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.).