Aldred Scott Warthin

“ AUTOPSY TECHNIQUE. The object of the autopsy is to examine thoroughly, in as short a time as possible, and in the easiest and most convenient method, all of the organs and tissues of the body, with reference to the occurrence of disease-changes, in such a way that nothing will be overlooked or obscured. The preservation of relationships becomes, therefore, a very important matter; and nothing should be done to disturb these until a complete pathologic picture has been obtained. All unnecessary handling and cutting must be avoided. ”

“ It is impossible in a book on general pathologic technic to consider all of the numerous staining methods that have been devised for the study of the nervous system. I have attempted, therefore, to pick out the best selective methods for the staining of the more important nervous structures, so as to cover adequately the general held of nervous pathology. ”

“ A physician who performs an autopsy without the consent of the person having the custody of the deceased does so at his own risk, except in those cases in which the autopsy is in accordance with legal statutes. In the majority of the States there are statutes providing that the Coroner or Board of Health shall order an autopsy whenever a person is found dead and the cause of his death is not apparent, and cannot be ascertained from the evidence given, or from a superficial examination of the body. ”

“ Contrast plays a very important part in pathologic diagnosis; and it is lost in high-power work, so far as the relations of cells and tissue-elements and pathologic products are concerned. The student almost invariably enters the pathologic laboratory with a fixed “high-power habit,” and he is usually greatly surprised to learn how much he misses with the high-power and how much he can see with the low-power. A motto used many years in my laboratory, “Low-power objective and high-power cortex,” is of greater educational value than may appear at first sight. ”

“ In private practice the autopsy is usually made in a private dwelling or, more rarely, in an undertaker’s shop. Under such conditions much depends upon the ability of the operator to make the best of things. In place of a proper table, the cadaver must be examined upon the bed, undertaker’s body-rest or shutter, in or upon the coffin, on the coffin lid, box, door, shutter, table or board. It is always advisable to move the body from the bed when anything else can be found upon which it can be placed. ”

“ It is an excellent plan for the student to purchase his microscope when entering the medical school and to use his own instrument throughout his course. It is the one instrument without which no physician can afford to enter practice; and the student who uses his own microscope before graduation will continue to use it afterward. The microscope obtained, the remaining expenditure necessary for the fitting-up of a practical working laboratory of clinical and pathologic diagnosis need not be very great if one’s financial condition does not warrant spending with a free hand. ”

“ As conditions exist at the present, crimes may be easily concealed, the safety of the community endangered by failures in diagnosis of communicable affections, and our morbidity and mortality statistics become a shame and reproach to the nation. The majority of our medicolegal autopsies are made by ignorant and imperfectly trained coroners and coroners’ physicians, mostly political appointees of inferior material. We need in our medical schools a greater amount of attention paid to the teaching of autopsy-technique and gross pathology. ”

“ In the case of medicolegal autopsies the ends of justice as well as the life, liberty or reputation of some individual may depend upon the results of the postmortem examination. In all cases to which there is any suspicion attached, or in which the cause or manner of death is doubtful an autopsy should be legally required, but unfortunately this is not yet done in this country. Physicians individually should endeavor to create in the public mind a more healthy attitude toward the autopsy and an appreciation of its usefulness. ”

“ While it is not possible that every medical graduate can enter into the active practice of his profession as an expert pathologist, yet the possession of the technical knowledge necessary to perform an autopsy properly and to select with discrimination the tissue for microscopic examination gives to a physician a distinct practical advantage. This advantage becomes the greater if to the possession of this knowledge there be added also a practical working knowledge of the technique necessary for the microscopic examination and diagnosis. ”

“ Alcohol and acetone are the only reagents fixing and hardening perfectly at the same time, as they remove the water from the tissue; for all other fixing agents an after-hardening in alcohol is necessary. In the case of such reagents the division of the process into a primary fixation and a second hardening stage has been the cause of the divergence in meaning of the two terms.
The best fixing agents are those that kill the cells at once, but cause a slow coagulation with little or no shrinking. ”

“ There is not a pathologic condition in the medical category that does not call out for illumination upon some point or other. The phenomena of malignant tumors, the earliest stages of the so-called chronic affections, as well as the majority of the infectious diseases, require further autopsy observations for their elucidation. The autopsy establishment of the diagnosis is also of the greatest importance in giving value to vital statistics. Until we have a more universal confirmation of the clinical diagnosis by the pathologic our vital statistics must of necessity be imperfect. ”

“ Many prosectors habitually omit the section of the neck-organs, intestines and genital tract when there is nothing to attract especially their attention to these parts. The examination of the spinal cord, orbits, nasal tract, ears, joints and bones may be omitted in the ordinary autopsy in the absence of especial considerations directing attention thereto; all other parts should be systematically examined. The pathologist must always maintain an unprejudiced state of mind toward the clinical diagnosis—rather a doubting mind than a disposition to accept the suggestions of the clinical opinions. ”

“ The loose connective-tissue is torn on both sides around the urethra and rectum until the hand can be passed beneath the rectum, completely encircling it and the prostate which must be freed as far as its anterior border. The legs of the cadaver are then separated, and an incision is made with the large section-knife, through the skin, beginning above at the root of the penis, at the termination of the main incision, and following the arch of the pubis around the external genitals down to the left, passing around the anus to the coccyx. ”

“ If the main-incision cannot be extended to the symphysis of the chin, the cartilage- or long section-knife is run up beneath the skin in the median line to the point of the chin, and, with the blade held nearly flat, the skin is loosened from the tissues of the neck, first on the left side, then on the right, as far back as the mastoid processes and the spinal column and to the ends of the clavicles. Great care should be taken not to cut through the skin. ”

“ During the inspection pressure may be made upon the organs to determine still further the blood- and fluid-content. The color, moisture or dryness, consistence, reflection or “shine” (dry-shining, moist-shining, fatty shine, pearly shine, etc.) , cloudiness, translucency, transparency or opacity of the cut surface must also be considered. Normal organs are never perfectly dry, although they vary greatly in the amount of moisture shown on the surface. They have, therefore, always a certain degree of reflecting power. ”

“ In the judgment of a section as to its fixation the following points may be of service: in alcohol fixation the red blood cells are haemolyzed, and there is much shrinking; with formol fixation the red cells stain copper-red with eosin; in mercuric chloride fixations the red cells stain rose-red with eosin, and pigment precipitates are present; in bichromate fixation the red cells preserve their natural color, and fat cells show a brownish color; osmic-acid fixation is shown by the black color of the oleates, and the failure of the tissue to stain by ordinary stains. ”

“ Another factor seriously interfering with the efficiency of the pathologist’s work is the failure of the surgeon to see that the material removed for diagnosis is properly taken care of before it reaches the pathologist. Tissues removed for examination should never be allowed to dry. They should not be exposed to the air, but should either be placed at once in a fixing fluid or covered with damp cloth. Curettings should be placed for a moment upon a pad of gauze to remove the excess of blood, and the fragments of tissue are then picked up and put into the fixing solution. ”

“ In adults the circumference of the body of the uterus is greater than that of the cervix; before the age of puberty it is less than that of the neck. In old age the entire organ contracts, but the body more than the cervix, so that the organ again assumes an infantile form. ”

“ The best idea of the cell is also gained by its study in a fresh condition. Vital phenomena and certain morphologic features, as cilia, can be observed only in fresh material. Many of the chemic constituents of cells (glycogen, fat, mucin, pseudomucin, albumin-granules, cholesterin, etc.) are either lost, or are so changed by processes of fixation or hardening that they can no longer be recognized. The majority of specific chemic tests can be made in fresh tissues only. Moderate and slight degrees of fatty degeneration and cloudy swelling are easily recognized in the fresh state ”

“ When the pathologic conditions have no definite relation to each other they should be classified separately. If a section of kidney shows cloudy swelling, congestion, œdema, small-celled infiltration, hæmorrhage and casts, these different conditions would all be included in the diagnosis of an acute parenchymatous degenerative nephritis. If the general picture corresponds to that of tuberculosis, syphilis, neoplasm, etc., the various associated changes need not be considered alone, but the broad and comprehensive diagnosis should be expressed in as concise terms as possible. ”

“ It is often more convenient to remove the kidneys before taking out the intestines, to examine the liver before the spleen, or to make other similar variations in the order. The order of examination of the larger divisions of the body (head, thorax, abdomen and pelvis) should always be followed strictly; but the neck and thoracic organs, or the thoracic organs alone, may be removed en masse and examined outside of the body, and the same procedure may be carried out in the case of the abdominal or pelvic organs whenever advisable. ”

“ Giantism or dwarfism, partial or complete, asymmetrical development, etc., should be noted and the type determined (rachitic, cretinoid, congenital and acquired deformities of bones may cause dwarfism; giantism may be congenital or due to disease of the hypophysis as in acromegaly) . In all cases of abnormal development of the skeleton the possibility of diseased conditions of the hypophysis, thyroid, thymus, adrenals and sexual glands must be borne in mind. In a general way the build of the body may be described as large, heavy, strong, medium, small, delicate, etc. ”

“ In private practice it is worth while, as a matter of courtesy, to invite several of one’s colleagues to witness or take part in the autopsy. An ideal way would be to have one of these perform the operation in expectation of future reciprocation. In the interests of objective observation a clinician should never perform the autopsies of his own cases, but should turn them over to a trained pathologist or to a colleague. ”

“ It is not to be supposed that, even when the cadaver is opened within a very short time after death, the color is that of the living body. Certain color-changes always take place as soon as death occurs, but it is necessary to create a color-standard for the different organs as seen under the conditions of the ordinary autopsy. Injections of formalin and other undertaker’s fluids destroy all color, and should not be permitted before the autopsy. Freezing likewise changes the color of many of the organs. ”

“ While the external genitals are forcibly pulled upward in the pelvic cavity toward the head, the encircling incision behind the anus is deepened, cutting the fat-tissue, connective-tissue, and muscle around and behind the rectum, until the whole mass of genital organs and rectum is so loosened that it strips up easily to the brim of the pelvis, where any remaining attachments of peritoneum or blood-vessels are severed and the entire mass removed for examination on the board. ”

“ Granting the existence of such a possibility of apparent death before absolute signs of death appear, it follows that in all autopsies made very soon after death has occurred, the prosector must bear such a possibility in mind, and satisfy himself beyond all doubt of the actual occurrence of death before beginning the autopsy. ”

“ In private practice the external genitals should be kept covered except for their examination. An abundance of large sponges and a gently-flowing stream of water under low pressure permit a clean and orderly autopsy. The use of a hose with water under high pressure is dangerous because of the accidental spattering that is sure to occur. Blood and fluids from a dead body should not be spattered about because of the great danger of spreading infection. When accidents do happen prompt cleaning up and disinfection should be carried out. ”

“ Each autopsy is a law unto itself in this regard. New complications constantly arise and must be studied before the right way of revealing the solution of the pathologic problem is found. Above all things nothing should be destroyed until its relationships have been fully [Pg 21] determined. False steps taken in an autopsy cannot be retraced, and the complete investigation and the successful attainment of a diagnosis may be made impossible by improper methods of technique. As in all other technical matters there is a best way of carrying out the different steps of the autopsy ”

“ Changes in the finer structure of cells and nuclei quickly take place, and certain tissues, such as parts of the nervous system, the medullary portion of the adrenals, the pancreas, mucosa of gastro-intestinal tract, etc., within an hour or so after death are usually no longer fit for microscopic study. In all cases, therefore, it is best to make the autopsy as soon as possible after death, that is, as soon as positive signs of death appear. ”

“ If the staining process is prolonged the entire tissue, as well as celloidin, becomes more or less heavily stained blue. A pure nuclear stain is obtained by interrupting the stain at the right time (examine in water) ; or if the sections are over-stained they may be differentiated in acid alcohol (1 per cent hydrochloric acid in 70 per cent alcohol) . Hæmatoxylin stains well after all fixing-solutions except osmic acid; some of its staining-formulæ stain slowly after fixation in Zenker’s fluid. On the whole, it is by far the best general nuclear stain for laboratory and diagnostic work. ”