THE ORDER OF THE AUTOPSY.
=ORDER OF THE AUTOPSY.= In so complicated a piece of work as the
complete autopsy it is absolutely necessary that a definite order
of procedure be followed at every autopsy, altered when necessary
to suit the requirements of individual cases. In medicolegal
examinations a definite autopsy order should be prescribed by law.
For the average case, in fact for nearly every autopsy, I believe the
following order, as given in my protocol book, to be the best one. It
is based upon topographic and anatomic relationships, preservation of
blood-content, ease and convenience of method, etc. As the protocol
should follow this order, it is given here in full.
Autopsy-Protocol No.
1. Name: 2. Sex: 3. Age:
4. Nationality: 5. Status: 6. Occupation:
7. Day and Hour of Death: 8. Time of Autopsy:
Clinical Diagnosis:
Pathologic Diagnosis:
_Prosector:_
A. External Examination. General.
==============================+==========================
9. Build: | 27. Muscles:
10. General Nutrition: | 28. Rigor Mortis:
11. Head: +——————————————————————————
12. Facies: | 29. Panniculus:
13. Eyes: | 30. Oedema:
14. Neck: +——————————————————————————
15. Thorax: | 31. Body Heat:
16. Abdomen: +——————————————————————————
17. Back: | 32. Hypostasis:
——————————————————————————————+——————————————————————————
18. Anomalies: | 33. Putrefaction:
19. Deformities: +——————————————————————————
20. Signs of Trauma: | 34. Orifices:
21. Surgical Wounds: | Mouth:
22. Scars: | Nose:
——————————————————————————————+ Ears:
23. Skin: | Genital:
24. Hair: | Anus:
25. Teeth: +——————————————————————————
26. Mucous Membranes: | 35. Postmortem
| Percussion:
——————————————————————————————+——————————————————————————
B. Internal Examination.
I. SPINAL CORD.
==============================+===========================
1. Dorsal Incision: | 4. Inner Meninges:
——————————————————————————————+——————————————————————————
2. Vertebrae: | 5. Cord:
——————————————————————————————+——————————————————————————
3. Dura: | 6. Inner Surface of
| Vertebrae:
——————————————————————————————+——————————————————————————
II. HEAD.
==============================+==========================
1. Scalp: | 13. Ventricles:
2. Periosteum: | Left Lateral:
3. Skull-Cap: | Right Lateral:
——————————————————————————————+ Third:
4. Dura: | Fourth:
5. Longitudinal Sinus: +——————————————————————————
6. Meningeal Vessels: | 14. Chorioid Plexus:
| 15. Pineal Gland:
| 16. Cerebral Ganglia:
——————————————————————————————+ 17. Peduncles:
7. Basal Vessels: +——————————————————————————
8. Inner Meninges, Left: | 18. Cerebellum:
9. Inner Meninges, Right: | 19. Pons:
| 20. Medulla:
——————————————————————————————+——————————————————————————
| 21. Hypophysis:
10. Cerebrum: | 22. Basal Sinuses:
11. Right Hemisphere: | 23. Basal Dura:
12. Left Hemisphere: | 24. Cranial Nerves:
| 25. Base of Skull:
——————————————————————————————+——————————————————————————
III. THORAX AND ABDOMEN. (Main Incision.)
==============================+==========================
1. Panniculus: | 6. Position of Diaphragm:
2. Musculature: |
——————————————————————————————+——————————————————————————
3. Abdominal Cavity: |
4. Omentum: | 7. Mammæ:
——————————————————————————————+ 8. Costal Cartilages:
5. Position of Abdominal | 9. Sternum:
Organs: |
——————————————————————————————+——————————————————————————
IV. THORAX.
==============================+==========================
1. Thoracic Cavity: | 11. Left Lung:
2. Position of Thoracic |
Organs: | 12. Right Lung:
——————————————————————————————+——————————————————————————
3. Anterior Mediastinum: |
——————————————————————————————|
4. Thymus: | 13. Bronchi:
——————————————————————————————| 14. Bronchial Glands:
5. Pericardium: |
——————————————————————————————+——————————————————————————
6. Heart: | 15. Pulmonary Vessels:
——————————————————————————————+——————————————————————————
7. Right Heart: | 16. Great Vessels of
| Thorax
——————————————————————————————| 17. Thoracic Portion of
8. Left Heart: | Oesophagus
——————————————————————————————+——————————————————————————
9. Cardiac Orifices and | 18. Thoracic Duct:
Valves: | 19. Thoracic Vertebræ.
10. Coronary Vessels: |
——————————————————————————————+——————————————————————————
V. MOUTH AND NECK.
==============================+==========================
1. Mouth: | 9. Thyroid:
2. Tongue: | 10. Parathyroids:
3. Pharynx: +——————————————————————————
4. Tonsils: | 11. Cervical Lymphnodes:
5. Nose: | 12. Parotid:
——————————————————————————————| 13. Submaxillary Gland:
6. Larynx: +——————————————————————————
7. Trachea: | 14. Cervical Vessels and
——————————————————————————————| Nerves:
8. Cervical Portion of | 15. Deep Muscles of Neck:
Oesophagus: |
——————————————————————————————+——————————————————————————
VI. ABDOMEN.
==================================+==============================
1. Peritoneum: | 15. Left Adrenal:
——————————————————————————————————+——————————————————————————————
2. Spleen: | 16. Left Kidney and Ureter:
——————————————————————————————————+——————————————————————————————
3. Large Intestine: | 17. Right Adrenal:
4. Appendix: +——————————————————————————————
——————————————————————————————————| 18. Right Kidney and Ureter:
5. Small Intestine: |
——————————————————————————————————+——————————————————————————————
6. Duodenum: | 19. Abdominal Aorta:
7. Bile Passages: | 20. Iliacs:
| 19. Ascending Vena Cava:
——————————————————————————————————+——————————————————————————————
8. Stomach: | 22. Lymph Vessels:
——————————————————————————————————| 23. Retroperitoneal
9. Pancreas: | Lymphnodes:
| 24. Hemolymph Nodes:
——————————————————————————————————+——————————————————————————————
10. Liver: | 26. Psoas Muscles:
——————————————————————————————————+——————————————————————————————
11. Gall Bladder: | 27. Vertebræ
——————————————————————————————————+——————————————————————————————
12. Portal Vein: |
——————————————————————————————————+——————————————————————————————
13. Mesentery: |
14. Mesenteric Lymphnodes: |
——————————————————————————————————+——————————————————————————————
VII. MALE PELVIS.
=================================+==============================
1. Penis: | 6. Prostate:
+——————————————————————————————
2. Scrotum: | 7. Seminal Vesicles:
—————————————————————————————————+——————————————————————————————
3. Testis: | 8. Seminal Duct:
—————————————————————————————————+——————————————————————————————
4. Epididymis: | 9. Urethra:
—————————————————————————————————+——————————————————————————————
5. Rectum: | 10. Bladder:
—————————————————————————————————+——————————————————————————————
VIII. FEMALE PELVIS
==================================+=============================
1. Rectum: | 9. Tubes:
——————————————————————————————————+—————————————————————————————
2. Vulva: |
3. Urethra: | 10. Ovaries:
4. Bladder: |
——————————————————————————————————+—————————————————————————————
5. Vagina: | 11. Blood and Lymph
6. Uterus:11. | Vessels of Uterus:
7. Cervix: |
8. Body: | 12. Ligaments of Uterus:
——————————————————————————————————+—————————————————————————————
IX. SPECIAL REGIONAL EXAMINATION.
==================================+=============================
1. Bones: | 6. Peripheral Nerves:
——————————————————————————————————+—————————————————————————————
2. Marrow: | 7. Sympathetic:
——————————————————————————————————+—————————————————————————————
3. Joints: | 8. Organs of Special Sense:
——————————————————————————————————| Eye:
4. Lymph Glands: | Ear:
——————————————————————————————————| Nose:
5. Peripheral Blood Vessels: |
——————————————————————————————————+—————————————————————————————
X. MICROSCOPIC AND BACTERIOLOGIC FINDINGS.
XI. SUMMARY OF CASE.
The organs may be inspected and opened in the body without removing
them; but when weights and measures are desired they should be
removed and sectioned on the table. When the spinal cord is removed
posteriorly it should be done at the beginning of the autopsy, for
the sake of convenience and cleanliness. If the thorax and abdomen
are examined first there is a loss of solidity and resistance,
making the posterior opening of the spinal canal more difficult.
The head may be opened while the cadaver is face downward and the
brain removed with cord attached. If the cord is examined anteriorly
this should be done at the close of the autopsy after the thorax and
abdomen are completely cleaned out. The head should be opened before
the heart and great vessels are cut in order to avoid bleeding the
sinuses and pial veins. It should be kept elevated until the heart
has been examined to avoid bleeding the latter through the jugulars.
The abdomen is opened before the thorax so that the position of the
abdominal organs and the height of the diaphragm can be correctly
noted. A complete survey of the peritoneal cavity should be made at
once before the appearances are changed through the loss of blood or
other fluids, or through drying or handling. The size of the liver
should be estimated before the heart is cut out, inasmuch as the loss
of blood through the cut inferior vena cava may reduce its size as
much as one-half. The pleural cavities should be examined before its
vessels are cut, as the escape of blood may alter the appearances
of the pleuræ. The heart is opened before the lungs are removed, so
that its blood-content may be judged. The section of the neck organs
is conveniently carried out according to anatomic relationships,
beginning with the tongue. In the abdomen the spleen is removed first
because it is the most easily gotten out of the way. The intestines
up to the duodenum may be taken next, or the adrenals and kidneys,
followed then by the gastro-intestinal tract, pancreas and liver.
When necessary the kidneys may be removed in connection with the
pelvic organs. In the case of extensive growth of neoplasms, marked
inflammatory processes, adhesions, malformations, anomalies, etc.,
the order must be changed to meet in the best way the demands of
the situation. Such changes in the order must always be mentioned
in the protocol. It is a great mistake to begin the autopsy with a
local examination of a supposed fatal lesion, except in the cases of
wounds, particularly in medicolegal cases, in which a most careful
and minute description of the wound is necessary.
Some writers (_Letulle_, _Heller_, _et al._) advocate the removal
of neck, thoracic, abdominal and pelvic organs _en masse_ and their
examination outside of the body. Except in rare cases in the adult,
and more frequently in the child, this method does not present any
special advantages aside from the preparation of museum specimens. It
may be convenient to follow it when a very short time is allowed for
the autopsy, just sufficient to remove the organs so that they can be
examined later. When this method is followed the order should be:
1. Organs should be turned over without twisting, so that their
posterior aspect is uppermost. Then the examination in the
following order: right and left azygos veins; thoracic duct;
removal of adrenals; opening of ureters; removal of kidneys;
opening of aorta, inferior vena cava, portal vein and branches, and
common duct; examination of pancreas; removal of aorta as far as
arch; opening of œsophagus; examination of mouth, pharynx, palate,
tonsils, tongue and sublingual glands, epiglottis, larynx, trachea
and large bronchi; roots of lungs, prevertebral lymphnodes, and the
pneumogastric nerves.
2. Organs are then turned over again without twisting, and examined
from anterior surface as follows: removal and examination of thymus
and thyroid; opening of superior vena cava, termination of thoracic
duct and right lymph-trunk; opening of pericardium, examination of
cardiac plexus, opening of arch of aorta; section and examination
of pulmonary arteries and veins and hilum of lung; examination
and removal of heart and lungs; examination of diaphragm, liver,
gall-bladder and bile-ducts; external examination and separation
of spleen, stomach, pancreas and duodenum; removal of œsophagus,
stomach, pancreas and duodenum; external examination, dissection
and removal of intestine to the rectum; examination of peritoneum,
mesentery and omentum; separation and examination of kidneys,
ureters, bladder and urethra; separation and examination of genital
organs (in male, prostate, seminal vesicles, vasa deferentia and
testes; in the female, oviducts, broad ligaments, ovaries, vulva,
vagina and uterus).
For the ordinary clinical autopsy this method is more inconvenient
and time-consuming, and offers not a single advantage over the
order advocated above. I use it only in young children and in
adult cases of generalized carcinomatosis, sarcomatosis, pulmonary
embolism, congenital cardiac lesion, tuberculosis, aortic aneurism
with tracheal or bronchial erosion and a few other rare generalized
conditions. For all other cases I advise that the first mentioned
order be followed, varying it as occasion demands. The autopsy should
be individualized. Departures from the routine order will take place
chiefly in the thoracic and abdominal cavities. It is often more
convenient to remove the kidneys before taking out the intestines,
to examine the liver before the spleen, or to make other similar
variations in the order. The order of examination of the larger
divisions of the body (head, thorax, abdomen and pelvis) should
always be followed strictly; but the neck and thoracic organs, or the
thoracic organs alone, may be removed _en masse_ and examined outside
of the body, and the same procedure may be carried out in the case of
the abdominal or pelvic organs whenever advisable. Removal _en masse_
with examination on the table is especially indicated in the case of
the neck and thoracic organs in aortic aneurism, pulmonary embolism,
congenital cardiac lesions, mediastinal neoplasms, generalized
carcinoma or sarcoma of thoracic organs, etc. The same procedure
is indicated in the case of the abdominal organs in generalized
carcinomatosis or sarcomatosis, inflammation and tuberculosis of the
abdominal organs or peritoneum, aneurism of the abdominal aorta,
pseudomyxoma peritonei, etc.
In my judgment it is extremely bad practice to examine first
that part of the body which the clinician believes to be chiefly
affected. Still worse is it to limit the autopsy to such a regional
examination. Imperfect and subjective conclusions will be avoided if
the regular order is followed and each organ examined objectively.
In all cases a complete autopsy should be made if permission can be
obtained, and the permit for an autopsy should be regarded as one for
a complete examination unless definite exceptions have been made.
The examination of any organ or part should never be neglected. Many
prosectors habitually omit the section of the neck-organs, intestines
and genital tract when there is nothing to attract especially their
attention to these parts. The examination of the spinal cord, orbits,
nasal tract, ears, joints and bones may be omitted in the ordinary
autopsy in the absence of especial considerations directing attention
thereto; all other parts should be systematically examined. The
pathologist must always maintain an unprejudiced state of mind toward
the clinical diagnosis—rather a doubting mind than a disposition to
accept the suggestions of the clinical opinions. The best cure for
subjectivity is the complete performance of the autopsy in regular
routine order, and the dictation of the protocol at the autopsy table
during the operation.