EXTERNAL EXAMINATION OF THE BODY.

External examination is often of great importance, especially in medico-legal autopsies, and should never be neglected, as it may throw great light on lesions found within. the body. It should be systematic and careful, and is best taken up in the following order:

I. Inspection of the Body as a Whole.

I. Sex.

2. Age.

3. The body-length should be measured on the table beside the body, between points opposite the vertex of the head and the sole of the foot beneath the ankle.

4. The development of the skeleton has reference to the bony framework, which may be powerful, slender, or deformed.

The

5. The general nutrition is shown by the amount of muscular development and of subcutaneous fat-tissue. latter is judged by pinching up a fold of skin.

6. The general condition of the skin includes amount of elasticity, bronzing, jaundice, edema, and decubitus.

7. Post-mortem discolorations may be divided into three varieties:

(a) Hypostasis of blood, or the settling of blood into the lowest lying blood-vessels; this form of discoloration dis

appears on pressure.

(b) Diffusion of blood-coloring matter out of the vessels into the surrounding tissues (due to blood-pigment being set free by post-mortem decomposition); does not disappear on

pressure.

(c) The greenish discoloration, usually seen earliest over the abdomen, is due to sulphate of iron formed through decomposition of the tissues. This discoloration is important, as it may modify the interpretation of appearances observed in the internal organs.

8. Post-mortem rigidity, degree and extent. It begins in the maxillary muscles, and spreads gradually from above downward, disappearing later in the same order. It is most marked and lasts longest in muscular individuals who have

been ill but a short time. Cholera furnishes the most marked cases. The rigor disappears quickest in cachectic diseases. When once it has been forcibly overcome, it does not recur. The time of beginning after death varies widely-from ten minutes to seven hours.

II. Special Inspection of the Different Parts of the Body.

The examination should begin with the head. Any lesion or abnormality found should be carefully noted. Particular attention should be paid to the condition of the pupils and to the color of the sclera. Then follow in order the neck, the thorax (size and shape), the abdomen (distended or retracted), the genitals, and the extremities.

INTERNAL EXAMINATION OF THE BODY.

The opening of the body-cavities is described first, because the brain is relatively much less frequently the seat of disease, and because in this country it is often impossible to obtain permission to open the head. Moreover, the lesions in the body often throw much light on those to be expected in the brain. The advantage of examining the brain first, particularly in those cases in which the important lesions are cerebral, is said to be that the amount of blood in the cerebral vessels can be more accurately determined. After the heart has been removed some of the blood in the brain may escape through the severed vessels below.

In routine examinations, however, the body is usually examined first, then the brain, and finally the cord. It is not a bad practice to remove the calvaria, to examine the meninges over the upper surface of the cerebrum, and then to make the examination of the body before removing the brain. In this way any change in the blood-supply of the cerebral vessels would be observed.

Opening of the Abdominal Cavity.-In the examination of the body the peritoneal cavity is opened first, the two pleural cavities next, and the pericardial cavity last. The cavities and their contents are to be inspected in the order and at the time that each is opened, but the organs are to

be removed from the cavities for further examination in the reverse order, beginning with the heart.

The primary or long anterior incision to bare the thorax and to open the abdomen (Fig. 5) should extend from the larynx to the pubes, passing to the left of the umbilicus, so as not to cut the round ligament. In cutting, the handle of the knife is depressed so as to use the belly of the blade rather

than the point. An incision beginning as high as the chin is, unfortunately, rarely allowable. Over the sternum the cut should extend down to the bone; over the abdomen, however, only into the muscles, or in fat people through the muscles into the subperitoneal fat-tissue. To open the abdominal cavity, nick carefully through the peritoneum just below the sternum, introduce the first and second fingers of

the left hand, and while making strong upward and outward traction on the right abdominal flap extend the incision to the pubes. Some operators prefer to separate the fingers and to cut between them.

The abdominal flaps are rendered much less tense by cutting the pyramidales and recti muscles from below just above the pubis. Care must be taken not to injure the overlying skin. The abdominal cavity can now be examined, but more room will be obtained if the skin and the underlying muscles be first stripped back from the thorax to about 5 cm. outside of the costochondral line.

The operation is most easily and neatly done by lifting the skin directly away from the chest-wall or turning it forcibly out with the left hand, and then cutting the tense tissue close to the cartilages and ribs with long sweeps of the knife held almost flat. The operation begins over the lower border of the ribs and extends upward. In dissecting off the skin and muscles from the left side the right hand works underneath the left. The mammæ can easily be incised from the under side of the flap, and if necessary the axillary glands can be reached by dissecting the skin farther out, especially over the clavicle. Before beginning the inspection of the peritoneal cavity it is important to examine first the surface of the incision into the abdomen, noting the thickness and color of the fat-tissue and the condition of the muscles.

Inspection of the Abdominal Cavity.-The character of any fluid present should be determined and its amount measured or estimated. The simplest way to remove it is to dip it up with a small cup or dish and pour it into a glass graduate for inspection and measurement. If the presence of gas within the peritoneal cavity is suspected, a small pouch should be formed in the first incision as soon as it has been made and water poured in. The first opening into the abdominal cavity should then be made with the point of a scalpel at the bottom of the water, through which the gas, if present, will escape in bubbles.

The various abdominal organs and their relations to each other are to be investigated in situ by sight and by touch.

As a rule, examine first the gastro-intestinal tract, including the appendix and the mesenteric lymph-glands. Ulcerations of the intestine can often readily be made out through the walls. The examination of the spleen, liver, kidneys, and pelvic organs follows. The pancreas is easily reached by tearing through the omentum between the stomach and the colon, so as to open the lesser peritoneal cavity.

After the inspection of the abdominal organs the position of the diaphragm is to be ascertained on both sides in the costochondral line by measuring with the right hand passed palm upward underneath the ribs, and the left hand outside at the corresponding height to mark the position of ribs or intercostal spaces. On the right side the hand is to be passed up on the outside of the falciform ligament. Normally, the diaphragm stands at the fifth rib on the left side, and at the fourth rib or fourth interspace on the right.

Opening of the Thorax.-To open the thorax, cut through the cartilages close to the ribs from the second down (about 5 mm. distant) with a scalpel held nearly horizontal, so that as one cartilage is cut through the handle of the scalpel will strike the next below and prevent the blade from penetrating too far and injuring the lung. In young people the cartilages can be cut easily by one long stroke on each side, but care must be taken not to go too deep. If the intercostal muscles are not divided by the same operation, the sternum can be depressed by the left hand and the muscles severed by one pass of the knife on each side. The lower end of the sternum can now be elevated and freed from below upward from the diaphragm and pericardium until the first rib is reached. The cartilage of this rib is to be cut about 1 cm. farther out than the others, and from below upward toward the clavicle, with the handle of the knife beneath the elevated sternum and with the point and edge of the knife directed upward and a little outward. The sternum is then to be still further freed from the anterior mediastinal tissue until its upper end is reached. The sternoclavicular joint on the left side can now be easily opened from below by entering a scalpel just above the cartilage of