Dark Side: Obvious Signs

 

EXTERNAL EXAMINATION

 

In contrast to the 'clinical autopsy' performed to evaluate natural disease, the importance of the external examination is far greater in the forensic case, especially in deaths from trauma. In the latter, the medico-legal value of the external.  description may be paramount, as it is often from the outer evidence that inferences may be made about the nature of the weapon, the direction of attack and other vital aspects. Thus the forensic pathologist must spend all the time that is necessary in a careful evaluation of the body surface and not be too impatient to wield the knife mainly to seek material for histology, which is more justified in the purely clinical autopsy. The routine for external examination will naturally vary according to the nature of the case but certain general principles apply. The following procedure is a useful baseline and may be adjusted according to personal preference. Variations in criminal cases to accommodate the needs of the investigating and scientific teams are mentioned later.

 

External examination must note every feature; here there is obvious abdominal distension in a battered child with facial bruising. The intestine had been ruptured by a blow, and oxygen administered by the ambulance crew escaped to distend the peritoneal cavity.

 

 

Ø After identification and removal of any clothing, the race and gender are noted. The apparent age is assessed in children by size and in adults by changes in skin and eyes, such as the loss of skin elasticity, senile hyperkeratosis, Campbell de Morgan spots, senile purpura and arcus senilis. Hair color, tooth loss and arthritic changes are also obvious signs of ageing. The apparent age should be compared with the alleged age and enquiries made about any obvious discrepancy, in case it is the wrong body, an error which plagues most autopsy rooms from time to time.

 

Ø The body length is measured from heel to crown (in infants, more detailed measurements are described later). Ensure that the attendant does not take the 'undertaker's height' from toe to crown, as due to the plantar flexion of rigor, this can be a considerable number of centimeters more than the live standing height. It should also be appreciated that the post-mortem height may differ from the known living height by several centimeters.

 

 

Ø The body weight in kilograms is measured if facilities are available; if not, it should be estimated. The weight of infants must always be measured. The general nutrition and physique is assessed in terms of obesity, leanness, dehydration, oedema, emaciation, and so on.

 

Ø Acquired external marks may be important for identification purposes or in relation to past injuries and disease. Tattoos, circumcision, amputations, surgical scars, old fracture deformities and scars of injuries, burns or suicidal attempts on the wrist and throat are noted.  Increasingly, artefacts - both external and internal - arise from resuscitation attempts and must be carefully distinguished from original trauma. This emphasizes the importance of the history, to determine whether cardiopulmonary resuscitation was attempted by trained or untrained persons.

 

Vomit, froth or blood may be present at the mouth and nostrils, and faeces and urine may have been voided. This must be correlated with the degree of post-mortem decomposition, which often leads to purging of fluids from orifices; most forensic pathologists have had the experience of being called by the police to the scene of 'a fatal hemorrhage', to discover only bloody fluid being purged by gases from a decomposing corpse. Vaginal discharge or bleeding is noted and the ears examined for leakage of blood or cerebrospinal fluid.

 

With head injuries, the scalp is examined in its original condition first and any trace evidence collected. Then any clotted blood that frequently obscures the injuries can be gently removed, using a sponge and water. After this stage has been studied, it is usually necessary to shave off hair carefully around the wounds, so that the full extent of the lacerations and especially the state of their margins can be assessed and photographed. This shaving is best carried out with a scalpel fitted with a new blade, the blade being kept almost parallel with the surface to avoid making false cuts.

 

 

Samples for serology, microbiology and for analysis for substances such as carboxyhemoglobin, which are not absorbed from the gastrointestinal tract, can be collected from any blood vessel, but blood should never be scooped up from the general body cavity after evisceration, as this can be contaminated with any leakage from other structures, such as gastric or bowel contents, mucus, urine, pus or serous fluids. Blood for microbiological culture has traditionally been taken from the heart but there is no particular merit in this as opposed to peripheral blood. If an infective endocarditis is suspected, it is best to open the heart later with a sterile scalpel and excise the mitral or aortic valve cusps or vegetations for direct culture. Otherwise, blood for culture for a suspected septicemia is taken from a peripheral vein. Urine can be collected by catheter before autopsy or even by suprapubic puncture with a syringe and long needle. However, it is usually obtained after the abdomen is opened, but before the organs are removed. If the bladder is full, the urine collected either by syringe or directly into a container. If almost empty and contracted, the fundus is gripped and pulled upwards so that it stretches, then is incised and the contents removed by syringe. Care should be taken not to contaminate the urine with blood.

 

Where in any autopsy spinal damage is suspected, a good preliminary test is to slide the hands under the back of the eviscerated body on the autopsy table and lift the dorsolumbar spine upwards, whilst watching the interior vertebral bodies. If a fracture or dislocation is present, abnormally acute angulation will be seen, instead of smooth bending. The cervical spine can be tested by manual manipulation. If suspicious angulation is seen, a slice can be taken along with the anterior spine, through the vertebral bodies and discs, with an electric or handsaw. This will reveal the interior of the spine and exhibit any crushing, hemorrhage, or torn disc spaces: if one of these is found, the cord must always be removed.

Going back in time, one must remember – forensic science, does not change quickly or have dramatic developments such as the current DNA revolution. Indeed, because its base is the interpretation of autopsy findings, forensic pathology still rests largely on the principles of morbid anatomy founded in the nineteenth century and earlier.

 

Acknowledgements

 

 

 

www.politie.nl and a Chief Inspector – Mr. Henk van Essen©

 

www.aivd.nl      AIVD – Mr. Erik Akerboom ©

 

 

 

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