MEDICOLEGAL AUTOPSY
WILLIAM A. COX, M.D.
FORENSIC PATHOLOGIST/NEUROPATHOLOGIST
September 28, 2009
Forensic Pathology is the study of the physiologic processes that ultimately lead to death and the circumstances under which these processes were placed in motion. To accomplish this end it is implicit that a thorough external and internal examination of the deceased be undertaken.
Prior to commencing with the examination of the deceased it is essential the forensic pathologist has an understanding of the circumstances that lead to the death, which not only includes knowledge of the medical history, but the scene in which the body was found. In regard to the latter, the forensic pathologist should speak to the investigator that went to the scene as well as review any photographs taken. Should the death have involved response of a police department, they should be spoken to. Under certain circumstances it may be necessary for the forensic pathologist doing the autopsy to have gone to the scene; this is especially true in homicides, deaths of an infant or child, or any death in which the forensic investigator and or police officer have concerns at the scene.
In the death of an infant or child, a scene reenactment with use of a mannequin, either before or after the autopsy is highly encouraged.
The deceased should arrive at the medical examiner or coroner’s office exactly as it was found at the scene; no clothing, jewelry, etc should have been removed from the deceased. If the deceased has an article of clothing, etc. that was utilized in bringing about their death, i.e. belt, etc. about their neck, it should remain on the body as it was found. If a gun was utilized in bringing about their death, it should not be removed until the forensic investigator and or the forensic pathologist has seen the body and has photographed the scene. The forensic pathologist prior to doing the autopsy should examine all physical evidence at the scene that was or appeared to be related to the decease death. Prior to removal of the body from the scene, the temperature of the environment should be taken and if deemed necessary that of the body. This information is very helpful in determining time of death.
Upon arrival at the morgue the body should be photographed as it is before any clothing, jewelry is removed. Following taking the photographs, the clothing and jewelry should be examined as to how they are arranged on the body and their condition, i.e. stained with blood, feces, urine, gastric contents, grease, dirt, etc. noted. Pragmatically, this should be accomplished at the scene due to the fact in the removal of the body from the scene; the position of the articles of clothing and jewelry may have changed. Attention to such details as tears in the clothing, broken or lost buttons, whether the clothing is in the form of being properly worn or in a state of disarray and whether jewelry is complete and in proper position is important. All of these features should be described in the autopsy report. The clothing, jewelry and any other articles should be removed from the body, each being described and photographed with each placed in a separate plastic bag, being certain that the clothing is dry. All such bagged clothing, etc. should be placed in a large plastic bag, properly labeled and sealed. Any significant evidence on the clothing, such as tears, defects due to missiles or sharp objects should be described and photographed. If at all possible the clothing should be removed intact, without the aid of scissors or any other instrument. All defects in the clothing should be measured as to size of defect and where it is from accepted landmarks, i.e., collar, buttons etc. in inches. If projectiles are discovered in the clothing or body bag, their position should be documented, the missile photographed, and placed in an evidence envelope, then sealed and properly labeled noting name of the deceased, case number, date and time and where found in reference to the body. All pockets should be examined and their contents described and placed in a sealed plastic bag, which then is placed in a secure storage area.
External Examination
Following removal of the clothing the body is weighed and length is determined. If at all possible the weight of the body should be determined by scale and not estimated. If you have to estimate the weight, so state in your report. The length of the body should be given in inches. If you chose to use the metric system, give its equivalence in inches. Prior to commencing with the external examination identification of the body must be accomplished. If for whatever reason this cannot be accomplished at the moment, before the body is released from the morgue, it must be positively identified, however that is accomplished.
If it is apparent that death was by violent means, whether as the result of a homicide, suicide, motor vehicular accident, etc., CAT scans, MRIs, x-rays should be reviewed and or their reports. If prior to the body arriving at the morgue this was not accomplished then x-rays should be taken at the morgue. Knowing where a projectile is in the body prior to doing the autopsy is immensely helpful. If there are fractures of the extremities, etc., having a record of their site and the bones involved aids in the completion, value and thoroughness of the report.
Note the general condition of the body (well developed, well nourished, appearance consistent with known age), race, color of the skin. If it is apparent that the deceased is white, however, their skin hue suggest an individual not of European ancestry, it is helpful to further clarify their ethnicity, such as American Indian, Hispanic, middle eastern, central or south Asia. The deceased hair should be described noting the color, texture, straight or curly, distribution and length in inches.
The overall configuration of the head should be noted. In the normal person, the skull viewed laterally is of an oval shape, larger above than below, and wider behind than in front. In the infant note the condition of the fontanelles. The anterior fontanell (site of junction of the coronal and sagittal sutures, which is called bregma) normally closes by the age of 16 to 18 months. The junction of the sagittal and lambdoidal sutures is known as lambda, the site of the posterior fontanelle, which normally closes by the age of 1 or 2 months. Delayed closure of the fontanelles is frequently noted in hydrocephalus, congenital syphilis and cretinism. Bulging fontanelles suggest increased intracranial pressure. Sunken fontanelles are indicative of dehydration.
The average circumference of the skull measured on a plane with the supraorbital ridges and the occipital protuberance is 13 inches at birth, 18 inches at one year, 20 inches at 7 years, and 22 inches in adulthood. The circumference of the skull equals that of the thorax (just below the nipples) up to the age of 2 years. Premature closure of the cranial sutures (craniostenosis) may result in a small skull (microcephaly) or an abnormally shaped skull. A large skull is characteristic of hydrocephalus. In hydrocephalus, the fontanelles are bulging, and the bones of the skull have a “cracked-pot” sound on percussion (Macewen’s sign). An increased size of the skull is also characteristic of Paget’s disease; the forehead is prominent and the face is small (“acorn” skull). In acromegaly, the head and face are larger than normal, the supraorbital ridges prominent and the forehead receding.
Oxycephaly or “tower skull” is a vertically elongated skull with an increased vertical diameter and markedly reduced anterior-posterior diameter; it is seen in craniostenosis. Although rare today, in congenital syphilis, the frontal and parietal eminences are also prominent and the skull, when viewed from above, appears like a cross-bun. The prominence of the frontal and parietal bones is called the natiform bossings of Parrot and is due to the deposition of subperiosteal new bone.
A palpable hard tumor of any bone of the skull is suggestive of an osteoma. A metastatic carcinoma may produce nodular swellings.
A common cause of focal enlargement is a hematoma. A scalp wound that is gaping indicates the aponeurosis has been lacerated.
Small pumps in the occipital portion of the head may be due to enlarged lymph nodes or rheumatic nodules. Focal enlargements may also be due to epidermoid cysts, sebaceous cysts or lipomas.
Softening of the skull, which is called craniotabes, is detected by pressing on the skull behind the pinna. It occurs in osteogenesis imperfecta, hydrocephalus, congenital syphilis, and hyperparathyroidism.
If the hair has been dyed that should be noted. If the deceased has a mustache or any type of beard this should be described noting color and length. The hair in the axillae, on the trunk, pubic region and extremities should be noted. Absence of hair on the anterior chest of a male is called pectoral alopecia, which, although not necessarily abnormal, suggests the possibility of feminization that in turn may be related to cirrhosis or endocrinopathy.
If there has been an injury to the scalp and there is suspicion of a homicide, than hairs should be plucked and retained for possible later comparison.
The eyebrows should be examined noting any loss. As an example, there is a characteristic loss of hair over the outer third or more, on either side, in myxedema. Although uncommon today, in secondary syphilis, there is patchy or uneven loss of hair.
When examining the eyelids note any change in color, swelling, lacerations, contusions, etc. If the eyelid’s margins appear red and swollen this is indicative of inflammation and is called Blepharitis. Focal redness and swelling at the edge of the lid is referred to as a stye or hordeolum, which is due to an infection of Zeis’ glands or the sebaceous glands. A chalazion is on the inner surface of the eyelid, feels like a bead and is a granuloma of the Meibomian glands. Zanthelasma palpebrarum are single or multiple flattened yellow or orange plaques over the inner ends of the upper eyelids and less frequently over the lower eyelids.
Incomplete closure of the palpebral fissures can be seen in the deceased as a normal finding. However, it can be a reflection of short eyelids (lagophthalmos), eversion of the free edge of the eyelid (ectropion), exophthalmos (due to tumor, inflammation, thyroid disease or trauma), facial paralysis or large eyeballs.
Periobital ecchymosis is an important observation and is considered to be the result of a skull fracture until proven otherwise.
The eyes are than described noting the clearness of the cornea, color of the irides, the presence or absence of arcus senilis, position of the pupils, and their confirmation, i.e., size, equal, round, regular. A cone-shaped projection of the cornea is characteristic of keratoconus, an idiopathic degenerative disease. A corneal opacity is called a nebula if it is faint and cloud-like; a macula, if it is denser; and leukoma, if white and opaque. The presence of corneal arcus in a young person strongly suggests a disturbance in lipid metabolism. Small gray or yellowish nodules characterize Phlyctenular keratitis over the cornea. It occurs in malnourished children who have tuberculosis and less frequently in adults who had tuberculosis in childhood. Whitish plaques are indicative of deposition of calcium in the cornea and are referred to as Band keratitis.
The conjunctivae should be examined noting the presence or absence of petechiae, hemorrhage or jaundice. A faint blue tinge is common in anemia and debility. A pearly white sclera is seen in anemia. Deep blue sclera is pathognomonic of osteogenesis imperfecta. The eyeballs should be palpated to determine whether prosthesis is present. This simple examination can elevate much embarrassment in the future.
The initial examination of the oral cavity should include the lips. Generalized swelling of the lips is suggestive of angioneurotic edema. Localized swelling may occur as the result of inflammation, trauma, insect bite, carcinoma or corrosive poisoning. Thick lips may be racial, artificially induced, or the result of acromegaly, myxedema or macrocheilia (permanent swelling of the lips that results from greatly distended lymphatic spaces). Thinness of the lips may be racial (American Indians) or familial characteristic. The color of the lips is an important observation to note. The lips may be purple due to peripheral or central cyanosis or to methemoglobinemia. Pale lips are a sign of anemia.
The oral cavity is examined for the presence or absence of teeth and if present the condition and number. The permanent teeth are thirty-two in numbers and consist of four incisors, two canines, four premolars or bicuspids, and six molars in each jaw. Teeth, which show evidence of being loose, recently dislodged by hemorrhage in the alveolar sockets, chipped or broken, should be described. Pitting of the teeth may occur as a result of excessive fluorine; a peculiar oval shape notching of the biting edges may affect the first permanent molars (mulberry molars). The teeth may be widely spaced as in acromegaly or hyperparathyroidism or commonly following extraction. Precise charting of the teeth for identification should be reserved for the Forensic Dentist or Dentist.
The gums should be examined as feasible. A black line along the gingival margins when teeth are present suggests deposition of bismuth or lead sulfide. Dilantin may give rise to swollen gums. There may also be a lesion projecting from the gums or peridental structures (epulis).
If it is possible observe the buccal mucous membrane. A pale brown or gray patches of pigmentation suggest adrenocortical insufficiency, however, similar pigmentation may occur as the result of heredity or heavy metal intoxication. Fordyce’s spots are small yellowish-brown slightly raised spots due to normal sebaceous glands.