CHAPTER VII.

PRESERVATION OF SPECIMENS OF MORBID ANATOMY, 326

INTRODUCTION

Before entering upon the study of any subject, it is of moment that the student be thoroughly convinced of the importance of the knowledge which he is about seeking to acquire, since his zeal in its pursuit will, in most cases, be in proportion to this conviction. We will, therefore, before entering upon the subject proper of this book, present in few words, some considerations on the _importance of a study of morbid anatomy as revealed by post-mortem examinations_.

The necessity of a study of anatomy and physiology by a medical student, is now so universally recognized, that an attempt to prove its importance would seem deserving only of ridicule; but the ignorance of many practitioners on the subject of morbid anatomy, shows that this study has yet to vindicate its claim as a necessary branch of a medical education.

From a purely theoretical standpoint, the educated physician—one whose motto is _Esse, non videri_—after combating a disease in vain, should not feel content to remain in ignorance of its real nature, so far as discoverable by anatomical changes, capable of being recognized after death, even had he no prospect of adding thereby one jot to his practical acquaintance with disease or to his power to combat it; yet his scientific conscience (if we may be allowed the expression) ought not to rest satisfied until, in all doubtful cases, his _ante-mortem_ diagnosis be confirmed or overthrown, and his conception of the case completed in all its details by a _post-mortem_ examination.

Besides this purely individual scientific interest, there are weightier practical reasons for an acquaintance with this branch of medical science by the physician as practitioner.

Among the almost innumerable questions upon medical, theological, and miscellaneous subjects which the American public feels at liberty to propound to its medical advisers, none are of more frequent occurrence and none are more justifiable than the two: “What is the matter with the patient?” and “Will he, or can he, recover?” and to none is an answer more imperatively demanded. The public very naturally, and with reason, requires on the part of a physician the ability to make a diagnosis and a prognosis. It will not be satisfied with being told that the name of the disease is of no importance, that the doctor only wants to hear the symptoms; that he does not cure _diseases_, but removes the symptoms of disease, &c. Only an exceedingly well-trained public will accept these truisms as an equivalent for diagnostic skill. Hence, it is the physician’s interest, as well as his duty, as we shall see, to seek, in all cases, to make a diagnosis, no matter how difficult the task may prove to be. The question how far his treatment will be modified by his diagnosis is a question of therapeutics, and does not belong here; but certain it is, that a mere combatal of the symptoms as isolated phenomena cannot be regarded as fulfilling the whole duty of a conscientious physician.

The ability to make a diagnosis, and consequently prognosis, depends upon a knowledge of pathology, with a knowledge of symptoms as signs of pathological states and changes; and as such they must be critically examined and their true import discovered, if possible. Thus treated, we arrive, by various processes of reasoning, at a diagnosis, under which the symptoms fall into their natural order of importance, and we run but little risk of contending with remote subjective symptoms (of great importance in differential therapeutics) to the neglect of more important, though perhaps less prominent ones.

Besides this, we are, in a measure, prepared to foretell the probable course of a disease, and can, therefore, in many cases, adopt anticipatory measures, while in all we will be guarded against the error, so often committed, of ascribing to the remedy used the so-called “_aggravations_,” which are often only natural symptoms of the unchecked and, perhaps, entirely uninfluenced morbid process. Such knowledge serves thus, by purifying our experience, to guard us against self-deception, and to prevent us from misleading others by reports of cures of diseases existing only by virtue of a false diagnosis.

A knowledge of pathology, furthermore, places in our hands a thread which can guide us through the labyrinth of our vast materia medica, and which enables us, from the myriad of symptoms, to eliminate the non-important ones. It shows us the “bearings” of the medicines and their various specific ranges, thus materially facilitating the choice of a remedy.

Again, medical science is virtually based upon pathology, and we see, therefore, how important, nay, how absolutely necessary, to the progress of the former is the study of the latter. The practice of medicine as an art can never be advanced knowingly by those who neglect its cultivation as a science. While each one may practice the art according to his own convictions, true medical science stands above all the belittling, bigoted prejudices of the schools. Here, every one claiming the name of an educated physician can and ought to work.

The wild vagaries of former ages, when philosophy set up purely theoretical views, under which observed phenomena were compelled to arrange themselves, have warned the present age to be guided solely by sober and exact observations and investigations; and it needs no proof that, in the advancement of our knowledge of disease, these are best accomplished by frequent post-mortem examinations, which thus become a necessary adjunct to a proper study of pathology.

In all cases of interest, therefore, the physician should feel it a duty which he owes to himself and the profession at large, to seek permission to make a post-mortem examination; but in order that the fullest benefit may be derived from the same, he must know how to look for what he is in search of, and how to recognize it when found.

To furnish this knowledge is the object of the following pages, to which we herewith introduce the reader.

PRELIMINARY CHAPTER.

INSTRUMENTS AND GENERAL DIRECTIONS.

=The Post-mortem Case=, as prepared by the instrument makers, will be found to contain, usually, the following instruments:

[Illustration: [Scalpels]]

1. A set of ordinary dissecting scalpels, four or five in number, and of graduated sizes, including one heavy cartilage knife.

[Illustration: [Knife]]

2. A brain knife with a long blade, for slicing the brain.

[Illustration: [Chisels]]

3. Chisels, of one or both the accompanying forms, for use in opening the head or spine.

[Illustration: [Hammer]]

4. An iron mallet or hammer, with a hook on the end of the handle for tearing off the culvarium.

[Illustration: [Enterotome]]

5. An enterotome, or scissors with blunt, hooked point, for splitting open the intestinal canal.

[Illustration: [Saw]]

6. A saw with movable back; this arrangement permitting of a deeper cut, in dividing large bones.

[Illustration: [Rachitome]]

7. The rachitome, a chisel-like instrument, to be used with the hammer in opening the spinal canal.

[Illustration: [Saw]]

8. The double saw, used for dividing the laminæ of the vertebræ. A side view of the instrument being given in the cut, one blade only is seen. The two are attached to one handle, placed parallel with one another, and about one and one-fourth inches apart. After the soft tissues have been removed, this saw is used by passing the spinous processes between the two blades, and thus dividing both laminæ at once.

[Illustration: [Clamp]]

9. A skull clamp, for steadying the head while removing the calvarium. After the removal of the scalp, this instrument may be employed, and be of much service for the above object. It is applied by placing the open end of the instrument over the crown of the head, turning down the screws, and thus fastening it just above the line of division of the bone. The arched end of the instrument now serves as a handle for turning or steadying the head.

10. Rib-shears, for dividing the ribs where that operation is found desirable.

11. A tube for inflating the lungs, and an ordinary blowpipe.

12. Dissecting forceps, tenacula in handle and with chain, grooved director, and assorted needles, straight and curved.

While a post-mortem case with all of the above instruments is very convenient, and important even, where there is frequent occasion for its use, still its absence should never deter the physician from making an examination where the ordinary dissecting case may be had; and with the country physician generally, this case is all that is absolutely essential, as a common carpenter’s saw and chisel may at any time be found, in cases where the head is to be opened; while for opening the chest and abdomen, the dissecting case contains everything that is essential.

Instruments used in post-mortem examinations should never be employed for operating upon the living, without first being repolished by the instrument maker, and the handles disinfected by careful cleaning in a solution of permanganate of potash.

PRELIMINARY PREPARATIONS.

=The Preliminary Preparations= at the place of the operation should consist in providing a sponge for absorbing fluids; newspapers and old cloths for filling cavities or wrapping up any morbid specimen that it may be desirable to preserve; a couple of quarts of clean sawdust or wheaten bran for throwing into the cavities before closing them up, and thus absorbing any excess of fluids; stout thread or twine for tying intestines and closing the cavities; lard or sweet oil for oiling the hands; a couple of empty slopbuckets for receiving the fluids, bloody water, &c., and plenty of water, hot and cold, with towels and soap. If the floor of the room is carpeted, to protect it from accident, a piece of old carpet, or quilt, or oilcloth should be spread alongside the table or box where the examination is made. Care should be observed to have all these matters provided before the operation is commenced, when the door should be fastened, that there may be no intrusion, by accident or otherwise.

In preparing the body for examination, if the head is to be opened and the body is in an ice-box, it will be absolutely necessary that it be removed. Placing the cover of the box on the floor, the body may be lifted out and placed on the same, when both may be again placed on the top of the box or on a table, for the examination. If only the chest and abdomen are to be examined, it will hardly be necessary to lift the body from the box. In all cases, the sheet in which the body is placed, with the underclothing, (the latter having been split down the centre,) should be carefully turned aside, and care observed during the operation to avoid as much as possible soiling them with blood-stains.

=Precautionary Measures.= That there is a certain amount of danger from absorption of virus in case of cuts or scratches received while conducting a post-mortem examination, cannot be denied; yet this danger is by no means common to every case. In the great majority of instances, probably no mischief whatever would follow such an accident, the danger being confined almost wholly to cases of peritoneal inflammation, erysipelas, and certain malignant forms of disease. In all cases, however, it will be well to look for any scratch, cut, or abraded point on the hands or fingers, and first touching them with nitrate of silver, cover them finally with collodian. Smearing the hands well with lard or olive oil will also aid much in preventing absorption.

Should an accidental cut be received during the operation, it will be prudent, in all cases, to wash the hands at once, squeeze and suck the part, to favor bleeding, and, finally, touch with a crystal of nitrate of silver. Punctures with a needle or slight scratches which do not bleed are, probably, more dangerous than a free cut; hence, in cases of suspected danger, when a puncture has been received, it would be safer to make a free incision with a knife, thus inducing bleeding, which will favor the washing out of any virus, and finally, use the caustic.

=Time for Making the Examination.= As a rule, post-mortem examinations should be made as soon after death as a due regard to the feelings of friends will permit, say within twelve to twenty-four hours; a longer delay would give time for such decomposition as not only to make the examination extremely disagreeable, but, from change of structure in tissues and organs, much less satisfactory. In cold weather, however, or where the body has been placed in ice soon after death, as is the custom in most cities, the examination may be postponed to any convenient time before the burial.

=Notes.= In all important cases, notes should be taken down by an assistant, on the spot, as dictated by the operator; heading these by the name and age of the patient and a brief sketch of the disease. In medico-legal cases, this is to be conducted with particular care, as will be pointed out hereafter.

=Consent of Friends.= Much difficulty will sometimes be met in obtaining the consent of friends for a post-mortem examination, the idea of the mutilation of the body of the deceased striking many with particular dread. With a little tact and management, however, consent may, in the majority of instances, be obtained. Instead of speaking to a single member of the family and leaving him or her to bring the subject before others, in all doubtful cases it will be better for the physician to see all the interested parties himself, either together or separately, and endeavor to interest them in the case, by pointing out the peculiar character of the disease, the satisfaction which the friends will themselves derive from a verification of the diagnosis of their physician, while, when too late, they may regret having withheld their consent; also the scientific interest which attaches to the case, and the benefit which will no doubt accrue to medical science through a post-mortem examination, and the possibility that the lives of others may depend upon a knowledge of the true state of this case. These, with like considerations, adapted with ready tact to the class of persons to be persuaded, will, in the majority of instances, be enough to overcome all scruples, especially when joined to the assurance that the examination will be so conducted as to leave no visible trace of the operation with which to embitter the remembrance of the well-known countenance.

PART I. THE HEAD AND SPINE.