Text-book of forensic medicine and toxicology

by R. J. M. Buchanan

21. In examining the organs situated in the several cavities of the body the inspectors must be guided in a great measure by their ordinary anatomical and pathological knowledge.

22. The inspectors should begin with that cavity over which there is a wound or other mark of injury. Or, if there be an injury on the extremities, the dissection ought to commence there. In the absence of any such guide, that cavity should be taken first where the circumstances of death, so far as they are ascertained, may lead the inspectors to expect unusual appearances. In other cases, the abdomen should be first opened but not dissected, and a general survey made of the parts exposed, without disturbing them materially, the position of the diaphragm being determined by examining it with the hand; then the thorax is immediately to be examined, unless there is good reason for doing otherwise. The reasons for this method of procedure are as follow: If the abdominal organs are removed, and the veins cut, the blood in the heart may drain away through the venæ cavæ, and error result. If, on the other hand, the thorax be first opened, the relation of the abdominal organs to each other cannot be clearly made, owing to the relaxation of the diaphragm, due to the severing of its thoracic connections. Again, if the thorax be first opened, the position of the diaphragm cannot be determined. The inspectors may begin with the head, which may be examined thoroughly in the first instance, afterwards the chest and belly, as above described; the spine being reserved till the conclusion. Wherever unusual appearances are discovered in the first cursory survey, the anatomical examination ought in general to be begun there.

23. In examining the several regions of the body it is to be observed that wherever a wound, or other obvious injury of the external parts, lies in the way of the ordinary incisions, that part must be avoided, so as to leave the external injury unaltered.

24. The most approved mode of opening the head in medico-legal cases is, after dividing the integuments from ear to ear, and reflecting the scalp over the forehead and occiput, to make the usual circular incision through the skull, about an inch above the orbits in front, and over the occipital protuberance behind, using the saw lightly and carefully after the outer table of the skull has been divided, so as to avoid injuring the membranes of the brain; and to raise the skull-cap from before backwards, taking care to detach the dura mater from the skull with the handle of the scalpel or a spatula where it adheres firmly. The chisel and mallet should never be used where there is any chance of finding a fracture of the skull; for how could it be distinguished from a fracture made with the mallet? Should the dura mater be firmly adherent to the skull-cap, the better practice is to divide it carefully, so as to remove both at the same time. Tearing the membrane and crushing the brain substance are thus avoided. In infants and young children this mode of procedure is most necessary, as in them the dura mater is, as a rule, adherent.

25. The ordinary mode of examining the membranes of the brain, and the brain itself, answers well in medico-legal dissections. Effusions of fluid within the skull should always be measured. After the brain is removed, the dura mater ought to be stripped from the base of the skull to facilitate the search for fractures there, which will, of course, indicate external violence. After the removal of the brain, the upper part of the spinal canal should be examined through the foramen magnum before any part of its course be laid open; and search should be particularly made for dislocation or other injury in the region of the atlas and dentata. In cases of fatal fractures of the head, the strength of the bones should be attended to. In cases of extravasation within the head, the state of the coats of the cerebral arteries should be examined.

26. The best mode of opening the spine is, after having finished the examination of the brain, to cut through the integuments from the occiput to the coccyx—to lay the vertebræ thoroughly bare on each side by cutting away the muscles—to make an incision with the saw on each side of the skull, from the postero-inferior angle of the parietal bones into the lateral edge of the occipital hole—to remove the triangular portion of the occipital bone thus detached, and then to cut the rings of the vertebræ on each side with the bone-nippers or spine-knife, beginning with the atlas. In these cases preference should be given to the saw, by which the operation is not only more easily accomplished, but there is no risk of confounding previous fracture with that made in dissecting. Where there is reason to think that the bones are injured, the laying open of the canal should stop at the distance of two or three vertebræ from the injury, and the injured bones, with two or three adjacent vertebræ on each side, should be removed entire before the examination is extended farther down the spine.

27. The organs of the throat may be examined, either by dividing the lower jaw-bone at the chin, cutting the soft parts close to the inner surface of each half of the bone backwards, and then turning the two segments outwards; or by freely reflecting the skin of the throat, separating the soft parts from the inside of the lower jaw, the knife being carried parallel with and close to the bone, drawing the tongue out below the chin, and then continuing the dissection backwards.

28. The best mode of examining the organs situated in the throat is, after detaching the soft parts from the lower jaw, as advised in Sect. 27, to dissect the soft palate from the bone, and proceeding backwards, to detach the whole soft parts from the base of the skull and vertebræ down to the sternum, leaving them connected with the organs in the chest. Besides the ordinary points to be attended to in this part of the examination, the presence of venereal or other ulcerations is a matter requiring attention in some cases.

29. It is necessary to examine the pharynx and gullet, the larynx, trachea, and its greater ramifications, the lungs, the heart, and the great vessels with particular care, because here are most frequently found the causes of sudden natural death. In examining the heart each auricle and each ventricle ought to be laid open by an independent incision of its parietes; and this should not intersect any of the valvular openings or the septum cordis.

30. For laying open the chest and abdomen, the most convenient method is to make an incision down the fore part of the neck, chest, and abdomen to the pubes; then cutting from the peritoneum upwards, to dissect back the integuments and muscles of the chest, and examine the abdomen, as in Sect. 22; next, divide the cartilages of the ribs, and, cutting upwards, close under them, to raise the cartilages along with the sternum. In separating the sternum from the clavicles, care must be taken not to wound the subjacent vessels; and this may be avoided by the dissector moving each shoulder so as to show the exact position of the sterno-clavicular joints, and then dividing both joints cautiously. In dividing the cartilages of the ribs, the saw is sometimes necessary. The cartilages should be cut as far from the sternum as possible, to give free space for the subsequent examination.