Organization of Part II

Some general remarks about objectives for the preparation of Part II can be found in the preface of this third edition. The following paragraphs explain the format in which diseases and conditions are listed in Part II. Diseases and Conditions. All main entries are arranged in alphabetic order of the noun. Thus, Viral hepatitis will be found under Hepatitis, viral and Lung abscess under Abscess, lung. In general, the organization of the entries corresponds to that used in Dorland's Illustrated...

Info

Death, Bolus (See Obstruction, acute airway.) Death, Crib (See Death, sudden unexpected, of infant.) Death due to Child Abuse or Neglect (See Infanticide.) Death, Intrauterine (See Stillbirth.) NOTE For special autopsy procedures, see p. 4. In some instances, procedures described under Death, anesthesia-associated may be indicated. For a thorough review of investiga-tional procedures and autopsy techniques in operating-room-associated deaths, see ref. (1). In patients who developed a cerebral...

Selection Of Tissue Blocks For Histologic Examination

BRAIN AND SPINAL CORD When the lesions in the brain are obvious, selection of the appropriate blocks is simple. For orientation and for possible evidence of pathologic involvement, some recognizable structures from the surrounding and presumably normal areas should be included. When gross lesions cannot be found despite the presence of clinical neurologic signs or symptoms, one must be familiar with the topographic distribution of the lesions expected in a given disease or syndrome to be able...

Vernard I Adams

DEFINITIONS, INDICATIONS AND LIMITATIONS OF THE METHOD Autopsy chemistry, or postmortem chemistry, is the term applied to the measurement of endogenous constituents in dead bodies. Toxicologic tests, which measure concentrations of drugs and exogenous toxins, are discussed in Chapter 2. Postmortem chemical studies provide direct information concerning derangement of physiology. In contrast, customary gross and histological autopsy examinations are primarily tests of structural derangement, from...

Persons Who Request Autopsy Permission

Typically, clinical residents or staff physicians will ask the next of kin to authorize an autopsy. In some institutions, specially trained technicians from the autopsy service or transplant-service coordinators assume this task (7). Although autopsy permission usually must be requested at what appears to be the most inappropriate time for the next of kin, a tactful explanation of the benefits for the family of the deceased and for other patients will usually be successful in securing...

Removal Of The Eye And Orbital Contents

ANTERIOR APPROACH In the vast majority of instances, the eye is removed by the anterior approach. (For the removal of orbital contents, see below under Intracranial Approach.) The eyelids are held apart with the aid of retractors (Fig. 7-2). Using curved scissors, the conjunctival attachments to the limbus are severed, care being taken not to cut the eyelids. Tenon's capsule is left intact to avoid leakage into the empty socket. The four rectus muscles are cut so that approx 5.0 mm of muscle...

Removal Of Brain In Fetuses And Infants

When the sutures are not closed and the cranial bones are still soft, Beneke's technique is used to open the cranium. The scalp is reflected as in adults. Starting at the lateral edge of the frontal fontanelle, the cranium and dura on both sides are cut with a pair of blunt scissors along the line indicated in Fig. 6-4A. (In this age group, the skull is often difficult to separate from the underlying dura in the manner described for adults.) This cut leaves a midline strip approx 1 cm wide,...

A213

For removal and dissection of pelvic organs, see p. 59. Leave ureters and kidneys attached to bladder. Open penile urethra (see Figs. 5-12 p. 63). Search for fistulas. If there is evidence of drainage via the urachus, demonstrate this before removal of pelvic organs. Posterior urethral valves strictures absence of canalization of penile urethra dilated bladder hypoplastic prostate hydroureters and hydronephrosis * renal cystic dysplasia fistulas to rectum or...

References

Medical Standards. Eye Bank Association of America, Washington, DC, 1996. 2. Forrest AR. ACP Broadsheet no. 137 April 1993. Obtaining samples at post mortem examination for toxicological and biochemical analyses. J Clin Pathol 1993 46 292-296. 3. Green MA, Lieberman G, Milroy CM, Parsons MA. Ocular and Cerebral trauma in non-accidental injury in infancy underlying mechanisms and implications for paedriatric practice. Br J Ophthalmol 1996 80 282-287. 4. Lee WR....

Shipping Of Autopsy Material

CONTAINERS FOR DRY MATERIAL Most commonly, slides and paraffin blocks are sent. Paraffin Blocks should be sealed with paraffin after microtomy to prevent tissue from drying out. Blocks can be wrapped in paper or plastic, but cotton should not be used because cotton fibers may stick to the paraffin and cause knife lines and abrasions. Glass slides should be shipped in unbreakable slide containers cushioned with cotton or other material. The packages should be sealed with tape because staples may...

Autopsy Diagnoses

Autopsy diagnosis represents an interpretation of objective, primarily morphologic, findings. For the next of kin, attending physicians, insurance companies, and public health authorities, these diagnosis sheets are important documents, but they may become meaningless in the future. Interpretations change, names of syndromes and diseases change, and so do autopsy diagnoses. This is one of the reasons why protocols should include objective descriptions. Autopsy diagnoses can be reported and...

Dissection Of Fresh Brain In Fetuses And Infants

Without an overriding need to secure unfixed samples for chemical or microbiologic examination, fetal and infantile brains are best kept intact until after proper fixation, because of their pronounced softness and ease of bruising. Our method is essentially similar to that described for adult brains. To increase consistency to fetal or infantile brains, we use as fixative 20 formalin solution containing 1 glacial acetic acid. No additional measures such as one or two changes of alcohol are...

Photography With William D Edwards

Color photographs, prepared with a 35-millimeter single-lens-reflex (SLR) camera or a digital camera, have become an integral part of autopsy records and the main tool of presenting findings at clinical conferences, in the classroom, and in court. These advantages have led to the decline of the pathology museum. Because most autopsy pathologists are sufficiently familiar with photographic equipment and the indications for its use, only a brief overview shall be provided here. INDICATIONS Four...

Examination And Removal Of Structures At Base Of Skull

VENOUS SINUSES, GANGLIA, AND DURA The venous sinuses including the cavernous sinuses are opened with curved scissors after removal of the brain. The Gasserian ganglia can be removed at this time. The dura at the base of the skull should be thoroughly stripped. This procedure is essential for exposing fracture lines. Before the dura is stripped, chisel and hammer should be used with caution because they may create arti-factual fractures. Removal of the cavernous sinuses with their contents may...

Methods Of Data Retrieval

INSTITUTIONAL AUTOSPY RECORDS The files containing autopsy documents tend to become quite voluminous. Traditionally, cases are numbered consecutively and filed by year. If no further provisions are made, information retrieval is possible only by manually searching each individual record. This may be quite acceptable if autopsy records are kept only for legal reasons and otherwise are used only in rare family studies. In these instances, only names, clinic number, and other essential identifiers...

General Precautions

Reducing time, increasing distance, and using shields are methods to reduce radiation exposure. Keeping the time of exposure at a minimum is the principal method of dose reduction for autopsy personnel. Extremity distance can be achieved through the use of long-handled instruments. Shielding with a radiology lead apron (0.5 mm lead equivalent thickness) would provide some protection for gamma radiation from 99mTc and 125I but would do little for highly penetrating gamma rays from 103Pd, 131I,...

Lamvlv

LV-I apex LV-PS base LV-S mid RA RAA RA-TV-RV RV-A base RV-A,L mid RV-I mid RV-PV-PA SN-1 Left internal mammary (thoracic) artery to LAD LIMA to radial artery segment to LAD Right internal mammary (thoracic) artery to RCA Atrioventricular conduction tissue (first cassette) AV-2 (second cassette), etc. Left atrial free wall Left atrial appendage Left atrium, mitral valve, and left ventricle (one specimen) Left ventricle, aortic valve, and ascending aorta (one specimen) Inferior wall of left...

Investigation Of Circumstances Of Poisoning

Frequently, medical examiner investigators or police detectives can use directed interview questions to elicit information Investigative Information Useful for Suspected Poisoning Casesa Date deceased was last known to be in good health Date and time last known to be alive Date and time pronounced dead in hospital, or Date, time, and content of last meal Prescribed drugs (append medication record if indicated) Symptoms nausea, vomiting, diarrhea, constipation, thirst, loss of weight, jaundice,...

I

Synonyms and Related Terms Thiamine deficiency Wernicke encephalopathy (cerebral beriberi). Possible Associated Conditions Chronic alcoholism chronic peritoneal dialysis hemodialysis Wernicke disease Wernicke-Korsakoff syndrome.* External examination and oral cavity Brain and spinal cord with dorsal-root ganglia Cerebral, spinal, and peripheral nerves Record weight and submit samples for histologic study (p. 30). For removal and specimen preparation, see pp. 65, 67, and 69, respectively....

Fixation

The best routine fixative that allows the widest choice of stains for the nervous tissue is formalin, usually as a 10 solution (see Chapter 14). In fetuses and infants, the addition of acetic acid to the fixative solution appears to be helpful. Acetic acid increases the specific gravity of the fixative and allows the brain to float in the solution it also makes the tissue firmer without altering its histologic characteristics (18). IMMERSION METHODS For detailed anatomic studies of the nervous...

Special Techniques

ARTERIOGRAPHY Adequate examination of the extrac-ranial portions of the cerebral arteries is important. The simplest method consists of injecting water through the proximal stumps to test patency. This test is conclusive only when vessels are completely occluded luminal narrowing cannot be appreciated by this method. Many postmortem angiographic studies of cerebral arteries have been described (29-31). We remove the neck vessels in most instances and thus, angiographic studies are not performed...

Specimen Collection

BLOOD CULTURES Postmortem blood cultures are frequently obtained but they rarely provide useful information. A recent study (5) from a general hospital showed that in 54 of patients with negative antemortem blood cultures, positive blood cultures were obtained postmortem although the patients had no infectious disease that could be considered a cause of death. Of patients with confirmed antemortem bacteremia fung-emia, only 34 had a postmortem blood culture from which the same organisms were...

Safety Concerns Of The Autopsy Service

GENERAL PRECAUTIONS Autopsy rooms should be clean, spacious, properly ventilated (3) and well lit. Safety-oriented design of the autopsy undoubtedly is part of the general precautions. For example, the level of the autopsy tables should be adjustable to the height of the prosector. It is preferred to have dissecting tables separate from the autopsy table. The autopsy laboratory also should have a safety-oriented design. These and other features are illustrated in Figs. 16-2 and 16-3. Morgue and...

Removal Of Spinal Cord In Infants

ANTERIOR APPROACH The basic principle is the same as in adults. The incomplete calcification of the spinal column permits the use of a scalpel blade instead of an oscillating saw blade. Fig. 6-8. Removal of cervical spine. Upper, scalpel blade is used to separate bone block at an intervertebral disk. Lower, bone block to be removed is reflected upward forcefully to break off at high cervical level. This method is faster, but not suitable when examination of the cervical spine (e.g., for...

And Microscopic Examination

Many suggestions have been made for sections to be taken for microscopic examination (3,42) most current policies are determined by the clinical history, the gross findings, special interests of the prosector (7), and cost restraints. GENERAL RECOMMENDATIONS For operated hearts and cases with a cardiac cause of death, a photograph of the heart should be taken before its dissection is begun. Preferably, the heart should be fixed in formalin for at least 5 min (to dull the surface) and then...

Indications

IN ADULTS Various aneuploidies of the sex chromosomes are the most common chromosome abnormalities encountered in autopsies of adults. The Turner (usually 45,X but mosaicism is common) and Klinefelter (47,XXY) syndromes are two examples (1). Deletions or unbalanced translocations and inversions are rarely seen at autopsies in adults because patients with these abnormalities seldom survive into adulthood. Approximately 1 500 adults carries a genetically balanced abnormality of chromosome...

Removal Of The Heart From The Chest

INITIAL STEPS Before the autopsy is begun, a radiogram of the chest may be performed (see Chapter 12). The removal of the chest plate has been described in Chapter 1. In patients who have had previous open-heart surgery via a median sternotomy, diffuse pericardial adhesions are common, which requires careful dissection of the heart away from the sternum so as not to disrupt any surgical sites. Pericardial exudate should be cultured (see Chapter 9). Pericardial blood clots should be weighed. If...

Of Postmortem Chemical Data

The most important changes of body-fluid components after death are compiled in Table 11-1. A synopsis of postmortem chemical findings in diseases such as diabetes mellitus is shown in Table 11-2. The tables show that glucose is best determined in vitreous because blood glucose values may increase dramatically in the agonal period, particularly after resuscitation attempts (1). Hyperglycemia and diabetic ketoacidosis can be diagnosed readily but hypoglycemia cannot be confirmed by postmortem...

Routine Sampling Of Toxicologic Material

In the author's office, it is usual practice in all autopsies to save 50 mL each of central blood, bile, urine, liver, and brain, plus available femoral vein blood up to 50 mL, and all retrievable vitreous. Approximately half the blood is placed in containers with sodium fluoride as a preservative. Sodium fluoride inhibits both bacterial growth and serum esterases which hydrolyze cocaine postmortem. If commercially available gray-top Vacutainer tubes are not used, 250 mg of NaF can be added to...

Liver And Hepatoduodenal Ligament

Before removal of the liver, the hepatoduodenal ligament should be dissected. First, the common bile duct is incised and Fig. 5-4. Posterior view of portions of liver, pancreas, and spleen. Note presence of micronodular cirrhosis. The splenic vein has been opened and the confluence with the portal vein the superior mesenteric vein is shown, together with the partially opened inferior vena cava. Fig. 5-4. Posterior view of portions of liver, pancreas, and spleen. Note presence of micronodular...

Processing Of Ocular Specimens

FIXATION, ORIENTATION, DOCUMENTATION OF LESIONS AND SECTIONING The enucleated eye is placed in 20-25 times its volume of 10 buffered formalin for 48 h of fixation. The neck of the container should be approximately twice the diameter of the globe for ease of removal of the specimen (Fig. 7-4). Injection of fixative into the globe is not necessary and should be avoided as it introduces artifact into the globe. If the eye and orbital contents have been removed in toto, the eye should be dissected...

Dissection Of Fresh Lungs

Dissection from Hilus The pulmonary arteries and bronchi are opened from the hilus toward the periphery of the media-stinal surface of the lung. Subsequently, the lungs are cut into several sagittal slices, that is, parallel with the mediastinal surface. This method permits study of many cross-sections of bronchovascular units and gives a good overall view of the parenchyma. Unfortunately, the continuity of the organs is lost so that it may be difficult to identify the original site of...

And Removal Of Bone Specimens

Routine preparation of gross and microscopic bone specimens can be carried out only on a limited scale. However, portions of rib with costochondral junction, sternum, vertebral body, or iliac crest, and sternoclavicular joint should be removed and permanently saved in every autopsy. Specimens suggested for study in cases of metabolic or other systemic bone and joint diseases are indicated below. The site of a circumscribed neo-plastic or inflammatory bone lesion can be determined from clinical...

A

Synonyms and Related Terms Acanthocytosis Bassen-Kornzweig syndrome. NOTE Autopsies on patients with this rare genetic disease (1,2) should be considered research procedures. Possible Associated Conditions Hemolytic anemia * malabsorption syndrome.* External examination Record body weight and length. Prepare chest roentgenogram (frontal and lateral view). Blood Submit for serum lipid analysis. Brain, spinal cord, peripheral nerves 1. Case records of the Massachussetts General Hospital. Case...

Postmortem Chemical Changes in Pathological Conditionsa

Diabetes mellitus Endocrine disorders Inborn errors of metabolismc Liver diseases (See also Hepatic coma) Postmortem change unrelated to clinical disease Vitreous (decomposition pattern) Uremia Vitreous Postmortem measurements of pH values probably not reliable. For ketoacidosis, see Diabetes mellitus. High sodium (> 155 meq L) and chloride (> 135 meq L) values with moderate increase (above 40 mg dL) of urea nitrogen concentration. High glucose (> 200 mg dL or > 11.1 mmol L) and ketone...

Medicolegal Forms With Legal Analysis P-47

Within 1 h after consumption of diluted alcohol (approx 15 ) on an empty stomach, assuming body weight of 140-180 pounds (63.6-81.7 kg) reproduced from (11) with permission. ounce (about 30 mL) of whiskey or 12 oz (about 355 mL) of beer. Within 1 h after consumption of diluted alcohol (approx 15 ) on an empty stomach, assuming body weight of 140-180 pounds (63.6-81.7 kg) reproduced from (11) with permission. ounce (about 30 mL) of whiskey or 12 oz (about 355 mL) of beer. What Is the Toxicity...

Quantitative Measurements Of The Heart

HEART WEIGHT Total heart weight is the most reliable single measurement at autopsy for correlation with cardiac disease states (7). The assessment must take into account the size of the patient. Other described measurements such as linear external dimensions, surface areas, and volume of the entire heart or myocardium (7) are less useful than the total heart weight. Hearts are weighed after the parietal pericardium has been removed, the great vessels have been trimmed to about 2 cm in length,...

E

NOTE (1) Collect all tissues that appear to be infected. (2) Usually, cultures are not required, only direct examination for parasites. (3) Request Giemsa stain for parasites (p. 172). (4) Special precautions should be exercised in removing the cysts, as the contents are highly infectious (p. 146). (5) Serologic studies are available from the Center for Disease Control and Prevention, Atlanta, GA (p. 135). (6) This is not a reportable disease. If the liver is the site of involvement, prepare...

Removal Of Spinal Cord In Adults

Spinal Cord Removal

Removal of the spinal cord has been traditionally neglected by general pathologists but can be accomplished very easily within 10-15 min by the use of an oscillating saw, as described below. This should be part of every autopsy. POSTERIOR APPROACH The body should be placed in the prone position with blocks under the shoulders. The head is rotated forward in a flexed position. Towels are placed under the face to avoid damage. A midline incision is placed over the spinous processes, muscles are...

Current Routine Autopsy Techniques

GENERAL POLICIES Autopsy techniques are learned from a preceptor in the autopsy room. This time-honored method still is integrated in the training of all anatomic pathologists and therefore, printed or audiovisual teaching aids, referenced in the earlier editions of this book, have played no appreciable role. Thus, a detailed description of autopsy techniques is beyond the scope of this book. Nevertheless, some recent guidelines may be helpful (2,4,5). Pathologists generally achieve the best...

Removal Of Brain In Adults

Coronal Mastoid Incision

INCISION OF SCALP The head is elevated slightly with a wooden block or a metal headrest attached to the autopsy table. The hair is parted with a comb along an imaginary coronal plane connecting one mastoid with the other over the convexity Fig. 6-1 . A sharp scalpel blade can then be used to cut through the whole thickness of the scalp from the outside. The incision should start on the right side of the head the viewing-side in most American funeral parlors just behind the ear-lobe, as low as...

Kaiserlings Solutions

Kaiserling I 85 g potassium acetate, 45 g potassium nitrate KNO3 , 4,800 mL formalin solution 3-4 . b.Kaiserling II ethyl alcohol, 80-95 . c. Kaiserling III 200 g potassium acetate, 300 mL glycerin, 900 mL tap water. 2. Procedure. Fix specimen for 1-5 d in Kaiserling I. Fixation time will vary with the thickness of the organ. Excessive perfusion with Kaiserling I solution causes loss of natural color because too much blood is rinsed out. Transfer to Kaiserling II for a few hours. Acid...

Carnoys Fixative

Preservation of nuclei and other structures rich in nucleic acids, protein sulfhydryl groups, and gly-cogen. 2. Composition. 640 mL absolute ethyl alcohol, 120 mL chloroform, 40 mL glacial 99.7 acetic acid. 3. Procedure. Slices up to 1.5 cm in thickness can be fixed. The fixation time will vary from 2-20 h. Transfer into absolute ethyl alcohol. 4. Storage. Fixed tissue should be stored in cedar oil reagent grade or USP or lightweight liquid petrolatum. Formalin Solutions...

Dissection Methods Of The Heart

Left Ventricular Hypertrophy Dissection

Many older methods 7 are impractical for routine diagnostic pathology. Only the inflow-outflow and short axis bread slice methods have withstood the test of time the latter technique is applicable to virtually any form of heart disease. In addition, some recently described methods are useful for teaching purposes and correlations with current cardiac imaging 8-14 . INFLOW-OUTFLOW METHOD OF CARDIAC DISSECTION This technique is suitable primarily for normal hearts. For each side of the heart, the...

Dissection Of Brain And Spinal Cord

Brain weight in the fresh and fixed state should be recorded. It is not necessary to use a very large knife to dissect the brain. We prefer a single-blade autopsy knife about 25 cm long and 2 cm wide. DISSECTION OF FRESH BRAIN IN ADULTS The most exacting examination of brain in terms of recognition of lesions and correlation of their topography with clinical symptoms and images generated by computerized trans-axial tomography CT or magnetic resonance imaging MRI techniques can be achieved only...

Intestinal Tract

Celiac Trunk Superior Mesenteric Artery

In the presence of tumors or other pathologic lesions involving the duodenum, papilla of Vater, head of pancreas, or hepatoduodenal ligament, the duodenum should be opened in situ. Precise orientation may become impossible after removal of these organs. This is particularly important in postoperative autopsies. Routinely, the intestinal tract is opened with an enterotome, that is, large scissors with one blunted branch that lies in the lumen of the intestine. The procedure is greatly...

Special Autopsy Techniques

POSTOPERATIVE AUTOPSIES Few autopsies present more difficulties because the pathologist is rarely familiar with all operative techniques that may have been used, the complications that were encountered, including anesthesia-related and drug-induced mishaps, and the postoperative events that may completely obscure the immediate surgical results. Possible medicolegal implications must be considered also 16 . The following general guidelines should be observed. 1. In any team, the most experienced...