EXTERNAL EXAMINATION - AUTOPSY

DEFINITIONS

AUTOPSY – seeing for one self i.e. making a personal inspection

Pathological sense – dissection of the dead body to determine, through observation, the cause of death and nature of disease.

EXTERNAL EXAMINATION – ritual full of meaning and common sense.

On the fabric of the human body

On the Seats and Causes of Diseases

PRELIMINARIES

Consent (hospital administrator (RMO/coroner) and relatives)

Identification of body Clinical details

Should have a statement pertaining to retention of body parts/ organs

Get specific permission for an unusual examination (removal of eyes/limbs) even if signed as NO RESTRICTIONS

Make sure the case is not medicolegal, like delayed accidents, homicides, deaths after abortions, occupational diseases, suspicious cases of poisoning, deaths on table.

Dictate as follows

Autopsy no, date and time Pathologists Name and designation Patient’s age (look for disparity) and sex State of body (built and nourishment) State any restrictions Final clinical diagnosis Clinical summary Height (crown to heel) Weight

Dictate as follows

Rigor mortis Livor mortis Algor mortis Post mortem drying Body built Nourishment Edema Cyanosis Skin Nails

RIGOR MORTIS

Rigor is tested by trying to lift eyelids, trying to depress the jaw and bending the neck and various joints of the body

RIGOR MORTIS Primary flaccidity (till ATP remains) – rigor –

secondary flaccidity Secondary flaccidity due to onset of

putrefaction Mechanism (4-8 hrs, 24-48hrs) NYSTEN’S rule – doesnot appear in all

muscles simultaneously and both voluntary and involuntary muscles affected

Contraction of erector pilae – cutis anserina/goose flesh

RIGOR MORTIS Commences in the heart (LV-RV-atria) , in sytole Diaphragm Skeletal musculature – first jaw, neck, face,

arms, lower extremities, last ankle joint Passes off in the same order Contraction of tracheal muscles causes white

dots on mucosa Postmortem intususception Iris – dilatation (postmortem) and then

contraction (rigor) Handling causes loss of rigor – patchy

distribution

Factors affecting rigor

Age – absent in fetus, early and milder in children and old

Early onset, short duration – wasting diseases, strychnine poisoning

Late onset – asphyxia, hemorrhage, pneumonia, paralytic diseases

Increased duration – CO poisoning Less duration – bacterial infection d/t

early putrefaction Environment – cold – late onset, more

duration, heat – early onset, less duration

CADAVERIC SPASM / INSTANTANEOUS RIGOR / CATALEPTIC RIGIDITY

CADAVERIC SPASM

Muscles that were contracted during life become rigid immediately after death without passing into a stage of primary relaxation

Affects single group of voluntary muscles, frequently hands

Sudden death, excitement, severe pain, convulsions, strychnine poisoning

LIVOR MORTIS

LIVOR MORTISHypostasis

Mechanism Initially intravascular (can blanch), then

extravascular Begins 30 to 45 mins after death in

dependent parts, max in 6-12 hrs Can enlarge the extent of subcutaneous

hemorrhages, can mimick suboccipital hemorrhage

Initially cut on the area of livor shows delicate hemorrhagic dots showing transected congested vessels.

Not possible to distinguish from antemortem cyanosis

BLANCHING TEST

Colour is a shade of blue No livor – hemorrhage, anemia,

wasting diseases Red in bodies kept in moist

refrigeration – higher affininty for O2 Cherry red – cyanide, CO Methemoglobinemia – smoky green,

brown Hydrogen sulfide – black

Tardieu spots develop in areas of lividity, such as this individual's shoulder area, as decomposing capillaries rupture.

ALGOR MORTIS

Rectal temp falls @ 1 deg/hr Also inferior surface of

liver/EAC/nasal passages Time of death = n body tem – rect t / rate of cool Post mortem caloricity – stroke,

convulsions, strychnine poisoning, septicemia

POST MORTEM DRYING develops when the eyelids are not completely shut, the areas of the sclera exposed to the air dry out, which results in a first yellowish, then brownish-blackish band like discoloration zonecholera, wasting dis

(Tache noire)

DRYING

Skin is wrinkled and leathery Loosening of hair, apparent

lengthning of finger nails due to shrinkage of finger tips

Body built and nourishment

BODY BUILT

Gigantism – Hereditary/endocrine proportioned/dys Endocrine –

Pituitry - d/t excess GH acromegaly, gigantism

Hypogonadism – eunuchoid - klienfelter

BODY BUILT

DWARFISM – hereditary / endocrine perfect/imperfect Hereditary – pygmies (primordial) sporadic (mutation)

achondroplasia

Endocrine – Hypothyroidism – cretinism Pituitary dwarfism – GH deficiency Gonadal dwarfism – Turner’s syndrome

AchondroplasiaUpper arms and thigh shorterTrident handFace disproportionately largeSpinal stenosis, kyphosis

TURNER SYNDROME

Spinal deformities

Old ageChronic emphysemaRicketsOsteomalaciaAcromegalyTuberculosis

Spinal deformities

Dislocation of hipsAscitesPregnancyPostural weakness

Spinal deformities

Weakness/paralysis of muscles on one side – poliomyelitis, shortening of one lower limb

NOURISHMENT

OBESITY Exogenous – food intake

Double chin and abdominal Endogenous - glandular

Cushing’s – truncal – moon face, buffalo hump, protuberant abdomen, thin extremities

Hypothyroidism – non pitting myxedema – eyelids, hands and tibia – hyaluronic acid infiltrn

Complications of obesity

NOURISHMENT

CACHEXIA Cancer TB Thyrotoxicosis Addison’s disease Anorexia nervosa Starvation

EDEMA

Generalized and localized Pitting and non pitting

(lymphedema/myxedema)

GENERALISED/ LOCALISED

GENERALISED Congestive heart failure Nephrotic syndrome Hypoproteinemia Cirrhosis

LOCALISED Filariasis Post operative Insect bites Vena caval syndromes

CYANOSIS

CYANOSIS

CENTRAL Conjunctive, mouth, nose, lips Pneumonia, chronic bronchitis, fallot’s,

shunts as in cirrhosis Associated with clubbing

PERIPHERAL Extremities, not associated with

clubbing Localised obstruction to blood flow like

raynaud’s, arterial obstruction, varicose veins

Raynaud’s

NAILS

KOILONYCHIA

FINGERS – MARFAN’S

DUE TO MUTATION IN FIBRILLIN I GENE

SKIN PIGMENT DISTURBANCES

Hyperpigmentation Generalised

Jaundice, Addison’s, Hemochromatosis, chronic malaria

Localised Chloasma, Acanthosis nigricans

Hypopigmentation Albinism, vitiligo Fungal disease (tinea vericolor, pityriasis

alba), leprosy

Signs of liver cell failure

Hemochromatosis

SKIN

Petechiae, ecchymoses Striae

HAIR AND FACE

HAIR

Loss – debilitating illness, malignancy, typhoid, male pattern baldness, alopecia, ringworms, thallium poisoning

Female distribution in male – portal cirrhosis, after castration

Hirsuitism – Male pattern hair in female – Cushing’s, ovarian tumors

Thinning and drying of scalp hair – myxedema

Cicatrical alopecia male pattern baldness

FACE

Hippocratic facies - A pinched expression of the face, with sunken eyes, hollow cheeks and temples, and relaxed lips, observed in one dying after an exhausting illness

Moon face – cushing’s Potter facies - oligohydramnios Mask like facies - parkinsonism Leonine facies - lepromatous leprosy

•Potter's facies. •Parrot-beaked nose. Recessed chin. Epicanthic folds. micrognathia •Low set ears (helices often folded). •Hypertelorism.

EYES

EYES – POST MORTEM CHANGES Loss of corneal reflex – not reliable Opacity of cornea – cholera, wasting

diseases Flaccidity of eyeball – sunken Pupils – dilatation then constriction Retina – Kevorkian sign – shunting/tracking

of blood due to fall in bp Steady rise in K+ values of vitreous upto

100 hrs

EYES

Exophthalmos Hyperthyroidism, myopia

Enophthalmos Cachexia, Horner’s syndrome

Cornea – Ulceration, opacity, Arcus senilis, Kayser-

Fleischer ring Sclera –

Icterus Blue sclera (osteogenesis imperfecta,

marfan’s)

Horner’s syndrome – due to compression of ipsilateral thoracic /cervical sympathetic chain – miosis, enophthalmos, ptosis and loss of sweating on same side with loss of ciliospinal reflex

Arcus senilis wilson’s disease

ORIFICES

Tongue

Geographic tongue – Vitamin B12 deficiency

Protuberant tongue – cushing’s

THYROID

LYMPH NODES – NECK, AXILLA AND INGUINAL

NECK

Look for neck veins Prominence indicates RVF

BREAST

CHEST

Pectus carinatum aka alar chest Prominence of vertebral border of sternum

Pigeon Chest Nasopharyngeal obstruction, respiratory

disease Barrel Chest

Emphysema, chronic bronchitis Pectus excavatum

Occupational deformity, cobblers Rachitic Chest

Pigeon breast, keel breast, Harrison’s sulci, Verical grooves, Rickety rosary

RIBS

LIVER AND SPLEEN

UMBILICUS

Perinatal autopsy

Weights lung:heart=3:1 Brain : liver = 3:1 Liver:heart = 6:1 Adrenal:thymus:spleen = 1:1:1 OFC=CR Lanugo hair, poorly formed ear

cartilage, absent breast buds, undescended testis, rugose scrotum, palmar and plantar creases