Info

Dissection, Aortic

Synonym: Dissecting aortic aneurysm; dissecting aortic hematoma.

Organs and Tissues

Procedures

Possible or Expected Findings

External examination

Pericardium Aorta

Heart

Other organs Brain and spinal cord

Record and photograph abnormal features (see right-hand column). Prepare chest roentgenogram.

Record appearance and volume of contents. Remove heart and major arteries attached to intact aorta. Open aorta along posterior midline. Photograph intimal tears and record their location and size. Record external rupture site, if possible, and extent of mediastinal or retroperitoneal hemorrhage. Record location and volume of blood in "false" lumen and presence or absence of intramural hematoma, not connected to lumen. Record location and size of re-entry tear, if present.

Request Verhoeff-van Gieson and PAS-alcian blue stains (p. 173).

Sections should include grossly involved and uninvolved portions of aortic wall and of adjacent elastic arteries. Procedures depend on expected findings or grossly identified abnormalities as listed in right-hand column.

For removal and specimen preparation of brain and spinal cord, see pp. 65 and 67, respectively.

Features of Marfan's syndrome* or Turner's syndrome.* Widened aorta or mediastinum.

Hemopericardium.

Coarctation of the aorta.* Dissection may involve major branches of aorta. Blood may be present in periaortic tissues and pericardium (see above). Intimal tear is most commonly located in ascending thoracic aorta. False lumen occurs with or without tear of reentry. The aorta may be atherosclerotic. In the descending thoracic or abdominal aorta, an intimal tear may involve an ulcerated plaque (penetrating ulcer). Cystic medial degeneration of aorta. Rarely, giant cell aortitis.

Congenitally bicuspid aortic valve.* Concentric left ventricular hypertrophy. Myxomatous mitral valve. Manifestations of hypertension* or of third-trimester pregnancy.

Ischemic lesions in brain and spinal cord and in other organs.

Diverticula

Related Terms: Diverticular disease; diverticulitis; diverticulosis; Meckel's diverticulum; pulsion diverticulum; traction diverticulum; Zenker's diverticulum.

Organs and Tissues

Procedures

Possible or Expected Findings

Esophagus

Stomach Small bowel

Colon

Dissect diverticulum in situ and photograph. Fix specimen in formalin before opening.

For preservation of jejunal diverticula by air drying, see p. 55. Prepare histologic sections of Meckel's diverticulum. Rinse carefully; openings of diverticula may be difficult to identify. Record thickness of colonic wall and extent, approximate number, and location of diverticula.

Hypopharyngeal pulsion diverticulum (Zenker's diverticulum) at lower margin of inferior constrictor muscle of pharynx. Traction diverticulum at midesophagus after an inflammatory process—for instance, tuberculous lymphadenitis. Epiphrenic diverticulum may also occur. Juxtacardiac or juxtapyloric diverticulum. Heterotopic tissue in Meckel's diverticulum, with or without peptic ulceration.

Colonic muscular hypertrophy and stenosis, usually in sigmoid colon. Diverticulitis with perforation, fistulas, or peritonitis.*

Diverticulitis (See "Diverticula.")

Diverticulitis (See "Diverticula.")

Diving (See "Accident, diving (skin or scuba).")

Drowning

Related Terms: Dry drowning; fresh-water drowning; near-drowning; salt (sea)-water drowning (see the following table).

Table II-1

Deaths from Drowning

Primary Drowning ("Immediate Drowning")

Secondary Drowning ("Near-Drowning")

Deaths occurring within minutes after immersion, before or without resuscitative measures

Deaths occurring from within 30 min to several weeks after resuscitation, because of metabolic acidosis, pulmonary edema, or infective or chemical pneumonitis

Type I ("Dry Drowning")

Type II ("Wet Drowning")

Deaths from hypoxia and acidosis caused by glottal spasm on breath holding. There may be no evidence of water entering stomach or lungs and no appreciable morphologic changes at autopsy.

Deaths from hypoxia and acidosis caused by obstruction of airway by water related to:

Hypervolemia

Hemolysis

Hyponatremia

Hypochloremia

Hyperkalemia

Hyperkalemia

NOTE: The diagnosis is one of exclusion. The pathologist should help the police to determine: 1) How did the person (or dead body) get in the water, and 2) why could that person not get out of the water? It is not enough to ask if a person could swim but investigators should find out how well (what strokes did the victim know?) and how far he or she could swim. The inquiry must include the depth of the water and must address hazards such as undertow or underwater debris, and the behavior of the victim immediately before submerging. Deaths of adults in bathtubs and swimming pools are usually from natural, cardiac causes, or they are suicides, unless the victim was drunk.

Diatom tests (1) have not proven useful in the United States but there is enthusiasm for such tests among European patholo-gists. The distinction between hyponatremic deaths in fresh water and hypernatremic deaths in salt water derives from experimental studies; in practice, one cannot reliably predict the salinity of the immersion medium from autopsy studies. Because many bodies of drowning victims are recovered only after the body floats to the surface, decomposition will often obscure even the nondiagnostic findings such as pleural effusions, which are often associated with drowning.

Organs and Tissues

Procedures

Possible or Expected Findings

External examination and skin (wounds)

If identity of drowning victim is not known, record identifying features as described on p. 11.

Prepare dental and whole-body roentgenograms. Submit tissue samples for histologic study of wounds.

Inspect inside of hands.

Collect fingernail scrapings.

Record appearance and contents of body orifices.

There may be wounds that were inflicted before drowning occurred—for instance, in shipwrecks or vehicular and diving accidents.

Other wounds may be inflicted after death— for instance, from ship propellers or marine animals. Sometimes, premortem and postmortem wounds can be distinguished histologically.

Object (hair?) held by hands in cadaveric spasm. Cutis anserina and "washerwoman" changes of hands and feet are of no diagnostic help.

Foreign bodies; semen (see also under "Rape").

Organs and Tissues

Procedures

Possible or Expected Findings

External examination and skin (wounds)

(continued)

Blood

Organ samples for diatom search

Serosal surfaces and cavities

Neck organ and lungs

Heart

Intestinal tract and stomach

Other organs

Genital organs Brain

Middle ears, paranasal sinuses, and mastoid spaces

Record features indicative of drowning.

Photograph face from front and in profile. Take pictures of all injuries, with and without scale and autopsy number. Remove vitreous (p. 85).

If diatom search is intended, clean body thoroughly before dissection to avoid contamination of organs and body fluids with algae and diatoms (see below). Submit sample for toxicologic study.

Sample early during autopsy, before carrying out other dissections. Use fresh instruments for removal of specimens to avoid contamination. Submit subpleural portion of lung: subcapsular portions of liver, spleen, and kidneys; bone marrow; and brain. Store samples in clean glass jars. For technique of diatom detection, see below. Record volume of fluid in pleural spaces. Photograph petechial hemorrhages.

Photograph layerwise neck dissection if strangulation* is suspected. Open airways posteriorly, and photograph, remove and save mud, algae, and any other material in tracheobronchial tree. Record size and weight of lungs.

Request frozen sections for Sudan fat stain (p. 173).

For coronary arteriography, see p. 118.

Save stomach contents (p. 16) and record volume. Record character of intestinal contents and submit for toxicologic study. Record appearance of serosal and mesenteric lymphatics.

Search for evidence of rape,* pregnancy,* or both.

For removal and specimen preparation, see p. 65.

Expose with chisel, and record presence or absence of hemorrhages; photograph hemorrhages; inspect eardrums for presence of perforation (p. 72). If perforated, prepare histologic sections.

Foam cap over mouth and nose. In the autopsy room, water running from nose and mouth is usually pulmonary edema or water from the stomach. Identification (p. 11).

High concentrations of alcohol indicate intoxication (see under "Alcoholism and alcohol intoxication").

Evidence of alcohol intoxication may be found.

Diatoms may occur in the liver and in other organs of persons who have died from causes other than drowning. Comparison with diatoms in water sample from area of drowning may be helpful.

Penny-sized or smaller hemorrhages may indicate violent respiratory efforts or merely intense lividity.

Presence of pleural fluid suggests drowning.

Presence of "aqueous emphysema" indicates violent respiratory efforts.

Fat emboli and bone marrow emboli indicate fractures during life. Coronary atherosclerosis and coronary thrombosis.*

Gastric and intestinal contents indicate type and occasionally time of last meal. Intestinal lymphatics ("lacteals") dilated and quite conspicuous during resorptive state. Tablet residues may be present. Evidence of disseminated intravascular coagulation* may be found after fresh-water submersion.

Anoxic changes.

Hemorrhages in middle ears or mastoid air spaces are strong evidence of drowning. Middle ear or mastoid hemorrhages can be documented histologically. Watery liquid in sphenoid sinuses.

Technique of Diatom Detection

For diatom detection (1), boil 2-5 g of tissue for 10-15 min in 10 mL of concentrated nitric acid and 0.5 mL of concentrated sulfuric acid. Then, add sodium nitrate in small quantities until the black color of the charred organic matter has been dispelled. It may be necessary to warm the acid-digested material with weak sodium hydroxide, but the material must soon be washed free from alkali to avoid dissolving the diatoms. The diatoms should be washed, concentrated, and stored in distilled water. For examination, allow a drop of the concentrate to evaporate on a slide, and then mount it in a resin of high refractive index. All equipment must be well-cleaned, and distilled water must be used for all solutions. There are several variations and adaptations of this method.

Reference

1. Camps FE. Immersion in fluids. In: Recent Advances in Forensic Pathology. J & A Churchill, London, 1969, pp. 70-79.

Drugs (See "Abuse,...," "Dependence,...," and "Poisoning,...")

Ductus Arteriosus, Patent (See "Artery, patent ductal.") Dwarfism

Synonyms and Related Terms. Achondroplastic dwarf; asexual dwarf; ateliotic dwarf; micromelic dwarf; normal dwarf; pituitary dwarf; true dwarf; and many other terms, too numerous to mention.

Organs and Tissues

Procedures

Possible or Expected Findings

External examination

Endocrine organs

Other organs

Record lengths of extremities and length of rump (calculate ratio), head circumference, and other suspected abnormal dimensions. Prepare skeletal roentgenograms.

Record weights and prepare histologic sections of all endocrine organs. For removal and specimen preparation of pituitary gland, see p. 71.

Follow procedures described under suspected underlying disease (see right-hand column). In true or primordial dwarfism, no associated abnormalities can be suspected.

Short or deformed extremities, deformed head, and other deformities. Abnormalities of primary and secondary sex characteristics. Osseous and cartilaginous deformities; skeletal tumor (adamantinoma). Tumor; infection; posttraumatic lesions; infiltrates of Langerhans cell histiocytosis.*

Achondroplasia;* congenital heart disease;* Hurler's syndrome (see "Mucopolysaccharidosis"); hypothyroidism;* malabsorption syndrome;* pituitary insufficiency;* renal failure* (chronic); sexual precocity with premature fusion of epiphyses; other systemic diseases.

Dysbetalipoproteinemia, Familial (See "Hyperlipoproteinemia.")

Dyschondroplasia, Ollier's

Synonyms and Related Terms: Multiple enchondromatosis; Ollier's disease; osteochondrodysplasia.

Organs and Tissues Procedures Possible or Expected Findings

External examination Record height and weight. Prepare skeletal Growth retardation. Abnormal growth of roentgenograms. epiphyseal cartilage with enlargement of metaphysis. Long bones and pelvis most commonly affected.

Skin and soft tissues Cavernous hemangiomas (Maffucci's syndrome).

Bones and joints For removal, prosthetic repair, and specimen See above under "External examination."

preparation, see p. 95. Chondrosarcoma.

Dyscrasia, Plasma Cell

NOTE: These conditions are characterized by abnormally proliferated B-immunocytes that produce a monoclonal immunoglobulin. Multiple myeloma,* plasma cell leukemia, plasmacytoma, and Waldenstrom's macroglobulinemia* as well as heavy-chain diseases and monoclonal gammopathies of unknown type belong to this disease family. Amyloidosis* is closely related to these conditions. For autopsy procedures, see under "amyloidosis," "macroglobulinemia," or "multiple myeloma" and under name of condition that may have caused the plasma cell dyscrasia. Such conditions include carcinoma (colon, breast, or biliary tract), Gaucher's disease,* hyperlipoproteinemia,* infectious or noninfectious chronic inflammatory diseases, and previous cardiac surgery.

Dysentery, Bacillary

Synonym: Shigella dysentery.

NOTE: (1) Collect all tissues that appear to be infected. (2) Request aerobic bacterial cultures. (3) Request Gram stain (p. 172). (4) Special precautions are indicated (p. 146). (5) Serologic studies are available from local and state health department laboratories (p. 135). (6) This is a reportable disease.

Organs and Tissues

Procedures

Possible or Expected Findings

Blood Bowel

Eyes

Joints

Submit sample for culture and for serologic study (p. 102).

Submit sample of feces or preferably blood-tinged mucus for culture. If bacteriologic diagnosis has already been confirmed, pin colon on corkboard, photograph, and fix in formalin for histologic study.

Submit sample of vitreous for study of sodium, potassium, chloride, and urea nitrogen concentrations (p. 85).

For removal and specimen preparation of eyes, see p. 85.

For removal, prosthetic repair, and specimen preparation, see p. 96.

Escherichia coli septicemia.

Colitis with microabscesses; transverse shallow ulcers and hemorrhages, most often in terminal ileum and colon.

Dehydration* pattern of electrolytes and urea nitrogen (p. 115).

Conjunctivitis, iritis.

Serous arthritis* of knee joints is a late complication.

Dysfibrinogenemia

NOTE: Bleeding and thromboembolism* may be noted at autopsy. Clotting studies with postmortem blood are not indicated. AIDS,* liver disease, and lymphoproliferative disorders are possible underlying conditions.

Dysgenesis, Gonadal (Ovarian) (See "Syndrome, Turner's.")

Dysgenesis, Seminiferous Tubule (See "Syndrome, Klinefelter's.")

Dyskinesia, Ciliary

Synonyms and Related Terms: Immotile cilia syndrome; Kartageners triad.

NOTE: Multiple conditions belong into this disease category, all characterized by a hereditary defect of the axoneme (the "motor" of the cilia).

Organs and Tissues

Procedures

Possible or Expected Findings

Chest cavity Lungs

Nasal cavities, sinuses, and middle ears

If situs inversus is present, photograph chest organs in situ.

Submit samples from one lung for microbiologic study (p. 103). Perfuse on lung with formalin (p. 47).

For exposure and specimen preparation, see pp. 71 and 72.

Prepare samples of mucosa for electron microscopic study of cilia (p. 132).

Situs inversus in Kartagener's triad (with sinusitis and bronchiectases—see below). Bronchiectases and bronchopneumonia.

Nasal polyps; sinusitis, and otitis media.* Missing dynein arms.

Dysphagia, Sideropenic (See "Syndrome, Plummer-Vinson.")

Dysplasia, Chrondroectodermal (See "Syndrome, Ellis-van Creveld.")

Dysplasia, Fibrous, of Bone

Related Term: McCune-Albright syndrome.

Possible Associated Conditions: Acromegaly;* Cushing's syndrome;* hyperthyroidism.*

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