Postmortem 
EAAil^rl^B 
Virchow, METHOD OF PERFORMING POST-MORTEM 
EXAMINATIONS. Fioj, 4r POST-MORTEM EXAMINATIONS, 
WITH 
ESPECIAL REFERENCE TO MEDICO-LEGAL 
PRACTICE. 
BY 
PROFESSOR RUDOLPH VIRCHOW, 
OF 
THE BERLIN CHARITE HOSPITAL. 
TRANSLATED FROM THE SECOND GERMAN EDITION 
Dr. T. P. SMITH. 
PHILADELPHIA: 
PKESLEY BLAKISTON, 
1012 WALNUT STREET. 
1880. TRANSLATOR’S PREFACE. 
In the following paper Prof. Virchow gives some 
account of his early experience as Prosector in the 
dead-house of the Berlin Charite Hospital, and traces 
the subsequent development, under his auspices, of a 
systematic method of conducting post-mortem exami- 
nations. He also criticises, explains, and illustrates 
the regulations which have been promulgated through- 
out Germany for the guidance of medical jurists in 
performing autopsies and drawing up reports. (Regu- 
lativ fur das Verfahren der Gerichtsarzte bei den 
gerichtlichen Untersuchungen menschlicher Leich- 
rlame. Herausgegeben von der Konigl. wissenschaft- 
lichen Deputation fiir das Medicinalwesen, 8, 1875.) 
fl € also gives three interesting cases in which the 
post-mortem examinations were performed by himself, 
-fhe order of sequence enjoined by the regulations 
b?ing closely adhered to. An examination of these 
cases will show that nothing has been omitted which 
throw any possible light on the cause of death. VI 
PKEEAOE. 
They may be taken as examples of the way in 
which all post-mortem examinations for medico-legal 
purposes should be conducted. Lest the length of 
the notes should seem excessive, Prof. Virchow ex- 
pressly states that three hours are sufficient, even for 
complicated cases. It will be obvious, on referring 
to the details, that only by following out a systematic 
plan could a thoroughly complete examination be 
performed in that time. Such an examination, how- 
ever, would be infinitely more satisfactory than one 
in which important points were overlooked, and only 
discovered on subsequent investigation. It is much 
to be wished that a method similar to the one which 
has received the high sanction of Prof. Virchow were 
adopted in this country. 
T. P. SMITH. CONTENTS. 
PAG E 
Historical Introduction 9 
Autopsies foe Clinical and Medico-Legal Purposes . . .11 
The Regular Method, and Deviations in Individual Cases . . 15 
Relation of the Skull-Cap to the Dura Mater . . . 15 
Order of Sequence and Plan to be pursued 16 
Position of the Diaphragm >16 
Opening op the Thorax and Abdomen 17 
Color op the Parts, especially of the Blood . . . . 20 _ 
Fullness of the Vessels . . . ■ 22 
Abnormal Contents of the Cavities 26 
Examination op the Thorax 26 
Examination op the Abdomen 29 
Intestines, Liver, Duodenum .... . . 29 
Stomach, Pancreas, Urinary and Generative Organs . . 31 
The Method of Making Pathological Incisions . . . .33 
Instruments 35 
Number op Incisions 40 
Preservation of the Connections of the Divided Portions . 40 
Dissection of the Brain 42 
Dissection of the Heart ......... 45 
Cases as Examples 55 
I. A Man unknown. Death prom Suffocation, Caused by 
Pulmonary Hemorrhage and (Edema . . . . 56 
IT. A Man known. Gunshot wound of Head (Suicide). Death 
from Pulmonary (Edema 68 
III. A Man known. Gunshot wound of Chest (Suicide). Death CONTENTS. 
PAGE 
from Double Pleuritis, Peri- and Myo-cabditis, Phleg- 
monous Mediastinums, and Peritonitis 85 
IY. A Twin Child, Still-born, at the Middle of the Tenth 
(Lunar) Month. Indications of Immaturity. Erysipelas 
of the Scrotum, Pharynx, and Brain. Incipient White 
Hepatization of the Lungs 103 
Method of Opening the Thorax 117 
Incision through the Sterno-Clavicular Joint, the First and 
Other Costal Cartilages 118 
Regulations (January 6, 1875, Confirmed February 13, 1875) for 
the Guidance of Medical Jurists in Conducting Post-mortem 
Examinations for Legal Purposes 120 
I. General Directions, g g I—B 120 
11. Proceedings at Post-mortem Examinations, g g 9—26 . . 123 
External Examination, § 13 124 
Internal Examination, g g 14—22 ...... 126 
The Head, g g 15, 16 126 
The Yertebral Column, g 17 128 
The Neck., Thorax, and Abdomen, g g 18—22 . . . 129 
General Directions, g 18 129 
The Thorax, g 19 130 
The Neck, g 20 132 
The Abdomen, g 21 133 
Oases of Poisoning, g 22 136 
New-born Children, g g 23, 24 138 
Examination of Other Parts, g 25 141 
Closure of the Cavities, g 26 141 
111. Drawing up of the Protocol and Report of the Exami- 
nation, g g 27—31 141 METHOD OF PERFORMING POST-MORTEM 
EXAMINATIONS. 
On taking up my appointment, in the year 1844, 
as assistant to Robert Froriep, the Prosector at the 
Charite, I found that the autopsies were at that time 
somewhat irregularly and unmethodically performed. 
The Prosector himself made but few examinations, 
and these only by special requisition; the greater 
number were performed, without any technical plan, 
by the Charite surgeons—young medical men, subse- 
quently styled “ assistants,” who had not yet passed 
the State examination. No minutes of the proceed- 
ings were made at the time, and only when the 
examination was over were notes taken down from 
memory. Froriep himself but very rarely gave a 
course on post-mortem examinations ; he did so only 
once during my experience. Notwithstanding his 
eminent scientific attainments and his great manual 
dexterity (perhaps, indeed, on account of these his 
qualifications—at any rate, as a consequence of their 
limited practical employment), there was but little 
thoroughness in Froriep’s method ; in many respects, 
indeed, it was so ill adapted for the purpose that it 
was a matter of difficulty to make any discoveries by 
its means. 
Thus, to take only one example, it was his custom, 
when examining the spinal cord, to divide it longitu- 
dinally, from before or behind, by one long, straight 10 
METHOD OF PERFORMING 
cut, and to dissect it in two equal lateral halves. This 
certainly made a very elegant section, and to do it 
properly required practice and care; but, however 
well it was performed, there were but very few cases 
in which it was of any use. The natural consequence 
was that Froriep’s attention was directed principally 
to the membranes and roots of the nerves, and that 
the commonest and most important alterations in the 
white substance remained unnoticed. 
I therefore had a double task to perform, especially 
after I became Prosector, in 1846. On the one hand, 
I aimed at causing the autopsies to be made by one 
person, at introducing a system of regular note-taking, 
and of collecting these notes, in order to obtain a use- 
ful series of reports. This was a matter of no great 
difficulty, after many startling incidents had shown 
how thoroughly erroneous were the results obtained 
in the absence of technical skill. It very soon hap- 
pened that every clinical teacher and class director 
became interested in the fact that the post-mortem 
examinations were made by my hand. When, in the 
year 1849, I accepted the call to Wurzburg, I left 
behind me a large collection of reliable reports. 
Unfortunately, only a few fragments of these were 
forthcoming when I was recalled to the Charite, in 
1856. 
On the other hand, it was necessary to discover a 
regular method for pathologico-anatomical investiga- 
tion, and to introduce a definite employment of tech- 
nical terms, which could be adhered to as a rule for 
all ordinary cases. Such a method I have perfected 
as years have rolled on, and it has now been suffi- 
ciently long in use for its value to have been tested 
by experience. It has naturally been formed into 
shape from a double point of view. The first require- 
ment was that it should permit of the most complete 
insight possible into the extent of the alterations in POST-MORTEM EXAMINATIONS. 
11 
every organ; and in the second place, in order to 
provide for a distinct demonstration, adapted for 
educational purposes, such an arrangement was ne- 
cessary as would cause the least possible disturbance 
in the connection of the parts examined. There were, 
therefore, these two problems, to some extent opposed 
to each other. They have, nevertheless, been solved 
in a satisfactory manner. 
I have at present no intention of discussing this 
method in all its details. This has been done, to a 
certain extent, in the recent regulations drawn up 
for the guidance of the medical jurist when making 
autopsies for legal purposes, by the Royal Committee 
of Science for Medical Affairs, under date of January 
6 of this year (1875), and confirmed by the Minister 
of the Ecclesiastical, Educational and Medical De- 
partments, under date February 13 of the same year, 
and which are appended to this work. 
It is true that these regulations do not correspond 
in all particulars with our system. This depends, in 
part, upon the difference in the nature of the tasks— 
which, for example, is very striking in every step of 
the external inspection, this latter being far more im- 
portant for the medical jurist than for the patholo- 
gical anatomist. Another point is that it has been 
thought expedient, in the deliberations of the Com- 
mittee, to make certain alterations, which permit of a 
more simple and rapid manipulation of those organs 
which are less important for legal purposes. Taken 
as a whole, the regulations are invariably an expres- 
sion of the knowledge, acquired through long experi- 
ence, of the most suitable arrangements for conduct- 
ing post-mortem examinations. 
The necessity for superseding the old rules of 
November 15, 1858, had gradually become very 
urgent. Strictly speaking, these were already anti- 
quated at the time of their issue. They had no 12 
METHOD OP PERFORMING 
sooner appeared than I pointed out their defects, and 
drew particular attention to the necessity of insisting 
—in autopsies for medico-legal purposes, as in every- 
thing else now—upon completeness of examination 
and exactness of method, both in the investigation 
and in note taking, so that it might be decided subse- 
quently, though not in anticipation, whether there 
was any significance or importance in what was ob- 
served, or whether it was accidental and unessential.— 
(.Deutsche KliniJc, 1859, No. 2.) There was, in truth, 
even at that time, no difference of opinion on these 
points. The regulations certainly continued in force 
for fifteen years ; this, however, is accounted for, not 
merely by the legitimate bias of the authorities against 
too frequent changes, but still more so by the recog- 
nition of the fact that, before making demands which 
in no trifling degree exceeded the limits of that 
amount of technical medical training which had pre- 
viously been deemed sufficient, it would be necessary 
first to train a larger number of well-educated medical 
jurists. This held good, not merely with regard to 
the microscopical examination necessary in so many 
cases, but even with reference to the ordinary ana- 
tomical technicalities of post-mortem examinations. 
So long ago as 1859 I indicated in my lectures the 
direction which the change should take. I then 
stated as follows : “ The present generation is con- 
versant with pathological anatomy only as a supple- 
ment of the clinic. As a rule, the clinical teacher 
determined while the patient was alive which organ 
was to be the object of investigation; and the autopsy 
likewise was usually confined to that organ, or at 
least dealt with all the others only in a secondary 
manner. The clinical anamnesis, consequently, de- 
cided the course of the anatomical examination. We 
all know what was the result. The fact is that we 
can further the advance of medical science in the POST-MORTEM EXAMINATIONS. 
13 
most essential manner by acquiring the habit of 
submitting all the other organs of the body to a min- 
ute examination; for it is obvious that we can do as 
much by anatomical as by clinical examination.” I 
ought, indeed, perhaps to have said that we have to 
do more by anatomical than by clinical observation, 
for the one reason that the anatomical examination 
must be completed once for all, and does not admit of 
repetition ; whereas, we can at the bedside, as a rule, 
return again and again to the same case, and if any 
omission has occurred in one examination, it can be 
remedied in the next or a subsequent one. But, 
irrespective of this, there is a great difference between 
being able to get directly at an internal organ and 
examine it in every particular, and having to content 
ourselves with following out and realizing certain 
symptoms. 
Medico-legal technics—with all due deference to 
the independence of forensic medicine—will, however,- 
always go hand in hand with pathological anatomy ; 
for this latter is the more universal; it has to deal 
with cases of all kinds, and for that reason is a great 
protection against that one-sidedness with which 
medico-legal practice is so much encumbered. As a 
matter of fact it must be conceded that the great 
majority of medico-legal reports have exhibited such 
an astonishing sameness, even in their phraseology ; 
such a very peculiar style, nowhere else to be found ; 
such a want of real objectivity, that it was an ex- 
tremely tedious business to read through any number 
of them consecutively. There was such an amount of 
similarity among many of them that it might have 
been thought that they all referred to the same case. 
The number of better educated physicians has 
gradually increased. The new examination for the 
North German Bund, and more recently for the 
German Empire, recognizes pathological anatomy as 14 
METHOD OP PERFORMING 
a special subject, and also tests the candidates in 
pathological histology. A more intimate knowledge 
of pathologico-anatomical technics and microscopical 
manipulation has been thereby introduced; and it 
was therefore high time, considering that the exami- 
nation rules of September 25th, 1869, had now been 
six years in force, to lay down similar directions for 
the forensic examination, and afterward to institute 
regulations for conducting autopsies for medico-legal 
purposes. This has now been done, and it is to be 
hoped that the innovation will prove very beneficial, 
and promote the efficacy of the laws; for a not insig- 
nificant portion of the administration of the criminal 
law is entirely dependent upon a correct and object- 
ive examination on the part of the medical jurist. 
Experience, indeed, teaches us that the great ma- 
jority of cases in which the Courts are compelled to 
appeal for advice to the Medical Colleges and to the 
Committee of Science for Medical Affairs, refer to 
those autopsies in which either the examination or 
the note taking has been so irregularly performed 
that the nature of the case still remains ambiguous. 
It would, I am sure, be a matter of no difficulty to 
collect a great number of examples in which the 
faulty performance of the autopsy has rendered 
obscure cases in themselves clear and simple, and has 
made unintelligible those which were at all ambiguous. 
This observation explains the increasing number of 
the revision remarks which are so complained of by 
many physicians, and also the necessity for inserting 
many detailed directions—perfectly obvious, but not 
always attended to—in the regulations for the due 
performance of autopsies. The revision remarks 
having been brought to the cognizance of the State 
Attorney and the Court, the prosecution of an ac- 
cused person can be resumed; this, for a long time, 
had not been possible, owing to faulty examinations POST-MORTEM EXAMINATIONS. 
15 
and the very arbitrary opinions expressed by those 
who performed them. 
After such experiences—which, considering the evi- 
dence obtained in the medical examinations, with 
reference to the ordinary way in which cases are in- 
vestigated and observed, may easily extend in various 
other directions—the practical necessity of laying down 
strict rules appeared quite imperative. In like man- 
ner, there could be no doubt that, for educational 
purposes and for the majority of ordinary cases, a 
methodical procedure in post-mortem examinations 
presupposes the establishment of a definite plan. 
It is scarcely necessary to point out that there are 
many cases in which deviations from this method are 
not merely allowable, but also absolutely necessary. 
The individuality of the case must often determine 
the plan of the examination. But we must not begin 
with individualizing, nor make a rule of the excep- 
tions. The expert may allow himself to make alter- 
ations, supposing they are well grounded, but he must 
be able to remember his motive for so doing, and also 
to state it. 
For this purpose, however, a full and intimate ac- 
quaintance with the reasons why the plan or rule has 
been laid down is quite imperative. The method 
should be practiced, not mechanically, but system- 
atically, as it has for its basis well-weighed experi- 
ence, and not mere casual observations. He who is 
conversant with these reasons will also be able to 
judge of their correctness, and of the occasions when 
a departure from the rule is indicated. Thus the 
rule will be that when the cranial cavity is opened, 
the exposed parts—viz., the dura mater, the great lon- 
gitudinal sinus, the pia mater, the surface of the 
cerebral hemispheres—must be first examined, and 
described in succession. But if the dura mater is ad- 
herent to the skull cap, the best plan is to divide the 16 
former before forcibly detaching the latter, and to 
remove the skull cap with the dura mater adhering 
to it; for if long and violent attempts be made to 
separate the skull cap from the still closed and adher- 
ent dura mater, this latter usually gets torn, the 
brain itself crushed, and the parts so altered that 
sometimes their original condition is quite undiscover- 
able. In new-born infants and in children these parts 
are, as a rule, adherent; so that in these young sub- 
jects, if we wish to avoid the risk of converting the 
brain into a mass of pulp, we must make an altera- 
tion in the method adapted for examining adult cases. 
But if these adhesions are found in adults as indi- 
vidual appearances in exceptional cases, we must also 
in such cases make an alteration in the method to be 
pursued. 
METHOD OF PERFORMING 
In a systematic and scientific performance of an 
autopsy nothing is more difficult, and at the same 
time more important, than the insight into the rea- 
sons for pursuing a definite order of sequence in every 
detail of the examination. Let us therefore consider 
this point somewhat minutely. The course of the ex- 
amination is generally dependent upon the order of 
succession. If for ordinary cases we require a defi- 
nite process and a prescribed order, we do so not 
merely because such an arrangement is the surest 
guarantee for the completeness of the examination, 
and the best preventive against omitting important 
parts, but for the still greater reason that an un- 
methodical plan is the greatest possible obstacle to the 
subsequent collection of valuable reports. An un- 
methodical examination artificially and prematurely 
obliterates the existent condition of the parts. 
Let us take a few examples. In many examina- 
tions the position of the diaphragm is of the greatest 
importance. This, generally speaking, cannot be 
determined if we open the thorax before the abdomen, POST-MORTEM EXAMINATIONS. 
17 
or even at the same time; or if, after first opening the 
abdomen, we do not examine the diaphragm before 
opening the thorax. In former times, when the phy- 
sicians allowed the assistants to make the post-mortem 
examinations, the custom was almost universal for a 
dissecting-room servant to open the thorax and ab- 
domen before the arrival of the medical staff. The 
object was to save time and trouble. It soon became 
evident in forensic practice that such a proceeding as 
this made it impossible to define exactly the state of 
the thorax and its contents. In new-born children 
especially, it is necessary to ascertain carefully the 
position of the diaphragm, because in them the main 
question hinges upon the establishment of respira- 
tion ; and not merely this, but the extent to which 
respiration has been carried is the important point. 
On this account the direction was that the abdomen 
should be opened first. The regulation of 1858 was 
in this respect quite correct. Section 17, a, ran as 
follows: “ After the abdomen has been opened, the 
position of the diaphragm is to be noted with refer- 
ence to the corresponding ribs; and to ascertain this 
correctly in new-born children the abdomen should 
be opened first, and subsequently the thorax and 
head.” Unfortunately, this very proper direction was 
made obscure by the words immediately preceding it. 
They ran thus: “ The respiration test must now be com- 
menced, and for this purpose, (a) after the abdomen 
has been opened,” etc. This preface was altogether 
out of place, for we do not determine the position of 
the diaphragm with a view to the respiration test, but 
both are co-ordinate means for establishing the fact 
that respiration has been performed. Still worse, 
however, was the ambiguity involved in the choice of 
the expression “ opening.” Taken by itself the word 
is not synonymous with “ dissection,” but the medical 
jurists made use of “ opening” in the sense of “ dissec- 18 
METHOD OF PERFORMING 
tion,” and instead of opening and dissecting the 
thorax immediately after opening the abdomen and 
determining the position of the diaphragm, they fin- 
ished the dissection of the abdomen before they even 
opened the thorax. Indeed, this bad practice was so 
universal that even when, as occasionally happened, 
a more enlightened physician examined the thorax 
first, and then dissected the abdomen, he was blamed 
for so doing by the medical boards, in their revision 
reports. 
What, however, is the consequence of thus first 
dissecting the abdomen ? I will assume that in the 
removal of the spleen, the stomach and the liver, the 
diaphragm has not been cut, although this indeed 
frequently happens; but on cutting through the veins 
of the liver (in removing this organ), and on opening, 
as particularly directed, the inferior vena cava, it is 
impossible to prevent the blood escaping partially, or, 
if not coagulated, completely, from the right auricle, 
through the large venous trunks which have been 
opened. If, after this has been done, the thorax be 
examined, it is quite possible that the right auricle 
and the right side of the heart may be found col- 
lapsed and containing little or no blood, in cases 
where proper examination would have revealed an 
entirely opposite state of things. How often it hap- 
pens that the report is, in consequence, very different 
from what it ought to be, and the opinion based 
thereon also falsified! 
For this reason the new regulation directs, what I 
have for years taught, that, under all circumstances, 
the abdomen is to be first opened, but not dissected. 
It is only necessary in this stage to determine the 
position of the diaphragm, as well as that of the or- 
gans, any abnormal contents of the abdomen which 
may possibly be present, and the color of the parts 
exposed. Then the thorax is immediately to be ex- POST-MORTEM EXAMINATIONS. 
19 
amined, unless there is some cogent reason for depart- 
ing from the rule. The suspicion of poisoning is 
always admitted to be a reason of this nature, as in 
this case the whole of the examination centres in the 
stomach ; and every precaution must be taken to place 
it and its contents, without loss or change, at the dis- 
posal of the law. 
The regulation that, as a rule, the dissection of the 
abdomen is to follow that of the thorax, but, on the 
other hand, that the abdomen is to be opened and its 
general state determined before the opening of the 
thorax, has necessitated, in the new regulations, the 
altering of certain directions referring to the minutes 
of examinations. It is to be hoped that medical 
jurists will readily familiarize themselves with these 
changes, and it is not necessary further to allude to 
them. On the other hand, it appears to me that it is 
not superfluous to explain why it is that we ought to 
determine the general condition of the abdominal 
organs before opening the thorax. In reference to 
this, the new regulations order as follows, in Section 
18, para. 2: “In addition to this, the position, color, 
and other appearances presented by the exposed in- 
testines, and also the occurrence of any abnormal 
contents, are next to be specified, and the position of 
the diaphragm to be determined by examining it with 
the hand.” 
It is evident that the position of the abdominal 
viscera cannot be exactly determined after the thorax 
has been opened and the anterior attachments of the 
diaphragm, to a great extent, divided. The further 
the examination of the thorax proceeds, the more 
numerous the organs which are removed, and the 
more freely the connections between the diaphragm 
and parts of the thorax are divided, the looser does 
this muscle become, and the greater the displacement 
of the abdominal viscera toward the thoracic cavity. 20 
METHOD OF PERFORMING 
A further examination may reveal something pre- 
viously unnoticed, and necessitating a comparison 
between the position of the abdominal viscera and 
injuries of the abdominal walls, and we may wish to 
examine thoroughly the relations to each other of two 
of the abdominal viscera; but the previous opening 
of the thorax will render all such attempts nugatory. 
I need only mention those by no means rare cases in 
which incipient peritonitis is discovered, and where it 
becomes necessary to ascertain whether the peritonitis 
was caused by injury or was due to a pathological 
process in any one of the abdominal viscera. In a 
case where the spot which exhibits the signs of a 
limited peritonitis is not exposed when the abdomen 
is opened, it will scarcely be possible to determine 
the causal connection if the position of the viscera 
has been much disturbed before the spot has been 
discovered. 
With regard to the color of the abdominal viscera, 
we must especially bear in mind that the notion is 
even now very prevalent that arterial blood, and 
therefore the arterial vessels, in the dead body as in 
the living, are distinguishable by their deep red 
([hochroth) or bright red (hellroth) color. This notion 
is founded on a primary error. Arterial blood in a 
dead body is always of a dusky-red color. This is 
just as true with regard to the blood of the pulmonary 
veins and left side of the heart as to that of the 
aorta and peripheral arteries. Any one who has care- 
fully noticed the large arteries on the base of the 
brain, which, on account of their relatively free and 
superficial course, are very convenient for observa- 
tion; any one who has been impressed with their 
bluish-red, thoroughly venous appearance; any one 
who has carefully observed in the left auricle the 
dusky-red blood which has just come from the lungs 
and just been aerated, and this in persons who have POST-MORTEM EXAMINATIONS. 
21 
not died from suffocation, ought forever to be cured 
of the mistake of supposing that a dead body contains 
bright-red arterial blood. No recently exposed por- 
tion of a dead body has a bright-red color; the lung 
certainly may form an exception to this statement, 
but only when filled with air, in which case, even after 
death, a certain quantity of oxygen may be absorbed. 
And even in the lung this is not usually the case to 
the extent supposed. In this organ the tissue con- 
taining the blood is full of alveoli containing air, and 
thus, as when froth is formed, a whitish color is pro- 
duced, which, mixed with dusky red, produces a 
bright-red shade. This is beautifully seen in the 
lungs of new-born children. 
It follows, as a matter of course, and in individual 
cases it can be directly proved, that in no portion of 
the viscera of a dead body can arterial injection be 
recognized by the color test., Even when the ar- 
terial injection is very considerable, the color of the 
part may be just as bluish red or blackish red as in 
venous hypersemia. Whoever wishes to assure him- 
self on this point may do so by examining the kidneys, 
where, with the naked eye or with a simple lens, he will 
easily see the Malpighian corpuscles, purely ar- 
terial structures, appearing as very dark-red points 
or granules, in consequence of the fullness of their 
vessels. 
After death, however, the blood does not lose its 
power of absorbing oxygen, and of thereby assuming 
an arterial appearance, i.e., a deep-red color. This 
statement, indeed, must be taken with certain limita- 
tions, for there are some cases in which the blood, 
even before death, possesses a much diminished power 
of absorbing oxygen, and there are others in which it 
becomes so altered after death that its capacity in 
this respect is entirely lost. In both cases it is, how- 
ever, arterial blood. On the other hand, even in 22 
METHOD OP PERFORMING 
ordinary cases, venous blood in the dead body pos- 
sesses the power of absorbing oxygen. Thus it may 
happen that a part atfected with venous hypersemia 
becomes, when exposed to the air, after a time, deep 
red in color, and exhibits the appearance of an arterial 
injection. Naturally, the change takes place much 
less readily and quickly in large and very full veins 
than in small ones; it is therefore of most frequent 
occurrence in the plexuses formed by the venous 
radicles. 
What a great number of erroneous judgments have 
been due to want of knowledge of these very simple 
facts! How often has irritation or even inflammation 
oeen inferred, merely because of a deep-red color of 
the parts, or of a deep-red injection of the small ves- 
sels, whereas this coloration has really arisen in the 
course of the dissection! For the time usually re- 
quired for the examination of the thoracic organs is 
amply sufficient for the change from dark red to 
bright red to take place in those viscera of the ab- 
domen which have been exposed. Hence the require- 
ment in the regulations that the color of the exposed 
portions of the abdomen is to be determined 
directly the cavity has been opened, that is, before 
the oxygen of the air that has gained access has had 
time to exert its influence. 
As I have just touched upon this subject, I may 
say a few words more with reference to the much 
misused term, “ fullness of the vessels.” With re- 
gard to this, it appears to me important, considering 
the only too frequent incidents impressed on my 
memory, to lay great stress on the following points:— 
1. Capillary injection cannot be recognized as such, 
in a general way, with the naked eye. The finest 
vascular network which the naked eye is able to dis- 
criminate is either arterial or venous, and in the POST-MORTEM EXAMINATIONS. 
23 
majority of cases, venous. This holds good especially 
of mucous membranes, in which the comparatively 
superficial position of the venous radicles very 
frequently causes them to be mistaken for capil- 
laries. All capillaries are microscopic objects, and 
when filled with blood it is not red capillaries but red 
tissue which is observable. This redness really gleams 
out from the interior of the tissue, and we can here, 
in a certain sense, justly say that the tissue is injected. 
Nowhere can this condition be so well observed as in 
the cerebral substance, especially in the soft, trans- 
lucent gray matter. All shades, from the faintest 
reddish tinge up to a dark hydrangea red, are here 
met with, and though single fine vessels filled with 
blood may be distinguished in the red spots, we can 
easily demonstrate that the color of the tissue is not 
due to these vessels. To this category belongs that 
peculiar mottled redness which is not unfrequently 
found in the white medullary substance and in the 
optic thalamus and corpus striatum, and which is very 
similar to the first symptom of frost redness on the 
surface of the body. In my “ Cellular Pathology” 
(fourth edition, page 107, Fig. 35) I have given an 
illustration of such a condition; it can easily be 
understood from this; only the few larger vessels 
which are shown in the drawing could with difficulty 
be made out with a lens; all the other vessels were 
only visible on careful examination with the micro- 
scope. It is, therefore, intelligible that to an expert 
there is something absurd in the expression “ inflam- 
matory hypersemia” (occurring as it does in numerous 
reports) referring to anything which can be directly 
discovered with the naked eye. Nowhere is this ex- 
pression more absurd than when it is used in reference 
to the stomach, as it can be proved, in the majority of 
the reports, that what the observer has noticed have 
only been veins. 24 
METHOD OF PERFORMING 
2. The venous or arterial character of a vessel is 
never to be determined by the quality of the blood 
therein contained; but in all cases we must be guided 
only by its structure, its connections and its position. 
In other words, it is not to be discovered at the 
autopsy whether a vessel is an artery or a vein ; but, 
with regard at least to all larger vessels, this ought 
to be known previously. It is true that it once 
occurred to me that a practicing physician who pre- 
sented himself for examination was very much 
astonished when (in consequence of various wrong 
answers) I asked him a question as to the nature of 
some of the larger vessels of the brain. His answer 
was that he had not prepared himself on that subject, 
because he had not expected to be asked any ques- 
tions, in this examination, in normal anatomy. How- 
ever, I think I can maintain the proposition that 
inasmuch as without a correct knowledge of angi- 
ology, and even of the smaller vessels, the results of a 
medico-legal investigation may so easily be false, no 
one can possibly be a good medical jurist who is not 
thoroughly conversant with these matters. In refer- 
ring especially to medical jurists, I do not, of course, 
mean to imply that such knowledge ought not to be 
possessed by ordinary physicians; but what I wish to 
express is that it is still more obligatory in the former 
class. In puzzling cases (which, I admit, do occur to 
the expert, and even to the anatomist) there is one 
plan which will be found to be of the greatest assist- 
ance, and that is to follow the course of the vessel 
until a point is reached where the size becomes a 
sufficient guide as to its nature, even to the less 
experienced observers ; and particularly if in a mem- 
brane we meet with a smaller vessel filled with blood, 
we can, by displacing the blood, often succeed in 
ascertaining the course and connection of the vessel. POST-MORTEM EXAMINATIONS. 
25 
3. A statement with reference to the quantity of 
blood contained in a part can be regarded as approxi- 
matively exact only when the description indicates not 
merely the kind of vessels in which the blood is con- 
tained, but also, to some extent, the degree of their 
fullness. By this I do not assert that we are able, 
without minute examination—which is not in all cases 
possible—to make such statements with regard to all 
parts; and with reference to many of them I confess 
that a general description of their appearance and 
color is all that is required. This holds good, for 
example, of the spleen, with regard to which no one, 
by simply looking at the surface of a section, could 
properly estimate which of the small vessels were 
tilled, and the extent of their fullness. But there are 
many parts of the body—and this refers especially to 
the mucous and serous membranes, consequently, to 
the majority of the internal surfaces—which can very 
easily be examined, and in which, in important cases, 
the attempt should always be made to ascertain posi- 
tively the nature of the vessels concerned. It is cer- 
tainly easier to pronounce an opinion than to give 
such a description; but the experience of the slight 
utility of such opinions has caused the Committee of 
Sciences to include the following direction in their 
new Regulations, section 28, para. 5:— 
“ In all cases a statement must be given with refer- 
ence to the amount of blood contained in each im- 
portant part; and what is required is a terse descrip* 
tion, not merely an opinion couched in such terms as 
‘ profuse,’ ‘ moderate,’ ‘ slight,’ ‘ much reddened,’ ‘ full 
of blood,’ ‘ bloodless,’ etc.” ■ 
This explanation may suffice to illustrate the way 
in which statements should be made with reference to 
the color of the exposed abdominal viscera, and to 
what extent it is important that this should be deter- 
mined immediately after the abdomen is opened. I 26 
METHOD OF PERFORMING 
will only make one more remark—that every ma- 
nipulation of the intestines and other parts of the 
abdomen, by which their position is altered, their 
mutual pressure diminished or increased, or even any 
direct pressure with the hand, alters the amount of 
blood contained, and not only of this, but also of the 
gaseous, fluid, or more solid matter contained in 
separate portions of the intestines. 
Still more important than the determination of 
the color is the immediate ascertaining of any for- 
eign substance which the abdomen may happen to 
contain. If there be gas, it is very obvious that its 
existence can be generally proved only at the moment 
of opening the abdomen. If it be a liquid, there is 
the danger of losing some of it unless it be collected 
at once. In every case, however, when the thorax is 
opened and its contents removed, it is almost impos- 
sible to prevent blood and other fluids from getting 
into the abdomen; and thus, when this flatter cavity 
is examined, the appearances are obscured or directly 
falsified. The like holds good of those cases in which 
the subsequent examination has particularly to be 
directed, not to the thorax, but to single parts of the 
abdomen ; for example, the stomach. It is extremely 
difficult, in removing and opening this organ, to avoid 
soiling the abdomen; and therefore, if the existence 
or non-existence of any anomalous contents has not 
been previously determined, it is scarcely possible to 
do this after the stomach has been interfered with. 
I can be much more brief in my remarks with re- 
gard to the first portion of the examination of the 
thorax. Nevertheless, clear as the conditions are, I 
know from manifold experience how difficult it is to 
arrange a definite method of procedure. In explana- 
tion, 1 must first make the apparently paradoxical 
remark that “ thorax,” strictly speaking, is quite an 
abstract term. In reality, there is nothing which POST-MORTEM EXAMINATIONS. 
27 
corresponds to it, except in the skeleton, or in a 
cadaver from which the viscera have been removed. 
In the living subject and in the ordinary condition 
of a dead body there is not one, but several, thoracic 
cavities. For there are, in the first place, two quite 
separate pleural sacs, and therefore, also, pleural 
cavities; and, in the next place, a pericardium, and 
in it a pericardial cavity. 
Therefore, in a dead body we never really open the 
“thoracic cavity,” but rather, if in removing the 
breast bone we do not somewhat awkwardly cut and 
“ open” the pericardium as well, the result is that 
when the sternum, together with the cartilages of the 
ribs, has been detached, we come on each side into a 
pleural cavity or space. The so-called mediastinum 
is no cavity in this sense, but a septum filled with 
loose tissue, and it would be far more intelligible if 
■we represented the mediastinum as a septum and did 
not speak of it as a space. As, therefore, in opening 
the thoracic cavity we really come into the pleural 
sacs, our duty is here, as in the abdomen, immediately 
to examine both these sacs, with regard to the posi- 
tion color, etc., of their contents, and also to look 
very particularly for any possible foreign body which 
may be present. This examination is much more 
important here than in the abdomen, for it happens 
only too often that in cutting through the first rib 
and the sterno-clavicular articulation, as well as in 
the actual removal of the sternum, large veins (such 
as the internal mammary, the internal jugular, and 
the innominate) are pierced, cut, or torn, and fluid or 
coagulated blood escapes. In a short time this finds 
its way into one or even both of the pleural sacs, and na 
matter whether these previously contained anything or 
not, it is subsequently impossible to express a positive 
opinion, either as regards the quantity or the quality, 
or in many cases even to decide as to the pre-exist- 28 
METHOD OF PERFORMING 
exice, of any contents whatever. I need not explain 
how very important the demonstration of any anoma- 
lous contents in one or both pleural sacs may be in 
helping us to form an opinion with regard to a case, 
and I therefore think that it is certainly proper al- 
ways to commence the examination of the thoracic 
cavity by ascertaining the condition of the pleural 
sacs, and to leave the lungs and the pericardium for 
subsequent observation. For he who would open the 
pericardium and dissect the heart before determining 
whether luematothorax or hydrothorax or pleuritis 
be present, is a man who ought not undertake a post- 
mortem examination at all. 
But it is just as evident that the lungs ought not to 
he removed from the thorax before the heart has 
been examined, for this cannot be done without 
separating the pulmonary artery and veins. Unless 
ligatures are previously applied to these vessels—and 
it is neither customary nor needful to do so—their 
division will be immediately followed by the escape 
of a certain amount of the contents of the left auricle, 
of the trunk of the pulmonary artery, and of the 
right ventricle; and just the same thing happens as 
when we remove the liver and open the inferior vena 
cava before opening the thorax—viz., a diminution 
in the quantity of blood contained, or else a complete 
emptying of important parts of the heart. 
Reflections such as these very naturally, and for 
certainly sufficient reasons, lead to the formation of a 
definite plan of examination of the parts, which is in 
no way dependent upon personal caprice or considera- 
tions of convenience, but follows necessarily from the 
nature of the thing itself. 
I do not here intend to offer any exhaustive expo- 
sition of the reasons why I adopt precisely that order 
of sequence of which the Regulations are the authori- 
tative expression. I may venture to give, however, POST-MORTEM EXAMINATIONS. 
29 
a few more explanations with regard to the order of 
sequence which is directed to he observed in examin- 
ing the organs of the abdomen. 
a. For cleanliness’ sake I examine the intestines 
last. To deal with the contents of the intestines is, 
in itself, a very disagreeable matter. Even with the 
greatest care, one can scarcely avoid soiling one’s self, 
the instruments and receptacles, the subject, and the 
table on which it lies. I will say nothing about the 
sense of smell, though it is a great puzzle to me how 
it is that some persons, when making autopsies, seem 
to have completely lost this sense. There is no pos- 
sible disadvantage in examining, as a rule, the intes- 
tines last; for all the other parts can be conveniently 
examined, removed and dealt with, without the intes- 
tines being interfered with. If, however, any one 
attaches less importance to cleanliness; if, perhaps, the 
physician is in a great hurry, and wishes especially to see 
the intestines examined; there is no technical reason 
why this should not be done before meddling with the 
other viscera, for the intestines also can be removed 
without injuring the other parts. There is an exception 
in the case of the duodenum, inasmuch as the excre- 
tory ducts of the liver and pancreas open into it, and 
its removal is impossible without cutting through 
these ducts and even a portion of the pancreas. 
b. The order of sequence which I adopt differs in 
one main point from that which was previously and 
formerly almost universally employed, inasmuch as I 
usually make the removal of the liver the last f>art but 
one of the examination. lam well aware that in so 
doing I depart essentially from the favorite custom. 
If the dissector places himself, as he usually does, on 
the right side of the body, having the head to his left, 
the liver is so immediately in front of his hand that METHOD OF PERFORMING 
it undoubtedly requires a sort of resignation to make 
up one’s mind to leave it alone. But, irrespective of 
what I have already enlarged upon (that in the re- 
moval of the liver the large veins are injured, and for 
the most part, the diaphragm as well), there is also 
this to be considered; that the hepato-duodenal liga- 
ment (the small omentum), and the tubes therein 
contained, especially the vena portse and gall duct, 
are injured more considerably and to greater disad- 
vantage, I confess that these two last-mentioned 
structures are, in the great majority of cases, of no 
importance to the medical jurist, and if the order of 
sequence necessary for a clinical case were to be en- 
joined on him, it might certainly appear superfluous. 
On the other hand, however, it will be no disadvan- 
tage to him, and it will involve neither more time 
nor more trouble, whether he examines the liver first, 
or last but one ; and even granting that the cases are 
but few in which the more correct method is requisite 
for the medico-legal investigation, this is quite a 
sufficient ground for requiring it to be universally 
adopted. For clinical investigation, the preservation 
of the hepato-duodenal ligament is of the greatest 
importance, because, if once divided, it is a mere 
chance if we succeed in replacing the parts in their 
natural position in such a way as to be able positively 
to elucidate their condition. It is here, however, 
that we have to look for thrombosis and obliterations 
of the vena portse, and to estimate the condition, as 
regards perviousness, of the ductus communis chole- 
dochus, particularly of its intestinal portion, and also 
of the cystic and hepatic ducts. I may refer to a 
former paper of mine on these subjects. In my 
Archives, 1865, vol. xxxii, page 117, I have discussed 
the various conditions of the ductus communis chole- 
dochus and its intestinal portion, and have alluded to 
the importance of these for explaining the origination POST-MORTEM EXAMINATIONS. 
31 
of jaundice; and in the Transactions of the Wurzburg 
Physico-Medical Society, 1857, vol. vii, page 21, and 
in my “ Gessamelten Abhandlungen,” page 620, I 
have treated of obstructions of the vena portse. The 
nature of the circumstances necessitates the following 
order of sequence in examining these parts. First 
we should open the duodenum, taking care to do so 
in situ; then determine its contents above and 
below the papilla biliaria; then this papilla should be 
examined and its contents gently pressed out; then, 
by pressing on the gall bladder, we should determine 
the presence or absence of obstacles to the flow oi 
bile; and lastly, the ductus communis choledochus 
should be slit up. Then the vena cava should be 
examined; and all this having been done, the liver 
should be removed. It is quite useless to pass a 
probe along the gall duct, for our being able to intro- 
duce a probe into the orifice is no evidence whatever 
that the portio-intestinalis was pervious during life. 
c. The examination and opening of the stomach 
are closely connected Avith the above-mentioned opera- 
tions. The simplest plan is to open the stomach at 
the same time as the duodenum, by continuing the 
incision; and this should, as a rule, be done in sit'd. 
Cases of poisoning, especially those Avhich come under 
legal investigation, may require a different course. 
In other cases there is no danger in alloAving the 
stomach to remain untouched until its turn comes. 
The spleen, the only organ closely connected with it, 
may, Avith moderate care, be so easily separated that 
there is no fear of causing damage. On the other 
hand, as is easily intelligible, the examination of the 
pancreas will folloAV that of the stomach and duode- 
num. The slight importance of this organ, in a 
pathologico-anatomical point of vieAV, causes its ex- 
amination to be of little consequence. 32 
METHOD OF PERFORMING 
d. All the urinary organs should, as a matter of 
course, be examined one after the other. We take 
them, therefore, in this sequence—the kidneys, the 
ureters, the urinary bladder, and the urethra. At all 
eyents, their condition will in this way be much more 
attentively examined than if some other object of an 
entirely different nature be allowed to intrude itself 
while the examination is going on. It is also per- 
fectly evident that the supra-renal capsules and the 
generative organs must be examined in connection 
with the urinary organs. They are immediately con- 
nected, inasmuch as portions of the generative organs 
are portions also of the urinary organs, so that for 
the sake of continuity of plan, and also for conve- 
nience in the removal of the parts, the examination 
of the generative and of the urinary organs should 
be performed at one and the same time. 
The order, therefore, which I adopt in examining 
the abdominal organs is as follows:— 
1. The omentum. 
2. The spleen. 
3. The left kidney, supra-renal capsule, and ureter. 
4, The right kidney, supra-renal capsule, and 
ureter. 
5. The bladder, prostate gland, vesicul£e semi- 
nales, urethra. 
6. (a) Testicles, spermatic cord, and penis. 
(b) Vagina, uterus, Fallopian tubes, ovaries, 
parametria. 
7. The rectum. 
8. The duodenum, portio intestinalis of the ductus 
communis choledochus. POST-MORTEM EXAMINATIONS. 
33 
9. Stomach. 
10. Hepato-duodenal ligament, gall ducts, vena por- 
tae, gall bladder, liver. 
11. Pancreas, coeliac (semilunar) ganglia. 
12. Mesentery, with its glands, vessels, etc. 
13. Small and large intestine. 
14. Retro-peritoneal lymphatic glands, receptacu- 
lum chyli, aorta, vena cava inferior. 
However useful and convenient it may be to keep 
to such a regular plan, it is impracticable in a small 
number of cases, in which considerable changes have 
taken place in the relations and connections of the 
parts. Chronic adhesive peritonitis, whether occur- 
ring per se, in a simple, tuberculous, cancerous, or 
other form, or connected with tumors (e.g. ovarian), 
or with aneurism of the abdominal aorta, usually 
makes it impossible to dispense with the considera- 
tions peculiar to the case, and to adopt any general 
rule. Even in such cases it will be advisable to com- 
plete in the usual way the examination of those or- 
gans which can be easily reached, and thus to lessen 
gradually the special alterations which are requisite. 
But a departure from the rule is finally requisite, be- 
cause it is, generally speaking, most convenient to 
remove together the remainder of the organs, and to 
examine them more particularly outside the body, in 
whatever way is the easiest. 
So much with regard to the order of sequence in 
which the organs are to be examined, and the method 
of dissection. 
The answer to the question, how to make incisions, 
belongs to quite another side of the subject. What 
I have to say in reference to this is the primary 
result of simple experience, acquired by frequent 34 
METHOD OF PERFORMING 
practice and constant endeavors directed toward sim- 
plifying the operative portion of our task. But also, 
in addition to this, I endeavored to account to myself 
for the reasons for my usual modus operandi. Thus 
became developed a systematic practice of the proper 
method of making incisions. The description which 
I shall now give is based upon grounds which were 
originally purely empirical, and which have only 
gradually become modified by additional theoretical 
considerations. In the first place, I assert emphati- 
cally that there must be an essential difference between 
the method of making incisions for pathological pur- 
poses and that which is adapted for the anatomical 
theatre or dissecting room. In the ordinary way or 
making preparations the young student is taught to 
hold his knife as he would a pen. The object is to 
make short, fine cuts, in order to expose muscles, 
nerves, and vessels, and to follow them out and show 
them clearly. Holding the knife in this way, the 
young student keeps his fingers in the position which 
became habitual to him, up to a certain point, when 
he was taught to write. The movements are con- 
fined almost entirely to the joints of the fingers—at 
any rate, to those of the hand. The arm itself is 
fixed generally in such a way that the elbow joint is 
brought close to the trunk, and often to the thorax, 
unless, indeed, it rests on the crest of the ilium. In 
this way, short, quick cuts may be made Avith great 
steadiness, the result of which is that neatness of ap- 
pearance in a preparation which is appreciated in a 
moment by the sharp glance of the anatomical teacher. 
If such fine work be required for pathological ana- 
tomy—and this is the case pretty often—not only is 
there no objection to this method, but it is absolutely 
requisite. 
This, however, must not be considered to be the 
rule. An autopsy in which short incisions only are POSTMORTEM EXAMINATIONS. 
35 
employed is an unduly tedious affair, and both the 
pathological anatomist and the medical jurist have 
far less time at their disposal than is the case with 
the descriptive anatomist. On the other hand, numer- 
ous short incisions cause the larger organs to be too 
much divided, and partial cuts in no way assist the 
inspection, and appear to be adapted rather for 
kitchen purposes than for those of science. In ex- 
aminations for pathological purposes we save time 
and gain increased insight and clearness by making 
free incisions, and, when possible, such as involve the 
whole of the organ to be examined. 
When this had become evident, I very soon per- 
ceived the necessity for holding the knife in a 
different manner. For all ordinary purposes of 
pathological dissection I now grasp the handle of the 
knife in the palm of my hand, so that when I stretch 
out my arm the blade appears as a direct prolonga- 
tion. I fix then, relatively, if not absolutely, the 
joints of the fingers and hand, and make the cutting 
movements with the entire arm, so that the principal 
movements occur in the shoulder joint, the secondary 
ones in the elbow joint. In this way I am able to 
make long and useful incisions, and smooth ones as 
well, for I can utilize the whole force of the arm, and 
especially of the muscles about the shoulder; and it 
is only on surfaces produced by such incisions as these 
that we are able to see anything really satisfactory. 
After I had got so far, I then perceived that in 
many roundabout ways I had reached the point which 
our predecessors in dissection, the butchers, had so 
long ago attained. I was not a little astonished when, 
one day, not very long ago, I went into a slaughter 
house and watched the men at their work. I then 
learned something else, which I have since brought 
into practice, viz., that the knife should be wider 
and longer than that commonly used. 36 
METHOD OF PERFORMING 
A knife of suck length and breadth, so well adapted 
for the butcher’s purpose, is certainly inadmissible 
for ours, and it is only for the brain, and even then 
only in particularly important cases, that we require 
a very large, flat-bladed knife, which exceeds the di- 
mensions even of those used in the slaughter house. 
But a knife for making sections should always be 
very considerably larger than the ordinary knife used 
in making preparations. The latter is too short, both 
in the handle and in the blade, for making really large 
cuts. On the other hand, the blade is still too large 
for ordinary preparation purposes; for, when held as 
a pen the point only of the knife is used—a portion 
measuring scarcely fifteen millimetres. The rest of 
the blade is so superfluous that the beginner in patho- 
logical technics, who comes to me to learn the art of 
dissecting, immediately takes the knife (which I place 
in his hand) between his fingers, and then moves them 
in a wriggling way forward on the handle, until their 
points touch the steel of the blade. It is then natu- 
rally impossible to use the whole of the edge, for a 
large part of it is covered by the hand. As the dis- 
sector how finds himself confined to the point of his 
knife, and can use no other part of it, it is easy to 
understand that he very soon blunts it, and whereas 
a good pathological anatomist is perfectly able to dis- 
sect all the viscera of one subject, or even of two, with 
one knife, a pathological “ layman,” holding his knife 
as he would a pen, requires three or four knives for 
one autopsy. 
The modified section knife (Secirmesser) which I 
have introduced differs from the ordinary dissecting 
knife (.Prdparirmesser), both in the blade and handle. 
Both these latter are not only longer, but stronger—• 
that is, thicker and broader. The anterior part of 
the blade does not form an acute angle, but is rounded 
off; the very broad surface terminates with a con- POST-MORTEM EXAMINATIONS. 
37 
siderable curve in the slightly projecting point. Thus, 
not only is the cutting edge still further lengthened, 
but, at the same time, the risk of pricking one’s self 
or others, or of getting a prick from others, during 
the examination, is considerable diminished. The 
number of dangerous wounds (and pricks are always 
more dangerous than cuts) has been very much di- 
minished among us since wre have adopted this useful 
kind of knife. As regards the back part of the 
knife, the blade is narrow and strong near its inser- 
tion, for this portion of it is generally not much used; 
the handle is flatter posteriorly, and much curved 
inward from both edges, so that it may lie more con- 
veniently in the hand. Such a knife is, in its original 
condition, before it has been ground down, twenty- 
three to twenty-four centimetres long, of which nine 
centimetres and a half belong to the blade. 
This knife should really be used for making inci- 
sions with a traction movement. It should not be 
pressed or pushed into the parts, but should be drawn 
through them with comparative rapidity. When 
necessary, we may employ the whole force of the 
muscles of the shoulder in this movement, and much 
power can be thus exerted. But the greater the force 
employed, the quicker must be the movement, or else 
the parts are liable to become crushed. Nowhere 
can this be better proved than in the brain. Even 
a very sharp knife pressed into the brain crushes the 
parts to a certain extent, and the resulting cut sur- 
face is, at least in some measure, useless for examina- 
tion ; often, indeed, the appearance it jmesents leads 
directly to false conclusions. 
An incision made by traction differs from one made 
by pressure, primarily in this: that in the former 
every point of the edge glides over or through a cer- 
tain spot in the organ; whereas in the latter the same 
point in the edge always presses upon the same spot 38 
METHOD OF PERFORMING 
of the organ. Whoever chooses to make incisions by 
pressure always, possibly involuntarily, places his 
forefinger on the back of the knife. He who makes 
incisions by traction places his forefinger on the sur- 
face of the handle, or he grasps the whole handle. 
At all events, it is a good practice, especially for be- 
ginners, to place the handle between the thumb and 
finger only, so that great pressure is impossible. 
Where it is necessary really to exercise great pres- 
sure, we require another kind of knife—namely, one 
with a broader back, to which the forefinger or even 
the thumb may be conveniently applied. I have for 
this purpose made a further improvement on the ordi- 
nary cartilage knife; the one which I use has a 
thicker and more bulging blade, and a much stronger 
handle. This latter is formed of two strong plates of 
wood or horn, one of these being applied to each side 
of a flat prolongation of the blade, reaching the en- 
tire length of the handle. The back of such a knife, 
sixteen millimetres broad, is a convenient support 
when pressure is required. The free end also of the 
handle is flattened and broad, so that for certain pur- 
poses, such as for separating the sterno-clavicular 
joint, it can be placed vertically in the palm of the 
hand, and can be conveniently used for making punc- 
tures. 
I therefore require for each examination three dif- 
ferent knives—an ordinary dissecting knife (Prdparir- 
messer), a peculiar section knife (JSedrmesser), and a 
very strong cartilage knife. I use the last for all the 
coarser sort of work—-not merely for dividing cartil- 
ages, but also for large incisions through skin, mus- 
cle, and joints. The section knife (Secirmesser) serves 
especially for dissecting the large viscera; the dissect- 
ing knife (Prdparirmesser) for the finer parts, vessels, 
nerves, etc. But inasmuch as the examination of the 
large viscera is the primary object of a pathological POST-MORTEM EXAMINATIONS. 
39 
dissection, it is evident that the section knife in its 
present modified form is the principal instrument. In 
order to use it, the right arm must be allowed to be 
quite free. The elbow must be raised quite away 
from the trunk, so that the flexed forearm may be 
moved freely, and in any direction, backward or for- 
ward. It is, then, easily practicable to divide the 
integuments of the trunk by one single long incision 
from the chin to the symphysis pubis. So, also, one 
incision is sufficient to display the lung from apex to 
base, in two halves. Perhaps this “dodge” (Schwaben- 
streicli)—I use the word in the sense of the worthy 
Frederick Barbarossa—may appear to some improper 
and culpable. But I candidly own that I am a 
fanatical admirer of a large incision. The freer the 
incision—always supposing that it is an even one— 
the larger will be the field of view, the more numer- 
ous will be the points of comparison between normal 
and abnormal parts, and the more exactly shall we 
be able to estimate the extent of the pathological 
territories. 
I maintain, indeed, that a free incision, even when 
wrongly done, is, as a rule, to be preferred to a small 
though accurate one, and is almost always better than 
several or many small cuts. The large even cut is 
peculiarly the one for demonstration purposes. To 
make it, I look carefully at each separate organ, to 
find where I can get the largest surface on section. 
I therefore cut through a spleen from above down- 
ward, over the middle of its outer (convex) surface, 
a kidney from without to within (from the external 
to the internal border), a liver from right to left in a 
horizontal direction ; the testicle I cut into two nearly 
equal parts in a perpendicular direction, from its free 
to its attached border, and snap the parts asunder. I 
divide each lobe of the lung by a perpendicular in- 
cision directed from above downward, and from its 40 
METHOD OF PERFORMING 
thick border toward its inner (anterior, medial, sharp) 
one. Each hemisphere of the brain I divide by an 
incision beginning internally just over.the corpus 
striatum, and directed somewhat obliquely outward. 
Each hemisphere of the cerebellum I divide by an 
incision which commences in the fourth ventricle, in 
the direction of the crus cerebelli, and is carried 
obliquely outward. 
For many cases, and for several organs, one such 
cut is sufficient in order to show all that is essential. 
It very often happens that alterations in the liver, 
spleen and kidneys are diffused so uniformly through- 
out the entire organ that one single cut affords us a 
sufficient insight into the internal structure of the 
parts. It is true that in other cases and in other or- 
gans—for example, always in the brain—we have to 
make a larger number of cuts in order to be sure that 
nothing has been overlooked. Indeed, in the case of 
the brain we can, properly speaking, never positively 
assert that it is quite normal, unless we divide it into 
quite microscopic portions, according to the new 
method of Herr von Gudden. But as this is only 
practicable in exceptional cases, we must perforce be 
content with approximative methods. This epithet, 
however, cannot be applied to any method where 
sections five millimetres thick are made of important 
parts. In the interior of such a section there is al- 
ways plenty of room for foci of morbid material 
sufficient to produce paralysis or convulsions. The 
less we find, the greater the number of sections we 
ought to make. 
But whether we make few or many incisions, it seems 
expedient in every case not to carry them so far as 
completely to separate the portions of the organ. 
Even if we only make one single cut, it is always 
useful to leave in one spot so much of the parts con- 
nected as to be able easily to restore the external POST-MORTEM EXAMINATIOKS. 
41 
form of the organ by merely placing the parts to- 
gether and adjusting them. Many an idea with ref- 
erence to external appearances has occurred only 
after the inspection of internal changes has directed 
our attention to certain conditions; and it is much 
easier to restore the form and general appearance of 
an organ when the natural continuity of the parts 
has been to some extent preserved, than when their 
connections have been completely severed. 
In those instances in which the necessity of the 
case demands that the incisions should be greatly 
multiplied—as, for example, in the brain and spinal 
cord—it would be utterly impossible to form any fur- 
ther opinion as to the extent of certain changes, or 
even as to their exact locality, or their relation to the 
vessels, etc., if the parts have been completely divided. 
It often happens here that only at a late stage of the 
examination changes become prominent which ren- 
der it desirable to re-examine, once or more fre- 
quently, all the cut parts in their natural order of 
sequence, to convince ourselves that nothing has been 
overlooked in our first examination. Very simple 
precautions are required to rearrange the parts of an 
organ thus dissected; it resembles a book, the leaves 
of which can be opened here and there, or even en- 
tirely separated, and then again closed. But the 
object in having a book bound is to secure to every 
leaf a definite place, where it can be found in a mo- 
ment without much trouble. 
The question now arises as to the place to be selected 
for the “binding of the book.” A close considera- 
tion of the relations of each separate organ enables 
us to answer this question with facility. The con- 
tinuity must be in all cases preserved exactly where 
the connection between the organ and adjoining parts 
is the most important. 
In all the large glandular organs, as in those which 42 
METHOD OF PERFORMING 
resemble glands (the spleen and lungs), the incision 
should he made from the outside, and we should take 
care of the spots where the vessels enter and leave, 
where the excretory ducts make their exit, and where 
the nerves reach the organ. These spots are called 
the hilus, porta, or root—the name varying with the 
organ. If, after the incision has been made, the or- 
gan is found to exhibit any important alteration, 
which may possibly be due to a primary vascular 
lesion, or be the result of some slow morbid process 
in the excretory ducts, we can, if the hilus has been 
preserved, either probe, dissect, inject, or use the blow 
pipe from the more distant portions of the vessels or 
canals. If one of these methods is unsuccessful, 
another of them will be practicable. 
The circumstances are different in the case of the 
brain and spinal cord. Here the only “binding” is 
the pia mater, which supports the vessels. Transverse 
incisions must therefore be made on the spinal cord, 
leaving the pia mater attached on the anterior or pos- 
terior surface, according as the incision has been 
made from the one or the other aspect. In the brain 
the incisions should always be directed through the 
hemispheres from within to without; so that, notwith- 
standing the number of cuts which it may be neces- 
sary to make in the internal parts, it may always be 
practicable, at the close of the examination, to put 
the brain together again. My general rule is that 
each successive incision should be made across the 
middle of the existing cut surface, and that each new 
half should be again and again divided. 
This procedure is naturally not practicable in the 
large ganglia. The optic thalamus and corpus 
striatum cannot be so divided that the pia mater may 
serve as a “ binding” to them. The reticulated mem- 
brane which reaches them, the velum interpositum, 
with its choroid plexus, comes in contact with only a POST-MORTEM EXAMINATION’S. 
43 
small streak, the so-called stria, or lamina cornea, 
and must be stripped off before the dissection of the 
large ganglia is commenced. These latter I divide 
by fan-shaped radial incisions, whose common start- 
ing point is the peduncle of the cerebrum. However 
great the number of these incisions may be—and it 
is necessary here to make numerous cuts—the relation- 
ship of the pai’ts may always be closely preserved, in 
consequence of the connection between each separate 
portion and the peduncle of the cerebrum. 
Before I go on with my description, this appears to 
me to be the place to say a few more words with ref- 
erence to the examination of the cerebral ventricles, 
in order to conclude in some degree my account of 
the method of dissecting the brain. My opinion is 
that the examination of the brain, after the mem- 
branes have been finished, should commence with the 
opening of the ventricles, since, apart from any tear- 
ing or squeezing caused by manipulation, the very 
weight of the organ increases the liability to lacera- 
tion as time goes on, and the consequent risk of the 
escape of the fluids. The first incision, therefore, 
which I generally make into the brain, is carried di- 
rectly into a lateral ventricle. 
This incision, however, is not to be made in the way 
very common, even now, in examining the lateral 
ventricles for descriptive anatomy. The custom is, 
first to expose the so-called centrum semi-ovale of 
Yieussens, and then to create cerebral ventricles— 
perhaps by digging, almost in mining fashion, with 
the handle of the scalpel. We ought rather to bear 
in mind that between the middle portions (celhe 
mediae) of the lateral ventricles there is only the very 
thin septum lucidum to form a partition wall, and 
that is exactly under the raphe of the corpus cal- 
losum. If we, therefore, make a lateral incision, at a 
distance of one millimetre from this raphe, perpendicu- 44 
METHOD OF PERFORMING 
larly into the corpus callosum, we come directly into 
a cell a media at a depth of two to three millimetres. 
This incision, which forms a right angle with the 
plane of the centrum semi-ovale, should be the first 
one made in the brain, unless a deviation is rendered 
necessary by any peculiar circumstances. 
But this incision is naturally not sufficient to open 
the ventricle completely. In order to open the an- 
terior and posterior cornua, or, at least, to demonstrate 
their condition (for the posterior cornua are more fre- 
quently completely or partially obliterated than 
open), it is necessary to make particular incisions 
anteriorly and posteriorly. These should not be 
made vertically, but horizontally, the anterior one 
higher, the posterior one deeper, in the anterior and 
posterior lobes of the brain. Then only we obtain a 
view of the lateral ventricles in their whole extent, 
for the entrance, at least, to the descending cornu is 
also exposed by the incision toward the posterior 
cornu. 
Having determined the contents of the lateral 
ventricles, the state of their Avails and venous plexus, 
and the condition of the septum, the latter is taken 
hold of Avith the left hand close behind the foramen 
of Monro, the knife is pushed in froijt of the fingers 
through this aperture, and the corpus callosum cut- 
through obliquely, upward and forward, and then all 
these parts (corpus callosum, septum lucidum and 
fornix) are carefully detached from the velum inter- 
positum and its choroid plexus. After these tAvo lat- 
ter have been exposed, Ave have to examine the state 
of their vessels and tissue. Then the handle of the 
scalpel is passed from the front, under the velum, 
which is thus detached from the pineal body and cor- 
pora quadrigemina, the state of these parts is de- 
termined, and the third ventricle now exposed. 
Lastly, with a long perpendicular incision, Ave divide POST-MORTEM EXAMINATIONS. 
45 
the corpora quadrigemina and the cerebellum as far 
as the aqueduct of Sylvius and the fourth ventricle. 
In the case of the brain, the pathologico-anatomical 
examination has to take a course peculiar to itself, 
and one which differs in many respects from that 
adopted in descriptive anatomy; and the above state- 
ment may suffice to demonstrate the most convenient 
and rapid method of dissecting with a view to a cer- 
tain object. It at the same time most clearly shows 
that here also a free incision is to be preferred to any 
other mode of division, and, as I again repeat, the in- 
cision should be made by traction. It is of the great- 
est consequence that the incisions should be even and 
smooth, in an organ like the brain, where the separate 
portions are of so great importance, and where one 
part is distinguished from another by peculiarity of 
function. How could we possibly demonstrate small 
foci of softening or induration upon an uneven, 
crushed, or torn surface? And these two are exactly 
those changes most frequently occurring in the brain. 
Therefore I say to my students, “Smooth though 
wrong incisions rather than correct and uneven ones!” 
It is true that with an incision made in a wrong 
direction we can scarcely tell what we are about, but 
an incision badly made is entirely worthless. 
On account of the importance of the subject, I 
shall now describe in detail the examination of a sec- 
ond organ, in order to explain the peculiarity of my 
method and the reasons for adopting it. 
What I refer to is the dissection of the heart; and 
although the general principles which I have laid 
down apply also to this organ, yet the details to be 
taken into account are so multifarious that numerous 
modifications of the general rules become requisite. 
After we have opened the pericardium and de- 
termined its condition, and also ascertained the ex- 
ternal appearance and the position of the heart, its 46 
METHOD OF PERFORMING 
size, shape, color, consistence, the amount of blood 
contained in the superficial vessels, the amount of fat 
in the sub-pericardial tissue, etc., we have then to 
open the heart—and we should do this in situ. In 
making this first opening, we have in view two objects: 
the determination of the quantity of blood in the 
separate cavities, and the examination of the capacity 
of the auriculo-ventricular orifices. Such an examina- 
tion is, of course, indispensably necessary. The de- 
termination of the quantity and quality of the blood 
contained in the different parts of the heart is of 
decisive importance' for ascertaining the kind of 
death. It is in the highest degree probable, even if 
not absolutely certain, that two of the most important 
kinds of death—that from asphyxia (Erstichungstod), 
and that from paralysis of the heart (Herzschlag, 
Apoplexia cordis)—occur in consequence of the over- 
filling, in the first case, of the right ventricle, in the 
second, of the left. We must, however, for clinical, 
and partly for forensic purposes, examine the capacity 
of the auriculo-ventricular orifices, especially of the 
one on the left side. 
Another question which may be raised with refer- 
ence to the auriculo-ventricular orifices can, un- 
fortunately, only in certain cases be answered from 
sufficient evidence. I refer to the question with regard 
to their capacity for closing (continentia, less accurately 
though more frequently described as sufficientia). In 
an ordinary post-mortem examination no method can 
be adopted whereby the capacity for closing of the 
auriculo-ventricular valves can be thoroughly tested. 
We must content ourselves with supplying this de- 
ficiency by a minute examination of the valvular 
parts; and I will here remark that for this purpose 
it is absolutely requisite to preserve in their integrity 
all the parts belonging to the auriculo-ventricular Tig .1. 
Wp.s'L, Co. lilt . POST-MORTEM EXAMINATIONS. 
47 
valves, therefore also the chordae tendiueae and the 
muscnli papillares. 
A consideration of the two objects to be kept in 
view in making the first opening in the heart teaches 
us that on both sides the base of the organ must be 
preserved—for to the base on the right side the slips 
of the tricuspid valve are attached; on the left side 
those of the mitral; and, therefore, if we cut through 
the base Ave injure at least one of the slips of these 
valves on each side. In addition to Avhich it would 
be quite impossible to estimate the quantity of blood 
contained in eacli side, therefore also in each auricle 
and each ventricle, unless Ave open each of them 
separately. It therefore follows that for the first por- 
tion of the examination of the heart four separate 
incisions are required.* 
There can scarcely be any dispute as to the position 
and direction of these incisions. The mechanism of 
the heart allows no great choice Avith regard to the 
spots to be selected. Variations are possible only 
Avithin certain limits. My method of dissecting the 
heart may be described under the folloAving heads:—- 
1. The right border of the heart is the natural and 
recognized place of incision for examining j;he right 
ventricle. The incision must here begin close to the 
base, and must be carried at once deeply and forcibly 
into the interior of the ventricle; toward the apex 
the knife must be brought out without going too far 
down, for otherwise there is considerable risk of cut- 
ting the septum. i 
2. This incision is at the same time the guide for 
the three others; and the place for the incision for 
each separate portion of the heart is to be found in a 
plane taking the direction of the first incision. 
• See PI. i. 48 
METHOD OF PERFORMING 
3. The incision for the right auricle commences 
half-way between the places of entrance of the venae 
cavse, and ends just in front of the base. 
4. The incision for the left auricle commences at 
the left superior pulmonary vein, and ends in like 
manner just in front of the base, which is usually 
indicated by the very prominent coronary vein. We 
should carefully avoid injuring the coronary vessels. 
5. The incision through the left ventricle begins 
just behind the base, and ends just short of the apex. 
It must be carried deeply and forcibly through the 
wall of the heart. 
6. To bring the heart into the right position for the 
dissection, when the incisions for the right side are to 
be made, I extend firmly the forefinger of the left 
hand, and push it under the heart, and keep it 
against the base, so that the ventricular portion hangs 
down over the forefinger, which is as a fulcrum to it 
(.Hypomochlion). Then I turn the heart on its axis 
toward the left until the right border presents an- 
teriorly, and I press the thumb of the left hand 
just behind this border at the base. When the heart 
is thus fixed, I make, one after the other, both the in- 
cisions for the right side. 
7. In dealing with the left side, I seize the apex of 
the heart, draw it upward and to the left, and place 
the heart in the left hand in such a way that my fin- 
gers can encircle it. Then, with gentle pressure, I 
make the posterior wall to bulge out a little, and 
withdraw itself from the septum. Then I make in 
like manner, one after the other, the incisions for the 
left side. 
So much for the method to be adopted in making the POST-MORTEM EXAMINATIONS. 
49 
incisions. I have now described in a connected way 
all that is necessary; but in practice the determination 
of the quantity of blood contained in the chambers, 
and of the size of the auriculo-ventricular orifices, 
intervenes during these operations. That is to say, 
after making the incisions in the right side of the 
heart, I first remove the blood from the right auricle, 
and determine its quantity and quality; then I in- 
sert two fingers of the left hand (the index and mid- 
dle fingers) from the auricle through the tricuspid 
opening into the ventricle, and endeavor to open this 
latter cavity. Then I remove the blood from the 
right ventricle, and determine it as before. I then do 
the same on the left side. 
With reference to the examination of the auriculo- 
ventricular orifices, I may again remark that in this 
first stage nothing but their size should be ascertained. 
The examiner must therefore not be tempted to intro- 
duce his finger at present, for the purpose of feeling 
whether, and to what extent, the valves are altered. 
This can be done later on, when the parts can not 
only be felt and handled, but are also fully exposed 
to view. Every attempt now made to ascertain, by 
feeling or rubbing, the condition of the borders of 
the valves is calculated to produce alterations or to 
remove any that may be present: any adherent co- 
agula, for example, may be easily broken up or 
altogether detached. When the two fingers have 
been introduced, and the size of the orifice determined, 
they must be withdrawn as gently as possible. I 
shall here remark that each individual examiner 
must find out for himself, by experience, how far his 
fingers are a measure of the normal size of the ori- 
fices. For thin fingers, as in my own case, we may 
assume that the tricuspid orifice permits the introduc- 
tion not merely of the index and middle fingers in 
apposition, but that we may separate the two fingers METHOD OF PERFORMING 
to such a distance from each other as to be able to 
introduce between them, from the ventricle, a third fin- 
ger, e.g., the index finger of the right hand. With large 
and thick fingers this is not practicable. We have, 
moreover, on the left side to take into consideration the 
contracted condition of the heart. If the left ven- 
tricle is strongly contracted, the contraction will ex- 
tend to the base of the heart, which is equivalent to 
the base of the orifice. We must then gently press 
the Avails asunder, in order to overcome the contrac- 
tion and the rigor mortis which is also very often 
present; this can be done without difficulty. It is 
only after the state of contraction has been overcome 
that we are able to form an opinion as to the actual 
size of the orifice. 
These investigations terminate the first act in the 
examination of the heart. The removal of the heart 
is the first step of the second act. To do this Ave seize 
the organ by introducing the index finger of the left 
hand into the left ventricle, and the thumb into the 
right, through the already existing incisions. We 
then raise up the apex, and with it the whole of the 
heart, and then, with three or four long, free, horizon- 
tal incisions, Ave divide the veme cavse and the pul- 
monary veins, the pulmonary artery and the aorta, 
all together, taking care that the incisions are not 
too close to the heart. When the heart has been re- 
moved, we first examine the cut openings of the 
aorta and pulmonary artery, determine the size of 
these A'essels and the thickness of their walls, and re- 
move from them any existing coagula. 
Then Ave investigate the capacity for closure of the 
arterial orifices by pouring Avater into the aorta and 
pulmonary artery. Before Ave do this, Ave must be 
always certain that all coagula have been re- 
moved, not only from the vessels, but also from the 
orifices and ventricles. For it is clear that coagula POST-MORTEM EXAMINATIONS. 
51 
in any of these parts may so occlude an insufficient 
orifice as to give the impression of one that is suffi- 
cient. When the water is poured in, the heart must 
he held freely suspended in the air, for, if it is sup- 
ported, a portion of the wall of the heart may be 
brought in contact with, and may stop up, the orifice 
we are examining. We must also avoid taking the 
heart in the hand and encircling it with the fingers, 
for we should in that way compress it, and prevent the 
escape of water through the orifice. The proper plan is 
to fix the heart by applying the points of the fingers of 
both hands either to the vessels to be examined, or 
externally near the base of the valves, in such a way 
that the plane of the orifice is exactly horizontal, and 
not drawn to any side. For in an oblique position 
of the orifice the weight on the separate portions of 
the valve becomes unequal, and fluid may escape 
through a valve which would otherwise close; and if 
the parts be dragged or stretched in a lateral direc- 
tion, so that the circular lumen of the vessel is made 
to assume a crescentic form, the conditions of normal 
closure which involve the coming together of corres- 
ponding parts of the valve no longer exist. We 
must, therefore, always use both hands in order to 
suspend the heart properly, and the water must be 
poured in by a second person. 
The best way to suspend the heart, when we are 
examining the aortic orifice, is to find a series of 
points where the tips of the fingers can be closely ap- 
plied round it, and these are to be found on the right 
and left auricles and pulmonary artery. To apply 
one’s fingers simply to the edges of the opening in 
the aorta is always somewhat hazardous, for there is 
then only room to hold the vessel in two places; and 
if we limit ourselves to these, we are always apt to 
stretch the parts unequally. Moreover, in every case 
the aorta should be again divided at a distance of 52 
METHOD OF PERFORMING 
four or five centimetres above the orifice, by an in- 
cision parallel to the plane of the aperture. We are 
then able, while the water is being poured in, to ob- 
serve the condition of the separate portions of the 
valve, and to ascertain positively the spots where the 
water escapes. I make, in conclusion, one remark— 
that sometimes the water sinks, and finally quite dis- 
appears, without passing away through the orifice. 
In this case it usually escapes through the coronary 
arteries, which are often divided when the left side of 
the heart is first opened. Particular attention must 
therefore be paid to this point. 
In the pulmonary artery the majority of these 
difficulties do not exist; we can, therefore, without 
any further preparation, almost always contrive to 
suspend the heart for the purpose of testing the pul- 
monary orifice by fixing between the fingers the edges 
of the opening into the vessel. 
We now come to the third part of the examination 
of the heart: the opening of both the ventricles. 
For this purpose, the best plan is to place the heart 
exactly in the position which it occupied in the body, 
upon a board or table, and then to make the neces- 
sary incisions. This has the advantage of exposing 
to view the directions the incisions are to take. The 
interior of the heart ought, by means of the following 
incisions, to be made so far accessible to eye and fin- 
ger that the parts remaining to be examined can be 
conveniently reached. Among these we must mention, 
in the first place, the auriculo-ventricular valves, with 
their chordae tendineae and musculi papillares. After- 
ward come the cavities themselves, their endocardial 
investment, the arterial valves, the septum between 
the ventricles and that between the auricles, and the 
muscular substance itself. The auriculo-ventricular 
valves are here first mentioned, not on account of 
their peculiar importance, but because the want, pre- Kg. 2. 
Wf st AV> " 'jjjrx, & (V.. *i POST-MORTEM EXAMINATIONS. 
53 
viously alluded to, of a proper closure test for them 
makes it requisite to subject them to a much more 
minute examination, and to preserve them in their 
integrity until this has been done. With regard to 
the arterial valves, which have meanwhile been tho- 
roughly tested and examined with reference to their 
capacity for closing, the same kind of care is no 
longer necessary. These considerations determine 
the directions of the incisions requisite for the com- 
plete opening of the ventricles. 
(a) The incision for the right ventricle* is in a 
straight line prolonged from the pulmonary artery, 
and near the base of the heart. The best instrument 
for this purpose is a long pair of scissors, such as those 
used for examining the intestines. One blade of the 
scissors is inserted into the previous incision made in 
the right border, and carried in a direction toward 
the pulmonary artery. There is just one thing to 
bear in mind, and that is, that in this direction we 
come upon the anterior papillary muscle of the tri- 
cuspid valve with its chordae tendinese; and this must 
be carefully preserved. If this or its chordae ten- 
dineae be cut through, we shall not be able subse- 
quently to demonstrate perfectly the arrangement of 
the valves of the tricuspid opening. The blade of 
the scissors must be introduced in front of this papil- 
lary muscle, and the incision through the anterior 
wall of the ventricle and of the pulmonary artery 
must, as described, be carried close to the base. 
(6) The incision for the left ventricle,f which 
should also be made with a long pair of scissors, is in 
a straight line prolonged from the ascending aorta, 
and close to the septum ventriculorum. It com- 
mences at the apex of the heart, and divides the am 
» See PI. 2, 
f See PI. 3, 54 
METHOD OF PERFORMING 
terior wall of the ventricle and of the aorta. The 
part which here requires the greatest care and atten- 
tion is the base of the mitral valve; and the expla- 
nation of this is as follows: If we cut directly 
upward from the apex of the heart to the aortic ori- 
fice, keeping too close to the septum, the incision will 
cross the pulmonary orifice, and, by simply continu- 
ing the same, we shall cut through the valves of the 
pulmonary artery. This can be avoided by drawing 
the pulmonary artery to the right when making the 
incision, and by continuing this to the left, close to 
and behind the artery. But we must not go too far 
toward the left; there is a Charybdis here to be 
avoided. The right border of the base of the mitral 
valve is inserted quite close to this spot, and this 
valve, as is well known, is connected immediately 
with the left border of the aortic orifice. If the in- 
cision goes only a few millimetres too much to the 
left, we shall cut off that portion of the mitral valve 
which forms the above named junction ; and then, if 
we attempt to put together the divided portions of 
the heart, we shall find an aperture in the mitral 
valve. Externally, this spot corresponds exactly 
with the right border of the base of the left auricle. 
This should be our guide. The incision must, there- 
fore, be carried through midway between the pulmo- 
nary orifice and the left auricle. 
The principal part of the examination is now fin- 
ished. The auricles can, however, be still further 
opened by cutting through their wall with the scis- 
sors, between the openings of the vena cavse on the 
right, and of the pulmonary veins on the left side. 
Further incisions can also be made into the muscular 
substance; for example, some very important ones 
running parallel to the surface from those last made 
in the ventricles, and which divide the wall of the 
heart into an inner and an outer half. The coronary Fioj.3 
/V'e.sr hTvwrr'Sty'S.''.' " EOST- MORTEM EXAMINATIONS. 
55 
arteries can also be further slit up, the incisions hith- 
erto made having, upon the whole, but little interfered 
with these vessels. In exceptional and peculiar cases, 
such steps as these may have to be taken; but, as a 
general rule, the examination is completed in the 
three acts which have been detailed, and which are 
also indispensable. The heart cannot possibly be 
regularly examined unless these three acts are prop- 
erly performed. 
One might suppose, after reading the long descrip- 
tion which I have just given, that it would take a 
long time for all this to be carried out. The reader’s 
idea might be similar to that of an unfortunate dis- 
trict physician, who, after studying the new Regula- 
tions, came to the conclusion that to make an autopsy 
in the prescribed manner would require at least two 
days. The one notion is as erroneous as the other. 
Ten minutes are sufficient to examine the heart in 
the way I have described, and an autopsy can be 
performed according to the new Regulations in three 
hours, and even in two where there are but few com- 
plications. 
In order to be able to judge for myself as to the 
requirements of the Regulations, I have taken a few 
suitable cases, and made the post-mortem examina- 
tions in the prescribed form. I give, by way of a 
supplement, the notes of these examinations as in- 
stances, and also, in a certain sense, as models. Ido 
not mean that they should (like Caspar’s autopsies) 
serve as examples of diction and technics, and should 
relieve those who nfake examinations from describing 
and specifying in their own way what they find be- 
fore them; but what I intend is that they should 
show what a report is like when the Regulations have 
been carried out. A certain amount of freedom has 
been used in dictating these notes, and a very critical 
eye may possibly discover a few places where the 56 
METHOD OF PERFORMING 
Regulations have not been complied with, and some 
strictures may be made thereupon. But these, I 
hope, are such subordinate points that there will be 
at least no necessity for any “revision notes” (Re- 
visionsbemerkungen) in the sense in which this word 
is used by the Committee of Sciences. 
The cases which I have selected are also of some 
interest in other respects, and I shall take the liberty 
of interpolating a few critical remarks. 
Case I. 
A man unknown. Dead when brought in; face 
covered with blood; left side of face, particularly 
about the ear, of a bluish-red color. Death from 
suffocation caused by pulmonary hemorrhage and 
oedema. 
Length of time occupied in the examination two 
hours and five minutes. November, 1875. 
1. The body is that of a man apparently from 
forty to fifty years of age; height 1.75 metre (68.89 
inches); very strongly built; adipose tissue slight in 
quantity; muscles greatly developed—those of the 
arm and thigh less so in proportion than those of the 
forearm and leg. 
A. External Examination. 
2. Body generally pale in color; abdomen slightly 
green; flanks posteriorly, scrotum and glans of a 
uniform bluish-red; dorsum the same, and pale only 
where exposed to pressure; on pressing with the fin- 
ger this bluish-red color can be made to disappear, 
not easily, though tolerably completely. On an in- 
cision being made, only distended vessels are visible 
in the skin and subcutaneous tissues, from which fluid 
blood escapes. POST-MORTEM EXAMINATIONS. 
57 
3. The body being turned over for the purpose of 
this examination, a thin, sanguineous fluid escapes 
from the nose and mouth. 
4. The face, particularly the left side as far as the 
ear, and the beard are much soiled with dried blood, 
the largest quantity being on the nostrils and lips. 
A brownish-red, dry, powdery substance, on the left 
side converted into larger coherent crusts of dried 
blood, covers the neck and upper part of the chest. 
5. Hair of head abundant, curly, light brown in 
color; numerous scattered gray hairs. The beard 
full, especially about the chin; whiskers strongly de- 
veloped, color more reddish-brown; eyebrows thick, 
and, like the eyelashes, of a dark grayish-brown 
color; pupil pale grayish-blue; face large; forehead 
prominent; nose large and straight; high cheek 
bones; front teeth perfect; molar teeth more or less 
carious and defective; no traces of recent injury; 
lips pale and thin. 
6. The body presents no other particular charac- 
teristics, only that the prepuce is unusually short, 
and covers no more than the edge of the glans; there 
is, however, no cicatrix of any kind to be seen. 
7. The hands large; the nails long and bluish, the 
projecting edges filled up with thick black dirt, 
traces of which are seen also in the palms of the 
hands. 
8. There is some amount of mobility in the prin- 
cipal joints of the extremities, but there are signs of 
rigor mortis in all the smaller articulations. 
9. The eyelids are only partially closed; the cor- 
ner transparent, and comparatively tense. 
10. No foreign body about the nostrils, with the 
exception of the blood already mentioned. 58 
METHOD OF PERFORMING 
11. The lips, as well as the teeth, are slightly 
parted; the tongue is behind the teeth, and, like the 
palate, covered with fluid blood. 
12. External parts of ears unusually large; the 
left ear of a dark brown-red color. On an incision 
being made, blood flows everywhere copiously from 
the divided vessels, but there is no sign of extravasa- 
ted blood in the tissue; auditory meatus empty. 
13. Neck not very easily movable; no change per- 
ceptible. 
14, Chest full; abdomen slightly distended. 
15. Cutis anserina slightly marked on the extremi- 
ties, especially on the lower ones; the legs above the 
ankles rather large, pitting on pressure; the tissues 
on section found to be infiltrated with fluid. Just 
above the ankles there is a loose knotted piece of 
cord, twisted round each of them; corresponding to 
this there is a transverse indentation on the inner 
and anterior aspects. This, when cut into, exhibits 
no extravasation of blood. 
16. The parts about the anus much soiled with 
brown excrement; the anus closed. 
17. In conclusion, there is no perceptible mark of 
external injuries. 
B. Internal Examination.—I. The Cranial Cavities. 
18. The soft parts covering the skull are divided, 
as directed, by an incision carried transversely over 
the head, and reflected back. All these parts are 
then seen to be somewhat red in color, the alteration 
being more marked posteriorly than in front—the 
redness, however, not being sufficiently distinct on 
any one spot for it to indicate extravasation; on the POST-MORTEM examinations. 
other hand, thick blood exudes everywhere from the 
divided vessels, and the soft parts appear to be uni- 
formly infiltrated with reddish serum. 
19. The skull cap, very broad and much arched, 
exhibits posteriorly a similar reddish infiltration of 
its tissue, especially at the sutures, which are deeply 
indented, and furnished in various places with ossa 
triquetra. The color of the remaining portions of 
the skull cap is a dirty yellowish-gray, somewhat 
more wdiitish in isolated spots. 
20. The skull cap is sawn through with difficulty, 
and when divided, cannot be taken off1 from the 
tough dura mater. The latter is therefore immedi- 
ately cut through. On attempting to detach the 
bone and dura mater, the brain also follows, and this 
latter has to be removed by separating methodically 
its connections in the base of the skull. 
21. The brain being removed, there is no appear- 
ance of serum nor of any other effusion on the basis 
cranii. The large sinuses in that situation contain 
only a moderate amount of fluid blood. 
22. There is some difficulty in separating the tough 
dura mater from the base of the skull and the pos- 
terior portions. There is no sign of any kind of in- 
jury to the bones of the base. 
23. There is no change, also, on the base of the 
brain itself. The great arteries are large, but flat 
and empty. The pia mater everywhere fine and 
soft, and its veins only filled with blood near their 
origin. 
24. After the removal of the brain from the roof 
of the skull, the inner surface of the dura mater is 
found to be everywhere of a pale color. There is 
no deposit connected with it,- it is somewhat thick 60 
METHOD OF PERFORMING 
and tendinous; the longitudinal sinus large, but filled 
throughout with fluid blood. 
25. The dura mater is then removed from the roof 
of the skull. Its external surface is also pale; the 
blood vessels very prominent, but empty. 
26. Neither fissure nor injury of any kind visible 
in the roof of the skull; diploe scanty in amount. 
The bones, on an average, are from five to six milli- 
metres thick. Fine, red, very vascular, soft growths 
on the inner surface of the frontal bone in the middle 
line. 
27. The surface of the brain well formed; the pia 
mater delicate throughout; the veins filled with 
blood, tumid even to roundness on the left side, some- 
what less so upon the right. 
28. On cutting into them, the lateral ventricles 
are found to contain a small, inappreciable quantity 
of clear fluid. Cavities of normal size; posterior 
cornua obliterated. Septum soft, and easily torn; 
choroid plexus and vessels of the velum of a dark 
red color, owing to great distention. The vessels 
separable only with difficulty from the corpora quad- 
rigemina. 
29. On cutting into the hemispheres of the brain 
the tissue is found to be moist and glistening; the 
white substance exhibits numerous blood}7 points, 
from which drops of blood exude on pressure; these 
drops can be washed away with water. The gray 
substance of the cortex pale reddish; that of the cor- 
pus striatum and of the thalamus similar in appear- 
ance, and also moist. No other change. Consistence 
of the brain good. 
30. Corpora quadrigemina pale. Pineal gland 
small and red. POST-MORTEM EXAMI N A TI OX S. 
61 
31. The fourth ventricle empty; its surface pale 
and soft, its choroid plexuses reddened. 
32. The cortex of the cerebellum reddened through- 
out, though the vessels are not perceptible; the medul- 
lary substance, on the contrary, traversed by congested 
venous branches. Consistence good; moisture mod- 
erate in quantity. No change. 
33. At the base of the brain, all the lobes cut 
through by numerous parallel transverse incisions; 
no alteration of any kind apparent. The gray sub- 
stance slightly reddened throughout. 
34. The gray substance of the pons Varolii and 
the cerebral peduncles of a reddish color; the white 
substance traversed by numerous congested veins. 
Consistence good. 
35. The medulla oblongata pale; the gray matter 
of the rhomboid fossa somewhat more reddened. 
11. Thorax and Abdomen. 
36. A long incision is made from the chin to the 
pubic symphysis as directed, the integuments divided, 
and the cavity of the abdomen laid open. Adipose 
tissue slightly developed; muscles somewhat pale. 
37. No foreign body in the abdominal cavity. 
Position of the parts normal. Csecum, transverse 
colon, and the ascending portion of the large intes- 
tine are much distended ; also a portion of the small 
intestine—in part with gas, and in part, apparently, 
with fluid. All these parts are pale in color ; the 
omentum only presents a few distended veins. 
38. The arch of the diaphragm on each side is 
between the fourth and fifth ribs. 62 
METHOD OF PERFORMING 
(a) The Thorax. 
39. After removal of the sternum the lungs come 
into view, somewhat distended, particularly the left 
one ; position of the parts normal in other respects. 
The pericardium to a great extent covered by the 
lungs. 
40. On the left side several very firm adhesions 
between the surface of the lung and the wall of the 
thorax. A tablespoonful of thin reddish fluid in the 
most posterior part of the pleural cavity. 
41. On the right side the adhesions to the upper 
lobe are somewhat more extensive, but equally firm, 
and traversed by vessels. A smaller amount of fluid 
than on the left side. Internally, near the pericar- 
dium, the adhesions are still more extensive. 
42. The pericardium contains a tablespoonful of a 
slightly reddish but clear fluid. 
43. The heart about the size of a man’s fist, its 
right surface flattened, a slight amount of tendinous 
deposit (Sehnenflecke, maculse albidse), the right ven- 
tricle moderately covered with fat, pale, and only the 
coronary veins somewhat distended with blood. The 
right auricle contains particularly fluid blood, mixed 
with a very small quantity of soft, friable, buffy clot. 
The quantity of blood collected from the right side 
of the heart and the large veins amounts to 150 
cubic centimetres. The right ventricle contains fluid 
blood only, inappreciable in quantity. The left 
auricle contains fluid blood and a small quantity 
of thick blood. The left ventricle quite empty. 
The blood everywhere equally dark. The aorta 
three centimetres in diameter, its walls thick, 
inner coat especially thickened. The pulmonary 
artery about the same size, but with thin POST-MORTEM EXAMINATIONS. 
63 
walls. The valves at the mouths of both vessels 
close. On section, right ventricle found to be dilated, 
left ventricle large. Muscular tissue somewhat dark ; 
a little paler on the right side. Valves without alter- 
ation, but of a deep red color. 
44. The large veins of the neck moderately dis- 
tended with fluid blood; arteries empty. The large 
nerves apparently unaltered. 
45, The cavity of the mouth opened, as directed, 
from beneath; the tongue drawn away, and the 
upper part of the throat exposed. All these parts 
covered with a layer of bloody mucus, which, how- 
ever, can be easily rubbed off; after its removal the 
mucous membrane appears slightly reddened, but 
otherwise unchanged. Lingual follicles large, whitish. 
Tonsils slightly swollen. 
46. A considerable quantity of bloody froth with 
large bubbles in the larynx and upper portion of the 
air tubes. This removed, the mucous membrane ap- 
pears only slightly reddened ; on the posterior aspect 
of the tubes the vessels of the mucous membrane dis- 
tended with blood, but no other change. 
47. The remaining thoracic viscera, with the lungs, 
are now removed, together with the costal pleura. 
48. Lower portion of the oesophagus is covered 
with reddish fluid, which can be easily taken off. 
After its removal, no alteration visible in the subja- 
cent mucous membrane. 
49. There is slight dilatation, and thickening of the 
internal coat, of the thoracic portion of the aorta, but 
no breach of surface. The same may be said of the 
large branches of the artery going to the neck. 
50. The upper part of the air tubes, as well as their 64 
METHOD OF PERFORMINS 
large ramifications, are filled with frothy and bloody 
matter. 
51. The lungs seem large, very concave on their 
diaphragmatic surface, studded over, especially on 
the right side, with smooth projections of their tissue 
greatly dilated (emphysematous). The lungs, in 
general, are gray in color, pale anteriorly, reddened 
posteriorly. Numerous furrows, due to absorption, 
on the anterior surface. These latter places feel 
harder to the touch ; the rest of the tissue is soft, but 
only slightly crepitant. 
52. On section, in the apex of the right lung is 
found a ramified cavity of irregular shape, about six 
centimetres and a half in diameter, consisting of two 
compartments, separated by a thin septum, and each 
of them four centimetres and a half in horizontal di- 
ameter. Each contains a bloody, slightly frothy 
liquid, which can be easily removed by water. The 
walls of both these cavities are irregular and rough, 
and, on water being poured upon them, they are seen 
to be covered with adhesions, which readily float. 
Many large eroded vessels, some of them lying free 
like rafters, are found in these cavities, into which 
branches of the air tubes may be directly traced. In 
other parts of the lung there are single smaller cavi- 
ties with smoother walls, and also separate circum- 
scribed spots, externally hard to the touch, some of 
which appear, on section, dense, dull, grayish-red, and 
finally granular; others dry, grayish-white, and 
caseous. The rest of the pulmonary tissue is full of 
frothy, whitish fluid, which can be easily pressed 
out. 
53. On the left side, below the apex, more toward 
the centre of the upper lobe, there are several similar 
cavities, varying in size from that of a walnut to a POST-MORTEM EXAMINATIONS. 
65 
hen’s egg, containing also fluid, slightly frothy blood, 
and connected with the air passages. The wall of 
these cavities is irregular and ragged ; the remains of 
the large vessels appear as whitish projections. There 
is a similar cavity about as large as a walnut in the 
upper part of the lower lobe. Throughout the 
remainder of the lung there are numerous nodules of 
varying size—some as large as peas ; a few with cavi- 
ties in their interior; others solid and caseous; 
others, again, solid and dark gray. 
(h) The Abdomen. 
54. Spleen closely adherent to the diaphragm and 
omentum ; fourteen centimetres long, nine centimetres 
broad, three centimetres and a half thick ; exter- 
nally, gray steel-colored. On section, dark brown- 
red ; pulp abundant, with numerous dark-red spots ; 
follicles slightly enlarged. 
55. Left kidney thirteen centimetres long, six cen- 
timetres and a half broad, three centimetres and a 
half thick. Capsule slightly dull, thin. Surface of 
the kidney smooth, brownish-red, bright; consistence 
firm. On section, the medullary and cortical sub- 
stance very red, not dull; no other change. Mal- 
pighian corpuscles bloodless. Supra-renal capsule 
with a small amount of cortical and medullary sub- 
stance ; the tissue connecting it with the kidney firm 
and well supplied with blood. 
56. On separating the parts surrounding the right 
kidney a fibrous adhesion between the large intestine 
and the under surface of the right lobe of the liver 
brought into view. 
57. Right kidney of same size as left, and resemb- 
ling it in other particulars. Supra-renal capsule in 
fi similar condition, 66 
58. Bladder contracted, and containing only a few 
drops of whitish urine. No change in mucous mem- 
brane. 
METHOD OF PERFORMING 
59. Left testicle somewhat mis-shapen, in conse- 
quence of fibrous adhesions on its surface. An offset 
from the right one at the upper part of the epi- 
didymis. 
60. The stomach distended, and containing a large 
quantity (about 200 cubic centimetres) of thick, 
clotted, bloody fluid, mingled to some extent with 
large air bubbles. 
61. Fluid of a similar kind in the commencement 
of the duodenum, but extending only as far as the 
opening of the gall duct. After this the contents are 
of a pale-yellowish color. Opening of gall duct 
normal. 
62. The mucous membrane of the stomach tinged 
throughout with blood, but without any lesion; only 
the large veins distended with blood. 
63. In the upper part of the intestine a large 
amount of a gray fluid resembling gruel, slightly col- 
ored with bile. This becomes thinner and more 
scanty in the upper part of the jejunum. The ileum 
contains a very large quantity of fluid of a brownish 
color. This part of the bowel is so soft that it tears 
when cut into with the scissors. The lowest part of 
the ileum contains a quantity of very fluid fieces. 
The large intestine from the ileo-caecal valve full of 
thick, pulpy faeces. The mucous membrane through- 
out the ileum thin and pale; the glands slightly tu- 
mid. In the jejunum the mucous membrane is 
thicker. Here and there a single gland appears 
tumid, but in other respects normal. In the upper 
part of the , jejunum the mucous membrane has a 
whitish appearance. POST-MORTEM EXAMINATIONS. 
67 
64. The liver (twenty-eight centimetres broad, 
twenty-three centimetres from front to back, and 
eight centimetres thick) is firm to the touch, its sur- 
face of a pale-brownish color, somewhat firm under 
the knife; breaks with difficulty, and appears on sec- 
tion uniformly red. The lobules are large, and their 
color uniform. 
65. The inferior vena cava contains fluid blood. 
This case is a remarkable instance of ulcerous con- 
sumption of the lung, occurring in a man in other 
respects vigorously developed, and in whom the dis- 
ease, though obviously of long standing, had con- 
fined itself to the lungs. Owing to the advanced 
stage of the disease, it cannot be ascertained whether 
the morbid process primarily originated in bronchi- 
ectasis or caseous pneumonia; at any rate, caseous 
pneumonia finally supervened. It is a matter of 
great interest that, notwithstanding the amount of 
hemorrhage from the lung, the fatal result was not 
due simply to loss of blood (anaemia), nor to simple 
occlusion of the air passages by the extravasated 
blood, but really to the supervention of oedema—a 
complication which is explained, on the one hand, by 
the robust condition of the patient; and, on the 
other, by the slow course of the hemorrhage. Not a 
single ruptured blood vessel could be discovered. 
The conclusions to be drawn from the foregoing 
statement are as follows:— 
1. That death occurred from suffocation caused by 
pulmonary hemorrhage and oedema. 
2. That no signs of any external injury were re- 
vealed by the autopsy. MITHOD OT PESrORMIjrff 
Case 11. 
A person known. Gunshot wound of head (sui- 
cide). Death in twelve hours, or rather more, from 
(edema of the lungs. On examination post-mortem, 
the track of the wound found to be through the right 
hemisphere, and involving the extra-ventricular part 
of the corpus striatum. Extensive oedema and in- 
terstitial emphysema of the lung. Numerous mani- 
festations of older affections; irregularly-shaped cra- 
nium; unsymmetrically formed brain; contracted 
aorta; endocarditis mitralis; berpes zoster; chylifi- 
cation going on in the intestines. 
B. W., aged twenty-one, a tradesman’s assistant, 
had shot himself through the head with a pocket 
pistol, above the middle of the left eyebrow. Quite 
insensible when brought to the Charite, at 6 a.m.; 
breathing stertorous; pulse scarcely perceptible; urine 
passed involuntarily; loud tracheal rales; heart 
sounds scarcely audible; no albumen or sugar in the 
urine; the left pupil larger than the right. From 
time to time a whitish greasy matter, mixed with 
blood, exudes from the small wound. At midday the 
pulse had somewhat risen; the respiration was still 
stertorous, though a little easier. In the afternoon 
the man’s condition rapidly changed for the worse, 
and he died at four o’clock. 
Post-mortem examination (occupying two hours 
and three-quarters), Nov. 3, 1875:— 
1. Body generally well developed; appears to be 
that of a man twenty years of age; height, 1.7 metre. 
A. External Examination. 
2. Anterior surface generally pale, but the left half 
of the face, the left ear, the adjacent part of the 
neck, the arms and forearms, and the thighs and legs. POST-MORTEM EXAMINATIONS. 
69 
much discolored, and exhibiting large, bluish-red, ir- 
regularly-shaped spots, of varying size, generally 
more marked on the left side; but on those parts of 
the back which have not been exposed to pressure the 
discoloration is uniform and of a deeper red. On 
pressing firmly with the finger the redness almost en- 
tirely disappears: on an incision being made, a few 
large drops of semi-fluid blood escape from the skin 
and subcutaneous tissue, but there are nowhere any 
permanent reddened patches, such as cannot be re- 
moved by water. There is one place on the left thigh, 
a hand’s breadth above the patella, where, on inci- 
sion, we find a small spot extending through the adi- 
pose layer, and infiltrated with blood which cannot 
be pressed out. On the right shoulder blade there 
are a few dry, brownish-red spots running obliquely 
from above, and externally in a direction downward 
and inward. These on section appear to be only 
thin, dry crusts, involving the corium proper. 
3. On turning the body over, a large quantity of 
yellowish-brown fluid, containing dark-brown parti- 
cles, escapes from the mouth. 
4. Rigor mortis marked in the extremities and in 
the muscles of the neck and abdomen. 
5. Numerous grayish-brown spots—not to be re- 
moved by washing—on the anterior surface of the 
body, especially on the breast. On the left side, near 
the seventh, eighth', and ninth ribs, there is a broader 
zone of these spots; this is continued to the arm, 
where the patches are brownish, and covered with 
thick masses of epithelium. Other parts, also, of the 
surface of the body, especially the lower extremities, 
are covered with gray spots, completely removable by 
washing. Blackish marks on many parts of the face, 
neck, arms, and trunk; some of the larger size on the 70 
METHOD OF PERFORMING 
abdomen; these appear, on section, to extend no fur- 
ther than the cuticle. 
6. A few pale-greenish faint spots on the abdomen, 
and in the neighborhood of the groins. Cadaveric 
odor not perceptible. 
7. Hairs dark brown, on right side stained red; 
much matted together, and their roots covered with 
dry blood. 
8. On the forehead, a finger’s breadth above the 
middle of the left eyebrow, a small hole, thz-ee milli- 
metres in diameter, surrounded by a dry, blackish- 
brown, somewhat depressed border of the skin, one 
to two millimetres broad, around which externally 
and toward the left side the integument is slightly 
reddened, and the cuticle abraded. The parts sur- 
rounding the wound are slightly swollen. A long 
transverse incision carried down to the bones shows 
extensive separation of the connections of the tendi- 
nous expansion and the subjacent connective tissue, 
extending in one spot to the periosteum, and corres- 
ponding with a hole in the bone. There is here a flat 
splintered piece of bone, triangular in shape, five mil- 
limetres long, four millimetres wide, retained in its 
place. The separation thus caused in the parts forms 
no regular cavity; the wound is traversed by numer- 
ous projecting filaments and cross bands of tissue. 
For five centimetres around this the soft parts are 
infiltrated with blood, which cannot be pressed out. 
The tissues for some distance beyond this contain a 
watery fluid. 
9. Eyelids open ; cornese firm and transparent. 
10. Nostrils filled with a great quantity of dried 
blood, which also covers the adjacent parts of the 
skin. POST-MORTEM EXAMINATIONS. 
71 
11. Mouth slightly open at the middle. Lips 
somewhat red. The teeth closely shut. 
12. No other foreign bodies discovered in the 
apertures of the head. 
13. A pale streak on the neck, three millimetres 
broad, over the larynx, increasing toward the left 
side to a breadth of fifteen millimetres, and termi- 
nating here under the ear ; neither a groove, nor 
injury of the surface, nor any change of color to be 
perceived. There is nothing of the kind to be seen 
on the right side. The skin and subcutaneous tissue 
quite pale on section. 
14. Thorax somewhat flat. 
15. Abdomen somewhat retracted. 
16. Penis small; much contracted; very little 
prepuce. The glans and what remains of the pre- 
puce dark red and rather dried. The scrotum like- 
wise small and much wrinkled ; externally on both 
sides some appearance of blood. On incision the 
integuments of these parts dry superficially and very 
red. 
17. Anus closed. 
B. Internal Examination.—I. The Cranial Cavities. 
18. Scalp divided by an incision across from one 
ear to the other, and reflected forward and back- 
ward. A few drops of blood seen emerging from 
the anterior portion—these more numerous pos- 
teriorly ; in front also a close network of distended 
vessels in the aponeurosis and pericranium. No 
other spots of extravasated blood, with the exception 
of those mentioned (in No. 8), in the left frontal 
region. 72 
METHOD OP PERFORMING 
19. The aperture mentioned in No. 8 is now seen 
more distinctly; but there are no fissures surround- 
ing it, and no increase in the quantity of blood in 
the periosteal vessels. 
20. The skull cap is now removed, the saw being- 
carried horizontally round below the aperture. The 
bones are difficult to saw through, and on being 
removed are found to be almost entirely composed of 
compact substance, and six or even seven or eight 
millimetres thick. The left frontal sinus is filled with 
pulpy matter, consisting of whitish, soft, brain-like 
substance, and dark-red clots, which are partly sepa- 
rable. The right frontal sinus is empty. No fissures 
are visible in the bones forming the sinuses; but the 
vessels, as far as they can be made out with the naked 
eye, are much distended with blood. The external 
opening (the transverse diameter of which in the 
outer table is eight millimetres, the diameter from 
above downward being six millimetres) has an 
irregular hexagonal shape, and leads directly into 
the left frontal sinus. In this sinus there is another 
opening, having the same direction, and passing 
through the inner table just above the orbital plate. 
This opening is almost completely closed by frag- 
ments of cerebral matter and clots of blood ; after 
these are cleared away, a somewhat irregular, but 
here rather triangular, opening is found, the sides 
averaging six millimetres. At the upper part, and 
close to the opening, there are two larger and two 
smaller scales of bone, splintered off from the inner 
table ; these are, however, still loosely connected with 
the bone. 
21. The form of the skull is seen, on section, to be 
somewhat oblique, the right half becoming wider pos- 
teriorly, the left narrower in front. On the left side 
there is incipient obliteration of the coronal, as well POST-MORTEM EX A MIX ATI 0X S. 
73 
as of the spheno-parietal suture. The right lamb- 
doidal suture is completely obliterated. On remov- 
ing the pericranium, recent red osseous deposits on 
various parts of the surface of the skull, especially 
numerous on the posterior upper part of the temporal 
ridge. The inner surface of the calvaria dotted over 
with numerous large pits, principally in the neigh- 
borhood of the anterior fontanelle. 
22. The dura mater everywhere thin and diapha- 
nous, except in the neighborhood of the longitudinal 
sinus, where it is of a dull-whitish color, andr tra- 
versed by numerous red vessels. On the left side, in 
front of the anterior part of the brain, there is an 
aperture in the dura mater, very irregular in shape, 
out of which protrude soft, broken-up masses of brain 
substance, mixed with blood; these are continuous 
with the previously mentioned debris in the aperture 
in the skull. The opening in the dura mater is on 
an average from six to seven millimetres wide; its 
margins are somewhat dentate and wrinkled. There 
is no blood extravasated anywhere else between the 
dura mater and the bone. 
23. The superior longitudinal sinus anteriorly nar- 
row and empty ; posteriorly, rather wide, and filled 
with dark semi-fluid blood. 
24. On the right side, the dura mater much dis- 
tended by a bluish mass, which gleams through it. 
The arteries of the dura mater filled with blood as 
far as their small ramifications, and projecting con- 
siderably above the surface of the membrane. 
25. On separating the dura mater on the right side, 
a large clot of blood, dark colored, is found to over- 
lay the whole right hemisphere of the brain. It is 
slightly moist; its own -weight causes it to slide from 74 
METHOD OF PERFORMING 
its position; and it amounts in quantity to twenty-five 
cubic centimetres. Some portions adhere pretty 
firmly to the surface both of the dura mater and of 
the pia mater. On washing the parts with water, the 
source of the hemorrhage is found in an aperture in 
the brain, situated nearly at the posterior part of the 
middle lobe, two fingers’ breadth behind the end of 
the fissure of Sylvius ; clots of blood protrude from 
this opening. The pia mater all around this spot is 
infiltrated with blood, especially at the anterior per- 
forated spot; also to a less degree in the sulci of the 
middle and posterior lobes, and to some extent in 
those of the anterior lobe. 
26. At the anterior extremity of the right anterior 
lobe, close to the falx cerebri, the pia mater appears 
more thickly and deeply infiltrated. This appearance 
is not connected with those above described ; it is 
more marked inferiorly and in front, where, at the 
same time, the consistence of the cerebral substance 
is softer and more yielding. 
27. A third, apparently also independent, spot is 
quite close to the longitudinal fissure at the top of the 
vertex, under a somewhat thickened part of the pia 
mater ; it projects somewhat, and is surrounded by a 
quantity of fluid blood, which spreads also freely 
toward the dura mater. 
28. The head being raised and drawn forward, a 
leaden bullet, measuring in one direction eight, in the 
other six millimetres, falls from the parts described 
in No. 25. This bullet is quite flattened, and bright 
on one side. 
29. Sulci of brain on right side very deep; per- 
ceptible beveling off of the convolutions just behind 
the vertex. eost-moetem examixatioxs. 
75 
SO. The dura mater being removed on the left 
side, blood is found effused on the surface in much 
less quantity ; it is, however, equally coagulated, and 
is more adherent to the membranes, especially to the 
dura mater. The pia mater infiltrated with blood, 
but only to a slight extent, anteriorly near the spot 
where the external opening touches the brain, the 
infiltration extending no further than a finger’s 
breadth toward the base, and not quite so far 
toward the convexity of the brain. A clot of blood 
eleven millimetres long and five millimetres thick in 
a small depression of the surface close by the side of 
the falx cerebri, on the margin of the longitudinal 
fissure at the vertex; this extends a finger’s breadth 
further backward than toward the right side. All 
around the spot the vessels are much distended, and 
posteriorly the pia mater infiltrated with blood. 
31. There is, in addition, an extravasation of blood 
in shallow layers between the falx cerebri and the 
projecting wall of the left hemisphere, amounting in 
quantity to scarcely a teaspoonful. 
32. The left hemisphere of the brain also appears 
depressed; the surface of the convolutions is even 
flatter than on the opposite side. 
33. The brain being removed, its base is seen to be 
infiltrated with blood to an irregular extent; this is 
especially marked in the direction from the aperture 
in the anterior lobe toward the olfactory nerve, at 
the anterior part of the middle lobe, around the in- 
fundibulum, as far as the pons Yarolii, and even in 
places as far as the medulla oblongata. The blood 
for the most part is contained in the meshes of the 
pia mater, but in several places there are clots obvi- 
ously non-adherent. 76 
METHOD 07 PERFORMING 
34. The pia mater delicate throughout, its vessels 
filled with blood up to the smaller branches. 
35. The brain itself appears shorter, and the con- 
volutions more simple, on the left side than on the 
right. The consistence good, with the exception of 
those spots already mentioned. 
36. Behind the above-mentioned (No. 22) opening 
in the dura mater, corresponding to the aperture in 
the bone, and which is just below the anterior part of 
the left anterior lobe, there is also a large perforation 
in the pia mater, fourteen to eighteen millimetres in 
circumference. Beneath this there is a funnel-shaped 
excavation, surrounded by soft debris of brain sub- 
stance, and a few large clots of blood. An oblique 
incision being made, extending from this spot trans- 
versely across to the opening (mentioned in No. 25) 
in the outer part of the right hemisphere, a continuous 
canal is exposed; this has a total length of thirteen 
centimetres, and extends through the middle of the 
brain substance, particularly through the base of the 
corpus striatum, and has a diameter anteriorly of 
twelve millimetres, posteriorly of eighteen millimetres; 
it is filled with coagulum and copious debris of brain 
matter. The wall of the canal is soi't throughout, 
formed directly of brain substance, and dotted over 
with numerous spots of extravasated blood. 
37. The point on the vertex of the right hemis- 
phere (described in No. 27) turns out to be a sangui- 
neous infiltration of the pia mater, five millimetres 
deep. Nothing abnormal found below the other spot 
particularly referred to in No. 26. 
38. The cerebral ventricles are empty, the choroid 
plexus and the large vessels of the walls of the ven- 
tricles filled with blood. The upper vessels of the 
velum delicate and transparent. POST-MORTEM EXAMINATIONS. 
77 
39. Optic thalamus and corpus striatum pale, but 
not dry. 
40. The white substance of the hemispheres is pale 
and dry ; in a few places only blood escapes from the 
divided vessels. The gray substance for the most 
part pale, but in places reddened to some depth. 
41. The fourth ventricle is empty ; the cerebellum 
generally pale, but less so on the left side, where the 
gray substance is somewhat reddened; and the white 
substance appears to be more infiltrated with a 
watery fluid. 
42. The pons is pale and firm, as is also the medulla 
oblongata. 
43. In the posterior fossa of the base of the skull a 
large quantity of fluid blood has collected during the 
examination ; this has escaped from the large blood 
vessels of the vertebral canal. 
44. The transverse sinus almost empty. In the 
middle fossa of the base of the skull, on the left side, 
the dura mater much covered with blood. 
45. On removing the dura mater, it is found that 
several fissures of the inner table extend from the 
opening in the skull (No. 19, 20) to the orbital plate. 
The cracks are filled with coagulated blood, but they 
extend for a distance of only seventeen to eighteen 
millimetres in a backward direction. 
11. Thorax and Abdomen. 
46. A continuous incision, carried as directed, from 
the chin to the pubic symphysis, and the abdominal 
cavity first laid open. Abdominal organs in their 
normal position. The intestines lie very far back. 78 
METHOD OF PERFORMING 
No foreign body in abdomen. The parts exposed of 
a pale color generally; only the small intestines 
slightly reddened. 
47. The diaphragm on both sides reaches the lower 
border of the fifth rib. 
48. The sternum having been removed, as directed, 
the lungs recede very slightly from the wall of the 
thorax; their anterior portions distended with air, and 
buoyant, much reddened in places. Between the 
lobules there are rows of large air bubbles; and in 
some spots these coalesce, and form large, continuous 
level patches. 
(a) Thorax. 
49. The left lung is free throughout. The pleural 
sac contains, at a rough guess, forty-five cubic centi- 
metres of a thin, watery liquid, of a dirty-red color. 
50. On the right side the upper parts of the lungs 
are somewhat bound down by connective tissue; at 
the base and back part of the pleural cavity there is 
a very minute quantity of fluid of a similar kind to 
that found on the other side. 
51. The heart, just the size of the man’s closed fist, 
is very rigid, and somewhat flattened on its anterior 
aspect and over the right auricle. The coronary 
arteries empty ; the coronary veins distended only in 
their primary ramifications, and somewhat deeply 
placed. Only a small amount of fat about the peri- 
cardium, on which there are a few small detached 
spots of a deep-red color, scarcely as large as a milli- 
metre. 
52. About forty cubic centimetres of dark blood, 
for the most part fluid, containing a small buffy clot, POST-MORTEM EXAMINATIONS. 
escapes from the right auricle. The right ventricle 
contains blood of a similar kind, dark-red in color, 
not more than twenty cubic centimetres, with very 
faint traces of coagula. In the left auricle the quan- 
tity of blood amounts to thirty cubic centimetres, and 
it is more coagulated and as dark, with a few spots 
of a faint huffy color. On the other hand, only a 
very slight clot, with a gelatinous huffy coat, occupies 
the left ventricle. 
53. The aorta so narrowed as only to be capable of 
admitting the tip of the ring finger. The pulmonary 
artery only a little more capacious. A stream of 
water being poured in, none passes into the ventri- 
cles. Valves on both sides thin; not discolored by 
blood. Narrowing of the mitral valve, which will 
not admit of two fingers, caused by thickening, con- 
traction, and adhesion of the slip of the valve poste- 
riorly. Muscular tissue much attenuated, of a brown- 
ish-red color. 
54. On the left lung rows of air vesicles in great 
abundance (as described in No. 48) on the lower part 
of the anterior border, and at the tongue of the upper 
lobe, and also in various places at the lower border of 
the lung at the base. Posteriorly, both lobes appear 
to contain but little air, and are of a tolerably uni- 
form bluish-red color; the lower lobe somewhat gray- 
ish-white, owing to thickening and serous infiltration, 
here and there, of the investing membrane. Numer- 
ous small, slightly raised patches of extravasated 
blood scattered about over both lobes. 
55. A large quantity of thick bloody froth escapes 
from the left bronchus. On cutting through the lung, 
entire portions appear red and filled with frothy 
liquid, but in other respects unchanged. 80 
METHOD OF PEKFOUMIXO 
56. The same appearances are found on the right 
side, but the rows of air vesicles are less numerous. 
On the other hand, all parts of the lung contain se- 
rous exudation, and the lung tissue is of a deep-red 
color. 
57. The tongue, retracted behind the jaws, is cov- 
ered with a dirty-brown coating, but normal in other 
respects. Some bloody mucus in the pharynx. Both 
tonsils very large, projecting almost like tumors, and 
seen on section to contain friable masses in the folli- 
cles ; parenchyma much increased. 
58. Veins of the neck filled with dark fluid blood. 
Arteries empty. Nerves normal. 
59. (Esophagus contains only a small quantity of 
light-brownish matter. 
60. Epiglottis slightly compressed laterally; glottis 
open. Larynx and air passages filled with thick 
frothy fluid, containing a few yellowish-brown flakes. 
These being removed, the mucous membrane of the 
upper part is seen to be traversed by an open net- 
work of vessels. In the lower parts the vascular 
network is close, and of a deep-red color. 
61. Aorta narrow, walls thin; contains only fluid 
blood. The superior vena cava has similar contents. 
62. The spleen is 14.5 centimetres in length, 10 
centimetres in its greatest breadth, and 2.7 centime- 
tres in its greatest thickness; it is very flabby, and 
somewhat wrinkled. On section, blood exudes from 
a few large vessels. The Malpighian corpuscles are 
unusually large, reaching even 1 millimetre in di- 
ameter. Splenic pulp scanty and brownish-red. 
(6) Abdomen. POST-MORTEM EXAMINATIONS. 
81 
63. Left kidney 10 centimetres long, 4.5 centime- 
tres broad, 2.9 centimetres thick; flabby; capsule 
easily separable; surface smooth, of a dark brownish- 
red color; veins easily distinguishable. The tissue 
on section very dark red; Malpighian corpuscles very 
prominent, but no other change. 
64. Left supra-renal capsule firm; cortical sub- 
stance slightly developed, medullary substance more 
so. 
65. Right kidney 9.2 centimetres long, 4 centi- 
metres broad, 2.5 centimetres thick ; in other respects, 
as on the left side. 
66. Right supra-renal capsule resembles left one. 
67. Bladder not much distended. Urine clear, and 
amounting to about 80 cubic centimetres. Bladder 
normal. 
68. A little clear fluid in both tunicas vaginales. 
The substance of the testicles pale, but normal. 
69, The stomach somewhat distended, its pyloric 
portion contracted; the veins on the external aspect 
but slightly distended, and only the larger ones mani- 
fest; its general aspect pale. It contains about 150 
cubic centimetres of a greenish, thick fluid. The 
mucous membrane of the fundus is stained greenish- 
yellow, in the other parts pale-red, and toward the 
pylorus somewhat granulated. 
70. The small intestine is contracted almost through- 
out its extent, only the most deeply situated portions 
are somewhat distended, and contain liquid. On the 
external aspect the large veins appear very full, as 
also some lacteal vessels in the upper portions of the 
bowel. METHOD O? PERFORMING 
71. The mesenteric glands small and slightly red- 
dened. Mesentery loaded with fat. 
72. The upper part of the duodenum contains a 
whitish fluid; lower down, the contents are decidedly 
yellow. On pressing the gall bladder, greenish-yellow 
bile flows freely from the orifice of the gall duct; 
pancreas pale; normal. 
73. On opening the jejunum it is found to contain 
some light-gray matter, here and there yellowish and 
consistent; in its lower portion some thinner fluid 
deeply tinged with bile. The ileum is almost empty, 
and contains only a few greenish, tolerably consistent 
fecal lumps. 
74. The large intestine contains pulpy, greenish- 
brown fluid masses, mixed with hard fragments, as 
far as the descending colon; in this latter portion, 
consistent and formed fleces. 
75. Mucous membrane of the jejunum very thick; 
the villi in the upper part enlarged and milky, from 
absorption of chyle. Lower down, marked redden- 
ing of the valvulse conniventes as far as the place 
where the contents are colored with bile; the mucous 
membrane here becomes also deeply bile-colored. 
Lower down, and as far as the beginning of the 
ileum, the villi are faintly red. Peyer’s patches 
slightly injected, and the glands enlarged in the lower 
portion of the ileum. There is also enlargement of 
the solitary glands close to the ileo-csecal valve. 
76. The mucous membrane of the large intestine 
very pale, and only in the lower part of a greenish- 
gray color. 
77. Liver about seventeen centimetres from front 
to back, twenty-three centimetres broad, and eight POST-MORTEM EXAMINATIONS. 
83 
centimetres thick; externally grayish-red; smooth 
and tense; on section, very uniformly reddened, but 
only a small quantity of blood escapes on the whole, 
and that merely from the larger vessels. Acini 
scarcely perceptible, but on closer examination they 
are seen to be surrounded by a faint light-gray bile. 
78. Gall bladder filled with a somewhat ropy, but 
otherwise clear, dark-gray gall. 
79. Inferior vena cava moderately distended with 
blood, for the most part fluid. 
This case is a truly remarkable example of the 
tolerance exhibited by the brain toward injuries of 
the gravest character. It seems almost miraculous 
that any one could possibly live twelve hours with a 
gunshot wound extending from the left frontal region 
and the apex of the anterior lobe to the external as- 
pect of the middle lobe on the right side (just above 
the parietal eminence), completely traversing, there- 
fore, in an oblique direction, the right hemisphere of 
the brain, and also the extra-ventricular part of the 
corpus striatum. It is only to be accounted for by 
the smallness of the projectile, and to some extent, 
also, perhaps, by the slight force which it possessed. 
The projectile must have been about the size of a pea 
(five millimetres in diameter), judging from an un- 
used bullet which was found upon the man. The 
width of the track of the wound in the brain (anteriorly 
twelve, posteriorly eighteen millimetres), is therefore 
quite out of proportion to the width of the aperture 
of entrance in the integument (three millimetres), 
and in the bones (six to eight millimetres), and also 
to the projectile. There can, therefore, be no doubt 
that the track of the wound in the brain was origin- 
ally much narrower, and that the width which it 
finally attained wras due to the increasing effusion of 84 
METHOD OF PERFORMING 
blood. The symptoms, therefore, of compression of 
the brain gradually developed as the extravasation 
increased. 
That the force of the projectile was very slight is 
evident from the fact that not only was there no in- 
jury to the bone in the neighborhood of its place of 
exit from the brain, but there was even no laceration 
of the dura mater. The force of the bullet, primarily 
weak, was still further reduced by its having tra- 
versed two layers of bones in its passage through the 
left frontal sinus ; and, on the other hand, the fact that 
both blood and cerebral matter found an exit 
through the frontal sinus may well have assisted to 
retard the development of the symptoms of com- 
pression. It thus happened that death resulted not 
from the brain primarily, but (in a medico-legal 
sense) from the lung, and, strictly speaking, was due 
to suffocation. Just as so often occurs in injuries to 
the head caused by contusion, a fatal oedema of the 
lung became developed in consequence of the pres- 
sure of the extravasated blood upon the medulla ob- 
longata. How greatly the respiration was affected 
is shown by the interstitial emphysema, which was 
more extensive in this case than I have ever seen it 
in the asphyxia of cholera. We should notice, by 
the way, a combination in itself so very unusual, for. 
according to current notions, oedema and interstitial 
emphysema ought strictly to exclude each other. 
The widespread indications that the digestive pro- 
cess had not yet terminated allow us to suppose 
that the suicide had taken his last meal shortly before 
the commission of the deed. In addition to this, 
there are various appearances, which I have grouped 
together in the summary, indicating the occurrence, 
in a very early stage, of numerous natural deficiencies, 
which amply warrants us in drawing conclusions as 
to the psychological development. The chlorotic POST-MOETEM EXAMINATION'S. 
85 
condition of the aorta, which may well be connected 
with the endocarditis mitralis, certainly not very com- 
mon in so young a man ; the obliquity of the cranium, 
together with the want of symmetry and somewhat 
detective formation of the brain, are all of them 
appearances well worthy of observation. 
If there were any doubt about the case, and had it 
been made the subject of legal inquiry, we might 
summarize our opinions provisionally as follows:— 
1. That death resulted from oedema of the lung, 
consequent upon a gunshot wound of the brain. 
2. That there is no evidence from the autopsy to 
contradict the assumption that the deceased came to 
his death by his own hand. 
Case 111. 
A person known (suicide). Gunshot wound of the 
chest. Death occurring in twelve days. Double 
pleuritis, pericarditis and myocarditis, phlegmonous 
mediastinitis, exudative peritonitis. 
F. K., a tradesman’s assistant, twenty years of age, 
shot himself in the chest, on the afternoon of Novem- 
ber 8, with a revolver held at a distance of six inches 
from his breast, he at the time having nothing on but 
his shirt. He was immediately brought to the 
Charite. The aperture of the wound is close to the 
left nipple, and measures eight millimetres in diame- 
ter ; it is filled up with clots of blood, and the parts 
around are emphysematous. The patient complains 
of difficulty of breathing, and pain all over the left 
side, where there is also dullness on percussion over 
the posterior and inferior parts of the chest, extending 
to the angle of the scapula, with bronchial expiration. 
The bullet was found in the back, above the eighth, 
rib, at a distance of four fingers’ breadth from the Mtrifoi) 6? PEitrdßMiife 
vertebral column on the left side, and was removed 
on the following day. It was conical in shape, eleven 
millimetres long, and seven millimetres in diameter 
at its base, quite flattened on one side, especially 
toward its apex. The opinion of the physicians in 
charge of the case was, that the bullet had passed in 
the soft parts outside the chest, and had been stopped 
by the rib. 
On the third day pain came on quite suddenly in 
the region of the left colon, with great soreness. 
Manifest improvement on the subsequent days, but 
great mental excitement and restlessness. The 
aperture of the bullet’s entrance closes, but in- 
flammation and swelling occur round the opening 
which has been made in the back. The symptoms 
of inflammation in the left breast gradually diminish. 
Bowels somewhat confined. On the eighth day 
a red-colored serum commences to escape from the 
wound in the back, and flows more freely during 
expiration. At the same time there are evident 
symptoms of pleuritis on the right side, and also of 
pericarditis. Increased fever and difficulty of respi- 
ration. On the eleventh day a puncture was made 
in the left side of the thorax, in the fifth intercostal 
space, in the anterior axillary line, and 900 cubic 
centimetres of a dirty brownish-red serum evacuated. 
The respiration then for a short time became easier, 
but very soon after all the serious symptoms became 
much aggravated, and the patient died on the thir- 
teenth day. 
Post-mortem examination (lasting three hours) 
Nov. 22, 1875 
1. The body is that of a man of about twenty years 
of age ; the height is 1.68 metre; bony conformation 
slight; adipose tissue in small quantity; muscles mod- 
crately developed. 
A. External Examination. ?6SI-Jf 6RTBM EXAMINATION^. 
2. Color generally pale, faintly yellow ; lower part 
of abdomen greenish. The posterior parts of the 
body, the head, and trunk generally, and also the 
extremities, covered with large, pale-bluish-red spots, 
interrupted by white patches where exposed to pres- 
sure. The intensity of the color of these spots can be 
only slightly diminished by pressure. On an incision 
being made, numerous small veins filled with blood 
can be seen extending from the skin into the sub- 
stance of the muscles. Fluid blood escapes from 
these, but there is nowhere any blood extravasated in 
the tissue. 
3. Slight cadaveric odor ; rigor mortis in the ex- 
tremities. 
4. Eyelids half closed ; eyeballs tense; cornese 
transparent. 
5. No foreign body in nose or auditory meatus. 
6, Lips open; teeth separated—the latter, in the 
upper jaw, very irregular. The tongue lying behind 
the teeth, and pale; the teeth of a brownish hue. 
No foreign body in the mouth. 
7. Nothing abnormal to be found about the neck. 
8. On the right side of the breast a line of four 
small brownish-red crusts, one after the other, but 
separated by intervals of various lengths. The first 
of these is over the fifth rib, the second over the sixth, 
the third and fourth are over the seventh. The upper 
one begins a finger’s breadth below the right nipple, 
and at about the same distance on the inner side. 
The whole line is ten centimetres in length ; its direc- 
tion is somewhat obliquely downward and outward. 
On cutting into these spots there is neither deposit, 
tumefaction, nor redness. On cutting through them 88 
METHOD OF PERFORMING 
there are no spots of blood, but only desiccated patches, 
extending in the highest crust through the whole 
thickness of the corium, in the others only through 
its most superficial layers. There is a faint, quite 
superficial, crescentic, red spot, rather more than a 
thumb’s breadth, on the outer side of the right nipple. 
This, on being cut through, is found to involve only 
the outermost layers of the corium. There are also a 
few more brown marks on the external aspect of the 
lower part of the thorax on the right side. 
9. On the left side, two millimetres above the nip- 
ple, but within the areola, a small round spot about 
1,5 millimetre in diameter, somewhat depressed, of a 
dirty brownish color, and covered with a dry pellicle. 
When this is cut into, a somewhat hard cord, trav- 
ersed by numerous small vessels filled with blood, and 
showing minute spots of blood, is found to extend 
obliquely outward and backward through the sub- 
stance of the gland into the subcutaneous fat. No 
canal can be discovered, but in a direction outward 
and downward there are some scattered spots, slightly 
moist, and blackish-red in color, both in the subcuta- 
neous adipose tissue and in the pectoral muscles, ex- 
tending down to the ribs, in a circumference of about 
seven centimetres. They are most strongly marked 
in the direction toward the axilla, where a few of 
these sanguineous infiltrations extend to the lymphatic 
glands. These latter are enlarged, hard, bluish-red 
externally. On being cut through they are found to 
be very moist, and the whole of their cortical layers 
of a dark bluish-red color. 
10. Posteriorly, on the left side of the chest, at a dis- 
tance of two fingers’ breadth from the middle line, on 
the tubercle of the ninth rib, the skin is separated 
from the subjacent parts, and exhibits a wound with 
sharply defined edges. The wound is four centime- POST-MORTEM EXAMINATIONS. 
89 
tres long and two centimetres and a-half wide, taking 
almost the exact direction of the rib—viz., from 
within and above, outward and downward. It is 
covered with slightly dull grayish-red serum, and 
looks quite clean where this latter has been removed; 
it penetrates the soft parts in a terrace-like form, to a 
depth of eight millimetres, and terminates in the 
muscles. The base of the wound is pale and smooth 
in the external portion; internally it is covered with 
a soft, velvety, very red film, which contrasts dis- 
tinctly with the neighboring parts. Only in an up- 
ward direction is there any blood infiltration of the 
muscular tissue seen on incision being made into the 
parts around. 
11. On cutting more deeply into the muscular 
layers lying externally, we come into a shallow cavity 
which communicates by a narrow opening with the 
base of the wound above described; it measures four 
centimetres and a-half transversely, and three centi- 
metres perpendicularly; its outer surface is tolerably 
smooth, and like the base of the external wound, 
covered with a similar soft, velvety, red membrane. 
On opening this cavity, the body being placed on its 
side, air emerges from beneath with an audible sound, 
and a small round opening not quite two millimetres 
in diameter is found on the upper part of the base of 
the cavity. This penetrates deeply the intercostal 
space between the eighth and ninth ribs, but on in- 
troducing a fine probe it cannot be passed directly 
into the thoracic cavity. The spiral direction of the 
track of the wound makes it difficult to pass the 
probe deeply. 
12. The two spots described in Nos. 9 and 10 are 
now connected by means of a free incision carried 
transversely round the thorax. The muscular septa 
in the neighborhood only of the first spot are found 90 
METHOD OF DfcRFORMING 
to be distended with dark-red serum, but otherwise 
there is no trace of any connection between the two 
wounds. 
13. Four fingers’ breadth external to and below 
the left nipple there is a roundish opening, scarcely 
one millimetre in diameter; the borders of this 
wound are sharp and rather dry. On incisions being 
made in various directions, dark-red bloody discolor- 
ations are found in the corium below this opening, 
and these are continuous with those described under 
No. 9. (This is the aperture of the puncture as stated 
by the assistant physician in charge, Dr. N.) No 
distinct canal can be traced inward from this open- 
ing. On the other hand, on cutting somewhat more 
deeply into the intercostal muscle, serum and bubbles 
of air escape from beneath, and there is a softish, 
reddish streak to be seen traversing the tissues. 
14. Nothing abnormal about the external organs 
of generation. 
15. Anus closed; some fecal matter round about it. 
16. No traces of any other external injury. 
B. Internal Examination.—I. Thorax and Abdomen. 
17. An incision is carried from the chin to the 
symphysis pubis, dividing the integuments of the 
neck and thorax, and opening the abdominal cavity. 
Adipose layer slight; muscles of a dull-red color. 
18. The omentum found to be connected by adhe- 
sions, which are easily separable, with the anterior 
part of the abdominal wall and the right border of 
the liver. This latter organ is somewhat deeply 
placed, and completely covered by a delicate false 
membrane, which can be easily stripped off; on the POST-MORTEM EXAMINATIONS, 
91 
left side it is dry and translucent; on the right side 
more greasy-looking, dull, and yellowish in color. 
The omentum is of a deep-red color, its veins being 
particularly full (this most marked on the right 
side); in the neighborhood of the gall bladder it is 
covered with opaque, yellow false membrane, that 
cannot be stripped off, and this extends as far as the 
lumbar region. 
19. The intestines distended with gas, covered in 
many places with fine, very superficial, red, vascular 
networks—generally, however, pale; the viscera of 
the pelvis only dense bluish-red, with numerous large, 
prominent veins. 
20. The pelvis contains about a tablespoonful of 
slimy, yellowish-red, opaque serum. 
(a) The Thorax. 
21. During the time that has elapsed since the ex- 
amination of the wound described in No. 10, a quan- 
tity, amounting to eighteen cubic centimetres, of thin, 
pale-reddish, turbid serum, has escaped from this 
spot into a vessel placed to receive it. 
22. On removing the integuments from the thorax, 
the tissues are found to be considerably infiltrated 
with blood, on the left side, in the fourth and fifth 
intercostal spaces; in the first of these at a distance 
of three, and in the second at a distance of two fin- 
gers’ breadth from the sternum. 
23. On cutting into the wall of the thorax on the 
right side, fluid escapes. This is immediately col- 
lected from the pleural sac. It is found to amount 
to 800 cubic centimetres, is thin, relatively only 
slightly turbid, and of a yellowish-red color. It con- 92 
METHOD OF PERFORMING 
tains numerous large, very loose flakes, yellowish- 
white in color. The surface of the pleura on this 
side is everywhere covered with somewhat soft, dirty- 
yellowish deposit, which can be stripped off. 
24. The sternum being removed, the whole of the 
mediastinum is found to be tough and difficult to cut, 
many of its smaller vessels tilled with blood, and the 
tissue throughout of a gelatinous appearance and of 
a dull, brownish-yellow color. 
25. On the left side the anterior portion of the 
lung is agglutinated to the wall of the thorax for a 
length of eight centimetres. After it has been sepa- 
rated we come to a space filled with fluid. The fluid 
is ladled out; it measures 900 cubic centimetres, is 
somewhat thick, but flows freely, is of a palish-red 
color, has a faint odor, and contains a few flakes. 
This cavity is the pleural sac, the walls of which, 
except where they are agglutinated, are covered with 
thick, dirty reddish-yellow, closely adherent deposits, 
with red infiltration in some places. The upper and 
lower lobes are agglutinated together below. There 
are also adhesions, which can be easily broken up, be- 
tween the thoracic wall and the lower part of the 
upper, and the anterior and lower part of the lower 
lobe. These adhesions extend over a surface as large 
as a child’s hand. In front, between the pericardium 
and lungs, is a closed space, containing large shreds 
of gelatinous coaguia. This cavity is found to be an 
incapsulated part of the pleural sac. 
26. The pericardium much thickened externally. 
Internally, extensive deposit of rough, stiff, elastic 
membrane, both on the parietal and visceral layer. 
The cavity contains about forty cubic centimetres of 
pale-reddish serum, mixed with yellowish flakes. The 
firm deposit is most abundant on the anterior portion POST-MORTEM EXAM IST ATI ON S. 
93 
of the parietal layer; and corresponding to this the 
heart is covered anteriorly by similar false membrane. 
27. The heart itself is somewhat larger than the 
closed fist of the man. It is rigid, its surface slightly 
arched, comparatively pale in color. The right auri- 
cle contains about ninety cubic centimetres of dark- 
red coagulated blood. The right ventricle contains 
a very small quantity of fluid blood, but a few large, 
gelatinous, buffy masses. The left auricle contains 
scarcely two tablespoonfuls of dark blood, very slightly 
coagulated. The left ventricle is almost empty. 
28. The heart is then removed. The arterial 
valves close. On being opened, a marked red infiltra- 
tion throughout the lining membrane. The muscular 
tissue firm; on the right side grayish-red; eighteen 
millimetres thick. On the posterior wall it is closely 
marked, to a depth of eight millimetres, with very ex- 
traordinary yellow spots and stripes. These spots 
being immediately subjected to microscopical exami- 
nation show the primitive muscular fasciculi to be 
without cross-markings and filled with coarse fat gran- 
ules. No other abnormal appearances. 
29. A very large quantity of dark, partly buffy 
coagula escapes from the larger vessels of the thorax. 
30. The left lung is rather flat, and contains but 
little air. Its serous covering on the upper and an- 
terior parts is thickened, opaque, here and there yel- 
lowish ; on the inferior and posterior parts of a dull- 
red color, softer and more lubricous, dotted over in 
several places with soft, gray, roundish granulations. 
In three places the covering of the lung is relatively 
smooth, and shows scarcely any deposit. These places 
are circumscribed by tolerably sharp edges, with sa- 
lient and receding angles. There are similar places 
corresponding to these on the wall of the chest. The 94 
METHOD OF PERFORMING 
first of these spots is close to the anterior border of the 
upper lobe, near the agglutination described in No. 
25. The second spot i§ on the lower tongue of the 
upper lobe. The surface of the lung is here indu- 
plicated in two directions, meeting in an angle, and 
taking a course toward the spot immediately to be 
described. The third spot is on the lower and ante- 
rior aspect of the lower lobe, and here, in a line, one 
below the other, we find (a) on the surface, turned to 
the cleft between the upper and lower lobes, one cen- 
timetre from the border, a roundish depression of a 
reddish color, three millimetres in diameter, exhibit- 
ing, on incision, a perforation of the pleural invest- 
ment; (6) two round spots close to one another, two 
and a-half to three millimetres in diameter; one of 
which is upon, the other close in front of, the border. 
These being cut through, are found to be yellowish- 
white channels in the pleural membrane and the ad- 
jacent pulmonary tissue. The latter is on this spot 
somewhat firmer, and of a deep-red color to a depth 
of eight millimetres. On section, the tissue in the 
upper lobe is found to contain very little air, is of a 
red color throughout; but it is only from the larger 
vessels that any blood escapes. The lower lobe con- 
tains still less air, and is moderately red; dark thick 
blood escapes from the vessels. 
31. The right lung is covered throughout its whole 
extent with firmly adherent but separable deposit; on 
the upper and middle lobes the pleural covering is 
whitish and thickened. On section, the tissue is 
found to contain but little air, and is somewhat gray 
in color; this is the case also in the lower lobe. 
32. On the inner aspect of the thoracic wall on the 
left side, exactly upon the eighth rib, at a distance of 
four fingers’ breadth externally from the vertebral 
column, there is a solution of continuity, twelve mil- POST-MOBTEM EXAMINATIONS. 
95 
limetres long and five millimetres wide, of a some- 
what long oval form, the long diameter being par- 
allel to the axis of the rib, the borders gradually 
sloping off, and of a yellowish color. In the base of 
this wound the bone lies exposed. In order to ex- 
amine the parts more closely, this rib and the ninth 
are removed together, and it is now seen that, at the 
spot corresponding to the external wound, the inner 
surface of the eighth rib, for a length of fourteen 
and a breadth of ten millimetres, is quite laid bare, 
and the soft parts stripped off. At this spot there 
are two small linear fragments of lead, the larger 
three, the smaller one and a-half millimetres long, 
wedged into the compact tissue of the bone. Round 
the denuded portion of the rib the tissue is raised up 
like a wall, thickened and much reddened. Beyond 
this wound, anteriorly, and on the same rib, a trian- 
gular, grayish-yellow spot is found on the costal 
pleura, which exactly corresponds with a similar tri- 
angular spot on the inferior lobe of the lung, imme- 
diately below the smooth spot described in No. 30, 
and in the direction of the appearances detailed un- 
der (a) and (6) in the same paragraph. A continu- 
ous canal connects the denuded portion of bone with 
the cavity mentioned in No. 11. 
33. In the anterior lateral portion of the circum- 
ference of the left pleural cavity, in the intercostal 
space between the fourth and fifth ribs, three centi- 
metres from the attachment of the cartilages, is a 
deepened cleft, placed transversely to the course of 
the third rib, seven millimetres long, and rather more 
than three millimetres wide; running somewhat ob- 
liquely from above and Avithin, doAvnward and out- 
wTard, ending above the border of the fifth rib, and 
separating the fasciae superficially. The floor of this 
cleft is tolerably smooth, slightly scaly. The borders 96 
METHOD OF PERFORMING 
of the cleft are sharp, neither thickened nor red- 
dened; in its base several small, angular, blackish 
fragments of lead are contained in the tissue. This 
spot corresponds to an area of the pulmonary pleura, 
free from deposit, and which had previously been ad- 
hei’ent (No. 25). 
34. Lower down in the intercostal space, between 
the fifth and sixth ribs, and almost exactly in the 
middle, there is a somewhat long cleft, with tolerably 
straight borders; it is scarcely two millimetres long, 
and its lateral edges are close together. It leads di- 
rectly externally into a small canal through the mus- 
cles. Its position corresponds to the external wound 
described under No. 13, but there is no open passage 
from one to the other. 
35. The veins of the neck are tumid, and contain 
thick blood; arteries and nerves normal. 
36. The oesophagus contains a yellowish-gray fluid, 
and numerous fragments of food. Mucous membrane 
pale. Palate much reddened, with very prominent 
venous networks; follicles of the tongue slightly 
swollen. 
37. The larynx contains a few similar yellowish- 
green fragments of food. Below, a little frothy 
liquid in the air tubes. Mucous membrane somewhat 
thick; that of the air tubes very red, owing to 
numerous vascular networks, which are distinctly 
visible. 
38. No change in the walls of the aorta; only a 
little thick blood in its descending portion. 
(5) The Abdomen. 
39. The spleen adherent on its upper aspect, 12£ 
centimetres long, 71 centimetres broad, 3.6 centime- POST-MORTEM EXAMINATIONS. 
97 
tres thick, firm on section, and pale; the pulp rather 
grayish-red and uneven, containing much blood and 
slightly indurated, but only in a part which is cov- 
ered externally by dirty yellowish-white membrane. 
Follicles small and gray. 
40. Left kidney 12 centimetres long, 5 centimetres 
broad, 3.2 centimetres thick. The capsule easily 
separated; surface smooth, brownish-gray-red in 
color, superficial veins slightly distended. On sec- 
tion, somewhat general faintly-gray cloudiness of the 
cortical substance, which appears bluish-red. The 
Malpighian corpuscles prominent on the cut surface, 
slightly reddened. 
41. The left supra-renal capsule reddish-gray in 
its cortical substance; tissue between it and kidney 
abundant and full of blood. 
42. Right kidney 11 centimetres long, 6 centime- 
tres broad, 3.2 centimetres thick. The surface some- 
what more darkly red than on the other side. In 
other respects, the same appearances both here and 
in the supra-renal capsule as on the other side. 
43. Urinary bladder strongly contracted; contains 
a tablespoonful of dark yellowish-brown urine. In 
other respects normal, as are also the prostate and 
vesiculse seminales. 
44. Testicles, both superficially and in their sub- 
stance, somewhat bluish-red in color, owing to nu- 
merous veins ; in other respects normal. 
45. Stomach rather capacious, containing a large 
quantity of greenish liquid and numerous fragments 
of food. Mucous membrane pale, whitish-gray, tol- 
erably thick, somewhat wrinkled toward the pylorus. 98 
METHOD OF PERFORMING 
46. The duodenum contains a large quantity of 
bilious, pasty fluid, A drop of bile exudes on pres- 
sure from the orifice of the gall duct, and also when 
the gall bladder is pressed. 
47. The liver twenty-five centimetres broad, twen- 
ty-two centimetres from front to back, and eight cen- 
timetres thick; the whole of its external surface 
covered with yellowish-white false membrane. On 
incision, the large vessels only found filled with blood. 
The tissue pretty uniformly brownish-gray, brittle, 
somewhat dull-looking. The acini large, externally 
yellowish, internally grayish-red. Gall bladder slight- 
ly colored ; bile grayish-brown, with yellow flakes. 
48. Pancreas somewhat flabby; its posterior por- 
tion infiltrated with blood. 
49. The mesenteric glands somewhat enlarged; 
their cortical portions somewhat white. But little 
fat about the mesentery. 
50. The small intestine contains a large quantity 
of pasty, bilious matter ; in the lower portion the 
contents are feculent and foul-smelling. The raucous 
membrane is rather thick ; in the jejunum reddened 
only in a few spots; a few turgid veins in other 
places. The only change in the glands is a very 
slight swelling of the solitary follicles in the lower 
part of the ileum. 
51. The large intestine contains soft faeces ; mucous 
membrane rather thick ; some difficulty in removing 
the adherent faeces; nothing abnormal. 
11. The Cranium. 
52. The soft parts cut through, according to the 
directions, and reflected backward and forward; 
nothing abnormal. POST-M 0 E T E M EX A MIN ATX 0X S. 
53. The skull of a somewhat long oval form, much 
reddened posteriorly, and presenting a pitted depres- 
sion on the frontal bone, just in front of the coronal 
suture, and to the right of the mesial line. On sec- 
tion, diploe scanty but red. Bones of skull four 
millimetres thick. Internal surface somewhat irreg- 
ular, in consequence of various depressions in the 
middle part of the frontal bone and along the sagittal 
suture; these are apparently due to elevations of the 
pia mater. 
54. The dura mater translucent, thickened, and 
copiously supplied with blood in the middle and 
anterior portion. The longitudinal sinus rather 
large, filled with huffy coagula. Inner surface of 
the dura mater on both sides smooth, exhibiting in 
places networks of distended vessels, but no abnor- 
mal deposit. 
55. The surface of the cerebral hemispheres sym- 
metrical in shape. The convolutions rather large. 
Veins very large, much distended with dark blood, 
particularly at the back of the head. 
56. Pia mater everywhere translucent, exhibiting 
large, wart-like excrescences along the median longi- 
tudinal fissure and under the frontal bone. 
57. Scarcely any fluid in the lateral ventricles. 
Posterior cornua obliterated. Choroid plexus and 
vessels of the velum of a dark-red color. 
58. On section, the cerebral hemispheres found to 
be very moist, and the veins much distended. From 
these latter large drops of blood exude all over the 
cut surface. Gray substance shining and of a dark 
reddish tinge. 
59. The gray substance of the large ganglia red- 
dened ; the tissue very moist throughout. Corpora 
quadrigemina pale. 100 
METHOD OF PEEFOKMISTC 
60. Fourth ventricle empty. Cortical portion of 
cerebellum uniformly reddened ; veins of medullary 
substance distended. 
61. The arteries at the base of the brain regular in 
their course, filled with dark blood. In the pia mater 
of this part nothing abnormal. 
62. The gray substance of the pons Varolii and 
medulla oblongata slightly reddened. 
63. The sinuses at the base of the skull filled with 
dark, thick blood. The dura mater thin and deli- 
cate. Condition of the bones normal. 
There is much that is worthy of remark about this 
case. Apart from the fact that the extensive perito- 
nitis did not occur as a clinical symptom (we must 
now regard as such the pain in the region of the left 
colon, which was noticed on the third day of the 
disease, but which afterward quite subsided), the 
rapidity with which death occurred must obviously 
be explained by the pericarditis and the resulting 
myocarditis. Some time ago (in my Archiv, 1853, 
vol. xiii, page 266) I reported several cases of malig- 
nant pericarditis, in which I demonstrated acute fatty 
metamorphosis of the muscular tissue, and showed 
that the morbid process advanced from without to 
within. I have several times since observed this 
very dangerous complication, of which the case before 
us is another and a very instructive example. 
The peritonitis, and also the pericarditis, and the 
pleural inflammation on the right side, have no im- 
mediate connection with the wound caused by the 
bullet. The probability is that all of these are the 
result of the phlegmonous mediastinitis, which in this 
case quite takes the form of a malignant erysipelas. 
The occurrence, however, of this mediastinitis is not 
a little extraordinary, for the bullet did not immedh POST-MORTEM EXAMINATIONS. 
101 
ately injure the mediastinum; and, moreover, the 
anterior portion of the track of the bullet showed no 
indications of mischief, for it was completely closed 
by the first intention. There is, therefore, nothing 
else hut to assume that all these morbid processes 
have extended themselves from the posterior part of 
the track, which was certainly in an unhealthy con- 
dition, and which was converted into a perforating 
wound when the bullet was excised. It is, therefore, 
very extraordinary that when the examination was 
made there was no disagreeable odor about the open- 
ing in the back. 
Notwithstanding this, however, a propagation of 
infectious matter from this quarter is indicated by 
the extensively diseased appearance of the left pul- 
monary pleura, and the alterations so unusually 
great for so comparatively short a period as twelve 
days. The pleura was so thickened, dull and wrin- 
kled, and so dotted over posteriorly with real sprout- 
ing granulations, and in large area almost trachoma- 
tous, as to present an appearance such as is only met 
with in very malignant forms of inflammation. Those 
portions of the pleura primarily agglutinated ap- 
peared, after separation, both on the lung and on the 
wall of the chest, so smooth and delicate that they 
looked quite normal when contrasted with what has 
just been described. 
The autopsy has not confirmed the supposition that 
this was a case in which the bullet, in consequence of 
the retracted position of the left side of the chest, 
took a curved direction through the external soft 
parts from the place of entrance near the nipple, un- 
til it was stopped posteriorly by the eighth rib. Cer- 
tainly, it appeared at first as if the sanguineous infil- 
trations (No. 9) extending to the axilla corresponded 
with the course taken by the bullet. But the further 
examination showed that the bullet had taken an en- 102 
METHOD OP PERFORMING 
tirely opposite direction, and that the infiltrations 
were caused only by the loose cellular tissue being 
filled with blood in the direction of the lymph cur- 
rent. Even the axillary glands were so infiltrated 
with blood as to prove distinctly that their appear- 
ance was due to absorption. I draw particular atten- 
tion to this, inasmuch as I am well aware that in 
medico-legal practice due regard is not paid during 
life to this form of propagation of sanguineous infil- 
trations, so very important, and yet so often mislead- 
ing, owing to the great possibility of a false inter- 
pretation. 
The shot has entered just above the left nipple, 
and taken an oblique direction outward, downward, 
and backward; it has left the wall of the chest, first 
of all, in the fourth intercostal space, and then en- 
tered the pleural cavity; it has then grazed the lung, 
but only a small portion of it—viz., the surface of 
the left lower lobe turned toward the cleft between 
the two lobes; it has then passed over the internal 
surface of the eighth rib, at a distance of four fin- 
gers’ breadth from the vertebral column, and close 
to this spot perforated the eighth intercostal space. 
Here it remained lying in the soft parts under the 
skin of the back until its early removal. 
Strange to say, at the end of the channel of en- 
trance, just where it passes obliquely over the upper 
border of the fifth rib, several small pieces of lead, 
obviously portions of the bullet, were found covered 
up in the soft parts. At the first glance they might 
be compared with the fragments of lead embedded 
in the bone at the posterior part of the circumfer- 
ence of the thorax, where the rib has been laid bare 
by the bullet. However, a closer examination proves 
that their origin is different. The latter were obvi- 
ously splintered off when the bullet struck against 
the rib, and they correspond probably to the small POST-MORTEM EXAMINATION’S. 
103 
scratches found on the smooth compressed surface of 
the much-flattened bullet. The former, on the other 
hand—those which are closed up in the anterior 
wound—could not have been splintered off* by the 
rib, for its border, although very close to the bullet’s 
course, has not been touched by it. These must, 
therefore, have been stripped off previously, perhaps 
in the grooved barrel of the revolver, and driven 
into the wound when the shot was fired. 
The medico-legal conclusions in this case are as 
follows:— 
1. That death was caused by a series of violent 
inflammatory attacks in the thoracic and abdominal 
cavities, inflammation of the heart being the princi- 
pal factor. 
2. That these inflammatory attacks were the result 
of a gunshot wound of the thorax. 
3. That there is nothing to contradict the assump- 
tion that the fatal shot was fired by the deceased 
himself. 
Case IV. 
A twin child, still-born at the middle of the tenth 
(lunar) month. Indications of immaturity. Inflam- 
matory oedema (erysipelas) of the scrotum, pharynx, 
and brain. Incipient white hepatization of the 
lungs. 
The case is peculiarly interesting, from the fact 
that the other child was born alive and throve well, 
and that the mother, to all appearances, had never 
suffered from syphilis or from any puerperal affec- 
tion. 
Post-mortem examination (lasting one hour and 
a-half), December 13, 1875:— 104 
METHOD OF PERFORMING 
A. External Examination. 
1. The body is that of a new-born male child, and is 
46 centimetres in length, 2120 grammes in weight; 
for the most part regularly formed, though the limbs 
are rather short. The subcutaneous fat is moderate 
in quantity; the muscles somewhat poorly developed. 
The legs slightly curved. 
2. The umbilicus projects about 1J centimetres, 
and has the remains of the umbilical cord, properly 
ligatured, attached to it. This latter is 101 centime- 
tres in length, and averages 11 centimetres in thick- 
ness; its extremity presents a flattened surface, the 
cord itself is rounded, tense, gelatinous, and presents 
no appearance of dryness. 
3. The color of the body is generally pale, even 
over the abdomen; yellowish about the head, of a 
washy pale-red over the back, and likewise (though 
of a darker red) over the right side of the head and 
face. Pressure, however, has caused portions of these 
latter parts, the right external ear especially, to look 
quite pale. Firm pressure with the thumb causes 
the greater part of the redness to disappear; on in- 
cision, the venous network for some depth is seen to 
be filled with blood, and a small quantity of fluid 
blood escapes. 
4, The skin of certain portions of the trunk, es- 
pecially about the groins, is covered with a wjhite 
caseous layer. 
5. Rigor mortis well marked in the upper extremi- 
ties and lower jaw; less marked elsewhere. 
6. The head of oblong shape, the occiput rather 
small. The long diameter 111 centimetres, the 
transverse 9J centimetres, the oblique 11 eenti- POST-MORTEM EXAMINATIONS. 
105 
metres. Pretty well covered with short, dark-brown 
hair, up to two centimetres in length, and extending 
rather far over the forehead and face. The bones of 
the head are readily movable, somewhat overlapping 
each other, the right parietal bone especially project- 
ing over the left. Both fontanelles small, the ante- 
rior one 2 centimetres broad, 3} centimetres long; 
the posterior 1 centimetre each way. 
7. The eyelids closed. The eyeballs tense, the cor- 
ner slightly cloudy, the pupils large and quite open; 
no trace of pupillary membrane. 
8. The nasal cartilages firm, the nasal openings 
free. 
9. Mouth closed, upper lip very prominent, both 
lips slightly red. Tongue behind the jaws pale red- 
dish. No foreign body in the mouth. 
10. Ears large, cartilages deficient in firmness, 
passages empty. 
11. Neck movable, but within the ordinary limits; 
nothing abnormal in other respects. 
12. Thorax somewhat convex. Circumference at 
lower part 27 centimetres, measurement across 
shoulders 13 centimetres. 
13. Abdomen flat. Anterior spinous processes 6J 
centimetres apart, crests of the ilia 71 centimetres 
at greatest distance apart. 
14. External organs of generation properly formed, 
both testicles descended. The scrotum pale, swollen, 
translucent; its subcutaneous tissue, on section, found 
to be infiltrated with a deep yellow, watery fluid, 
which escapes in abundance on pressure. 106 
METHOD OF PERFORMING 
15. Anus closed ; no foreign body present. 
16. The finger and toe nails somewhat soft; the 
former reaching the tips of the fingers, the latter not 
extending to the end of the toes. 
17. The cartilaginous layer having been gradually 
removed, no centre of ossification discoverable in the 
lower extremity of the right femur. The same 
deficiency observable on the left side, on making a 
longitudinal incision. At the boundary between the 
bone and cartilage a small, slightly yellowish layer 
visible. 
18. Incisions having been made into the upper 
ends of the tibia, fibula, femur, and humerus on both 
sides, nothing abnormal discovered at the margin of 
ossification. No formation of nuclei in the epiphyses. 
19. No sign of any injury to the body. 
B. Internal Examination.—I. Thorax and Abdomen. 
20. The integuments divided by an incision from 
the chin to the pubic symphysis and carried to the 
left of the umbilicus ; the abdominal cavity opened. 
The diaphragm found to correspond to the lower 
border of the fourth rib. 
21. The umbilical vessels almost empty; on 
incision only a drop of semi-fluid blood escapes. 
22. The liver fills the whole of the epigastric 
region, so that the stomach is not visible. The large 
intestine distended by meconium and of a green 
color; the greater part of the transverse colon,the 
caecum and a loop of the sigmoid flexure prominently 
visible, but in their normal situation. The interval 
between the two latter filled by the much distended 
bladder. Numerous loops of the small intestines POST-MORTEM EXAMINATIONS. 
107 
occupy the remainder of the space; these are some- 
what flattened, from mutual pressure, apparently 
empty, of a rosy grayish-white color ; a few congested 
veins to be seen only in the omentum, which is 
devoid of fat, and in the mesentery. On turning up 
the liver the stomach is seen to be pale and closely 
contracted. 
23. No foreign body in the abdominal cavity. 
(a) The Thorax. 
24. The trachea having been ligatured in the pre- 
scribed manner, and the sternum (still almost entire- 
ly cartilaginous) having been removed with the costal 
cartilages, the thoracic organs are found to be in their 
regular position. The upper part of the mediastinum 
is occupied by the very large thymus gland, the left 
lung is withdrawn behind the pericardium, so that an 
interval almost as wide as the little finger separates 
the thoracic wall from the latter structure; the right 
lung covers the lateral portion of the thymus and of 
the pericardium, and almost all the right portion of 
the diaphragm. 
25. The prominent portions of both lungs present 
a pale grayish-red, clearly lobulated appearance, the 
more distinct by reason of the dark congested state of 
large superficial vessels; in many places the color is 
almost yellowish-red. These parts are flabby, and do 
not crepitate when handled. 
26. The pleurse empty, their surface moist. On 
the diaphragm, especially on the left side, small, 
dark-red, injected patches visible. 
27. The pericardium contains about half a tea- 
spoonful of a dark brownish-yellow, but clear fluid. 
The internal surface pale and smooth. The heart 108 
METHOD OF PERFORMING 
somewhat larger than the closed fist of the child, firm, 
its surface slightly arched, pale in color; the super- 
ficial veins filled with blood up to their roots; the 
auricles, with their appendages, bluish-red, moder- 
ately distended. 
28. On incision the right auricle found to contain 
scarcely a teaspoonful of fluid blood. Also the right 
ventricle contains only fluid blood, but in less quan- 
tity. The left ventricle is almost empty ; about half 
a teaspoonful of fluid blood in the auricle. 
29. The heart is now removed and further incisions 
made. All the valves are regular in form, of a 
slightly reddish tinge (from imbibition). The fora- 
men ovale still perfectly open. The muscular tissue 
pale, somewhat grayish-red. 
30. Rather less than a teaspoonful of dark fluid 
blood escapes from the large vessels of the thorax. 
31. The thymus gland is now carefully removed. 
It is 41 centimetres broad, 4 centimetres long, and 
9 millimetres thick ; grayish-white, medullary-looking 
in color, and presenting the same appearance on sec- 
tion. 
32. The veins of the neck tumid with dark fluid 
blood. The arteries also contain blood of a similar 
character. The large nerves are pale and appar- 
ently normal. 
33. The tongue, with the organs of the neck, 
removed from below, as directed. The posterior por- 
tion of the mouth contains no foreign body. The 
uvula and soft palate found to be much swollen, pale 
and gelatinous ; on incision a yellowish fluid escapes. 
34. The mucous membrane of the epiglottis and POST-MORTEM EXAMINATIONS. 
109 
aperture of the larynx is similarly, though less, 
swollen and thickened by watery infiltration ; similar 
though less decided swelling of the mucous membrane 
of the pharynx, which part is somewhat reddened 
throughout, owing to a superficial fine network of 
vessels. 
35. The upper part of the oesophagus contains 
some yellowish fluid ; mucous membrane decidedly 
pale. 
36. The epiglottis folded together laterally. The 
glottis very narrow; larynx and trachea empty, 
mucous membrane delicate and thin ; on the softer 
spots superficial vascular networks visible. 
37. After dividing the trachea above the ligature, 
the remaining thoracic viscera were removed together, 
and placed in a vessel with water. They were found 
to sink. 
38. The external surface of the lung posteriorly 
is of a uniform, rather bluish-gray-red color, but 
without marked congestion of the superficial vessels. 
The surface of these posterior portions, especially 
on the left side, is for the most part perfectly 
smooth. On closer examination no air vesicles are to 
be seen, but on many of the lobules small, whitish- 
gray, racemose marks. 
39. Each separate lung sinks in water, as do also 
separate lobes and small fragments, even from the 
generally bright-colored portions of the anterior 
border. 
40. The lower portion of the trachea and its 
branches are empty but deeply reddened. 
41. Incisions being made, the tissue of the lung 
appears grayish-red, very moist and glossy, and 110 
exhibits clusters of small, firm, whitish-gray spots 
corresponding to the internal parts of the lobules. 
There is no crepitation, and neither froth nor air 
bubbles escape by pressing the sides of the cut sur- 
faces, but only a little clear fluid and a few drops of 
blood. Even when incised under water no air 
bubbles escape from the tissue. The lungs were set 
aside for microscopical examination. 
METHOD OF PERFORMING 
42. The lower portion of the oesophagus is empty 
and pale. 
43. The aorta contains a little fluid blood; its 
internal surface is somewhat reddened. The vessels 
are given off irregularly from the thoracic portion. 
44. The foramen ovale is perfectly open (12 milli- 
metres in circumference), and presents on its anterior 
wall an oblong, fiat, dark, grayish-red projection, 
which, on section, is found to consist of coagulated 
blood deposited in the wall of the heart. 
(h) The Abdomen. 
45. The spleen 4.1 centimetres long, 2.2 centime- 
tres in its greatest breadth, 8 millimetres in its great- 
est thickness; its upper end wrinkled and turned 
inward, dark brownish-red in color, flabby consist- 
ence on section, the follicles small; pulp fragile, 
abundant, brownish-red. 
46. The left supra-renal capsule 25 millimetres 
long, 32 millimetres broad; on section, very vascular, 
brownish-red almost throughout, the different por- 
tions distinguished with difficulty, scarcely any fat in 
the coi’tex. 
47. The left kidney 50 millimetres long, 20 milli- 
metres broad, 18 millimetres thick. The capsule POST-MORTEM EXAMINATIONS. 
easily separable, the surface showing deep divisions, 
but otherwise smooth, pale, and with a faint brown- 
ish-red tinge. On section, the cortical substance 
similarly colored;. the medullary substance for the 
most part grayish-red, without cloudiness or deposit, 
but of a deeper red in the external portions. A little 
urine in the pelvis of the kidney and ureter. 
48. The same organs on the right side in much 
the same condition. 
49. The urinary bladder contains clear fluid; the 
mucous membrane pale. 
50. Both testicles in the scrotum, of normal size 
and somewhat bluish-red appearance. 
51. The duodenum now opened on its anterior 
aspect. It is seen to be full of soft pultaceous con- 
tents, whitish in color, with a slight tendency to 
yellow. The mucous membrane itself is faintly red- 
dened. The papilla of the biliary duct is open and 
very prominent, and from it a drop of watery bile 
exudes on pressing the gall-bladder. 
52. A thin transparent layer covers the wall of the 
stomach; the mucous membrane is thrown into 
marked longitudinal folds, which exhibit patches of 
redness. On some of these patches fine vascular net- 
works are visible; other patches are uniformly dark- 
red. 
53. Pancreas somewhat firm, pale anteriorly, slightly 
reddened posteriorly. 
54. The liver 10 centimetres broad, 58 millimetres 
wide, and 22 millimetres in thickness, pretty uni- 
formly reddened, exhibiting at one spot on the ante- 
rior surface both of the right and left lobe a flattened 
extravasation of fluid blood under the capsule. The 112 
METHOD OF PERFORMING 
substance of the organ flabby, uniformly grayish-red 
on section, turning to a uniform gray after pressing 
out the blood, which escapes pretty freely. The lob- 
ules not clearly recognizable. At the portal fissure 
a small whitish firm body, the size of a hemp-seed, is 
firmly adherent to the capsule of the liver. 
55. The mesentery contains many whitish-looking, 
slightly enlarged, lymphatic glands. 
56. The small intestine contains flocculent, pulta- 
ceous, slightly yellowish-white, epithelial matters. 
The ileum is much contracted; its contents are brown- 
ish-yellow, feebly resembling meconium, and are more 
abundant near the ileo-csecal valve. The large intes- 
tine is filled with meconium. The mucous membrane 
throughout is tolerably thick, faintly reddened, green- 
ish in the parts containing meconium; no other change. 
57. The large vessels on the vertebras are almost 
empty. 
11. The Cranial Cavities. 
58. The integuments having been divided as 
directed, and turned aside, are seen to be infiltrated 
with a yellowish fluid, the infiltration extending to 
the periosteum. On the right side, especially at the 
posterior part, there is also a pale-reddish infiltration 
of all the tissues down to the periosteum. Conges- 
tion of the veins up to their small branches. The 
scalp exhibits in places thick red spots, as large as a 
flea-bite or a lentil; these, on incision, are found to be 
the result of uniform sanguinary infiltration. 
59. The skull cap is now sawn through, the dura 
mater divided, and the brain, which is very soft, 
removed. A teaspoonful of clear fluid found at the 
base of the skull, but nothing else abnormal in this 
part. / POSTMORTEM EXAMINATIONS. 
113 
60. The bones of the skull relatively thin, movable. 
61. On the inner surface of the dura mater, near 
the coronary suture, there are a few minute red specks 
of blood in the tissue. The longitudinal sinus con- 
tains only fluid blood. 
62. The brain itself regularly formed; the pia 
mater delicate, and containing everywhere very nu- 
merous venous networks. 
63. After cutting through the hemispheres, each 
lateral ventricle is found to contain a small quantity 
of fluid; the lining membrane of these cavities 
somewhat firm, the veins on the surface congested, as 
are also those of the velum and choroid plexus. 
64. The section through the hemispheres shows a 
remarkably pale tissue of a peculiar yellowish-white 
color, the medullary substance being with difficulty 
distinguished from the cortex, the only difference be- 
ing that the latter appears paler and whiter than the 
former. The medullary substance is also very moist 
and shining, and of gelatinous appearance. These 
parts put aside for microscopical examination. 
65. The optic thalamus, corpus striatum, and the 
corpora quadrigemina are pale-yellowish in color and 
moist throughout. 
66. The cerebellum in the same condition; a few 
congested veins visible only in the corpus dentatum. 
The fourth ventricle empty. 
67. At the base of the brain very marked conges- 
tion of the veins of the pia mater, especially at the 
fissure of Sylvius. 
68. The pons Varolii somewhat firmer in consist- 
ence, pale on section. 114 
METHOD OF PERFORMING 
69. The medulla oblongata very firm, but at the 
same time very pale. 
70. There are no injuries to the bones at the base 
of the skull. 
On microscopical examination of the lungs we find 
that the ends of the bronchioles, the infundibula, and 
the alveoli are completely packed with dense accu- 
mulations of epithelial cells, some of which are full 
of fine, shining granules (myelin). On examining 
the brain, the white substance is found to contain 
scattered, highly refractile globular granules; the 
gray substance numerous pale-gray nucleated cells. 
This case presents a series of post-mortem appear- 
ances of an extremely singular character. The most 
important are those which, even at first sight, ap- 
peared to be connected together, viz., the oedema of 
the scrotum, the oedema of the uvula, soft palate, 
pharynx, and upper parts of the larynx, and likewise 
the oedema of the brain. All these parts were found 
to contain a clear but yellowish fluid, abundant in 
quantity, and removable by pressure; in the brain 
the yellow color somewhat less marked, but unusually 
decided in the scrotum and uvula. There can be no 
doubt as to the acute nature of these appearances. 
But what is their import? The absence of venous 
hypersemia in the affected parts is most decisive evi- 
dence against attributing the appearances to effusion, 
the results of passive congestion. We may, however, 
with some show of truth, refer the symptoms to a 
general dropsy. If we consider by itself the state of 
the soft palate, pharynx and larynx, there need be no 
scruple about designating it as acute laryngo-pharyn- 
geal oedema. This oedema, however, belongs to 
the class of the so-called active processes; as a 
general rule, it is purely an erysipelas. In my work 
on “Special Pathology and Therapeutics” (Erlangen, POST-MORTEM EXAMINATIONS. 
115 
-1854, vol. i, pp. 209, 217) I have minutely discussed 
the conditions of this form of oedema, and I can only 
say that my subsequent and much-enlarged experi- 
ence has convinced me of the relationship between 
this affection and erysipelas; or, I should rather say, 
of the identity of the two processes. I have repeat- 
edly observed in new-born infants, even clinically, a 
primary oedema of the scrotum followed by acute 
oedema of the pharynx and larynx, sometimes, indeed, 
assuming a phlegmonous type. These are allied 
branches of that affection which, when it occurs in a 
more diffused form, occasionally presents the appear- 
ance of the so-called sclerema, or induration of the 
cellular tissue (see my “ Gesammelten Abhand- 
lungen,” pp. 112, 701). 
In the case before us there are two appearances 
indicative of the existence of several general derange- 
ments of an allied kind. The first of these is that 
peculiar infiltration of the soft parts of the head with 
a deeply yellowish fluid, the signification of which 
was suggested in the external examination, and the 
second is that peculiar, almost brownish coloration of 
the pericardial fluid. That these appearances were 
not due to post-mortem changes is evident from the 
fact that there were no signs of decomposition present. 
Very unusual, and likewise very remarkable, is the 
oedema of the brain, a condition which was found to 
be associated with general paleness of the organ, and 
marked fatty metamorphosis of the cells of the neu- 
roglia of the medullary substance. I have no hesita- 
tion in assigning this condition to the same group as 
before, and in describing it as acute oedema, or even 
as erysipelas, of the brain. 
Had the mother suffered from puerperal fever, the 
further interpretation of the morbid appearances 
could have presented less difficulty. But not only 
was the mother perfectly healthy, but the other child 116 
METHOD OF PERFORMING 
was free from all similar symptoms. The fact is, 
therefore, that the case is one of a congenital affection 
which must have become developed in utero. As I 
have before shown (see my Archiv, vol. xxxviii, p. 
135,1867; vol. xliv, p. 472,1878; Geschwiilste, vol. ii, 
p. 469), fatty metamorphosis of the white substance of 
the brain, and more especially, incipient white hepa- 
tization of the lungs, are very frequently met with in 
syphilitic cases. But I have already alluded to the 
fact that the mother showed no signs of syphilis, and 
although syphilis in the father was not excluded by 
such evidence, there was no real support for such an 
assumption. Besides, as I have before mentioned, 
both the conditions in question occur in new-born 
children, free from any suspicion of syphilis. We 
cannot, therefore, go further into the question of cau- 
sation. The case may be provisionally described as a 
rare example of congenital erysipelas, involving vis- 
ceral as well as external organs. 
From a legal point of view the case is extremely 
interesting, not only because, in an otherwise viable 
child, death was the result of such latent morbid pro- 
cesses, but also from the fact that there were such 
extraordinary signs of immaturity in a child of the 
tenth month. Not only were the nails imperfectly 
developed, and the cartilages of the ears very delicate 
and movable, but there was no trace of any centre of 
ossification in the inferior epiphysis of the femur. 
We have, it is true, other observations with reference 
to this defect: I refer especially to G. Hartmann’s 
“ Dissertation ” (Beitrage zur Osteologie der Neu- 
gebornen, Tubingen, 1869, p. 18), So complete a 
defect, however, in the ossification of the extremities 
(and in the sternum), co-existing with the advanced 
stage of the same process in the bones of the skull, is 
well worthy of attention. 
The case well illustrates the importance of micro- POST-MORTEM EXAMINATIONS. 
117 
scopical examination for the decision of medico-legal 
questions, for by this means we were enabled to detect 
changes both in the brain and lungs. Owing to the 
proliferation of epithelium in the infundibula and 
alveoli, the lungs appeared so bright-red in color 
that I was at first inclined to believe that respiration 
had taken place. But on very close examination I 
noticed that the air cells were occluded, and my ob- 
servation was confirmed by the microscope. 
The medico-legal conclusions to be drawn in this 
case would be as follows : 
1. The body was that of a new-born child. 
2. The question whether the child was of the full 
term or not could not positively be determined by 
the examination. 
3. Respiration had not taken place, either during 
or after birth. 
4. The child was not capable of living out of the 
womb of its mother ; its death in utero was caused by 
disease implicating the lungs, larynx, and brain. 
5. There were no signs of any external violence. 
This concludes my list of cases, though it might 
easily be enlarged. Those given will suffice to indi- 
cate the method pursued. 
I should like to add a few words with regard to 
one point in conducting an autopsy, and that is the 
method of opening the thorax. It is evident to me 
that not a few young practitioners, in common with 
the majority of students, sometimes experience great 
difficulties in this part of the examination, simply 
because they do not clearly appreciate the anatomical 
conditions. 
In opening the wall of the thorax, the division of 118 
METHOD OF PERFORMING 
the cartilages should be made at a point as distant as 
possible from the sternum. As a matter of course, 
this direction applies only to non-ossified cartilages. 
If, however, the cartilages are even only partially 
ossified, the bone forceps must generally be substi- 
tuted for the knife, and under these circumstances 
we may with advantage go further outward, and 
divide the bones of the ribs, in order to obtain free 
access to the viscera of the thorax. It may be ob- 
served that the sterno-clavicular joint is, as a rule, 
not ossified unless it has been the seat of severe 
disease. This joint is, therefore, always to be cut 
through ; and inasmuch as it is crescentic in form, 
and its surfaces are separated by an inter-articular 
cartilage (see Fig. 4), separation is to be effected by 
means of steady strokes of the knife, directed in a 
crescentic curve round the sternal end of the clavicle. 
The cartilage of the first rib, on the other hand, is 
very frequently ossified, even in cases where the other 
costal cartilages are free from bony deposit. As a 
rule, what we meet with here, as in the other costal 
cartilages, is a supra-cartilaginous, i. e., a perichon- 
drial ossification, of great hardness, always enough to 
spoil the knife. 
If there be no ossification, we first cut through the 
costal cartilages on each side, close to their union with 
the ribs, the knife being held horizontally, so that its 
point may not penetrate deeply into the thorax. The 
important point is to obtain as large an opening as 
possible into the thoracic cavity. The line of incision, 
therefore, describes on each side a curve, the convexity 
of which is toward the sternum, its lower end being 
continued for some distance in an outward direction, 
so as to strike the insertions of the cartilages of the 
last false ribs. A glance at Plate 4 will clearly 
show that from the second rib downward the point 
of insertion of each successive rib becomes somewhat POST-MORTEM EXAMINATIONS. 
119 
more distant from the mesial line. If these points 
are taken as a guide for the incisions, on removing 
the sternum and costal cartilages we obtain a wide 
opening into the thorax, the width being much in- 
creased below. 
The first rib, however, requires exceptional notice, 
for if the incision, as above described, be prolonged 
toward it, the knife will generally come against the 
bony manubrium sterni, which increases much in 
width at this part. Corresponding to the increase, 
the cartilage of the first rib extends much further ex- 
ternally than that of the second, and the incision for 
its division must therefore be carried from one to two 
centimetres further outward than that for the second 
costal cartilage. The best way to proceed is to insert 
the knife, with its edge looking upward and forward, 
under the cartilage of the first rib, below its inferior 
border, and then cut upward and forward. This is 
the best way of avoiding injury to the vessels which 
are close beneath. Even in cases in which the peri- 
chondria! ossification is far advanced, the bony in- 
vesting layers can often be readily cut through, if the 
knife is used in the above manner. 
It is, therefore, always impossible to cut through 
the sterno-clavicular articulation and the first and 
second costal cartilages, by means of a single straight 
incision. Each of these parts must be divided sepa- 
rately and specially, and the knife must be directed 
in a suitable manner. Plate 4, which, moreover, 
shows partial duplication of the third costal cartilage 
on the right side, plainly illustrates the anatomical 
conditions, and any one who will carefully study it 
will be able, without difficulty, to draw the line by 
which the incisions are to be guided. 120 
REGULATIONS FOR THE 
REGULATIONS 
FOB 
THE GUIDANCE OF MEDICAL JURISTS 
IN CONDUCTING 
POST-MORTEM EXAMINATIONS FOR LEGAL 
PURPOSES. 
I. General Directions. 
§ 1. The Examining Medical Officers and their 
Duties.—The examination of a dead body for legal 
purposes is, in accordance with the existing regula- 
tions, to be undertaken by two medical practitioners 
only; as a general rule, one of these is to be a district 
physician (Physicus Gerichtsarzt) and the other a 
district surgeon (Gerichts-Kreis-Wundarzt). A mag- 
istrate is to be present during the examination. 
Those performing the examination are charged 
with the duties of legal experts. 
Should any doubts arise as to the method of per- 
forming the examination, they are to be decided by 
the district physician or his substitute ; but the sur- 
geon shall have the right of expressing his dissentient 
view in the minutes of proceedings. 
§ 2. Substitutes.—Only when lawfully hindered 
from performing their functions may the above- GUIDANCE OF MEDICAL JURISTS. 
121 
mentioned medical officers delegate tlieir duties to 
substitutes. When possible, a physician who has 
passed the pro physicatu examination is to be selected 
as a substitute. 
§ 3. Time of Performance.—Autopsies should not, 
as a rule, take place until twenty-four hours after 
death; but the mere inspection of the dead body may 
be made earlier. 
§ 4. Course to be adopted when Putrefaction has set 
in.—The presence of putrefaction is not, as a general 
rule, a sufficient reason for omitting the examination, 
and does not justify the medical jurist in refusing to 
proceed with his duties. For even if putrefaction be 
very far advanced, abnormalities and injuries of the 
bones can still be ascertained, and likewise many 
other circumstances, such as the color and state of 
the hair, the absence of limbs, etc., which may assist in 
establishing the identity in doubtful cases. Foreign 
substances within the body may also be discovered, 
as also the presence or absence of pregnancy and of 
poisons. When, therefore, the question arises of 
disinterring a dead body for the purpose of gaining 
information on matters of this kind, it is the duty of 
the physicians to recommend the exhumation, re- 
gardless of the time that has elapsed since death took 
place. 
§ 5. Instruments.—It is the duty of the medical 
jurists to take care that the following instruments, 
which are requisite for the performance of the exam- 
ination, are forthcoming and in good order: Four 
to six scalpels—two small, with a straight edge, and 
two large, with a curved edge. One razor. Two 
strong cartilage knives. Two pairs of forceps. Two 
double hooks. Two pairs of scissors—one pair large, 
having one blade with the point rounded off, the 122 
REGULATIONS FOR THE 
other sharp ; the other pair small, one blade probe- 
pointed, the other sharp-pointed. One pair of 
scissors, for laying open intestines. One blow pipe, 
furnished with a stop-cock. One thick probe and 
two fine ones. One saw. A mallet and chisel. 
A pair of bone forceps. Six curved needles of vari- 
ous sizes. A pair of caliber compasses. A metre 
measure, divided into centimetres and millimetres. A 
measure graduated into divisions, showing 100, 50, 
and 25 cubic centimetres. A pair of scales, with 
weights up to 10 pounds. A good magnifying glass. 
Blue and red test paper. 
The cutting instruments must all be perfectly 
sharp. Physicians performing a post-mortem exam- 
ination should, in addition, have at their com- 
mand a microscope with two objectives, magnifying 
at least 400 diameters, as well as the various instru- 
ments required for making preparations; also glasses, 
reagents, etc. 
§ 6. Place for the Examination, and Light.—For 
the examination a sufficiently spacious and light room 
should be chosen, where the body can be placed in a 
suitable position, and in a quiet situation. It is not 
allowable to perform autopsies by artificial light, 
except in cases which admit of no delay. In such 
a case the fact must be expressly alluded to in the 
protocol (§ 27), and mention made of the reason 
which rendered the performance at such a time 
imperative. 
§ 7. Frozen Bodies.—If the body is frozen, it is to 
be brought into a warm room, and the examination 
is not to be proceeded with until the parts are 
sufficiently thawed. The employment of warm water, 
or other warm materials for expediting the thawing, 
is not allowable. GUIDANCE OF MEDICAL JURISTS. 
123 
§ 8. Transport of Dead Bodies.—In moving the 
dead body in any way, and particularly in moving it 
from place to place, the greatest care must be taken 
to avoid applying any great pressure to any portion 
of it; and the large cavities should be kept as nearly 
as possible in a horizontal position. 
11. Proceedings at Post-mortem Examinations. 
§ 9. The Judicial Objects of the Examination.— 
Those charged with making the examination must 
keep their attention fixed upon the judicial objects 
in view, and all things which are subservient to these 
objects must be investigated with minuteness and 
completeness. 
Everything that appears important, before being 
noted down in the minutes, must be shown to the 
magistrate. 
§ 10. Duties of the Examiners with Reference to 
the Investigation of any Pecidiar Circumstances con- 
-72 ected ivith the Case.—Before commencing the exami- 
nation, those charged with its performance should, 
whenever it appears necessary, request the magistrate 
for permission to inspect the place where the body 
was found, and ascertain the position which it occu- 
pied, and also to examine the clothes which were 
found on the deceased. As a general rule, however, 
they need not undertake these investigations uidess 
requested to do so by the magistrate. 
They are also entitled to request the judgment of 
the magistrate with regard to all other circumstances 
previously ascertained which may bo of importance 
for the examination, and the opinions to be formed 
thereupon. 
§ 11. Microscopical Examination.—In all cases in 
which a microscopical examination is necessary in 124 
REGULATIONS FOR THE 
order to decide rapidly and positively as to any 
doubtful appearance—for example, to distinguish blood 
from colored fluids (holding hsematin in solution)— 
such examination must be made while the autopsy 
is going on. When, owing to circumstances, this is 
impossible, or when it is necessary to make a difficult 
microscopical examination (e.g., of portions of tissue) 
which cannot be done at once, the portions required 
are to be set aside in proper custody, and submitted 
to examination as soon as possible. In the report, 
the time at which this subsequent examination was 
made is to be definitely stated. 
§ 12.— The Examination of the Body.—The exami- 
nation of the dead body consists of two principal 
parts:— 
A. The external examination (inspection). 
B. The internal examination (dissection). 
§ 13. External Examination.—The external exami- 
nation includes that of the external surface of the 
body in general, and of its separate portions. 
With reference to the condition of the body gen- 
erally, the following are the points to be ascertained 
and noted:— 
1. Age; sex; size; bodily conformation; general 
state of nutrition; any signs of disease, such as 
ulcers about the legs, peculiar abnormalities, as spots, 
cicatrices, marks of tattooing, excess or deficiency of 
limbs. 
2. The signs of death and of any decomposition 
which may be present. 
Should the body be soiled with blood, fseces, dirt, 
and the like, these must be washed off, and it must 
then be ascertained whether rigor mortis is present or GUIDANCE OF MEDICAL JURISTS. 
125 
not; the color of the skin generally must be noticed, 
and the kind and degree of any coloration or dis- 
coloration due to decomposition that may be present 
in any part, also the color, position, and extent of 
the post-mortem stains, which must be cut into, ex- 
amined, and carefully described, in order to discrimi- 
nate between such appearances and those due to 
extravasation of blood. 
With reference to individual portions of the body, 
the following points must be attended to;— 
1. When the body is that of a person unknown, 
the color and other peculiarities of the hair (of the 
head and beard), and likewise the color of the eyes, 
are to be noted. 
2. The presence of any foreign substances in the 
natural apertures of the body, the state of the teeth, 
and the condition and position of the tongue. 
3. The following parts are then to be examined : 
the neck, chest, abdomen, back, the anus, the exter- 
nal organs of generation, and lastly, the limbs. 
Should there be an injury on any portion of the 
body, a description must be given of its shape, posi- 
tion and direction, with reference to fixed points ; also 
its length and breadth, in metric measurement. In 
this external examination any probing of wounds 
and injuries is, as a general rule, to be avoided, inas- 
much as the depth can be readily ascertained during 
the internal examination of the body and of the 
injured parts. If those performing the autopsy deem 
it necessary to introduce a probe, they must do this 
very carefully, and state their reasons for so doing in 
the notes of the proceedings (§ 27). 
When wounds have been discovered, the condition 
of their borders and surrounding parts is to be deter- 
mined, and after the examination and description of 126 
REGULATIONS FOR THE 
the wound in its original state, it should be enlarged, 
in order to ascertain the internal condition of its bor- 
ders and base. 
When the body presents wounds and injuries which 
have clearly nothing to do with the cause of death— 
for example, marks made in attempts at rescue, bites 
of animals, and the like—it is sufficient that such 
appearances should be summarily noted. 
§ 14. Internal Examination—General Directions.— 
In the internal examination, the three principal cavi- 
ties, of the body, viz., the head, thorax, and abdomen, 
are to be opened. 
The opening of the vertebral canal or of separate 
joints is never to be omitted in cases in which any in- 
formation may be expected from such examination. 
When there is any definite suspicion with regard 
to the cause of death, that cavity is first to be opened 
in which the principal changes are supposed to exist; 
but in other cases the head is to be opened first, then 
the thorax, and lastly, the abdomen.* 
In each of these cavities, the first thing to be done 
is to determine the position of the organs therein 
contained; then the color and condition of their sur- 
faces, the presence or absence of any unnatural 
contents, especially of foreign bodies, gases, fluids or 
coagula; and with regard to the two last substances, 
their quantity should be determined. Each separate 
organ is finally to be examined, both externally and 
internally. 
§ 15. The Cavity of the Skull.—Unless there are 
any injuries which have to be avoided by the knife, and 
which would necessitate some other method of proced- 
ure, the head is to be opened by means of an incision 
carried across the middle of the skull, from one ear to 
* With regard to new-born children, see Sections 23 and 24. GUIDANCE OP MEDICAL JURISTS. 
127 
the other; the soft parts covering the head are then to 
be reflected backward and forward. 
Attention having been paid to the condition of the 
soft parts, and of the surface of the bones, these latter 
are to be sawn through in a circular manner, and the 
skull cap is to be removed. The cut surface, the 
internal surface, and the general condition of the cra- 
nial arch, are to be examined. 
In the next place, the external surface of the dura 
mater is to be examined, the superior longitudinal 
sinus opened, and its contents determined; the dura 
mater is then to be divided on one side, and turned 
back, and its inner surface examined, as also the con- 
dition of the exposed portions of the pia mater. 
After this has been done on the other side, the 
brain is to be carefully removed, and the base of the 
skull is to be examined for any unusual contents. 
Attention must be paid to the condition of the dura 
and pia mater at the base and sides of the skull, and 
to that of the large arteries. 
The transverse sinuses are next to be opened, and 
also the other sinuses (if there is any cause for so 
doing), and their contents are to be determined. The 
size and shape of the brain are next to be ascertained, 
and the color, the fullness of the vessels, and the 
consistence and structure of the organ are to be deter- 
mined by means of a series of incisions through 
individual portions, viz., the hemispheres of the 
cerebrum, the great ganglia (the optic thalamus and 
corpus striatum), the corpora quadrigemina, the cere- 
bellum, the pons Yarolii, and the medulla oblongata. 
In addition to this, attention must always be paid 
to the condition of the tissue and vessels of the velum 
interpositum and choroid plexus. 
The size and contents of the different ventricles, 
and likewise the condition and amount of fullness of 
the various venous plexuses, are to be carefully 128 
REGULATIONS FOR THE 
ascertained, and the presence or absence of any 
coagula external to the vessels is to be determined. 
Finally, the bones of the base and lateral portions 
of the skull are to be examined, for which purpose 
the dura mater must be previously removed. 
§ 16. The Face, Parotid Gland, and Ear.—When 
it is necessary to lay bare the internal parts of the 
face, and to examine the parotid gland or the ear, 
the incision carried over the head is to be prolonged 
behind the ears to the neck, and the skin is to be 
dissected forward, in order to spare it as much as 
possible. Particular attention is to be paid to the 
condition of the large arteries and veins. 
§ 17. The Vertebral Column and the Spinal Cord. 
—The vertebral column (§ 14, par. 2) is to be 
opened from the posterior aspect. The skin and the 
subcutaneous fat are first to be divided exactly over 
the spinous processes; the muscles are then to be 
removed from the sides of these latter, and from the 
arches of the vertebrae. Extravasations of blood, 
lacerations and other injuries, particularly fractures 
of the bones, are to be carefully looked for. 
Then by means of a chisel, or a vertebral saw, if 
at hand, the spinous processes, together with the 
adjoining portions of the vertebral arches, are to be 
detached and removed. The dura mater is now ex- 
posed, and after its external surface has been exam- 
ined, it is to be carefully slit open longitudinally, and 
the presence of any serum, or extravasated blood, or 
other abnormal matters, is to be determined. The 
color, appearance, and general condition of the pos- 
terior portion of the pia mater are next to be 
noticed, and the resistance to pressure of the spinal 
cord is to be ascertained by gently passing the finger 
over it. 
The roots of the nerves are next to be divided on GUIDANCE OF MEDICAL JURISTS. 
129 
both sides by a longitudinal incision; the lower end 
of the cord is to be carefully taken out, its anterior 
connections are next to be gradually separated, and 
finally, the superior extremity is to be removed from 
the occipital foramen. 
In carrying out these directions, great care must 
be taken that the spinal cord be neither pressed nor 
bent. When removed, the condition of the pia mater 
on the anterior aspect is first to be examined, then 
the size and color (external) of the spinal cord are 
to be noted; and, lastly, numerous transverse inci- 
sions are to be made with a very sharp and thin knife, 
to determine the internal condition of the spinal 
cord, both of its white strands and of the gray sub- 
stance. The dura mater is then to be removed from 
the bodies of the vertebrae, and the dissector is to 
examine for extravasation of blood, injuries or altera- 
tions in the bones or intervertebral cartilages. 
§ 18. Neck, Thorax, and Abdomen—General Di- 
rections.—In opening the neck, thorax, and abdomen, 
it is generally sufficient to make one long incision 
from the chin to the pubes, passing to the left of the 
umbilicus. In ordinary cases, the incision is to be 
carried right into the abdominal cavity, care being 
taken not to injure any of its contents. The best 
plan is to make at first a very small incision into the 
peritoneum. Notice must be taken whether any gas 
or fluid escapes. First one, and then a second finger 
are introduced, the integuments are raised from the 
intestines, and the further incision through the peri- 
toneum is to be made between the two fingers. 
This being done, the position, color, and other ap- 
pearances presented by the exposed viscera, and also 
the occurrence of any abnormal contents, are next to 
be specified, and the position of the diaphragm is to 
be determined by examining it with the hand. 130 
REGULATIONS FOR THE 
The examination of the abdominal organs is not 
to be continued at this stage, unless there be particu- 
lar reasons for believing that the cause of death will 
be found in the abdominal cavity (§ 14). As a gen- 
eral rule, the examination of the thorax must precede 
the further examination of the abdomen. 
§ 19. The Thorax.—For opening the thorax it is 
necessary that the soft parts of the chest should first 
be dissected back beyond the points of attachment of 
the cartilages to the ribs. The cartilages are then to 
be divided with a strong knife a few millimetres in- 
ternal to their attachments. Care must be taken to 
avoid injuring the lung or the heart. When the car- 
tilages are ossified, the best plan is to divide the ribs 
with a saw or bone forceps a little external to the at- 
tachments of the cartilages. The clavicles are then 
to be separated from the manubrium of the sternum 
by means of a crescentic incision, the knife being 
held vertically, and the junction with the first rib, 
whether cartilaginous or bony, is to be divided with 
the knife or bone forceps, the greatest care being 
taken to avoid injuring the vessels lying beneath. 
Then the attachments of the diaphragm between the 
ends of the two incisions are to be divided close to 
the cartilages of the false ribs and the ensiform car- 
tilage ; the sternum is to be turned upward, and the 
mediastinum cut through, care being taken to avoid 
injuring the pericardium and large vessels. 
After removing the sternum the condition of the 
pleural cavities is to be determined; the presence, 
condition, and quantity of any abnormal contents, 
the state of distention, and the general appearance of 
the exposed portions of lung are to be noticed. If, 
in the removal of the sternum, any vessel has been 
injured, this must be tied, or a piece of sponge must 
be applied, to prevent the blood from escaping into GUIDANCE OF MEDICAL JURISTS. 
131 
the pleural sac, where its presence might give rise to 
mistakes. The condition of the mediastinum, the 
state of the thymus gland, and likewise the condition 
of the large vessels outside the pericardium (which 
vessels, however, are not yet to be opened) are now 
to be noticed. 
Then the pericardium is to be opened, and its con- 
dition noticed, and the heart examined. With regard 
to the latter, its size, the fullness of the coronary ves- 
sels, and of its separate cavities (auricles and ventri- 
cles), its color and consistence (post-mortem rigidity), 
are all to be noticed before any incision is made, and 
before the heart is removed from the body. Then, 
while the heart is still unsevered from its connections, 
each ventricle and each auricle are to be separately 
opened, and the contents of each cavity are to be 
determined with regard to their quantity, state of co- 
agulation and general appearance, and the size of the 
auriculo-ventricular valves is to be tested by intro- 
ducing two fingers from the auricle. Then the heart 
is to be removed; the condition of the arterial open- 
ings is first to be tested by pouring in water, and 
then, by slitting them up; the condition of the mus- 
cular tissue of the heart is to be determined with 
reference to its color and general appearance. If 
there be reason to suppose that the muscular struc- 
ture has undergone considerable alteration—fatty de- 
generation, for example—a microscopical examination 
must always be made. 
The examination of the heart is to be followed by 
that of the large vessels, but the descending aorta is 
to be left until the lungs have been examined. In 
order to examine the lungs minutely, they must be 
removed from the thoracic cavity. Their removal 
must be effected with great care, and the lung tissue 
must not be torn or squeezed. If extensive adhesions 
exist, and particularly if they are old standing, they 132 
REGULATIONS FOR THE 
must not be divide*!, but a portion of the costal pleura 
should be removed with the attached adhesions. After 
removal of the lungs, their surface is to be again 
carefully examined, in order that recent changes— 
for example the commencement of inflammatory exu- 
dation—may not be overlooked. The capacity for 
air, the color, and the consistence of each portion of 
the lungs, are to be noticed; finally, large, smooth 
incisions are to be made, and the following points 
attended to : The state of the cut surfaces ; the 
amount of air, blood, and serum ; the presence of any 
solid contents in the pulmonary vesicles ; the condi- 
tion of the bronchial tubes and pulmonary artery, 
with especial reference to obstruction, etc., in the 
latter. For this purpose the air passages and the 
large branches of the pulmonary artery are to be 
divided with the scissors, and followed out to their 
finer ramifications. 
In cases where it is suspected that foreign matters 
have entered the air passages, and where substances 
the nature of which is not evident on simple inspec- 
tion are found in the air tubes, recourse must be had 
to the microscope to determine their nature. 
§ 20. The Neck.—According as circumstances may 
require, the neck may be examined, either before or 
after the opening of the thorax or the removal of the 
lungs. Those performing the autopsy may, if they 
think fit, make a special examination of the larynx and 
air tubes, if such investigation be of particular 
importance, as, for instance, in cases of death from 
strangulation or drowning. 
As a general rule, the best plan is first to examine 
the large vessels and the nerve trunks, and after- 
ward to open the larynx and trachea by an incision 
carried along their anterior aspect, and to examine 
their contents. In cases where it is especially im- GUIDANCE OF MEDICAL JURISTS. 
133 
portant to examine tliese parts, they should be looked 
to before the lungs are removed from the body, and 
pressure should be carefully made upon these latter 
organs, in order to see whether any liquid matters, 
etc., ascend into the trachea. 
The larynx is then to be removed, together with 
the tongue, the soft palate, the pharynx, and the 
oesophagus ; each of these parts is to be incised and 
its condition ascertained, the state of the mucous 
membrane being particularly noticed. The thyroid 
gland, the tonsils, the salivary glands, the cervical 
lymphatic glands, are all to be examined. 
In cases where the larynx or trachea has been 
injured, or where important changes are supposed to 
exist in these parts, an incision is not to be made into 
them until they have been removed from the body, 
and they are then to be opened from their posterior 
aspect. 
Where death has resulted from strangulation, or 
presumably from suffocation, and the carotid arteries 
are opened in order to ascertain whether there is any 
injury of the lining membrane, the vessels should be 
examined while still in their natural position. 
Finally, the state of the cervical vertebrse and of 
the deep muscles of the neck should be noticed. 
§ 21. The Abdomen.—In the further examination 
of the abdominal cavity and of its contents (§ 18), a 
certain order of sequence is always to be adopted, so 
that the removal of an organ shall not interfere with 
the minute investigation of its relations to other 
parts. Thus the duodenum and biliary ducts should 
be examined before the removal of the liver. As a 
general rule, the following order of sequence is ad- 
visable : 1. The omentum. 2. The spleen. 3. The 
kidneys and suprarenal capsules. 4. The urinary 
bladder. 5. The organs of generation (in the male 134 
REGULATIONS FOR THE 
subject the prostate gland and vesiculse seminales, 
the testicles, the penis, with the urethra; in the 
female, the ovaries, Fallopian tubes, uterus, and 
vagina). 6. The rectum. 7. The duodenum and 
stomach. 8. The gall-ducts. 9. The liver. 10. The 
pancreas. 11. The mesentery. 12. The small in- 
testines. 13. The large intestines. 14. The large 
blood vessels in front of the vertebral column; their 
contents to be examined and determined. 
The Spleen.—The length, breadth, and thickness of 
the spleen are to be ascertained while the organ is 
lying free, and not when placed in the hand, and the 
spleen is not to be compressed by the measure. A 
longitudinal incision is then to be made, and if any 
alterations of structure are manifest, the organ should 
be incised in various directions. The quantity of 
blood is always to be noticed. 
The Kidneys.—Each kidney is to be removed by a 
vertical incision through the peritoneum, external 
to and behind the ascending or descending colon, the 
intestine is to be pushed aside, and the kidney de- 
tached from its connections. The capsule is then to 
be carefully removed, a long incision being made into 
it over the convex border of the kidney. The surface 
thus exposed is to be noticed with reference to the 
size, shape, color, quantity of blood contained, and 
any morbid appearances that may be present. A 
long incision is then to be made through the kidney, 
as far as its pelvis, the cut surface is to be washed with 
water, and described with reference to the condition 
of the cortical and medullary substance, vessels, and 
parenchyma. 
The Pelvic Organs.—The organs of the pelvis (the 
bladder, rectum, and generative organs therewith 
connected) are best removed together, but the blad- GUIDANCE OF MEDICAL JURISTS. 
135 
der should first be opened in sitfi, and its contents 
determined. Then the parts should be further ex- 
amined, the generative organs being taken last. The 
vagina should be opened and examined before the 
uterus. In examining the body of a woman who has 
died after delivery, special attention should be paid 
to the condition of the veins and lymphatics, both on 
the inner surface of the uterus and in its walls and 
appendages, the size and contents of the vessels being 
especially noted. 
The Stomach and Duodenum.—The external con- 
dition of the stomach and duodenum is first to be 
ascertained while the parts are in situ. Then, with a 
pair of scissors, the duodenum is to be slit up on its 
anterior aspect, and the stomach along the great cur- 
vature ; the contents are then to be examined, the 
permeability of the gall duct and any matter con- 
tained therein are also to be noticed, and then the 
parts are to be removed for further examination. 
The Liver.—The external appearance of the liver 
is first to be described, and the organ is to be removed 
after the examination of the excretory ducts. Long, 
smooth incisions are then to be carried transversely 
through the organ, and the amount of blood and 
general condition of the parenchyma are to be ascer- 
tained. The description is to contain a short account 
of the general condition of the lobules, the appear- 
ance of their centres and circumference being partic- 
ularly noticed. 
The Small and Large Intestines.—The small and 
large intestines are to be examined with reference to 
the degree of distention, color, and other external 
appearances of their various parts; they are then to 
be removed together, the mesentery being cut through 
close to the intestine. After removal, the intestine is 136 
REGULATIONS FOR THE 
to be slit up with the scissors along the line of 
attachment of the mesentery. As this is being done, 
the contents of each portion are to be noticed and 
estimated. Then the intestine is to be well cleansed 
with water, and the condition of the various portions 
noticed, particular attention being paid to the agmin- 
ate and solitary glands, the villi, and valvulse conni- 
ventes of the small intestine. In every case of peri- 
toneal inflammation examine carefully the vermiform 
appendage. 
§ 22. Cases of Poisoning.—In cases where poison- 
ing is suspected, the abdominal cavity is first to be 
examined. Before anything further is done attention 
is to be paid to the external appearance of the prin- 
cipal viscera, their position and size, the fullness of 
their vessels, and also as to whether there be any 
odor perceptible. 
With regard to the vessels, the points here to be 
determined, as in other important organs, are as 
follows : Are the vessels arteries or veins ? Does the 
congestion prevail in the finer ramifications, or only 
in the trunk and branches of a certain size ? Are 
the intervascular spaces of considerable extent or 
not ? 
Double ligatures are then to be placed around the 
terminal portion of the oesophagus, just above the 
cardiac orifice, and two more around the duodenum, 
below the opening of the gall duct. The parts are to 
be divided between the ligatures. The stomach is 
then to be removed with the duodenum, care being 
taken to avoid injuring the parts. They are then to 
be opened as described in § 21. 
The contents are to be immediately examined with 
regard to the quantity, consistence, color, composition, 
reaction, and smell, and placed in a clean porcelain 
or glass vessel. GUIDANCE OF MEDICAL. JURISTS. 
137 
The mucous membrane is then to be washed with 
water, and its color, thickness, surface and consist- 
ence are to be noticed. Particular attention is to be 
paid to the state of the blood vessels, and to the 
tissue of the mucous membrane generally, and of each 
of the principal portions of the stomach. Particular 
care should be taken to ascertain whether any blood 
that may be present is within the vessels, or extrava- 
sated, also whether it is recent, or altered by 
putrefaction or digestion, and under these circum- 
stances has penetrated by imbibition into the parts 
around. If extravasated, its situation should be 
determined—whether on the surface or in the tissue, 
and whether coagulated or not. 
The surface of the mucous membrane is to be care- 
fully examined for any breaches of continuity, such 
as loss of substance, erosions, or ulcers. The question 
as to whether the alterations manifested may have 
occurred after death, from natural decomposition, or 
from the action of the fermenting contents of the 
stomach, is to be carefully kept in mind. 
This examination having been completed, the 
stomach and duodenum are to be placed in the vessel 
which contains the contents (see above), and delivered 
to the magistrate for further investigation. The 
oesophagus having been tied in the neck and divided 
above the ligature, and subjected to examination, is 
also to be placed in the same vessel. In a case where 
the stomach contains but very little, the contents of 
the jejunum should be reserved in like manner. 
Lastly, other materials and portions of organs, such 
as blood, urine, pieces of liver, kidneys, etc., are to be 
taken from the body, and made over to the magistrate 
separately, for further examination. The urine is to 
be placed in a separate vessel. The blood is to be 
kept separately only in cases where a definite con- 
clusion may be anticipated from spectrum analysis. 138 
REGULATIONS EOE THE 
Portions of other organs reserved are to be placed 
together in one vessel. 
Each vessel is to be carefully closed, sealed, and 
marked. 
If on simple inspection the gastric mucous mem- 
brane appears particularly opaque and swollen, no 
time should be lost in examining it with a microscope, 
especial attention being paid to the condition of the 
peptic glands. 
The microscope is also to be used in cases where 
the stomach contains any suspicious substances, such 
as portions of leaves or other vegetable matters, the 
remains of animal substances taken as food, etc. 
Where trichinosis is suspected, the contents of the 
stomach and upper part of the jejunum are first to be 
subjected to microscopical examination, but portions 
of the muscular tissue (of the diaphragm, cervical and 
pectoral muscles) are to be put aside for further 
investigation. 
§ 23. New-horn Children: Determination of Ma- 
turity and Period of Development.—In the post-mortem 
examination of new-born children special attention 
is to be directed to the following points, in addition 
to the above mentioned general rules:— 
In the first place, the signs indicative of maturity 
and period of development must be looked for. 
These are: the length and weight of the child, the 
condition of the general integuments and of the 
umbilical cord, the length and state of the hair of 
the head, the size of the fontanelles, the diameter of 
the cranium (longitudinal, transverse and diagonal), 
the condition of the eyes (membrana pupillaris), the 
state of the cartilages of the nose and ear, the length 
and condition of the nails, the transverse diameter of 
the body at the shoulders and hips; in male infants, 
the condition of the scrotum and position of the testi- GUIDANCE OF MEDICAL JURISTS. 
139 
cles; in females, the condition of the external organs 
of generation. 
Finally, we must examine the size of the centre of 
ossification (if present) in the inferior epiphysis of the 
femur. For this purpose, the knee joint must be 
opened by means of a transverse incision below the 
patella, the joint fully bent and the patella removed; 
thin layers are then to be cut from the cartilaginous 
end of the femur, till the greatest transverse diameter 
of the centre of ossification (if present) be reached; 
this is to be measured in millimetres. 
Should the condition of the foetus be such as 
clearly to prove that it was born before the comple- 
tion of the thirtieth week, it is not necessary to proceed 
further with the examination, unless the magistrate 
distinctly requires it. 
§ 24. Determination of the Question whether the 
Child has Breathed.—If it shall appear that the child 
has been born after the thirtieth Aveek, the next step 
is to ascertain ivliether it has breathed during or after 
birth. For this purpose the respiration test must be 
applied, and the proceedings conducted in the folloiv- 
ing order:— 
(a) Immediately on opening the abdominal cavity 
the position of the diaphragm is to be ascertained, 
Avith reference to the corresponding rib, and on this 
account, in new-born children the abdomen is always 
to be opened first, and afterward the thorax and 
cranium.* 
(h) Before opening the thorax a ligature is to be 
placed around the trachea above the sternum. 
(c) The thorax is then to be opened, and attention 
must be paid to the degree of dilatation of the lungs, 
* The dissection, however, of the abdominal organs is never to 
precede the opening and examination of the thorax. 140 
REGULATIONS FOR THE 
and their position dependent upon such dilatation, 
particularly with reference to the pericardium. The 
color and consistence of the lungs should also be 
ascertained. 
(d) The pericardium is then to be opened, and its 
condition and that of the heart externally are to be 
ascertained. 
(e) The cavities of the heart are then to be opened, 
and their contents to be examined, and the condition 
of the heart in other respects is to be determined. 
(/) The larynx and that portion of the trachea 
above the ligature are then to be opened by means of 
a longitudinal incision, the condition of their walls 
is to be ascertained, and any contents are to be 
examined. 
(g) The trachea is to be divided above the ligature 
and removed, together with all the organs of the 
thorax. 
(,h) After removing the thymus gland and the 
heart, the lungs are to be placed in a capacious vessel 
filled with clean, cold water, in order to test their 
buoyancy. 
(i) The lower part of the trachea and its subdi- 
visions are to be laid open and examined, especially 
with reference to their contents. 
(Jc) Incisions are to be made in both lungs, and 
notice taken whether any crepitating sound be heard, 
and also with reference to the amount and quality of 
the blood issuing from these cut surfaces on slight 
pressure. 
(I) Incisions are to be made into the lungs below 
the surface of the water, in order to see whether any 
air-bubbles rise from the cut surfaces. GUIDANCE OF MEDICAL JURISTS. 
141 
(m) Both lungs are next to be separated into their 
lobes, and these are to be divided into several small 
pieces, the buoyancy of each of which is to be tested. 
(ri) The oesophagus is to be opened and its condi- 
tion ascertained. 
(o) Lastly, in cases where it is suspected that air 
cannot gain access to the lungs, in consequence of the 
filling up of their cells and passages with morbid pro- 
ducts (hepatization) or foreign substances (mucus, 
meconium), the lung tissue is to be examined with the 
microscope. 
§ 25. Other Examinations.—In the last place, it is 
the duty of those performing the autopsy to examine 
all other organs or parts not mentioned by name in 
the regulations, in any case in which the parts in 
question are found to be injured or otherwise abnor- 
mal. 
§ 26. End of the Examination—The Cavities to be 
Closed.—The examination being completed and the 
body cleansed as far as possible, it is the duty of the 
district surgeon, who is relatively the junior of the 
medical examiners, to close up carefully those cavities 
of the body which have been opened. 
111. Framing the Protocol and Report of the Examin- 
ation. 
§ 27. Drawing up of the Protocol of the Examination. 
—A protocol of everything connected with the post- 
mortem examination must be drawn up by the mag- 
istrate upon the spot. 
The physician (Gerichtsarzt) has to take care that 
the appearances in all details, as determined upon by 
the inspectors, are literally described in the protocol. 142 
REGULATIONS FOR THE 
The magistrate is to direct that this should be done 
in such a way that the description and the report of 
each separate organ are to he placed on record before 
another portion is submitted to examination. 
§ 28. Arrangement and Drawing up of the Protocol. 
—The technical portion of the protocol of the autopsy 
must be dictated by the physician ; it must be clear, 
definite, and intelligible to non-medical persons. And 
for this latter purpose, especially in the description 
of the appearances found, the use of foreign scientific 
terms is to be avoided, when this can be done without 
loss of distinctness. 
The two principal divisions—the external and inter- 
nal inspections—are to be distinguished by large cap- 
itals (A & B); the sections describing the opening of 
the cavities, in the order in which this has been done, 
by Roman numerals (I, II). The opening of the 
thoracic and abdominal cavities will come under one 
number. In the section which deals with the thorax 
and abdomen, the general appearances, mentioned in 
the last paragraph of Section 18, are first to be de- 
scribed, then under a and b the appearance of the 
thoracic and abdominal organs respectively. 
The result of the examination of each separate part 
is to be contained in a distinct paragraph headed 
with Arabic numerals. The numerals run consecu- 
tively from the beginning to the end of the protocol. 
The appearances found must be accurately de- 
scribed as matters of fact, and not in the form of mere 
opinions (e.g., “inflamed,” “gangrenous,” “healthy,” 
“normal,” “a wound,” “an ulcer,” and the like). 
But the inspectors may, if they please, for the sake 
of distinctness, add to their statement of actual ob- 
servations expressions of this kind in parenthesis. 
In all cases a statement must be given with refer- 
ence to the amount of blood contained in each im- GUIDANCE OP MEDICAL JURISTS. 
143 
portant part, and what is required is a terse descrip- 
tion, not merely an opinion couched in such terms us 
“intensely,” “moderately,” “somewhat,” or “very 
reddened,” “ full of blood,” “ bloodless.” In the de- 
scription, the size, shape, color, and consistence of 
the various parts are to be mentioned seriatim before 
making any incisions. 
§ 29. Provisional Opinion.—At the conclusion of 
the autopsy the medical inspectors must enter in the 
protocol their provisional opinion regarding the case, 
summarily, and without the addition of any reasons. 
If any particular facts influencing their opinion 
have come to their knowledge, whether from the pro- 
ceedings or otherwise, these must be briefly mentioned. 
If any particular questions have been put to them 
by the magistrate, it must be shown in the protocol 
that the answer is the result of such questions. 
In every case the cause of death as evidenced by 
the objective appearances is first to be set forth in the 
opinion, and next the question of criminality is to be 
dealt with. 
If the cause of death has not been discovered, the 
fact must be expressly mentioned. It is never suffi- 
cient to say that the death has resulted from internal 
causes or from disease; the disease must be specified. 
In cases where further technical examination is 
necessary, or where there are any doubtful circum- 
stances, a special opinion, giving reasons, is to be for- 
mally deferred. 
§ 30. Supplementary Explanation with regard to 
Weapons.—lf there be any injuries on the dead body 
which may have been the cause of death, and if it be 
suspected that a weapon found has been used to cause 
the injuries, then the medical inspectors, at the request 
of the magistrate, must institute a comparison be- 144 
REGULATIONS FOR THE 
tween them, and must state whether and what injuries 
could have been caused by the weapon, and whether 
any conclusions can be drawn, from the position and 
condition of the injury, as to the mode in which the 
perpetrator has acted, and as to the force used. 
Should weapons not be forthcoming, the inspectors 
must express an opinion, as far as the appearances 
will permit, with regard to the way in which the in- 
juries have originated, and with reference to the 
nature of the weapon employed. 
§ 31. Report of the Examination.—Should a report 
(a reasoned opinion) of the examination be required 
from the inspectors, it is to be furnished in the follow- 
ing form : 
All useless formalities being avoided, and after a 
statement of what has been done, it is to be com- 
menced with a condensed but minute history of the 
case, so far as their cognizance permits. They must 
then incorporate in this report the protocol of the 
autopsy, but only so much as is necessary for the elu- 
cidation of the case, using the exact words of the 
protocol and the same numerals, expressly drawing 
attention to any deviations in this respect. 
The style of the report must be concise and clear, 
and the ground on which the opinion is formed must 
be displayed in such a way as to be intelligible and 
convincing, even to non-medical men. The inspectors 
must employ, therefore, as far as possible, expressions 
and terms in popular use. Especial references to 
literary authorities are, as a rule, to be avoided. 
If the magistrate has placed definite questions 
before the inspectors for their opinion, these must be 
answered as fully and literally as possible, or reasons 
given why this cannot be done. 
The report of the examination must he signed by 
both inspectors, and if a district physician has as- GUIDANCE OF MEDICAL JURISTS. 
145 
sistecl at the autopsy, his official seal must be affixed 
to the report. 
Every report, when required, must be furnished 
by the inspectors within four weeks at latest. 
Berlin, January 6, 1875. 
The Royal Scientific Commission for Medical Affairs. 
The foregoing regulations are hereby approved, and 
their observance is rendered obligatory upon all med- 
ical officers who may be concerned. The regulations 
of the 15th of November, 1858, are abolished. 
Berlin, February 13,1875, 
The Minister for Ecclesiastical, Educational, and 
Medical Affairs. 
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