Practical pathology

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.

B. Internal Examination.

I. SPINAL CORD.

II. HEAD.

III. THORAX AND ABDOMEN. (Main Incision.)

IV. THORAX.

V. MOUTH AND NECK.

VI. ABDOMEN.

VII. MALE PELVIS.

VIII. FEMALE PELVIS

IX. SPECIAL REGIONAL EXAMINATION.

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:

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.