CHAPTER XIV.
THE MEDICOLEGAL AUTOPSY.
As has been stated above, every autopsy should be conducted as if it were a medicolegal case, and autopsy-protocols should be so complete and accurate that they may be accepted as evidence in any case in which such testimony can be introduced. While the ordinary autopsy may give satisfactory evidence as to the nature of the pathologic processes found and the cause of death, the scope of a medicolegal autopsy includes not only the cause and manner of death, but also the identification of the body, the determination of the commission of a crime, the manner in which the crime was performed, its motive and the detection of the criminal. Under such conditions the prosector must extend the field of his observations and conclusions to meet the possibilities of the witness-stand. The general technique of the medicolegal autopsy will vary but little from that of the ordinary, and these variations will be given here, as follows:—
The medicolegal autopsy should always be performed in the presence of two witnesses, one of whom should be a physician competent to judge of the methods employed in the autopsy. The autopsy findings should be dictated during the progress of the autopsy, and at its close should be verified and signed in the presence of the witnesses. No other spectators should be permitted in the room. The examination should be made by daylight, and not until positive signs of death appear. If the cadaver has been frozen it must first be allowed to thaw out at room-temperature. The prosector should, if possible, see and examine the body before it is removed from the place where it is found, and he should carefully examine the surroundings, clothes and external surface of the body for possible clues. All known information concerning the circumstances of the case, the personal history of the deceased, the occurrence of any injury, previous illness, etc., should be in the hands of the prosector. Undertaker’s manipulations, such as the injection of embalming fluids, puncture of intestines, aspiration of fluid-contents, etc., must not be permitted before the autopsy.
Especial attention should be given to the identification of the body (measurements, weight, build, shape of head, deformities or defects, color of hair and eyes, teeth, dental work, thumb-markings, tattoo marks, birth-marks, scars, evidences of previous diseases, occupation, clothing, etc.). In doubtful cases the body should be photographed. Roentgen-ray pictures may also be made. When only portions of a body are found the microscopic examination alone may be able to throw light upon the case and give positive evidence as to the sex, age, existence of certain physical characteristics, birth-marks, scars, disease, etc. When no conclusions can be reached a minute description of the remains should be placed in the protocol. The approximate time of death is to be determined with greater care in the medicolegal case (temperature of body, rigor mortis, putrefaction, dissolution, mummification, character of stomach-contents, changes in eye-balls, etc.).
In the performance of the autopsy the greatest care should be taken to avoid the production of artefacts. Hammer, chisel or wedge should not be used; bones should be sawed through completely, particularly in the case of the skull and spine. Especial care should be exercised in the removal of brain and cord. Examine vertebræ in all cases when cause of death is unknown. The main-incision may begin at the chin. The mouth and pharynx should be examined for foreign-bodies before the mouth- and neck-organs are removed. These should be taken out en masse. Particularly in young infants is the examination of the larynx of great importance. Examine thoracic organs in situ before removing them; then remove in connection with neck-organs and examine on table. Ligate cardiac end of œsophagus to prevent escape of stomach-contents. Cut œsophagus above ligature. Open pulmonary artery before lungs are sectioned. Examine abdominal organs in situ before removing them. Bullet- and stab-wounds should be accurately located, traced, measured and course described. Recover missiles for use as evidence. The origin and cause of hæmorrhage must be accurately determined. Remove genital organs en masse after examination in situ. Examine particularly contents of vagina and anus; make microscopic examination of same (semen, blood, foreign-bodies, etc.). Do not put probe, knife or shears into cavity of uterus, but open with a clean cut in the median posterior line. Examine ovaries for presence of corpus luteum.
In cases of suspected poisoning especial attention should be paid to the condition of the gastro-intestinal tract (position, distention, odor, consistence, condition of blood-vessels, etc.). A ligature should be placed about the cardiac end of the stomach and another around the duodenum below the mouth of the common duct, and both organs removed. They should then be opened outside the body and the contents examined (amount, consistence, color, composition, reaction, odor), and the latter then placed in clean, sterilized glass or porcelain jars, which are sealed and labeled. The mucosa of the organ is then carefully examined and described, and the organ itself finally preserved in a sealed and labeled jar. The small and large intestines and the œsophagus are similarly ligatured, removed and examined, and with their contents are preserved for chemic reaction by sealing them in separate sterilized jars properly labeled. Blood from the heart and large veins should be saved for spectroscopic and chemic examination. The contents of the urinary bladder likewise are saved for chemic analysis. Finally, portions of the brain, liver, kidney, intestine, spleen and other organs and tissues are preserved in separate vessels for chemic and microscopic examination. When possible an expert chemist should be present at the autopsy and receive the organs and contents directly from the pathologist. Especial care must be taken that no contamination of the material can occur. The manner of removal of the organs, the character and condition of the instruments used, nature and condition of receptacles for material, manner of sealing, use of preservatives, method of transportation to the chemist, and other fine points of detail will all be threshed over in court in the endeavor to discredit the testimony, and the pathologist and chemist must be thoroughly prepared to meet all questions of this nature. In certain cases the presence of a poison may be told by the finding of a granular or crystalline substance in the stomach or intestines (arsenic-poisoning), by the color (green from aceto-arsenite of copper, yellow from potassium chromate or iodin, purple from iodin, red from bromin) or by the odor (bitter almonds, phosphorus, alcohol, chloroform, laudanum, carbolic acid, lysol, garlic in arsenic poisoning). Excessive acidity or alkalinity of the stomach contents is found in poisoning with acids, alkalies or potassium cyanide. Portions of poisonous plants, mushrooms, match-heads, etc., may be found in the stomach.
Certain pathologic conditions, as fatty degeneration of the liver, cloudy swelling of the kidney, nephritis, malignant jaundice, acute yellow atrophy of the liver, dysentery, and others may be caused by such poisons as phosphorus, arsenic, mercuric chloride, potassium chlorate, chloroform, etc. When such changes are found at autopsy the pathologist must always carefully differentiate between disease and poisoning. He must decide as to the actual occurrence of poisoning, the source and nature of the poison, how and when administered, amount of poison, number of poisons, primary and secondary effects, attendant circumstances, accidental, suicidal or criminal administration, motive, etc. Some poisons produce no characteristic gross or microscopic changes in the organs or tissues. In such cases no pathologic conditions sufficient to cause death may be found, and when there is doubt a chemical examination should be made. Other poisons produce more or less characteristic changes, either by their local action, by selective action upon certain organs, by excretion, or by acting upon the blood. The effects will vary according to the amount of the poison, its concentration, length of action, condition of gastro-intestinal tract, rapidity of excretion, etc. The most important and common poisons producing recognizable autopsy conditions are as follows:—
Acids. In carbolic-acid poisoning there may be dry, brown, leathery spots on the face about the lips; grayish-white eschars on mucosa of lips, mouth, tongue, pharynx and œsophagus; œdema of the glottis and pharyngeal submucosa; white or gray longitudinal eschars in stomach and duodenum; leathery appearance of stomach wall; cloudy swelling of kidneys, odor of phenol in urine, which is dark in color; general passive hyperæmia. In sulphuric-acid poisoning there may be brown, leathery and dry eschars on lips and skin, grayish-white to black eschars in mucosa of mouth, stomach and œsophagus; black, dry and brittle clots in the blood-vessels; perforation of stomach; sloughing of mucosa; parenchymatous nephritis. Hydrochloric acid has little or no action on the skin; on mucous membranes the action is similar to that of sulphuric acid except that the drying of the eschars and blood-clots is less marked. In nitric-acid poisoning the eschars are yellowish; hæmatin is not separated and dissolved, so that the brown black eschars seen in sulphuric- and hydrochloric-acid poisoning are not formed. Oxalic acid causes a white or grayish escharotic condition of the mouth, œsophagus and stomach; crystals of calcium oxalate may be found in the blood-clots and in the kidney-tubules. Glacial acetic acid may produce a grayish-white escharotic condition of the mucosa of the upper respiratory tract, and pneumonia, when inhaled.
Alcohol. In concentrated solutions coagulates albumin and has a corrosive action on mucous membranes. The ingestion of large amounts causes asphyxia, gastro-enteritis, cloudy swelling of ganglion cells of brain, and parenchymatous degeneration of kidney and liver. Lungs, liver, brain and stomach may give an alcoholic odor. In chronic alcoholism there may be chronic atrophic or hypertrophic gastritis, atrophic cirrhosis, sclerosis of arteries, miliary aneurisms of pial vessels, fatty degeneration of heart and liver, and “hog-back kidney.”
Alkalies. Mucosa of mouth and œsophagus swollen and red, with desquamation of epithelium; mucosa of stomach swollen, dark brown and ecchymotic, with diphtheritic patches; croupous bronchitis may result from aspiration of caustic soda or potash, and bronchopneumonia from inhalation of ammonia. Stricture of the œsophagus, due to contraction of scar-tissue, may occur when the patient survives the immediate effects of the poison.