Complete Text (Part 4)

mat- ters, all of which have this in common, that they stain the protoplasm (especially the nuclei), either exclusively or at any rate more deeply than the intercellular substance. Methyl- aniline is a very convenient coloring matter on account of the rapidity with which it acts, and in an aqueous solution of one to one thousand stains the nuclei of the cells a beautiful blue in a few minutes. The fact that it stains bright red those tissues which have undergone amyloid degeneration, adds to its value. After removal from this staining fluid the prepara- tion should be washed and then examined, in either water or a concentrated solution of potassic acetate ; the color fades rapidly in glycerine. Hcematoxyline is also a valuable color- ing matter. The following formula for its preparation is that recommended by E. Klein : — Eub together thoroughly 5 grams of the officinal extract of haema- toxyline and 15 grams of powdered alum in a mortar, adding gradu- ally 25 cubic centimeters of distilled water ; filter and add to the filtrate 5 grams of alcohol. Rub the residue again in a mortar with 15 c. c. of water, which should be added gradually, and add, after filtering again, 2 grams of alcohol to the filtrate. Mix the two fluids, and preserve in a well stoppered bottle. If it become turbid filter again. For use put sev- eral drops into a watchglass full of distilled water. After straining put the preparations for some minutes into distilled water and examine in pure glycerine or a solution of potassic acetate. The inconvenience of hsematoxyline is that the color is decomposed by the presence of the smallest quantity of any acid, while though acetic acid destroys the above mentioned aniline color, a preparation may be restained in it even after 8 DIAGNOSIS IN PATHOLOGICAL ANATOMY. it has been boiled in glacial acetic acid. Carmine is not af- fected by acids at all, but is not so well adapted for rapid tingeing, as it then stains the interstitial tissue somewhat, as well as the protoplasm. A neutral solution of carmine may. be prepared by rubbing powdered carmine with an equal amount of concentrated aqua ammonia, and leaving tlie mixture exposed to the air in an open glass till it has become perfectly dry. Then dissolve the resulting powder in a quantity of dis- tilled water equal to three times the original mixture, filter, and add one gram of carbolic acid for every hundred cubic centimeters of the so- lution as a preservative (Ranvier). This strong solution may be diluted before using if desired. After staining in carmine, preparations should be washed in water, then put for a few minutes into a one per cent, so- lution of acetic acid, and examined in glycerine or potassic acetate. EXAMINATION OF THE BODY. Two grand divisions may be made of every autopsy : — A. External examination or inspection. B. Internal . examination or section. A. INSPECTION. In medico-legal cases, especially, this may yield impor- tant information, — as to the time when death occurred, the manner of it, etc., — but in purely pathological cases the external appearances are, as a rule, of very subordinate in- terest. It scarcely lies within the scope of this compend to treat exhaustively those conditions which are important solely from the point of view of legal medicine, and the reader is therefore referred for the discussion of such to the text- books of medical jurisprudence, while we propose to confine ourselves to those points which are of importance in patho- logical as well as in most medico-legal cases. Inspection may be general or special ; general as applied to the condition of the body as a whole, and special as ap- plied to the condition of its several parts. I. INSPECTION OF THE BODY AS A WHOLE, (a.) GENERAL ATTRIBUTES OF THE BODY. Under this head may be included age, sex, stature, frame, general nutrition, and general character of the skin. The frame may be powerful, feeble, delicate, deformed, 10 DIAGNOSIS IN PATHOLOGICAL ANATOMY. etc. ; if deformed, rachitis is generally the cause. The degree of general nutrition is indicated by fullness and roundness of form or their absence, and by the degree of prominence and thickness of the muscles. Emaciation may be dependent on either of two conditions : 1st. On atrophy of the fatty layer of the skin, in which case the integument is loose, and can everywhere be raised up in large thin folds. If a fold be rolled between the fingers it is easy to appre- ciate by the sense of touch the amount of subcutaneous fat. It is also evident that the thinner the integument the more sharply will the contour of the muscles be defined. 2d. On atrophy of the muscles, in which case they are thin and slender, their contours are ill-defined, the prominence of the biceps and the calf of the leg have disappeared, etc. Of course both these forms of atrophy are very often associated, and, indeed, in many wasting diseases but little more than skin and bones are left. In raising a fold of skin we can also determine its tension and elasticity ; the former is in an inverse ratio to the length of the uplifted fold. If the elasticity be normal the fold will resume its former position as soon as it is released ; sometimes, in those dead of cholera, for example, it does not do this. The general color of the skin should also be noted, and this can be properly done only when the body is clean. The usual color is pale grayish white, and is most marked on those parts of the body which have been protected by clothing. Those parts which have become browned by exposure to light and air during life remain so after death, and one sometimes meets with individuals, generally from the lower classes of society, in whom this is so marked and so widely extended over the neck aiid chest, that one is almost in dan- ger of confounding it with that bronzed hue of the skin which is so prominent a feature in Addison's disease. This latter hue, however, extends over the whole body, and is especially marked on the belly, while if the brownish color be due to atmospheric influence, such is not the case. It may as well be incidentally mentioned here that the bronzing of the INSPECTION. 11 skin, even if it extend to the mucous membrane of the mouth, does not point with absolute certainty to disease of the supra- renal capsules. These bodies may be diseased and the skin not bronzed, and the reverse. The coloring matter of the bile gives rise to a uniform pale yellow (lemon color) dis- coloration of the skin (icterus)^ which is usually most marked in the face and on the forehead. If the jaundice be of long duration and very intense, the discoloration may be dark yel- low or even nearly black (icterus melas). A waxy pallor of the skin indicates ancemia or oligcemia.) either acute (from loss of blood) or chronic. A clayey tinge is associated with various cachexias, such as carcinoma, etc. ; and a peculiar dirty grayish hue, especially on those parts which have been exposed to the sunlight, occurs in those who have been tak- ing the salts of silver for a long time (argyria). (5.) SIGNS OP DEATH AND DECOMPOSITION". Those changes of color in the skin which result from de- composition, naturally lead to the consideration of the signs of death and commencing putrefactive change, and are of im- portance in all cases on account of the light which they throw on the condition of the internal organs. In medico-legal eases their importance is still greater. Two different kinds of discoloration are to be carefully distinguished from each other : 1st. A greenish discoloration which is due to decom- position in the tissue, and first appears in those situations where the viscera lie nearest the surface, at the sides of the belly, the intercostal spaces, etc. 2d. That light or dark red, faded red, or livid discoloration which occurs in underly- ing portions of the body in discrete spots (suggillations), or more or less uniformly diffused over the body, and is due to blood. These spots, again, may be divided into two classes ; those which depend on simple gravitation of the blood within the vessels (hypostasis., hypostatic spots^, and those which depend on diffusion of the coloring matter of the blood in the vessels into the surrounding tissue. These conditions are readily distinguishable. If the discoloration be due merely 12 DIAGNOSIS IN PATHOLOGICAL ANATOMY. to gravitation it disappears on pressure, but if it be due to diffusion of the coloring matter of the blood, though origin- ally less distinct, it does not disappear. Dull livid streaks, which are due to diffusion of the coloring matter of the blood from the larger cutaneous veins, indicate a high degree of the latter condition. Sometimes the whole venous cutaneous net- work is thus mapped out, as it were. In the usual position of the body these discolorations appear first and most mark- edly on the back and neck ; but they appear first on the chest, neck, and face, if these parts happen to have been undermost. This fact should be borne in mind to avoid the error of con- sidering a normal post-mortem appearance to be of cyanotic or pathological nature. In medico-legal cases these post-mortem discolorations (which never give rise to elevation of the surface) should al- ways be incised, to avoid the risk of confounding them with extravasations of blood. In the hypostatic form fluid blood from the small vessels which are severed appears on the cut surface of the undiscolored tissue ; diffusion of the coloring matter of the blood is indicated by diffuse redness which per- sists even after pressure ; while extravasation, which more often causes slight elevations of the surface, is shown by the presence of blood, whether fluid or coagulated, in the tis- sue itself, more or less of which blood can generally be re- moved. The more fluid the blood in a body (as in cases of suffocation, of the acute infectious diseases, etc.), the more numerous and extensive are the post-mortem discolorations. Cadaveric rigidity is another important sign of death. It appears first in the muscles of the jaw, gradually progresses from above downwards, and disappears in the same sequence. The more robust the individual and the shorter the duration of the disease, the more marked and persistent is this mus- cular rigidity, which attains its maximum in cholera. The sharply defined and thick bellies of the muscles, the contrac- tion of which can scarcely be overcome, combined with the cyanotic hue of the skin, enables us to recognize this disease from a distance. Cadaveric rigidity disappears earliest in INSPECTION. 13 those dead of a disease attended by hectic. After having been forcibly overcome it does not reappear. II. INSPECTION OF THE SEVERAL PARTS OF THE BODY. In examining the several parts of the body, one should be- gin with the head, and then take up in order the neck, the chest, the abdomen, the surface of the back, the anus, the external genital organs, and, finally, the extremities. In medico-legal cases special regard must be paid to the possible presence of foreign bodies or substances in the natural outlets of the body, the condition of the teeth, the condition and situation of the tongue, and, finally, the presence of injuries. Evidences of suppuration, of the formation of granulations or cicatricial tissue in a wound, the presence of gaping edges with adherent coagulated blood, warrant with more or less certainty the conclusion that the wound occurred before death. Further changes to be noted are : — (a.) Modifications of Size and Form, — Under this head are included distention and retraction of the abdomen, also swelling, especially of the extremities, due to oedema of the skin and subcutaneous cellular tissue. The latter is made evi- dent by the doughy consistency of the parts, and the fact that they pit on pressure. On section the fatty tissue is flabby and infiltrated with clear fluid, which gradually collects more and more in the lowest part of the cut ; if the cedema has ex- isted for a long time the connective tissue is white and thick- ened. It is noteworthy that in trichinosis, where an oedera- atous swelling exists in the neighborhood of striped mus- cular fibre, there is no oedema of the external genitals, which become so extensively oedematous in other affections. Be- sides the relative proportion of the parts in general, that of the skin and its component parts are also to be noted. The epithelium and the true skin, one or both, may be either thickened or atrophied, and an idea of their relative propor- tion is to be obtained by incisions in several places. (6.) When noting the color of a part it must be borne 14 DIAGNOSIS IN PATHOLOGICAL ANATOMY. in mind that when the color of parts depends on the amount of blood in the vessels, they generally lose it after death in great measure. Yet the bluish or livid hue of the nose, lips, ends of the fingers, etc., called " cyanotic," which depends on venous stasis, and is generally associated with dilatation of the vessels, is usually quite distinct after death. The presence of changes due to extravasation of blood should be carefully noted. Sometimes these are of large extent (trau- matic), sometimes small or even punctate (purpura haämor- rhagica, acute hgemorrhagic exanthemata, ulcerative endocar- ditis). When post-mortem discoloration can be excluded, indistinct redness of the skin points to extravasation before death, while a yellowish or greenish yellow zone around an extravasation (partial hgematogenous icterus) shows that it is of some standing. A brownish discoloration, especially when occurring in nu- merous small, scattered spots, is generally the result of cir- cumscribed inflammatory processes, and hence is often met with near scars — in connection with ulcers of the leg, for instance ; or else it is congenital, as in pigmentary n«vi. White cicatrices are also met with ; their effect is striking in proportion to the degree of pigmentation of the rest of the skin (in Addison's disease, for example, they are very con- spicuous) ; irregular white spots (partial albinismus) are sometimes met with, especially on the genitals. III. INSPECTION OF NEW-BORN CHILDREN. It being often of the utmost importance to decide as to the viability and period of development of a new-born child, we will now take up systematically the points which aid in the solution of these questions, and which have not already been mentioned. The average leiigth of new-born children at full term is 50-51 cm., the figures being rather larger for boys than for girls. During the last five lunar months of foetal life the length in centimeters is five times the number of the lunar month which the child has reached in its development (at the INSPECTION. 15 sixth month 5x6= 30, at the eighth month 5x8 = 40, etc). The average weight of boys at full term is 3,300 grams, that of girls, 3,250 grams. The normal skin is firm and somewhat on the stretch, not wrinkled ; its color is no longer red but white, and it is more or less covered with light downy hairs. At full term this down is chiefly marked on the shoulders. The umbilical cord, the average length of which is about 48—56 cm., is inserted somewhat below the middle, of the body and falls off from five to eight days after birth. The head should be examined with great care. The length of the hair should first be noted : at full term this is generally 2—3 centimeters. Next the size of the fontanels ; the anterior or great fontanel measures 2-2.5 cm. in length at full term. Next come the different measurements of the head — the circumference of the head, 34.5 cm. ; the longi- tudinal diameter from the glabella to the occiput, 11.5 cm. ; the anterior transverse at the end of the coronal suture, 8 cm. ; the posterior transverse at the eminences of the pari- etal bones, 9 cm. ; the long oblique, from the chin to the high- est point of the occiput, about 13.5 cm. ; the short oblique, from the anterior border of the nape of the neck to the far- thest point of the forehead (inexact), about 9.5 cm. Then the eyes should be examined, the pupillary membrane disappear- ing about the commencement of the eighth lunar month. The cartilages of the nose and ears are hard to the touch at full term. The finger nails are hard and horny, and project somewhat beyond the end of the fingers. The width of the shoulders should also be measured (11 cm.), and likewise the distance from one trochanter major to its fellow (9 cm.). Finally, the genitals should also . be examined. The testicle descends into the scrotum during the seventh month, and at full term both testicles should occupy the wrinkled scrotum. In girls at full term the labia majora are generally long enough to hide the clitoris and labia minora, though this is not always the case. (We shall speak of the examination of the centre of ossification of the femur under the head of Bones of the Extremities.) 16 DIAGNOSIS IN PATHOLOGICAL ANATOMY. IV. MORBID COKDITIONS OF THE SKIN AND SUBCUTANEOUS CELLULAR TISSUE. Before entering on the consideration of morbid conditions of the skin and subcutaneous cellular tissue, we must state that we do not consider it to lie within the scope of this work, which is only a corapend of diagnosis in pathological anatomy, to treat exhaustively all those diseases of the skin which may be met with in the dead body, but which are