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CHAPTER 3 Postmortem Examination

Thomas T. Noguchi, M.D.

INTRODUCTION tions such as hepatitis and other infections due to use of contaminated needles in the Regardless of the suspected cause of death, administration of a drug. a medical examiner or coroner's postmortem 3. Death, usually violent, from situations examination should always be thorough and created by a person who, under the influence comprehensive, for deaths which come under of a high but nonlethal dose of a drug, acts in the jurisdiction of this office are often ex­ a manner incompatible with life, exposing tremely complex, dealing as they do mostly himself to life-risking situations, such as run­ with instances of sudden and unexpected de­ ning in front of a moving vehicle, jumping mise. The postmortem examination should be from a high place, or aggressively inviting vio­ approached with a certain degree of suspicion lence from others) of ot.her possible but hidden etiological fac­ tors. The true cause of death may be masked Hospital Versus Forensic Postmortt)m by the obvious findings. Examination In the simpler ca.ses, the specific cause of The primary purpose of a postmortem death may be accurately determined by any examination conducted in a hospital is to con­ competent pathologist and even by an alert firm a known or suspected diagnosis of the non pathologist physician. In more complex disease which caused the death of the patient. cases, however, those without the trained or In addition, the hospital postmortem may ingrained sense of suspicion of a forensic path­ provide knowledge concerning the tissue dam­ ologist may be misled by the apparent and age caused by the disease. Emphasis is on the. may seek no further information beyond the detailed study of specific internal organ or obvious. The average physician is often either organs involved in the disease process; only a unaware of or has a rather lax attitUde toward cursory external examination is conducted. the potential medicolegal ramifications and The forensic pathologist is not only inter­ significance of the autopsy report in coroner's ested in the direct cause of death but also in cases. As an example, a history of heart attack trying to reconstruct the circumstances and should not automatically lead to the conclu­ events which led to the death. Whatever the sion that a sudden death was due to heart immediate cause of death, he must also ascer­ disease. Drug abuse or misuse may be highly tain whether the death was an accident, a unlikely, but adverse reaction to therapeutic suicide, or a homicide. Thorough external drugs is a possibility which should not be over­ examination of the clothing worn by the looked, especially in persons under intensive deceased at the time of death and study of drug treatment of medical conditions. A nUln­ the deceased's state of mind just prior to bel' of deaths due to drugs have probably been death are as important as the examination missed because of bias induced by the medical of the internal organs. A complete and history of the deceased. thorough medical examiner/coroner's post­ Deaths involving psychoactive drugs may mortem examination must include: be divided into three categories, each of which calls for a thorough postmortem investigation: 1. Death due to the direct toxic effect of a lThese parallel the distinctions represented in drug. categories of Code 3 of the UCI form, i.e., drug in­ 2. Death as a result of secondary complica- duced and drug related (see appendix A),

15 16 NOGUCHI 1. Detailed study of the scene of death, 2. The name of the deceased noting any signs of disorder, position of the 3. The case number deceased, presence of any possible evidential 4. The date and time material, such as pills and prescription bottles 5. The name of the medical examiner in suspected drug deaths (see chapter 2, "On­ Finally, each document should be signed by sitt' Investigation "). the medical examiner. 2. Precise and detailed study of the type In addition to the written reports and and extent of any morphological damage or charts, photo-documentation is absolutely trauma, including microscopic examinations. essential. Photographs should be taken of all 3. Determination of the diref't cause of the pertinent findings, clothing, external body injury-disease, physical force, chemical surfaces, including identity photo of the de­ agents, etc. ceased's facial features as well as internal 4. Followup toxicological, biochemical, body organs. Color photographs are preferable microbiological, and other laboratory tests on to black and white. Needle marks and bruises selected tissues and body fluids as indicated in black-and-white photographs may appear as by gross findings. ambiguous dark areas on the skin which can 5. Analysis of information obtained from be misinterpreted. With color photographs family and friends pertaining to the attitudes fresh injuries can be readily distinguished from and lifestyle of the deceased. old bruises.2 The forensic pathologist has the training to Each photograph should have incorporated recognize the significance of the various infor­ within the picture the following clearly visible mation obtained, to put it together like a jig­ information: the official name of the medical saw puzzle, interpret the findings, and come examiner or coroner's office, the case number, up with a reasonable reconstruction of the the date and time, a scale (which can be a circumstances and events which led to the simple ruler) to indicate dimensions, and the death of the individual. names of the photographer and medical ex­ aminer. Chain of Evidence Finally, in approaching postmortem pro­ cedures, always keep in mind Ont, cardinal rule In the handling of any medical examiner/ of forensic postmortem examination: Do not coroner's case, the proper identification of all probe, enlarge, cut into, incise, or otherwise materials connected with each case is a MUST. distort or destroy any wound, including All articles of clothing, contents of pockets, needle pUllcture site, until it has been com­ all tissues, and other biological materials re­ pletely measured, charted, and photographed. moved for testing (e.g., blood), and all records and documents must be properly and legibly identified at the time of removal and exami­ OUTLINE OF PROCEDURE nation. Much grief and problems can be avoided when this rule is strictly adhered to 1. Review of Reports (see also chapter 2, "Onsite Investigation"). The first step in the handling of a case is Docli mentati on the complete review of all available documents Just as important as a thorough post­ pertaining to the death, including reports mortem examination is proper documentation from the police, hospital, mortuary, or coro­ of the findings. The written documentation ner's at-scene investigation. Initial and d~ e all reports read. may be in the form of "check and fill-in" sheets supplemented with short, simple nan'a­ 2. Clothing ;. tive reports and picto-charts of body sections and organs showing pertinent findings and Examine clothing for damage and unusual dimensiol)s for easy reference. Each document stains. When injury to the deceased is evident, should be identified with: 1. The official name of the medical exami­ 2Editor's note: Chapter 2 mentions the fact that ner or coroner's office not all jurisdictions accept color. ------~~-~---~----,

POSTMORTEM EXMHNATION 17 pay careful attention to the relationship of fluid. Note degree of turbidity of the any damage to the clothing and the pattern of vitreous fluid. Aspirate the fluid and injury, the location of stains from blood or place in test tube for toxicological and other body fluids. Include as part of the post­ biochemical analyses. mortem protocol: The degree of turbidity of the vitreous a. Description of the clothing: type, color, fluid can be a clue to the postmortem size, manufacturer's labeJ, cleaner's interval, and in drug-induced deaths, the marks, etc. conjunctiva of the eye may show pete­ b. Description of pattern, shape, and loca­ chial hemorrhages. tion of stains, tears, bullet holes, powder d. Naso-orop!lmYllx: Examine contents of burns, knife holes, etc. nostrils and the oropharynx for the c. Description of shoes, any scuffing or possible presence of blood and foreign unusual markings. bodies. Palpate the nose for possible Preserve dirt, glass, paint, spent bullets fracture or swelling of the subcutaneous caught in clothing, or other foreign materials tissue. found on the clothing. In cocaine sniffers the nasal mucosa of Photo-document all significant findings. the septum often shows ulceration. e. Lips alld oral cavity: Closely examine 3. General External Examination the upper and lower lips (the mucosal surface as well as the external surface) Unclothe the body. Photograph the un­ for any impressions or breaks. Check the washed body. Examine the body in a system­ buccal cavity and mucosa. atic manner starting from the top of the head Drug addicts often use the buccal and going to the tip of the toes. Note the mucosa as the site of injection in an location and extent of any injuries. attempt to hide the needle marks. Also, balloons containing heroin have been 4. Detailed Examination of Skin known to be hidden in the oral cavity. In cases where problem of identifica­ Closely examine the skin surface of the tion exists, use dental charts to record entire body with a hand or head visor type condition of teeth. 6-10 x magnifying lens. Inspect the unwashed Check for presence of blood. Des­ body for staining by foreign dyes or com­ f. Ear: cribe and chart all trauma noted. monly identifiable smears such as lipsticks In drug-involved deaths, examination and lip prints. Photo-document findings. of the ear may not be critical but will Wash the body and inspect it for scars, eliminate the possibility of other con­ ecchymoses, and abrasions as well as gross trauma. Critically examine the skin surface tributing factors to the death. for possible hidden needle marks. Palpate the body surface along with the visual inspection 6. Examination of the Neck and properly document all significant findings. Closely examine and note any unusual markings. Check back and sides of neck as 5. Examination of !-lead and Facial Structures well as the front. Photo-record all significant a. Head: Chart, measure, describe, and findings . photo-document all trauma. . Attempts to disguise a drug death as a sui­ b. Face: Note color for possible cyanosis cide hanging have been Imown to occur. A or other indications of poisoning: Take body hanged after death will show rope marks identification photograph of facial fea­ but no vital tissue reactions. tures. c. Eyes: Describe and chart trauma. Look 7. Examination of the Torso for petechial hemorrhages of the con­ junctiva. Check both upper and lower Examine, chart, measure, and describe all lids. Use ophthalmoscope and critically trauma, scars, and tattoos. Photo-record all examine the fundus and the vitreous pertinent findings. 18 NOGUCHI In suspected drug deaths the examiner Retention of Biological Tissues for should always he on the lookout for needle Laboratory Testing marks. Certain precautions should be takrll during the selection and preservation of specimens to 8. Examination of the Extremities be analyzed. Labelillg contaillers. A specimen should Carefully inspect fingernails and hands for never be placed in an unlabeled or even a par­ trauma. Check the antecubital fossae, ankles, tially labeled container. The container should dorsum of the hands, etc., for needle marks. always be fully labeled before the specimen is Inspect carefully tattoos overlying superficial placed in it, and the label should contain the veins, which are frequently used as camouflage following information: official name of the for needle marks. Palpate the veins for possi­ medical examiner's or coroner's office name ble fibrotic changes. Needle marks are some­ , of the deceased, case number, date and time, times deliberately defaced by cigarette burns. name of the medical f'xaminer, [1.nd a descdp­ Check feet for abrasions. Study 13 brasions for direction of tissue piling. Findings may tion of the contents. give indication that the body may have been Tissues for microscopic examination. Re­ dragged. taining tissues from all organs, even from Chart, measure,' describe, and photo­ normal-appearing organs, for microscopic document all significant findings. examination should be an integral part of all autopsies and should be routinely done. In the investigation of drug-involverl deaths, micro­ scopic examination of tissues is often ne­ AUTOPSY glected. There is a preoccupation with and a tendency to rely solely on chemical and toxic­ In processing drug-involved deaths, the ological tests, the results from which are not coroner or medical examiner will find only always clear cut. Microscopic studies can pro­ two situations in which he may decide to vide supporting or confirmatory evidence. finalize a case without autopsy. The fil'st Tissues for chemical analysis. Each speci­ occurs with a drug overdose patient dying men taken for drug or poison analysis should in a hospital, when the hospital toxicology be placed in its own separate container, fully laboratory records indicate lethal drug levels and legibly identified with the proper infor­ and thel'e are no other circumstances that mation. Each specimen should also be accom­ would warrant an autopsy, The second is a panied by a test request sheet indicating the drug overdose case of unequivocal suicide, specific drug or group of drugs to be tested SUbstantiated by an indisputable suicide note for. or a history of suicidal tendencies, coupled Selection of the tissues and the amounts 3 with definite knowledge of missing medica­ will vary with the tests to be performed. The tion, etc., and the absence of any suspicion of amounts suggested in table 1 are the approxi­ another possible cause and mode of death. mate minimum" With those two possible exceptions, all Blood. Blood should always be saved for medicolegal postmortem examinations of testing whenever possible in an medical drug deaths should include an autopsy. It is examiner/coroner's cases. Submission of blood mandatory in all cases for which there is a alone, however, for toxicological examination suspicion that a drug or poison is involved as in drug-related deaths is fraught with danger. a possible cause of death; such cases merit Many drugs are rapidly removed from circula­ complete and thorough autopsy, including ti~n. Unless .highly sophisticated technological examination of the head and neck structures. SkIlls and ll1struments are available, some A complete autopsy is also indicated, what­ drugs may not be detectable in blood within ever the cU'cumstances, in all cases for which tissues are needed for laboratory confirmation 3See also chapter 5, "Forensic Toxicology in of the suspected cause of death. Death Investigation." POSTMORTEM EXAl\UNATION 19 TABLE 1. Biological specimens to be double refractile materials may be seen in the retained for drug and poison tissue at the injection site under a phase con­ analyses trast microscope. The materials in the tissue can also be Tissue Amount needed chemically identified. Nails. Two or three whole nails should be Adipose tissue 25-50 gm retained for chemical analysis in cases of Bile 5 ml suspected arsenic or heavy metal poisonings. Blood 200 ml Remove nail from toe with a forceps by Bone (see text) inserting one of its blades under the nail plate to obtain a good grip and pulling with a twist. Brain 250 gm This can be done with little damage to the Gastric content all nail bed. Place the nails in a properly and Hair 5 gm legibly labeled envelope. Kidney 100 gm Hair. Hair samples should be retained for Liver 100 gm analysis in suspected arsenic and various heavy metal poisonings. Lung 250 gm Retain samples from head and pubic areas. Lymph node whole Remove by plucking to Qbtain whole lengths Nails 2 or 3 whole nails of hair including roots. Skin all pertinent areas Bone. For bone samples, remove 1-2 inch Spleen whole organ lengths of half of the body of the vertebrae Urine 50 ml with an electric bone saw. Brain. The head is often forgotten in Vitreous fluid all medicolegal examinations unless there is ex­ ternally obvious injury. No postmortem examination is complete without dissection of as short a time as 5-10 minutes after oral or the hdad. Absence of externally obvious signs parenteral administration. of injury does not rule out the possibility of Submission of blood alone for testing brain injury. Even in cases of drug deaths with should be permitted only for cases in which a confirmed high blood levels of drugs, unless fatal overdose is substantiated by such un­ the head has been opened and the brain exam­ equivocal evidence as a suicide note, history ined, possible brain injury as an alternative of suicidal tendencies coupled with definite direct cause of death cannot be disputed with knowledge of missing medication, and state­ certainty. ments of the deceased, together with an ab­ When other tissues are not available in sence of suspicion of other conditions that usable form due to extreme decomposition or might have caused death. other reasons, the brain may be found in Obtain blood from the heart by aspirating better condition. Under these circumstances with a needle and syringe or from a peripheral the brain should be retained for toxicological vessel (neck, arm, or leg) by use of a catheter. examination also. (See chapter 5, "For~nsic Toxicology in Cerebral edema and lesions of the capil­ Death Investigation" for fUrther details.) laries and the nerve cells are frequent findings Skin and subcutaneolls tissues. Dissect out in deaths involving many drugs. and retain for microscopic examination and Dissect out the whole brain and examine chemical analyses the skin and SUbcutaneous for signs of injury and possible disease. Retain tissues at sites of drug injection, injuries, and appropriate specimens for microscopic exam­ other areas of significance. ination and for chemical analyses as needed. The skin and subcutaneous tissues at the Neck organs. Examination of the neck site of a recent drug injection may show organs is essential for excluding other possible foreign body reaction to the extenders mixed causes of death. The lumina of the neck with the drug. In suspected heroin deaths, organs cannot be inspected in situ adequately. 20 NOGUCHI Remove by a block dissection the tongue, esophagus, stomach, and the intestines should pharynx, larynx, and the trachea. Dissect and be dissected and carefully examined. examine for: Mm1Y of the commonly ingested drugs are 1. Evidence of trauma to the soft tissues artificially colored, and their presence in the 2. Fractures of the hyoid or other bony or digestive tract may be readily detected. The cartilaginous structures color, amount, and location of the ingested 3. Submucosal laryngeal or epiglottal hema- drug in its original form are important clues tomata in the overall interpretation of the circum­ 4. Edema and petechial hemorrhages stances of drug-related deaths. 5. Other signs of abnormal conditions Such findings as the type of food and the 6. Foreign body in the airways amount and stage of digestion are also signifi­ Cardio)IGSClllar system. The heart and the cant and should be noted and recorded as aorta should be carefully examined, especially important clues to the sequence of events in older persons, to rule out deaths due to preceding the death. cardiovascular diseases. Many drugs, including In all cases of death suspected of being due those used for the treatment of hemi: diseases, to or?lly ingested substances, the entire con­ will cause changes in the heart tissues. tents of the stomach and intestine should be Remove the aorta and the whole heart retained for chemical and other appropriate from the body. Carefully examine the pericar­ laboratory analyses. This protocol applies to dium and the surface of the heart. Dissect and deaths suspected of being due to any ingested examine the coronary vessels for arterioscler­ materials, including foods suspected of being otic changes. Dissect and check the linings of contaminated with bacteria, pesticides, or the aorta and the heart chambers and the poisons, as well as to cases due to simple drug valves for Rr'y pathological changes. Check the ingestion. whole heart for myocardial abnormalities. Stomach. Tie or clamp off the stomach at Retain tissues frorn appropriate areas for both ends, above the diaphragm and at the microscopic examinations. duodenal junction, and remove intact from Lungs. In cases where inhalation of gas or body. Dissect and collect entire contents into chemical vapor is the suspected cause of a lm-ge chemically clean; properly labeled jar. death, sections of the lung tissue should be Examine stomach lining and contents. Record retained for chemical and microscopic analy­ by detailed descriptions and photographs all ses. significant findings. Retain tissues from m-eas In deaths due to intravenously injected showing significant deviations from the nor­ "street drugs," the lungs often show foreign mal for microscopic examination. body reactions to the extenders used in these Intestines. Tie off the intestine into easily preparations. Foreign body reactions are also handled segments (1-2 ft) and remove the seen in cases of chronic respiratory exposure whole length from the body. Open each seg­ to many industrial chemicals. ment separately and retain contents of each In cases of deaths due to suspected gas poi­ segment in separate containers which are soning, tie off the bronchus, dissect above the properly identified with the location of the tie, remove the whole lung, and quickly place segment as well as the information identifying it in an airtight metal container. Avoid cutting the case. Carefully examine contents and the into the lung tissue which would cause the mucosal lining. Record all significant findings lung to collapse with escape of the gas con­ and retain tissues for microscopic exami­ tent. Most gases will readily diffuse out of the nation. lungs into the container. Gas samples may be Liver. Liver should be retained in drug­ rel'i.10ved from the container by puncturing it related deaths, for many drugs are rapidly and filling a syringe for analysis by gas chro­ concentrated in the liver for detoxification, matography. and appreciable quantities may be found in Gastrointestinal tract. The lining and con­ the liver in acute drug deaths while blood con­ tents of the entire digestive tract starting from centration may be minimal. the oropharynx and proceeding through the Portal triaditis has been a consistent finding POSTMORTEM EXAMINATION 21 in acute narcotism; in heroin addicts, the have made routine procedures of previously lymph nodes in the portal region are often time-consuming and tedious techniques for enlarged and contain deposits of the drug. detecting drugs in body fluids and tissues. In cases of chronic exposure to hepatotoxic Without the proper knowledge to interpret chemicals and drugs, cirrhosis and other the findings in relation to the functioning of degenerative changes of the liver are commonly the total living hUman body, all the toxic­ observed. Prior damage to the liver will pre­ ological data from the analyses of blood and vent the proper detoxification of subsequently other body fluids and tissues are valueless. administered drugs, resulting in a detrimental Understanding of the physiological action and reaction to a normally nontoxic dose of a the metabolic pathways through which the drug. For proper eValuation of drug-induced body processes the various foreign chemicals d'eaths, microscopic study of liver sections is wi th which we intentionally or unintentionally essential. insult our bodily systems is required. The Dissect out the whole liver; examine for latter is a complex specialized field in itself, gross pathological changes; retain appropriate and much of the needed information concern­ areas for microscopic examinations and for ing many of the currently used drugs is still drug analyses as needed. incomplete. Gallbladder and bile. Many drugs are con­ For proper interpretation of the post­ centrated and retained in the gallbladder for mortem laboratory test findings, the following as long as 48 hours and high concentrations factors must be taken into conside!'ation; in the bile are usually indicative of chronic drug usage. 1. Route of administration Remove the whole gallbladder with con­ 2. Dosage in relation to the size of the indi­ tents and retain bile in properly labeled jar for vidual chemical analyses as needed. 3. Interval between the time of intake and the Kidneys and urine. Some portion of prac­ time of death tically all of the drugs and chemicals taken 4. Normal route and !'ate of metabolism and into the body will be excreted or resorbed excretion of the drug into the body through the kidneys. Many of 5. Physical condition of the individual that these substances are nephrotoxic and damage might affect the normal body disposal of the kidneys. In addition, preexisting damage the drug such as liver or kidney disease to the kidneys will affect the excretion of a 6. Physiological condition of the individual drug and may prevent its proper removal from relative to the specific drug, whether habit­ the body with consequent greater concentra­ uated, sensitized, or without previous tion and toxic effect on the body for a given contact dosage. 7. Simultaneous presence in the body of High concentration of a drug in the urine is alcohol or other drugs which might have a usually indicative of chronic usage. potentiating effect Use catheter to obtain urine. Measure the 8. Susceptibility of the drug to postmortem total volume in the bladder and retain amount degradation and the interval of time after needed for required testing. death when the specimen was taken and '. Remove both kidneys. Dissect and examine analyzed or treated for preservation for abnormalities. Retain appropriate speci­ 9. Individual genetic variations in enzyme mens for mi.croscopic and chemical analyses. systems which dispose of the drugs and foreign chemicals taken into the body

INTERPRETIVE FORENSIC TOXICOLOGY Due to all of the (bove factors which influ- ence the drug levels in the various body fluids Toxicology has a definite place in the inves­ and tissues, the lethal dosage will vary widely tigation of drug-related deaths. The recent with the individual as will the postmortem advances in technology and instrumentation levels found in the blood and tissues following for chemical analyses of biological materials the ingestion of a given amount of a drug. t, I 22 NOGUCHI Appendix B lists data on some potentially Addendum: Toxicological examination of toxic chemieals.4 skeletal remains: In a recent case the five lumbar vertebrae of 4Sce also chapter 5, "Forensic Toxicology in Death a dried mummified remains were used to de­ Invesligation," and chapter 4, "Treatment for Survival termine a toxicological cause of death. The Prior to Death and Interpretation 0: Postmortem 'l'oxicologic Findings," for further discussion of this volume of the marrow was used to estimate topie. the concentration of the drug found.