THE PROTOCOL.
=THE PROTOCOL.= Autopsy findings should be recorded in the form of
complete, concise notes, following the order of the autopsy. Such a
protocol should consist of _descriptive_ statements of the pathologic
changes found, as well as of all negative conditions. It must be a
guarantee that all organs have been examined and that nothing has
been overlooked. Herein lies the great value of the use of a protocol
blank book with printed autopsy forms. When such are used and both
positive and negative pathologic findings are recorded during the
progress of the autopsy the chances of omission are reduced to a
minimum.
The protocol must be purely objective and exact. All appearances
should be so carefully described that from the protocol itself a
diagnosis may be formulated. Conclusions and diagnoses have no
place in the protocol until the final summing up. It is better to
describe the appearance of organs than to class them as “normal”
or “negative,” “nothing notable,” etc. The only excuse for the
employment of such phrases is a lack of time for the dictation of a
proper protocol, but the scientific value of the autopsy is thereby
impaired. As the complete description of the normal appearances
would require too much time and lessen that available for the
pathologic examination, the prosector should describe briefly the
chief characteristics of the normal organ, any variation in any one
of these characteristics being sufficient evidence that the organ
had suffered pathologic change. The description of the normal organ,
however, usually offers the greatest difficulty to the beginner, and
so much time may be spent upon this that the pathologic changes are
slighted. However, the relatively small number of points constituting
the criterion for the normal organ may be learned by experience and
by the study of autopsy-protocols made by experts. The latter study
is also necessary for the acquisition of the extensive protocol
terminology that has been developed. A knowledge of this terminology
lightens greatly the difficulties of the protocol; but its misuse
leads to confusion and incorrect interpretations.
It is not a good plan to write up the protocol after the autopsy
has been finished. It should be dictated during the progress of
the autopsy. Only in this way can an accurate and purely objective
description be obtained. The use of simple, terse English and the
proper employment of autopsy terminology are also chief factors in
the production of a good protocol.
The importance of following a definitely-outlined routine of
procedure is very evident in the case of protocol-making. The general
order of the autopsy should be followed strictly in the protocol; and
all deviations from the usual method noted and described. Aside from
this general order, each organ or part as it is examined should be
systematically described according to the following scheme:
1. =Location and relation to other parts.=
2. =Size and weight.=
3. =Shape. (Contour, lobes, edges, borders, character of surface,
etc.)=
4. =Color.=
5. =Consistence.=
6. =Odor.=
7. =Cut surface.=
8. =Blood-content.=
9. =Histologic features in detail. (Capsule, surface, parenchyma,
stroma, vessels, etc.)=
10. =General and localized pathologic conditions.=
For the _hollow viscera_ and _body-cavities_ the following points
should be systematically noted in addition:
1. =Size and shape of cavity.=
2. =Free gas or air?=
3. =Fluid or solid contents? (Amount, odor, color, cloudiness,
consistency, precipitation or separation on standing, presence
of blood, fibrin, pus, parasites, etc.)=
4. =Condition of wall of cavity (serosa or mucosa).=
1. =Location and Relation.= The organs and parts should be located
according to the landmarks of regional anatomy. Brain-lesions may be
charted upon the printed outline sheets of the different parts of the
brain. Similar outline sheets may also be used for other parts of the
body.
2. =Size and Weight.= The exact weights and measurements should be
given in the metric terms. Organs should be weighed and measured
after the removal of other tissue in which they may be imbedded
(fatty capsule of kidney, etc.) or to which they are attached
(diaphragm from liver, blood-vessels from heart, etc.). The volume
of the organ may be estimated by putting it into a graduated vessel
containing water and noting the amount of displacement. In the
absence of facilities or the time necessary to take weights and
measurements an approximate estimate of size and bulk may be given
by comparisons with well-known objects, such as peas, mustard-seed,
pepper-corns, walnuts, apple, hen’s egg, etc., but such terms are
only relative and not accurate, and their use should be avoided as
much as possible. That the weight and measurements of any given organ
fall within normal limits cannot be taken as evidence that the organ
is normal. The judgment as to the size and weight of the organ must
always be controlled by a consideration of the pathologic conditions
present as to the exact factor in the increase or the loss of size or
weight.
3. =Shape.= The organs should be removed with the least possible
disturbance of shape. If it is not possible to do this, the shape of
the organ should be noted as it lies within the body. A knowledge of
the normal form of the organs must serve as the basis for judgment.
Comparison of pathologic alterations in form with the shape of some
familiar object is permissible (horse-shoe, hour-glass, shagreen,
cauliflower, mushroom, coral, polypoid, hog-backed, etc.) Borders,
contours, edges, external surfaces, etc., are rounded, sharp,
flatter, thinner, saccular, lobulated, smooth, wrinkled, folded,
villous, polypoid, granular, nodular, fissured, etc. All possible
anomalies of form exist from the very slightest deviations up to the
most marked distortions.
4. =Color.= The color of an organ or part should be noted as soon
as possible after its removal from the body, or, better, as soon as
the cadaver is opened, since oxidation, evaporation, loss of blood,
and contact with water quickly cause color-changes. Venous blood may
quickly become bright red, notably in the spleen and cerebral veins
and sinuses. It is not to be supposed that, even when the cadaver
is opened within a very short time after death, the color is that
of the living body. Certain color-changes always take place as soon
as death occurs, but it is necessary to create a color-standard for
the different organs as seen under the conditions of the ordinary
autopsy. Injections of formalin and other undertaker’s fluids destroy
all color, and should not be permitted before the autopsy. Freezing
likewise changes the color of many of the organs.
The judgment of the color of the tissues and organs of the human
body is extremely difficult because of the fact that only rarely
is a pure simple color seen. Ordinarily a combination of colors is
present, and the analysis of these is often not easy. If the organ
is held before the eyes at a distance of about a yard an impression
of a single color-unity may be obtained, but when brought nearer to
the eyes the surface presents a variegated, mottled, speckled or
streaked effect of many colors, sometimes running the entire range
of the spectrum. The colors most frequently seen in the body are
yellow, red and brown in all possible combinations and shades. Blue,
gray, slate, black, green and purple are also common in combination
with these three or with one another. The analysis of the color is
concerned, first with the color proper of the parenchyma, secondly
with the color of the blood and the blood-content, thirdly with
the color of some pathologic substance contained in the tissue,
as blood- or bile-pigment, carbon, melanin, etc. In describing
color-combinations use the predominant color last; as, for example,
a reddish-yellow-brown means that the predominant color is brown
with more yellow in it than red. Innumerable combinations of these
three colors exist (light brown, chocolate, yellowish-brown, brownish
yellow, brownish red, etc.). The macroscopic color will not be
apparent in microscopic preparations except when due to a true
pigment.
The term discolored is applied to dirty, cloudy colors, particularly
gray or greenish, as in gangrene. Spotted, mottled, streaked,
variegated, etc., have the same application in the autopsy-protocol
that they have elsewhere. The judgment of the color of an organ
should be made twice: as seen through the capsule or external
covering, and again on the cut surface of the organ. In the latter
case the transparency, translucency or opacity of the surface should
be noted with the color. Normally translucent structures become
opaque as the result of inflammatory thickening, parenchymatous
degenerations, leukocyte infiltrations, tubercles, postmortem
digestion, etc. An increase in translucence may be due to œdema,
hydropic degeneration, amyloid, mucoid and colloid degenerations,
liquefaction necrosis, anæmia, atrophy, loss of pigment, etc.
(translucent, transparent, jelly-like, colloid, mucoid, lardaceous,
sago, bacon, ham-fat, pearly, etc.).
5. =Consistence.= This is best estimated by placing the four fingers
of the right hand beneath the edge of the organ as it lies on the
board or in the body and lifting it slightly upward and inward toward
the main mass of the organ. This should be done in several places,
so that an idea of the general consistence of the organ is obtained.
Hollow organs must be tested before and after opening, in the latter
case, to get an idea of the consistence of the wall. Organs with
capsules should be tested through the uncut capsule and also on the
cut surface. After the general consistence has been determined an
examination of the entire organ by thumb and fingers should be made
to determine localized areas of different consistence (soft: abscess,
cyst, œdema, areas of degeneration, etc.; hard: amyloid, tubercles,
tumors, chronic passive congestion, fibroid indurations, pneumonic
areas, etc.). The size and location of such areas should be carefully
noted. The presence of fluctuation, loss of elasticity, pitting on
pressure, friability, hardness, etc., should be described in ordinary
terms, although a comparison with familiar objects often gives a more
definite impression than the simple use of adjectives describing the
condition (consistence of leather, dough, mush, pea-soup, putty,
wood, jelly, stone, iron, etc.). The relaxation or softness of an
organ is often judged by its flattening on the board, or by its
hanging down over the index-finger when this is placed beneath its
middle and the organ raised, or by the jelly-like tremors of the
organ when the dish containing it is agitated.
An increased friability is noted in diseased bones, muscles,
pneumonic lungs, organs showing acute congestion, etc. An increase
or a loss in elasticity is to be noted chiefly in the large
blood-vessels, lungs, skin, etc. In describing a condition of loss
of normal firmness the German School makes frequent use of the
termination _malacia_ (softening) in such words as _myomalacia_,
_osteomalacia_, _gastromalacia_, _myelomalacia_, _encephalomalacia_,
etc. When such softening is the result of postmortem autolysis
or digestion, as is so often the case in the stomach (postmortem
perforations), thymus, pancreas, adrenals, brain, etc., the term
_postmortem softening_ is more frequently used in this country. Soft
tumors are described as medullary, encephaloid, etc. In all judgments
as to consistence the normal differences between the organs must
be considered, as well as the length of time between death and the
autopsy, the cause and manner of death, undertaker’s manipulations,
temperature, moisture, rigor mortis, putrefaction, etc.
6. =Odor.= But little attention is paid in the average autopsy
to the odors of the body, and very little has been written about
their importance. This is probably due to the fact that the average
individual more or less consciously or unconsciously suppresses the
sense of smell. Yet a keen sense of odors and an ability to analyze
them are of the very greatest importance in autopsy work. Certain
infections, and other diseases as well, have peculiar and distinctive
odors (small-pox, measles, colon-bacillus infections, pulmonary
gangrene, diabetes, uræmia, acute yellow atrophy, leukaemia, etc.).
The odor of many drugs and poisons may also be distinguished in the
tissues, gastro-intestinal tract or body-cavities (alcohol, ammonia,
amyl nitrite, aromatic and ethereal oils, assafétida, carbolic acid,
chloral, chloroform, creosote, ether, hydrocyanic acid, iodoform,
musk, nicotine, nitrobenzol, phenacetin, phosphorus, etc.) Many
foods may be recognized in the stomach by the odor (onions, garlic,
cabbage, turnips, pineapple, oranges, apples, peaches, vinegar,
grape-juice, caraway and anise seeds, celery, sage, cardamom, and
many others). In describing odors we should compare them with natural
odors or class them as sweet, sweetish, sour, bitter, pungent, sharp,
heavy, yeasty, pus-like, fruity, etc.
7. =Cut Surface.= The cut surface of the organs and tissues should
be examined immediately after the organ is sectioned. During the
examination the organ should be moved in different planes so that the
light may fall upon the surface in various angles. Color-changes,
differences in reflection and refraction, minute inequalities of
the surface, etc., are often brought out in this way when otherwise
they might be overlooked. During the examination the surface may be
gently scraped over by the blade of the large section-knife held
at an angle of 45° to the surface. The character and amount of the
blood and fluid exuding from the surfaces and vessels should be
noted; after this has been done the cut surface may be gently washed
with water and examined with regard to histologic and pathologic
details. During the inspection pressure may be made upon the organs
to determine still further the blood- and fluid-content. The color,
moisture or dryness, consistence, reflection or “shine” (dry-shining,
moist-shining, fatty shine, pearly shine, etc.), cloudiness,
translucency, transparency or opacity of the cut surface must also be
considered. Normal organs are never perfectly dry, although they vary
greatly in the amount of moisture shown on the surface. They have,
therefore, always a certain degree of reflecting power. Different
parts of the cut surface of the same organ should be compared as
to color, moisture and dryness. (Areas of suppuration, congestion,
œdema, inflammation, recent hemorrhage, hydropic degeneration,
liquefaction necrosis, etc., are more moist than normal; old thrombi,
fibrinous exudates, old hemorrhages, simple, coagulation, caseous and
Zenker’s necrosis, dry gangrene, anæmic and hemorrhagic infarctions,
amyloid, concretions of cholesterin, bile-pigment, lime-salts,
urates, etc., contents of dermoid cysts and cholesteatomata, etc.,
are dry.) The cut surface must be described also as to its even
or uneven character, finely or coarsely granular, shagreened,
rough, nodular, elevated or depressed portions, fissures, folds,
umbilication.
The cut surface of neoplasms is examined especially by scraping it
with a dry knife held at an angle of 45°. The cells thus obtained
constitute the _tissue-juice_ (“_cancer- or sarcoma-milk_”). Soft
medullary neoplasms yield an abundance of such cell-scrapings,
hard tumors but little. The cells thus obtained may be treated
according to the various methods given on Page 219, and then examined
microscopically. The cut-surface of the soft parenchymatous organs
(bone-marrow, spleen, thymus, lymphnodes, liver, pancreas and
kidneys) also yields material for examination by this method.
8. =Blood-Content.= The blood-content of the organs should be
estimated both before and after they are sectioned. This estimation
should be based upon the color of the organ, condition of the
blood-vessels, amount of blood exuded from the cut surface, number
of bleeding-points (anæmia, hyperæmia, stasis). Capillary, arterial
and venous hyperæmia should be differentiated when possible. Only
rarely are evidences of arterial congestion seen in the cadaver. It
is also necessary to observe the occurrence, location and extent
of hypostasis and to differentiate antemortem and postmortem
(lungs, brain, intestines, etc.). The association with œdema and
inflammation, particularly in the lungs (hypostatic pneumonia)
speaks for antemortem hypostasis. A red color in parts possessing
no blood-vessels (heart-valves, endocardium, intima of aorta,
cartilage, etc.) indicates an imbibition of diffused hæmoglobin
(hæmatin-imbibition). Changes in the color of the blood (carbon
monoxide, hydrocyanic acid, and hydrogen sulphide poisoning, all
poisons producing methæmoglobinæmia, icterus, leukæmia, etc.) should
be described and recorded; likewise all hemorrhages, extravasations,
etc.
9. =Histologic Features.= After the general points given above have
been considered the histologic features of the organ should be taken
up in routine. For example, in the case of the spleen, the capsule,
trabeculæ, pulp, stroma, follicles and vessels should be examined;
in the liver, the capsule, trabeculæ, liver-acini, blood-vessels
and bile-ducts; in the kidneys, capsules, cortical surface, cortex,
labyrinths and medullary rays, glomeruli, columns of Bertini,
medullary pyramids, vessels, pelvis and beginning of ureter. When the
organs are thus systematically examined there is but little chance
that anything visible to the naked eye has been overlooked.
10. =Pathologic Lesions.= Anomalies, defects, erosions, ulcers,
evidences of trauma, inflammations, abscesses, tubercles, gummata,
neoplasms, parasites, and all forms of pathologic changes, local
or general, must be accurately located and described. The changes
peculiar to certain diseases and infections must always be borne in
mind during the examination of any organ in which such conditions are
likely to be found. The relationship of lesions in different parts
of the body must be recognized. Localized lesions must be described
according to position, size, form, color, consistence, etc. Their
nature must be recognized, their relation to other or to pre-existing
conditions determined, the stage of the process estimated, and the
part played in the causation of death ascertained.
In the examination of the _body-cavities_ and _hollow organs_, as
well as _pathologic hollow structures_, the first thing to note is
the escape of gas or air under pressure. Occasionally it is best to
open the organ under water to note the escape of bubbles. The odor
of the gas, inflammability, etc., are to be noted. The fluid or
solid contents (blood, bile, urine, féces, mucus, pus, exudates and
transudates, altered secretions, food-remains, concretions, foreign
bodies, parasites, etc.) are described as to their amount, color,
consistence, odor, reaction, chemical nature, precipitate, presence
of cellular elements, etc. The size of the cavity, monolocular
or multilocular, the character of its lining (transparency,
translucency, cloudiness or opacity, color, “shine,” moisture,
smoothness, roughness, villous or polypoid, consistence, thickening,
swelling, elevations, atrophy, incrustations or deposits on the
lining, etc.) are to be considered. In the case of cystic tumors
(adenocystomata, dermoid cysts, cholesteatomata, etc.) especial
attention should be paid to the character of the cyst-contents
(mucoid, glairy, colloid, jelly-like, pea-soup-like, pultaceous,
mushy, doughy, caseous, pearly, laminated, flaky, powdery, etc.).