of the case, it is easy to make too few sections, impossible to make too many. In sections half an inch thick many a spot of softening or small hemor rhage may lurk concealed. This is particularly true of the "pons" and medulla, where very small lesions may be the cause of very formidable symptoms. It is in this particular part of the brain, therefore, that the sections should be most numerous, perhaps even microscopic. It is recommended that the first sections be made from within the great longitudinal fissure outward serially until the level of the corpus callosum is reached. At this point the lateral ventricles are to be opened by two incisions a quarter of an inch on either side of the raphe. The cavity of the ventricle once found, the rest of the ventricle may be exposed by cutting through the roof with the probe-pointed scissors, following the floor with the probe blade. The presence or absence of serum in the ventricular cavity is to be noted, and its quantity, if present. For the purpose of measuring the contained fluid, it may be withdrawn from the cavity of the ventricle by the aid of a small syringe, and measured in a graduate. Some writers recommend that the ventricles be opened first before any other incisions are made in the brain, lest the manipulations necessary for the other incisions should so lacerate the substance of the brain as to permit the escape of fluid. It is difficult to see how a satisfactory dissection of the ventricles is possible without removing so much of the cerebral lobes as to bring the cut surface on a level with the corpus callosum which forms the ventricular roof. It is evident, however, that the utmost care is needed to prevent the occurrence of lacerations in handling so soft a tissue as that of the brain. The most important parts

to be examined in the ventricles are the choroid plexuses. After ascertaining their condition, the pillars of the fornix are to be divided and reflected, when the velum interpositum will come into view, with the veins of Galen. The state of the vessels in this tissue is to be noted, after which the velum is to be reflected, and the cavity of the third ventricle may be then inspected, together with the corpora quadrigemina, the geniculate bodies, and the iter.

With regard to the further dissection of the brain, which involves the making both of macroscopic and microscopic sections, it has already been stated that the examiner, in a certain class of cases, is more likely to make too few than too many. Indeed, the only limit which can be placed on the number of the sections to be made in cases like that of Harris or Buchanan is that which time imposes. In ordinary instances, sections of the convolutions made at intervals of half a centimeter will usually be sufficiently close, although it is quite possible, as before stated, for small foci of softening to lie concealed in sections of this thickness. Much must be left to the judgment of the examiner in each individual case with regard to the thickness and number of the sections. Virchow's remark in this connection is significant: "The less you find, the greater ought to be the number of the sections." Microscopic sections will rarely, if ever, be required in any number save in the regions of the medulla and pons. Where these are required, the examiner may remove the parts mentioned and preserve them in alcohol for the subsequent microscopical examination. In the examination of the internal capsule, particular attention should be given to that portion supplied by Charcot's artery of hemorrhage, the lenticulo-striate artery. This is a branch of the middle cerebral, which, passing through a separate hole in the anterior perforated space, runs upward between the lenticular nucleus and the external capsule, then perforates the internal capsule, terminating in the caudate nucleus. In the dissection of the basal ganglia the incisions should be made radially in an antero-posterior direction, converging toward the peduncle.

The floor of the fourth ventricle should be inspected for the petechial hemorrhages, which are of quite frequent occurrence in this vicinity. In cases where fracture of the skull has occurred they are not uncommon, and are probably the result of concussion. The writer has also seen them in cases of death from opium poisoning, and from gunshot wound of frontal lobe. In one case they were in the pneumogastric nucleus, on each side. It has been shown that they also are found in this vicinity in criminals who have been put to death by electricity.

The examination of the spinal cord is next in order. There is no part of the autopsy which should be conducted with more care. It has been conclusively shown by Van Giesen that injuries may be inflicted on the cord by rough handling during its removal, which may simulate softening, displacement of both gray and white matter, etc. For a complete account of the various injuries which may be inflicted on the cord in process of removal, the reader is referred to the original paper, which appeared in the New York Medical Journal, June, 1892, "A Study of the Artefacts of the Nervous System." The conclusions which the writer draws which are to be noted in describing the technique of the removal of the cord from its bony canal, are as follows: The use of mallet and chisel is inadmissible for the purpose of cutting through the lamina of