CHAPTER IV.
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 H2S; 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.