The pericardium may now be laid open by a longitudinal incision, and we should note the quantity of fluid found in this cavity; in that of a healthy subject there is generally as much as a tea-spoonful of serum. It is important also that we should observe the quality, as well as quantity, of this liquor. Blood has occasionally been found in this situation, when neither a rupture of the heart, or any of its vessels could be discovered; in such cases Dr. Baillie is of opinion that the blood has either passed through the coats of the vessels upon the surface of the heart, by transudation, or been poured out by the relaxed extremities of the small vessels opening upon the surface of that portion of pericardium which forms the immediate covering of the heart.[[32]] The general appearance of the heart, as to colour, flaccidity, size, and external character, should be observed before its cavities are opened; for the energy of the heart may, in some degree, be inferred from the tension of its fibres, and the red colour of its substance; on the contrary, the opposite appearances would indicate a very different condition of this vital organ, as is well illustrated in the asphyxia idiopathica of Mr. Chevalier.[[33]] It is not very unusual to find adhesions connecting the heart more or less closely to the pericardium; and it is perhaps worthy of remark that the length of these adhesions will furnish, in some measure, an indication of the interval that has elapsed, since the occurrence of the inflammation by which they were produced; for they become gradually elongated by the heart’s motion. Dr. Baillie has noticed in his “Morbid Anatomy” an appearance which the author has frequently met with in his dissections,—a white opaque spot, as if from a thickening of the pericardium; in some cases, it is not broader than a sixpence, at other times, it equals in size that of a crown piece; it is most commonly situated on the surface of the right ventricle, and consists of an adventitious membrane formed on a portion of the pericardium, which covers the heart, and may be easily dissected off, so as to leave that membrane entire. The attention of the enquirer is directed to the subject with a view to remind him, that the appearance is one that ought not to be considered as morbid in its origin, or dangerous in its effects. In acute rheumatism a fatal translation of the disease to the heart sometimes occurs, in which case, its surface will be found encrusted with coaguable lymph.—The condition of the blood-vessels forms the next object of research; and they should be examined previous to the removal of the heart, as to their calibre, and thickness, and whether any inflammatory indications are observable, or any aneurism; this latter disease has often existed without exciting any suspicion during life. In opening the body of George II, the aorta was found callous at the lower border of its curvature, and so dilated at its upper border, that it was as thin as the finest paper, in which part the rupture took place, and which was succeeded by a fatal hemorrhage; and yet the king, before his death, had not the slightest symptom that appeared to deserve much attention. In every case of sudden death the heart should be removed from the body for the purpose of examination, and no anatomical evidence should be received as conclusive, unless such an operation has been duly performed. For this purpose, the blood-vessels should be first secured by ligatures, for it is very essential to prevent the effusion of blood; and, having then separated it from its attachments, we should proceed to examine the organ in the following manner. Slit open, longitudinally, by means of scissars, the right auricle, at its foreside, then make an incision from the mouth of the pulmonary artery to the point of the heart, guarding against the accident of injuring the two sets of valves; now cut open the whole length of the pulmonary artery, except at its beginning, and at its valves, which ought to be left entire; lastly, open the pulmonary veins, and then the left auricle and ventricle, in a similar manner with what was done to the corresponding parts of the right side.
We beg to direct the attentive consideration of the anatomist to this important part of the inquiry; he ought to notice the quantity of blood contained in the cavities of this organ, as well as its colour, and state of coagulation, especially in relation to the arterial and venous sides of the heart; the indications which such an examination may afford will be fully appreciated by referring to our chapter upon “the causes and phenomena of sudden death,” and that upon “suffocation.” In examining the cavities of the heart, especially the ventricles, it not unfrequently happens, that a mass of coagulated lymph, of a yellowish colour, and of considerable firmness, is found to occupy them; this phenomenon, from the manner in which its processes extend into the fasciculi of muscular fibres of the heart, has acquired the name of “polypus of the heart,” and was regarded by the older anatomists as a very common and fatal disease. It is necessary to observe that the phenomenon is now better understood, and it is universally admitted to be the result of slow coagulation after death. The state of the valves of the heart should be attentively inspected, for a disease in these parts may have been the cause of the sudden death which we are endeavouring to discover. The three semi-lunar valves at the origin of the aorta, and the mitral valves, are sometimes in a state of ossification; those placed at the commencement of the pulmonary artery, and the tricuspid are less disposed to take on morbid action than the preceding ones that occupy the arterial side; indeed, there are very few well authenticated instances of such a change. Such a state of the valves of the heart necessarily places the life of the individual in extreme jeopardy, a rupture may be induced, and thus prove instantly fatal, or the action of the heart may be suddenly arrested, and a fatal syncope be the result; and from the suddenness with which death takes place in such cases, there is no doubt that many persons so dying, have been erroneously included in the list of apoplectic deaths. In certain diseased states of the valves, the extremities of the body become gangrenous, as if the heart were unable to propel its blood to the extreme parts: the author well remembers two females who were admitted into the Westminster hospital, with a disease of this kind, in which the gangrene gradually extended upwards, and that, after death, the valves of the heart were found ossified. The coronary arteries are occasionally ossified, a circumstance which often accompanies a diseased state of the valves of the heart, and that of the aorta; a change which has been regarded as giving rise to the disease, termed angina pectoris, but which would seem to be symptomatic of any morbid state of the heart. In some cases the heart itself has been found ruptured; we have already offered some observations upon this event, under the history of syncope, p. 27. Dr. Baillie has seen only one case, and in that, the blood escaped into the pericardium, and the person instantly expired.
Examination of the abdomen.—In proceeding to the examination of this cavity, and its contents, the first appearance to be noticed, is that of the peritoneum, in which we have to observe whether any marks of inflammation exist, as displayed by a crowd of very small vessels, injected with florid blood, and a change in the texture of the membrane, by which it appears to be thickened, more pulpy, and less transparent. The existence and character of any fluid in the abdominal cavity should be noted, for its nature will be found to be immediately connected with the nature and extent of the disease by which it has been produced; if the liver be schirrous, the fluid will be tinged with bile, and of a yellowish colour; if extreme debility accompany the disease, it will often be of a chocolate colour, from the admixture of blood; should no disease exist in any of the viscera, it will resemble that of the serum of the blood. Previous to the removal of the viscera for more minute examination, it will be proper to observe their general situation and appearance, and to notice particularly whether the calibre of the visceral tube be natural, distended, or contracted; in some instances its diameter is sensibly diminished, as in cases of poisoning by lead. It sometimes occurs that the intestines are glued together with extravasated lymph; and, at others, that the abdominal viscera are more or less joined together by adhesions, which are the effects of former inflammation; these adhesions become gradually so elongated as to produce little or no inconvenience. If upon opening the cavity of the abdomen we should have reason to suspect the existence of any perforations in the stomach or bowels, the anatomist must proceed with great caution, so as not to enlarge their diameters, or alter their appearance. In the case of Miss Burns, the medical report lost much of its value, from the want of due precaution in this particular; see our account of the dissection, vol. ii, page 178. Should the contents of the stomach or intestines have escaped into the general cavity, we should be careful in collecting such matter, with a view to its future analysis. The size and appearance of the stomach must be noted, and we should observe whether any marks of inflammation, or gangrene, are visible on its external surface; in tracing the intestinal tube through its course, any appearance of inflammation, or phlogosis, should be attentively examined; for which purpose a ligature may be passed at some distance above and below the patch, and the portions of the intestine be then removed. In many cases it will be essential to remove the stomach, as where poisoning is suspected; for which purpose double ligatures, about an inch asunder, must be placed above the cardia, and similar ones in the duodenum; the division may then be made by the scalpel in the space between them. The stomach should be examined without delay, for no one who has not been engaged in such researches, can form an idea of the rapidity with which this viscus loses its characteristic appearances by exposure to air. The stomach is to be slit open with a pair of scissars, care being taken that none of its contents are lost. If the deceased had been found in the water, the quantity of that fluid, found in this viscus, should be noted; and under such circumstances, the presence of any weed, mud, or other extraneous matter, requires particular notice. The quantity of alimentary matter will also afford an object of remark, and it will be right to observe whether, by odour or inflammability, the presence of any spirit can be detected. Having then disposed of the contents of the stomach, and referred them to the chemist for examination, we proceed to examine the viscus itself; in the first place, we should be careful in ascertaining whether any white, or shining particles adhere to its coats; if so, the substance must be preserved for future analysis; the cardia and whole interior of the stomach is to be carefully inspected, and every indication of inflammation, ulceration, gangrene, and schirrosity, is to be noted in reference to its exact situation and appearance; with a view to deduce an opinion as to the probability of its being the effect of poisonous ingesta, or of recent, or remote disease. The mucous membrane of the stomach should be squeezed between the fingers, and the nature of the matter, if any should ooze out, must be noted, which on some occasions will furnish a valuable diagnosis; where, for instance, the person had died of melæna, a black matter, similar to that vomited will exude, a phenomenon which is never visible in cases of acrid or corrosive poisoning. We have already entered so fully into the history of gastric perforations, that it will be only necessary to allude to them on this occasion; see vol. i, page 164. The state of the villous coat should always be minutely inspected, we should however be cautious in pronouncing every red appearance as indicative of inflammation; it may in some cases depend upon the presence of colouring matter derived from the ingesta; (see the case related in vol. ii, p. 231.) Nor ought the state of the œsophagus to be overlooked, which in cases of poisoning will afford an important indication; it should, therefore, be removed from the body; had this dissection been performed in the case of Miss Burns, the medical witnesses on that memorable occasion, would have been spared, at least, one great cause of censure. It is not impossible but that the œsophagus may be ruptured in a violent paroxysm of vomiting, and thus be the cause of death. Boerhaave relates an interesting case of this kind, which occurred to Baron Van Wassener, Admiral of Holland.
Rupture of the stomach is an occurrence which sometimes takes place from the action of vomiting, during the progress of ulceration, when the membranes of this viscus are nearly perforated. It also occasionally happens from external violence. In the Medical Repository,[[34]] a case of ruptured stomach is related by Mr. Brown, in which the accident must have been occasioned by the action of the diaphragm and abdominal muscles, at the time of exertion, the stomach of the individual having, from disease, been less capable of sustaining any degree of violence. The following are the particulars of the case; “A coal-heaver, aged 50, whilst stooping in the act of lifting some coals, placed his hand suddenly on the pit of the stomach, and complained of severe pain in that situation; this was immediately succeeded by two deep sighs, when he dropped down and expired. On dissection, the parts immediately round the opening were in a higher state of vascularity than the rest, and put on a decidedly torn appearance, which was also observable in the peritoneal coat.”
In pursuing the track of the alimentary canal we have to observe whether any marks of peritoneal inflammation present themselves; and whether any signs of inflammation in the muscular or mucous coats are visible through the transparent parietes of the intestine; and although no appearance of this kind can be discovered on the external coat of the bowels, we are not, on that account, to conclude that they have been free from inflammation; we must persevere in our dissection, and slit open the intestines in different parts, especially at the entrance of the ilium into the colon; the valve of the latter gut should also be inspected; nor should the rectum escape our attention, for its extremity is sometimes inflamed together with the stomach, while the intermediate portions of the canal are not in the least affected; this peculiarity occurs in many cases of poisoning, as those, for instance, in which colocynth or elaterium have been exhibited. An empoisoned clyster may have been administered; or, as in the case of King Edward II, a hot poker, or some other instrument thrust up the rectum. We should also in this part of the dissection, ascertain whether any intus-susceptio has taken place, a derangement not very rare, and frequently fatal; it consists in a portion of gut passing for some length within another portion, and dragging along with it a part of the mesentery; it may take place in any part of the canal, but it more usually occurs in the small intestines, especially where the ilium terminates in the colon; in the examination of infants an intus-susceptio is not unfrequently found, which had been unattended with mischief, and in which the natural peristaltic motion of the intestines would have easily disentangled them; but, in other cases, an unrelenting obstruction is established, inflammation follows, and life is soon terminated, as was exemplified in the case of the infant Princess Elizabeth of Clarence.
The liver may present several morbid phenomena, which, in a dissection instituted for the purpose of discovering the cause of death, ought not to be overlooked. It may also be found ruptured, an occurrence which may take place where little or no external injury can be perceived, as from a sudden fall, or from the application of strong pressure applied to the upper part of the abdomen, such as might be occasioned by the passage of a heavy carriage over the body. Morgagni relates several instances of ruptured liver, by mechanical causes, without any considerable injury of the integuments. In the Medical Transactions of the College of Physicians,[[35]] a very interesting case is communicated by Dr. George Pearson, of a young man who fell with his right hypogastrium and epigastrium, upon the edge of a pail, which he held in his hand, as the sixth step of a ladder, upon which he was standing, suddenly broke; his death happened ten hours after the accident, and upon dissection, the right lobe of the liver was discovered divided, in an oblique direction, through its whole substance, from its extremity on the right side, to the border of the left lobe; the two portions being only connected by the vena cava, and the trunks of the venæ cavæ hepaticæ.
The author has been informed by Dr. Harrison that, while at Mantua, he saw a man who had received a kick on the right hypochondrium from a horse that he was shoeing; he did not complain of much pain at the time, but exhibited an anxious countenance, and was attacked with coffee-ground vomiting. He died on the following day, and upon opening the abdomen the liver was found ruptured, and the peritoneum inflamed.[[36]]
The spleen may be brought into view for our examination by drawing the stomach towards the right side, when the one viscus will follow the other. This organ, like the liver, may be ruptured by violence; of which we have already cited an instance[[37]].
The pancreas is to be seen by tearing through the great omentum, between the large curve of the stomach, and the arch of the colon. The anatomist will proceed to the examination of the remaining structures in the abdomen with a facility that renders any farther directions unnecessary; we have only to repeat that in cases of forensic interest, the inspection cannot be too minute. The appearance of the kidneys, although not generally an object of dissection, ought to be noticed, as it is frequently connected with the exhibition of poisons; like the other solid viscera too, the kidneys may be ruptured by external violence, and several instances are recorded of sudden death having been thus occasioned.
Examination of the uterus and its appendages.—In the case of a female the organs of generation should always be inspected; very important conclusions may be deduced from the discovery of an unimpregnated uterus. In the case of Miss Burns, to which we have so frequently alluded in the progress of our work, this part of the dissection was so incomplete as to occasion considerable dissatisfaction. The uterus and its appendages having been carefully removed from the body, we should proceed to expose the cavity of the former by an incision, from near the os tincæ to the fundus, and by a transverse section at the fundus, between the inner ends of the fallopian tubes. This organ is liable, amongst other diseases, to inflammation, ulceration, schirrus, tubercles, polypus, dropsy, and organised masses, or moles; upon which we shall offer such observations as appear to connect the dissection with questions of forensic interest. In an adult and unimpregnated female its length is about 2½ inches; its thickness, 1 inch; its breadth at the fundus 1½ or 2 inches, and at the cervix about 10 lines. Although it returns after parturition to its original size, it never becomes again so small as it was in the virgin. In women who have borne many children, the neck of the uterus is generally thicker, and more rounded; its orifice, or os tincæ, is always very gaping, and the lips more or less irregular, presenting generally one or more grooves, or chops, separated by what appear like tubercles. The os uteri may, however, be as regular in its figure in women who have borne children, as in others; and on the contrary, it may present in the latter, those irregularities which are more usual in the former; hence the inferences drawn from the state of this part, in cases where infanticide is suspected, or where parturition is supposed to have been concealed, cannot be received as being unexceptionable, although they will add to the weight of evidence, and assist us, in conjunction with other evidence, in attaining that high degree of probability, which practically amounts to certainty. The cavity of the cervix uteri undergoes also a change in form and appearance, which it is necessary to notice, although we are not disposed to assign very great importance to its indications. In women who have never borne children, the figure of the cavity may be said to resemble that of two cones joined bases to base, more capacious in the middle than at the two extremities; but, from the time of conception, that extremity of the canal, which opens into the vagina, is dilated; and, after parturition has once occurred, it is always found much wider than before, when it represents a cone with the basis towards the vagina, and the apex towards the fundus uteri. By a schirrous enlargement, the uterus may arrive at a very considerable size. Dr. Baillie has seen it as large as the gravid uterus at the sixth month; the cavity may also enlarge and contain a polypus, which is a very common disease at middle or advanced age; it has been defined “a diseased mass, which adheres to some part of the cavity of the uterus, by a kind of neck, or narrower portion.” An attempt was made on the trial of Charles Angus to explain the appearance presented by the uterus of Miss Burns, upon the supposition of an hydatid having been recently ejected from it, (see vol. i, p. 254.) Water has been known to have accumulated in very considerable quantities in the cavity of the uterus,[[38]] in some cases to the amount of fifty, sixty, or even a hundred pints.