not to be separated from its surroundings by a cutting instrument, as it is liable to be wounded in so doing, but should be isolated more in accord- ance with the method employed in ligating arteries in the living subject, by the use of a director, scalpel-handle, or forceps. The duodenum is to be tied in two places in a similar manner, below the entrance of the gall duct, and preferably at the end of the descending portion. Care must be taken here also that the ligatures are situated at a certain distance from each other (two to three centimeters), otherwise they may be easily cut or may slip off, when the intestine between them is cut through. <Callout type="warning" title="Ligature Placement">Ensure ligatures are spaced correctly to avoid cutting or slippage.</Callout> The stomach is then to be removed in connection with the duodenum, all possible injury to them being carefully avoided. They are opened in the usual way. After the contents have been examined in the manner already mentioned, they are to be put into a glass or porcelain vessel, in which the stomach and duodenum are also placed after being further examined. The Regulations give the following detailed directions concerning the examination : <Callout type="important" title="Mucous Membrane Examination">Examine mucous membrane for thickness, color, surface, consistency, blood-vessel condition, and texture.</Callout> The mucous membrane is to be washed off, and examined with regard to its thickness, color, surface, and consistency, special attention being paid at the same time to the condition of the blood-vessels and the texture of the mucous membrane, and every part is to be noted separately. It is very necessary to determine whether the blood which is present is within the vessels or outside of them, whether it is fresh or altered by putrefaction, or softening (fermentation), and in this condition has infiltrated (been imbibed by) the neighboring tissues. If the blood has escaped, whether it lies upon the surface or within the tissue, whether it is coagulated or not, etc. <Callout type="risk" title="Post-Mortem Decomposition">Be aware that post-mortem changes may mimic natural disease processes.</Callout> Finally, particular attention is to be paid to the continuity of the surface, with reference to the presence of losses of substance, erosions, or ulcers. The remainder of the examination is made in the usual manner, except that the oesophagus is ligated 'near the neck' before being taken out, and is then cut off above the ligature and put in the vessel containing the stomach. In those cases where the stomach contains but little, the contents of the jejunum are also put in the same vessel. <Callout type="tip" title="Oesophagus Handling">Ligate oesophagus near the neck to prevent contamination.</Callout> Finally, other substances and parts of organs, as blood, urine, pieces of liver, kidney, etc., are to be removed from the body, and given to the legal authority for further examination. The urine is to be kept in a vessel by itself, and the blood also in those cases where it may be possible to draw important conclusions from a spectrum analysis. All the other material is to be put in one vessel.<br><br>2. Changes produced in Poisoning. The substances which commonly cause poisoning may be divided into two classes, according as they do or do not corrode the surface. The two act differently, the former by causing a direct lesion of the mucous membrane, the second by entering the blood, and thus causing changes in different organs, which are injurious only secondarily. To the first class belong the alkalies, a great number of mineral acids, as sulphuric, hydrochloric, nitric, and also a few vegetable acids, as oxalic, etc. To the second group belong phosphorus and arsenic, substances which produce marked anatomical changes in the organs, and the alkaloids, hydrocyanic acid, etc., which do not cause any appreciable changes, death being caused by the effects upon the nervous system.<br><br>(a.) The changes produced by the substances belonging to the first group vary considerably according to the nature of the substance ; still the differences are not so great, as was formerly supposed, especially when the effects are produced by large quantities. The alkalies cause a marked swelling of the mucous membrane, and later of the submucous tissue and muscular coat also, which become converted into a soft, greasy, brown or blackish mass. The acids^ on the other hand, especially nitric, when their action is not intense, first produce a parchment-like induration of the surface of the mucous membrane, of a yellowish, brownish, or blackish color. This, however, becomes converted after continued or very intense action, into a brown or black pulp, very similar to that produced by alkalies. The muscular layer of the oesophagus and stomach is strongly contracted, so as to diminish greatly the size of the lumen and to throw the mucous membrane into folds. As may be readily understood, the changes are most marked in those places where the substance remains longest in contact with the surface, consequently the effects are found to be only slight in the mouth and oesophagus, and along the lesser curvature of the stomach, and between the very prominent folds produced by the strong contraction ; on the other hand, they are the most intense at the fundus, and along the tops of the folds. It not unfrequently happens that the action is so intense at the fundus that the whole thickness of the walls is found softened and perforated.<br><br>An opposite condition of things may occur, especially when there is but a small amount of fluid taken, for this may run along the lesser curvature as far as the pylorus, where its further progress is obstructed, and consequently its effects greatest. On account of the slight intensity of the poisoning, the individual lives longer, so that at the autopsy, only ulcers, or even firm cicatrices, which may cause more or less stenosis, are found. In the most severe cases of poisoning, the blood in the gastric veins is very often altered in such a manner as to be converted into a black mass, that is often quite firm, and distends the vessels. The effects of the substance are not confined to the digestive tract, but constantly extend to the contiguous organs, within which the blood contained in their vessels undergoes the above change. The spleen, liver, heart, and left lung, are the organs most frequently affected.<br><br>(5.) The condition produced by poisoning with phosphorus or arsenic is entirely different. Here there is absolutely no trace of deep corrosion, and even inflammatory hyperaemia and haemorrhages are only met with when death has been sudden. Of course it is not intended to state that no ulcerative process can then arise, though if produced it is the result of accompanying circumstances (for instance, pieces of matches swallowed at the same time, vomiting, etc.). The changes produced are parenchymatous inflammation of the liver, kidneys, heart, and stomach, all of which have been or will be considered under their respective heads. Poisoning by arsenic may often be diagnosticated by a portion of the poison appearing in the mucus in the form of a white deposit, which is found under the microscope to be composed of octahedral crystals.<br><br>7. EXAMINATION OF THE LIGAMENTUM HEPATO-DUODENALE. Before removing the liver from the body the ligamentum hepato-duodenale, together with the ductus communis choledochelius and portal vein, are to be examined.<br><br>(a.) The Common Bile-Duct. The bile and pancreatic ducts have a common opening in the posterior wall of the duodenum at a point where there is a slight projection (longitudinal fold), the papilla of the gall-duct. In order to find the opening quickly, the head of the pancreas, which is easily felt, is to be sought for, the intestine stretched out transversely, and the papilla will be seen situated just below the middle of the head. The next step is to see whether the duct is pervious in its whole extent, more especially in the duodenal portion, the stoppage of which by catarrhal secretion gives rise to the so-called catarrhal icterus. In order to determine this latter point the gall-bladder must not be pressed upon, as the force thus produced is too great, and no conclusions can be drawn as to the condition during life ; but the duct itself is to be pressed upon in a direction towards the intestine to see if the bile is forced through. While this is being done the papilla is to be carefully watched, as the plug, composed principally of desquamated epithelium, which closes the duct is often very small, and therefore liable to be overlooked. After this part of the examination is completed, the gall-bladder is to be pressed upon to see if the duct is pervious throughout its whole extent, and then a probe is to be introduced (care being taken at the same time to introduce it into the pancreatic duct), and the duct slit open with the scissors. The size of the duct is to be observed, the color of its surface, and its other conditions. The normal size is about that of a small goose-quill. Under pathological conditions it may attain that of a large finger. The usual cause of this dilatation is the presence of gall-stones, and, consequently, when it exists one may conclude with tolerable certainty that gall-stones were present here for a long time, although they may not be found at the autopsy. The color of the surface is of great importance in determining the point whether bile flowed through the duct during life or not, or how far it was possible for it to advance. When an obstruction existed at any point, only that portion posterior to it is colored with bile, the lower portion being uncolored ; in this connection the amount of coloring caused by the bile in the oblique extremity of the duct, the portio duodenalis, which passes through the intestinal walls, is of great importance in the recognition of simple catarrhal icterus. Among the remaining alterations of the surface are the ulcers., which are also most frequently caused by gall-stones. They are usually situated at those points where the stones are wedged in, i.e. at the entrance of the duct into the intestine, also in front of the portio duodenalis. A perforation of the walls of the duct and of the intestine may be caused at this point by ulceration, so that there will be two openings leading into the small intestine, a large one produced by the ulceration and extending perpendicularly through the wall, and a smaller passing through obliquely — the physiological duodenal portion of the duct. The former opening may become obliterated after the gall-stone or stones have been discharged. In such a case it is still possible to judge of the previous conditions by the dilatation of the duct, and by the cicatrix at the above-mentioned point. Complete closure of the common gall-duct may result from ulceration, or rather from the cicatrix produced by it, and usually occurs also in the duodenal portion. Purulent and diphtheritic inflammations are very rare here, though they occasionally occur in diphtheritic dysentery, typhoid fever, etc. ; tumors are also exceptional, though small papillary growths of the mucous membrane are sometimes seen near the orifice of the duct.<br><br>(b.) The Portal Vein. Another very important structure lies within the ligamentum hepato-duodenale, viz., the portal vein, which is easily found behind the common duct. The surface and surroundings of the vessel are first to be examined, as very important inflammatory changes (periphlebitis portalis') are sometimes found here. These are either acute and purulent (periphlebitis apostematosa) or chronic, with a resulting formation of fibrous tissue and contraction of the same (periphlebitis chronica fibrosa). The acute forms especially are usually continued from the neighboring parts, and when this is the case they too must be carefully examined. The trunk of the vessel is then to be opened throughout its whole length, that the condition of its walls and contents may be examined. The walls may be somewhat contracted in parts, owing to chronic periphlebitis, in consequence of which the canal is narrowed, whilst, on the other hand, it may be dilated and the walls rendered thinner. The condition of the contents is most important ; they may consist of liquid or clotted blood, which may be variously altered, and of pus or morbid growths. Simple thrombosis is sometimes found in connection with cirrhosis of the liver, as a result of pressure from tumors, etc. Softened thrombi, or those mixed with pus, occur associated with inflammation of the wall (thrombophlebitis'). These conditions usually commence at the roots of the portal vein ; they are most common in new-born infants, in consequence of thrombophlebitis of the umbilical vein, but often occur in adults, as a result of disease of the intestine, especially in cases of perityphlitis. A purulent periphlebitis may also lead to secondary thrombosis and perforation of the wall with the escape of pus into the canal, where it becomes mixed with the softened thrombus. Cancerous masses sometimes perforate the wall from without and grow in the vein, thus acting as a cause for the formation of a thrombus.<br><br>8. THE GALL-BLADDER AND LIVER. After completing the examination of the common gall-duct and portal vein, which is carried as far as possible while they are in situ, the relation between the liver and gall-bladder and their surroundings is to be determined, if this has not already been fully ascertained. The liver is then to be removed from the body for further examination, the method of its removal being dependent upon the conditions present (adhesions from gastric ulcers, pericystitis felleae with perforation, fistula, etc.). The removal is best accomplished by raising the side of the right lobe and separating all the attachments, as far as the middle of the spine, so that the lobe may be laid over the edges of the ribs of the same side ; the left lobe is then to be raised and the remaining attachments separated. In so doing it is not necessary to exercise great care, as there are no important organs here which have not been already examined. If there are very extensive abnormal adhesions between the liver and diaphragm, the latter is also to be removed at the same time, and it is always well to do this whenever tuberculous or cancerous nodules are situated upon the peritoneal covering of the diaphragm, as they usually hold a very important relation to the surface of the liver.<br><br>(a.) The Gall-Bladder. The exterior is first to be examined, and subsequently the interior of the gall-bladder.<br><br>1. External Examination.<br><br>(a.) General Appearances. The size (distention) depends essentially upon the quantity of the contents, and consequently may vary under normal conditions very considerably ; an increase or diminution in size may, however, result from pathological causes. Enlargement arises from an increase in the contents, and is therefore due to closure of the cystic duct. A diminution in size, which sometimes becomes extreme, may depend upon many different causes ; as chronic fibrous inflammation with contraction, cancerous degeneration (scirrhus), etc. The color of the external surface is usually light or dark yellow, reddish- or greenish-yellow ; a gray or even white color results from thickening of the capsule, or from alteration of the contents. In the latter case the bladder is enlarged, in the former usually diminished in size. Blood-vessels are generally seen in very small numbers, and are most apt to be found at the part where the bladder is in contact with the liver. They are more numerous in inflammatory affections, especially in those of the serous covering (peri-cystitis), and the color is, consequently, more or less red. The consistency depends upon the degree of fullness and the condition of the walls. The greatest distention occurs in closure of the duct ; a tough consistency, in the absence of the previous condition, arises from fibrous thickening of the walls.<br><br>(b.) Changes in the Serous Covering of the Gall-Bladder. The changes of the serous coat are mostly of an inflammatory nature. The most frequent forms are chronic, and are, in part, simply fibrous, and in part adhesive (pericystitis chronica fibrosa and adhesiva). Adhesions between the colon and fundus of the gall-bladder, are very commonly met with ; they also occur between the fundus and the abdominal wall, and also other parts. Acute inflammations of this coat and the immediate surroundings (excepting in cases of general peritoneal affection) proceed from the gall-bladder or the neighboring parts, especially the transverse colon, or they occur without any apparent anatomical cause. They generally present an ichorous character (pericystitis ichorosa or gangrenosa), since they are often associated with perforation either of the intestine or gall-bladder. The pericystitis resulting from perforation is usually due to dysenteric processes, or cancer in the colon, to calculi in the gall-bladder, which cause ulceration and perforation, or to other ulcers in this organ (typhoidal, etc.). All perforations of the gall-bladder, however, do not extend from within outwards, but some proceed from without inwards, in consequence of pericystitis. The direction which the perforation has taken may be determined here, as elsewhere, by the greater extension of the ulceration upon the mucous membrane or upon the serous coat. A general peritonitis results when perforation takes place from within, before adhesions to the neighboring parts have been formed. If adhesions between the gall-bladder and colon or abdominal walls have arisen before the perforation occurs, of course the pericystitis does not extend.
Key Takeaways
- Properly ligate and examine stomach and intestines to diagnose poisoning effects
- Examine mucous membrane for signs of corrosion or inflammation
- Recognize the differences in changes caused by alkalies vs. acids
Practical Tips
- When examining organs, ensure they are properly isolated to avoid contamination.
- Use a scalpel-handle or forceps when ligating arteries to prevent accidental injury.
- Carefully note any ulcers or erosions on the mucous membrane as signs of poisoning.
Warnings & Risks
- Be cautious with handling organs to avoid cutting through them, especially in cases where they are inflamed.
- Post-mortem changes can mimic natural disease processes and must be accounted for.
- Do not overlook the importance of examining the serous coat for adhesions or inflammation.
Modern Application
While many of these techniques have evolved with modern medical practices, the principles of careful examination and identification of poisoning effects remain crucial in forensic science and emergency response. Understanding these historical methods can provide valuable context and a deeper appreciation for current protocols.
Frequently Asked Questions
Q: How should I handle organs during an autopsy to prevent contamination?
Handle organs carefully, using tools like scalpel-handles or forceps when ligating arteries, and ensure they are isolated from their surroundings. This prevents accidental injury and contamination.
Q: What signs on the mucous membrane indicate poisoning with alkalies or acids?
Alkalies cause a marked swelling of the mucous membrane, which later turns into a soft, greasy mass. Acids produce a parchment-like induration that can turn into a brown or black pulp under intense action.
Q: How can I determine if there has been poisoning with phosphorus or arsenic?
Look for changes in the liver,