Thorax and Abdomen.

The body being placed on its back, and the operator standing on the right side, an incision is made through the skin, fascia, and muscles from the top of the sternum to the pubic bone, passing to the left of the umbilicus and dividing everything down to the sternum and the subperitoneal tissue. A small incision is now made through the peritoneum below the ensiform cartilage. Into this opening two fingers of the left hand are inserted, and by spreading the fingers and holding the knife horizontally the peritoneum can be divided to the pubes without injuring the intestines. The skin and muscles are now dissected from the chest as far back as the false ribs. This dissection may be facilitated by keeping the skin and muscles on the stretch and cutting with the flat part of the knife. In order to better expose the abdominal cavity, the recti muscles are divided beneath the skin at their insertion in the pubic bone. Examine the cut surface of the chest and abdominal muscles, and note their color, amount, and consistency. Observe whether the chest muscles show the evidence of any parasitic disease such as trichinosis. The mammary glands are now examined from behind and opened if necessary.

Superficial Examination of Abdominal Cavity.—This should be done before opening the chest cavity, because the position of organs may become modified, and blood and other fluids are liable to find their way from one cavity into another; and again, the blood in the presenting portion of the abdominal organs will change its color after exposure to the air.

Note the Following Points: (a) The relative position and general condition of the abdominal organs.

(b) The color and amount of blood in the presenting parts.

(d) Examine the vermiform appendix.

(e) The amount of fluid in the abdominal cavity. Normally a small quantity of reddish serum will be found, particularly in warm weather, at the most dependent portion of the abdominal cavity. If the quantity is small it can only be ascertained by raising the intestines from the pelvis. When the fluid is considerable, the exact amount should be ascertained and its character noted.

(f) Perforation, invagination, and hernia of the intestines should be looked for.

(g) Determine the height of the diaphragm. Normally, on the right side, it is at the junction of the fifth rib with the sternum, and on the left it reaches as high as the sixth. A variety of pathological conditions change its position. For instance, it may be raised when the contents of the abdomen are greatly increased in volume, and in new-born children who have never breathed. It may be depressed by enlargement of the lungs, disease of the heart, or fluid in the pleural or pericardial cavities. The presence of air or gas in the pleural cavity can be determined either by filling the abdomen with water and puncturing the diaphragm beneath the fluid so that the air will bubble up, or a puncture may be made through the thorax between the ribs, and the flame of a match will be deflected by the escaping air.

Thorax.

The thorax is opened by cutting the sterno-costal cartilages as close to the end of the ribs as possible, the cut being made downward, outward, and backward, and the knife held obliquely so as not to injure the underlying parts. Quite often the cartilages will be found ossified and it will be necessary to divide them by a costotome. Next, separate the clavicles by a semi-lunar incision at their attachment to the sternum.

Raise the sternum with the left hand and separate it from the underlying parts. If there is any adherence of the sternum a slight twist will be sufficient to remove it.

Superficial Examination of Thorax.—Observe the position, color, and degree of distention of the lungs. It should be remembered that healthy lungs, as soon as the chest is opened, owing to their inherent elasticity, will collapse, and when this normal collapse is not seen it is generally due to a loss of elasticity as occurs in emphysema, to inflammatory diseases binding the lung to the chest wall, or to the alveoli being filled with solid or fluid substances or pent-up air. Most complete distention is seen when death is due to drowning or suffocation.

The area of the heart uncovered will vary according to the degree of collapse of the lungs and to the abnormal size of the heart. Normally the cardiac area exposed is quadrangular in shape, and about three and a half inches in its longest diameter. Examine the pleural cavities for the presence of adhesions, foreign bodies, or fluid. If fluid is found it should be removed, measured, and its character noted. It is to be remembered that in warm weather, or when putrefaction has commenced, a moderate amount of reddish serum is found in the pleural cavities which has no pathological significance. Lastly, examine the mediastinum as to the condition of the thymus gland and great vessels outside the pericardium.

Pericardium.—Open the pericardium by an oblique incision along the anterior wall, and prolong this incision downward and outward toward the diaphragm and upward to its reflection from the great vessels. Normally, about a drachm of clear serum, sometimes, however, blood-stained from decomposition, will be found in the pericardial sac. The amount is best ascertained by raising the heart. Note next the contents of the pericardium and whether there is any serous, fibrous, or purulent exudation. If an abnormal amount of fluid is present, remove, measure, and note its character. Observe whether there are any adhesions between the two surfaces of the pericardium. White patches are often seen on the visceral surface of the pericardium, especially over the ventricles. These have no pathological significance and are due to slight thickenings of the pericardium.

The Heart.—Having passed the hand over the arch of the aorta and noticed whether there is any evidence of aneurism or dilatation, we grasp the heart firmly by the apex, raising and drawing it forward. We remove it by cutting through the vessels at its base. Test the sufficiency of the aortic and pulmonary valves by allowing a stream of water to flow into these vessels, the heart being held in a horizontal position and care being taken not to pull the valves open.

To apply the water test to the mitral and tricuspid valves, the auricles are first opened so as to expose the upper surface of these valves, and by allowing a stream of water to flow through the aortic and pulmonary valves into the cavities of the ventricles, the degree of sufficiency of these valves can readily be ascertained.

Another rough test is what is known as the “finger test.” The mitral valve will normally allow two fingers, held flat and in contact, to pass through its opening. The tricuspid in the same way allows, normally, three fingers to pass; or if a more accurate test of the degree of insufficiency is desired, the valvular orifices should be measured. Normally, the aortic orifice is one inch across; the mitral, one and eight-tenths inches; pulmonary, one and two-tenths inches; and the tricuspid about two inches.

We open first the cavity of the right ventricle by making an incision over its anterior border close to the septum. Prolonging the incision downward to the apex and upward through the pulmonary artery, the cavity of the ventricle will be fully exposed. The left ventricle is similarly opened by an incision through its anterior wall which is prolonged upward through the aortic valve. The cavities of the auricle and ventricle, especially those of the right side, will often contain blood-clots. These clots are usually post-mortem clots formed during the last hours of life or after death. It may sometimes be necessary to distinguish these post-mortem clots from what are known as ante-mortem clots. The latter are usually of firm consistency, dry, of a whitish color, and closely entangled in the trabeculæ, while the former are succulent, moist, of a reddish-yellow color, and are easily detached from the walls of the heart cavities. Ante-mortem clots are rarely seen, and the medical examiner should be careful not to attribute the cause of death to the post-mortem clots which are so often seen. After the heart is opened we can with more care and greater accuracy examine the condition of the valves and recognize the extent of valvular lesions.

The condition of the endocardium should now be examined and any abnormality noted. Often it will be seen stained a deep red color. This is not due to disease, but is caused by the absorption of the coloring matter of the blood which has been set free by decomposition. The size of the heart cavity and the thickness of the heart walls should be noted, as also their consistency and color. It should be remembered that the heart walls may appear unusually flabby as the result of decomposition, or apparently thickened when death occurs in extreme systole. The interior of the heart can be further examined by passing the enterotome into each auricle, carrying the incision through the mitral and tricuspid valves to join at the apex with the previous incision, which has been prolonged through the ventricles to the apex. Thus the auriculo-ventricular valves are completely exposed.

Having removed the blood from the heart it is next weighed. The average normal weight of the human heart is about twelve ounces in the male, and a little less in the female: its size roughly corresponding to the closed hand of the individual. Normally, the thickness of the walls of the left ventricle about its middle is five-eighths to two-thirds of an inch, and of the right ventricle one-eighth to one-quarter of an inch.

Note the condition of the aorta above the heart, whether it is dilated, atheromatous, or shows calcareous deposits. Examine the coronary arteries by opening them with a blunt-pointed scissors. Disease of these vessels with thrombosis is one of the causes of sudden death which is often overlooked.

The Lungs.—The lungs are removed by lifting them from the pleural cavity and cutting through the vessels and bronchi at their base. If a lung is very adherent it is sometimes better to remove the organ with the costal pleura attached so as not to tear the lung substance. Examine the external surface of the lung as to its shape, color, and consistency. Next open the large bronchi with a blunt-pointed scissors, and prolong the incision into the pulmonary substance along the minute bronchi. Observe the contents of the bronchial tubes, the appearance of the mucous membrane, and their relative thickness. Remember that it is very difficult to tell the condition in which the mucous membrane was during life on account of the early post-mortem changes which affect it, and also because the contents of the stomach may have been forced after death up the œsophagus and down the bronchi, giving the tubes a peculiar reddish and gangrenous appearance.

Having examined the bronchi, the lung is turned over and its base grasped firmly in the left hand. An incision is made from apex to base, which will expose at a single cut the greatest extent of pulmonary surface. Note the color of the lung substance, and whether the alveoli contain blood, serum, or inflammatory products. Blood and serum can easily be forced from the lungs by pressure between the fingers, while inflammatory exudations cannot. Examine carefully for the presence of miliary tubercles.

If a question should arise whether a portion of a lung is consolidated, this part can be removed, placed in water, and if the air cells are consolidated the portion will sink; if there is only congestion it will float. By squeezing the lung between the fingers an inflammation of the smaller bronchi (bronchitis) can be recognized by the purulent fluid which will exude at different points. It should be remembered that in normal condition the lower lobes and posterior aspect of the lungs will apparently be very much congested as a result of gravity.

Neck, Larynx, and Œsophagus.—Throw the head well backward, and place a block beneath the neck. Make an incision from the chin to the upper part of the sternum. Dissect the soft parts away on each side from the larynx and thyroid body, then cut along the internal surface of the lower jaw from the symphisis to its angle. Through this incision introduce the fingers into the mouth, and grasp and draw down the tongue. By dividing the posterior wall of the pharynx and pulling downward these parts, the trachea and œsophagus can readily be removed together, a ligature having been first placed around the lower portion of the œsophagus. Open now the pharynx and œsophagus along their posterior border. Examine the mucous membrane carefully for the evidences of inflammation, caustic poison, tumors, foreign bodies, or strictures. With an enterotome open the larynx and trachea along their posterior wall. Observe if there is any evidence of œdema of the glottis, and note the condition of the mucous membrane. Remember that redness of the larynx is very commonly the result of post-mortem changes and is also seen in bodies which have been kept cold. Dissect off and examine the thyroid gland.

Abdomen.

Having completed the examination of the organs of the thorax, we next proceed to examine those contained in the abdominal cavity. We first raise and,dissect off the omentum, noting if it is abnormally adherent.

The first organs to be removed are:

The Kidneys.—Drawing the intestines aside we cut through the peritoneum over the kidneys, and introducing our left hand we grasp the organs with their suprarenal capsules attached. Raising first one kidney and then the other, we easily divide the vessels and the ureters as close to the bladder as possible. The kidneys are often found imbedded in a mass of fat which must first be removed. Their surface is sometimes of a greenish color owing to the beginning of putrefaction. We note the size of the organ, its color and weight. A normal kidney weighs from four and one-half to five ounces. Grasping the kidney firmly in the left hand, we make an incision in its capsule along its convex border, and with a forceps strip off the capsule and note its degree of adherence and the condition of the surface of the organ; whether it is smooth or granular. Prolonging our incision already made through the cortex of the organ, inward toward the pelvis, we divide the organ into two halves and now closely examine the internal structure. The average thickness of the cortex, which should be about one-third of an inch, is noted; as also its degree of congestion, and whether the normal light (tubes) and reddish (vessels and tufts) lines are seen running through it. If these alternate light and dark markings are lost and the organ has not undergone decomposition, the presence of some of the forms of Bright’s disease may be suspected. If the cut surface of the organ presents a waxy appearance, the amyloid test should be applied by first washing the cut surface of the organ and dropping upon it a few drops of Lugol’s solution of iodine, when the amyloid areas will appear as dark mahogany spots on a yellow background.

The pelvis of the kidneys should be examined for calculi and the evidence of inflammatory lesions. The suprarenal capsules readily decompose, but if the autopsy is not made too late hypertrophy, tuberculosis, tumors, and degeneration in them may be recognized.

The Spleen.—This organ will be found in an oblique position at the left side of the stomach. Grasping it firmly in the left hand and drawing it forward, it can easily be detached. Normally in the adult it is about five inches in length by three inches in breadth by one inch in thickness, and weighs about seven ounces. The size, color, and consistency of the organ should be noted, as well as abnormal thickenings of its capsule and the presence of any tubercles or tumors in its substance. The spleen softens very early as the result of decomposition, and this decomposition should not be mistaken for a pathological condition.

The Intestines.—In cases of suspected poisoning the greatest care should be taken in the removal of the intestines and the stomach. Double ligatures should be placed in the following situations so as to preserve the contents of the organs intact: (1) at the end of the duodenum; (2) at the end of the ilium; and (3) at the lower portion of the rectum; and an incision should be made with a pair of scissors between these ligatures. The jejunum and ilium should first be removed together by seizing the gut with the left hand, keeping it on the stretch, and cutting with a pair of scissors through the mesentery close to its intestinal attachment. The cæcum, colon, and rectum should then be removed in a similar manner.

The intestines being placed in large absolutely clean dishes, which have previously been rinsed with distilled water, are opened; great care being taken that none of the intestinal contents are lost. The small intestines should be opened in one dish and the large intestine in another. A portion of the intestines where morbid appearances are most likely to be seen in cases of poisoning are the duodenum, the lower part of the ilium, and the rectum. The comparative intensity of the appearances of irritation should be especially noted. For example, if the stomach appears normal and the intestines are found inflamed the possibility of poison from an irritant may be denied.

The intestines are opened along their detached border by the enterotome. Care should be taken to distinguish the post-mortem discolorations which are usually seen along the intestines from those produced by disease. The former are most marked in the dependent portions. They are apt to occur in patches which can be readily recognized by stretching the wall of the gut. The darkish brown or purple discolorations which are sometimes seen as the result of decomposition are due to the imbibition from the vessels of decomposed hæmoglobin. Much care and experience are necessary to tell the amount of congestion which is within normal limits and to recognize changes of color produced by decomposition.

The pathological lesions ordinarily looked for in the examination of the intestines are ulcers, perforation, hemorrhages, strictures, tumors, and the evidences of various inflammations. To obtain an accurate idea of the various portions of the mucous membrane of the intestines, it is sometimes necessary to remove their contents. When very adherent this should be done by allowing as small a portion of distilled water as possible to flow over their surface. If any abnormalities are noticed along the intestinal tract, an accurate description should be given of their situation and extent; as also the amount of congestion seen in different portions of the intestinal tract.

If possible the different portions of the intestines, as well as the stomach, should be examined immediately after being exposed to view, as under the influence of the air those parts which are pale may become red, and slight redness may become very pronounced. In this way only can we estimate the degree of vascularity of the various parts after death. However, in cases of suspected poisoning, when it is impossible for the chemist to be present at the autopsy, the medical examiner should not open the stomach and intestines, but place them in sealed jars. As soon as possible afterward, the chemist being present, they should then be examined in the manner indicated. What may be lost by waiting, in changes of color which have taken place, will be more than counterbalanced by the data which the chemist will obtain from observing the contents and mucous membrane of the stomach and intestines when they are first exposed. The characteristic odors of certain poisons are so evanescent that they quickly disappear after opening of the stomach and intestines.

After a thorough examination of the intestines, they are to be put with their contents into wide-mouthed vessels, each part by itself, and the basins in which they were opened washed with distilled water and the washings put into the same bottle. As soon as the intestines are transferred to the jars they should be sealed.

The Stomach.—The stomach and duodenum are removed together. They are opened by passing the enterotome into the duodenum and dividing it along its convex border, the incision being continued along the greater curvature of the stomach as far as the œsophageal opening. They should be opened in a large glass dish which has been carefully washed with distilled water. The chemist and medical examiner will carefully note the quantity, odor, color, and reaction of the stomach contents; also whether luminous or not in the dark; the presence or absence of crystalline matter, foreign substances, undigested food or alcohol.

Portions of the contents should be placed in a small glass bottle and sealed, so that at a future time they may be examined microscopically. Only in this way can an absolute knowledge of the character of the stomach contents be obtained. In certain medico-legal cases the ability to decide the character of the stomach contents is of the utmost importance. The mucous membranes of the stomach and duodenum must be next carefully examined for evidences of hemorrhages, erosions, tumors, and of acute or chronic inflammations. The appearance of the rugæ and their interspaces, principally in the region of the greater curvature, should be noted; because here traces of poison and its effects are most frequently seen. If the stomach is inflamed, the seat of the inflammation should be exactly specified, as also that of any unusual coloration.

The condition of the blood-vessels are also noted. Vascularity or redness of the stomach after death should not be confounded with the effects of poison or the marks of disease. It may occur in every variety of degree or character and still be within normal limits. Vascularities which we might call normal are seen in the posterior part of the greater end and in the lesser curvature, and may cover spaces of various extent. Rigot and Trosseau have proven by experiment that various kinds of pseudo-morbid redness may be formed which cannot be distinguished from the varieties caused by inflammation; that these appearances are produced after death and often not until five or eight hours afterward, and that they may be made to shift their place and appear where the organ was previously healthy, merely by altering the position of the stomach. Ulcers, or perforations of the stomach as the results of disease, as also the digestion of the stomach after death, have been mistaken for the effects of irritant poisons.

When perforation of the stomach is the result of caustic poisons, the edges of the opening are very irregular, and are of the same thickness as the rest of the organ. The parts not perforated are more or less inflamed, and traces of the action of the caustic are found in the mouth, pharynx, and œsophagus. This is the opposite condition to that seen in spontaneous perforation.

In considering perforation of the stomach the following points given by Taylor are well to remember:

(1) A person may have died from perforation of the stomach and not from poisoning.

(2) A person laboring under disease may be the subject of poison.

(3) A person laboring under disease may have received blows or injuries on the abdomen, and it will be necessary to state whether the perforation did or did not result from the violence.

(4) The perforation of the stomach from post-mortem changes may be mistaken for perforations from poison.

Corrosives, if they do not produce perforation of stomach, will generally cause intense inflammation accompanied by softening of the inner coat, sometimes ending in gangrene. The inflammation varies as to its extent and intensity, sometimes affecting principally the mouth and œsophagus, but generally the changes are more pronounced in the stomach and duodenum, while in rare cases the inflammatory process may extend through the whole alimentary canal. The mucous membranes are sometimes bright red with longitudinal or transverse patches of a blackish color, formed by extravasated blood between the coats. Carbolic acid often produces in the stomach and œsophagus white patches—when these patches are carefully examined, an ulcerated surface beneath them is generally seen.

Narcotic Poisons.—It is a common but mistaken idea that these poisons produce some mark or characteristic effect upon the stomach walls; that they induce a rapid tendency to putrefaction; that the blood is in a fluid state; that hemorrhages are seen in various parts; that the stomach and intestines show sloughing without any inflammation. Some of these conditions may and probably do occur, but they are far from being invariable in their appearance. Experiments made by Orfila on animals with narcotic poisons prove the above statement. In conclusion, I would emphasize the fact that the narcotic poisons produce no characteristic changes in the stomach that can be detected.

The Liver.—The liver should be removed from the body and no attempt made to examine the organ in situ. After raising first one lobe and then the other, the diaphragm should be cut on either side and the suspensory and lateral ligaments divided, then the organ can easily be removed. The weight of the organ is ascertained, as also the measurements of its size recorded. The normal weight is from fifty to sixty ounces. The organ is normally about twelve inches in length by seven inches in depth by three and one-half inches in thickness.

The gall bladder is first examined to determine the character and amount of the bile and the presence or absence of gall stones, inflammatory lesions, and tumors.

At autopsies the surface of the liver, especially along the free border, is generally seen to be of a greenish or dark-brown color. This discoloration is due to the action of the gases developed by decomposition on the coloring matter of the blood, and has no pathological significance. The character of the surface of the liver is now noted, whether smooth or rough. The organ is opened by deep incisions in various directions, and the color, consistency, and blood supply of the liver tissue carefully recorded. The presence of new connective tissue, amyloid degeneration, abscesses, or tumors should not be overlooked. It should be remembered that, of all the poisons, phosphorus alone leaves characteristic appearances in the liver.

The Pancreas.—The pancreas is now easily removed, and its size and weight recorded. Normally it should weigh three ounces and measure eight inches in length by one and one-half inches in breadth by one inch in thickness. The organ should be opened by a longitudinal cut and examined for evidences of acute or chronic inflammation, fat-necrosis, tumors, calculi, and amyloid degeneration.

Genito-Urinary Organs.—It is very important in medico-legal cases that all the urine should be preserved and obtained uncontaminated; therefore before the bladder is opened a catheter should be introduced and the urine drawn off into a clean bottle which has previously been rinsed with distilled water. If more convenient the bladder itself can be punctured at its upper portion, a pipette introduced, and the urine drawn off in this manner.

The genito-urinary organs are removed together. This is done in the following manner. The body of the penis is pushed backward within the skin and cut off just behind the glans penis; the remaining portion of the rectum is raised. This with the prostate gland, bladder, and penis attached is removed by carrying the knife around the pelvis close to the bone and separating the pubic attachments. The organs are then laid on a clean board and the urethra is opened on a grooved director passed into the bladder, and the incision prolonged so that the internal surface of the bladder itself will be completely exposed. Examine the urethra for strictures, inflammatory lesions, and ulcers. Examine the bladder for congestion, hemorrhages, inflammation, and ulcers of its mucous surface, and note the thickness of its walls. Open the rectum and examine for ulcers, strictures, tumors, and the evidence of hemorrhage. The prostate gland is opened by a number of incisions into its substance. Examine for hypertrophies, tumors, and inflammatory lesions. Force the testicles through the inguinal canal, and cut them off. Weigh, open, and examine them for evidence of inflammation, tuberculosis, and tumors.

Female Organs.—Before removing these organs, any abnormalities such as adhesions, malpositions, and tumors should be noted. Dissect the organs away from the pelvic bones by carrying the point of the knife around the pelvis close to the bone. Cut through the vagina at its lower third, and the rectum just above the anus. The organs can now readily be removed. Examine the vulva for ulcers, hypertrophies, and tumors. Open and examine the bladder. Open the vagina along its anterior border and carefully examine its mucous surface for evidences of inflammation.

The Uterus.—Before opening the uterus, its size and shape should be recorded. The average normal weight of the organ is about one and one-quarter ounces; its length three inches, breadth two inches, and thickness one inch. Open the organ along its anterior surface by a blunt-pointed scissors passed through the cervix, and the incision carried as far as the fundus. Note the thickness of its walls and any abnormalities of its mucous membrane. During menstruation, the mucous membrane of the body is thickened, softened, and covered with blood and detritus. Retention cysts are found in the mucous membrane of the cervix and are not generally of pathological significance.

Remove, measure, and weigh the ovaries. Their normal weight is about one drachm each; their size, one and one-half, by three-quarters, by one-half inch. Open the organs by a single incision and examine for the evidences of acute and chronic inflammations, tumors, and cysts. The corpora lutea in various stages can be easily recognized in the substance of the organ. Open the Fallopian tubes and examine their contents and the condition of their membranes (see Disputed Pregnancy and Delivery, Vol. II.).