Autopsy

AUTOPSY

the cause of death.* It is customary to distinguish between pathological-anatomical autopsies and forensic-medical autopsies. The former are performed on the corpses of persons who died from various diseases in hospital institutions; the performance of such pathological-anatomical autopsies should be a rule for these institutions and, if possible, concern all persons who died in them. Pathological-anatomical autopsies can also include the autopsy of laboratory animals (see). Forensic-medical autopsies are performed by order of judicial authorities on the corpses of persons whose cause of death can be assumed to be related to any violent or criminal acts. Historical data. The first autopsies of corpses date back to the last centuries B.C.; it is known that in Egypt, by order of King Ptolemy, the corpses of criminals began to be handed over to physicians for scientific research. The first anatomical studies of Herophilus date back to this time. However, in the subsequent period, in connection with the development of religious prejudices, the autopsy of corpses ceased; only a few (e.g., Galen, 2nd century A.D.) occasionally dissected animal corpses. In the early Middle Ages, autopsies were viewed as a sacrilegious act, and persons suspected of performing them were subjected to the harshest repressions. During this period, it was only very rarely that anyone managed to perform an autopsy and publish its results (Mundinus in the 13th–14th centuries). After a special 'encyclical' (circular) of Pope Pius IV (16th century), which not only permitted but also recommended autopsies to clarify the causes of death, autopsies gradually began to enter the practice of physicians as a scientific method (Vesalius, 1514–64) and to be practiced for the purposes of anatomy, pathology, and forensic medicine. It should be noted that even in the first half of the 19th century, autopsies were performed very infrequently, and the departments of anatomy existing at that time suffered greatly from a lack of corpses. Usually, almost exclusively the corpses of persons who had no relatives were subjected to autopsy. Subsequently, the number of corpses autopsied in hospital institutions began to increase, and at the beginning of the second half of the 19th century, Virchow was already autopsying 40–45% of all those who died in the Berlin Charité hospital. This figure is slowly increasing, and at the present time, for many medical institutions in Germany, it is equal to 75–80%. In France and England, and especially in America, due to the fact that less importance is attached to pathological anatomy there and in many hospitals there are not even prosectors, this figure is lower (about 65%); in Switzerland, it is equal to 100% due to the fact that about 25 years ago a law was passed there on the mandatory autopsy of persons who died in hospital institutions. In Russia, before the revolution, due to the existing rule that autopsies are performed no earlier than 24 hours after death, and due to the lack of culture of the population, the number of corpses autopsied in hospitals did not exceed 60–65%; the only exceptions were the clinics of Moscow University, in which a rule (existing at the present time) on the mandatory autopsy of all those who died in them had long been established. After the revolution, it can be definitely noted that in the large centers of the USSR, the percentage of corpses autopsied in hospitals has become significantly higher than before. In Moscow, in recent years, it has reached, on average, 85%, and in some Moscow hospitals (e.g., the S. P. Botkin Hospital) — up to 91–92%. All this provides for Moscow about 8,000–9,000 autopsies annually; in other words, about 1/3 of all those who died in Moscow are autopsied. The rules by which the hospital administration and the prosector are guided in the matter of autopsies are not the same in different republics of the USSR. In Moscow, at the present time, the following 'Instruction on the section of corpses in medical institutions of the Moscow Department of Health' dated September 12, 1924 ('Weekly of the Moscow Health Department', 1924), supplemented on January 28, 1925, is applied: '1. In connection with the reorganization of medical affairs in the hospitals of the Moscow Department of Health and its direction towards prevention, a particularly deepened setup of clinical and anatomical research is required, and therefore, if possible, all corpses of those who died in communal medical institutions are subjected to section. Note: To ensure teaching at medical faculties, it is desirable not to subject the corpses of the destitute to section. - 2. An autopsy is performed with the permission of the chief physician of the hospital or medical institution. When authorizing an autopsy, the chief physician of the hospital or medical institution is guided by: a) the requirements of scientific control of hospital affairs; b) the interests of studying occupational diseases and rarely encountered or complex forms of diseases; c) the need to determine initial cases of epidemic diseases. - 3. The autopsy of the body of a person who died in a hospital or medical institution may be canceled upon the petition of relatives no further than the second degree; a statement about this must be made to the chief physician or his deputy. - 4. The autopsy of the body of a deceased person is not subject to cancellation: a) in case of the need to determine initial cases of an epidemic disease; b) for special scientific reasons for a detailed and accurate study of the disease process, according to paragraphs 1 and 2 of the instruction. An autopsy is mandatory and not subject to cancellation in all cases when death occurred after a short stay of the patient, i.e., before the expiration of 24 hours from the moment of the patient's admission to the medical institution (1267-28/1-25). Note: the cancellation of an autopsy in forensic-medical cases depends on the judicial authority. - 5. A pathological-anatomical autopsy of the body cannot be performed earlier than 2 hours from the time of death. Note: for scientific and scientific-practical purposes, it is permissible for clinical and hospital institutions to perform autopsies on corpses before the expiration of 2 hours, but not earlier than half an hour after death, with the prosector specifying in the protocol the reason for the necessity of an early autopsy. - 6. In the presence of bodily injuries, signs of violence, or phenomena depending on other criminal actions in the deceased, the appropriate administrative authority must be notified, and the autopsy is suspended for the transfer of this case to forensic-medical authorities.' - Subsequently, the instruction pursues the goals of distinguishing between the performance of autopsies by pathologists and forensic-medical experts (paragraph 6). The question of injuries and poisonings observed in the order of practical medical activity is of great importance, especially in connection with the widespread use of surgical methods of treatment, complex instrumental examinations, X-rays, intravenous infusions of various medicinal substances, etc. In all cases of death associated with such interventions (for example, anesthesia, encephalography, injection of salvarsan, etc.), if they were performed in a normal clinical or hospital setting and do not bear traces of clearly negligent or criminal actions, the autopsy is performed in the general order, i.e., pathologically-anatomically. It is especially important to emphasize the necessity of observing paragraph 6 of the instruction in relation to abortions: all cases of death after abortions performed outside the walls of institutions authorized for these operations are unconditionally subject to forensic-medical autopsy. In individual cases, when the decision on the direction of the corpse to one or another instance cannot be given with certainty, joint participation in the autopsy by both a pathologist and a forensic-medical expert is necessary; the autopsy itself is conducted with careful observance of the relevant rules guaranteeing the socio-legal side of the matter. Pathological-anatomical autopsies of corpses in non-clinical institutions are always performed by written order of the chief physician or director of the institution. The significance of an autopsy is very great and diverse. First of all, one can emphasize the already mentioned role of autopsy in the development of correct materialistic views on the structure of the human body, its functions, and the essence of disease processes. Autopsies are, in addition, the main base for developing the problems of so-called thanatology, or the study of death. Furthermore, autopsies play a very large role in teaching. Autopsies also have great sanitary-epidemiological significance, since often, thanks to autopsies, the appearance of certain infectious diseases, which could be the beginning of an epidemic, is established. In hospital institutions, through autopsies, control over the activity of their departments is carried out in the sense of the correctness of diagnosing and treating diseases. The enormous significance of autopsies in this regard is revealed by comparative-statistical data obtained by comparing clinical (resp. hospital) and anatomical diagnoses. Firstly, only as a great exception is a case observed where an autopsy would not introduce something new to the antemortem diagnosis of a disease, and in 16–25% of all autopsies (depending on the qualifications of the institutions, the workload of the staff, etc.), there is even a complete discrepancy of diagnoses concerning the underlying disease; in an even greater percentage of cases, there are unrecognized or incorrectly recognized concomitant ailments. - The significance of forensic-medical autopsies lies in the fact that they detail the cause of death of the subject, and also establish or reject the role of certain violent influences in the fatal outcome; these data have a very important, often decisive significance in judicial terms. Pathological-anatomical autopsy. The methodology of autopsy has developed and improved gradually; only at the beginning of the second half of the 19th century R.

Virchow was the first to indicate a definite and most rational order for the autopsy of a corpse. This Virchow method is to this day the most widespread and serves as the basis for all other methods (Heller-Zenker, Chiari, Letulle), which differ from it only in details. Pathological-anatomical autopsies are performed in specially adapted institutions existing at hospitals and clinics. In medical faculties, such an institution is the pathological-anatomical institute, to which the corpses of those who died in university clinics are sent. In hospitals (see), autopsies are usually performed in special premises—anatomical theaters or prosectoriums, serviced by special physicians-pathologists, called prosectors (see), and assistants to the prosectors. Forensic medical autopsies in cities that have medical faculties and medical institutes are performed for the most part at the departments of forensic medicine by a professor and the instructors of this subject; in other cities, by special forensic medical experts in so-called morgues (see). In medical districts remote from cities, autopsies, both pathological-anatomical and sometimes forensic medical, have to be performed by district physicians. In pathological-anatomical institutes, prosectoriums, and morgues, there are special dissection halls or rooms with dissection tables for autopsies. In the absence of a specially adapted room, autopsies are performed on a simple table, on some boards, etc. Special dissection instruments are used for autopsies. The person performing the autopsy puts on a gown and an oilcloth apron over their clothes, and protects their hands with rubber gloves; in the absence of gloves, the hands are greased with fat, for example, a mixture of petroleum jelly and lanolin. An autopsy must be performed in daylight, since with artificial lighting it is difficult to make correct conclusions about changes in the color of the skin and organs of the corpse. The corpse for the autopsy is placed on its back, with the head facing the window; a block (or log) is placed under the corpse; a vessel with water is placed at the feet of the corpse. The person performing the autopsy remains at the side of the table, at the right side of the corpse, throughout the entire autopsy, and only when opening the skull and extracting the brain does he stand at the head of the corpse. For a pathological-anatomical autopsy of a corpse, the general order is as follows. The autopsy itself is preceded by familiarizing the prosector and those present with the clinical course of the disease and the antemortem diagnosis by reading the medical history or by an oral report from the physician who observed the course of the disease. After this, the prosector performs an external examination of the corpse, noting data on sex, age, body dimensions, physique, constitutional appearance, nutrition, condition of the skin (color, postmortem lividity, rashes, hemorrhages, wounds, ulcers, scars, bedsores, swelling and edema of the skin, etc.), rigor mortis, and cadaveric odor. The external examination is followed by an incision and separation of the skin and the opening of the body cavities; for this, a main incision of the skin is made, most often running from the chin to the pubis; some use incisions of a different type; following the incision, the skin is separated to the sides from the midline, which opens the abdominal cavity and exposes the thoracic cage. The latter is opened by cutting the cartilaginous parts of the ribs near the place of their transition into the bony parts. After opening the cavities, a detailed examination of them is performed, clarifying the peculiarities in the position and relationship of the organs, the presence of accumulations, adhesions, etc., and then the extraction of organs from the corpse begins. The order of extracting organs from the corpse and examining them can be different depending on the peculiarities of the case; in general, for each autopsy, it is customary to individualize the course of the autopsy and, based on the data of the medical history and the results of the examination of the organs in situ, to make a departure from the main method. As for the main method of extracting and examining organs, it is different in various pathological-anatomical institutions, in connection with tradition, the peculiarities of the school, or the personal habit of the director, representing certain deviations from the Virchow scheme. In some pathological institutes, various organs are extracted one by one, cutting them off from their connection with others; in others, it is preferred to extract complexes of organs; some pathologists consider it rational to perform incisions of organs in situ, i.e., before their extraction; in the Moscow school, proceeding from the desire to not separate organs and parts of anatomical-physiological systems as much as possible, the organs of the neck and thoracic cavity are usually extracted as a general mass, then the intestine separately, the liver, stomach, and duodenum together, the kidneys, urinary tract, and genital organs together; in Leningrad, those performing autopsies for the most part use the method of complete evisceration, developed by Shor, which consists in the fact that the organs of the neck, thoracic cavity, abdominal cavity, and small pelvis are extracted as one continuous complex, and furthermore, the organs are not separated from each other, but are examined in their mutual connection. The organs extracted from the corpse by one method or another are studied in terms of their size, weight, shape, surface condition, color, and consistency, after which incisions of the organ are made and the surface of the incision and the condition of the cavities are examined, if it concerns a hollow organ. To open the skull and examine the brain, an incision of the scalp is made from one ear to the other across the crown, the scalp is separated from the incision forward and backward, and a circular sawing of the skull and removal of the skull cap are performed; after separating the dura mater, the brain is removed. The spinal cord is extracted after an incision of the skin along the line of the spinous processes and the opening of the vertebral canal by sawing through the posterior arches of the vertebrae. The opening of the skull and vertebral canal may precede the opening of the body cavities or follow it, depending on the peculiarities of the case. The limbs are opened last, if there is data for this; in the limbs, the condition of the muscles, bones and bone marrow, joints, vessels, and nerves is examined. During the autopsy of newborns, a longitudinal sawing of the lower epiphysis of the femur is mandatory; with the help of this sawing, the condition of the lines of enchondral ossification (the border between the epiphysis and diaphysis) is clarified, which is important in relation to congenital syphilis, and the presence and size of the epiphyseal ossification center (see Beclard's ossification center) are also established. Upon completion of the autopsy, the person who performed it briefly summarizes the detected changes and reports the anatomical diagnosis. After this, he makes a comparison of the detected findings with the antemortem manifestations of the disease and explains, from the point of view of the detected data, everything concerning the development and manifestation of the main disease, its complications, and the causes of death. The examination of the autopsied corpse does not end there, since material is taken from its organs and tissues for microscopic study; in addition, it is often necessary to perform a bacteriological examination of the corpse (see below), and sometimes serological reactions with its blood. The final act of the autopsy is the cleaning of the corpse, consisting of placing the organs back into the cavities, suturing the incisions, washing the corpse, and dressing it. Due to the fact that no incisions are made on the exposed parts of the body during an autopsy, there are no visible signs of the performed autopsy on the dressed corpse. One should not perform partial autopsies, for example, only of the abdominal cavity or the cranial cavity, etc., as this can yield completely incorrect results. It is most correct to record the autopsy protocol during the autopsy under the dictation of the person performing it. In the absence of appropriate personnel, as well as if it is necessary to explain the detected changes in detail during the autopsy, the protocol can be written after the autopsy from memory. Each autopsy protocol consists of a descriptive part, representing a strictly objective and accurate description of the observed pictures, and a concluding part, or anatomical diagnosis, which represents the definition of the essence of the detected changes by means of brief pathological-anatomical terms. Sometimes the prosector, in addition, adds an explanatory conclusion to such a protocol, highlighting the essence of the main disease and its complications, the role of the changes that preceded the given disease, etc.; considerations about the cause of death can also be given here. One should not limit oneself to just an anatomical diagnosis when recording an autopsy, as this lacks the extremely important description of the altered organs and does not record information about the condition of those organs that did not present definite changes to the naked eye. At the end of the protocol, space is left for recording the results of the microscopic (and bacteriological) examination. Shor recommends dividing the pathological-anatomical diagnosis into four categories: 1) constitutional anomalies, 2) distant diseases and conditions, 3) recent diseases and conditions, 4) immediate diseases and conditions. Such a diagnosis is followed by a "thanatological conclusion," containing considerations about constitutional anomalies, signs of conditional and unconditional disability, wear and tear of organs and systems, the presence of nutritional disorders and poisoning, and data on the nature of death (gradual fading of life, accelerated death, sudden death); such a thanatological conclusion ends with an indication of the "dynamics of death." Copies of autopsy protocols are issued only at the request of the militia and judicial authorities.

A forensic medical autopsy differs little in technique from a pathological-anatomical one, but it differs significantly in its purpose and the range of questions posed by investigative authorities. Besides determining and clarifying the causes of death, it must: establish the influence of other numerous conditions on the cause of death, the influence of their combination and competition on the terminal outcome, the connection of injuries with disease processes; recognize whether sudden death occurred from natural or violent causes; establish whether the discovered injuries resulted from accidents, from intentional outside violence, or from the hand of the victim themselves; clarify the age of the injuries and the time of death, the sequence and significance of cadaveric changes; assist in establishing the identity of the person and resolve many other questions important for criminalists and judicial authorities. An autopsy of a corpse is often the main, and sometimes the only, factor in solving a crime. All this requires the forensic medical expert to have significant experience in posing and resolving all the above-mentioned questions. As for history, it can be noted that individual indications of a forensic medical autopsy of a corpse exist already in the books of the Bible, in the legislation of the Hindus (600 years B.C.), in the ancient histories of Greece and Rome; in Russia, the beginning of forensic medical autopsies must be considered from the time of the "Military" Statute of Peter I (in 1716). With the establishment of the first Russian university in Moscow (1755), the teaching of forensic medicine began there, and with the publication in 1829 of the instructions for the examination of dead bodies, medical expertise was finally established by law. With the introduction of public legal proceedings in 1864, the autopsy of a corpse reached its greatest development and caused the need for more thorough training and specialization of forensic doctors. But the lack of funds and specially equipped institutes of forensic medicine long hindered the proper development of this discipline in our country, especially in comparison with Western Europe. In the post-revolutionary period, the matter of forensic medical expertise has moved significantly forward. Rules establishing the procedure for a forensic medical autopsy of a corpse have been issued repeatedly, but a general manual has not yet been developed. All persons who have signs of violence or suspicion thereof, suicides—to exclude the possibility of simulation of suicide, those poisoned, those who died suddenly (see Sudden death) and those patients regarding whose disease and death the attending physician or those around them have a suspicion of its unnaturalness, and, finally, corpses of unidentified persons are subjected to a forensic medical autopsy. An autopsy is usually performed by qualified forensic medical experts, but in the absence of such, any doctor can be called upon by investigative bodies to perform an autopsy, without the right to refuse. The expert must receive an order for the autopsy from the appropriate investigative authorities. The authorities must provide the expert with all possible assistance in delivering the corpse to a room suitable for an autopsy, in providing the necessary instruments and materials, in protecting the doctor from outside interference, in removing persons not involved in the autopsy, etc. All information about the last moments of the deceased's life, the place and time of finding the corpse, the anamnesis and clinical phenomena preceding death, and other observations must be unconditionally communicated to the expert by the investigative authorities; in case of refusal or lack of such data, the expert may postpone the autopsy if no significant damage to the case is foreseen, or refrain from a conclusion until the necessary data is obtained. In cases of a doctor's arrival at the scene of an incident, it is their duty to assist the inquiry bodies in clarifying the crime by applying scientific knowledge, experience, giving instructions for preserving traces of the crime and objects that could serve as material evidence to expose the criminal, as well as instructions for the correct removal and packaging of the corpse's viscera, vomit, suspicious medicines, or other objects for chemical analysis. During a forensic medical autopsy of a corpse, the presence of a representative of the authority from which the proposal for the examination originates is mandatory, as well as at least two legally competent witnesses, whose role consists not only in observation but also in the right to ask the expert questions concerning the given case, to demand clarification of the observed phenomena; at the same time, in case of disagreement with the doctor's opinion, their objections must be entered into the autopsy protocol. The expert is obliged to draw up an examination protocol during the autopsy, which must be read immediately to all those participating in the autopsy, checked against the protocol recorded separately by the investigative authorities, and signed by all participants; the opinion, which is given by the doctor either immediately after the autopsy or after 3 days (in complex cases after a much longer period upon the doctor's statement), is signed only by the performing doctor. One should strive in every way for a prompt autopsy of the corpse, without waiting for the expiration of 24 hours from the moment of death, especially in warm weather, when often due to the putrefaction of the corpse, only one conclusion can be drawn: "Due to the putrefaction of the corpse, the cause of death cannot be determined." A major obstacle to an earlier autopsy of the corpse can be the impossibility of quickly obtaining inquiry data from the investigative authorities, without which in many cases it is impossible to successfully perform an autopsy (poisoning with alkaloids, ptomaines, sudden death, etc.), especially in the absence of hospital records. The technique of a forensic medical autopsy of an adult corpse, as indicated above, differs little from the technique of a pathological-anatomical autopsy. Just as with a pathological-anatomical one, during a forensic medical autopsy of a corpse, it is completely unacceptable (although, unfortunately, this occurs) to limit the autopsy of the corpse to 1-2 cavities; the cranial, thoracic with the neck, and abdominal cavities must be opened, no matter how clear the cause of death may seem upon the autopsy of 1-2 cavities, and only the spinal cavity may not be opened when, after making incisions of the soft parts along the spine, no injuries to it are noted. The order of the autopsy largely depends on the individuality of the case and the experience of the person performing it; with a clear indication of a specific cause of death, one can start the autopsy with the cavity where it is easy to find the main changes; in the absence of such an indication, it is better to start with the cervical-thoracic cavity in order to see in situ the blood filling of the heart and lungs, which is very important when determining or clarifying certain types of death (from cold, asphyxia, heart paralysis, in certain poisonings, etc.). The compilation of the autopsy report (if possible at the place of examination) differs significantly from a pathological-anatomical one: a systematic description of organs is not always convenient in a forensic medical autopsy; often with injuries, it is better to set out the direction and sequence of the infliction of wounds in different cavities. The use of printed forms with the entry of phenomena noticed during the autopsy is unacceptable: it is difficult to judge the experience of the expert from a template record; the description of certain sections cannot always be fitted into the allotted space, and leaving a space free from writing in the text can be used for malicious alteration of the meaning of the exposition. When writing an autopsy report, it is necessary to adhere to a specific plan so as not to miss any organs or parts of the corpse unmarked. The report of the examination of the corpse must consist of the following sections: 1) introduction, where it is indicated by whose order, of what date, under what number the corpse of such-and-such is being autopsied, if the deceased is identified, or an unknown person; indicate the place, date, and hour of the autopsy (which should be performed in daylight, if there is no extreme necessity for an immediate autopsy); designate in the presence of which persons the corpse is being autopsied; 2) preliminary information, where the main data about the anamnesis, phenomena preceding death, circumstances, and peculiarities of finding the corpse are briefly entered; if the preliminary information is extensive and sufficiently set out in the inquiry, then one can refer to this inquiry; 3) the most essential section of the report is the external and internal examinations; the exposition itself must be written in simple, concise, precise language, understandable to persons unfamiliar with medicine; a pathological-anatomical diagnosis should not be made without a proper description, according to which other experts and members of the court could clearly imagine the changes set out in the report. In the external examination, first of all, the identity of the corpse is noted: if the corpse is identified, then they are limited to determining its sex, age, height, physique, and nutrition and describing the general appearance; if the corpse is of an unknown person, then the expert is obliged to assist in identifying the deceased by giving a verbal portrait, anthropometric measurements according to Bertillon (see Bertillonage) and taking fingerprint impressions (see Dactyloscopy); the next part of the external examination consists of describing the signs of actual death, i.e., cadaveric changes, which include cadaveric spots, rigor mortis, clouding of the corneas, signs of putrefaction. Well-known signs of death, such as: cessation of breathing, circulation, cooling of the corpse, are not entered into the report as superfluous in the presence of cadaveric phenomena.

The description of livor mortis and their location can provide valuable indications about the time of death, about the position of the corpse after death (whether it was brought from somewhere several hours after death or turned over by someone). The color and intensity of the spots can sometimes indicate the manner of death or its cause (certain poisonings, asphyxia). Rigor mortis, just like livor mortis, can provide valuable data for the expert. Putrefaction of the corpse in the form of greenish spots usually begins in the iliac regions, due to the combination of hydrogen sulfide from the large intestines with hemoglobin into sulfmethemoglobin, which turns green under the influence of oxygen, so that the greening of the corpse proceeds from the outside inward. After describing the post-mortem changes, the expert accurately and clearly characterizes the type, properties, location, and size of those injuries which are visible to the naked eye on the surface of the body, whereby it is extremely important to note the most important sign distinguishing antemortem injuries from post-mortem ones—the presence of extravasates from capillaries damaged during life, which does not occur with post-mortem ruptures of small vessels or is observed only to a very weak degree in those cases when injuries are inflicted on the corpse at a time when rigor mortis of the heart and large blood vessels is occurring. Further, the expert must carefully examine all natural orifices of the body and its individual parts and, in the absence of signs of violence and injuries on the corpse, note in the report that no signs of violence and nothing unusual were discovered during the examination. After a proper external examination, which sometimes takes up the greater part of the report, they proceed to the internal examination of the corpse, without which giving a correct conclusion about the cause of death is inadmissible, no matter how clear the cause of death may apparently be. This must be remembered, because it is precisely in this that experts often err. As already mentioned, the internal examination of the corpse must consist of an autopsy of at least three cavities—cranial, thoracic, and abdominal—and the organs of the neck. The general course of an autopsy is generally identical to the course of a pathological-anatomical autopsy (see above); only in some parts during an autopsy for forensic-medical purposes is it necessary to make deviations, and also to pay attention to special data. In particular, in the neck region, only the skin is carefully separated from its soft tissues so as not to overlook even small bruises characteristic of grasping the larynx with a foreign hand during attempts at strangulation; at the same time, the integrity of the horns of the thyroid cartilage and the hyoid bone is determined; one must remember that damage to these horns during life, as well as after death, may sometimes not be accompanied by hemorrhage at the site of the fracture. It is necessary to immediately make an incision along the anterior surface of the trachea to verify the absence of a foreign body in it. For forensic-medical purposes, the heart is opened in situ—for examination and collection of its contents. The stomach is removed separately; having tied it at the entrance and exit, it is opened along the lesser curvature, holding it over a clean plate, in order to examine and collect the contents for analysis; the latter is measured; the color, quality, and property of undigested food parts and the odor are described; the condition of the gastric mucosa can provide weighty indications of poisoning or another cause of death. The cranial cavity is usually opened after the thoracic and abdominal ones, if there are no indications of the cause of death in the head; it must be kept in mind that when opening the skull before the thoracic cavity in cases of asphyxia, sudden death, death from cold, etc., the blood supply of the heart and lungs changes significantly due to the outflow of blood from the severed large vessels of the skull, and thus a valuable sign for establishing the manner of death is lost. During an autopsy of the skull, after removing the brain, the dura mater is separated from the base of the skull, the skull is examined as a whole, and its configuration, asymmetry, thickness of the bones, their porosity or density, thinning in places, smoothness or bumpiness of the inner surface, strong or weak development of ridges and depressions (impressiones digitatae et juga cerebralia) at the base of the skull, the depth of the edges of the sinuses, imprints of blood vessels in the bones of the skull, and, what is of particular importance in sudden death and in suicides, especially at a young, juvenile, or even childhood age, this is premature closure of the cranial sutures, most often the sagittal, then the coronal, and less often the occipital; closure usually proceeds initially from the inside, later from the outside. The significance of this early closure is expressed in the altered configuration of the skull and increased intracranial pressure (see Sudden death, Suicide). In case of suspicion of poisoning, the expert is obliged to take viscera for chemical analysis, namely: 1) the stomach with its contents, 2) parts (not less than 1 m) of the small and large intestines with their contents, 3) a third of the liver with the gallbladder, 4) a kidney and the urinary bladder with urine, 5) parts of the remaining organs, and place them in clean jars with ground-glass stoppers or tie the jars with parchment, ox bladder, etc., seal them, and hand them over to the authorities for dispatch to the destination. For microscopic examination of organs, pieces of 0.5-1.0 cubic cm are taken and placed in 10% formalin or strong alcohol; for bacteriological examination, material is taken in compliance with the technical rules of bacteriology into sterile vessels. For biological examination of blood, the latter is dried on filter paper in an amount of 2-3 cubic cm and, if possible, immediately sent to the laboratory in a sterilized container. The autopsy report is signed by all persons involved in the autopsy, after which the forensic-medical expert writes his opinion. The questions resolved by the forensic-medical expert on the basis of the autopsy data and the preliminary investigation can be very diverse; the cardinal ones are considered to be: determination of the cause of death, whether death is the result of one or several causes, which of the competing causes could have been the immediate one; whether death depends on ordinary pathological changes in the organism or was caused by external unfavorable circumstances; whether death is the result of injuries received either accidentally or with the intent of intentionally ending life or harming health; whether the injury or death was caused by the hand of the deceased or by another person; which of the discovered injuries are classified as unconditionally fatal, which as grave, life-threatening, which as less grave or light; whether one or several persons participated in inflicting the injuries; whether there were special individual conditions at the time of receiving the injuries that accelerated the onset of death, etc. All these questions and similar ones, proposed to the expert by the investigative authorities, are not always resolvable, often require long, calm discussion, consultations with authoritative leaders, and it would be better if the expert more often used the right granted to him by law to give an opinion after three days, and in difficult cases even to petition for an extension of this period. Only the physician who performed the autopsy and other experts invited to assist him sign the opinion.—Features of the autopsy of newborns—see Infanticide.

Bacteriological examination of a corpse differs in principle very little from bacteriological examination of a living person. One must only keep in mind the following peculiarities of cadaveric material. 1. The time of agony, along with part of the pre-agonal period of the disease, creates many opportunities for the introduction of various microorganisms into the blood, especially streptococcus; the latter is observed in the blood of 25-30% of corpses and to a certain extent independently of the primary ailment, but in general, it is more frequent the more entry points for infection exist in the given organism (ulcerative tuberculosis of the lungs, gangrenous-ulcerative changes of the pharynx in scarlet fever, acute leukemias, etc.). In some cases, such findings of streptococci have, perhaps, a more or less definite etiological significance and do not bear the character of an accidental (secondary) infection. 2. The blood and bile of corpses with peritonitis, especially perforative, are very often infected with Escherichia coli and various saprophytes. 3. The freshness of the corpse increases the value of bacteriological examination; on the other hand, the sterility of the blood, noted in the first hours after death in approximately 40-50% of corpses, is maintained throughout the next 2-3 days, especially with proper preservation of the corpse (from +2° to +3°). 4. Microorganisms present in the blood and tissue juices of a corpse can multiply strongly within it, especially if complete cooling of the body has not occurred; therefore, during bacterioscopic examination of organs, it is often possible to see colonies of microbes (e.g., streptococci, typhoid bacilli), whereby the absence of any reaction around such colonies indicates the post-mortem nature of the phenomenon; there are opposite cases, where the onset of death quickly entails plasmolysis of bacterial bodies, and the latter are stained and cultured with great difficulty (e.g., meningococci). Bacteriological examination of a corpse has a very important, sometimes decisive significance, especially in the diagnosis of diseases of the typhoid group, cholera, anthrax, plague, various types of septicemia, etc. Since sometimes both autopsy and histological examination do not provide an answer to the question about the causative agent of a given disease (e.g., in cases of typhus and paratyphus), it should therefore be generally recognized as necessary to perform bacteriological examination of the corpse during all autopsies or, at the very least, an examination of the blood and bile, which technically presents no difficulties. General technique of bacteriological examination of a corpse. Blood can be taken from the veins of the elbow bend and from the heart; in the first case, the skin is sterilized with alcohol or iodine, and the skin and veins are cut with a sterile knife, then blood is collected with a sterile Pasteur pipette; massage of the forearm increases blood flow. Blood can be taken from the heart only at the beginning of the autopsy, when the brain has not been removed and the large vessels of the neck have not been injured; the sternum with the ribs is cut away (see above) carefully, without injuring the large vessels near the base of the heart; after dissection of the pericardium, the heart, held in the left hand, specifically the right ventricle, is cauterized with a red-hot spatula or thermocautery, and a pipette is inserted through the thus sterilized area; with light pressure of the left hand, the blood flow is increased; in the case of large blood clots in the heart cavity, one has to change the depth of the pipette insertion or change the collection site (right atrium, orifice of the inferior vena cava). Many prefer the examination of blood from the elbow veins, because heart blood is more easily infected post-mortem (e.g., from the intestines or from nearby septic foci along the course of the vena cava system); there are frequent cases when bacteriological examination of heart blood turns out to be positive while peripheral blood is sterile; however, the explanations given for this phenomenon are various (Canon, Simmonds). The main advantage of the peripheral method is that it is applicable even after the autopsy is completed. Bacteriological examination of bile (from the gallbladder) is performed similarly to the bacteriological examination of heart blood. Various fluids in cavities and hollow organs are taken with the observance of the usual precautions in bacteriology. The collection of tissue juices or particles of organs is also performed after cauterizing the surface, operating with a red-hot knife or thermocautery. Conradi recommends pre-treating pieces of organs with hot (200°) sesame or olive oil; one can immerse the pieces in alcohol and then burn them. These methods are expedient in those cases when the autopsy has already been performed, but without observing the usual rules of asepsis. Bone marrow is obtained from tubular or, better, short spongy bones (for example, the lower lumbar vertebrae), squeezing it out from a saw cut disinfected by burning. Bacteriological examination of fluid from the cranial cavity, cerebrospinal fluid, is done before the autopsy, obtaining the fluid by the Quincke method or by the Leede method (puncture through the foramen occipitale magnum, between the occipital bone and the atlas, with a strong forward tilt of the corpse's head). The contents of the brain ventricles (lateral) are taken by puncture through the corpus callosum after separating the cerebral hemispheres. Deposits on heart valves in endocarditis are taken by a preliminary sterile incision of the areas corresponding to the valves of an unopened or (better) not-yet-removed heart. Bacterioscopic examination of exudates and organ juice occupies a prominent place in the general bacteriological examination of a corpse; it is especially important to examine wound juice in surgical operations if it is turbid, serosanguinous, and abundantly permeates the walls of the wound (usually streptococcus). Bacteriological examination of various parts of a corpse for tuberculosis is best performed by the antiformin method (see Antiformin) by preliminary grinding of tissue pieces (e.g., on a freezing microtome). Sometimes there is a need to perform serological reactions on a corpse (Wassermann, Widal, Weil-Felix reactions); it is important to point out that these reactions on a corpse are quite accurate and can serve as an aid to anatomical and bacteriological examinations of the corpse. Bacteriological examination of animal corpses is performed with the observance of the same rules (see also Laboratory animals).