THE EXTERNAL EXAMINATION.
=THE BEGINNING OF THE AUTOPSY.= The autopsy begins with the
examination of the exterior of the body. The cadaver should be
completely stripped of clothing and examined as a whole, then as
to its separate parts. Time is saved and omissions prevented if a
definite order is followed in the external examination, such as
follows here.
1. =Identification of the Body.= In ordinary cases the name of the
deceased will be given upon the autopsy-permit, and this will serve
as sufficient identification. In large autopsy-services, when several
cadavers may be brought in at the same time, each one should be
properly tagged so that no mistake is possible. It is necessary in
medicolegal cases to make a more formal identification by having the
cadaver positively identified by persons having knowledge of the
individual during life, or by those who first saw the body, or who
took it in charge. In such cases when identification is impossible
at the time of autopsy the protocol should give in full details
the place, time, and conditions of discovery of the body, with an
accurate description of its external characteristics, clothing,
articles found on the body, surroundings, etc. Bertillon measurements
and finger-markings may be taken; dental work should be carefully
described; false teeth and hair, eyeglasses, etc., should be
preserved, and the most careful attention should be paid to bodily
anomalies or peculiarities, birth-marks, tattoo, etc. Photographs,
casts, Roentgengrams, etc., may be taken. Powder-marks, blood-stains,
as well as those of semen and other discharges, should be described
and, if necessary, preserved. Legal names, as well as aliases, should
be recorded and attested in all cases of legal significance. In fact,
the only proper way to conduct any autopsy is with the assumption
that the results will have legal value; and such an assumption is the
best safeguard against important omissions.
2. =Sex.= This should always be mentioned in the protocol. In the
case of pseudohermaphrodism the determination of the real sex may
be difficult and may eventually be decided by microscopic studies.
Likewise in bodies that have been burned or mutilated the question of
sex becomes a matter of anatomic and histologic study. The character
of the bones, pelvis, remains of sexual organs, etc., are used as
criteria to decide the question. In cases of burning, the uterus
in the female and the prostate in the male may often be recognized
microscopically when the head and extremities are burned off and only
a charred mass of flesh and bone remains.
3. =Age.= When the true age is not known the apparent age must
be estimated by considering the general appearance of the body,
development, bones, epiphyses, sutures, blood-vessels, skin, hair,
teeth, sexual organs, etc. Roentgengrams of the epiphyses, hands
and feet may be made. The presence of an arcus senilis should be
noted. Arteriosclerosis of the temporal and radial arteries may be
determined by inspection and palpation. The determination of the age
of the new-born will be considered in a later chapter.
4. =Nationality.= When not definitely known this may be estimated
by such criteria as color of skin, finger-nails, character of hair,
facies (cheek-bones, jaw, forehead, cephalic index, facial angle,
eyes, etc.), hands, feet, general build, etc. For ethnologic and
anthropologic data the body may be described according to the
primitive type it represents (Australioid, negroid, mongoloid,
xanthochroic, melanchroic, Iberian, dolichocephalic, etc., according
to the different classifications).
5. =Status.= Unmarried, married, widow, widower, divorced, legal
status, citizen of what country, state, county or town, etc.
6. =Occupation.= As this often throws light upon the pathologic
condition present in the body, the trade or occupation should be
ascertained and stated in the protocol. When no direct information
is available a judgment concerning it may be made on the basis of
certain conditions, occupation or industrial diseases found in the
body (anthracosis, argyrosis, siderosis, silicosis, chalicosis,
lead-poisoning, chronic phosphorus poisoning, nitrobenzol and other
forms of poisoning, localized muscle-hypertrophy or atrophy, callus,
etc.).
7, 8. =Time of Death and Time of Autopsy.= The day and hour of death
and the time of autopsy should be noted. When the time of death is
not known with certainty it can only approximately be estimated
by the condition of the body with respect to such postmortem
changes as rigor mortis, algor mortis, hypostasis, diffusion-spots,
decomposition, etc. From no one of these signs of death can an
absolute statement be made as to the time of death; so great a
variation may occur with any one or with all of these so-called
_positive signs_ of death that only very relative estimates can
be given. Between the actual time of death and the appearance of
positive signs of this event there exists a variable period in
which death announces its appearance by _negative_ signs only; the
cessation of the vital functions, respiration, circulation and
nervous excitability. These functions may, however, be reduced to so
low a degree of strength that their existence cannot be made out by
the usual methods, and a condition of _apparent death_ or “_suspended
animation_” may be present. Such a condition is most frequently
seen in cases of cholera, hysteria, catalepsy, hypnosis, excessive
fatigue, prolonged exposure to cold or to high temperatures,
concussion, severe hemorrhage, action of certain poisons, electrical
currents and lightning stroke, strangulation, asphyxia, suffocation,
drowning, etc. The condition of apparent death may last hours or even
days, but as a rule it is one of very short duration. 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.
=Tests for the Determination of the Occurrence of Death.= Loss of
reflexes or response to stimuli are early signs. Mirror, flame or
feather held before the mouth and nose, or vessel containing fluid
placed on epigastrium show absence of respiration. Opening of artery,
temporal or radial; if death has occurred vessel will be empty. Tests
with blood-pressure apparatus are negative in dead body. Electrical
tests and Roentgengrams of heart and lungs show no movement in
these organs. Subcutaneous injection of ammonia; no congestion or
vesicle formed in the dead body. Subcutaneous injection of fluorescin
(_Icard’s test_): in the living body a greenish color soon appears
in skin, mucous membranes and conjunctivæ; but not in the dead body.
Heat applied to the skin causes no reddening in the dead body, and,
if a vesicle forms, the fluid contained in it has no albumin and the
underlying skin is dry and glazed and not red. The application of
caustics produces no eschar in the dead body. A steel needle inserted
into the living tissues becomes quickly tarnished; in the dead body
oxidation will not take place after many hours. Glazing of the
eyes (if these are open) takes place very quickly after death; the
eye-ball collapses ordinarily, but may remain prominent in death from
hanging, suffocation, apoplexy, etc. The eye loses its elasticity;
the pupils can be made oval by compressing the globe (_Ripault’s
test_). The patch of dark discoloration on the part of the sclerotics
exposed to evaporation is known as _Larcher’s sign_. The hands held
against a strong light lose the pink tinge between the fingers,
and the soles and palms become yellow. A tight ligature about a
finger or limb causes no reddening (_Magnus’s test_). Relaxation
of the sphincters occurs soon after death. It should be borne in
mind in this connection that the discharge of gas and féces is not
uncommon after death, that a fetus may be expelled by the increase of
intra-abdominal pressure due to rigor mortis and gas-formation, that
a discharge of semen or prostatic fluid almost always occurs in the
adult male, that electric contractility may last several hours after
death, that muscles may twitch during this period, and that atropine
will dilate the pupils for some time postmortem.
9. =Build.= The body should be measured by stretching in a straight
line a metal tape-measure from the vertex to the centre of the
external arch of the instep, the foot being held at a right angle
to the surface of the table. 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. Racial, sex and age differences should be noted. Roentgen-ray
examination may here also be made use of in the determination of
stages of skeletal development. Approximate estimates of the general
build may be made when only part of the body is preserved. Such
rules as nineteen times the length of the middle finger equals the
approximate height, four times the length of the femur equals the
height, the distance from the tip of the olecranon to the tip of the
middle finger is five-nineteenths of the height, etc., are obviously
very uncertain.
10. =General Nutrition.= The body should be weighed. Nutrition good,
medium, poor, emaciated, etc. Condition of skin, muscles, panniculus,
etc. Differentiate loss in fat from loss in muscle. Distinguish
physiologic fat from pathologic (lipomatosis, etc.).
11. =Head.= The size and shape of the head should be noted, and
any peculiarity or pathologic condition described (microcephalic,
macrocephalic, dolichocephalic, brachycephalic, etc.).
12. =Facies.= Aside from individual and racial characteristics the
face of the cadaver may show varying expressions (Hippocratic
facies, hepatic facies, expression of peace, pain, horror,
distortion, etc.). Note all anomalies and pathologic conditions
(leontiasis ossea, leonine expression of leprosy, hare-lip, etc.).
13. =Eyes.= Closed or open, shape, size, color, deep-set, changes
due to death, condition and size of pupils, arcus senilis, color of
conjunctivæ and sclerotics, eye-lids. The pupils are usually dilated
at death, but after a short time they contract, usually unequally,
and remain so for several days. Note particularly all anomalies and
pathologic conditions (corneal scars, coloboma, cataract, strabismus,
etc.).
14. =Neck.= Short and thick, long and narrow, thin or fat, smooth
or wrinkled, scars, enlargements, marks of rope, fingers, string,
evidences of strangulation, hemorrhages, abrasions, etc., other forms
of trauma, cysts, enlarged glands, condition of thyroid, etc.
15. =Thorax.= Shape, length, breadth and depth, angle of Louis,
epigastric angle, symmetry of sides, prominence or depressions,
pigeon-breast, shoemaker’s or funnel breast, rachitic rosary,
character of ribs and interspaces, mammæ, degree of hairiness,
eroding tumors or aneurisms, etc.
16. =Abdomen.= Depressed, scaphoid or elevated, distended,
tympanitic, presence of fluctuation, symmetry, results of palpation
(neoplasms), character of abdominal wall (tightly stretched or lax,
wrinkled), presence of linea fusca or lineæ albicantes (pregnancy,
ascites, tumor). The existence of enteroptosis or gastroptosis can
often be told by inspection of the abdomen.
17. =Back.= General build and contour, bedsores, etc. Spine should
be carefully examined (anterior, posterior or lateral curvatures,
evidences of trauma, etc.).
18. =Anomalies.= Malformations and anomalies of any region should
be thoroughly examined and carefully described. The most common
ones found in adults are hare-lip, cleft palate, branchial
cysts, bifid sternum, accessory ribs, malformations of fingers
and toes, hypertrophy of great toe, hypospadias, cryptorchidism,
pseudohermaphrodism, congenital dislocations, particularly of
hip, lumbosacral meningoceles and dermoid cysts, microcephalus,
club-foot and hernia, its variety, location, size and condition.
Under anomalies may be considered the stigmata of degeneracy and
the _homo delinquens_ type. These should also be mentioned in the
identification of the cadaver.
19. =Deformities.= Location, degree, character, probable cause, etc.
Most commonly caused by tuberculosis, rachitis, gonorrhœa, syphilis,
osteitis deformans, trauma, burns, osteomalacia, tabes, muscular
atrophies, gout, rheumatism, tumors, aneurism, diseases of the
lung causing asymmetry of the thorax, acromegaly, etc. Most common
forms are Pott’s disease, spondylitis, ankylosis, spinal curvature,
contractions and retractions of parts, bow-leg, knock-knee, changes
in the pelvis, dwarfism, shortening of extremities, exostosis,
drumstick or clubbed fingers, flat foot, loss of bones, amputations,
occupation deformities, swelling of joints, tophi, Charcot’s joint,
hygroma, ganglion, etc.
20. =Signs of Trauma.= Location, size, character and condition of
wound (bruises, bloody suffusions, hæmatoma, erosion, denudation,
lacerations, punctures, crushing, blister, fractures, dislocations,
bullet-wounds, marks of hanging, strangulation (abrasions in the neck
caused by hanging show minute hemorrhages in and about their edges,
particularly in the upper border; section of the neck shows small
hemorrhages in the cervical tissues), or drowning, burns, action
of corrosives (brown spots on lips), effects of electric currents,
etc. In the case of powder-markings note number, direction, burning,
singeing of hairs, etc.) In medicolegal cases the description of
traumatic lesions should be especially minute and complete. An effort
should be made to distinguish postmortem from antemortem wounds.
Recent wounds have clean cut walls and edges covered with blood; old
wounds show reaction, vascularization, granulations, adhesion of
edges of wound, or of exudate. Postmortem wounds are usually free
from blood unless large veins are ruptured. Loss of the epidermis
before or after death causes in the cadaver yellowish or brown, firm,
leather-like spots.
21. =Surgical Wounds.= Location, size, nature of operation, state of
wound, character of surgical dressings, drainage, etc., discharge
from wound as blood, pus, féces, urine, etc., odor of wound, age as
shown by stage of repair, evidence of infection, etc. Hypodermic
marks, saline injections, blisters, venesection, cupping, exploratory
punctures, recent vaccination marks, etc., should be noted.
22. =Scars.= Location, size, character, recent or old, pigmented
or pale, rough or smooth, contractures, keloids, traumatic or
surgical, nature of injury or surgical operation, hypodermic scars,
vaccination, acne, cupping, small-pox, chicken-pox, shingles,
“electric belt,” croton oil, burns, etc.
23. =Skin.= Color (racial differences), brown, gray or black
pigmentations in Addison’s disease, pellagra, syphilis, vitiligo,
xanthoma, chloasma, pigmented nodes or nævi, argyria, arsenical
poisoning, pernicious anæmia, xeroderma pigmentosum, chronic
jaundice, vagabond’s skin, tan, following blisters, plasters,
cupping, use of croton oil, Roentgen irradiation, effects of violet
rays, melanotic tumors, pregnancy, etc.; bronzing in Addison’s
and chronic icterus; lemon yellow in chlorosis and pernicious
anæmia; yellow to dark green in icterus; grayish-brown in potassium
chlorate poisoning; bluish-red (cyanotic) in cardiac insufficiency;
yellowish-bluish-red (“Herz-farbe”) in cases of complete loss
of compensation; cherry-red or rose-red in carbon-monoxide or
hydrocyanic acid poisoning, rarely as the result of an erythema,
although this condition usually disappears after death; dirty sallow
to grayish or greenish in tumor cachexia and poisoning with H_{2}S;
white after severe hemorrhage, cachexia of chronic Bright’s disease,
leucoderma, vitiligo, albinism, leprosy, etc.; red, yellow, green
or brown in hemorrhages according to their age. Eruptions should
be classified and described as to location, abundance, stage, etc.
(macules, papules, wheals, desquamation, scales, blebs, bullæ,
pustule, tubercles, ulcers, abscess, phlegmon, herpes, crusting,
granuloma, etc.). With the exception of chicken-pox and small-pox
the eruptions of the acute exanthemata disappear after death, as do
all erythematous rashes except in rare instances. Emphysema of the
skin should be differentiated from œdema. The most common lesions
of the skin are acne, eczema and syphilis. Tuberculosis (lupus)
is not uncommon; anthrax, favus, rhinoscleroma, actinomycosis and
blastomycosis and Aleppo or Delhi boil are more rarely seen. Tinea
versicolor and tricophyton (barber’s itch and the various forms
of ringworm) are the most common parasitic affections. In the
Southern states ground-itch due to the hook-worm is the most common.
Leprosy should be considered in connection with individuals coming
from Norway, Sweden and Finland and other leper-foci. The most
common tumors of the skin are all the various forms of hæmangioma
and lymphangioma (freckles, moth patches, naevi, moles, warts,
birth-marks), fibroma, lipoma and squamous-celled carcinoma (horny
and basal-celled types). The latter is the most common form of
malignant tumor. Sarcoma of the skin is more rare; the melanotic
sarcoma, arising usually in a pigmented mole, is the most common
form. Next to this is the round-cell sarcoma or lymphosarcoma
(mycosis fungoides, leukaemic and aleukaemic lymphocytoma, etc.).
Spindle-cell sarcoma, angiosarcoma, endothelioma and other forms
are less common. Sebaceous cysts (wen, atheroma, steatoma) are
very common. Less frequent are molluscum contagiosum, xanthoma
(endothelioma lipomatodes), myoma, myxoma, chondroma and osteoma.
Adenoma sebaceum and sudoriparum are rare. Other conditions of the
skin to be noted are cleanliness, elasticity, general nutrition,
moisture, presence of scales, atrophy, hyperplasia (ichthyosis,
horny warts, cutaneous horns, the various forms of elephantiasis),
scleroderma, keloid, xeroderma pigmentosum, albinism, leucoderma,
vitiligo, myxœdema, seborrhœa, alopecia, erysipelas, dermatomyositis,
psoriasis, impetigo, rhinophyma, herpes, miliaria, sudamina,
symmetrical gangrene, trophic changes, “goose-flesh,” hemorrhages,
scars, tattoo-marks, etc. The various forms of skin-diseases should
be described and recorded whenever present.
The presence of petechiæ or ecchymoses in the skin (purpura) is
characteristic of all the forms of essential purpura (simplex,
peliosis rheumatica, hæmorrhagica, senilis, morbus maculosis
Werlhofii, scurvy, Möller-Barlow disease, etc.); such skin
hemorrhages occur also as the result of trauma, congenital
hæmophilia, in the course of many infections (small-pox, plague,
typhus, yellow fever, endocarditis, measles, scarlet fever,
septicæmia, pyæmia, rheumatism, meningitis, typhoid fever), in many
intoxications (snake-bite, icterus, nephritis, iodine, bromine,
phosphorus, chloroform, etc.), also in severe anæmia, pernicious
anæmia, leukæmia, sarcoma, carcinoma, acute yellow atrophy of
the liver, hysteria, vicarious menstruation, reflex hemorrhages,
stigmatization, etc. The number, size, color and location of all
cutaneous hemorrhages should be recorded.
24. =Hair.= Color, abundance, distribution, character, quality,
condition, length, pathologic conditions (alopecia areati, senilis,
præsenilis, pityrodes, syphilitica and symptomatica, trichorrhexis
nodosa, hypertrichosis, parasites, etc.). In prolonged fevers and
wasting diseases the diameter of the hair is diminished. Symptomatic
alopecia occurs after syphilis, typhoid fever, scarlet fever,
measles, erysipelas, anæmia, Roentgen irradiation, etc. The length,
color and quality of the hair as well as amount and distribution
vary in different races. Hypertrichosis is often associated with
degeneracy, criminal tendency, epilepsy, idiocy and certain forms
of insanity. An apparent growth of hair after death may be caused
by retraction of the tissues; an actual postmortem growth is not
conceded by the majority of authorities in spite of the numerous
tales to that effect. Loss or absence of pigment is seen in albinism,
leukotrichia due to infection, Graves’ disease, exposure, burns,
nervous affections, fright, worry, etc. The presence on or about
the body of hairs not belonging to the cadaver is a point of great
importance in medicolegal cases and one that should be thoroughly
investigated as to their source. Human hair can be identified
microscopically, and it is possible to recognize different specimens
according to their variation in color, length, quality, etc.
The =nails= should be considered in connection with skin and hair,
with reference to the following points: presence or absence,
hypertrophy, atrophy, color, condition, length, development,
onychia, hyperonychia, paronchyia, onychogryphosis, longitudinal and
transverse ridges, fissures and cracks, opacity, brittleness, etc.
25. =Teeth.= Number, character, condition, anomalies, dental work,
caries, Hutchinson’s teeth, odontoma, dental osteoma, dentigerous
cysts, epulis, papilloma, etc.
26. =Mucous Membranes.= Color, deposits or incrustations, eruptions,
erosions, herpes, mucous patches, rhagades, ulcers, fissures,
moisture, trauma, effects of corrosives, burns, pigmentation, as in
Addison’s disease, leukoplakia, hairy tongue, hemorrhages, tumors,
etc.
27. =Muscles.= Musculature and condition of muscles (slight,
athletic, well developed, poor, flabby, soft, etc.), anomalies, etc.
28. =Rigor Mortis.= Postmortem rigidity is one of the absolute signs
of death. It begins usually 1-2 hours after death, the involuntary
muscles and heart showing it first. Externally it shows first in
the muscles of lower jaw and neck, extends downward, involving the
lower extremities last and disappearing in the same order. Its
appearance, however, is subject to the greatest variation, and the
presence or absence of rigor mortis cannot be used as a criterion
for the estimation of the length of time the body has been dead.
Instantaneous rigor has been reported in suicides and in people
killed in battle. Intense excitement, great muscular exertion, etc.,
favor its rapid appearance. It also comes on very quickly after
death from rabies, tetanus, strychnine poisoning, cholera and a
number of other conditions. It sometimes is delayed or absent after
heat-stroke; chronic alcoholism also delays its appearance. Usually
the contraction lasts 24-48 hours, but under certain conditions may
persist for several days. It is prolonged in muscular individuals,
after death by suffocation, rabies, strychnine poisoning, etc. The
stiffening of the muscles may be broken by application of heat or the
use of force (removal of clothes from the body); when once broken it
rarely returns. In a case of death from rabies seen by the writer
the rigor was so strong that it required the united efforts of two
men to straighten the limbs, and before the close of the autopsy the
rigor had returned as strong as in the beginning. Rigidity due to
undertaker’s injections and freezing must not be mistaken for rigor
mortis. The possibility of rigidity due to ankylosis must also be
borne in mind.
29. =Panniculus.= The subcutaneous panniculus is estimated by
pinching up a fold of skin between the thumb and fingers of the
right hand and the thickness determined. The amount is described as
panniculus abundant, moderate, absent, etc. Estimates should be made
of panniculus of upper extremities, thorax, abdomen, back and lower
extremities. Pathologic conditions, such as general obesity, adiposis
dolorosa, multiple lipomata, elephantiasis lipomatosa, fatty collar,
etc., should be described in full.
30. =Oedema.= At the same time that the panniculus is being examined,
the presence or absence of œdema (pitting on pressure) should be
noted in the same regions. When present it may be described as
slight, moderate, marked, extreme, localized, universal, etc.
_Emphysema_ of the subcutaneous tissue is shown by the presence of
elastic swellings of the skin, not pitting on pressure, but giving a
crepitation when palpated.
31. =Body Heat.= The absence or presence of the body heat is of great
importance in giving some idea as to the relative length of time the
body has been dead. The nose, ears and extremities first become cool,
the liver region retaining the heat longest. The rate of cooling
depends upon the external temperature and the conditions of the body.
Nude bodies, cadavers exposed to water and cold, and bodies that
have suffered severe hemorrhages lose their heat more rapidly. Under
ordinary conditions the rectal temperature is the same as that of the
surroundings in about forty hours. During the formation of the rigor
there may be a slight increase in the temperature of the cadaver.
An increase above the normal temperature has also been noted in the
dead body immediately after death from tetanus, cholera, small-pox,
peritonitis, electric currents, suffocation, gangrene, etc.
32. =Hypostasis.= After death the blood passes into the veins and
very soon through gravity collects in the greatly distended veins
of the lowest portions of the body, except where these are pressed
upon by the weight of the body. Such a settling of the blood begins
usually within 1-2 hours after death, but may take place even
before death (hypostatic congestion) in cases of long-standing
recumbent position, cardiac lesions with failure of compensation,
wasting diseases, acute infections, death from suffocation, etc.
Postmortem lividity should be described as to its extent, location
and color. In anæmia the color is pale purplish red, in congestion
dark purple, in cyanosis the color may be dark bluish red and the
fingers, toes, ears, etc., retain the cyanotic appearance for some
hours after death; in potassium-chlorate poisoning the color is
chocolate, in hydrogen-sulphide poisoning grayish green, in poisoning
with hydrocyanic acid or carbon monoxide it is rose or cherry red.
Fresh hypostatic patches can be made pale by pressure and when cut
they will bleed freely. Hemorrhages cannot be pressed out nor will
hemorrhagic areas bleed as freely as hypostatic patches. In all
medicolegal cases care should be taken to differentiate bruises and
ecchymoses from hypostatic patches, as in the popular mind the latter
are often regarded as evidences of trauma or violence. The location
of the hypostasis is of importance in showing the position of the
body after death; if the anterior portion of the body is hypostatic
the cadaver must have been lying upon its face for some time after
death; suspension of the body for some time after death by hanging
causes a hypostasis of the lower extremities. Of the internal organs
the brain, lungs, stomach and coils of intestine chiefly show
hypostasis. Antemortem hypostasis of the lungs is distinguished from
postmortem by its deeper color, firmer consistence, more marked
œdema and microscopic signs of beginning inflammation (hypostatic
pneumonia). Cadaveric lividity reaches its maximum in 24-48 hours,
and after this time diffusion gradually occurs. In connection with
the examination of hypostatic areas the condition of the superficial
vessels as to size, distention, etc., should always be noted.
33. =Putrefaction.= The first signs of putrefaction are seen in the
transformation of the hypostatic areas into _diffusion spots_ and
_stripes_ following the course of the larger veins. The color is at
first a dirty red or brownish-red, but soon becomes gray or green
as a result of the action of hydrogen sulphide diffusing from the
intestines. Diffusion spots cannot be made pale by pressure, nor do
they bleed when cut. The greenish coloration begins first over the
abdomen and lower intercostal spaces, and this gradually spreads over
the body, showing first in the hypostatic areas and along the veins.
The abdomen then becomes distended; gas may form in the subcutaneous
tissues so that the skin becomes swollen, crackles on pressure and
gives off gas-bubbles when cut. The epidermis becomes loosened in
spots, forming blebs containing a dirty-brown exudate, while the
tissues become soft and are easily torn. The odor of putrefaction
is evident. Decomposition sets in more quickly in infants, in fat
and plethoric individuals, and after death from snake-bite, active
syphilis, plague, sepsis, heat-stroke, suffocation, acute infectious
fevers, icterus, gangrene, diabetes, etc.; it is delayed by
hydrocyanic acid and other poisons. When putrefactive bacteria are
present in the body, decomposition may begin immediately after death.
34. =Orifices of the Body.= The _mouth_, _nose_, _ears_, _anus_,
_urethra_ and _vagina_ are to be examined with special regard to
their condition and contents (open, closed, gaping, torn, bleeding,
discharge of pus, blood, mucus, féces, stomach contents, semen,
urine, foreign substances, parasites, ear-wax, etc.). In cases of
suspected rape an especial examination of the orifice of the vagina
or anus is indicated.
35. =Percussion and Palpation.= The external examination may be
closed by the percussion of the heart, lung, spleen, liver and
stomach boundaries, and by the palpation of the abdomen. The fine
opportunity for control of technique, judgment as to sound, size,
consistence, shape, etc., should not be lost. Rigor mortis of the
abdominal muscles can be removed by kneading the muscles or by the
application of hot cloths.