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.

=Antimony.= In acute cases the mucosa of mouth, œsophagus and
stomach is inflamed, with erosions and ulcerations; in chronic
cases there is marked emaciation.

=Arsenic.= Mucosa of stomach œdematous, hyperæmic and ecchymotic;
over the hæmorrhages there may be grayish-white sloughs or
erosions. In these there may be found granules or crystals of the
poison. The glands of the mucosa show cloudy swelling and fatty
degeneration. Yellow sulphide of arsenic may be seen on the gastric
mucosa. The small intestine is filled with a rice-water-like
fluid, as in cholera, and the mucosa is congested, swollen
and hæmorrhagic; the lymphoid tissue may be swollen. There is
slight icterus, cloudy swelling of all organs and ecchymoses in
pericardium and pleura. In chronic poisoning with dilute solutions
characteristic gastro-intestinal changes are wanting. In cases of
suspected arsenic poisoning it is important to take portions of all
organs and tissues for chemical examination.

=Atropine.= Death from asphyxia, resembles heat-exhaustion.

=Chloral-hydrate.= Hyperæmia of lungs, brain and cord. Examine
urine.

=Chloroform.= Fatty degeneration of liver and heart. In delayed
poisoning the liver shows picture of acute yellow atrophy, with
marked icterus, widespread ecchymoses, cloudy swelling of kidneys
and fatty degeneration of heart. Lungs, brain and liver may or may
not give odor of chloroform.

=Ergot.= Sclerosis and contraction of arteries; gangrene of
endometrium; in chronic cases sclerosis of the posterior columns of
the cord.

=Formalin.= Corrosive action on mucosa of stomach; formic-acid in
urine.

=Hydrocyanic Acid and Potassium Cyanide.= The mucosa of stomach is
deep red, swollen, softened and sometimes translucent; soapy to the
touch; odor of bitter almonds or ammonia; blood is fluid, dark or
light cherry-red; red hypostasis.

=Illuminating-gas and Carbon-monoxide.= Blood fluid and cherry-red;
cadaver life-like; pink hypostasis; carbon-monoxide-hæmoglobin in
blood demonstrated by spectroscope. In poisoning by coal-gas the
changes are less marked because of the greater amount of carbon
dioxide present. Inhalation of smoke is shown by black, sooty
deposits upon the mucosa of the respiratory tract.

=Lead.= In acute cases severe gastro-enteritis; black fluid
in intestines; cloudy swelling of kidneys. In chronic cases
arteriosclerosis, fatty degeneration of muscles, liver, kidneys and
spleen; cirrhosis; blue line on gums.

=Mercury.= Mucosæ congested, ecchymotic or showing grayish-white
eschars; diphtheritic inflammation of pharynx, colon and vagina;
decalcification of bone; cloudy swelling and calcification of
kidney. In chronic cases ulcerative stomatitis.

=Nitrobenzol.= Cadaver cyanosed; blood and muscles brown; mucosa of
stomach hyperæmic and ecchymotic; odor of bitter almonds; brownish
methæmoglobin in collecting tubules of kidney.

=Opium and Morphine.= No characteristic findings. Condition of
pupils not conclusive.

=Phosphorus.= In very acute cases there may be few changes; odor of
phosphorus; cloudy swelling of heart, liver, kidneys and gastric
mucosa. In subacute cases there is icterus, hæmorrhage, marked
fatty degeneration of all organs; in chronic poisoning there is
universal fatty degeneration, and not rarely a necrosis of the
jaw-bone.

=Potassium Chlorate.= Hypostatic spots and blood are of chocolate
color; methæmoglobinæmia; hæmorrhagic nephritis.

=Ptomaines.= Gastro-enteritis, fatty degeneration; icterus, cloudy
swelling of kidneys.

=Strychnine.= Intense and persistent rigor mortis; blood fluid and
dark as in asphyxia. Urine should be saved for the frog-test.

Other causes of death requiring especial consideration in a medicolegal examination are:—

=Abortion.= Determined by the finding of fœtal tissues, chorionic villi, decidua, enlargement of uterus, formation of sinuses at placental site, curetted surface, corpus luteum of pregnancy in ovary, punctures or lacerations of uterus and cervix, effects of corrosive fluids, infective endometritis, evidences of poisoning.

=Asphyxia.= Death due to lack of oxygen and excess of carbon dioxide, produced by interference with respiration, choking, drowning, hanging, paralysis of muscles of respiration, intoxication, etc. When respiration is suddenly checked ecchymoses are usually found in the pericardium, pleura, meninges, thymus, and rarely in peritoneum. Lips, skin of face and neck, and finger-nails may be deeply cyanotic; the blood is dark and fluid; passive congestion of lung is usually present. In death caused by hanging or strangling there may be fracture of the hyoid bone, thyroid cartilage or tracheal rings, marks upon the skin, hæmorrhage, laceration of the intima of the arteries, fracture or dislocation of the cervical vertebræ and injury to the cord. In death from drowning the bronchi, lungs and stomach may contain fluid, there is watery fluid in the pleural cavities, maceration of skin, greater water-content in blood of right heart than of left, with consequent raising of freezing point.

=Infanticide.= The points to be considered in determining the age and viability of the child are given in Chapter XIII. The most important causes of death in the new-born are also given in the same chapter.

=Electric Shock.= Burns of skin, “lightning figures,” signs of asphyxia, laceration of internal organs.

=Burns and Scalds.= Extent of burn more important than depth of the burn; death usually ensues if one-third of the surface is burned. Burns show scorching, singeing or marks of the hot object; scalds usually show some action of the hot fluid on the skin or mucous membranes. Demonstration of carbon-monoxide in blood of internal organs proves the inhalation of carbon monoxide. When exposed to intense heat the soft parts of the body show marked shrinking.

=Heat or Cold.= No characteristic lesions in death from these causes. Diagnosis must be made by exclusion and history of case.

=Starvation.= Marked disappearance of fat and atrophy of all organs, stomach and small intestines empty, marked emaciation, blood anæmic, concentrated when subject was deprived of water.

=Violence.= Wounds must be minutely described as to character, degree of laceration, contusion, extravasation, damage to tissues, direction of force, character of instrument, means and method of infliction, path of projectile or stab-wound, etc. Postmortem changes and injuries must be differentiated, as must be also antemortem and postmortem lesions, primary and secondary effects of the injury, effects of injury and pre-existing diseases. Intracranial hæmorrhages must be carefully differentiated with respect to causation by violence or disease. Effects of _contrecoup_ must be borne in mind. The presence of other marks of trauma, the exclusion of disease, the location of the clot, the age of the clot, the age of the patient, etc., are some of the factors to be considered. In young people without alcoholic history or syphilis intracerebral hæmorrhages without signs of violence are rare. When associated with fractured skull they are usually regarded as due to the trauma.