autopsy internal examination, forensic medicine, post-mortem examination
DESCRIPTION
Deals with the post-mortem examination (autopsy) particularly the internal examinations of the various organs based on Virchow's technique of organ removal.TRANSCRIPT
AUTOPSY: INTERNAL EXAMINATION
Aishwarya SinhaVI SemesterForensic Medicine – PBLCMS - TH
INTERNAL EXAMINATIONIt consists of:
1. Incising the body2. Inspecting the various organs3. Examining the cavities systematically4. Weighing and measuring the organs5. Checking for any pathology6. Putting all the organs back in and padding7. Suturing the body
SKIN INCISIONS1. ‘I’ shaped Incision: It is a straight line incision extending from the chin to the symphysis pubis.
2. ‘Y’ Shaped Incision: This type of incision starts near the acromian process and progresses downwards towards the xiphoid process. The incision is then extended till the symphysis pubis. Also, a similar incision is made on the opposite side of the body.
3. Modified ‘Y’ Shaped: A ‘Y’ shaped incision is made from the suprasternal notch to symphysis pubis. It extends from the suprasternal notch over the clavicleto its center on both sides and passes upwards over the neck, behind the ear.
REMOVAL OF ORGANS1. Virchow’s Technique: Head Thorax
Abdomen
2. Rokitansky’s Technique: in situ dissection in parts combined with en block removal.
3. Letulle’s Technique: Cervical Thoracic Abdominal Pelvic Organs Removed en masse and dissected as organ block.
ORDER OF EXAMINATIONVIRCHOW’S TECHNIQUE
Head
Thoracic (Cervical)
Abdominal Organs
HEAD• The neck is extended by placing a wooden
block under the shoulders.• Fix head using a head rest.• Intermastoidal incision is made i.e. from
the mastoid process behind one ear to the vertex and again to the mastoid process of the other ear.
• Scalp flap is reflected forward to the superciliary ridge and backwards to the occipital protuberance.
HEAD• With the help of a saw, ‘V’ shaped cut is made
so that the skull fits back correctly after autopsy.
• This ‘V’ shaped cut passes through: the center of the forehead base of the mastoid process occipital protuberance the base of the other mastoid process and back to the center of the forehead.
CAUTION• Care must be taken to avoid any damage to the
meninges or the brain during the process of skull removal.
• Therefore, chisel and hammer should never be used.
• Instead, a chisel should be inserted and twisted at various points in order to remove the skull flap.
• By doing so, superior longitudinal sinus can be exposed.
BRAIN
• Dura is incised along the lines of the incision of the skull folded to the midline falx cerebri is freed from the cribriform plate dura is pulled back.
• 4 fingers of the left hand are inserted into the frontal lobe and the nerves and vessels are cut.
• Tentorium is also cut along the posterior part of the petrous bone.
BRAIN• A knife is then inserted into the occipital foramen
and the cervical cord cervical nerves and the vertebral arteries are cut as far as possible.
• With the right hand the cerebellum is grasped and examined.
• Any signs of hemorrhage, injury or any other disease should be carefully seen.
• Vessels, especially the Circle of Willis, should be checked for any arteriosclerosis or aneurysm etc.
FIXATIONBrain will start to deteriorate as soon as the blood supply is interrupted. This deterioration is rapid and therefore, it is of utmost importance to arrest this procedure.This process of preservation of the brain is called fixation.There are 2 main methods of fixation:1. Freezing2. Prefusion
FIXATION OF THE BRAINBrain is fixed in 10% formalin for
at least 1-2 week(s).To help with the penetration of the
preservative, lateral fissures are made through, which tear open the pia and the arachnoid mater.
A long sagittal cut is made through the corpus callosum so as to allow the formalin to pass into the ventricles.
AFTER FIXATION Brain is placed on a board and the
cerebellum along with the pons and the medulla are removed.
Straight cut is made to expose the fourth ventricle.
Thereafter an oblique cut is made to expose the dentate nucleus.
Entire stem is sectioned at a few millimeters distance and examined for any pathology.
Cerebellum is examined by making a series of sagittal cuts beginning from the frontal pole passing backwards to the occiput.
Sequentially cuts are made and serially placed aside in the same order for later identification.
SPINAL CORD• Not examined unless there is an indication.• In prone position, wooden block is placed
under the chest and the head is bent downwards.
• Mid-line incision from the occipital protuberance to the L4 vertebra is made.
• Muscles are dissected all the way.• Atlas is disarticulated.• With the help of a double bladed saw, the
laminae are sawed through the entire length and separated by a chisel.
SPINAL CORD• Dura is cut open and checked for
haemorrhage, inflammation, tumours, pus etc.
• Nerves are cut from below as they pass though the spinal formaina.
• And the cord is separated from the foramen magnum.
• Cord is then sectioned transversely and serially.
• Lastly, the vertebral column is examined for any fractures or dislocations.
THORAX
• Chest muscles are dissected away.• Chest is opened by cutting the costal cartilages with
the help of a cartilage knife.
• In case of elderly subjects, the costal cartilage may be calcified, hence, a bone saw or a rib shear is used to cut it out.
• Thereafter, both the sternoclavicular joints are disarticulated and the chest is opened.
HEART Held at the apex and lifted
upwards so that the pulmonary vessels, SVC & IVC and the ascending aorta can be examined.
The pulmonary artery is palpated and then the vessels are cut open.
Pericardium is incised and examined for any blood or fluids.Heart, opened in the direction of the blood flow i.e. (Inflow-outflow method).
HEART The enterotome is inserted into the: RA Tricuspid valve RV Pulmonary Trunk
Pulmonary vein LA Mitral Valve LV Ascending aorta.
Both the auricular appendages are examined for thrombi.
Heart should eventually be weighed and the various measurements of the circumference of the valves or the thickness of the ventricles etc. are taken.
CORONARY ARTERY Examined by making serial cross sections to check
for ante mortem clots. To check for infarction and fibrosis, muscles of the
right and the left ventricles are incised.
SUBENDOCARDIAL HAEMORRHAGE: Flame shaped, confluent, patchy, haemorrhages
may be seen in the LV on the left side of the inter ventricular septum.
Seen in severe hypotension, intracranial damage, death due to ectopic pregnancies, arsenic poisoning etc.
LUNGS• Anterior surface is faced upwards PA
is identified and cut as far as possible using small scissors check for atherosclerosis, thrombi or emboli.
• Steps are re-traced via PV check for thrombi.
• At hilum, a long bladed knife is placed with the blunt end facing upwards pierced into the hilum and the knife is turned upwards so that the sharp end now faces upwards Sawing motion hilum is cut.
LUNGS• Lungs are mounted on a board or held in
the left hand incision is made from the apex to the base.
• Hence, producing an antero-posterior slice.
• Cut sections are then examined for consolidations, edema, atelectasis, congestion, emphysema, Tardieu spots, emboli etc.
If PENUMOTHORAXis suspected:
• Pocket dissection on affected side between the chest wall and the skin filled with water wall is punctured under water.
• If bubbles are present Pneumothorax.
• 16 gauge needle attached to a syringe without its plunger is inserted into the subcutaneous tissue over the ICS water is filled in the syringe needle is pierced into the pleural cavity if water bubbles are seen Pneumothorax.
• Thereafter, X-ray is done.
If AIR EMBOLISMis suspected:
• In such cases, before touching the thoracic organs, the pericardium and the heart should be examined.
• The heart is lifted up and cut open at the apex.1. Left ventricle is filled with frothy blood if air
is present is good amount.2. If right ventricle is filled with air, the heart
will float in water.
If AIR EMBOLISM is suspected:1. Pericardial sac is filled with water heart is punctured with
a scalpel and twisted if bubbles are present AIR EMBOLISM.
2. A wide bore needle is attached to a syringe and water is filled in it it is inserted in to right ventricle if air is present bubbles are seen.
3. PYROGALLOL TEST: 4 mL of 2% freshly prepared pyrogallol is taken in two 10 mL syringes.In one of the syringes, 0.5 M NaOH is added. Gas is aspirated from the right heart and the needle is retracted and removed. A stopper is fixed to the syringe and the syringe is shaken. If the aspirate contains air, the colour of the solution would turn brown.
4. Air in the IVC can be demonstrated by puncturing it underwater.
5. Lastly, X-ray is done.
NECK
• Identify the oesophagus incise it from the posterior aspect up till the cardiac end of the stomach inspected for capsules, tablets or powders.
• Larynx, trachea and the bronchi are also cut from the posterior aspect and checked for foreign bodies, blood, mucous, tumours, inflammation etc.
• Thyroid is removed and examined.• The carotid arteries are examined for thrombi, esp. at
their bifurcation.• Later, the hyoid bone, cricoid and the thyroid cartilages
are examined.
ABDOMEN
ABDOMEN• 5 cm above the symphysis pubis the rectus
muscles are divided and a small cut is made.• Middle and the index fingers are then inserted
and spread in a ‘V’ shape.• Sharp braded knife is inserted between them
and the peritoneum is cut up to the xiphoid process.
ABDOMEN• Firstly, inspection is done and if any
damage, free fluid, perforations etc. are seen then these are noted.
• Also, note should be made about the abnormalities, positions, abdominal organs, adhesions, pathology (if any), injuries etc.
STOMACH
After applying double ligatures, the stomach is opened along the greater curvature from the cardiac to the pyloric end size of the pyloric ring is noted.Contents are examined for any nature of food which might be present & its state of digestion, smell, colour, character, the presence of foreign bodies or any other suspicious matter etc.Mucous membrane is examined for congestion, haemorrhage, ulcerations or any other abnormality.
INTESTINES
• Note the colour, consistency, adhesions, herniae, haemorrhage, serosal surface etc.
• Small intestine is opened along its line of mesenteric attachments.
• Large intestine is opened along the anterior taenia coli.
• Examined for inflammation, congestion, erosions, perforations etc.
LIVER• Either liver is removed by itself or attached to
the stomach and the duodenum.• It is examined for its weight, size, consistency
and for the presence of any other pathology / injury.
• It is cut along the long axis into 2 cm thick slices.
SPLEEN• It is removed by itself.• Size, weight, consistency, capsule condition,
rupture injuries or any pathology is noted.• This is also sectioned along its long axis and
the character of the septa and the parenchyma are noted.
PANCREAS• Along the long axis cuts are made at right
angles.• Examined for fat necrosis.
KIDNEYS• Size and weight are noted.• Capsules are excised and
examined carefully.• Kidney is sectioned
longitudinally the convex border of the hilum so that it splits into half and opens the pelvis.
• Checked for calculi, inflammation etc.
• Ureter is cut into and examined.
BLADDER• Incision is made from the
fundus and carried to the urethra.
• Wall condition, amount and character of urine is noted.
PROSTATE & TESTES• Examined for enlargement and malignancies.• Vertical cross-sections are made through the lateral and
median lobes and the prostate is split open for examination.
• Inguinal canal is incised from the peritoneal aspect and the loop of the vas deference is pulled to free it from the internal inguinal ring.
• The testes is pushed with one hand and pulled out of the scrotum easily by the other.
• These are cut longitudinally and checked for any clotted blood inside the scrotum and in the testis.
FEMALE GENITALIA• Vagina and the uterus are cut either anteriorly
or posteriorly upto the fundus.• Two short incisions are made at the fundus
from the main incision towards each cornu so as to expose the endometrium.
• Ovaries are sectioned longitudinally and the fallopian tubes are cut longitudinally.
If the uterus contains a foetus, its age should be determined.
AFTER COMPLETING INTERNAL EXAMINATIONS• Body cavities should be cleaned and made free from
blood, fluids etc.• Organs are placed back in and excess space is packed
with cotton/cloth etc. (esp. in the pelvis and the neck regions.)
• Dissection flaps are closed and sutured with thin twine.• Skull is filled with cotton and absorbent material and
the skull cap is placed back in and the scalp is stitched.• Body is washed with water, dried, covered with clothes
and handed over to the police officials.