Forensic and Clinical Forensic Autopsy

Forensic and Clinical Forensic Autopsy

An Atlas and Handbook

Edited by
Cristoforo Pomara MD, PhD and Vittorio Fineschi MD, PhD
Second edition published 2021
by CRC Press
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Library of Congress Cataloging‑in‑Publication Data

Names: Pomara, Cristoforo, editor. | Fineschi, Vittorio, editor.
Title: Forensic and clinical forensic autopsy : an atlas and handbook /
edited by Cristoforo Pomara, MD, PhD and Vittorio Fineschi, MD, PhD.
Other titles: Forensic autopsy
Description: Second edition. | Boca Raton : CRC Press, 2020. | Includes bibliographical
references and index. | Summary: “All too often, forensic pathologists perform autopsies
that are limited only to the body parts that are suspect, leading to biased and inaccurate results.
A correct diagnosis for cause of death can only be reached by a strict and systematic examination of
the whole body. Forensic and Clinical Forensic Autopsy: An Atlas and Handbook, Second Edition
provides a step-by-step, photo-assisted guide illustrating the complete autopsy, from pre- through
postautopsy procedures. Chapters look at external cadaver examiner, organ removal methods,
laboratory procedures including recording and imaging techniques, microscopy applications, pediatric and
fetal autopsies, and checking for genetic disease and DNA diagnosis. New chapters and sections to this
edition cover histology and immunohistochemistry, in addition to added coverage on forensic anthropology
and molecular autopsy. From macroscopic to microscopic approaches, this volume provides detailed guidelines
for performance of autopsy on every part of the human body. Using these standardized protocols and with the
proper knowledge, training, and experience, pathologists-and students of pathology and forensic pathology-can rely
on this book to help them develop the skills needed to become experts in their field”— Provided by publisher.
Identifiers: LCCN 2020004883 (print) | LCCN 2020004884 (ebook) |
ISBN 9780367330712 (hardback) | ISBN 9780367502782 (paperback) |
ISBN 9781003048114 (ebook)
Subjects: LCSH: Autopsy. | Forensic pathology.
Classification: LCC RA1063.4 .F662 2020 (print) | LCC RA1063.4 (ebook) |
DDC 614/.1—dc23
LC record available at https://lccn.loc.gov/2020004883
LC ebook record available at https://lccn.loc.gov/2020004884

ISBN: 978-0-367-33071-2 (hbk)

ISBN: 978-1-003-04811-4 (ebk)

Typeset in Minion
by codeMantra
 To my Wife and her big blue eyes, light of my life and beacon in the night.
To our children Salvatore Giuseppe and Maria Vittoria who make us
proud every day also of their small and big successes in studies.
To my parents who taught me the value of the study.
To Prof. Vittorio Fineschi, my Master.
To Prof. Maurizio Ricci, the perfect representative of an authentic University.
To Prof. Nunzio Pomara, my uncle, a guide.
To the Universities of Foggia, Malta and Catania.
To the Mafia victims and to the new generations who are finally seeing it end,
thanks to the effort of the judiciary and the men and women of the Police.
To Paolo Borsellino and Giovanni Falcone and to the agents of their escorts.
To my students and pupils.
To Pepo Ginestra who has finally found his place.

Cristoforo Pomara
Contents

Preface ix
Contributing Editors xi
Editors xiii
Contributors xv

1 A Methodological Approach to the External Examination 1

STEFANO D’ERRICO AND MONICA SALERNO

2 Adult Autopsy 7
CRISTOFORO POMARA, MONICA SALERNO, AND VITTORIO FINESCHI

3 Pediatric and Fetal Autopsies 117

STEFANO D’ERRICO, ANGELO MONTANA, GIULIO DI MIZIO, AND
MONICA SALERNO

4 Postmortem Radiology and Digital Imaging:

From Traumatic Injuries to Natural Death 153
GIUSEPPE BERTOZZI, FRANCESCO PIO CAFARELLI, ANDREA GIOVANNI
MUSUMECI, GIULIO ZIZZO, GIAMPAOLO GRILLI, AND CRISTOFORO POMARA

5 Forensic Genetics and Genomic 177

FRANCESCO SESSA, FRANCESCA MAGLIETTA, ALESSIO ASMUNDO,
AND CRISTOFORO POMARA

6 Human Skeletal Remains: A Multidisciplinary Approach 193

FRANCESCO SESSA, DARIO PIOMBINO-MASCALI, NICHOLAS
MÁRQUEZ-GRANT, LUIGI CIPOLLONI, AND CRISTOFORO POMARA

Index 205

vii
Preface
This book represents one of the major results of my
professional and academic career. It attests to 18 years
of work (out of 46 of age) dedicated to forensic autopsy
practice.
A real passion that first motivated me and continues
to push me is to make autopsy a more precise tool in
accomplishing the core ethos of forensic pathology
and forensic pathologists, in assisting in getting jus-
tice right.
Many say that hospital autopsy is extinct because of
the worldwide decline in its practice. Nevertheless,
forensic autopsy resists and stands tall and strong
alongside modern technological evolution and cul-
tural and religious prejudices. No other tool can better
determine why and how death happens.
There is no doubt on the need to use forensic radiol-
ogy, including multi modal imaging techniques such
as MRI-CT, together with forensic genetics and toxi-
cology, but only to complement the investigation of
traditional autopsy and to render it a more precise and
modern tool.
In Italy, the rising numbers of malpractice claims and
the need for autopsy reviews of all suspected medi-
cal malpractice cases, have now made the forensic
pathologist, recognized as the only properly trained
professional with the skills for reliably determining
the physiopathology of death.
He is the only one capable of distinguishing the dif-
ferent anatomies, the surgical one and the post sur-
gery anatomy with all the many changes to organs and
their appearances and position, with all the changes
to whole systems so transformed to the point that a
dissection skill comparable, and even superior, to an
anatomical skill is required.
This is why I wished to highlight the concept of clini-
cal forensic autopsy on the book title.
This is why this dedication over a long period of time
has now become a strong ethical value for me.
The need to understand the mechanisms that under-
lie death has never ceased to be considered of primary
importance among the scientific community, to better
study and understand the reasons that determine our
limits, to expand our knowledge and to face the fact
ix
that individual differences can lead to success in some
cases and to death in others in Medicine. This is what
autopsy is.
Legal/forensic medicine must demand that autopsy,
both forensic and clinical, is seen as the gold standard
and must be protected with the awareness that we can
always improve no matter if the forensic pathologist
or the pathologist has the last word. Autopsy is and
always will be a tool to improve treatment and diagno-
sis, an invaluable instrument for clinical and surgical
research.
This is the intended message of this book which, after
ten years since its first publication, now includes a
description of the significant improvements in techni-
cal skills which have been made during this period.
Compared to the previous edition, thanks to our wise
editor’s foresight, each technique described finds a
practical approach in the accompanying forensic case
studies.
May it be an easy to read guide for all, and may the
readers find this book useful to apply the techniques
that we have described.
Finally, the greatest achievements and my greatest
pride are in having successfully assembled a large
number of experts that contributed to this book which
includes over 50 professionals from all over Italy.
We have the presumption that we have made a humble
contribution to Science in the steps of the great anato-
mists and the great forensic pathologists of the euro-
pean tradition.
Our students and trainees are our witnesses, and we
anticipate that some of them will continue our work
and hope that they will improve it. This will repay us
for all our efforts and sacrifices and give us confidence
that they will continue our legacy to face up any new
challenges and protect autopsy practice in the future.
I dedicate this work to them, to all the victims of vio-
lence who remind us every day how cruel men can be
and how the most violent ferocity can hide behind
unnecessary personal, political, and religious beliefs.
Cristoforo Pomara
Contributing Editors

Alessio Asmundo Francesca Maglietta

Department of Forensic Pathology Department of Forensic Pathology
University of Messina University of Foggia
Messina, Italy Foggia, Italy

Giuseppe Bertozzi Dario Piombino-Mascali

Department of Forensic Pathology Institute of Biomedical Sciences
University of Foggia Vilnius University
Foggia, Italy Vilnius, Lithuania

Francesco Pio Cafarelli Angelo Montana

Department of Radiology Department of Forensic Pathology
University of Foggia University of Catania
Foggia, Italy Catania, Italy

Luigi Cipolloni Andrea Giovanni Musumeci

Department of Forensic Pathology Department of Radiology
University of Foggia A.O.U. “Policlinico- Vittorio Emanuele”
Foggia, Italy Catania, Italy

Stefano D’Errico Cristoforo Pomara

Department of Forensic Pathology Department of Forensic Pathology
University of Trieste University of Catania
Trieste, Italy Catania, Italy

Giulio Di Mizio Monica Salerno

Forensic Medicine - Department of Law Department of Forensic Pathology
University “Magna Graecia” of Catanzaro University of Catania
Catanzaro, Italy Catania, Italy

Vittorio Fineschi Francesco Sessa

Department of Forensic Pathology Department of Forensic Pathology
Sapienza University of Rome University of Foggia
Roma, Italy Foggia, Italy

Nicholas Márquez-Grant Giulio Zizzo

Cranfield Forensic Institute Department of Radiology
Cranfield University A.O.U. “Ospedali Riuniti”
Shrivenham, United Kingdom Foggia, Italy

Giampaolo Grilli
Department of Radiology
A.O.U. “Ospedali Riuniti”
Foggia, Italy

xi
Editors
Cristoforo Pomara, MD, PhD, is the Director of
the Institute of Forensic Medicine at the University
of Catania, Italy, and a full professor in Forensic
Medicine. His research activity focuses primarily on
forensic pathology, histopathology, dissection tech-
niques, forensic toxicology, and forensic genetics. He is
also an expert in medical professional liability, clinical
governance and risk management, bioethics, compen-
sation for personal injury, and vaccination issues, and
is experienced in professional diseases. Pomara has
authored over 200 scientific publications, as well as a
number of textbooks, including the Manual Forensic
Autopsy: A Handbook and Atlas (CRC Press, 2010).
He is a leading scientist in his field of investigation.
xiii
Vittorio Fineschi MD, PhD, is a full professor in
Forensic Medicine at the Sapienza University of Rome,
Italy. His over-35-year expertise encompasses foren-
sic pathology, histopathology, dissection techniques,
forensic toxicology, as well as forensic genetics. He is
also trained in medical professional liability, clinical
governance and risk management, bioethics, com-
pensation for personal injury, as well as professional
diseases. He has authored over 400 scientific papers,
as well as a number of textbooks, including Pathology
of the Heart and Sudden Death in Forensic Medicine
(CRC Press, 2006). He is the Director of the Legal
Medicine and Insurance, Policlinico Umberto I, at the
Sapienza University of Rome.
Contributors

Francesco Amico Gianpaolo Di Peri

Department of Forensic Pathology Department of Forensic Pathology
University of Catania University of Catania
Catania, Italy Catania, Italy

Benedetta Baldari Eugenia Di Stefano

Department of Forensic Pathology Department of Forensic Pathology
Sapienza University of Rome University of Catania
Roma, Italy Catania, Italy

Livia Besi Martina Fichera

Department of Forensic Pathology Department of Forensic Pathology
Sapienza University of Rome University of Catania
Roma, Italy Catania, Italy

Filomena Casella Sabrina Franco

Department of Legal Medicine Department of Forensic Pathology
A.O. “S.Anna e S. Sabastiano” University of Catania
Caserta, Italy Catania, Italy

Sergio Castorina Pasquale Giugliano

Department of Anatomy Department of Legal Medicine
University of Catania A.O. “S.Anna e S. Sabastiano”
Catania, Italy Caserta, Italy

Mario Chisari Salvatore Iannuzzi

Department of Forensic Pathology Department of Forensic Pathology
University of Catania University of Catania
Catania, Italy Catania, Italy

Giuseppe Cocimano Francesca Indorato

Department of Forensic Pathology Police Department
University of Catania Catania, Italy
Catania, Italy
Aldo Liberto
Federica Colosimo Department of Forensic Pathology
Forensic Medicine - Department of Law University of Catania
University “Magna Graecia” of Catanzaro Catania, Italy
Catanzaro, Italy
Carla Loreto
Dario Condorelli Department of Anatomy
Department of Forensic Pathology University of Catania
University of Catania Catania, Italy
Catania, Italy
Pasquale Malandrino
Alessandra De Palma Department of Forensic Pathology
A.O.U. “Policlinico S.Orsola-Malpighi” University of Catania
Bologna, Italy Catania, Italy

Nunzio Di Nunno Francesco Maria Galassi

Department of History, Society and Studies on Humanity Department of Humanities, Arts and Social Sciences
University of Salento Flinders University of South Australia
Lecce, Italy Adelaide, Australia

xv
xvi Contributors

Pietro Mazzeo Matteo Scopetti

Department of Forensic Pathology Department of Forensic Pathology
University of Catania Sapienza University of Rome
Catania, Italy Roma, Italy

Patrizia Moschetti Edmondo Scoto

Department of Forensic Pathology Department of Forensic Pathology
University of Catania University of Catania
Catania, Italy Catania, Italy

Federico Giuseppe Patanè Roberto Testi

Department of Forensic Pathology Department of Forensic Medicine
University of Catania ASL TO 2
Catania, Italy Torino, Italy

Lorenzo Polo Marco Torrisi

Scientific Manager Brain SCH Department of Forensic Pathology
Pavia, Italy University of Catania
Catania, Italy
Amalia Piscopo
Forensic Medicine—Department of Law Giuseppe Tumino
University “Magna Graecia” of Catanzaro Department of Forensic Pathology
Catanzaro, Italy University of Catania
Catania, Italy
Ilenia Russo
Department of Forensic Pathology Fabrizio Vanaria
University of Catania Police Department
Catania, Italy Catania, Italy
A Methodological Approach to
the External Examination
STEFANO D’ERRICO
University of Trieste
1
MONICA SALERNO
University of Catania

Contents
1.1 Introduction 1
1.2 Clothing 1

1.3 Jewelry 2
1.4 Tattoos 2
1.5 Sex, Race, and Age 2
1.6 Height and Weight 2
1.7 Time of Death Indicators 2
1.8 General Recommendations 3
1.9 Head Examination 3
1.10 Neck Examination 3
1.11 Chest Examination 4
1.12 Abdominal Examination 4
1.13 Shoulder and Upper Extremities 4
1.14 Lower Extremities and External Genitalia 4
1.15 Dorsal and Lumbar Regions 5
Bibliography 5

1.1 Introduction clothing should be carefully examined and described

Pathologists must perform a careful external exami-
nation of the cadaver prior to the actual autopsy, as the
external findings may sometimes be more important
than anything revealed by the internal examination.
The external examination often provides significant
clues and sometimes may even reveal the cause of
death. External examination is especially important in
forensic cases where close attention to detail is manda-
tory. The examination must be documented with pho-
tographs and a full-written description of findings.
Diagram sheets should also be used to graphically
reproduce the locations of anatomical findings.
1.2 Clothing
Examination of the clothing should always be per-
formed by the pathologist, not only in criminal cases
or in cases of suspicious death, but also in traffic and
industrial accidents, falls, and drownings. Each part of
before and after its removal from the body. If clothes
have been removed before transfer to the mortuary,
the pathologist should always specifically ask for the
clothes of the victim to be returned, especially when
trauma is the provisional cause of death.
A record of size, type, make, and color of the
clothing should always be created. In cases where
trauma is thought to be the cause of death, body inju-
ries should be matched with the damage found on the
clothing, such as tears, slashes, stab wounds, and gun-
shot wounds. A complete photographic documenta-
tion of the clothes should be performed. The number,
position, morphology, and size of lacerations should
be noted. In cases of gunshot tears in the clothing, the
tears should be “triangled” by measuring their dis-
tance from the upper, lower, and lateral landmarks.
Gunshot residue on the clothing may provide vital
evidence, revealing the range of the discharge and the
type of ammunition. The Na rhodizonate technique
should be used to examine bullet holes for gunshot
residue.

1
2 Forensic and Clinical Forensic Autopsy
When dealing with traffic fatalities, the clothing
should be examined for tears, grease marks, road dirt,
and broken lamp or windscreen (windshield) glass.
Every metallic or plastic fragment related to the vehi-
cle should be collected with the hope that it will even-
tually be possible to use these materials to reconstruct
the event or identify the unknown vehicle in a hit-
and-run. A careful inspection of pockets should also
be performed. Because pockets can contain needles or
other sharp objects, the examiner should always use
forceps to avoid sharp injuries. All personal effects
found need to be inventoried.
If possible, remove clothing in the usual way, by
pulling the shirt over the head and limbs unless doing
so might interfere with any injuries or cause soiling
of the clothing. If rigor is intense, clothes may be cut
off, taking care not to cut through preexisting damage
or areas of staining already noted to be present on the
garments. In cases of sudden infant death syndrome,
examination of the clothing and diapers (which are
often saturated with urine) is of particular impor-
tance. If a urine sample from the bladder has not been
collected at the time of external examination, the dia-
per can be submitted for laboratory analysis as well as
toxicological and metabolic screening.
Clothing examination is also very important in
sex-related deaths. In these cases, the clothing of the
victim could reveal the presence of bloodstains or
seminal liquid, and the samples should be collected
for genetic testing. As with any other type of traumatic
death, the clothing should be carefully examined for
tears, missing buttons, dirt, gravel, grease, and leaves.
Their collection might aid in later efforts at scene
reconstruction.
1.3 Jewelry
Jewelry must be inventoried and a short description
(e.g., a yellow metal ring was worn on the fourth finger
of the left hand) included. The presence of body pierc-
ing should be recorded.
1.4 Tattoos
The shape, size, site on the body, and color of any tat-
too should always be recorded. Sometimes tattoos may
be found inside the mouth (particularly the mucosa of
the lips). Attempts at removal of a tattoo, which usu-
ally leave a typical and unique appearing scar, should
also be noted.
1.5 Sex, Race, and Age
The sex, race (white, Afro-Caribbean, Asian, and so
forth), and age of the cadaver are always recorded. The
color of the skin sometimes may provide clues about
possible diseases (yellow discoloration of skin and
mucosa in liver disease, i.e., jaundice) or suggest the
mechanism of death (e.g., cherry-pink colorations of
carboxyhemoglobin in carbon monoxide poisoning).
The sex of the decedent may not always be obvious; a
body that is phenotypically female could be genetically
male, or vice versa. Estimating the age of a cadaver is
generally difficult, so when stating age, the pathologist
should always indicate that the margin of error is at
least 3–5 years. Finally, the general state of cleanliness
of the body should be recorded; this is of particular
importance in cases where neglect is considered the
possible cause of death.
1.6 Height and Weight
Once undressed, the cadaver is weighed, preferably in
kilograms. The height in centimeters is also measured
from heel to crown (in infants, a more detailed mea-
surement is taken). When the height and weight of the
cadaver are known, the body mass index can be eas-
ily calculated using the formula BMI = weight (kg)/
height (cm)2. This is important to note because a BMI
above 30 may suggest the presence of certain under-
lying diseases, such as hypertension, coronary artery
disease, or diabetes. Some comment should be made
on the general state of nutrition if it has not already
been indicated in the general external examination.
It should be noted whether the decedent was obese,
emaciated, edematous, dehydrated, or well nourished.
These are all important observations, but they cannot
always be relied upon because in today’s work, addicts
are increasingly likely to have a normal diet.
1.7 Time of Death Indicators
Body temperature should always be recorded, pref-
erably at the scene. In jurisdictions where the physi-
cian does not always travel to the scene, experienced
death investigators can, at least, take rectal, if not liver,
temperatures. At the same time, the ambient air tem-
perature should be recorded. Obviously, if the body
is found naked in subzero weather, the observation
alone may help to limit the differential diagnosis. The
dictated report should also note the temperature at
Methodological Approach to External Examination
the time of autopsy and whether the cadaver had been
refrigerated. The presence or absence of rigor mortis
and distribution of livor mortis (hypostasis) should
be documented at the scene and again at the time of
autopsy.
1.8 General Recommendations
The cadaver should be inspected from head to foot
(head, neck, chest, abdomen, pelvis), from the left to
the right side, in supine and prone positions, includ-
ing both the dorsal and volar surfaces of extremities
(arms and legs). Bruises, abrasions, lacerations, incised
wounds, burns, fractures, surgical and nonsurgical
scars, medical intervention, congenital or dimorphic
features, and the presence of natural diseases should
all be noted, photographed, and meticulously mea-
sured by recording observations about length, breadth,
orientation to the axis of the body, and position with
reference to surface anatomical landmarks. When
widespread burns are present, an estimate of the total
area using the rule of nines should be done. A centime-
ter scale, along with appropriate body identifier codes
and the decedent’s name (if known), should always be
placed near the lesion when it is photographed.
1.9 Head Examination
The presence or absence of head hair, as well as its
color and length, should be recorded. If the dece-
dent is wearing a wig, the name of the manufacturer
should also be noted. A generous hair sample should
always be collected and preserved as natural hair
can be used to establish race or for later toxicologi-
cal analysis (e.g., drug-related death). No particular
special procedures are required for the storage of hair
samples (a sterile blood collection tube or even an
envelope can be used), and the hair samples can be
stored at room temperature for years without degra-
dation. Although there is no particular need for hair
toxicology as a routine component of every forensic
examination, the retained sample may prove invalu-
able if the cause of death is disputed at some later
date. Hair analysis may also be valuable in the diag-
nosis of drug-related deaths. If no drug is found in
the hair root, then blood drug concentrations are sub-
stantial, which would indicate the decedent had no
prior exposure to the drug. On the other hand, high
concentrations in the hair would indicate regular use
and suggest that the decedent may have been tolerant
to the drug in question.
3
Lacerations of the scalp can produce profuse
bleeding despite their size, due to the great vascular-
ity of the scalp. Any deformity of the skull should be
carefully noted (depression or elevation). Dislocated
or depressed skull fractures can be detected by firm
palpation. Palpation of the cranium should be per-
formed from the left to the right side, from the pari-
etal region to the temporal and frontal, in this order.
Palpation of the occipital region should be done when
the cadaver is lying in the prone position. Small hem-
orrhagic cutaneous petechiae can sometimes be found
behind the ears in asphyxia-related deaths or when
there are temporozygomatic and orbitonasal injuries.
The color of the irises and the symmetry of the
pupils should be noted. If the decedent was wearing
contact lenses or glasses, these glasses or lenses should
be removed before the eye examination. The acoustic
meatus and canal should be examined using an oto-
scope if necessary. The nose and oral cavity should
always be investigated in order to exclude the pres-
ence of blood, foam, vomit, and foreign bodies. In the
case of a suspected death by poisoning, for example,
foam found on the mouth and nose could be sampled
for laboratory analysis. In cases of narcotic overdose,
foam may be found emanating from the nostrils or
the mouth. The foam is comprised of the protein-rich
transudate that is more often than not present in cases
of narcotic overdose.
The presence of small petechiae of the eyes and
conjunctivae is of particular relevance in asphyxia-
related deaths, and should always be photographed.
However, studies have been published demonstrating
that these lesions can occur after death, so, their pres-
ence should not be considered as proof of asphyxial
death – they are merely consistent with it. Finally,
the mouth and lips, including the mandibular region,
should be examined. The state of dentition and the
presence of dental restoration can be of very great
importance when dealing with unidentified cadavers.
When the body is unidentified, a detailed dental chart
must be prepared. In all suspected cases of suffocation,
smothering, or strangulation, bruises and abrasions of
the face (e.g., fingernail marks) or oral mucosa (e.g.,
teeth marks) provide evidence either that the victim
put up a vigorous resistance or that violent compres-
sion of the nose and mouth had been exerted.
1.10 Neck Examination
The neck should be examined from the left to the right,
region by region (jugular vs. hyoid). Neck mobil-
ity should be examined only after rigor has resolved.
4 Forensic and Clinical Forensic Autopsy
This  is accomplished by flexing and hyperextending
the head toward the chest. Abnormal mobility should
be noted. Bruises, abrasions, and lacerations should be
carefully described as well as any findings suggesting
ligature strangulation (i.e., hanging). In all cases of
hanging, a complete description of the furrow should
be provided, and it should indicate if the furrow com-
pletely encircled the neck and whether it had sharp
margins. A rope will give a deep, well demarcated, and
distinct furrow, often with a mirror-image impression
of the twist of the rope on the skin. If a soft material
was used as the ligature, the resultant groove may be
poorly defined, pale, and devoid of bruises and abra-
sions. Should the ligature still be present, the type of
material should be noted and the ligature itself sub-
mitted for further testing.
1.11 Chest Examination
External examination of the chest should be per-
formed from the left to the right side, over all the
ribs and intercostal spaces. The first thing to note is
whether or not the chest is symmetric or asymmetric.
Chest palpation is needed to detect the presence of rib
fractures and subcutaneous emphysema, and while
this examination is being performed, the presence of
any visible markings or lesions is noted. The cadaver
must be placed in a prone position to firmly palpate
the thoracic vertebrae.
1.12 Abdominal Examination
An abdominal examination of upper and lower
abdominal squares should follow a careful downward
inspection, from the left to the right side. Bruises, abra-
sions, and lacerations have to be carefully recorded.
1.13 Shoulder and Upper Extremities
Any abnormal movement of acromioclavicular joint
should be noted. External examination of the upper
extremities should be performed from the shoul-
ders downward to the hands, and any injuries of the
dorsal and ventral sides should be noted. When self-
incised wounds have been inflicted, they are usually
superficial (hesitation marks), but they may be found
adjacent to or overlying a fatal incised wound. When
the decedent has attempted to ward off a pointed
or sharp-edged weapon, defensive marks may be
found on the palms of the hands, which is a result
of attempts to grasp or ward off the knife. Defensive
wounds may be found on the back (extensor surface)
of the forearms and upper arms, and on the ulnar
aspect of the forearms. In drug-related deaths, needle
marks (recent or past) on elbows and wrists should
be carefully investigated and recorded although there
is little to be gained by testing the skin for drugs, as
once a drug is in the body, it circulates everywhere,
including the skin. If skin around an injection site is
submitted for toxicological testing, it must be accom-
panied by a control sample of skin taken from the
other arm. Hands should also be carefully examined
as electrical marks are generally difficult to see unless
the rigor of a flexed finger is overcome. Samples of the
fingernails should be collected for later toxicological
measurement as questions about drug use may arise
at a later date.
1.14 Lower Extremities and
External Genitalia
As with the upper extremities, an examination of the
lower extremities is performed from the left to the
right side, downward and backward. Careful palpa-
tion is needed to detect excessive joint mobility and
fractures of long bones. Some drug takers inject into
the interdigital spaces, and these spaces must be care-
fully examined. A detailed perineal examination is
required in cases of suspected sex-related deaths.
Bruises, bites, and laceration of the perineal region
can have very great investigative significance. Careful
investigation for any foreign hairs mixed with the
cadaver pubic hairs is required, which means that the
victim’s pubic hair should be combed. Sometimes, a
vaginal speculum is required to complete a detailed
inspection of the vagina and cervix, which should
include the collection of appropriate secretions. An
anal examination is often misleading because of the
postmortem flaccidity of the sphincter. Therefore,
the diagnosis of sexual abuse, especially in children,
must not be assumed without other evidence (i.e.,
fresh mucosal tears or swabs positive for semen). Even
if there is no suspicion of sexual assault, the presence
or absence of circumcision should be noted as it may
contribute to the identification of the cadaver. The
presence of semen on the external urethral meatus is
a frequent finding, but one of very little significance;
it is not specific to sexual activity immediately before
death, nor does its presence prove asphyxial death as
sometimes stated.
Methodological Approach to External Examination
1.15 Dorsal and Lumbar Regions
When the external examination is concluded, the
cadaver can be placed in a prone position. Dorsal and
lumbar injuries should be recorded using the same
methodological approach as used in the other regions,
from the left to the right side and downward.
Bibliography
DiMaio VJ and DiMaio D. 2001. Forensic Pathology, 2nd
edition. Boca Raton, FL: CRC Press.
Dolinak D, Evan M, and Lew E. 2005. Forensic Pathology:
Principles and Practice. Burlington, MA: Elsevier
Academic Press.
Finkbeiner WE, Ursell PC, and Davis RL. 2004. Autopsy
Pathology: A Manual and Atlas. Philadelphia, PA:
Churchill Livingstone.
5
James JP, Busuttil A, and Smock W. 2003. Forensic Medicine:
Clinical and Pathological Aspects. San Francisco, CA:
GMM.
Ludwig J. 2002. Autopsy Practice, 3rd edition. Totowa, NJ:
Humana Press.
Pomara C and Fineschi V. 2007. Manuale Atlante di Tecniche
Autoptiche. Padova: Piccin.
Randall BB, Fierro MF, Froede RC, and Bennett AT. 2003.
Forensic pathology. In Autopsy Performance and
Reporting, 2nd edition, (eds.) Collins KA and Hutchins
GM, 55–64. Northfield, IL: College of American
Pathologists.
Rutty GN and Burton JL. 2001. The external examination.
In The Hospital Autopsy, 2nd edition, (eds.) Burton
JL and Rutty GN, 42–51. London: Oxford University
Press.
Saukko P and Knight B. 2004. Knight’s Forensic Pathology,
3rd edition. London: Oxford University Press.
Wagner SA. 2004. The color atlas of autopsy. Boca Raton, FL:
CRC Press.
Adult Autopsy
CRISTOFORO POMARA AND MONICA SALERNO
University of Catania

VITTORIO FINESCHI
2
Sapienza University of Rome

Contents
2.1 Adult
 Autopsy 9
2.1.1 General Autopsy Principles 9
2.1.2 Autopsy Preliminaries 9
2.1.2.1 Autopsy Forms 10
2.1.3 The Instruments 12
2.1.4 Regulation of the Autopsy Table and Positioning of the Dissector 12
2.2 Primary Incision of the Soft Tissues of the Thoracic–Abdominal Wall 13
2.2.1 Cutting
 Sequence 14
2.2.1.1 Handling the Scalpel 14
2.2.2 Approaching Dissection by Single Layers: The Thoracic Wall 16
2.2.3 The Abdominal Wall 17
2.2.3.1 Case Study #1 21
2.3 Access to the Thoracic Cavity 22
2.3.1 Incision of the Thoracic Wall 22
2.3.2 Disarticulating Clavicular Joints 22
2.3.3 The Chondrocostal Incision 23
2.3.4 Removal of the Anterior Rib Shield 23
2.3.5 Inspection of the Anterior Chest 25
2.3.6 Inspection of the Pleural Cavities 25
2.3.7 Incision of the Pericardial Sac: Examination of the Heart In Situ 25
2.3.8 Examination of the Pericardial Cavity and Its Content 27
2.3.9 Cardiac Examination 27
2.3.10 Collecting Blood Samples 27
2.3.11 Examination in Situ of the Main Pulmonary Artery 29
2.3.11.1 Case Study #2 30
2.3.11.2 Case Study #3 32
2.3.11.3 Case Study #4 35
2.4 Evisceration According to Virchow’s Technique 37
2.4.1 Heart Extraction 38
2.4.2 Lung Sections and Removal 38
2.4.3 Exploration of the Anatomical Structures of the Posterior Mediastinum 39
2.5 Access to the Neck Region 39
2.5.1 Removal of the Muscular Heads of the Sternocleidomastoid Muscle 40
2.5.2 Removal of the Muscle of Superficial, Medium, and Deep Surface Regions 41
2.5.3 Removal of the Thyroid 42
2.5.4 Inspection and Section of the Neck Vasculature: Neurovascular Bundle 42
2.5.5 Removal of the Muscles of the Posterior Face of the Neck 42
2.5.5.1 Case Study #5 43
2.6 Evisceration According to Ghon’s Technique (En Bloc) 45
2.6.1 Direct Access to the Mouth Floor 45
2.6.2 The Floor of the Mouth 45

7
8 Forensic and Clinical Forensic Autopsy

2.6.3 Ghon’s En Bloc 46

2.7 Access to the Abdominal Cavity 49
2.7.1 Incision of the Parietal Peritoneum 49
2.7.2 Abdominal Inspection 49
2.8 The Letulle Technique: En Masse Removal 50
2.8.1 Case Study #6 51
2.9 The Virchow Technique 53
2.9.1 Removal of the Spleen 53
2.9.2 Small Intestine Removal 54
2.9.2.1 Complete Removal of the Small Intestine 54
2.9.2.2 Isolation of the Small Intestine Through Linearization of the Single Intestinal Loop 56
2.9.3 Removal of the Large Intestine 57
2.9.3.1 Isolation and Removal of the Cecum 57
2.9.3.2 Isolation and Removal of the Ascending Colon 57
2.9.3.3 Isolation and Removal of the Right Colon Flexure 57
2.9.3.4 Isolation and Removal of the Transverse Colon 57
2.9.3.5 Isolation and Removal of the Left Colon Flexure 57
2.9.3.6 Isolation and Removal of the Left, Descending, and Iliac Colon 58
2.9.3.7 Isolation and Removal of the Sigmoid Colon 58
2.9.3.8 Isolation and Removal of the Rectum 58
2.9.3.9 Bile Collection 58
2.9.4 Isolation and Removal of the Liver 59
2.9.5 Examination of the Stomach, Duodenum, and Pancreas 59
2.9.5.1 Case Study #7 61
2.9.6 Removal of Kidneys and Suprarenal Glands 62
2.9.6.1 Access to the Renal Cavity and Excision In Situ 62
2.9.6.2 Excision of the Renal Cavity and Ureter In Situ 63
2.9.6.3 Inspection and Resection of the Ureters 63
2.9.7 Examination and Removal of the Bladder 63
2.9.7.1 Drawing Urine 63
2.9.7.2 Bladder Removal 63
2.9.8 Removal of the Uterus and Adnexae 64
2.9.9 Examination and Removal of the Large Arterial–Venous Retroperitoneal Pelvic Veins 66
2.9.9.1 Case Study #8 66
2.10 Dissection of the Head 68
2.10.1 Preparation of the Dissection Field 68
2.10.2 The Bimastoid Resection 69
2.10.3 Inspection and Resection of the Temporal Muscles 70
2.10.4 Removal of the Skullcap 70
2.11 Removal of the Brain 73
2.11.1 In situ Examination of Lateral Ventricles 73
2.11.2 Brain Dissection 74
2.11.2.1 Case Study #9 76
2.11.3 Access to the Face 78
2.11.3.1 Case Study #10 79
2.12 Face and Neck Approach: The “face/off” Technique (Pomara C.) 81
2.13 Vertebral Resection and Cord Removal 83

2.13.1 Posterior Approach 83

2.13.2 Anterior Approach 83
2.13.2.1 Case Study #11 87
2.14 Upper limb and Axilla dissection 88
2.14.1 Case Study #12 91
2.14.2 Case Study #13 92
Adult Autopsy 9

2.15 Lower Limb Dissection 94

2.15.1 Case Study #14 96
2.16 Macroscopic Examination and Dissection of Organs 97
2.16.1 Brain
 97
2.16.1.1 The Ludwig Scheme 97
2.16.1.2 Classic Variations (Virchow Method) 99
2.16.1.3 Blood Samples 99
2.16.2 Heart 99
2.16.2.1 Inflow–Outflow Method in Cardiac Dissection and in situ Coronary Tree Isolation 99
2.16.2.2 Method of Heart Valve Dissection 101
2.16.2.3 Dissection by Chamber 103
2.16.2.4 Dissection of the Base of the Heart 103
2.16.2.5 Recommended Cardiac Samples 106
2.16.3 Upper Respiratory Tract 107
2.16.3.1 Examination of the Larynx and Pharynx 107
2.16.4 Trachea and Primary Bronchi 107
2.16.4.1 Case Study #16 108
2.16.4.2 Case Study #17 110
2.16.5 Lungs 112
2.16.5.1 Lung Resection 112
2.16.5.2 Lateral Lung Resection 112
2.16.5.3 Sampling 112
2.16.6 Liver 114
2.16.7 Spleen 114
2.16.7.1 Sample Collection 114
2.16.8 The Kidneys 114
2.16.8.1 Sample Collection 114
Bibliography 115

2.1 Adult Autopsy
The dissection techniques used in adult forensic autop-
sies, or medicolegal autopsies, do not differ signifi-
cantly from those used in hospital autopsies. In both
instances, a regional technique is used to gather the
evidence necessary to reach the correct anatomical–
pathological diagnosis. However, when performing a
forensic autopsy, it is also important to gather evidence
that may later be of forensic relevance in a judicial
trial. To this end, some specific requirements of the
hospital autopsy may need a modification to provide
the answers needed by the courts. It is understood
that approaches, other than those described here, may
prove equally effective provided that they address the
same basic issues outlined here.
performed (1–3 hours). The dissector must take the
time to describe, in broad terms, the in situ appearance
of the organs, which are then removed, weighed, and
measured. Photographs should be taken of each exter-
nal anatomical region, each body cavity showing any
possible collections of liquids, the presence of clots/
thrombi, tumors, and foreign bodies as well as macro-
scopic abnormalities. Recesses of muscular, tendon, and
osseous structures need only to be examined in cases
where the presence of an abnormality is suspected.
The extraction and resection of the single organs and
tissue blocks must be done to permit their effective study.
If a lesion extends to more than one organ, the
selected technique must allow for the reconstruction
of organ relationships and collection of sufficient tis-
sue for sampling.

2.1.1 General Autopsy Principles 2.1.2 Autopsy Preliminaries

Whatever technique is chosen, it must allow for easy Any unique features of the cadaver must be noted and
access to the organs and cavities in each region of the recorded, and every effort should be made to obtain a
body. It must also not require too much time to be detailed information about the circumstances of death.
10 Forensic and Clinical Forensic Autopsy

Figure 2.1 Autopsy table with adjustable height. Positioning of the body and first photographs. Identification sign
in which corpse’s full name, dissector’s full name, date and place of autopsy, and requesting authority are specified.
The first picture must be taken with the body in a supine anatomical position (a); the second will be taken with the
corpse in posterior exposition (b).

Meanwhile, a technician should prepare the
identification cards to be included in every autopsy
photograph; otherwise, the validity of the photo-
graphs might be challenged in court (Figure 2.1a
and b).
Every case is different and no one routine
approach should be used to the exclusion of all oth-
ers. Nonetheless, the use of X-rays, CT (computed
tomography), or MRI (magnetic resonance imaging)
scanning is encouraged if available. The interpreta-
tion of postmortem artifacts can prove a challenge,
especially for less experienced radiologists and
pathologists, and only those people with experience
in reading these scans should be asked to provide a
formal opinion.
2.1.2.1 Autopsy Forms
Identification cards are important for a correct identity
check of the cadaver. They should be filled in before
the autopsy takes place. The first two (Figure 2.2a and
b) are identification cards: A larger format is used for
the first two identification cards, while a smaller one
is used for the remaining steps of external examina-
tion and autopsy. The other forms concern the autopsy
checklist (Figure 2.2c), a sampling chart (Figure 2.2d),
and a synoptic drawing to localize all relevant injures.

Figure 2.2 (a–e) Standard autopsy forms.

(Continued)
Adult Autopsy 11

Figure 2.2 (Continued)  (a–e) Standard autopsy forms.

12 Forensic and Clinical Forensic Autopsy

2.1.3 The Instruments
The use of forceps with rubber prongs rather than ana-
tomical forceps, or forceps with toothed prongs, can
considerably improve the quality of the specimen and
the integrity of the anatomical area investigated. The
examination of the vena cava in cases of suspected
surgical malpractice is a good example; substantial
problems can result when the injection itself can cause
iatrogenic lesions. The basic instruments essential for
every dissector are illustrated in Figures 2.3–2.9.

2.1.4 Regulation of the Autopsy Table

and Positioning of the Dissector
If right-handed, the autopsy pathologist should stand
on the right of the corpse, or on the left if left-handed
(Figure 2.10). Once the autopsy table has been adjusted

Figure 2.5 Blades case sets. It is advisable to have a

minimum of three of equal dimension and at least two
different types (for a total of six). The figure shows three
blades from case N 22 (our preferred choice).

Figure 2.3 Minimum set of instruments necessary for

a basic autopsy.

Figure 2.4 Anatomical forceps with toothed prongs. Figure 2.6 Set of scissors. It is important to have
The different dimensions support the dissector’s choices rounded blunt bulbs that allow access to body cavities
depending on the anatomical region operated on or the without the fear of parietal lesions. (Enterotomes: first
organs subject to study. two from the bottom.)
Adult Autopsy
Figure 2.7 Rib shears. These are essential for cutting
the costochondral margin. They are instruments to use
with extreme care to avoid injures to the lungs and heart.
Figure 2.8 Test tubes, sample pots, swabs, and syringes:
They are essential to sample organs, tissues, and biologi-
cal liquids for toxicological, genetic, and histopathologi-
cal investigations.
13
Figure 2.9 Set of clothes: disposable surgical gown,
surgical gloves, surgical mask, surgical cap, waterproof
boots.
Figure 2.10 Dissector position at the autopsy table with
dissection kit set.
to a height that is comfortable for the examination
(Figure 2.1), arrange the body in a supine position,
and then place a support beneath the body’s shoulders.
This will ensure a good extension of the neck and pro-
vide adequate exposure of the chest.
2.2 Primary Incision of the Soft Tissues
of the Thoracic–Abdominal Wall
The primary thoracic–abdominal incision should
be made before opening the skull since extraction
of the heart involves the drainage of a good part of
14 Forensic and Clinical Forensic Autopsy

the blood present in the cranial vault via the superior

cava venous system. Removing the heart first mini-
mizes the possibility of blood overflow within the
meningeal spaces when the skull is finally opened.
It is important to prevent this from occurring as it
may lead to the appearance of artefactual bleeding
in the neck.
Although several approaches are possible, some
variation in the Y-shaped thoracic–abdominal inci-
sion is preferred (in the United States, it is better
known as a T-shaped incision). This first portion of
the procedure involves an initial transverse incision
in the upper part of the thorax, made from shoulder
to shoulder (biacromial), creating a trough that will
be more or less located at the jugular bifurcation
(Figure 2.11). A single midline incision is then made,
passing 3–4 cm to the left of the umbilicus down to the
pubic tubercle (Figures 2.12 and 2.13).
The resulting T-shaped incision is called “calyx-
like” because it creates a cuplike structure. At the tho-
racic level, the blade will sink deeply into the middle Figure 2.11 First transversal incision with superior con-
line of ante sternal soft tissues, whereas at the abdomi- cavity and bisacromial extension (shoulder to shoulder).
nal level, this type of incision preserves the deepest
structure, the parietal peritoneum. This avoids opening
the peritoneal cavity and the exposure of its content.

2.2.1 Cutting Sequence
The sequence described here applies for all actions to
be carried out on the right and left sides of the body. If
possible, a second dissector will stand in front on the
left side of the autopsy table to help the first dissec-
tor. The second dissector follows the actions of the first
and helps retract the incision.

2.2.1.1 Handling the Scalpel

If the dissector is right-handed, the handle of the scal-
pel should be held with the right hand, and vice versa.
A serrated handle with forceps-like grips is the pre-
ferred instrument.
2.2.1.1.1 Thoracic Incision
After the antesternal soft tissues have been transacted,
the following sequence or combined actions are required
(Figures 2.14a–c).1 With the scalpel oriented tangentially
to the plane of the ribs, dissection is facilitated by bilat-
eral traction of the antecostal soft tissues (Figures 2.15
1 In women the presence of the breasts as well as in male sub-
jects with abundant subcutaneous adipose tissue (i.e., when
the tissue cannot be gripped between the prongs of toothed
pliers), the dissector may use a fabric sponge on his left hand
for easier grasp. With first and second finger in opposition, the
dissector can cut thick, soft antecostal tissues by using lateral
traction.
Figure 2.12 Second single midline incision passing 3–4
cm to the left of umbilicus up to the pubictubercle.
and 2.16). Skin and muscle flaps can then be reflected
one by one to reveal the rib cage. The incision should be
carried out around the borders of the pectoralis major
muscle always keeping the blade oriented tangentially to
the rib cage; otherwise, all costal insertions may not be
detached from the chest wall. Once detached, the muscle
is reflected. The same procedure should be carried out
around the borders of the pectoralis minor.
If the technique is well done, once reflected both
muscles at the level of their anatomical insertion (tip of
coracoid process and humerus), the course of the axil-
lary artery and vein in its bundle should be revealed
(Figure 2.17).
Adult Autopsy 15

Figure 2.13 (a) The first part of the second incision of the resection at the calyx goes down the middle of the first
(with sagittal course) along the median line of the thorax and abdomen (b and c). The abdominal resection proceeds
in the median direction, up to the proximity of the umbilical region.

Figure 2.14 The dissection runs 2 or 3 cm to the left of the umbilicus describing a curve whose concavity will depend
on the anatomical conformation of the region (fat, cutaneous ligaments, previous surgical operations). Traction of the
cutaneous flaps to the origin of the secondary dissection (sagittal branch of the calyx resection) (a) with combined
drawing action carried out with the pliers and cutting action carried out with the scalpel, following the margins of
the incision. (b and c) Symmetrical lifting of the left and right side of the body’s two antimeres (left thoracic antimero
section).
16
Figure 2.15 Combined pulling and cutting action.
Incision phase followed by removing phase. Fully sink-
ing the blade in the antecostal tissues, one gets a draw-
ing action with the help of pliers. The blade tangentially
oriented follows the rib cage.
Figure 2.16 Overturning of the antecostal tissues and
exposition of the rib cage. Serratus anterior muscle is
very clear (white arrows), as well as the pectoralis major
adhered to the thoracic wall (black arrows).
2.2.1.1.2 Abdominal Incision
Our preferred approach for abdominal dissection
has been described as the “eggshell-like” technique.
Dissecting and reflecting one by one the skin and the
abdominal muscles (rectus, transverse, and obliqui of
abdomen), the entire fascial covering of peritoneum
should be revealed, resulting in an appearance, not
unlike the diaphanous inner membrane of an eggshell
(Figure 2.18a and b).
For both women due to the presence of the breasts
and for male subjects due to presence of abundant
Forensic and Clinical Forensic Autopsy
Figure 2.17 Isolation of brachial plexus and axillary
vein and artery after overturning the pectoral muscles.
subcutaneous adipose tissue (i.e., when the tissue can-
not be gripped between the prongs of toothed pliers),
the dissector may use a fabric sponge on his left hand
for an easier grasp. With the first and second finger in
opposition, the dissector can cut antecostal tissues by
using lateral traction of the tissue flaps.
2.2.2 Approaching Dissection by Single
Layers: The Thoracic Wall
After producing the chest calyx incision, gently cut
the skin with the point of the blade, limiting the dis-
section to the subcutaneous margins. Place traction
on the skin using a toothed forceps held in the left
hand. Each anatomical layer is cut in a row, advanc-
ing toward the midline, with the scalpel blade oriented
tangentially to the layers themselves (Figure 2.19a–m).
Incise the pectoral fascia, up to the posterior axil-
lary line. Underlying the skin is the triangle-shaped
pectoralis major muscle. At its lateral apex, it attaches
to the major tubercle of the humerus, located at the
base of the medial sternocostal convex insertion.
Sever the insertion with a continuous, half-moon-
shaped movement of the scalpel, so that the incision
runs vertically from above to below. Then, cut the cla-
vicular portion of the muscle from its insertion into
the clavicle. Reflect the muscle lateral to its humeral
insertion (Figure 2.20). Finally, the costal insertions
of the pectoralis minor are incised, and the muscle
is then severed from its bony attachments with com-
bined traction–dissection; invert the muscle laterally
Adult Autopsy
Figure 2.18 (a) Recti muscles of the abdomen are indicated with black arrows and isolated along the white lines.
Once the blade is inserted at the end of the xiphoid process, the incision is then carried down the lineaalba. (b) Once
the recti muscles of the abdomen are removed, itis possible to highlight multiple parietal peritoneum lacerations due
to stab injuries.
on the coracoid process of the scapula, paying atten-
tion not to accidentally cut the subclavian vein or any
of its branches. If necessary, separate incisions can be
made into the costal insertion of the serratus anterior
muscle. This allows the sternal–costal area to be easily
examined for evidence of traumatic alterations (e.g.,
hemorrhagic infiltrations, rib fracture line, and mal-
formations) (Figures 2.21 and 2.22).
2.2.3 The Abdominal Wall
In the abdominal area, the subcutaneous edge of the
incision is retracted using toothed forceps, held in
the left hand (use of a cloth sponge can be helpful),
and the anatomical layers are dissected in succes-
sion, always proceeding toward the midline, using a
scalpel oriented tangentially to the layers themselves
(Figure 2.19e–j). Dissect the skin from the subcutane-
ous tissue beginning at the aponeurosis of the external
oblique muscle (Figures 2.23–2.25).
The external oblique muscle must be detached
from the posterior costal plane above. With the blade
held obliquely, make a mid-lateral incision in the apo-
neurosis of the external oblique muscle, at the lateral
edge of the rectus muscle, then separate the external
oblique and the underlying internal oblique muscles,
everting both laterally (Figure 2.26).
Divide the internal oblique muscle (sometimes
called the little oblique), making sure that the blade
continues to remain obliquely oriented toward the
midline. The aponeurosis of the internal oblique
17
blends in with the transverse muscle fibers of the
abdomen. Detach the aponeurosis at the lateral mar-
gin of the rectus muscle, and then free it from the
fascia involving the peritoneum, dissecting the pre-
peritoneal connective tissue, reflecting it downward
by traction applied laterally on one side (Figure 2.27).
At this stage, the rectus muscles of the abdomen
are removed, leaving a V-shaped, upside-down inci-
sion at the severed corner of the sternal–costal area.
Once that has been accomplished, all the sternal–costal
insertions of the two rectus muscles are divided along
their lateral margins. The muscle is then detached
bilaterally, using medial to lateral traction, from the
posterior laminae of the rectus sheath up to linea
alba (this technique is usually called flap dissection
or butterfly flap dissection). After creating the flaps,
incise the remaining skin, detach it, then position it
tangentially, oriented toward the pubis; the sheaths of
the rectus muscles lying on the midline are separated
from the underlying peritoneum and are simultane-
ously reflecting downward with their sheaths resting
on the pubis (Figures 2.27 and 2.28). Other approaches
are possible. After cutting through the sternal–costal
insertions of the two rectus muscles, using a perpen-
dicularly oriented scalpel, incise them at the linea
alba, separate them at the midline, then detach the
muscle with the help of the cutter, which is placed tan-
gentially to the peritoneal plane. This will expose the
muscular fascia of the back of the peritoneum up to
the pubic bone, after which it is finally reflected down-
ward (Figure 2.28).
18 Forensic and Clinical Forensic Autopsy

Figure 2.19 (a) First part of second incision of the resection at the calyx that goes down the middle of the first (with
sagittal course) along the median line of the thorax and abdomen (b and c). The abdominal resection proceeds in the
median direction, up to the proximity of the umbilical region. The resection runs 2 or 3 cm to the left of the umbi-
licus describing a curve whose concavity will depend on the anatomical conformation of the region (fat, cutaneous
ligaments, previous surgical operations) (d, e, f, and g). Traction of the cutaneous flaps to the origin of the secondary
resection (sagittal branch of the calyx resection) (e) with combined drawing action carried out with the pliers, and cut-
ting action carried out with the scalpel, following the margins of the incision (f). Symmetrical lifting of the left and
right side of the body two antimeres (left thoracic antimero section) (g and h). The overturns of the thoracic abdomi-
nal cutaneous flaps are evident in figure (i). Removal of thoracic and abdominal cutaneous and subcutaneous tissue
(j). Hemorrhagic infarction of the left subclavicular area (k).Presence of a pacemaker device above the lateral margin
of the right pectoralis major muscle (l). Details of the pacemaker device (m).
Adult Autopsy 19

Figure 2.20 Incision of the major pectoralis muscle Figure 2.21 Sternocostal area revealed after both
origin (blue dashed line). pectoralis major and pectoralis minor origins have been
detached.

Figure 2.22 Dissection of the cutis–subcutis at the thoracic and abdominal levels reveals multiple hemorrhagic
infiltration areas (a). Application of dissection by anatomical layers in a fatal road accident: hemorrhagic infiltration
areas of subcutis as well as the thoracic wall soft tissues after muscle layer removal are evident (b, c).
20 Forensic and Clinical Forensic Autopsy

Figure 2.23 Gunshot injuries with a study of the cuta-

neous and muscular edges. Dissection by anatomical lay- Figure 2.26 Incision and lifting of the external oblique
ers in the study of injuries due to firearms. muscles.

Figure 2.24 Stab wounds with a study of the cutaneous

and muscular layers. Application of the dissection by the
anatomical layers in cases of stab wounds.

Figure 2.27 Incision and detachment of the rectum

abdominis muscles from the anterior face of the parietal
peritoneum, dissection known as flap dissection (butter-
fly flap dissection).

Figure 2.28 Incision and detachment of the rectum

abdominis muscles. After incision and detachment of
Figure 2.25 Dissection of the cutis–subcutis plane at the single rectum muscle, it is reflected down, leaving
the abdominal level. the distal insertion in situ.
Adult Autopsy 21

2.2.3.1 Case Study #1

Amico F., Torrisi M., Testi R.
A 58-year-old man shot himself twice after killing his
wife with several gunshots.
The man was carried to the nearby E.R., where
he underwent an emergency explorative surgery
that allowed surgeons to measure more than 4 liters
of blood in the abdominal cavity and twelve bowel,
omental apron, and mesentery full-thickness lesions.
During the surgery, he died.
2.2.3.1.1 Radiological Examination
The full-body CT scan allowed us to identify a small
metallic foreign body in the soft tissues of the left
gluteal region.
2.2.3.1.2 Autopsy
The external examination showed three lesions: one in
the right-hypochondriac region (letter “A”), another
one 4 cm above the navel in the context of laparotomy
(letter “C”), and the last one in the left iliac fossa (letter
“B”) (Figures CS-1.1 and CS-1.2).
Dissection by anatomical layers was carried out.
Abdominal wall inspection was performed for skin,
muscles, fascial structures, and parietal peritoneum
until the access to the abdominal cavity (Figure CS-1.3).
The intestinal lesions were not identified because most
of the bowel had been surgically removed, except the
omental and mesenteric lesions (Figure CS-1.4). The
foreign body in the gluteal region was identified after
another access from behind (Figure CS-1.5).
2.2.3.1.3 Histological Assessment
Histological examination was performed on all skin
samples. The lesion of the right hypochondrium
showed an interruption of epidermal continuity, the
loss of the stratum corneum, and preservation of the
basal layer, which showed an intense alteration of
nuclei that appeared elongated. All these characteris-
tics are compatible with an entrance gunshot wound
(Figure CS-1.6).
22 Forensic and Clinical Forensic Autopsy

CT scan allowed us to study the involved

organs better and identify the bullet in the
gluteal region.

2.3 Access to the Thoracic Cavity

2.3.1 Incision of the Thoracic Wall

Before exposing the thoracic cavity, make an inci-
sion through the intercostal muscles (external, inter-
nal, a posterior muscle).The parietal pleura could be
useful to have an idea of the pulmonary expansion
(Figure  2.29).

2.3.2 Disarticulating Clavicular Joints

The sample performed on the left iliac fossa skin The sternoclavicular joints need to be separated before
showed an interruption of epidermal continuity, the chest cavity and its contents can be inspected. A
raised from the underlying dermis compatible with small knife with a narrow blade is used to incise the
the exit wound (Figure CS-1.7). ligaments, the articular capsule, and the insertion

Key Points
• The cause of death was a hemorrhagic shock
due to the massive abdominal organs wounds.
• Dissection by anatomical layers is fundamen-
tal to study the abdominal wall, especially in
gunshot cases, because of the possibility to
explore the trajectories inside the body with
the best accuracy. In this specific case, a bul-
let entered by the right hypochondriac region
without hitting the abdominal cavity, but
exited by the left iliac fossa.
• Macroscopic and microscopic study of gun- Figure 2.29 Incision plane and the parietal eyelet real-
shot wounds allows defining ingoing and out- ized into the second intercostal space laterally to the
going wounds. hemiclavear line.
Adult Autopsy
of the sternal head in the upper sternocleidomastoid
muscle on the manubrium of the sternum.
Identify the articular heads first by making an
incision running through the articular line by rhyth-
mically moving the corresponding shoulder with the
left hand. Sink the point of the scalpel into the inferior
or superior border of the articular line, taking care
not to damage the arteries and veins of the neck that
lie just below, especially the trunk of the innominate
artery. The result is a half-moon-shaped incision with
a lateral concavity.
2.3.3 The Chondrocostal Incision
Once the clavicles have been disconnected on each
side, open the thoracic cavity by removing the ster-
nochondrocostal surface. Each rib is severed with
Figure 2.30 Running plane of the shears rib (chondro-
costal edge).
Figure 2.31 (a and b) Rib cutters are necessary to open the thorax.
23
the rib shears starting from below or, better still,
at the costal arch of the tenth rib (an incision here
will involve the diaphragm and its costal insertions)
(Figure 2.30). The process is then carried upward to
the first rib at a maximum of 1–2 cm inside the chon-
drocostal line. Rib shears must be held with the right
hand, perpendicularly oriented to the costal arches
(Figure 2.31). Some chondral fragments will remain
on the costal stump, but these will help protect the
hands of the dissector (although dissectors are wear-
ing gloves, the cartilage will protect their hands
against the irregular and sharp bony surface of the
costal stump).
By the time the first intercostal space is reached,
position the rib shears (blade point bent at 30° toward
the inside) so that they are aligned with the incision on
the sternoclavicular articular surface, then resect the
first rib (because the bone is thicker and stronger in
this area, pressure must be applied to both ends of the
rib cutter) (Figure 2.31a and b).
2.3.4 Removal of the Anterior Rib Shield
Lift the right inferior corner of the sternocostal trian-
gle with the forceps held in the left hand. At the same
time, use the point of a scalpel to dissect the aponeu-
rotic sternal insertions of the parietal pleura and from
the posterior surface, the ligaments – especially the
inferior and superior sternal pericardial ligaments –
proceed upward, at all times taking great care to not
cut the underlying pericardial sac (Figure 2.32). At
the level of the manubrium sternum, the ligaments
connecting with the chest plate are stronger. Be care-
ful not to cut vessels at the base of the neck. A firmer
drawing action, done with the left hand (Figure 2.31),
is required to the remove the rib shield, thereby open-
ing the pleural cavities and removing the parietal
pleura (Figures 2.33 and 2.34).
24 Forensic and Clinical Forensic Autopsy

Figure 2.32 Manual traction of the rib shield.

Figure 2.33 (a) Removal of the rib shield and opening of the pleural cavities. (b) Thoracic area exposed. From bottom:
Cut off insertions of the diaphragm, pericardial sac, cardiophrenic ligaments, and clavicular stumps.

Figure 2.34 Internal surface inspection of the rib shield. (A)Metal clips along the internal surface following cardiac
surgery can be observed.
Adult Autopsy 25

2.3.5 Inspection of the Anterior Chest

Inspection of the internal surface of the rib shield
is performed for medicolegal purposes. It is impor-
tant to note all possible injuries, which will usually
be manifested as fractures or hemorrhagic infiltrates
(Figure 2.33).

2.3.6 Inspection of the Pleural Cavities

First, explore the pleural cavities that have already
been opened (Figures 2.33 and 2.34). Use the right
hand to outline the convexity of the lung, then lower
the hand downward to reach the costal–vertebral cor-
ner (Figure  2.35a and b). Such a technique leads to
the detection of fibrotic adhesions that must either Figure 2.36 Thoracic area. From above, pleural and
be trimmed or cut off with a blade. In cases of very pericardial adhesions that cannot be trimmed off.
strong, extensive adhesions, as are sometimes found
in the fibrothoracic chest plate, it may be necessary to
cut along the endothoracic fasciae, leaving the parietal 2.3.7 Incision of the Pericardial Sac:
pleura adherent to the underlying lung (Figure 2.36). Examination of the Heart In Situ
Pleural effusions on either side should be collected The pericardial sac is incised by making an upside-
for later microscopical and toxicological analyses. down Y-shaped incision with rounded nose scissors
Ultimately, an evaluation of the macroscopic char- (Figure 2.39–2.41). After having grasped and lifted the
acteristics of the lungs, pericardial sac, and the other sternal surface of the sac, toothed forceps, held in the
mediastinic organs must be performed (Figures 2.37 left hand, are used to make a sagittal incision (opening
and 2.38). hole), some centimeters in length in the lower portion

Figure 2.35 (a and b) Manual examination in situ of the lungs. The dissector gathers in his palm the lung surface
to make his way into the cavity.
26
Figure 2.37 (a and b) Inspection of pleural cavities. No liquids and adhesions are present.
Figure 2.38 Evaluation of the macroscopic characteris-
tics of the lungs, pericardial sac, and the other medias-
tinic organs.
of the sac, just above the pericardial phrenic limit.
This will help to identify the pericardial sac and to
raise it from the underlying heart. In the case of adhe-
sions between the epicardium and the pericardium,
the sac cannot be easily incised. The best approach in
such cases is to gently separate the adhesions using the
fingers: The maneuver require too much force than it
Forensic and Clinical Forensic Autopsy
Figure 2.39 Use of pliers with pericardial layers: round-
shaped interruption of the pericardial layer.
has to be suspended and the heart should be removed
with the pericardium.
Once the opening hole has been created, direct
the cuts upward, first making a sagittal incision of the
pericardial layer up to the reflection point on the heart.
Then, starting again from the same opening hole inci-
sion, make two wide oblique incisions directed to
Adult Autopsy
Figure 2.40 Outlined in blue are the cut lines. The first
sagittal incision goes until the reflection point on the
big vessels. Then, two oblique incisions are performed:
One runs oriented to the left toward the heart point (sec-
ond oblique incision); the second, oriented to the right,
runs to cross the acute edge of the heart (third oblique
incision).
Figure 2.41 Pericardial flaps in upside-down Y-shaped
incision.
the left and right, producing oblique incisions of the
pericardial layer. Then, a third oblique incision of the
pericardial layer is made across the acute margin of
the heart.
27
2.3.8 Examination of the Pericardial
Cavity and Its Content
Reflecting the pericardial flaps allows for the evalua-
tion of their structural characteristics and allows the
visualization of the inner surface of the pericardium,
where adhesions may be evident (Figures 2.42 and
2.43). If a substantial pericardial effusion is present,
it must be collected and its physical characteristics
clearly recorded, including (and particularly) the
appearance of the fluid (clear, straw-colored, serosan-
guineous, frankly bloody, or cloudy) and the volume
of the infusion present which should be measured in
centiliters (use a graduated test tube or syringe, but
never guess the volume of fluid present). If neces-
sary, specimens should be collected for microbiologi-
cal, cytologic, biochemical, and toxicological testing
(Figure 2.42).
2.3.9 Cardiac Examination
Examination of the external macroscopic features of
the heart and great vessels will reveal any evidence
of spontaneous or traumatic damage, or preexisting
malformation (Figures 2.44–2.47). External examina-
tion of the heart also allows for the examination of the
shape and dimensions of the heart; these dimensions
should be correlated with those made of nearby ana-
tomical structures.
2.3.10 Collecting Blood Samples
Most of the time, the results of heart blood measure-
ments will suggest that more drugs were present at the
Figure 2.42 Open pericardial sac open with wide-open
flaps.
28 Forensic and Clinical Forensic Autopsy

Figure 2.43 (a–d). Use of pliers in the pericardium sac to preserve its continent. Abundant serum-hemorrhagic effu-
sion in the pericardial cavity. The cardiovascular peduncle can be clearly seen. Phases of inspection: description of
specimens and photographic report of details (a). Pacemaker device electrodes’ entry into the right subclavian vein (b).
Isolation of the superior vena cava, right anonymous vein, right subclavian vein, and right jugular vein (c). Isolated
veins opening and visualization of the correct positioning of the catheter electrodes in the right atrial cavity (d).

Figure 2.44 Cardiac tamponade. Large hematic intra-

pericardial clot surrounding the anterior pericardial Figure 2.45 Hemopericardium due to gunshot injury
surface resulting from aneurysm and aortic dissection. running through the cardiac sac and the heart.
Adult Autopsy 29

time of death than was actually the case, and the mea-
sured concentrations will be much higher than if they
had been measured in the periphery. On the other
hand, heart blood provides a wonderful medium for
drug screening, simply for the purpose of detection,
even if attempts at quantitation provide little useful
information. Venous blood should be collected with
a needleless syringe. An incision through the inferior
vena cava, inside the pericardial sac, allows for the
passage of a syringe for blood aspiration. The blood
samples must be collected in a test tube containing a
preservative (usually 1% sodium fluoride), labeled with
the autopsy number and the full name of the decedent,
and then kept in a refrigerated environment at −2°C
to 4°C until processing. If, for some reason, arterial
blood is desired, the samples can be taken from the
descending thoracic aorta as it crosses the mediasti-
num. This can be an especially useful approach when
there is evidence of extreme postmortem coagulation.

2.3.11 Examination in Situ of the

Figure 2.46 Cardiac lacerations. From the base of the
heart toward the apex (top), laceration in the wall of the
left atrium, and laceration with diastasis in the left ven-
tricle wall.
Main Pulmonary Artery
Before removing the heart, it is best to open the main
pulmonary artery in situ. This step is mandatory when
pulmonary thromboembolism (PTE) is suspected.

Figure 2.47 (a–d) Cutting in situ of the pulmonary artery in a fatal PTE. Clamping the ascending aorta in two points
(a, b). Cutting the ascending aorta in the medium point between the two clamps (c). Visualization and incision of
the underlying pulmonary trunk and pulmonary bifurcations: an incongruous formation attached to the pulmonary
artery wall can be observed (d).
30 Forensic and Clinical Forensic Autopsy

nonsignificant stenosis of the descending coronary

artery (left anterior descending artery (LAD)) was
diagnosed. He underwent an intervention of isolated
mitral valve surgery for mitral regurgitation. During
the procedure, an iatrogenic aortic dissection was
observed from thoracic aorta to aortic bifurcation.
The death was due to a ventricular arrhythmia. The
prosecutor requested an autopsy because of a malprac-
tice claim.
2.3.11.1.1 Autopsy
The external examination showed suture of the tho-
rax and the left inguinal region (Figures CS-2.1 and
CS-2.2).

Figure 2.48 Opening in situ of the right ventricle in

a fatal PTE: an incongruous formation attached to the
chordae tendineae prolonged until the pulmonary bifur-
cation (white arrow) can be observed.

It should also be done when there is a prolonged hos-

pitalization. The ascendant aorta is separated from
the pulmonary artery; then, a complete section of the
aorta is made to offer a free plane of cutting of the
pulmonary artery. To open the pulmonary artery in
situ, make an incision using pointed scissors held with
the right hand. At the same time, use forceps held in
the other hand to pull down the heart, and draw it
away from the artery; in the process, the pulmonary
artery will be almost completely exposed. A sagittal
incision is made at the trunk of the pulmonary artery,
just above the infundibulum of the conus arteriosus,
that is, the anterosuperior portion of the heart’s right
ventricle, at the entrance to the pulmonary trunk. If
emboli are present, they can be extracted using for-
ceps. Extending the incision to the left makes it easy
to explore the lumen of the left branch of the pulmo-
nary artery. However, to explore the right branch of
the bifurcation of the pulmonary artery, it is neces-
sary to dissociate the main pulmonary artery from the The autopsy study was carried out by anatomical lay-
adjacent ascending aorta artery as they are normally ers. Ghon’s technique was performed to remove neck
juxtaposed (Figures 2.47 and 2.48). and thoracic organs taking care to preserve the integ-
rity of the vascular structures.
2.3.11.1 Case Study #2
After formalin fixation, according to Fineschi–
Piscopo A., Di Stefano E., Di Nunno N. Baroldi variation, inflow–outflow method in cardiac
A 68-year-old man was admitted to the cardiac surgery dissection was performed that allowed us to appreci-
department because of symptomatic mitral valvular ate the resistance of the cardiac suture (Figures CS-2.3
insufficiency. Coronarography was performed, and and CS-2.4).
Adult Autopsy
It was possible to appreciate the presence of an aortic
dissection that started from the supravalvular aorta
up to the iliac bifurcation (Figures CS-2.5a–c).
31
2.3.11.1.2 Histological Assessment
A complete histopathological study with hematoxylin–
eosin (H&E) stain was performed. Lung histological
examination showed acute and chronic emphysema
(Figures CS-2.6 and CS-2.7).
Cardiac histological examination showed interstitial
fibrosis, stretching, waviness of the myocardial fibers,
and diffuse coronary sclerosis (Figures CS-2.8 and
CS-2.9).
32
Key Points
• An accurate autopsy technique allows main-
taining the integrity of the heart and vascu-
lar structures. It is important in cases where
malpractice in cardiac surgery needs to be
evaluated.
• Iatrogenic type A aortic dissection is uncom-
mon but has a high mortality of between 30
and 50%.
2.3.11.2 Case Study #3
Condorelli D., Vanaria F., Iannuzzi S.
A 41-year-old woman was found dead on the floor
of her bedroom. She wore pajama pants, panty-
hose, and nightgown displaced upward. There were
abundant bloodstains on the floor, on the bed,
and all over the body (Figure CS-3.1). Her hus-
band was found alive with a knife inside his chest
(Figure CS-3.2).
Forensic and Clinical Forensic Autopsy
2.3.11.2.1 Autopsy
The external examination showed wounds all over
the body: face, back, and limbs (Figure CS-3.3a
and  b). On hands, there were active defense wounds
(Figure  CS-3.4a and b). A dissection by anatomical
layers was carried out. The stab wounds showed hem-
orrhages of the cutaneous and subcutaneous tissues
(Figures CS-3.5 and CS-3.6).
After bilateral pectoralis major and pectoralis
minor origins were detached, we highlighted the pres-
ence of two lacerations of intercostal muscles (Figure
CS-3.7), which continued into the pericardium and
the right ventricular wall (Figure CS-3.8a and b).
Adult Autopsy 33
34 Forensic and Clinical Forensic Autopsy

2.3.11.2.2 Histological Assessment
Histopathological sections from marginal to tear
showed viable myocytes, erythrocytes, and few full
of blood vessels with no evidence of ischemic changes
(Figures CS-3.9 and CS-3.10). In correspondence to
the diaphragm muscle (Figures CS-3.11 and CS-3.12),
there was a laceration of the muscles, with erythrocytes
between the fibers, indicating the vitality of injuries.

Key Points
• The crime scene is a critical element of crimi-
nal investigations and where forensic science
begins. An accurate crime scene investigation
is essential in order to establish the manner
of death.
• Defensive wounds are often found on the
hands and forearms, where the victim has
raised them to protect the head and face, or to
fend off an assault.
• Histological examination is fundamental to
determine wounds’ vitality.
Adult Autopsy 35

2.3.11.3 Case Study #4

Testi R., Scoto E., Fichera M.
A 47-year-old woman was admitted to the gynecology
ward for persistent metrorrhagia, anemia, and cough-
ing. The patient showed very high D-dimer levels. She
died after one day of hospitalization.
2.3.11.3.1 Autopsy
Dissection by the anatomical layers was carried
out. A diffuse superficial vein stasis was observed
(Figure CS-4.1). In situ pulmonary artery examination
showed the presence of soft and reddish color mate-
rial, similar to a thrombus attached to the main pul-
monary artery wall that was sampled (Figure CS-4.2).
In the left pulmonary artery, a similar material was
found. Abdominal inspection showed a big fibroma-
tous uterus with small and large bowel compression
(Figure CS-4.3). Pelvic and thigh vein examination
revealed a diffuse stasis of blood (Figure CS-4.4). After
positioning the cadaver in the prone position, a large
thrombus in the left popliteal vein was found that was
sampled in conjunction with the surrounding vascu-
lar wall (Figure CS-4.5).
36 Forensic and Clinical Forensic Autopsy
Adult Autopsy 37

2.3.11.3.2 Histological Assessment

A histochronological evaluation of the deep vein
thrombosis (DVT) and the relationship with PTE was
performed according to the Fineschi et al.’s method:
Pathologic features were estimated using histological
sections stained with H&E, and the more specificz
trichromic (Masson), and histochemical (Perls, VON
KOSSA) stains, as well as by immunohistochemi-
cal investigations (CD 15, CD 45, CD 61, CD 68,
fibrinogen), for the material detected in the right
popliteal vein.
In lung samples, multiple emboli in small vessels
with preserved and agglomerated erythrocytes were
revealed (Figure CS-4.6).
In the pulmonary artery embolus, no reactions
between endothelium and thrombus and membrane
ruptures were visible (Figure CS-4.7). Perl’s coloration
was negative for the presence of iron (Figure CS-4.8).
Few leucocytes (CD45 staining) were observed In the left popliteal vein thrombus sample, erythro-
(Figure CS-4.9). cytes agglomerated with fibrin with no endothelial
reaction were evident (Figures CS-4.10 and CS-4.11).
The cause of death was attributed to PTE phase
1 (1st–7th day), according to the Fineschi et al.’s
classification.

Key Points
• In all malpractice claims, autopsy, medi-
cal chart evaluation, and a possible previous
autopsy are essential in order to assess the
suitable autopsy technique.
• When PTE is suspected, the forensic patholo-
gist needs to carry out the examination of in
situ pulmonary artery and right ventricle wall.
• Lower limb veins are the most frequent
localization of DVT; therefore, a full lower
limb veins examination in these cases is
mandatory.
• In cases of DVT and PTE, the thrombus needs
to be collected with the vessel wall for histo-
logical assessment.
• The histological age determination of throm-
boses and pulmonary embolism is an essen-
tial task of forensic medicine and requires a
thorough knowledge of general and specific
pathology of PTE.

2.4 Evisceration According to

Virchow’s Technique

The Virchow technique is used to extract the thoracic

organs one by one (see Section 2.8), extracting the
heart first and then both lungs.
38 Forensic and Clinical Forensic Autopsy

2.4.1 Heart Extraction
To extract the heart, the examiner should hold it at
its base, using the left hand in a forceps-like fashion,
or even actually using forceps with rubber prongs,
then lifting it up firmly, so that the inner face of the
pericardial sac can be seen, together with its car-
diovascular connections. These are then transacted
with a blade held tangentially to the serosal surface
(Figure 2.49). Cut off all the vessels as closely as pos-
sible to the serosal surface. Then, proceed clockwise,
first making a half-moon-shaped cut, at the supe-
rior concavity, from left to right, starting from the
left superior superiorly (imagine a transposed clock Figure 2.49 Vascular peduncle. Once the heart is in
face set at 3 o’clock). Cut off the two left pulmonary traction, exposing all vascular roots, the dissector will
veins, with the incision oriented toward the inferior cut clockwise the first time with a half-moon-shaped
vena cava (at 7 o’clock). The terminal portion of the incision with superior concavity from left to right. The
half-moon-shaped incision will transect the two blade must be tangential to the pericardial sac (green
lines). Then, the second time he will make an incision
right pulmonary veins: first the inferior and then
parallel to the first (black lines).
the superior (at 9 o’clock). While maintaining trac-
tion on the heart, a second incision is made parallel
to the previous one, only closer. This will first cut damage to the pericardium and, even more impor-
off the pulmonary arterial trunk immediately under tant, damage  to  the myocardium, by carrying out
the pericardial point of reflection on the artery (at the incision too close to the interior pericardial sac
1 o’clock). Next, the half-moon-shaped resection is (Figure 2.49).
carried out to the right to cut off the superior vena
cava at its trunk (at 1 o’clock). Finally, firmly pull
up the heart with the left hand, and the ascending
aorta where it passes through the aortic arch will be 2.4.2 Lung Sections and Removal
visible. Make a third resection running completely The lungs were also removed following Virchow’s
parallel to the others but shorter in length, thereby technique (one by one) and then extracted from the
dividing the aorta at its internal pericardial reflec- thoracic cavity, starting with the left lung and moving
tion point (at 12 o’clock). All incisions must be per- to the right lung. The left hand is plunged into the chest
formed firmly, with a continuous bending movement cavity from above and moving downward, keeping
of the wrist, to avoid leaving residual elements that the hand aligned with the left costal–vertebral sinus
resemble saw cuts. It is also important to avoid any (Figure 2.50a–c). Removed by repeating exactly the

Figure 2.50 Blunt dissection of the anterior mediastinum and isolation of all great cardiac vessels. The following
structures are visible: brachiocephalic vein, internal jugular vein, superior vena cava, lingula of left lung, vagus
nerve, brachiocephalic artery, common carotid subclavian artery, phrenic nerve, trachea, arch of the aorta, common
carotid ascending aorta, pulmonary trunk (a–c).
Adult Autopsy 39

same set of motions, except now the incision is made

with the knife moving downward, from 6 o’clock to
12 o’clock.

2.4.3 Exploration of the Anatomical

Structures of the Posterior
Mediastinum
After the heart and both lungs have been removed, the
structures of the posterior mediastinum are then sys-
tematically explored, moving from top to bottom and
from front to back. The trachea divides into its two
main bronchi, the aortic arch will be over the left bron-
chus, and a portion of the thoracic descending aorta
will be seen ascending along the left anterior side of
the thoracic column. Anteriorly, on the right side of the
aorta, the esophagus passes through the diaphragm
muscle via the esophageal (diaphragmatic) hiatus.
2.5 Access to the Neck Region
Adequate dissection of the musculocutaneous layers
of the neck requires that the neck be hyperextended,
elevating the shoulders if necessary. Great effort must
be taken to avoid accidentally cutting the skin in this
region as it is particularly thin. If sufficient care is
not taken, it may not be possible to do an adequate
reconstruction of the neck. Layered dissection is the
method of choice for neck dissection. If there is no
reason to examine the soft tissues of the face, it is best
to begin the dissection from the superior cutaneous
flap produced by the primary incision of the “calix-
like” cut. However, the transversal, either biacromial
incision (shoulder to shoulder) or Y-shaped incision,
of the soft tissues of the thoracic–abdominal wall can
be used (Figures 2.51 and 2.52).
Figure 2.51 Primary incision.
Then, proceed as follows:
1. Grasp the skin flap with forceps held in the left
hand and pull the flap upward. (Alternatively,
the dissector can use a fabric handkerchief to
seize the flap.)
2. Hold the scalpel so that it is oriented tan-
gentially to the cervical superficial fascia.
When held in this manner, the blade edge
follows the cutting plane between the sub-
cutaneous tissue layers and the superficial
cervical fascia, which can then be detached
from the other. Cut from one acromion to
the other, and extend the cephalad dissec-
tion to the mandibular arch (Figure 2.52).
Finally, reflect the flap onto the face. This
allows the inspection of the anterior lateral
region of the neck within its anatomical
limits (the jugular–clavicular plane on the
bottom, the inferior border of the mandib-
ular arch, and a plane extending from the

Figure 2.52 (a) Traction and recission of the cutis and subcutis limited only to the neck region from an acromial
extreme to the other. (b) While dissecting the cutis–subcutis of the neck region, a metal foreign body was detected.
40 Forensic and Clinical Forensic Autopsy

Figure 2.54 Side view of the superficial cervical band

with hemorrhagic infiltrate due to vein cannulation.

Figure 2.53 Reflection of the collar skin and exhibition

of the anterior region of the neck. From below upward,
the jugular–clavicular plane, inferior edge of the man-
dibular arch, and anterior edge of the trapezius muscles.

mastoid processes on the top to the anterior

margin of the sternocleidomastoid muscle
bilaterally) (Figure 2.53).2

2.5.1 Removal of the Muscular Heads of

the Sternocleidomastoid Muscle
An incision is made from above downward through
the superficial cervical fasciae lamina, and then car-
ried along the anterior border of the right sternoclei-
domastoid muscle. Use toothed forceps to hold the
muscle, which is then drawn laterally to allow for the
separation of the deep cervical surface (fasciae) from
behind the superficial cervical fasciae. The muscle is
then completely detached, including the two anterior–
inferior insertions of the muscle, respectively, sternal
and clavicular. The muscle will flip upward, alongside
the insertion of the mastoid (Figures 2.54 and 2.55).

2 The superficial cervical fascia covers the muscles in the supra-

hyoid region, which extend between the cranial base and the
mandibular arch, and down to the hyoid bone (digastric mus-
cle, stylohyoid muscle, mylohyoid muscle, geniohyoid muscle);
then, it adheres to the hyoid bone. In the infrahyoid region, the
muscle passes like a bridge over the vascular nervous bundle
(vessels and nerve region) and the muscles of the superficial lay-
ers of this region (symmetric and ribbon-like muscle, stretched
between the hyoid bone, above, and sternum and clavicle,
Figure 2.55 Anterior view of the superficial cervi-
below), wrapped by the medium cervical fasciae (sternohyoid
muscle and omohyoid muscle). On the deepest surface, one can cal band. The two sternocleidomastoid muscles with
find the infrahyoid muscles (sternothyroid muscle and thyrohy- their sternal insertions close to the jugular notch are
oid muscle) wrapped by the deep cervical fasciae. evident.
Adult Autopsy 41

2.5.2 Removal of the Muscle of Superficial,
Medium, and Deep Surface Regions
The deep fascia is divided from the middle cervi-
cal band of the muscles that comprise the superfi-
cial layer: the sternohyoid and the omohyoid, from
beneath the sternothyroid and thyrohyoid muscles,
taking care not to damage the nerves and vessels of
the deep neck (common carotid artery, external jugu-
lar vein, and the vagus nerve (also known as cranial
nerve X)) (Figure 2.56).
The muscles are reflected upward over the man-
dibular arch, such that they resemble the segments
of a fan. The sternothyroid and thyrohyoid mus-
cles are dissected and detached from the thyroid
gland in the back and from the thyroid cartilage;
these structures  are also reflected upward so that
the thyroid and larynx–tracheal axes are revealed
(Figures 2.57–2.60).

Figure 2.56 View of the middle cervical band. The pliers Figure 2.57 View of the middle and deep cervical band.
hold the superficial cervical band. Hemorrhagic infiltrate The pliers hold the muscular venters of the omohyoid
on both right sternal head of the sternocleidomastoideus muscles (close up) showing the thyroid area, the thyroid
muscle and sternohyoid muscle surface is evident. cartilage, and the cricoid cartilage.

Figure 2.58 (a and b) Particulars of the “fan rays” technique in a strangulation case. (a) Sternal and clavicular heads
of sternocleidomastoideus muscles are first detached and flipped upward. (b) Sternothyroid muscles (blue arrows).
The pliers hold the omohyoid muscles (yellow arrows). Sternothyroid muscles and thyrohyoid muscle are still in situ.
42
Figure 2.59 Exhibition of the thyroid gland fan-shaped
muscles of the neck region overturned above the man-
dibular corner. The stylets draw the vascular nervous
bundle of the neck. From left to right: the jugular vein,
the vague nerve, and the carotid artery.
Figure 2.60 Particulars of the “fan rays” technique.
The thyroid area with perithyroid sheath is evident.
2.5.3 Removal of the Thyroid
The thyroid is a U-shaped or horseshoe-shaped gland
with a superior concavity. It is formed by two sides,
or lobes, on the right and left, and connected by a
median isthmus that overlays the cricoid cartilage of
the larynx, extending downward to the first two tra-
cheal rings. It is covered with an inner fibrous layer
and outer perithyroid sheath, part of the superficial
fascia of the neck. This fascia is particularly dense
and must be removed with a scalpel. Continue the
dissection superiorly until reaching the perithyroid
sheath that is attached directly to the gland, along
with the thyroid and cricoid laryngeal cartilage and
the first tracheal rings. This strip of tissue is referred
to as the median ligament with the right and left
Forensic and Clinical Forensic Autopsy
suspensory ligaments lying on each (see in detail
Figure 2.59).
2.5.4 Inspection and Section of the Neck
Vasculature: Neurovascular Bundle
The vascular bundle should be dissected in situ, from
the superior to the inferior, using rounded scissors. The
lumen of both the carotid artery and the jugular vein
must be inspected and the condition of the vessel walls
determined, even if no trauma or other abnormalities
are evident.
2.5.5 Removal of the Muscles of the
Posterior Face of the Neck
Adequate dissection of the musculocutaneous layers
of the posterior face of the neck requires the neck to be
overflexed. Layered dissection is the method of choice
for the posterior face of the neck and dorsal region
dissection, and the transversal or biacromial incision
(shoulder to shoulder) of the soft tissues of the dorsal
wall can be used (Figure 2.61a and c).
Then, proceed as follows:
1. Grasp the skin flap with the forceps held
in the left hand and pull the flap upward.
(Alternatively, the dissector can use a fabric
handkerchief to seize the flap.)
2. Hold the scalpel so that it is oriented tangen-
tially. When held in this manner, the blade
edge follows the cutting plane between the
subcutaneous tissue layers. Cut from one
acromion to the other, and extend the dissec-
tion to the nuchal line of the occipital bone.
Finally, reflect the flap onto the posterior
region of the head. This allows the inspec-
tion of the posterior lateral region of the neck
within its anatomical limits.
The muscles of the posterior face of the neck and the
dorsal region are divided into superficial, middle, and
deep layers. The muscle of superficial layer is the tra-
pezium muscle; the middle layer is composed of the
splenius capitis, splenius cervicis muscle, and eleva-
tor scapulae muscle; the deep layer is composed of
the longissimus capitis muscle, semispinalis capitis,
obliquus capitis, and rectus capitis posterior major
muscles.
Adult Autopsy 43

Figure 2.61  Muscles of the posterior face of the neck in a fatal strangulation case. Dissection of the cutis and sub-
cutis; (a) muscles in situ; (b) detached muscles: Muscle “A” is the splenius capitis, “B” is the trapezium muscle, and
“C” is the semispinal is capitis.

2.5.5.1 Case Study #5 garments, with a deep sharp injury of the neck; an

Gianpaolo Di Peri, Loreto C., Di Stefano E. angle grinder was found on his legs (Figure CS-5.1a).
A large pool of blood was noted on the floor, near
A 48-year-old man, professionally experienced with
the cadaver, and another one on the worktable
power-saws, was found lifeless, close to a wooden
(Figure CS-5.1b and CS-5.2).
­workbench, lying supine on the floor, wearing bloody

2.5.5.1.1 Radiological Examination
A complete CT scan was performed before the
autopsy, revealing a cut surface on the left side of the
body of C6.

2.5.5.1.2 Autopsy
A wide deep incised wound on the left side of the
neck, 13 cm long and 3 cm wide, with regular mar-
gins, was described at the external examination
(Figure CS-5.3).
44 Forensic and Clinical Forensic Autopsy

Gross examination of the neck structures was

performed after cervical and thoracic organs removal
(Ghon technique – en bloc), revealing massive hem-
orrhages of the subcutaneous tissues and a complete
disruption of muscular and vascular structures of the
left side of the neck (Figure CS-5.4).
2.5.5.1.3 Histological Assessment
A histopathological study with H&E stain was per-
formed: Lung samples revealed red cells in the alveolar
spaces because of blood aspiration (Figure CS-5.5);

tearing of the sternocleidomastoid muscle with eryth-

rocytes between the fibers, indicating the vitality of
the injures (Figure CS-5.6); tearing and blood infiltra-
tion of the common carotid artery and jugular vein
(Figures CS-5.7 and CS-5.8).
Adult Autopsy 45

Key Points
• A careful documentation of conditions at a
crime scene, recognizing all relevant physi-
cal evidence is mandatory. In this case, crime
scene investigation excluded struggle and sug-
gested a fatality occurring at the workstation.
• Medical history and circumstantial data
analysis is crucial in order to exclude suicide
attempt: Psychiatric disorders were excluded
and family members stated the man used to
spend time working at home with his own
angle grinder. Toxicological analysis were
unremarkable.
• Cause of death was attributed to hemorrhagic Figure 2.62 The cut section and access to the oral cav-
shock due to sharp injury on the left side of ity is outlined. In close up is the insertion root of the
anterior part of the digastric muscle surrounded by the
the neck, involving left common carotid two submandibular glands.
artery and internal jugular vein.
and the more posterior-located structures, including
the lingual tonsil, the three epiglottis folds delimiting
2.6 Evisceration According to the two epiglottic valleculae, epiglottis, and the two
Ghon’s Technique (En Bloc) epiglottic folds (Figure 2.62).

The preferred method for the examination of the

tongue, oropharynx, and hypopharynx is en bloc
extraction, taking out the larynx, trachea, and esopha-
gus together as a block, and then continuing into the
thorax, removing the tracheal bifurcation, bronchial
tubes, lungs, descending aorta, inferior vena cava, and
the esophagus. These are then clamped in the upper
diaphragmatic area. This is the preferred technique
because it leads to the discovery of abnormalities in
both the alimentary and respiratory tracts, and allows
for the study of their anatomical relations with the
heart and great vessels (Figure 2.57–2.59).
2.6.2 The Floor of the Mouth
There are alternatives to the aforementioned method,
the most effective being dissection by the anatomical
layers. Using toothed forceps, first place traction on
the anterior portion of the digastric muscle, then use
the scalpel to cut tangentially and behind the internal
border of the mandible, then sever the insertion of this
muscle. Detach the muscle from the front to the back
until the dissection reaches the tendinous portion of
the muscle that attaches to the hyoid bone by a fibrous
loop (Figure 2.63).

2.6.1 Direct Access to the Mouth Floor

The muscular aponeurotic structures that form the
floor of the mouth are incised using a narrow blade,
making a horseshoe-shaped incision, from one cor-
ner of the mandible to the other (Figure 2.62). Begin
the incision just behind the internal surface of the
mandibular arch and remove the posterior portion
of the digastric muscle lying just behind the jaw, and
the stylohyoid muscle lying in front and just above
the digastric muscle. Carry out the incision centrally,
transecting the mandibular insertions of the supra-
hyoid muscles of the neck, including the anterior
portion of the digastric, mylohyoid, geniohyoid, and
genioglossus muscles. The mucosa of the oral cavity is Figure 2.63 Removal of the anterior part of the digas-
tric muscle. The mandibular edge, the hyoid bone, and
then incised, allowing visualization of the base of the the cricoid cartilage are visible. Beneath the plane, indi-
tongue. Using a rubber pronged, toothed forceps to cated by the arrow, is the central part of the sectioned
apply traction, expose the superior face of the tongue mylohyoid muscle.
46
Figure 2.64 Anterior view of the section plane of the
mouth floor.
Figure 2.65 Descending the tongue.
Figure 2.66 (a and b) Particulars of the descended tongue (a). Follow the section plane next to the larynx–tracheal
axis. The resection plane runs very close to the rachis–cervical axis. The dissector must be careful not to injure the
underlying vascular–nervous axis with the point (a).
Forensic and Clinical Forensic Autopsy
Proceed in the same manner with the hyoid
muscle, dissecting it free from the mandibular arch,
close to its insertion (Figure 2.63); the muscle is then
reflected downward onto the hyoid bone. Then, make
a horseshoe-shaped incision behind the mandibu-
lar arch, thereby creating communication with the
mouth, through which the tongue may be grasped
and pulled downward, taking care to expose the
superior face of the tongue, its terminal track, and
the structures located at the back, such as the lin-
gual tonsil, the three glossoepiglottis folds delimit-
ing the two epiglottis valleculae, and the epiglottis
(Figures 2.63–2.65).
2.6.3 Ghon’s En Bloc
Regardless of the chosen method, the next step is
to orient the scalpel blade vertically and dissect
the root of the tongue, including the glossopalatal,
glossopharyngeal, hyoglossus, and genioglossus
muscles. Identify the superior horn of the thyroid
cartilage, then excise the overlying mucosa of the
pharynx and stylopharyngal muscles. Detach the
muscles moving from proximal to distal, separate
the posterior face of the hypopharynx and esoph-
agus complex from the opposite larynx–tracheal
axis, and then remove the deep cervical band at the
back of the thorax.
Adult Autopsy 47

The creation of an antivertebral cleavage plane

is relatively simple. Removal of the esophageal–
larynx–tracheal block requires the following com-
bined actions: pulling the block downward with
the left hand (using toothed forceps), pulling the
block forward, and then cutting along the vertebral
plane to isolate the tissue block from the muscular–
vertebral plane at the back (Figure 2.66a and b).
Once the chest is entered, the first thing to do is dis-
sect the  vessels adjacent to the aorta, the ones that
supply the upper limbs, the innominate artery on
the right, and the common carotid artery on the
left (Figures  2.66 and 2.67). The posterior medias-
tinal structures are then detached from the verte-
bral plane at the back, beginning superiorly and
proceeding inferiorly, until the area just above the

Figure 2.69 Ghon’sen bloc still in situ anchored to the

Figure 2.67 Block tongue–esophagus–trachea isolated
from the vertebral–cervical segment and first thoracic
tract.
Figure 2.68 Particular of Ghon’sen bloc. The arrow
indicates the cutting plane of the ascending aorta.
diaphragmatic edge. In situ examination of the tracheal
lumen with esophagus and aorta.
diaphragmatic plane is reached. The block, thus iso-
lated, will contain neck and thoracic organs, includ-
ing the heart whose pericardial cavity has been
previously opened in situ. All of these structures
are then everted downward onto the diaphragm.
To complete the cervical–thoracic evisceration, iso-
late the descending aorta from the esophagus lying
opposite (Figures 2.68 and 2.69). The descending
aorta is divided transversely, just below its origin
while the esophagus is incised 3–4 cm above the dia-
phragmatic aperture, but not before first applying
an intestinal clamp. The clamp is needed to avoid an
outpouring of the gastric content through the inci-
sion. Finally, raise the tissue block and cut the peri-
cardium along the line of fusion with the tendinous
center of the diaphragm. This completes the cervi-
cal–thoracic evisceration (Figures 2.70–2.73).
48 Forensic and Clinical Forensic Autopsy

Figure 2.70 (a and b) Ghon’sen bloc, anterior face.

Figure 2.71 (a and b) Ghon’sen bloc, posterior face.

Figure 2.72 Ghon’sen bloc. In detail is the intra- Figure 2.73 Pleural cavities
corporeal trough caused by a gunshot wound. after Ghon’sen bloc removal.
Adult Autopsy
Figure 2.74 Access to the still intact peritoneal serosa.
2.7 Access to the Abdominal Cavity
2.7.1 Incision of the Parietal Peritoneum
The parietal peritoneum is incised along the midline,
from the xiphoid process downward to the pubis.
First, make a keyhole incision through the area where
the prongs of the forceps are to be introduced. Hold
the forceps vertically and introduce them through the
Figure 2.75 (a–c) Detaching and overturning of the peritoneum. Outlined are its section layers.
49
keyhole, so that the scalpel blade runs between the
forceps opened prongs, from the top to the bottom
(Figure  2.74) tangentially to the costal arch. A mid-
lateral oblique incision from the xiphoid process
is carried up to cross the anterior axillary line with
the serosal flaps being turned inferiorly and later-
ally. This allows the peritoneal cavity to be opened in
such a way as to permit the optimum visibility of the
enteroperitoneal organs (Figure 2.75).
2.7.2 Abdominal Inspection
The purpose of general abdominal inspection is
to check for the presence or absence of any perito-
neal effusion. If present, the fluid would be of great
importance. The total fluid present should be esti-
mated, and the fluid itself should be collected in a
sterile container and then submitted for analysis.
The tests to be done would include bacteriologic cul-
tures, biochemical measurement, and microscopic
examination. The presence of fibrous, visceral, and
visceroparietal adhesions should also be described,
as well as the gross appearance of the gallbladder
(Figures 2.76 and 2.77).
50
Figure 2.76 Hemoperitoneum. Multiple stab wounds
can be observed in the stomach and the great omentum.
Figure 2.77 Wall opening of the abdominal cavity. A
large-sized fibroid uterus is evident.
Figure 2.79 (a and b) Letulle block, posterior face. Block cleaning with emphasis on the aorta in all its extensions (b).
Forensic and Clinical Forensic Autopsy
Figure 2.78 Letulle block, anterior face in a malprac-
tice case regarding cardiac surgery having undergone an
atrial myxoma. The advantage of such a technique is that
it allows total sight of the anatomical relations of the
organs, and a careful and detailed analysis.
2.8 The Letulle Technique:
En Masse Removal
The removal of the abdominal organs en masse is done
according to the Letulle technique. This technique
offers significant advantages when injuries involve or
extend across the diaphragm, as, for instance, in the
case of a suspected acute aortic dissection. If this is the
case, proceed to the removal of the posterior surface
of the organs first (Figures 2.78–2.84). If injury is not
Adult Autopsy 51

Figure 2.80 Letulle block. Serial removal of the abdom-

inal organs in order to emphasize the tracheal–bronchial
tree and the lungs, heart, thoracic–abdominal aorta,
renal arteries, and kidneys in situ.

suspected, the “organs in block removal technique” as

developed by Ghon is preferred; no other reason than
this approach makes it convenient to preserve the
abdominal vascular axis.

2.8.1 Case Study #6

Russo I., Fichera M., Liberto A., Castorina S.
A 17-year-old boy, hit by a car, went to the local hospi-
tal feeling pain at the right side of the thorax; he was
hemodynamically stable. The physicians performed
a total-body CT scan that revealed a right pneumo-
thorax and a blunt hepatic trauma involving the sixth,
seventh, and eighth liver segments. The study of the
clinical record shows that on the same day, the patient
underwent to the drainage of the right pneumotho-
rax and surgical resection of the damaged right liver
Figure 2.82 Isolation of the entire digestive tract after
formalin fixation.
segments. After the surgery, the clinical conditions
worsened, and after four days of hospitalization, the
patient died. An autopsy was performed to confirm or
exclude any malpractice claim.

Figure 2.81 (a and b) Letulle block after fixation in formalin.

52 Forensic and Clinical Forensic Autopsy

Figure 2.83 (a–d) Thoracic–abdominal aorta, right and left iliac arteries, internal and external, in situ (a) and after
removal (b). Such a removal technique becomes a protocol in suspected or ascertained cases of aorta aneurysm, dis-
section, vascular operations on the aorta contingent to the autopsy (i.e., in the clinical history of the patient), and
in cases of direct or indirect damage of the vessel or its main branches. In all these cases, the dissector will have to
judge the possibility of fixing all the findings in formalin for a following detailed study (for instance, in cases of type
I, II or III aortic dissection, according to the DeBakey classification) in order to verify origin and dissection. (c) Heart
and aorta of a malpractice case regarding an aortic dissection. (d) A false lumen (white arrow) after a vertical incision
of the abdominal aorta wall.

Figure 2.84 Aorta and inferior vena cava isolation after
Letulle block removal.
2.8.1.1 Autopsy

The external examination of the body was not remark-
able for any traumatic injury (Figure CS-6.1).
The evisceration technique was performed
according to the Letulle (en masse) method, in order
to preserve the hepatic parenchyma and the operative
field (Figure CS-6.2).
Macroscopic examination of the liver showed the
subsistence of all the segments; along the posterior,
subdiaphragmatic right margin, there was the pres-
ence of a lesion of the hepatic parenchyma, of the size
of 18.5× 5.0 cm, sutured with five atraumatic surgi-
cal sutures (Figure CS-6.3). The caval insertion of the
right suprahepatic vein was sutured in several points
with a mechanical stapler (Figure CS-6.4).
The right side of the liver was sutured with five
atraumatic surgical sutures (Figure CS-6.3). The study
of the retrohepatic region showed the right hepatic
vein origin sutured by mechanical sutures (high-
lighted in the yellow circle).
Adult Autopsy 53

Despite the operating report, all hepatic seg-

ments were present. The cause of death is still under
inspection.

Key Points
• Postmortem inquiry pointed out the incon-
gruity between what reported in the clinical
records and what autopsy revealed.
• It is not yet clear if the cause of death is directly
related to the injuries caused by the car crash
or to medical management.

2.9 The Virchow Technique

When injuries are not suspected, many dissectors pre-

fer to use the Virchow technique, with the removal of
one organ at a time.

2.9.1 Removal of the Spleen

If the Virchow technique is to be used, the spleen is
removed first. First, visualize it by gently moving it
to the right side of the stomach’s greater curvature,
to which it remains connected by the gastro-lineal
ligament (Figures 2.85 and 2.86). Insert the left hand
into hypochondrium, passing along the spleen’s dia-
phragmatic surface, until the fingertips can grasp the
inferior edge of the spleen (Figure 2.87). The spleen is
then  everted and pulled anteriorly and to the  right.

Figure 2.85 The spleen is well visible between the vas-

cular pole beneath the gastric–lienal ligament.
54
Figure 2.86 Bending of the great stomach curvature.
Figure 2.87 Spleen exposition. Great stomach curva-
ture, diaphragmatic face, and holding plane of the lienal
organ in the dissector’s left hand.
This  maneuver will expose both components of the
spleen’s posterior ligament: (i) the superior or phrenic–
lienal ligament and (ii) the inferior or pancreatic–
lienal ligament (Figures 2.88 and 2.89), which are
then incised with a continuous, semicircular incision
carried out from the top to the bottom. Continuing
the same incision will incise the veins adjacent to the
hilum, as well as the anterior gastric–lienal ligament,
that fixes the spleen to the stomach body. Splenic
resection must be performed quickly and gently as the
spleen is a fragile and inelastic structure.
2.9.2 Small Intestine Removal
After the spleen has been removed, proceed to the small
intestine, but first examine it in situ. Overturn  the
omentum with the transverse colon and its mesocolon
to visualize the mesentery (Figures 2.90 and 2.91).
Forensic and Clinical Forensic Autopsy
Figure 2.88 Blood clots inside the splenic fossa in a
motor-vehicle crash case.
Single loops of the small intestine become visible as
they are drawn through the examiner’s hand. The
small intestine can then be removed in toto by resect-
ing the mesentery that fixes it to the posterior abdo-
men wall (Figure 2.92).
2.9.2.1 Complete Removal of
the Small Intestine
Even though the small bowel can be removed as a
block in toto (Figures 2.92 and 2.93), it is prefera-
ble to identify the first jejunal loop, where it passes
between the duodenum and jejunum (the so-called
duodenal–jejunal flexure), first. It is important to
identify this first loop before attempting to remove
the remainder of the intestine. The duodenal–jejunal
flexure lies close to the left side of the second lumbar
vertebra, where the suspensory muscle of the duo-
denum (Treitz muscle, also known as the ligament
of Treitz) fixes the passage point between mesenteric
and non-mesenteric intestine, anchoring it to the left
middle pillar of the diaphragm (Figure 2.94).
Make another keyhole incision in the mesentery
and introduce the prongs of two parallel intestinal
clamps. They should be applied at a distance of 3 cm
from each other. With the scalpel held perpendicu-
larly to the intestinal loop, divide the wall and then
proceed to the ileocecal junction at the extreme lower
insertion of the mesentery, in the right iliopsoas
recess. Make another small keyhole incision in the
mesentery, introduce the prongs of two parallel intes-
tinal clamps applied approximately 3 cm from each
other, and divide the intestine with a perpendicular
cut (Figure 2.94).
Adult Autopsy 55

Figure 2.89 (a–c) Celiac tripod isolation by blunt dissection.

56
Figure 2.90 Raised caul or apron omentum, which cov-
ers the transverse colon and the small intestine.
Figure 2.91 Transverse raised colon.
Figure 2.92 Intestinal bulk. Mesentery section edge.
Forensic and Clinical Forensic Autopsy
Figure 2.93 Retrocecal recess and ileocecal colon
with omentum tapeworm and wormlike appendix in
close-up.
Figure 2.94 Section plane for the intestinal bulk
removal passing through the first jejunal loop, high at
the right under the hand, and for the last loop, low at the
left, close to the cecum.
2.9.2.2 Isolation of the Small Intestine
Through Linearization of the
Single Intestinal Loop
If one particular loop is of interest or if intestinal con-
tents are to be collected, a slightly different approach
should be used. Once the loop in question has been
identified, proceed from a proximal to distal direc-
tion until reaching the ileocecal junction and release
the loop from its mesentery connection (Figure 2.95).
Ideally, the small intestine should be disconnected
from the cecum, using the method already described.
Sometimes it is convenient to use forceps to dissect
the wall of the small intestine axially. This will allow
the evaluation of both the intestinal mucosa and the
endoluminal content.
Adult Autopsy
Figure 2.95 Intestinal bulk isolated by linearization of
the single masses.
2.9.3 Removal of the Large Intestine
2.9.3.1 Isolation and Removal of the Cecum
To isolate the large intestine, begin at the cecum. This
first part of the large intestine is easily immobilized.
Simply, seize it with the left hand, pulling it forward
and upward with some force (Figure 2.96).
2.9.3.2 Isolation and Removal of
the Ascending Colon
The ascending colon, unlike the cecum, is a retroperi-
toneal structure. Free it with an incision made parallel
to the posterior wall of the abdomen. Proceed from
the bottom to the top and from the left to the right, so
as to detach the colon all the way up the posterior wall,
Figure 2.96 Left colon removal. The section line runs
from the cecum to the right colon or hepatic flexure.
57
until reaching the right or hepatic flexure, situated in
the right hypochondrium (Figure 2.91).
2.9.3.3 Isolation and Removal of
the Right Colon Flexure
The right colon flexure, in addition to being intra-
peritoneal, is “fixed” to the overlying liver by a strong
ligament known as the hepatic–colic ligament. This
ligament must be incised. Hold the blade parallel to
the superior edge of the flexure. This will allow the
resection of the colon and, at the same time, allow
for its detachment from the abdomen’s posterior wall
(Figure 2.91).
2.9.3.4 Isolation and Removal of
the Transverse Colon
The transverse colon is interposed between the two
flexures, right and left, and provided with a broad
transverse mesocolon (the peritoneal process attach-
ing the colon to the posterior abdominal wall, which
is referred to either as the ascending or as descend-
ing mesocolon, according to the portion of colon
to which it attaches) (Figure 2.91). The mesocolon
is behind the two kidneys, on the descending part
of the duodenum, and on the head and body of the
pancreas.3
The superior margin of the greater omentum (a
large fold of the peritoneum shaped like an apron)
is divided into two roots: anterior and posterior. The
anterior root fits into the first portion of the duo-
denum and the greater curvature of the stomach.
Using these two landmarks, colic and gastric colic,
it is easy to locate the opposite side of the transverse
colon. In fact, its posterior root fits into the trans-
verse colon (Figure 2.90). Using the left hand, pull
the colon anteriorly. Make a broad incision from the
right to the left. This will cut the anterior root of the
omentum into its two components: the duodenum
colic ligament and the gastrocolic ligament. Then, as
the incision is carried more posteriorly, the posterior
root is divided.
2.9.3.5 Isolation and Removal of
the Left Colon Flexure
Once the transverse colon has been isolated, proceed
to the left colon flexure or, as it is sometimes called,
the lineal flexure. This is the point at which the
colon becomes, again, a peritoneal organ, lying in
the left hypochondrium, immediately below where
3 The root of the meso of transverse colon has an insertion on
the colon at the posterior–superior taenia called the mesoco-
lon. The colon’s superior face delimitates the omental bag.
58 Forensic and Clinical Forensic Autopsy

the spleen was previously located, anchored to the

left costal tracts of the diaphragm by a short hori-
zontal ligament, called the phrenicocolic ligament.
All of these connections are severed using sharp
dissection.

2.9.3.6 Isolation and Removal of the Left,

Descending, and Iliac Colon
The removal of the left colon essentially follows the
same method as the removal on the right (Figures
2.91, 2.94, and 2.96).

2.9.3.7 Isolation and Removal of

the Sigmoid Colon
The sigmoid portion of the colon runs a tortuous
course from the medial border of the psoas muscle to
the superior margin of the third sacral vertebra area,
where it continues into the rectum (Figure 2.91). This
part of the intestine is covered with peritoneum, actu-
ally a fold of peritoneum connecting the upper por- Figure 2.97 Linearization of the left pelvic colon.
tion of the rectum, along with the sacrum. To remove Above, the lineal flexure, to follow it, there is the left
the sigmoid, the peritoneum must be divided first, paracolic groove, then the sigmoid colon, and below, the
then the sigmoid can be pulled forward (Figure 2.97). rectum.
This technique allows for the visualization of
the pelvic organs and their anatomical relationships.
The root of the transverse mesocolon inserts into the
colon, close to the posterosuperior taenia coli, and for
this reason, it is called mesocolic. The superior sur-
face of the mesocolon delimits the omental bag. At
its root, it is shaped like an upside-down V, with the
right sagittal and median branch lying on the bodies
of the lumbar and the first three sacral vertebrae; the
left branch of the medial margin of the psoas muscle
ascends to converge with it on the right.

2.9.3.8 Isolation and Removal of the Rectum

The inferior half of the pelvic rectum is retroperito-
neal and is loosely covered with the so-called rectal
band. Pull the rectum forward in such a way that the
two pararectal recesses can be visualized. Then, incise
the peritoneum and the underlying rectosacral liga-
ments sagittally, from the top to the bottom, taking
care to isolate and detach the rectum from the sacral
wall (Figures 2.97 and 2.98).
If the cadaver is male, locate the rectovesical cav-
ity and pull the bladder forward. Cut the peritoneum
of the rectovesical cavity, as well as the underlying
connective tissue of the rectosacral ligaments, thereby
isolating the rectum from the bladder. If the rectum
is incised in the region of the perineum, it is possible
to remove all of the large intestine merely by resecting
the walls of the rectum above the external sphincter.
If the cadaver is female, first locate the rectouterine
Figure 2.98 Opening of the rectum in situ.
space (pouch of Douglas). With the left hand, gently
pull the uterus and underlying vagina forward. Make
an incision parallel to the rectum, then incise the rec-
touterine cavity and the underlying connective tissue,
including the uterosacral ligaments. Isolate the rectum
from the uterus and vagina, then remove the rectum
and all of the large intestine by excising the rectum in
the perineal plane area (Figures 2.97 and 2.98).
2.9.3.9 Bile Collection
The Virchow technique (removing organs one by
one) requires that the liver and the biliary tract
be removed  together. Before removing the liver,
Adult Autopsy 59

examine the area for evidence of gallbladder inflam-

mation or infection and, if possible, collect a bile
sample. Though not absolutely necessary, in cases of
poisoning, bile analysis may provide useful informa-
tion about the timing and type of drug that has been
ingested. The simplest way to collect bile is to expose
the bottom of the gallbladder and then clamp the
sac midway. Using toothed scissors, make a sagittal
cut across the bottom of the gallbladder. The inci-
sion should be just large enough to allow access of a
needleless syringe for sample collection (see forward
the paragraph 4.6 Picture 02x....).

Figure 2.99 Examination of the hepatic fossa by man-

2.9.4 Isolation and Removal of the Liver ual traction.
The liver occupies the right hypochondrium and a
portion of the epigastrium. It is almost completely cov-
ered by the peritoneum and the suspensory ligaments
of the liver: the falx ligament,4 the coronary ligament,5
and the lesser omentum, which fix the liver in place.
The inferior vena cava is also fixed to the liver’s dor-
sal ligament6 (Figures 2.99 and 2.100). To remove the
liver, move it laterally and medially, up and down, to
free it from its suspensory ligaments (Figure  2.99).
Then, cut each of the ligaments by first placing trac-
tion on the ligament to be incised and making an inci-
sion inclined at 90° perpendicular to the ligament and
parallel to the hepatic surface curvatures. First, incise
the right triangular ligament, then the coronary liga-
ment, orientating the scalpel posteriorly and parallel Figure 2.100 Side taking of the liver.
to the inferior surface of the liver. Take great care to
preserve the right adrenal gland as it is immediately are then divided with a crescent-shaped incision. The
adjacent. The lesser omentum and the ileocecal folds same procedure is followed with the triangular left
ligament and the coronary ligaments. Lower one hand
below the right dome of the diaphragm and stretch the
4 Except for where it lies in contact with the diaphragm, the
liver is entirely covered by peritoneum. The peritoneum folds
fingers like a fan, thereby separating the dome itself
back on itself to form the falciform ligament, and the right of the liver from the diaphragm. Finally, separate the
and left triangular ligaments. These “ligaments” are not true remaining ligaments and inferior vena cava, freeing
anatomical ligaments, like those found in joints, and they
have essentially no functional importance; but they are eas- the organ.
ily recognizable surface landmarks. The round ligament (in
Latin called the ligamentumteres) represents the remnant of
the fetal umbilical vein and is a degenerative string of tissue 2.9.5 Examination of the Stomach,
located in the free edge of the falciform ligament of the liver.
5 The convex diaphragmatic surface of the liver (anterior, supe-
Duodenum, and Pancreas
rior, and a little posterior) is connected to the concavity of the
inferior surface of the diaphragm.
The stomach is normally opened in situ so that the
6 The lesser omentum is extremely thin and is continuous with characteristics of the wall and the stomach contents,
the two layers of peritoneum that cover, respectively, the if any, can be observed. The physical characteristics of
anterosuperior and posteroinferior surfaces of the stomach
and first part of the duodenum. On the left of the posterior any fluid present should be described and the quantity
surface, the fold is attached to the bottom of the fossa by the measured. The best way to collect stomach contents is
ductus venosus, then continues on to the diaphragm, where
the two layers separate to embrace the end of the esophagus.
to lift up the greater curvature with toothed forceps in
At the right border of the lesser omentum, the two layers are one hand and scissors in the other hand. Make a key-
continuous and form a free margin that constitutes the ante- hole incision roughly 5 cm from the pylorus. Then, use
rior boundary of the epiploic foramen. Enlarged lymph nodes
are often found in this area and are usually a sign of chronic
scissors to cut along the greater curvature of the stom-
intravenous drug abuse. ach, beginning at the pylorus and cutting toward the
60 Forensic and Clinical Forensic Autopsy

cardia (Figures 2.96 and 2.97). A ladle is used to col-

lect the stomach contents, which are then measured.
Samples for toxicological testing can then be prepared
if necessary. Microscopic examination of the gastric
contents is to be encouraged, as microscopic pill frag-
ments, even if not visible to the naked eye, may have an
important evidentiary value. When the stomach has
been emptied, complete the initial incision to obtain
an optimum view of the stomach wall. If the decision
is made to remove the stomach together with its con-
tents, two ligatures must be applied: one close to the
cardia and the other close to the pylorus, after which
the stomach is incised (Figures 2.101 and 2.102). The
duodenum is also normally opened in situ along with
the stomach, so that the walls and the papilla of Vater
can be inspected. The best way to do this is to make
the incision with scissors, cutting along the anterior
wall of the duodenum, extending from the pylorus to
the ligament of Treitz (Figure 2.103). Because of the
close anatomical and functional links between the Figure 2.101 Esophagus, stomach, and duodenum
duodenum and pancreas, it is better to remove these resected. GC, great curvature; O, esophagus; LC, little
organs en bloc, together with the esophagus and stom- curvature; D, duodenum; FL, first loop.
ach. To remove the esophagus–stomach–duodenum–
pancreas block, first slide the esophagus (previously
transacted close to the pharynx–esophageal opening)
through the hiatus of the diaphragm (medial pillar of
the diaphragmatic muscle), by resecting its connec-
tions, then moving the block to a subdiaphragmatic
location).7
The stomach is then isolated and removed, except
for the connection with the duodenum, close to the
pylorus. The duodenum, which is the initial part of
the small intestine, located between the stomach and
jejunum, is a retroperitoneal structure. The C-shaped
duodenum contains the head of the pancreas, which
secretes into the duodenal lumen as does the liver; the
ducts of these two glands, whether isolated at the ori-
gin, or fused at their insertion, drain into the superior
portion of the papilla of Vater. This structure is easily
recognizable in the descending duodenum segment
(Figure 2.101).8

7 The stomach is kept in situ from the peritoneum. It presents

ligaments in certain points: anteriorly, the lesser omentum
with its components (hepatic–gastric ligament and hepatic–
duodenal ligament); posteriorly, the reflection folds on the dia-
phragm holding the gastric–phrenic ligament and, inferiorly, Figure 2.102 Opening of the stomach.
the gastric lienal and the gastric–colic ligaments.
8 The peritoneum covers the duodenum only on its anterior
surface; it is fixed to the hepatic ileum by the hepatic duode-
nal ligament containing the lesser omentum, which receives The pancreas stretches transversally in the ret-
in its interior bile duct, the portal vein, and hepatic artery roperitoneal space, and it is attached to the abdomen
(from right to left). Inferiorly, it is attached to the medial left
pillar of the diaphragm by the Treitz at some point near the
posterior wall, at approximately the same height of the
duodenal–jejunal junction. L1–L2 vertebral bodies. The head of the pancreas is the
Adult Autopsy
Figure 2.103 (a) Stomach–duodenum–pancreas block. H, head; B, body; Cd, end. (b and c) Stomach–duodenum–
pancreas and liver block. H, head; B, body; L, liver, Cd, end.
largest part of that organ that becomes thinner in its
mid-portion (body) and thinner still in the tail located
on the left.9
After removing the liver along with the right
side of the lesser omentum, including the hepatic–
duodenal ligament, incise the parietal peritoneum
along the C-shaped duodenal convexity, then com-
pletely remove the tissue block. Starting at the pylo-
rus, detach the duodenum and pancreas from the
structures behind them, following the cleavage plane
of the retropancreatic sphincter of Oddi (this struc-
ture is also called the hepatopancreatic sphincter, or
Glisson’s sphincter). This structure controls the flow of
9 The anterior surface of the head of the pancreas is covered by
the omentum. At its inferior margin, the mesocolon crosses
its root. Posteriorly, it is linked to the bile duct, the portal
vein, the inferior cava vein, and to the right kidney vein with
the interposition of Told’s retropancreatic band. The head and
body of the pancreas are covered anteriorly by the peritoneum
of the omentum sac, and it is linked to the stomach and the
lesser omentum. The posterior surface is located at the L1
level, and it is covered with a ligament linking the lower mes-
enteric vein and the aorta, as well as the celiac and superior
mesenteric vessels, left medial pillar of diaphragm, renal vein,
left kidney, and the suprarenal gland.
61
secretions passing from the liver, pancreas, and gall-
bladder into the duodenum of the small intestine. It is
actually composed of muscle located at the surface of
the duodenum. It is located slightly distal to the point
where the common bile duct and pancreatic duct
join as they enter the descending duodenum to form
the ampulla of Vater. The opening is on the inside of
the descending duodenum, the sphincter of Oddi, is
a muscular valve that controls the flow of digestive
juices (bile and pancreatic juice) through the ampulla
of Vater into the second part of the duodenum.
2.9.5.1 Case Study #7
Tumino G., Torrisi M., Cocimano G., Castorina S.
A 50-year-old man suffering from severe obesity
(BMI 58.8), hypertension, and diabetes was subjected
to a mini-gastric bypass (MGB). Two days after, the
patient underwent another laparoscopy because of a
laceration of the intestinal wall. Despite the medi-
cal treatment, after a month of hospitalization, the
patient died in the intensive care unit. An autopsy
was performed to confirm or exclude any malprac-
tice claim.
62
2.9.5.1.1 Autopsy
The external examination showed nine surgical skin
incisions due to laparoscopic accesses and drainages
(Figure CS-7.1).
Dissection by the anatomical layers was performed.
After access to the peritoneal cavity, no liquids were
found. The result of a mini bypass surgery was observed:
a mini (bypassed) gastric pouch and an ante colic latero-
lateral anastomosis (Figure CS-7.2, yellow arrow).
A hydraulic test was carried out to detect the integrity
of all anastomoses (Figure CS-7.3): A nasogastric tube
was used to inject water into the esophagus. The test
excluded any leak from the anastomoses.
Forensic and Clinical Forensic Autopsy
The block from the esophagus to small bowel was
extracted to complete the study (Figure CS-7.4). Two
prosthetic meshes were found inside the esophago-
gastro-jejunostomy (yellow arrows). The anastomosis
was continent, without any signs of peritonitis. The
cause of death and medical management of the patient
in the postoperative period are still under study.
Key Points
• A complete surgical site study in collaboration
with a consultant surgeon improves autoptic
accuracy.
• The hydraulic test performed during the
autopsy allowed us to exclude any leak from
the anastomoses, and to confirm that, the
mini-bypass surgery was performed using
the correct technique.
2 .9.6 Removal of Kidneys and
Suprarenal Glands
The kidneys are symmetric in appearance and retro-
peritoneal in position. They are located at roughly the
height of the 11th and 12th vertebra.10 To remove the
kidney, first locate it by palpation. Once it is identified,
wrap the hand around it, and pull medially and upward.
2.9.6.1 Access to the Renal Cavity
and Excision In Situ
To gain access to the kidney cavity, make an inci-
sion in the parietal peritoneum and the underlying
kidney fascia, hold the scalpel sagittally to the organ,
10 The right kidney is generally 3 cm lower than the left kidney
because of the overhanging liver. Each kidney, together with
its suprarenal gland, is contained in a separate cavity called
the renal cavity. The cavity is created by the splitting of the
renal band and the thickening of the peritoneal subserosa into
two layers: the anterior (prerenal) and the posterior (postrenal).
Inside this cavity, a wall of connective tissue divides the kid-
ney from the overlying suprarenal gland. Between the two lay-
ers of the renal band and the kidney capsule can be found some
more adipose connective tissue located adjacent to the kidney.
Adult Autopsy
Figure 2.104 (a and b) Particular of the kidneys and their vascular connections.
and make an incision from the top to the bottom. The
edges of the incision can then be widened by inserting
the fingers of the left hand to reveal the top part of the
suprarenal gland. This organ is extremely delicate and
must be removed very carefully.
2.9.6.2 Excision of the Renal Cavity
and Ureter In Situ
Alternatively, the parietal peritoneum can be detached
from the posterior structures of the renal cavity using
a pointed scalpel. The scalpel is moved from superior
to inferior to resect the hilar structures. Then, taking
great care not to damage the urethra, follow it and
separate it from the underlying structure continuing
on up to the pelvic recess behind the posterior wall
of the bladder, and then resect it (Figure 2.104). Once
the kidney has been removed, peel off the renal fascia
and capsule by first making a sagittal incision. In the
absence of chronic renal disease, the capsule will strip
easily. In the presence of chronic disease, the surface
will appear granular.
2.9.6.3 Inspection and Resection
of the Ureters
If the links to the ureters are kept attached during the
process of kidney removal, their endoluminal surfaces
can be examined. Using scissors with rounded blades,
create a keyhole incision, insert the scissors, and then
open the ureter from the top to the bottom to reveal
the ureteral mucosa (Figure 2.104a and b).
2.9.7 Examination and Removal
of the Bladder
2.9.7.1 Drawing Urine
Unless the presence of a tumor is suspected, the main
reason to examine the bladder is to obtain a urine
63
specimen. Use toothed forceps and scalpel to detach the
soft structures of the prevesical space; then grasp the
bladder with forceps, and cut a keyhole incision suffi-
ciently large as to allow access with a needleless syringe
and withdraw a urine specimen. Unfortunately, urine
is present in the bladder only about one-third of the
time, though it may still be possible to collect a sample
for the kidney calyx (see figures 2.80 and 2.89c).
2.9.7.2 Bladder Removal
If the bladder needs to be removed, it is important
to remember that it is a retroperitoneal organ. It is
located in the front part of the pelvic fundus, behind
the pubis, where it is attached by the pubic–vesical
ligaments. In males, the bladder is located in front
of the rectum. In females, this ligament is located in
front of the uterus and vagina.11 To remove the blad-
11 The bladder is normally held firmly in place by its ties with
the urethra and the ureters, by the adherence to the underly-
ing tissues in males, and to the vagina in females. The peri-
toneum that covers its superoposterior and lateral faces of
the bladder also fixes it in place. Specifically, the peritoneum
extends from the bladder to the abdominal wall anteriorly,
and it is elevated by the umbilical medium (uracoobliteratus)
and lateral (umbilical artery obliterata) to the right and to the
left, respectively. The bladder has three ligaments: the middle
and two lateral umbilical folds. When the bladder is full, the
peritoneum descends along the anterior wall of the bladder,
before continuing on to the abdominal wall. The peritoneum
in males reflects itself onto the rectum behind, creating the
vesical–lateral cavity, surrounded on both sides by the two
vesical–rectal folds, composed of the homonymous ligaments.
In women, the peritoneum is reflected onto the uterus behind,
creating the vesical–uterine cavity. The telasubserosa (some-
times just referred to as the subserosa, a layer of tissue between
the muscularis and serosa) lies just under the peritoneum. It
forms the so-called vesical fascia. In males, this fascia merges
with the rectal band, making the rectovesical band (fascia) pos-
terior and deep. In women, this fascia adheres to the connective
tissue that surrounds the vagina, creating the vesicovaginal fas-
cia. The bladder also has a so-called prevesical fascia, located
anteriorly, where it is partially joined to the vesical fascia.
64
der, grasp it with toothed forceps, and pull it superi-
orly and posteriorly while incising the peritoneum.
Begin first at the bladder’s posterior concavity and the
peritoneum where it extends from the anterior abdo-
men wall to cover the superior and lateral face of the
bladder. Then, incise the middle and lateral umbilical
ligaments. Holding  the blade turned parallel to the
bladder surface, enter the prevesical space of Retzius
(the extraperitoneal space between the pubic symphy-
sis and urinary bladder), and incise the two pubic–
vesical ligaments, which constitute the floor of this
space.
Stop the incision once the trigone is reached, as the
trigone should be preserved intact. Finally, make bilat-
eral incisions in the paravesical space, with the inci-
sion running parallel to the levator ani, then onward
to the trigon. Resection of the peritoneum depends
on the sex of the cadaver. In males, the peritoneum
reflects itself from the bladder to the rectum located
behind it in the area known as the vesical–rectal cav-
ity. This cavity is surrounded on both sides by the two
vesical–rectal folds, and by the homonymous ligaments
that must also be divided (if this has not already been
done), together with the terminal portion of the ureters.
The vesical fascia lies beneath the ureter and must be
detached from the rectum posteriorly (Figure 2.105). In
women, the peritoneum reflects onto the uterus behind
Figure 2.105 Upper urinary tract blunt dissection in a
malpractice case: An old man died for septic shock after
a ureteral calculi removal delay. In such cases, a urinary
tract organ en bloc removal is suggested in order to per-
form a better evaluation after formolic fixation.
Forensic and Clinical Forensic Autopsy
the vesical–uterine area. It should be detached from the
wall of the bladder and from the attached vagina with
an incision along the vesical–vaginal region.
2.9.8 Removal of the Uterus and Adnexae
The uterus is midline and partly retroperitoneal. It is
located behind the bladder and in front of the rectum.
The pelvic peritoneum only partially covers the uterus,
so that while most of the uterus is preperitoneal (body
and posterior face of the supravaginal part of the
cervix), the remaining part lies deep in the connective
tissue of the subperitoneal pelvic space.12
Remove the uterus and adnexae with toothed
forceps while placing tension on the peritoneum
that covers the pelvic organs, pulling the perito-
neum toward the midline, just medial to the hilar
veins. Dissect along the anatomical borders of the
organ (Figure 2.106), then incise the peritoneum
forming the broad ligament (the wide fold of peri-
toneum that connects the sides of the uterus to the
walls and floor of the pelvis), cutting from back to
front. Finally, incise the infundibular ligament and
round ligaments. Then, make a second, deeper inci-
sion, and divide the transverse cervical ligament
(ligament of Mackenroth), thereby isolating the
uterus from its lateral suspensory structures. Once
the round ligament has been divided, continue and
divide the peritoneum of the vesical–uterine cavity
12 The uterus can be divided into four parts: the fundus, which
is the top part and lies between the openings of the fallopian
tubes; the isthmus, which is a narrow area that lies at the bot-
tom; the body, which lies between the fundus and isthmus and
is the largest part; and the cervix, which is the entrance to the
uterus and lies below the isthmus. Anteriorly, the peritoneum
sinks between the bladder and uterus, creating the vesical–
uterine cavity. The cavity formed by the peritoneum is even
more evident where it is surrounded by the two rectouterine
folds. The peritoneum then is reflected from the posterior sur-
face of the uterus and the rectum behind it, which form the
rectouterine cavity or pouch of Douglas. The peritoneum cov-
ers the whole uterus and then stretches out bilaterally to form
a large fold that extends to the wall of the pelvic cavity, at
which point it spreads out as the parietal peritoneum; these
are two large ligaments. Each ligament adapts to the forma-
tions that install themselves close to the tubaric corner of the
uterus, that is, the uterus–ovarian ligament, or proper ovar-
ian ligament, to which it supplies a meso and round ligament.
At a deeper level, the subperitoneal portion of the uterus is
surrounded by connective tissue, the so-called parametrium,
which contains substantial amounts of fibrous tissue. Uterine
suspensor ligaments link it to nearby organs and to the pelvic
walls. The transverse and lateral uterine ligaments, or cardi-
nal ligaments of Mackenroth, are joined to the pubic sacral
ligaments near the uterine cervix in midline and laterally
(these ligaments go from front to back and are inserted in the
pelvic wall). The back or uterine rectal ligaments are inserted
in the two homonymous folds, and linked to the rectum and
to the sacral bone behind it; the anterior or vesical–uterine
ligaments attach to the bladder and to the pubis anteriorly.
Adult Autopsy 65

located in front of the uterus and behind the blad-

der. At deeper levels, use sharp dissection to detach
the bladder wall from the contiguous vagina, cutting
along the vesical–uterine septum. After separating
the uterus from the nearby structures, both in front
of it and on its side, it is necessary to detach it from
behind the rectum. Pull the peritoneum back using
toothed forceps while cutting the peritoneum close
to the uterine–rectal fold and the pouch of Douglas.
Once the pouch of Douglas has been excised, use for-
ceps to grip the rectum and move the blade forward
to excise the back wall of the vagina, and then the
vaginal vault, moving from the back to the front and
from the top to the bottom. This will allow for the Figure 2.108 Uterus. F, fundus; B, body; C, cervix.
extraction of the uterus together with the vaginal
vault (Figures 2.106–2.110).

Figure 2.109 Examination of the external orifice of the

uterus.

Figure 2.106 Blunt dissection of the uterus and its vas-

cular connections: Right ovarian vein (white arrow) and
left ovarian vein (blue arrow) are evident, and a systemic
vein stasis is visible.

Figure 2.110 Wide opening of the fibroid uterus (piece

Figure 2.107 Fibroid uterus. subjected to formolic fixation).
66 Forensic and Clinical Forensic Autopsy

2.9.9 Examination and Removal

of the Large Arterial–Venous
Retroperitoneal Pelvic Veins
A complete autopsy examination of the abdominal–
pelvic region cannot be performed without the exami-
nation of the large retroperitoneal vessels, such as the
abdominal aorta, with its two branches (the left and
right iliac arteries), and the inferior vena cava with the
two vessels that form it(the right and left iliac veins).
The parietal peritoneum must be cut and detached
before these vessels can be seen. The whole aortic
trunk should be examined (i.e., along its entire length
from the arch to the abdominal and thoracic aorta),
and finally, both internal and external iliac arteries are
removed (Figure 2.84).13

2.9.9.1 Case Study #8

Patanè G.F., Chisari M., Colosimo F., Indorato F.
An 86-year-old man was hit by a truck in his place
of work. After the accident, the man was taken to
emergency department and underwent surgery to
treat multiple upper and lower limb fractures. He
died after a day of hospitalization in the intensive
care unit.
2.9.9.1.1 Radiological Examination
An antemortem total-body CT scan was performed
before autopsy. This examination showed fractures of
the fourth and fifth right ribs, left humerus, ulna and
radius, and both femurs, tibia and fibula.
2.9.9.1.2 Autopsy
The external examination showed multiple injuries of
the head (Figure CS-8.1) and upper and lower limbs
(Figures CS-8.2–CS-8.4), consistent with the recon-
struction of the dynamics of the accident.
Dissection by the anatomical layers was carried
out. Abdominal inspection showed a large hemor-
rhagic infiltration of the structures near the inferior
vena cava and the abdominal aorta (Figure CS-8.5).
A hydraulic test was carried out detecting the
integrity of the main abdominal vessels, pelvic vessels,
and their major branches (Figure CS-8.6): Through a
syringe, we pumped water inside the inferior vena cava

13 The aorta is the body’s main arterial vessel. It emerges from

the heart’s left ventricle and, as the ascending aorta first heads
superiorly, forward, and slightly to the right. It then turns
toward posteriorly and to the left, passing over the left bron-
chus. It then descends as the thoracic aorta within the poste-
rior mediastinum. It crosses the aortic diaphragmatic tract,
then descends as the abdominal aorta, at which point it is a
retroperitoneal structure. Finally, at the level of the IV lumbar
vertebra, it splits in the two common iliac arteries and termi-
nates in the thin sacral median artery.
Adult Autopsy 67

2.9.9.1.3 Histological Assessment
Histological examination of the spinal cord sample
taken at the level of L4 showed an infiltration of eryth-
rocytes between the connective layers of the dura
mater (Figure CS-8.9). Blood infiltration was found in
most wound samples, such as in the brachial biceps
muscle (Figure CS-8.10) and spleen (Figure CS-8.11).

and abdominal aorta. The study of all major branches

excluded any leak.
After evisceration of abdominal organs, we
observed a full-thickness fracture of the fourth lumbar
vertebra (Figures CS-8.7 and CS-8.8) that was missed
by the CT scan, near the abdominal hemorrhagic area.
Such a lumbar fracture is indicative of impacts in an
erect position of the man before the accident.
68 Forensic and Clinical Forensic Autopsy

Figure 2.111 Bimastoideum resection, left side. Posi-

tioning of head on a metal support.

Key Points
• Radiological examination is a good prelimi-
nary phase, but it requires an autoptic integra-
tion to fill the detection gaps, as happened in
this case (L4 full-thickness fracture).
• The hydraulic experiment performed during
the autopsy allowed us to exclude any blood
vessel injury near the abdominal hemorrhagic
infiltration.
• The vehicle examination and the accident
scene investigation should be performed to
confirm that the injuries are consistent with
the accident reconstruction.

2.10 Dissection of the Head

2.10.1 Preparation of the Dissection Field
The head must be slightly raised with appropriate sup-
ports. There is no one correct device; each autopsy
surgeon prefers his or her own method (Figures 2.111–
2.113). The hair is divided with a comb along an
imaginary coronal plane that runs across the cranial
convexity connecting the two mastoids. A No. 22
blade on a long scalpel holder should be used to incise
the whole scalp from the outside. Before the incision
Figure 2.112 Detaching of the back half of the scalp to
the occiput.
is made, a generous sample of hair should be cut from
the vertex and preserved, should toxicological test-
ing prove necessary at a later date (an empty red top
tube or even a glassine envelope can serve as a con-
tainer). Once deposited in hair, drugs do not degrade,
and can be detected and even quantitated years or
decades later.
Adult Autopsy 69

same point at the opposite side of the head. This is

Figure 2.113 Scalp and galea capitis inspection.
2.10.2 The Bimastoid Resection
Begin the incision on the right side of the head, as
low as possible just behind the earlobe, but with-
out going below it. Then, extend the incision to the
the so-called bimastoid resection. When the inci-
sion is made in this fashion, it facilitates overturning
the scalp. A large enough strip of tissue behind the
auricle must be saved to allow for suturing the scalp
back in place (Figures 2.111 and 2.112). After enough
of the scalp has been incised to allow the prosec-
tor to grasp the two edges with his hands, the front
and back halves of the scalp are overturned, anteri-
orly and posteriorly, respectively (Figures 2.113 and
2.114). Using a strip of cloth placed on the free edges
of the scalp simplifies the procedure. If considerable
resistance is encountered, slide the scalpel along the
edge being retracted, with the blade inclined at 15°
to the edge. With the other hand, continue to stretch
the scalp. The scalpel blade must be pointed toward
the bony outer table of the skull, not toward the scalp
(Figure 2.108). The front strip of scalp must be turned
back 1–2 cm above the supraorbital edge, while the
back strip should be pulled just slightly over the

Figure 2.114 (a–c) Front and back scalp overturning. The root of the bimastoideum resection is clearly shown,
slightly below the external acoustic meatus, 1–2 cm behind the auricle. Scalp and galea capitis inspection (a–c).
Continuous solution of a roughly round shape (entrance hole of a bullet fired with a shotgun armed with single
ammunition) in the temporal muscle (b, c).
70
occipital swelling. The only exception would be if
the examiner thought there was a need to visualize
the orbital cavities (Figures 2.109 and 2.110).
2.10.3 Inspection and Resection of
the Temporal Muscles
After overturning the scalp strips, while the top
of the skull is still intact, examine and describe the
Figure 2.115 Inspection of the skull once the galea
capitis has been removed.
Figure 2.116 Dissected temporal muscle.
Figure 2.117 (a and b) Electric portable swinging saw sample.
Forensic and Clinical Forensic Autopsy
scalp thoroughly before it is dissected (Figure 2.115).
Hemorrhagic infiltrations or gunshot fragments
should be removed and submitted for microscopic
examination, and evidence of bruising is noted
(Figure 2.116).
2.10.4 Removal of the Skullcap
The skull is generally opened using an electric saw,
usually referred to as a Stryker saw after the name of
the most common brand (Figure 2.117). Alternative
methods to this extremely common practice can be
used when a particular surgical intervention on the
skull is required. A less bloody and more conser-
vative approach (such as sawing by metallic wire or
hacksaw) may be more appropriate (Figures 2.118 and
2.119). For example, in cases of massive head trauma
and occasionally when examining skeleton remains,
the findings of historic archaeological relevance need
to be preserved, and therefore, the least destructive
approach is preferred (Figures 2.120–2.122). The bony
dust dispersion produced by the use of the Stryker
saw constitutes a health hazard; thus, the procedure
must be carried out with appropriate means of protec-
tion. Collecting the dust inside a protective plastic bag
or, alternatively, by wearing protective suits should
minimize the dispersion of potentially infectious
bone dust.
Whatever the method, the Stryker saw should
always be equipped with a vacuum aspirator. The
shape of the cut through the skull should be designed
so that it reduces the slipping of the cranial vault dur-
ing the reconstruction of the head. Ideally, the cut
through the outer table of the skull should not go
beyond the internal face of the skull since the latter
can be easily removed with a scalpel. The goal of this
is to leave the dura mater and the underlying arach-
noid untouched, thus allowing the visualization of
Adult Autopsy
Figure 2.118 Posterior view of a bare skullcap. The out-
line indicates the ideal resection line and the orientation
of the swinging saw.
Figure 2.119 Surgical suture of the scalp, following the
neurosurgical operation.
Figure 2.120 Access to the skullcap through detaching
surgical sutures. The cranial breach and the dura with
bent edges by suture are clearly shown.
71
Figure 2.121 Removal and sample of hematoma for
microscopic examination.
Figure 2.122 Conservative incision of the skullcap
with the preservation of the dural cover, which appears
intact.
the brain and the surrounding cerebrospinal fluid
(Figures 2.122 and 2.123). After the cranial vault has
been removed, the dura must be incised along the
resection line of the saw and then everted. To pro-
tect the brain, the forefinger of the hand holding the
saw has to measure the penetration level of the blade.
The Stryker blade must be moved from one side to the
other to avoid excessive penetration. Many saws are
equipped with a safety system that features a mechan-
ical depth block designed to prevent excessive pen-
etration (Figure 2.117). Actual removal of the brain
begins in the thinner parietal region. This allows for
a better assessment of the resection depth and vis-
ibility of the curved line that links the superorbital,
biparietal, and occipital structures (Figure 2.118).
The incision must begin approximately two fingers’
width above the supraorbital lobes. The goal should
be to preserve as much of the dura mater as possible.
72 Forensic and Clinical Forensic Autopsy

Figure 2.123 (a and b) Left access to the dura. Above, close to the left frontal lobe, detachment of the dura mater
made with a scalpel. It is imperative in this phase to describe the macroscopic characteristics of the dura carefully, in
particular with reference to its translucency and to the blood injection of dural veins. It is also important to palpate
the part to evaluate its consistency.

When the dura is left intact, the cranial vault can be
easily removed. Once the dura has been opened, the
fingers can easily enter inside the cranium, making it
possible to pull the skullcap off with minimal trauma
to the skull (Figure 2.122). With a scalpel, incise the
dura along the line produced by the Stryker saw and
the anterior connection of the falx cerebri to the
skull, where the dura passes between the frontal lobes
(Figures 2.123–2.125). The posterior portion of the
falx can be incised from the inside part of the skull,
once the cranial vault has been overturned, and the
dura removed from the vault. The inferior sagittal
sinus can then be opened with forceps. The remain-
ing dural strips on both sides can be easily removed
from the brain using the bridge veins for traction
(Figures 2.123–2.128).

Figure 2.124 (a and b) Dura mater removal. Symmetric bilateral incision of the dura in the frontal lobes area. This
first cut emphasizes the dural sinus, and median, which will be macroscopically described in situ (a). Incision and
detaching “as a book,” along the parietal–occipital line at the right and the parietal at the left (b).
Adult Autopsy 73

Figure 2.125 Incision and median overturning of the

dura mater and front parietal–occipital resection at the
right.

Figure 2.127 (a and b) Examination in situ of the brain

in a malpractice case: a diffuse subarachnoid hemorrhage
due to a left internal carotid artery aneurysm rupture
after endovascular treatment with a flow diverter device
by femoral access.

Figure 2.126 Dura mater resected and overturned still

in situ. The abscised skullcap portion must always be
documented by photographs to prove by autoptic docu-
ments the substantial anatomical integrity (granted the
integration of eidologic datum if necessary).

2.11 Removal of the Brain

2.11.1 In situ Examination of

Lateral Ventricles
Before removing the brain, an in situ assessment of the
lateral ventricles should be performed. Gently divide
the cerebral hemispheres by placing the fingers on
the cingulate gyrus (Figure 2.129a–f). Then, with the
Figure 2.128 Incised dura mater. Inspection of the dura.
scalpel blade inclined at about 45° to the cingulated
gyrus, make a semicircular incision in the inferior
concavity.
74 Forensic and Clinical Forensic Autopsy

Figure 2.129 (a) Divaricating of telencephalic hemispheres in the gyrus cinguli area. (b) Incision and semicircular
resection of lateral ventricles. (c) Opening of left lateral ventricle. (d–f) Lateral ventricles opened and shown. After
exposing the ventricular cavities, they will be described in detail, and a photograph will be taken to support the
description record.

2.11.2 Brain Dissection The pituitary stalk is then transected, followed by the

internal carotid arteries at their entrance in the cranial
After examining the ventricles, gently lift the frontal
cavity. Cranial nerves II, IV, V, and VI must be cut as
lobes (Figure 2.130) and the mammillary bodies along
near as possible to the base of the skull (Figure 2.131a).
with the optic tract lying on the cribriform plate. The
Then, the attachment of the falx tentorium to the
optic nerves are stretched and easily visible when the
petrosal bone is divided bilaterally (Figure 2.131b).
frontal lobes are retracted. Divide them, preferably at
The falx must be cut with the scalpel blade held paral-
their entrance in the optic foramina (Figure 2.131a).
lel and close to the bony edge of the greater wings of
The brain will then fall, under its own weight, from
the sphenoid.
the anterior recess of the brainpan into the prosec-
At this stage, be very careful not to allow stretch-
tor’s hands. The hands should be placed as closely as
ing of the cerebral peduncles. Removal of the brain is
possible to the brain as it falls forward (Figure 2.130).
Adult Autopsy 75

facilitated with the neck in hyperflexion; therefore,

Figure 2.130 Extraction of encephalon. Frontal lobes
raised and encephalon received in the forensic surgeon’s
left palm.
rest the head on a firm, elevated support. Cranial
nerves VII, VIII, IX, XI, and XII are the next struc-
tures to be divided, but prior to their isolation,
describe their position and course in situ. The verte-
bral arteries are described and divided in the same
fashion (Figure  2.131b). Last, the cervical portion
of the spinal cord is transacted. It is easier to insert
the scalpel blade if the brainstem is slightly stretched
(Figure 2.131c). If a critical lesion is identified, a section
should be taken, then cut transversely across the area.
The cerebral peduncles are exposed by gentle force,
pushing the brain backward with the hands. They are
then extracted from the cranial vault, along with the
brainstem. Care should be taken to avoid excessive
stretching of the upper portions of the cervical cord.
The lateral portions of the tentorium are incised close
to the petrosal bone freeing the brain, which can then

Figure 2.131 (a) Cutting the optical nerves and hypophysis peduncle. In the photograph, the scalpel point hits the
tentorium base on the petrosal bone. (b) Resection of the tentorium of the petrosal bone and access to the posterior
cranial cavity. Note how the scalpel proceeds with the blade oriented near the bony edge of the petrosal bone along
the great wings of the sphenoid. (c) Dissection of the stretched portion of the intraforaminal marrow. Note the orien-
tation of the scalpel blade, orthogonal to the marrow plane.
76 Forensic and Clinical Forensic Autopsy

Figure 2.132 Examination of skullcap and cranial cav-

ity, and photographic record.

be lifted out. A detailed examination of the cranial

skullcap and the cranial cavities, and a proper photo-
graphic record are carried out (Figure 2.132).

2.11.2.1 Case Study #9

Loreto C., Giugliano P., Franco S.
A 40-year-old woman was admitted to the ED
because of a long-term cephalea. Angio-CT of the
brain was performed, and a fusiform aneurysm of
the supraclinoid portion of the left carotid artery was
diagnosed. She underwent an endovascular treat-
ment with a flow diverter device by femoral access.
During the procedure, a sudden flow reduction was
observed with contrast spreading out of the vessels.
After a few hours, an intraoperative CT scan was per-
formed and showed a diffuse subarachnoid hemor-
rhage. The woman fell into a coma and died the day
after. The prosecutor requested an autopsy because of
a malpractice claim.
2.11.2.1.1 Autopsy
The external examination showed a suture of the scalp
following the neurosurgical operation (Figure CS-9.1).
After surgical suture detachment and skullcap
removal, there was a galea capitis and internal face of
skullcap hemorrhage (Figure CS-9.2). After the cra-
nial vault and dura removal, an intense, diffuse, bilat-
eral subarachnoid hemorrhage was detected (Figure aneurysm in its supraclinoid portion (Figure CS-9.4).
CS-9.3). Blunt dissection of circle of Willis was per- Blood was visible after lateral ventricle in situ opening
formed: The left internal carotid artery was followed (Figure CS-9.5). After fixation, an aneurysm lacera-
until its cranial cavity entrance and showed a fusiform tion was observed (Figure CS-9.6).
Adult Autopsy 77

2.11.2.1.2 Histological Assessment
H&E staining of brain samples showed intrapa-
renchymal hemorrhages and abundant stratified
erythrocytes in the subarachnoid space (Figures
CS-9.7–CS-9.9). Lung samples showed a massive
edema (Figure CS-9.10).
78
Key Points
• An accurate autopsy technique allows main-
taining the integrity of the brain and its vascular
structures. It is important in cases where mal-
practice in neurosurgery needs to be evaluated.
2.11.3 Access to the Face
In cases of trauma, it may be necessary to dissect the
soft tissue of the face that lies in close proximity to the
bony or cartilaginous framework of the head, namely,
the bones of the cranium and face. When working in
this area always bear in mind that dissection should
not be so radical as to preclude adequate cosmetic
Figure 2.133 (a and b) Access to the face.
Forensic and Clinical Forensic Autopsy
reconstruction. To this end, we use a slightly modified
version of Adams’s incision.14
An incision is made in a plane passing behind
the acromion. Andover, the scapular edge on either
side, until they join in the middle of the neck along its
posterior surface. Visualize the muscles over scapu-
lar cavities, the insertions of the sternocleidomastoid
muscle, and the muscular cavities of the cervical plane.
Extending the incision from the front to the back edge
of the mandible allows for direct visualization of all
the facial soft tissues (Figures 2.133a and b–2.135).
Figure 2.134 Access to the face; mandibular edge,
revealing the posterior edge of the sternocleidomastoid
muscle.
14 Resection according to Adams: curtain resection of the neck
skin plane starting from the external edge of the sternocleido-
mastoid muscle.
Adult Autopsy 79

2.11.3.1.1 Radiological Examination
A postmortem total-body CT scan was performed
before autopsy and showed a diffuse neck soft tissue
and muscle hyperdensity as well as hyperdense mate-
rial in the upper digestive tract and upper airways.
2.11.3.1.2 Autopsy
External examination showed a complete trans-
verse soft ligature mark surrounding all the neck
(Figure CS-10.4). Hemorrhage to the soft tissues of the
face (Figure CS-10.5). Fan rays technique was carried
out and showed bilateral hemorrhage of the sternohy-
oid muscles that were sampled for histological assess-
ment (Figure CS-10.6). Left and right trapezius muscles
were hemorrhagic (Figure CS-10.7). The  supraglottic

Figure 2.135 Access to the face in a homicide case;

detaching of the soft tissues until the mastoid edge of
the sternocleidomastoid muscle, the zygomatic arches,
and the nasal pyramid.

2.11.3.1 Case Study #10

Maglietta F., Chisari M., Giugliano P.
A 32-year-old man was found at home by his room-
mate lying on the ground in the prone position in a
pool of blood. The roommate called the emergency
services, who removed the cadaver. The medical
examiner found the cadaver supine, with multiple
abrasions and ecchymosis on his face. A laceration
of the inner face of the labial mucosa was evident
(Figures CS-10.1–CS-10.3). A red-violet ribbon area in
the anterior face of the neck was observed suggestive
of a ligature mark. The roommate referred to the police
that the man some days before had been involved in
a fight. An autopsy was requested to assess the cause
and manner of death.
80 Forensic and Clinical Forensic Autopsy

tract of the larynx, the lower third of the pharynx,

showed hemorrhage (Figure CS-10.8). Blood was pres-
ent in the lower third of the trachea after in situ open-
ings (Figure  CS-10.9). The gross examination of the
brain showed a diffuse stasis.

2.11.3.1.3 Histological Assessment
Lung samples showed alveolar edema and rupture of
the alveolar septa, accompanied by intra-alveolar hem-
orrhages and emphysema (H&E) (Figures  CS-10.10
and CS-10.11.).
Adult Autopsy
Subfascial hemorrhage of both sternohyoid muscles
was highlighted. Trapezius muscle samples showed
intramuscular hemorrhage (HeE) (Figures CS-10.12
and CS-10.13 – arrows indicate the red cell).
81
The cause of death was attributed to a mechanical
asphyxia secondary to homicidal ligature strangulation.
Key Points
• Postmortem radiological investigations are
crucial in suspected homicides and traumatic
injury cases.
• Both anterior and posterior neck muscle
examination is mandatory when mechanical
asphyxia is suspected.
• Upper airways in situ examination helps
highlight neck compression signs.
2.12 Face and Neck Approach: The
“face/off” Technique (Pomara C.)
An initial transverse incision in the upper part of
the thorax is made from shoulder to shoulder (bisa-
cromial). Then, a bimastoid resection is performed
and it is continued to the bisacromial resection
(Figure 2.136).
The cadaver is placed in a sitting position in order
to access the posterior compartment of the cervical
superficial fascia. The anterior biacromial transverse
incision is continued posteriorly, through a longitu-
dinal incision following along the posterior midline,
extending to the sixth cervical vertebra. The skin was
reflected superiorly (Figure 2.137a–c).
The scalp is incised enough to allow the prosector
to grasp the two edges with his hands, and the front
half of the scalp is overturned anteriorly. The bimas-
toid  incision is continued, by a scalpel, up to the
superficial layers of the alveolar process of the maxil-
lary bones. Eyelids and the skin of the nasal bone are
preserved (Figure 2.138a and b).
Figure 2.136 Bisacromial and bimastoid incisions are
performed.
82 Forensic and Clinical Forensic Autopsy

Figure 2.137 (a–c) Overturning of the skin from the biacromial transverse incision.

Figure 2.138 (a and b) Dissection of the scalp from the bimastoid incision to the alveolar process of the maxillary
bones.

The upper half of the skin from the poste-

rior biacromial transverse incision is overturned
until the posterior half of the bimastoid incision
(Figure 2.139).
From the upper half of the skin of the anterior
biacromial transverse incision, a dissection of the
cutaneous and subcutaneous tissues is performed
until the superficial layers of the alveolar process of
the maxillary bones (Figure 2.140a and b).

Figure 2.139 Dissection of the posterior cervical face.

Adult Autopsy
Figure 2.140 (a and b) The face approach.
2.13 Vertebral Resection and
Cord Removal
The spinal cord can be removed relatively quickly
and easily using a Stryker saw (removal should add
no more than 15–20 minutes to the process), and
should always be performed, unless there is insuffi-
cient time.
2.13.1 Posterior Approach
There are many different approaches and entrances
to the dorsal spine, though these are seldom used
unless there is trauma, especially caused by a gunshot
wound, or prior surgery (Figures 2.141–2.143). In fact,
though seldom performed, the entire autopsy can be
accomplished using a posterior approach to access the
thoracic and abdominal cavities using a semicircular
biacromial incision or a median perpendicular/sagittal
incision (Figures 2.141 and 2.144). The latter allows for
the inspection and isolation of the arches of the pos-
terior neck muscles, paravertebral muscles, ligaments,
vertebrae (spinal and transverse processes as well as
vertebral bodies), and vertebral arteries (Figures 2.141
and 2.144). Once the spinal cord has been exposed,
make an incision with a scalpel blade inclined at 30° to
the vertebral body. This method provides easy expo-
sure of the superior part of the cervical trunk, permits
direct visualization of the cranial–cervical joint, and,
83
of course, allows for complete resection and isola-
tion of the cord (Figure 2.144). This is the preferred
method in cases when death occurs as a consequence
of surgery.
2.13.2 Anterior Approach
The anterior approach is the fastest and simplest way
to remove the cord because the cadaver does not have
to be turned. The peripheral nerves can be followed
after the removal of the cord. A detailed examina-
tion of the vertebral bodies is also possible. Removal
of only a part of the cord is another option with this
approach, but it is generally better to take the entire
cord. The lumbar–sacral muscles are easily removed
from the spine by the saw. Depending on the tech-
nique used (Letulle, for instance), the cord can often
be removed whole, free from any muscular con-
nections. Freeing the cauda equina from the sacral
bone requires some time, as it is difficult to use the
saw inside the pelvic cavity. In rare cases, it will be
necessary to remove a bone wedge near the midline
and then remove the remaining side of the sacrum
with a rongeur. This is the best way to avoid damag-
ing nerve roots as they traverse the vertebral fora-
men. The cauda equina is covered by the dura mater,
and it should be lifted out the spinal canal with as
many spinal ganglions as possible (Figures  2.145
and 2.146).
84 Forensic and Clinical Forensic Autopsy

Figure 2.141 The cadaver is placed in the prone position. A bimastoid incision of the scalp is performed through the
trapezius and splenius capitis muscles (a). The second incision is carried out posteriorly by a longitudinal incision
following along the posterior midline, extending to the sixth cervical vertebra (b). Posterior access by bisacromial
resection (c–h).

Figure 2.142 (a and b) Posterior partial access: right scapular region. Gunshot injuries in subcutaneous tissues are
evident (a, b).
Adult Autopsy 85

Figure 2.143 Inspection and isolation of the trapezius muscle, rhomboid major muscle, splenius capitis–cervicis,
and semispinalis capitis muscles (a and b). Detail of the cervical rachis after removal of the muscular layers (c). The
posterior cranial fossa is opened using an electrical saw through two oblique and symmetrical incisions (d). The
dura mater is removed through a falx cerebri section, close to the cerebellum tentorium, prolonged laterally along
the residual bone edges up to the frontal portion of the brain (e). Subsequently from the same access, we proceed to
section the tentorium in order to uncover the cerebellum. Brain and cerebellum exposure after removal of the dura
mater (f). Removal of the cervical vertebrae peduncles up to the C7 level, using an oscillating saw inclined at 30 °,
taking care to preserve the integrity of the vascular structures (g). View of the brain and spinal cord (h). Extraction of
the spinal cord in a caudal–cranial way through the bilateral dissection of the nerve roots (i and j).Result of removal
of the brain, cerebellum, and spinal cord up to level C7, preserving the integrity of the vascular structures (vertebral
arteries, basilar arteria, and circle of Willis).
86 Forensic and Clinical Forensic Autopsy

Figure 2.144 Rachis exposition by posterior access, as per median resection. (a) The rachis–thoracic–lumbar axis.
(b) Close-up of the rachis–cervical axis (spinal surgery).

Figure 2.145 (a) Anterior access: resected rachis. Wide opening (a libro) of the right resecting border. (b) The probes
subtend the spinal marrow, leaving the vertebral canal visible (medullar bed).

Figure 2.146 Medullar resection carried out from the extreme clavicular to the extreme lumbar region. Resections
at complete borders and vertebra removal (a). Brainstem and medullar resection in a fatal case due to lumbar puncture
in which medullar hemorrhage occurred (b).
Adult Autopsy 87

2.13.2.1 Case Study #11

De Palma A., Moschetti P., Casella F.
A 79-year-old man, driving his own car, was involved
in a frontal-impact crash, hit by another car. He arrived
comatose (GCS 3) to the ED. The patient underwent a
brain CT scan and angio-CT scan, directed, in partic-
ular, to study epiaortic vessels. CT scan showed a wide
ischemia of cortical and subcortical areas particularly
affecting left frontal and occipital encephalic lobes
and cerebellum; angio-CT scan revealed the complete
occlusion of the lumen of both vertebral arteries, at
the level of the third cervical vertebra. The man died
about 4 days after.
Before performing the autopsy, a CT scan of the
skull and neck was conducted. Then, the autopsy
was performed with a particular dissection protocol
borrowed from the neurosurgery. The examination,
indeed, was focused on the vertebral artery segments
between the third and fourth cervical vertebrae.
2.13.2.1.1 Autopsy
Once the splenius capitis of the head had been uncov-
ered, the semispinalis muscle was exposed, bilaterally,
also affected by hemorrhagic infarction of the muscle
fibers (Figure CS-11.1 and CS-11.2). Once the nuchal
ligament was removed, in correspondence of the C4
vertebra, a multi-fragmentary fracture of the spinous
process of the vertebra was detected. Moreover, the
same vertebra appeared separated from the underly-
ing C5 vertebra with posterior exposure of the spi-
nal cord and hemorrhagic infarction of the dural
sac. Then, through the use of a rongeur, the section
of the transverse processes was performed to visual-
ize the course of the vertebral arteries into the trans-
verse foramen. The same presented a regular course,
replete of blood up to the level of their emergencies
and from the transverse processes of the atlas to the
point of perforation of the atlanto-occipital mem-
brane (Figures CS-11.3 and CS-11.4).

Then, the skull was dissected according to a

plane passing from the occipital protuberance up to
the frontal bone, above the superciliary arches; then,
another section of the occipital region laterally, bilat-
erally, was conducted from the lateral margins of the
88 Forensic and Clinical Forensic Autopsy

foramen magnum, posteriorly to the occipital con-

dyle, continuing along the scale of the storm up to the
previous section margins. The occipital segment was
thus removed, allowing the brain to be removed in
continuity with the spinal cord up to the upper border
of C5, corresponding to the afore mentioned C4–C5
disarticulation.
2.13.2.1.2 Macroscopic Examination
The analysis of the epiaortic vascular structures
included the emergence of vertebral arteries, bilater-
ally, from the subclavian arteries. The right vertebral Figure 2.147 Right arm dissection of the cutis–
subcutis. Two continuous solutions because of the split
artery showed a lumen reduction of about 40%.
ammunition used in the long head of the biceps brachii
2.13.2.1.3 Histological Assessment muscle (6) and deltoid muscle (4) are observed.
Ubiquitary extended intraparenchymal erythrocyte
collections that substituted for large tracts the nervous
parenchyma.

Key Points
• Whiplash is a traumatic event affecting the
cervical spine. In most cases, it arises follow-
ing a sharp movement of the head that exceeds
the physiological limits of joint excursion.
• Many studies document the presence of isch-
emic accidents following the compression of
the vertebro-basal system arteries after whip-
lash in predisposed patients.
• The forensic pathology has to know in depth
the anatomy in order to adapt the dissection
techniques to each specific case, even borrow-
ing them from other surgical specialties.

2.14 Upper limb and Axilla dissection

The arms at autopsy must first be x-rayed, or a full-body

CT scan should be performed. Once the X-rays have
been performed, make a biacromial incision along the
volar surfaces of the arm and forearm, stopping at the
wrist. Then, continue with a layered dissection, tak-
ing care to expose all aponeurotic bands and muscle
tendons (Figures 2.147–2.151). The dissection could
be extended up to the axilla and the posterior axillary
line; then, continue the incision back to the thoracic–
abdominal wall (Figure 2.152). Once pectoralis major
and pectoralis minor muscles have been reflected, this
Figure 2.148 Sequence of stratum openings of the
approach allows the visibility of the muscular ten- superior limb; the extension of the bisacromial resec-
dons, and the vascular and nerve bundles of the axilla tion at the calyx is clearly shown (pointed out from the
(Figure 2.153 and see also Figure 2.17): forceps). (a) The resection is extended until the median
face of the wrist. (b) Overturning of the cutaneous layer
1. After cleaning and removing fat tissue and near the arm–forearm. (c) Stripping of left superior limb,
limited to the cutaneous and subcutaneous layers only.
lymph nodes from the axilla, identify and An intense hemorrhage in soft and muscular tissues
isolate the musculocutaneous nerve that runs is observed: This case concerns a crush syndrome that
into the coracobrachialis muscle; occurred after a fatal road accident.
Adult Autopsy
2. Follow proximally the musculocutaneous
nerve and find the lateral cord;
3. The lateral cord gives rise to the lateral branch
of the median nerve. Identify the median
nerve and the letter “M” formed by the ulnar
nerve (medial cord) and the musculocutane-
ous nerve (laterlat);
Figure 2.149 Glenohumeral cavity with homer (head)
and vascular–nervous bundle in close-up.
Figure 2.150 Dissection of arm and forearm cutis and
subcutis: A stab injury in the anterior compartment
muscles of the forearm is evident.
Figure 2.151 Dissection of arm and forearm muscles: A
stab injury in the anterior compartment muscles of the
forearm is evident. No lesions were detected in the fore-
arm nerves.
89
Figure 2.152 Blunt dissection of arm vessels is car-
ried out in a fatal dog attack. A brachial artery lesion is
present.
4. Posterior to the letter “M,” identify the third
part of the axillary artery;
5. Retract posteriorly the axillary artery, lateral
and medial cord in order to expose the poste-
rior cord;
6. Follow the posterior cord, and find the radial
nerve and axillary nerve.
Axillary approach as the cannulation site for mul-
tiphase postmortem CT angiography (MPMCTA)
allows the full detection of the vascular system of the
lower limbs and is very useful in all cases with risk
factors for venous thromboembolism or in cases of
sudden unexplained death to enhance the quality of
postmortem investigations (Figure 2.154).
The study of the upper limbs starts with the
cadaver placed in the supine position. A vertical
incision is made along the lateral sides of the upper
limb to about the middle of the forearm, which is
then continued horizontally across the forearm to its
medial border. The skin is then reflected by placing
traction and using a scalpel to free the taut collagen
fibers below it. The superficial fascia is cleaned away
via blunt dissection while preserving the cephalic
and basilic veins, and the median cubital vein in
between. The deep fascia is incised and removed
along the length of the arm in the midline via blunt
dissection. The superficial muscles are cleaned by
blunt dissection and then identified. Scissors are
used to transect the biceps brachia muscle about
5  cm proximal to the elbow while preserving the
musculocutaneous nerve and thus the deep muscles
and other deep structures.
90 Forensic and Clinical Forensic Autopsy

Figure 2.153 (a–c) Blunt dissection of the brachial plexus and axilla contents is carried out in a fatal motor-vehicle
accident: The white arrow indicates the brachial plexus roots avulsion.

Figure 2.154 Axillary approach: The first incision, no more than 5 cm long, is made along the upper third of the
anterior axillary line, in correspondence to the anterior axillary fold (anterior wall of the axilla-lower border of the
pectoralis major muscle and the underlying pectoralis minor muscle). The arm is abducted to about 45°. A second
incision, with a maximum length of 5 cm, made from the anterior axillary fold (first cut) along the medial side of the
arm (lateral wall of the axilla). The skin flap is reflected superiorly and inferiorly, followed by the subcutaneous fascia
with the axillary sheath and the axillary bundle. The anterior surface of the axillary sheath is opened with the use of
scissors followed by the blunt dissection of the brachial artery, brachial vein, median and lateral roots of the medial
and lateral cords, and the median and ulnar nerves. Following the course of the brachial artery and vein, the cannulas
are inserted in the so-called third part of the axillary artery (for the arterial system) and into the underlying axillary
vein (through to the axillary sheath).
Adult Autopsy 91

2.14.1 Case Study #12

Besi L., Baldari B., Scopetti M., Polo L.
A 27-year-old man was found dead on the front seat of
his car. The safety locks were locked. There wasn’t any
evidence of struggle, either, in the car.

2.14.1.1 Autopsy

At the external examination, three skin wounds were
found:

• One incised wound on the anterior side of

the left forearm, 10 cm in length and 5 cm in
width (Figure CS-12.1);
• One incised wound on the anterior side of the
left forearm, 7 cm in length and 5 cm in width
(Figure CS-12.2);
• One 2.5-cm-long cut on the anterior side of
the right wrist (Figure CS-12.3).

The autopsy study of the upper limbs was carried out

by dissection by the anatomical layers. After skin and
subcutaneous-layer dissection, we detected a blood
infarction of forearm muscle fibers (Figure CS-12.4).
At the middle third of forearms, lacerated tendons
of the deep flexor muscles of the fingers, and hemor-
rhagic infarction of the radial artery and vein were
observed (Figures CS-12.5 and CS-12.6).
92
2.14.1.2 Histological
 Assessment
Wound skin samples revealed a laceration of the skin
with a large amount of erythrocytes between the der-
mal layer and the subdermal layer (Figure CS-12.7).
Blood infarction was found; the blood was also
found in correspondence of lesions of the vessel walls
(Figure CS-12.8).
Forensic and Clinical Forensic Autopsy
The cause of death was attributed to an acute hemor-
rhagic anemia secondary to stab wounds on the fore-
arms with the excision of radial arteries and veins
bilaterally.
Key Points
• Homicide should be carefully ruled out in
every case of sharp weapon injury.
• Only a careful assessment of all the elements,
including examination of the scene and post-
mortem findings, can reconstruct the lethal
chain of events, and elucidate the time, man-
ner, and cause of death.
• In cases of vessel injuries, dissection by single
anatomical layers is the only method that can
assess, in such cases, the bleeding source.
2.14.2 Case Study #13
Vanaria F., Patanè F.G., Iannuzzi S.
A 53-year-old man suffered a severe trauma after a
road accident, which caused pelvic bones, sternum,
ribs, lumbar vertebrae, left radius, and left ulna bones
fractures which got exposed in a lacerated and con-
tused wound.
The man was carried to the nearby hospital E.R.,
where he underwent a lumbar spine surgery and sutu-
ration of the left forearm wound, before plastering the
limb.
After a 20-day hospitalization, he suffered from an
increasing hyperpyrexia and the left forearm became
necrotic. Because of the worsening conditions, ortho-
pedists amputated the left forearm; after few days, the
right hand and the forearm showed signs of necro-
sis, and the patient underwent an escharotomy. The
patient died few days later. The prosecutor asked the
forensic pathologist if any healthcare malpractice
caused the death.
2.14.2.1 Autopsy

The external examination confirmed the amputation
and outer lesions (Figures CS-13.1, CS-13.2–CS-13.3),
while autopsy confirmed inner lesions. Figure
CS-13.1 details the left superior limb amputation,
Figure  CS-13.2 the surgical amputated left superior
limb, and Figure CS-13.3 the right forearm, showing
the outcomes of a escharotomy.
Dissection by the anatomical layers was car-
ried out. The outcomes of consolidating fractures
were identified in sternum, ribs, and pelvic bones.
The left forearm was inspected and got frozen for
Adult Autopsy
further examinations. The right forearm and hand
were also inspected and dissected, and confirmed the
medical and clinical observations (Figures CS-13.4–
CS-13.7). The samples were taken for further histo-
logical examinations. The cause of death is still under
investigation.
Lastly, Figure CS-13.7 illustrates a suspicious
intravascular formation inside the ulnar artery.
93
Figure CS-13.4 details the right forearm after layer-by-
layer dissection, showing muscle and vessels integrity:
(A) Cephalic vein; (B) biceps brachii muscle; (C) basilic
vein; (D) brachioradialis; (E) pronator teres; (F) flexor carpi
radialis; (G) palmaris longus; (H) flexor carpi ulnaris; (I)
flexor digitorum superficialis
Figure CS-13.5 details the right hand after layer-by-
layer dissection, showing muscle and vessels integrity,
until area of surgical escharotomy: (A) Extensor indi-
cis tendon; (B) extensor digitorum tendons; (C) extensor
digiti minimi tendon; (D) cephalic vein.
94
Figure CS-13.6 details the right hand after layer-by-
layer dissection, showing muscle and vessels integrity on
the palmar side: (A) Ulnar artery; (B) superficial palmar
arch; (C) flexor pollicis longus tendon; (D) flexor digito-
rum superficialis tendons.
Figure 2.155 (a and b) Dissection by anatomical layers of the thigh. Two lacerations of the vastus lateralis muscle
(G) and vastus medialis muscle (H) are present.
Forensic and Clinical Forensic Autopsy
Key Points
• A complete anatomical study of interested
body regions is mandatory especially when a
healthcare malpractice is doubtful.
• Macroscopic and microscopic studies are
mandatory to define the cause of death.
2.15 Lower Limb Dissection
As with the arms, a radiological evaluation of the legs
must be completed before beginning the dissection.
Make the initial incision in the femoral triangle, at
the medial third of the inguinal fold, and continue
along the medial border of the thigh–knee and, if
necessary, the leg, until reaching the medial malleolus
(Figure 2.155). While removing the superficial fascia
of the leg, the great saphenous vein can be observed
in front of the medial malleolus. The small saphenous
vein can be observed behind the lateral malleolus.
The femoral triangle has been identified too (sartorius
muscle, inguinal ligament, and adductor longus
muscle).
Once the first artery and vein have been individu-
ally isolated, they should be followed along their entire
course (Figure 2.156). Dissect them by anatomical layers
always preserving the underlying muscular structures.
Make sure to expose all muscles and their insertions,
including the sartorius muscle. The dissection must be
tailored to the individual case, and any method chosen
will have to take into account the specific features of
the case. Whatever method is chosen, always pay spe-
cial attention to the isolation and the examination of
the vascular structures. The muscles should be removed
one by one to allow for the visibility of bone segments
and articular structures. The posterior compartment of
lower limb dissection is shown in Figure 2.157.
Adult Autopsy 95

Figure 2.156 Dissection of the lower limb carried out in a fatal met hemorrhagic shock secondary to injury of a vein
in the subject with varicose vein at the lateral malleolar region of the left foot.

Figure 2.157 Dissection of the posterior compartment of the thigh. (a) Perform an incision 2 cm lateral to the tip of
the coccyx vertically downward to the ischial tuberosity. (b) Make two transverse incisions from the first vertical one
to aid in the skinning process of the gluteal region. Perform a vertical incision across the midline of the thigh and the
leg. (c and d) Remove the skin from the superficial fascia. Dissect by anatomical layers, always preserving the under-
lying muscular structures. Make sure to expose all muscles and their insertions. Popliteal fossa contents (popliteal
vein, popliteal artery, tibial nerve) are visible (black arrow) (e). Lower limb vessels are the most common localization
of DVT; therefore, in all cases in which a PTE is suspected, lower limb vessel isolation and cutting is mandatory.
96 Forensic and Clinical Forensic Autopsy

2.15.1 Case Study #14 round-shaped skin laceration, with a diameter of

0.3 cm (Figures CS-14.3 and CS-14.4).
Tumino G., Amico F., Moschetti P., Polo L.
A 61-year-old man was found dead in the basement of
a psychiatric hospital. During the crime scene investi-
gation, diffuse bloodstains were found on the floor of
all the rooms (Figures CS-14.1 and CS-14.2).
The external examination showed, at 1 cm inferiorly
from the lateral malleolus of the left foot, a roughly

2.15.1.1 Autopsy

The skin of the lower limb was detached. In cor-
respondence to the skin lesion, there was a roughly
round-shaped lesion of the subcutaneous tissue, with
a diameter of 0.2 cm (Figure CS-14.5).

The deep dissection of the back of the foot and the

medial and lateral malleolar regions showed the dor-
sal metatarsal veins, the dorsal cutaneous venous arch,
the lateral marginal vein, the small saphenous vein,
and the lateral dorsal cutaneous nerve.
We isolated the muscular heads of the anterior
loggia of the leg, which appeared unscathed. The
muscular heads were detached from the distal inser-
tions, and overturned to allow the isolation and study
of the vascular–nervous components (anterior artery
and anterior tibial vein, a superficial peroneal nerve
and a deep peroneal nerve) that appeared unharmed
(Figures CS-14.6 and CS-14.7).
Adult Autopsy 97

Figure 2.158 Telencephalon hemispheres: frontal view.

Key Points
• The death was attributed to a hemorrhagic
shock secondary to injury of a varicose vein
of the lateral malleolar region of the left foot.
• The dissection for single anatomical layers Figure 2.159 Telencephalon hemispheres: inferior sur-
allowed us to isolate the vascular structures face. The Willis polygon is clearly seen.
in the lesion area and to discover the lesion
of the venous vessel from which the bleeding
originated.

2.16 Macroscopic Examination
and Dissection of Organs

2.16.1 Brain
Prior to brain dissection, photographs and measure-
ments should be taken. If there are any concerns
about vascular integrity, photographs of the circle
of Willis (also called the Willis polygon) should be
taken before it is incised and removed as one block
(Figures 2.158–2.161).

2.16.1.1 The Ludwig Scheme

Many methods have been proposed for the examina-
tion of the brain. The Ludwig method seems the most Figure 2.160 Close-up of the Willis polygon.
98 Forensic and Clinical Forensic Autopsy

brain is fixed, though it is possible to observe a good

Figure 2.161 Particulars of the Willis polygon from the
vertebral artery.
attractive as it combines the best features of classic
anatomopathologic methods and the classical method
of Virchow (Figure 2.162a–d). An adequate basic
examination can be performed no matter whether the
deal more detail if the brain is fixed for 2 weeks prior
to dissection; in either case, the brain is cut into coro-
nal sections. Initially, the hindbrain must be severed
from the cerebral hemispheres. The best way is to use
a long-handled scalpel with a No. 22 blade to incise
both of the cerebral peduncles. Hold the blade at a
right angle to the brain for as long as possible. Once
the incisions are made, the brain can be removed and
placed on a cloth or large sheets of absorbent paper.
Position the brain so that the hemispheres rest on
the cloth and the inferior surface of the brain faces
upward, with the frontal horns oriented anteriorly.
The first incision is made approximately 1–2 cm ante-
rior to the mammillary bodies, separating the hemi-
spheres. If the brain has not been preserved, it will
only be possible to make two more coronal cuts. If the
brain has been fixed, it will be possible to cut each slice
with a thickness of approximately 1 cm, allowing a
much more detailed view of the cerebral parenchyma.

Figure 2.162 (a–d) Study of the brain after formolic fixation. (a) The Ludwig scheme, a section of the brain, brain-
stem, and Willis polygonare clearly seen. (a) The “cross-sectional method.” (b–d) Using the cross-section method, it
is possible to accurately highlight ischemic areas or hemorrhagic infiltrates.
Adult Autopsy
Figure 2.163 Virchow resection.
An analogous procedure is used for the corpus cal-
losum and the cerebellum, which are incised at right
angles 2–3 cm.
2.16.1.2 Classic Variations (Virchow Method)
Classic variations are based on sagittal and coronal
cuts, made 2–3 cm from one another, producing sym-
metric slices, and bilateral cuts made at 45° into the
two hemispheres, beginning with the lateral ventricles
(Figures 2.163).
2.16.1.3 Blood Samples
The origin of blood samples must always be specified.
This is especially true when a subdural hematoma is
present; the origin of the blood must be described in
detail (origin, extension of the hematoma, estimated
volume). The brain should also be inspected for areas
of possible dural coagulation anterior to, and contigu-
ous with, the margins of any hemorrhagic zone. If a
subdural hematoma is present, it provides an ideal
matrix for toxicological testing, as centrally acting
drugs persist much longer in the hematoma than in
the peripheral blood.
2.16.2 Heart
There are several ways to examine the heart of an
infant, and each has adherents. No matter which
method is chosen, the external description of the
heart is very important. Cardiac enlargement may
indicate the presence of hypertrophic cardiomy-
opathy, hypertension, or even maternal drug abuse.
99
Hypertrophic cardiomyopathy occurs as a conse-
quence of many different polymorphisms, some of
which do not produce obvious changes that are mac-
roscopically obvious, whereas others, like LAMP2
cardiomyopathy (lysosomal-associated membrane
protein 2), manifest anatomical changes that are
diagnostic. When suspicion of inheritable cardio-
myopathy is strong, DNA testing must be requested,
if for no other reason than to determine whether
the rest of the family must be screened. The normal
heart is vaguely cone-shaped. If its shape is globular
or irregular, as in the case of ventricular aneurysm,
then extensive sampling for subsequent histologi-
cal examination is necessary. If the subepicardium
has a grayish tinge, this suggests congenital heart
disease. In the case of preexisting heart failure and
chronic anemia, the myocardium may appear pale,
spotted, or even hemorrhagic when there is acute
heart failure or heart rupture. The consistency of the
left ventricle can be hard (suggesting hypertrophy,
fibrosis, amyloidosis, calcification, or rigor mortis)
or soft (due to acute myocardial infarct, myocardi-
tis, dilated cardiopathy, or decomposition). Most of
the older methods of dissection are not practical for
routine diagnostic purposes, which is why only the
inflow–outflow and the “short-axis” methods have
survived.
The last technique is useful in virtually every form
of cardiac dysfunction. A number of recent methods
have been developed that are very useful for teaching
purposes, as they allow for easier comparisons and
an easier demonstration of normal heart structures
(Figures 2.164 and 2.165).
2.16.2.1 Inflow–Outflow Method in
Cardiac Dissection and in situ
Coronary Tree Isolation
The most widely used technique is the one originally
proposed by Virchow and modified by Prausniz. The
heart is opened in the direction of flow through the
vena cava, adjacent to the right heart border, up to
the conus and the pulmonary artery. On the left, the
chambers of the atria are opened by cutting the pul-
monary vessels, then continuing the incision to the
infundibulum and aorta (Figure 2.166). Recently, it
has become common practice to open the coronary
arteries all along their course, and then remove them
before complete dissection. The problem with this
approach is that it becomes impossible to precisely
estimate luminal diameter, remove clots, and still do
an adequate examination of the myocardium itself.
For these reasons, forensic pathologists now prefer
100 Forensic and Clinical Forensic Autopsy

Figure 2.164 Heart: (a) anterior face; (b) posterior face.

to make transverse scalpel cuts in situ, at intervals of

3 mm (Figure 2.167).15 Once the heart is removed from
the pericardial sac, the chambers must be carefully
washed, the heart weighed, and only then externally

15 Many methods have been used to examine coronary arter-

Figure 2.165 Heart, aorta, and iliac arteries after for-
molic fixation. This photograph shows a large aneurysm
of the thoracic aorta extending to the abdominal aorta.
ies. Chalk injection was first introduced by Bianchi in 1904;
injection of radiopaque materials, sometimes colored, into
intact hearts (Gross, 1921); diaphanization as introduced by
Spalteholz in 1924; opened and spread out heart (Schlesinger,
1938); injection of plastic substances while dissolving the
myocardium (James, 1961); and tissue abscission for a histo-
logical examination before myocardial dissolution (Baroldi
et al., 1967). If the goal is to make comparisons with echocar-
diographic images, specific dissection layers must be created.
Each method has its advantages and disadvantages, depending
on the intended purpose of the examination. Nevertheless, a
method that allows the study of population groups (Baroldi
et  al., 1974) has been adopted, allowing a quantitative and
morphological–functional valuation of the parameters to be
correlated with the clinical history. It is a modification of
Baroldi’s method and can be adopted without an excessive
waste of time or material (Fineschi et al., 2005).

Figure 2.166 (a) Outlined are the access ways of the resection according to the blood flow. The resection follows,
for example, the venae cavae flow to the right border of the heart, at the cone, and at the pulmonary artery. To the
left, opening of the atrial diaphragm by resection of the pulmonary vessels, and then continues with the left border
dissection of the infundibulum and the aorta. (b) Through this section, it is possible to highlight the semilunar and
atrioventricular flaps.
Adult Autopsy 101

Figure 2.167 Great care is taken to keep the aorta, pulmonary artery and veins, and venae cavae intact when they
are dissected out of the pericardial cavity (a). Using the blunt dissection technique, the serous pericardium is removed
from the aorta and the pulmonary trunk, leading to their separation. The blunt dissection technique involves the
cautious opening of a closed pair of blunt scissors following their insertion into tissues that are about to be separated
(b–c). The origin of the left coronary artery is located (d).Origin of the right coronary artery (e).

inspected.16 Regrettably, many forensic pathologists
forgo the next step, but the heart should then be
suspended in a large container, filled with neutral
10% formalin solution, for 24 hours. Even though a
period of only 24 hours does not allow for complete
fixation, it will harden the tissue, allowing myocar-
dial dissection without any damage to the tissue itself.
Transverse incisions through the semifixed heart are
made at intervals of 3 mm, along the course of the
extramural arterial branches, and each segment is
then removed. Once these measures have been under-
taken, it becomes possible to section the whole heart
with a mechanical slicer, producing slices that are each
about 1 cm thick, cutting from apex to base, parallel
to the atrioventricular sulcus. The final slice is made
at the apex of the papillary muscles. The heart slices,
atria and valves, and the coronary segments are then
placed in anatomical sequence and photographed in
color, using a camera equipped with a metric scale.
This gives the option of calculating macroscopic data
(wall width, cavity volume, etc.) and the ability to
16 When hearts are surgically excised prior to transplantation,
most of the atria remains in the pericardial cavity. To allow
comparison with autopsy hearts, the weight of the first has
been reported as the total weight of the heart, adding the theo-
retic weight according to the following formula: Weight of the
heart without atria × 100/75 (Reiner, 1968).
estimate the extension of a lesion as a percentage of the
total heart mass. Finally, atria, valves, and any other
structure are easily examined by whichever technique
seems appropriate (Figure 2.168).
2.16.2.2 Method of Heart Valve Dissection
The pulmonary valve and the aortic valve are viewed
from above. Following palpation, a horizontal incision
is made approximately 2 cm above each of the valves
by using a pair of sharp-ended scissors. Observation
of the right and left aortic sinuses is made by the iden-
tification of the origins of the two coronary arteries.
Two sets of incisions are made at specific points of
the ventricular walls of both the left and right sides
of the heart using a blunt-ended scalpel, in order to
create two flaps. One pair of incisions is made roughly
1  cm above  the atrioventricular groove on the left
side of the heart. The first cut is made approximately
1 cm to the left of the LAD and the second 1 cm to
the right of the posterior interventricular sulcus.
These two incisions are then extended to meet at a
point approximating the apex. The same procedure
is repeated for the right side of the heart. This time
the first cut is made 2 cm to the right of the anterior
interventricular sulcus, while the second one is made
along the right marginal artery. In this way, two tri-
angular flaps are created to reveal the underlying
102 Forensic and Clinical Forensic Autopsy

Figure 2.168 Coronary anatomical Dissection. (a) After detaching the aorta from the pulmonary trunk, the forensic
surgeon locates the origin of the left coronary (common trunk). This is very short compared to the right coronary
artery because it divides earlier on into its main branches while still posterior to the pulmonary trunk. These divi-
sions include the left anterior interventricular artery (LAD) and circumflex artery. With a scalpel, the resection is
started following the artery course. The scalpel is placed at the base of the open common trunk. Descending coronary
artery is isolated and cut. The plier holds the right coronary artery (b), which is then sectioned to visualize lumen
patency (c). The right coronary artery passes between the right auricle and the pulmonary trunk, and runs along the
coronary sulcus. It follows the coronary sulcus posteriorly where it then gives rise to the posterior interventricular
artery in 55% of cases. The main coronary arteries (d).

mitral and tricuspid valves on the left and right sides,
respectively. Observation of muscular ridged (trabec-
ulae carneae) is made. Papillary muscles and chordae
tendineae are subsequently identified. The results of
heart valve dissection reveal that the three semilunar
cusps of the aortic valve are similar to, but thicker and
stronger than, the pulmonary valve cusps. Muscular
ridges, called trabeculae carneae, which characterize
the right ventricle’s inner wall, are identified, and a
few of them are ridges, while others bridge a small area
of the ventricular surface. On observation, the three
cusps of the tricuspid valve were identified: septal –
recognized as having a medial orientation adjacent to
the septum – anterior, and posterior. Meanwhile, on
observation of the mitral valve (left atrioventricular
valve), its two cusps are observed. Papillary muscles
are seen to attach to the anterior and posterior cusps
of this valve by means of chordae tendineae in a man-
ner similar to that observed in the right ventricle
(Figure 2.169a–e).
Adult Autopsy 103

Figure 2.169 Heart section following the blood flow: tricuspid valve (a), pulmonary semilunar valve (b), mitral valve
(c), and aortic semilunar valve (d). Figure (e) shows all the cardiac valves. The aortic valve is found between the left
ventricle and the ascending aorta. This consists of three semilunar cusps: the right, left, and posterior semilunar
cusps. Between the semilunar cusps and the wall of the aorta are pocket-like sinuses from which the left and right
coronary arteries originate.

2.16.2.3 Dissection by Chamber

Using a long-handled scalpel, make an incision at the
apex of the heart, and extend the incision past the
acute border of the right ventricle, the obtuse border of
the left ventricle, and the interventricular septum. The
incision must extend through the mitral valve, the tri-
cuspid, and the atria (Figure 2.170). When this type of
incision is used, it is possible to split the heart into two,
allowing for easy comparison of all four chambers of
the heart. The superior half will be opened along both
ventricular outflow paths, following the “flow-down”
flow method.

2.16.2.4 Dissection of the Base of the Heart
Using this method preserves all four valves, and it is
also very helpful in demonstrating the anatomical rela-
tions between the valves themselves, adjacent coronary
arteries, and the atrioventricular conduction system.
This technique is more suitable for hearts with major
valve disease. It is also useful in individuals who have
received prosthetic valves. The right coronary artery,
left main, and left anterior descending coronary arteries
must be examined individually, and should be isolated
Figure 2.170 Four chambers. RA, right atrium; IAS,
interatrial septum; IVS, interventricular septum; AP,
apex; LV, left ventricle.
prior to sectioning the base of the heart (Figure 2.171).
The ventricles are incised so that coronary flow to the
papillary muscles can be traced. One incision allows for
the removal of the atria. It is made through the atrial-free
wall, taking care not to tear the adjacent coronary artery,
which should be supported and held under traction in
104
Figure 2.171 (a and b) Coronaries with stylets placed in traction. The isolation and the use of the stylets are essen-
tial in cases in which the forensic surgeon wants to prepare the heart for resection, according to the method of the
base of the heart.
Figure 2.172 Opening of the “atrial dome.” Also visible
are the infundibulum and valvular flaps, with the tendi-
nous chords and the papillary muscles.
Figure 2.173 Heart base and section in slices from the
apex to the base.
Forensic and Clinical Forensic Autopsy
Figure 2.174 Base of the heart method. The aortic ostio
(with mechanical, valvular prosthesis), the ostio of the
pulmonary, and the two atrial floors are shown.
the left atrium; the ostium of the coronary sinus is held
next to the inferior vena cava, and then incised posteri-
orly, along the external wall of the coronary sinus up to
the ventricular atrium. The incision should extend from
the inferior edge of the interatrial septum as far as the
level of left atrial appendage. Next, extend the incision
below the mitral valve – annulus valve, including the
left atrial wall that lies opposite the ascending aorta. At
the top edge of the interatrial septum, the left atrial inci-
sion should meet the incision on the right. Cut through
the interatrial septum, from the superior to the inferior
edge, and then remove the two atria. A transverse inci-
sion is made of the two great arteries along their sino-
tubular junction, up to the valves. After the ascending
aorta and the pulmonary artery have been removed,
the arterial sinus may be removed as well, using only
forceps. This allows for better vision of the pulmonary
valves. The circumflex artery should not be dissected
until after the first part the dissection has been photo-
graphed (Figures 2.170, 2.172–2.174).
Adult Autopsy 105

2.16.2.4.1 Case Study #15

Torrisi M., Malandrino P., Indorato F.
A 51-year-old man died during a scuba diving. There
was no evidence of injury at external examination
(Figure CS-15.1).Toxicological analyses were negative.
2.16.2.4.1.1 Autopsy
The Baroldi and Fineschi technique was carried out
to examine coronary arteries. A significant atheroscle-
rotic narrowing within the anterior descending coro-
nary artery (Figures CS-15.2 and CS-15.3) and within
right and circumflex coronary arteries was detected.
Transverse heart sections showed whitish areas of the
left-lateral ventricle wall (Figure CS-15.4).

2.16.2.4.1.2 Histological Assessment

Descending coronary artery, right coronary artery,
and circumflex coronary artery samples showed a
significant atherosclerosis (Figures CS-15.5–CS-15.7).
Diffuse patchy fibrosis was detected in left ventricle
samples (Figure  CS-15.8); contraction band necrosis
was found in subendocardial areas (Figure CS-15.9).
106 Forensic and Clinical Forensic Autopsy

Key Points
• Circumstantial data, a complete autopsy, his-
tological assessment, and toxicological exam-
ination are necessary to understand the cause
of death.
• Coronary atherosclerosis is the most common
finding in sudden death in people older than
21 years.
• A careful study of coronary artery lumen must
be performed in all sudden cardiac deaths.

2.16.2.5 Recommended Cardiac Samples

Certain specimens should be taken as a matter of
routine:

1. The major coronary arteries and their main

extramural branches should be sampled. Any
segment where macroscopic lesions are evi-
dent should be removed as well, although they
may need decalcification prior to fixation.
2. Sections of epicardium and myocardium
should be collected in every case.
3. A 2-cm, full-thickness block should be taken
from the wall of each ventricle. Sections
should be taken from the front, side, and back
of each ventricle as well.
4. The anterior and posterior interventricular
septum must also be sampled, as well as any
The cause of death was sudden cardiac arrest due areas where abnormalities are apparent on
to coronary artery disease. visual inspection.
Adult Autopsy
Figure 2.175 Soft palate, tongue, trachea, larynx, and
esophagus after detachment of the cervical vertebral
plane.
5. If a more complete survey is required, both
the inferior and superior portion of each ven-
tricle should be sampled. The remaining tissue
should be completely fixed, then preserved in
hermetically sealed plastic bags for further
possible examinations.
Figure 2.176 (a and b) Larynx–pharynx examination. (c) Three incisions in situ to open the trachea and the main
bronchi along posterior membranous walls.
107
2.16.3 Upper Respiratory Tract
2.16.3.1 Examination of the
Larynx and Pharynx
A single block should include not only the trachea,
but also the larynx, cervical esophagus, the floor of
the mouth, the tongue, the soft palate, and the tonsils
(Figure 2.175). As a rule, the larynx and pharynx are
opened with forceps following the posterior median
line; the sides are stretched outward to study the
mucosa (Figure 2.176). In adults, this operation could
require the disruption of the bony laryngeal cartilage.
If the cartilage is not totally ossified, the larynx may
easily be incised transversely, yielding good specimens
for subsequent histological examination. During dis-
section, look for any alterations of the mucosa and cri-
coarytenoid joint. This joint lies just below the vocal
chords, at both sides of the median posterior line of
the larynx. In cases of suspected strangulation, the
hyoid must be carefully isolated and studied, both
in situ and after its removal to detect possible fractures
and hemorrhage (Figure 2.176).
2.16.4 Trachea and Primary Bronchi
Three separate incisions are required to open the tra-
chea and the main bronchial tubes along their pos-
terior membranous walls, one for each segment of
the trachea and the bronchial tubes (Figure 2.177).
In cases of suspected drowning and aspiration, or
when medical misadventure following bronchoscopy
is a concern, make an in situ anterior incision. If a
tracheal–esophageal fistula is suspected, it is better
seen through an incision made in the anterior midline
or, alternatively, by completely removing the anterior
portion of the trachea.
108 Forensic and Clinical Forensic Autopsy

Figure 2.177 (a–c) Lung resection starting from the hilum. Squeezing of the hilum shows liquid reddish material (a)
and (b). The pulmonary arteries and the bronchial tubes are opened from the hilum toward the distal portion of the
mediastinal pulmonary border or, according to a more complex method, from the resection planes obtained with the
introduction of buttoned forceps inside the vascular–bronchial hilum tree. This last method leads to a resection, so
to say “umbrella-like,” and it is certainly more conservative than the previous one, since it allows for the reconstruc-
tion of the lung with an unharmed hilum region.

2.16.4.1 Case Study #16

Scopetti M., Baldari B., Besi L.
After a licorice candy ingestion, a 7-year-old child
started coughing and wheezing, and immediately
turned cyanotic. His mother called the emergency
services whose resuscitative procedure attempts were
unsuccessful. Recent medical history was positive for
an airway infection. He had been undergoing an anti-
biotic treatment for 5 days prior to death.

2.16.4.1.1 Radiological Examination
A total-body CT scan analysis was performed and
excluded any traumatic injury as well as any foreign
body in the upper airways and the main bronchi.

2.16.4.1.2 Autopsy
Cervical and thoracic organs were dissected with
Gohn’s method (en bloc). Reddish dense material
and white foam were observed inside trachea and
main bronchi; in the right bronchus, such material
was denser (Figures CS-16.1 and CS-16.2). After for-
malin fixation, the cervical and thoracic organ bloc
was examined. Inside a secondary right bronchus was
Adult Autopsy 109

and trachea samples showed the thickening of the

wall and signs of chronic lymphocytic inflamma-
tion (Figures CS-16.7 and CS-16.8). H&E samples
of all organs revealed the presence of lymphocytes.
Immunohistochemical staining of lung samples
showed a strong positive reaction to antitryptase
antibodies as a mastcell-specific marker with signs of
degranulation (Figures CS-16.9 and CS-16.10, black
arrows show the mastcell degranulation; yellow arrows
indicate the tryptase).

identified a black foreign body, hard in consistency,

which measured 0.5 × 0.4 cm (Figures CS-16.3 and
CS-16.4).
2.16.4.1.3 Histological Assessment
Histological examination was performed using H&E.
The immunohistochemical staining method of lung
samples was performed by using antitryptase anti-
bodies as a mastcell-specific marker. H&E-stained
lung samples revealed acute emphysema, endoal-
veolar hemorrhagic edema, as well as thickening of
alveolar septa (Figures CS-16.5 and CS-16.6). Bronchi
110 Forensic and Clinical Forensic Autopsy

The cause of death was attributed to an acute respi-
ratory failure due to a bronchospastic reaction after
foreign body aspiration (licorice) in a child with a
lymphocytic inflammation of the lungs.
2.16.4.2.1 Autopsy
The cadaveric section allowed us to detect an extensive
hemorrhagic infarction of the left – lateral region of
the neck that extended to the ipsilateral deltoid region.
Extensive hemorrhagic infarctions bilaterally affected
the large dorsal and dentate anterior muscles until reach-
ing, below, the insertion of the external oblique muscle;
on the left, this infarction extended to the perimuscular
subscapular tissues. The bisacromial cut was extended to
the left, along the outer edge of the arm and the ulnar
margin of the forearm, until reaching the wrist; here,
we described the presence of an area of hemorrhagic
infarction that extended from the deltoid region, along
the posterior compartment of the arm, to the tricipital
loggia, up to the two-third lower of the forearm, exter-
nal face. The vascular–nervous axis inspected up to the
wrist appeared to be undamaged by traumatic injuries.
The palpation of the muscles allowed us to appreciate a
diminished consistency as from massive wetting of the
same. Therefore, the muscular heads of the biceps and
triceps muscles were dissected so as to appreciate the ana-
tomical integrity of the circle of the circumflex humerus
vessels and the glenohumeral capsule. Finally, after emp-
tying the thoraco-abdominal cavities, it was possible to
appreciate fractures involving the posterior costal arches
of the IV, V, VII, and IX left ribs, as well as the fractures
of the cervico-thoracic vertebrae already highlighted by
the CT examination (Figures CS-17.1–CS-17.4).

Key Points
• Recent medical history evaluation was crucial
in order to assess the pathologic child substrate.
• Foreign body aspiration may trigger the rele-
vant inflammatory responses in children with
respiratory illnesses.
• Upper and lower airways, as well as lung
inflammation, need to be properly detected in
foreign body aspiration-related deaths, espe-
cially in children.
• The antitryptase immunohistochemistry as a
mastcell-specific marker is helpful to identify
lung inflammatory reactions.

2.16.4.2 Case Study #17

Liberto A, Condorelli D, Russo I.
A 75-year-old man was involved in a road accident,
whose signs and symptoms, and whose apparent good
general clinical condition, concealed the presence of
a crush syndrome that, rapidly, induced acute renal
failure and, consequently, a multiple organ failure
­syndrome (MOFS) that led the patient to the death.
Adult Autopsy 111

2.16.4.2.2 Histological Assessment
Histological investigations revealed areas of necro-
sis with contraction bands and interfascial edema of
the heart (Figure CS-17.5), endoalveolar edema and
acute emphysema of the lungs (Figure CS-17.6) as
well as tubular paracellular necrosis of the kidneys
(Figures CS-17.7 and CS-17.8). Furthermore, an immu-
nohistochemical test was carried out on renal samples
for the detection of antimyoglobin antibodies, which
were positive (Figures CS-17.9 and CS-17.10).
112
Key Points
• Crush syndrome is a complication known to
most, but infrequent and, therefore, rarely
suspected in the management of the multi-
trauma patient.
• In such cases, it is crucial to quickly diag-
nose in order to avoid the most feared com-
plications: hypovolemic shock and acute renal
failure.
• The diagnosis of crush syndrome must be
made on the basis of clinical evidence and
data obtained from the laboratory tests.
• The latter should include the search for bio-
humoral alterations induced by rhabdomy-
olysis (myoglobinemia and myoglobinuria,
increased creatinine phosphokinase, hydro-
electrolyte, and metabolic alterations).
2.16.5 Lungs
2.16.5.1 Lung Resection
For this procedure, the classic method was, and still is,
to begin dissection in the hilum with dissection pro-
gressing outward. First, locate the hilar pulmonary
structures, and then observe the macroscopic char-
acteristics (caliber, width, content). The pulmonary
arteries and the bronchi are opened from the hilum,
with the incision extending outward to the distal por-
tion of the mediastinal pulmonary margin. The lungs
are then incised with a series of sagittal cuts made in
parallel to the mediastinal surface. This allows for
the study of multiple transverse sections of both lung
parenchyma and vessels. The limitation of this process
is its destructive nature. If a lesion is found, it may
become difficult to identify its original location.
2.16.5.2 Lateral Lung Resection
With this approach, an incision is made from the apex
to the base of the lungs, with the incision running
Forensic and Clinical Forensic Autopsy
along the major lateral axis of the lungs. When this
approach is used, the hilum is preserved. Using this
method allows the reconstruction of the lung with the
hilum intact (Figure 2.179).
2.16.5.3 Sampling
Tissue samples from pulmonary lacerations, ecchy-
motic areas, and contusions should always be collected.
A thorough basic examination should include the
samples taken from each lobe and the hilum (to study
the vascular–bronchial component of each). In foren-
sic cases, it is always appropriate to mark the site where
the sample was obtained in order to provide accurate
topographic and histopathologic information. Under
no circumstances should sampling of the pleural
serosa be omitted. Rapid fixation will be required if
examination with an electronic microscope is to be
performed.
2.16.5.3.1 Special Procedures for Pulmonary Tissue
Lungs should be fixed in formalin, using a perfu-
sion device that forces preservative fluid through the
lungs. This allows for the collection of well-preserved
samples, making histological examination easier and
accurate.
A somewhat more cautious approach involves the
perforation of one lung, and the dissection of the other,
when it is still “fresh.” This will allow for the collection
and study of samples that can be used for subsequent
microbiologic studies or staining, as in cases of infec-
tion thought to be caused by Pneumocystis carinii. This
method also allows for better evaluation of edema and
pulmonary embolism, all conditions better appreci-
ated when examining an unfixed lung. If a perfusion
machine is not available, the lungs can be inflated with
a 10% formalin solution, injected through the main
bronchus. Nearly 2 L of fluid will be required to inject
an adult lung. Infusion can be performed using a large
bore syringe or, even better, a bottle suspended 30–40
cm above the lungs so that the fluid drains by gravity.
After all the fluid has been infused, the main bronchus
is closed, and the lung is immersed in a formalin bath.
The lungs will swell slightly during the process.
2.16.5.3.1.1 Lung Removal and Preparation Prior to
Wet Fixation With most of the specialty studies per-
formed on isolated lungs, measures must be taken to
preserve the lung intact during the evisceration pro-
cess. We normally induce a pneumothorax through
a small parasternal incision. In many cases, the tho-
racic chest plate can be removed with minimal, if any,
damage to the lungs. To protect the lungs even more,
incise the anterior connections of the diaphragm up
to the chest, so that the hand of an assistant can be
Adult Autopsy
introduced and the lung gently removed at the same
time as the chest plate. The resected rib ends should
be covered with thin, absorbent paper or plastic, as
the bones could tear the pleura or injure the prosec-
tor. Before removing the lungs, connections to the
parietal pleura must be carefully severed. This is par-
ticularly difficult to do when the posterior base of an
inferior lobe is diseased, because adhesions are likely
to be present. If the adhesions are extensive, try to
remove the lungs together with the parietal pleura,
which must be separated from the muscular and bony
regions of the thoracic wall. Any small pleural lacera-
tions that occur during the removal process should be
repaired with a fixative spray. Connection of the lung
to the perfusion apparatus is much easier if the extra
pulmonary, bronchoarterial rami are left connected to
the lung. Note that the bronchial arteries are typically
enlarged and tortuous in chronic pulmonary throm-
boembolic hypertension. It is also possible to leave the
lungs attached to the trachea to be able to examine
them both at the same time. Pulmonary angiography
can also be performed by leaving the lungs connected
to the main pulmonary artery. Both procedures may
be executed in situ. Prior to beginning the perfusion,
aspirate any mucous or pus from the bronchial tubes.
If all of the obstructing materials cannot be cleared
completely, the lungs should be perfused through the
pulmonary vessels.
Fixation time: Normally 3 days is required to
completely perfuse and fix the lungs, but hardened or
fibrous lungs could require more time, and filling of
the bronchial tubes can be delayed by the expansion
caused by fixation. If this is the case, portions of the
damaged lungs will not inflate.
Pressure fixation: If a pressure fixation machine
is available, the normal pressure range of 15–95 cm of
H2O may be too high for routine purposes, and alter-
native methods should be considered. This same device
can also be used to perfuse livers or other organs, such
as hearts or kidneys, at autopsy and for surgical pathol-
ogy. With pressure fixation, the fixation fluid enters
through valves that have been connected to the main
bronchus or to the trachea. An electric pump allows
the fixative to circulate; a modified Kaiserling solution
is the preferred fixative, but formalin can also be used.
If angiography is to be performed, introduce a 10%
formalin solution into the lungs first. After three days
of pressure perfusion, the lungs are incised with a very
long knife.
Dry lung preservation: Many obsolete tech-
niques that allow perfusion fixation without pres-
sure have been attempted; fixation with formaldehyde
gas or with formalin vapor has been used with the
113
expectation that they will help “dry the lungs.” After
drying, the macroscopic characteristics of the lungs
are well preserved, but tissue samples for histological
study are generally unsatisfactory.
2.16.5.3.1.2 Resection of Fixed Lungs A special knife
and a resection table should be used for the resection
of fixed lungs. Resection tables are made of cork set on
a metallic support, where drained formalin solution
is collected. The knife should be 78 cm long to allow
cuts through the entire lung with a single movement.
This ensures that the cut surface will be intact and free
of artifacts. The same type of knife is also useful for
sectioning the liver and spleen. The lung is usually cut
on a frontal or sagittal plane, in thin slices of about
1.5 cm thick. For incisions along the frontal plane,
the lung is positioned in such a way that the hilum is
turned upward, allowing the first incision to be placed
adjacent to the hilum. If the resection is located along
the axis of a bronchus, guide the knife with previously
inserted probes. For the preparation of very thin but
large sections, gel infiltrations are required.
Barium sulfate saturation: This method of
preparation opacifies the pulmonary tissue, making
abnormalities of the parenchyma, like emphysema,
easier to see. After saturation with barium sulfate, the
lung is sectioned, immerged in water, and may be pho-
tographed, studied with a naked eye, or examined by
dissection microscopy.
The “listening” method: Place a section of lung,
already fixed, in a barium nitrate solution (75 g of
barium nitrate dissolved in 1 L of warm water). The
pulmonary tissue is slowly pressed so the solution can
penetrate the tissue. After approximately 1 minute, the
section is removed from the solution and excess fluid
squeezed out. Then, the tissue is immersed in a solu-
tion containing 100 g of sodium sulfate dissolved in
1 L of warm water. The pulmonary tissue is squeezed
again, withdrawn from the solution, drained, and
placed in a bath of barium nitrate. Repeat this oper-
ation as many times as needed until the air bubbles
have been eliminated from the tissue, and the barium
sulfate precipitate has made the pulmonary tissue
opaque with a white grayish color.
Storage: “Fresh” lungs may be kept refrigerated
fora few days provided the temperature is kept below
zero. Fresh lungs may remain frozen for months, but
better histological results are obtained if the samples
are collected earlier rather than later. Lungs that have
already been fixed are best cut and stored in plastic
bags, warmed, and then sealed in a 5%–20% formalin
solution. Several sections may be stacked on the top of
one another without damaging the pulmonary tissue.
114
Paper mounting: For showing demonstrations,
cut 2-cm-thick sections of formalin-fixed lung, wash
them, and then emerge them in a gel mixture contain-
ing a disinfectant. After the gel mixture has penetrated
the tissue, the sections to be examined are frozen and
cut into 400-mm-thick sections, then refixed again in
the gel solution, and finally mounted on paper. This
same technique may be applied to other organs, like
the liver (Figure 2.177).
2.16.6 Liver
After positioning the organ convex face down, and
with the diaphragmatic convex surface turned
upward, it will be possible to decide if some cuts at full
width are required. If so, cut coronal sections, each of
3–4 cm thickness (Figure 2.178).
2.16.7 Spleen
Place the spleen with its anterior facing downward,
and make a series of parallel coronal sections.
Figure 2.178 Liver. Full-width resections performed by resections parallel to the support plane in a front-to-back
direction.
Figure 2.179 (a and b) Spleen. Perform a transverse resection with a single cut.
Forensic and Clinical Forensic Autopsy
2.16.7.1 Sample Collection
Obvious lesions are always sampled, but it is appro-
priate to collect some samples, even from tissue that
appears normal. For a standard examination, three
samples are more than sufficient (Figure 2.179).
2.16.8 The Kidneys
Place the kidneys in their anatomical position, make
a small incision in the capsule, and then strip off the
capsule with toothed forceps. Make a transverse inci-
sion through the convex border of the organ, from the
superior pole to the inferior pole, ending at the hilum.
This will divide the kidney into two equal halves,
allowing an easy distinction between the cortical and
the medullar portion of the organ (Figure 2.180).
2.16.8.1 Sample Collection
Samples must include the capsule, cortex, and medul-
lary portions of the kidney. It is always a good idea
to take samples from the hilum, although it is not
mandatory.
Adult Autopsy
Figure 2.180 (a–c) After placing the kidneys in the anatomical position, perform a transverse resection with a single
cut, on the convex border of the organ, from the superior pole to the inferior pole.
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Pediatric and Fetal Autopsies
STEFANO D’ERRICO
University of Trieste
ANGELO MONTANA
University of Catania
GIULIO DI MIZIO
University “Magna Graecia” of Catanzaro
MONICA SALERNO
University of Catania
Contents
3.1 Introduction
3.2 The External Examination
3.3 Removal of the Brain
3.4 Access to the Neck, Chest, and Abdomen
3.5 Evisceration
3.6 Gross Examination of Fetal Annexes
3.6.1 Placenta and Umbilical Cord
3.7 Histological Sections
3.7.1 Case Study #1
3.7.2 Case Study #2
3.7.3 Case Study #3
Bibliography
3.1 Introduction
Fetal death is defined as death prior to the complete
extraction or expulsion from its mother of a product of
conception irrespective of the duration of pregnancy.
It is divided further as early (<22 weeks of gestational
age), intermediate (22–27 weeks of gestational age),
and late (≥28 weeks of gestational age). Early deaths
are designated as abortions, whereas intermediate and
late deaths are known as stillbirths. In all situations,
postmortem may provide information relevant to the
management of subsequent pregnancies.
Postmortem examination of a baby following spon-
taneous or missed miscarriage in the second trimester
may provide a complete or partial explanation of the
pregnancy loss. However, following the termination of
pregnancy for fetal abnormality, a postmortem exami-
nation may provide a specific diagnosis. In perinatal
medicine, despite the improvements in prenatal diag-
nosis, autopsy remains important in the confirmation
and further delineation of prenatal diagnosis. Neonatal
autopsy has a particular valuable role in the counseling
of the families after the loss of an infant as it can help
117
3
117
118
124
126
128
134
135
145
145
147
149
151
the grieving process, improve parental understanding,
and alleviate concerns over prenatal events.
Congenital anomalies, infection, nonimmune
hydrops, and malnutrition account for 25%–40% of all
stillbirths. Neural tube defects, hydrops, and congeni-
tal heart disease were the most common congenital
anomalies. Placenta, membrane, and cord abnormali-
ties constitute about 25%–35% of the causes of fetal
deaths. Infections are not only much more common in
premature deliveries, but also indeed probably a main
reason for most premature births before 30 weeks of
gestation. In all situations, postmortem examination
may provide the information relevant to the manage-
ment of subsequent pregnancies.
Pediatric autopsies are the most useful investi-
gations to establish the circumstances and causes of
death and to exclude child abuse. Pediatric hospital
autopsies provide pieces of information that signifi-
cantly add to the clinical diagnosis or change it: They
are a valuable tool of clinical care and may facilitate
learning from adverse events.
It has been found that fetal autopsies performed by
an experienced pathologist in collaboration with clinical
118
specialists could identify the cause of death in 94% cases;
anyway, lower diagnostic rates have been also reported.
During the last decade, many guidelines have
been proposed from national and international scien-
tific societies to assist the pathologist in undertaking
autopsies in cases of second-trimester (late) miscar-
riage, second-trimester intrauterine death (missed
miscarriage), and termination of pregnancy for fetal
abnormality. All of these provided practical technical
advices on performing the autopsy, guidance on the
use of additional investigations, and minimum stan-
dards for the content of the autopsy report.
The autopsy of the fetus, newborn, or infant requires
an approach, which is different from the adults and must
be provided from experienced and trained pathologists,
and should follow the accepted protocols, finally.
Adequate clinical information is essential for any
postmortem examination. This is because having
the appropriate information helps the pathologist to
decide the best approach to perform the examination.
Having the mother’s (and baby’s) clinical notes would
be the ideal situation.
Information about the mother’s past medical his-
tory, including any conditions that may affect pregnancy
outcome, for example, chronic hypertension and diabe-
tes, must be collected as well as history of previous preg-
nancies and their outcome (Figure 3.1). The gestation
based on the mother’s last menstrual period, as well as
any revisions using ultrasound scans, should be stated.
Any pregnancy complications such as preeclampsia,
gestational diabetes, pyrexia, and antepartum hemor-
rhage should be included. Investigations undertaken
during pregnancy and their results are essential. If
the mother’s clinical notes are not available, a copy of
any abnormal scan reports is essential, especially if the
pregnancy had been terminated due to fetal anomalies.
Information such as time and date of delivery, mode of
delivery, and baby’s birth weight is also essential. For
live births, the condition of the baby at birth, postnatal
progress, including any medical procedures, and clini-
cal cause of death should be included (Figure 3.2).
Photographic collection of autopsy is strongly
recommended in all cases, to document external and
internal abnormalities. Whole-body anterior and pos-
terior photographs must be always captured before
starting autopsy. Digital photography and secure
storage are preferred. Images of dysmorphic features
and any other abnormalities detected on external and
internal examinations are mandatory and are invalu-
able for later study or consultation (Figure 3.3).
Before autopsy, a whole-body X-ray represents the
commonest modality to assess gestational assessment
and malformations, followed by computed tomography
Forensic and Clinical Forensic Autopsy
(CT) scan. CT scan should be considered mandatory in
all cases of suspected skeletal dysplasia (Figure 3.4).
Other imaging modalities may be appropriate in
some circumstances and if available. For example,
MRI can give useful information, particularly on CNS
malformations; however, it is poor in detecting infec-
tion and in cases of significant maceration.
The autopsy requires the availability of appropri-
ately sized instruments for small and very small fetuses;
balances for weighing babies and organs (to at least
nearest 0.1 g); and charts of typical values (baby weight
and measurements, organ weights, and placenta weight).
At the end of autopsy, a complete report should
include all the following sections: (i) demographic and
identification data, (ii) details of autopsy consent and
limitations, (iii) body weight and appropriateness for
gestation, (iv) body measurements, (v) a list of main
findings, (vi) clinicopathological summary, (vii) sum-
mary of clinical history, (viii) systematic description
of external and internal findings and placental exami-
nation, (ix) organ weights with relevant reference val-
ues and ratios, (x) details of ancillary tests taken (and
results – final report), (xi) histological summary, and
(xii) A list of histologically treated tissue blocks.
3.2 The External Examination
External examination is essential and must be most
accurate as possible. It’s a standard component, recom-
mended in all cases, and essential to document external
and internal abnormalities. In cases of stillbirth, the
degree of skin slippage, as well as the laxity of the joints,
and the presence of overlapping cranial bones may
give some information about the time of death in utero
(Figures 5.5). The appearance and color of the skin may
provide clues about the time of death (maceration) and
maturity (bright pink in the very preterm baby, and
wrinkled and flaking in postmaturity) (Figure 5.6).
Precise measurements, such as the crown–rump,
the crown–heel, and the rump–heel length, are
absolutely required and must be measured with a
centimeter ruler. The head, chest, and abdominal cir-
cumferences are measured with a flexible measuring
tape (calibrated in centimeters). The thorax circumfer-
ence is measured at the level of the nipples, while the
abdominal circumference is measured at the level of
the umbilicus (Table 3.1) (Figures 3.5–3.10).
The external examination of the fetus or newborn
should focus on the search for malformations. Some
of these may be easy to observe, as in the case of a cleft
palate, congenital coronal atresia or stenosis, or anal
and vaginal atresia (Figures 3.11 and 3.12).
Pediatric and Fetal Autopsies 119

Figure 3.1 Clinical reports for fetal/perinatal examination.

120
Figure 3.2 Clinical reports for fetal/perinatal examination.
The shape of the head abnormalities related to
molding, trauma, soft tissue edema, and hemorrhages
is recorded. Facial measurements are helpful in deter-
mining hypotelorism and hypertelorism. The external
examination needs a detailed description of muscle
bulk, local/generalized edema, pallor, and dysmorphic
features.
In eyes, the color of the sclera, iris, and conjunc-
tiva should be recorded (Figure 3.13). Examination
Forensic and Clinical Forensic Autopsy
of the oral cavity begins with digital palpation of the
palate, followed by direct observation of the gums
(Figures 3.14 and 3.15).
Any injuries related to delivery, like abdominal
wall defects, should be carefully recorded, even in
miscarriages and stillbirths, and these should be dif-
ferentiated from true malformations.
The external genitalia are inspected for male
or female phenotype and normal development for
Pediatric and Fetal Autopsies 121

Figure 3.3 Photographic collection of second-trimester products of conceptions.

Figure 3.4 Total-body CT scan study in newborn sudden death. Examination of musculoskeletal apparatus. Aspects
of consolidation of the left pulmonary parenchyma, confirmed microscopically.
122
Figure 3.5 Head circumference.
Figure 3.6 Chest circumference.
Figure 3.7 Abdominal circumference.
gestational age. In a male infant, the scrotal sac should
be palpated for the presence of the testes. In females,
the vaginal and urethral openings are identified and
the vagina is probed. The anus is identified and probed.
In addition, the cases of possible birth trauma
in intrapartum or neonatal deaths are likely to be
investigated.
Forensic and Clinical Forensic Autopsy
Figure 3.8 Crown–heel length.
Figure 3.9 Femur length.
Figure 3.10 Foot length.
In cases of neonatal death, sites of venepuncture,
drains, catheters, and surgical incisions should be
noted. All drainage tubes, central lines, and umbili-
cal arterial and venous catheters should be left in situ
until the position of the tip is checked internally.
The attached umbilical cord can also provide
useful information, especially if the placenta is not
Pediatric and Fetal Autopsies
Figure 3.11 Fetal maceration characterized by skin dis-
coloration and slippage with a darkened umbilical cord
stump typical of an in utero death (stillbirth).
Figure 3.12 Prone position.
Figure 3.13 Eye examination. The color of the sclera,
iris, and conjunctiva should be recorded.
submitted for examination. The umbilical cord should
be measured (length and diameter) and the number of
vessels recorded. Abnormalities such as hypercoiling
and strictures at the fetal end should be assessed as
these might give important clues in miscarriages and
stillbirths.
123
Figure 3.14 Inspection of oral cavity, lips, gums, and
mouth roof.
Figure 3.15 Inspection of oral cavity, lips, gums, and
mouth roof.
The face, ears, and hands may display the char-
acteristic signs, for instance, in Down syndrome
and gargoylism. Always suspect renal agenesis when
there is anhydramnios (from 17 weeks) and an empty
fetal bladder (from as early as 14 weeks). The corpse
is always measured and weighed first. The fontanels
must be measured, as should the landmarks of the face.
The interpupillary distance, the distance between the
inner and outer canthal folds, the interalar distance,
the length of the lips, the upper and lower lip thick-
ness, and the intercommisural distance should all be
measured and compared with what is considered nor-
mal for an infant at the same stage of development.
In addition, the color of the sclera, iris, and conjunc-
tiva should also be recorded, as should the configu-
ration of the ear. Precise measurements, such as the
crown–rump, the crown–heel, and the rump–heel
length, are absolutely required and must be taken with
a centimeter ruler. The head, chest, and abdominal
124 Forensic and Clinical Forensic Autopsy

circumferences are measured with a flexible measur- 3.3 Removal of the Brain
ing tape (calibrated in centimeters). The thorax cir-
cumference is measured at the level of the nipples, An intermastoid incision is performed and the scalp is
while the abdominal circumference is measured at the retracted, reflecting anteriorly over the eyes and poste-
level of the umbilicus (Table 3.1). riorly in a caudal direction. Galea capitis as well as tem-
Skin color helps in assessing/confirming gesta- poral muscles must be carefully described (Figure 3.16).
tion of the baby, as very preterm babies have bright Once the galea capitis has been retracted forward
pink skin, while post-term babies can have dry, wrin- and backward to expose the skull, the fontanelles may
kled skin. Pale skin can indicate fetal anemia, and in be measured. In infant and fetuses, when birth trauma
near-term or term babies, it raises the possibility of is suspected, it could be important to preserve the
feto-maternal hemorrhage. Other features that can superior sagittal sinus. In this case, a scalpel is used
be assessed include bruising, petechial hemorrhages, to incise the dura at the lateral angles of the anterior
edema, and jaundice in neonatal deaths. In addition, fontanelle; the two small incisions allow access for a
the color of the sclera, iris, and conjunctiva should pair of heavy-duty scissors to cut through bone par-
also be recorded. allel to and approximately 1 cm lateral on both sides
In cases of stillbirth, the degree of skin slippage, of the midline, preserving the superior sagittal sinus.
as well as the laxity of the joints, and the presence of The midline bone and sinus can be removed only after
overlapping cranial bones may give some information a careful inspection of hemispheres, falx cerebri, and
about the time of death in utero (Table 3.2). tentorium cerebelli through opening the large bone
Table 3.1 List of Anatomical Fetal Measurements
Anatomical Fetal Measurements
• Inner canthus
• Outer canthus
• Interpupillary distance
• Philtrum length
• Crown–heel length
• Crown–rump length
• Femur length
• Foot length
• Head circumference (measured above the eyebrows and ears, and around the back of the
head)
• Biparietal diameter
• Chest circumference (nipples)
• Abdominal circumference (umbilical)
• Weight

Table 3.2 External Features of Maceration and Approximate Timing of Intrauterine Fetal Death.
Timing Gross Skin Findings
6 hours Desquamation of patches >1 cm; brown or red discoloration of umbilical
stump
12 hours Desquamation on face, back, or abdomen
18 hours Desquamation of 25% of body, or two or more body regions
24 hours Brown or tan skin discoloration on abdomen. Moderate desquamation.
36 hours Any cranial compression
48 hour Desquamation of >50% of body
72 hours Desquamation of 75% of body
96 hours Overlapping cranial sutures (4–5 days)
1 week Widely open mouth
2 weeks Mummification (dehydration, compression, tan color)
Data taken from Genest DR, Williams MA, Greene MF. Estimating the time of death in stillborn fetuses: I Histologic
evaluation of fetal organs: An autopsy study of 150 stillborns. Obstet Gynecol 1992;80:575; Genest DR. Estimating
the time of death in stillborn fetuses: II Histologic evaluation of the placenta: A study of 71 stillborns. Obstet Gyncol
1992;80:585; Genest DR. Estimating the time of death in stillborn fetuses: III External fetuses examination: A study
of 86 stillborns. Obstet Gynecol 1992; 80:593.
Pediatric and Fetal Autopsies 125

Figure 3.16 Bitemporal incision passing near the vertex. The scalp is incised down to the bone and the skin and
subcutaneous tissues are peeled back below the occipital protuberance posteriorly and to the level of the forehead
anteriorly by a combination of sharp and blunt dissection. In detail, diffuse hemorrhagic infiltration of the galea
capitis and temporal muscles due to partum-related trauma.

flaps. In older children, removal of the brain is per-
formed as described for adults. In younger children,
infants, and fetus, prior to fusion of the sutures, it’s
possible to perform the skull incision along the periph-
ery of the sutures. This cut produces two frontal and
two parietal bony flaps that are attached to the skull on
each side. Then, manually, spread the four segments
that have been created to facilitate the removal of the
brain. The bone plates of the skull can be separated by
sharp dissection and carefully retracted in a butterfly
manner (Figure 3.17).
The brain should be inspected in situ, opening
the lateral ventricles (Figure 3.18). The tentorium can
be cut with a scalpel or scissors around its periphery
without damaging the cerebellum beneath it. The cer-
vical spinal cord can be transected transversely with
a sharp scalpel blade as low into the foramen mag-
num as possible. The dura is then cut as close to the
base of the skull. This method has the advantage of
protecting the surface of the infant brain from dam-
age during its removal. The tentorium is transected
in this position by separating the parieto-occipital
lobes. After the tentorium is sectioned, the body is
suspended upside down by the assistant, while the
brain is supported during the movement by the hand
of the forensic pathologist. The brain is cut away
from the base of the skull in this upside-down posi-
tion, which minimizes the movement of the brain
and damage to its surfaces and parenchyma. After
removal, brain must be measured, weighed, and then
fixed in 10% buffered formalin. After adequate fixa-
tion, the brain is inspected and cut finally (Figures
3.19 and 3.20).
Gross photographs should be taken if any abnor-
malities are identified on the macroscopic examina-
tion. The brain should be cut into coronal sections
approximately 1 cm thick using a long sharp knife. The
slices should be made at 1-cm intervals in firm brains.
Soft, friable brains should be cut at larger intervals to
preserve the anatomy.
Once the brain has been cut into sections, col-
lect multiple samples for histological examination
(mid-frontal gyrus, mild corpus callosum, basal gan-
glia, parietal cortex, splenium, thalamus, caudate,
126
Figure 3.17 Brain removal in infant and fetuses. Before skull ossification and suture closure are complete, the fon-
tanelles can be separated, allowing access to the anterior and middle cranial fossae. Full reflection of the flaps can
maximize the opening and makes brain removal easier.
Figure 3.18 Opening in situ of lateral ventricles.
hippocampi, etc.). After removing the brain, the dura
mater should be removed and the skull base observed
(Figure 3.21).
The removal of the fetal and neonatal whole spinal
cord is performed in the same way of adults.
3.4 Access to the Neck, Chest,
and Abdomen
With the shoulders elevated by a towel roll and hyper-
extended neck, the initial incision is performed as
Forensic and Clinical Forensic Autopsy
described in the same way as in adults, through a
calyx-shaped incision. Then, the section is performed
by single anatomical planes. Sternocleidomastoid
muscles have to be isolated one by one, bilaterally,
to visualize the vascular–nervous tracts. Then, the
cervical, thorax, and abdominal areas are exposed
(Figures 3.22 and 3.23).
Sternocleidomastoid muscles have to be isolated
one by one, bilaterally, to visualize the vascular–
nervous tracts (Figures 3.24–3.27).
After the dissection of neck muscles, inspection
of thyroid gland must be performed, taking care to
describe anatomical relationship with nervous and
vascular structures, and finally removed for measur-
ing, weighing, and sampling (Figure 3.28).
The large veins and arteries of the neck should be
carefully dissected and identified (Figure 3.29).
Anatomical dissection by the planes of thoracic
and abdominal walls is preferred (Figure 3.30).
Pectoralis major is carefully removed with scal-
pel dissecting from pectoralis minor, which will be
removed after a detailed inspection (Figures 3.31 and
3.32). Hemorrhagic infiltration of muscles of the tho-
racic wall must be noted and photographed.
When pectoralis minor is removed, the inspection
of axilla could be useful to exclude or confirm lymph-
adenopathies (Figure 3.33).
Pediatric and Fetal Autopsies
Figure 3.19 (a-b)At term neonates brain, examination of a fixed and a fresh brain. (c-d). Fetus brain in a miscarriage
at 22 weeks of gestation.
Finally, when the anterior serratus is removed, the
ribs are counted on both sides and analyzed for abnor-
malities (Figure 3.34).
The chest plate is removed by separating the ster-
noclavicular joint, bilaterally, and cutting rib cartilage
at the costochondral junctions through an upside-
down V-shaped incision, to provide a wide opening
(Figure 3.35).
The chest plate is examined through transillumi-
nation to visualize ossification centers of the manu-
brium and the body of sternum (Figure 3.36).
Fluid contents of the pleural cavities should be
measured or, at least, estimated as accurately as pos-
sible, and collected (Figure 3.37).
127
Reflecting the lung completely out of the hemitho-
rax let in situ inspection of lungs and the thoracic por-
tion of aorta which courses along the left side of the
vertebral column (Figures 3.37–3.39).
Then, before evisceration, the thymus should be
carefully dissected off the mediastinum and weighed
(Figure 3.40).
After opening the chest, the anatomical relation-
ships can be studied in situ. The first inspection of the
heart and lungs should be performed in situ. A nick is
made into the pericardium: The cut extends along the
lateral side of the right ventricle till the apex, through
an upside-down Y-shaped opening of pericardium
(Figure 3.41).
128
Figure 3.20 Fixed brain cut into coronal section.
Figure 3.21 Two frontal and two parietal bony flaps
allow us to examine the skull base.
Figure 3.22 Calyx-shaped incision and opening by sin-
gle planes.
Forensic and Clinical Forensic Autopsy
By retracting the apex of the heart toward the
right, it will be possible to examine the connec-
tions of the pulmonary veins to the left lung and the
left atria. Retracting the heart to the left, the right
pulmonary veins can be observed in the opening
between the superior vena cava and the heart. The
great vessels must be observed, in particular for
arteries branching from the aortic arch and from the
ductus arteriosus. Aortic arch and descending aorta
could be easily observable, moving the left lung
outside the pleural cavity. The inferior vena cava is
present in the middle of the inferior (diaphragmatic)
surface (Figure 3.42).
Layer-by-layer dissection of abdominal wall is
preferred. Rectal muscles need to be removed with
care to save parietal peritoneum (Figure 3.43).
Parietal peritoneum is opened along the mid-
line by the side of the umbilical vein, finger inserted
under the umbilicus and the umbilical arteries, and
the urachus and the urinary bladder palpated. The
course of the umbilical vein and the umbilical arteries
is observed (Figure 3.44).
The contents of abdominal cavity must be care-
fully described and collected. The positions of
the abdominal organs should be inspected in situ
(Figure 3.45). The color, size, and relationships of the
organs are noted. In fetuses and young infants, the
liver is relatively large, extending well across the mid-
line (Figure 3.46).
The mesenteric attachments are examined, and
the position of the appendix is noted. In a female, the
uterus, fallopian tubes, and ovaries are identified. In
a male, the testes are located and may be in the abdo-
men, the inguinal canal, or the scrotal sac.
3.5 Evisceration
All evisceration techniques allow an adequate visu-
alization of malformations, but the Letulle method
(removal of entire organ block, en masse) seems to be
the most suitable one in pediatric autopsies. It allows
a total sight of the anatomical relations of the organs,
and a careful and detailed analysis. The anterior and
posterior aspects of the block are examined (Figures
3.47–3.49).
A detailed macroscopic examination is generally
performed after the fixation of Letulle’s block in 10%
buffered formalin (Figures 3.50 and 3.51).
Whether fixed or fresh, the upper airways are dis-
sected while still in continuity with the heart–lung
block, while esophagus must be left connected with
Pediatric and Fetal Autopsies 129

Figure 3.23 Fetuses (second trimester) and newborn. Standard calyx-shaped incision. The skin and subcutaneous
tissues are reflected off of the thorax and abdomen.

Figure 3.24 Neck skin flap turnover, performed until Figure 3.26 Isolation of sternocleidomastoid muscle
the lower margin of the jaw. Exposure of the anterior part and visualization of vascular–nervous tract.
of neck and thorax. Inspection of the platysma muscle.

Figure 3.25 Isolation of sternocleidomastoid muscle

and visualization of vascular–nervous tract. Figure 3.27 Sternocleidomastoid muscles.
130 Forensic and Clinical Forensic Autopsy

Figure 3.28 Isolation of the sternocleidomastoid muscle.

Figure 3.31 Pectoralis major and minor removal.

Figure 3.29 Visualization of vascular–nervous tract.

Figure 3.32 Pectoralis major and minor removal.

Figure 3.33 Axilla inspection.

digestive apparatus. Fauces and laryngotracheal adi-
Figure 3.30 The thorax–abdominal area performed by tus had to be necessarily explored, and then larynx
opening single planes and overturning of skin obtained and trachea are opened posteriorly after dissected
by peritoneum in situ. from esophagus (Figures 3.52–3.54).
Pediatric and Fetal Autopsies 131

Figure 3.34 Chest and ribs inspection.

Figure 3.37 Inspection of left pleural cavity, reflecting
the lung completely out of the hemithorax.

Figure 3.35 Removal of chondrosternal layer, and Figure 3.38 Inspection of right pleural cavity, reflecting
inspection of thoracic cavities and diaphragm. the lung completely out of the hemithorax.

Figure 3.39 Inspection of pleural cavities. In situ exam-

ination of the lungs showed subpleural hemorrhagic
Figure 3.36 Inspection of chest plate. petechiae.
132
Figure 3.40 Dissection of thymus. The thymus should
be carefully dissected off the pericardium elevating it off
the mediastinum, cut against the thymus, and let the
pericardial sac fall back into the thorax. This approach
minimizes the risk of cutting the brachiocephalic vein
just behind the thymus (black arrow).
After a detailed inspection, the thoracic block
must be dissected from the abdominal block with
the thoracic and abdominal aorta still in continu-
ity with the heart–lung block. After that, the rela-
tionship of the great arteries is confirmed (Figures
3.55–3.57).
Figure 3.42 Upside-down Y-shaped opening of pericardium.
Forensic and Clinical Forensic Autopsy
Figure 3.41 Upside-down Y-shaped opening of
pericardium.
The heart could be opened still connected to the
block or disconnected while in continuity with tho-
racic and abdominal aorta (Figure 3.58).
The heart is opened along the lines of normal blood
flow. The right atrium is opened by a long-axis incision
passing through the course of inferior and superior
venae cavae. This opening allows the inspection of the
ostium of the coronary sinus and the oval fossa as well
as the tricuspid valve. Using the probe, the connection
of the atrium and the right-sided ventricle is checked.
The ventricle should be opened by an incision pass-
ing through the atrioventricular junction and into
the ventricle along the inferior aspect, parallel to the
interventricular groove to the apex. After turning the
Pediatric and Fetal Autopsies
Figure 3.43 Rectum muscle isolation using “butterfly”
technique.
specimen back to the anterior aspect, the right ventri-
cle is probed to check if the pulmonary valve is patent.
The outflow tract is opened by continuing the same
incision into the main pulmonary artery. The arterial
duct is also opened completely and patency checked.
Back on the inferior aspect of the heart, the left
atrium should be entered through a separate incision
showing the connection of the pulmonary veins with
the left atrial cavity and exposing the mitral orifice.
After the orifice is probed, the incision should be
made through the valve and the left ventricle to the
Figure 3.44 Dissection and inspection of umbilical veins and umbilical arteries.
133
apex again parallel to the ventricular septum. On
the anterior aspect, the left ventricular outflow tract
should be opened by continuing the incision along the
septum toward the anterior aspect of the ascending
aorta through the isthmus and into the descending
aorta (Figure 3.59).
The lungs must be weighed and measured before
sectioning (Figure 3.60). One section of each lobe is
routinely taken for histological examination with
additional sections as needed.
The esophagus is dissected while in continuity
with abdominal organs (Figure 3.61).
Before one-by-one evisceration of abdominal
organs, exploration of duodenal lumen could be neces-
sary to investigate the functionality of duodenal major
papilla and the regularity of outflow of the common
bile duct and pancreatic duct (Figures 3.62 and 3.63).
Otherwise, the pathologist proceeds to the
exploration of esophagus, gastric and duodenal
lumen, describing and measuring its contents (Figures
3.64 and 3.65).
Integrity of the lower digestive tract should be pre-
served as in figure, and then, the lumen fully explored
until rectum (Figure 3.66). Overall length of the small
and large intestine must be noted as well as the pres-
ence or absence of meconium in the lumen.
Liver and spleen must be weighed, measured, and
then carefully described; both organs should be cut in
half along their axis plan parallel to their inferior sur-
faces, thereby preserving the major vessel (in the liver)
and the hilum (in the spleen) (Figures 3.67 and 3.68).
The vessels on the undersurface of the liver should be
134
Figure 3.45 Inspection of abdominal organs in situ.
Figure 3.46 Liver examination.
Figure 3.47 The Letulle method.
opened in the fetus and neonate. A section of liver and
spleen must be sampled for histological analysis. The
pancreas should be cut in half longitudinally and then
one sample collected for histological analysis.
Forensic and Clinical Forensic Autopsy
Figure 3.48 Letulle’s block, front side.
Bowels are opened, and their contents and status
of the mucosa are noted. The mesenteric lymph nodes
are inspected and sectioned. The liver is examined
next. The portal structures are examined by expos-
ing the portal vein and the hepatic artery posteriorly.
Record the small and large intestine length, and the
presence or absence of meconium in its portions.
The kidneys can be dissected away from the block,
taking care to preserve the ureters. The first rule in exam-
ining the kidneys at autopsy is not to strip the capsule
but to clear away the peritoneal fat and inspect the sur-
face (Figures 3.69 and 3.70). Sections of kidneys should
include cortex, medulla, and collecting system. Ureters
should be opened or at least probed to document patency.
Removal of female internal genitalia must be per-
formed in one block (uterus and ovaries) (Figure 3.71).
Dissection of testis needs to be provided with sper-
matic funicle (Figure 3.72).
Weight and measurement of all organs need to
be compared with the reference values for a similar
developmental stage (see Appendix).
The forensic pathologist should record the weights
of the organs that can be reasonably isolated; later,
these data are compared with the reference values for
a similar developmental stage.
3.6 Gross Examination of Fetal Annexes
The examination of fetal annexes is an essential part
of the autopsy in cases of fetal or perinatal death. It is
important, before gross examination, to: (i) verify the
Pediatric and Fetal Autopsies 135

Figure 3.49 Complete block following evisceration by the Letulle method. Anterior and posterior aspects.

Figure 3.50 A 16-week-old fetus. Letulle’s block after fixation.

assessment of gestational age at death and the modal- 3.6.1 Placenta and Umbilical Cord
ity of birth (natural childbirth or c-section); (ii) weigh
Placenta should be possibly examined in the fresh
the whole fresh organ (ideally placentas should arrive
state or at least prior to fixation, and should never be
to the laboratories in a sterile container, and clearly
frozen before the gross examination. Formalin fixa-
labeled); and (iii)weigh the single placenta disk after
tion prior to examination is not optimal as it obscures
removing mem branes (resected when the placental
many macroscopic findings and makes examination
disk is inserted) and the umbilical cord (cut 1 cm from
more difficult. Examination of unfixed placenta prior
the insertion to the placental disk).
136
Figure 3.51 Evisceration by the Letulle method.
Complete block fixed in formalin.
Figure 3.52 Inspection of fauces, laryngotracheal aditus.
Figure 3.53 Dissection of the esophagus from the pars membranacea of the trachea, and then larynx and trachea
are opened posteriorly.
Forensic and Clinical Forensic Autopsy
to fixation affords the opportunity to view lesions in
both fresh and fixed states. If storage is needed, pla-
centas should be stored in tightly sealed containers at
4°C. It is important to remember that during storage,
the placenta loses some weight due to evaporation and
leakage of blood and serum, and after formalin fixa-
tion, the placenta gains approximately 5% in weight.
Gross examination of placenta needs the respect of
a rigid protocol so that nothing will be omitted. Before
starting, a ruler or tape measure, a long sharp knife,
a forceps with teeth, scissors, and a scale are needed.
After removing the placenta from the container
and rinsing briefly in water, before sectioning a com-
plete external examination of the placenta should be
provided. Immersion of the fresh placenta in water will
Pediatric and Fetal Autopsies
Figure 3.54 Visualization of trachea opening up to the
bronchi branch point.
Figure 3.55 Visualization and isolation of the aorta.
Figure 3.56 Careful observation of great vascular
trunks to detect any congenital heart condition.
return the placenta to its original shape. This is partic-
ularly important in case of abnormally shaped placen-
tas and in cases of uterine abnormalities (Table  3.3).
The placenta must be measured in three dimensions
137
Figure 3.57 Careful observation of great vascular
trunks to detect any congenital heart condition.
Figure 3.58 Heart disconnected from the Ghon bloc.
(average diameter at term: 22 cm, thickness 2.5 cm)
and weighed without umbilical cord and membranes
(average weight at term: 470 g).
Description of the placental disk must be com-
plete and should always provide shape (discoid,
irregular, bilobed, succenturiate, etc.), fetal surface
(color and appearance, surface and subchorionic
region (describing the presence of nodules, plaques,
amniotic bands, hemorrhage, cysts, fibrin, masses,
etc.), vessels (looking at vascular thrombosis, hem-
orrhage, or disruption), maternal surface (checking
for completeness, cotyledonary development, blood
clots, calcifications), and the presence of retroplacen-
tal hematoma (adherent blood clot, compression of
villous tissue, underlying infarct) (Figure 3.73).
Membranes must be checked for completeness.
Sufficient membranes should be present to enclose
the fetus. The distance from the placental edge to the
138 Forensic and Clinical Forensic Autopsy

Figure 3.59 Careful analysis of origin of the supra-aortic trunks.

Figure 3.61 Esophagus inspection while kept in conti-

Figure 3.60 Lungs’ section. nuity with abdominal organs.
Pediatric and Fetal Autopsies
Figure 3.62 Letulle’s block: visualization of bile
collection.
Figure 3.63 Letulle’s block: visualization of pancreas
and duodenum.
Figure 3.64 Stomach detail before lumen exploration.
nearest rupture site must be measured. If it is greater
than zero in a vaginally delivered specimen, a pla-
centa previa can be ruled out. Color and appearance
of membrane as well as membrane insertion should
139
Figure 3.65 Stomach detail after lumen exploration.
Figure 3.66 Small and large intestine examination.
Figure 3.67 Spleen inspection and measurements.
be noted. Finally, a membrane roll must be prepared
for histological analysis taking a strip approximately
10 cm wide and rolling the membranes with the rup-
ture site in the center and with the amnion inward
(Figures 3.74 and 3.75).
140 Forensic and Clinical Forensic Autopsy

Figure 3.68 The liver is weighed and measured.

Figure 3.69 Gross examination of kidneys without capsules.

Figure 3.70 Kidneys: transverse incision through the convex border.

Pediatric and Fetal Autopsies 141

Figure 3.71 Gross examination of uterus.

Figure 3.72 Testis isolation and examination.

142 Forensic and Clinical Forensic Autopsy

Figure 3.73 Placenta must be measured and weighed.

Table 3.3 Growth Characteristics of Placenta

and Fetus
Growth Characteristics of Placenta and Fetus
Gestation (week) Placental Weight (g) Fetal Weight (g)
24 195 680
26 220 880
28 280 1,070
30 290 1,330
32 320 1,690
34 370 2,090
36 420 2,500
38 450 2,960
40 480 3,250
42 495 3,410
Adapted from Wigglesworth JS, Singer, DB, Textbook of Fetal
and perinatal pathology, 2nd Edition. Blackwell Scientific Pub.,
Boston, 1991 Figure 3.74 Gross examination of fixed placenta: fetal
surface.

Umbilical cord must be measured in length and excessive or minimal twisting or constriction). The
diameter (average values: 55 cm in length, 1–1.5 cm insertion of the umbilical cord should be always
in diameter), and the presence of spiraling of the noted (velamentous, paracentral, central, eccentric,
umbilical cord must be recorded (right or left twist, marginal). In case of velamentous insertion, the
Pediatric and Fetal Autopsies 143

Figure 3.77 A two vessels’ umbilical cord.

Figure 3.75 Placenta with eccentric insertion of umbil-
ical cord is fixed in formalin. Umbilical vessels are
evident.

distance from the insertion to the placental edge

needs to be recorded as well as the presence of hem-
orrhage or thrombosis of vessels. Description of true
knots should be carefully provided (the descrip-
tion should include the characteristics of the knots:
number, tight or loose, etc.). After inspection, the
umbilical cord can be removed from the placenta at
the insertion site. Two or four umbilical vessels may
occur (Figures 3.76 and 3.77).
After a gross examination of the fixed placenta
(Figure 3.78), a serial sections of the placental tissue
along its major axis at 0.5- to 1-cm intervals must be
performed by a long flat knife, (Figure 3.79) starting
from the central region toward the peripheral region Figure 3.78 Gross examination of fixed placenta:
and taking care that one section crosses through the maternal surface. The maternal face is intact, with no
point of the umbilical cord insertion. Thickness of retroplacental hematomas.
slices as well as color of villous tissue must be noted.
In  case of measurement of villous lesions, location
(fetal versus maternal surface; peripheral versus

Figure 3.79 Fixed placenta: in red, the intervals of

Figure 3.76 Gross examination of the umbilical cord. 1–1.5 cm for section along its major axis.
144 Forensic and Clinical Forensic Autopsy

Figure 3.80 A synoptic report of macroscopic placental examination.

Pediatric and Fetal Autopsies
central), single or multiple, and percentage of placenta
involved must be recorded.
Photographic and written documentation of pla-
cental morphology is useful, particularly when there has
been perinatal death, questionable or unusual findings,
or an untoward outcome of therapeutic intervention,
and may be useful in recording widespread multifocal
processes and in other situations in which a permanent
visual record of lesions is sought (Figure 3.80).
3.7 Histological Sections
As a minimum requirement for pediatric autopsies,
histological sections that should be taken are – at least –
one sample of each pulmonary lobe, multiple samples
of the heart (including the conduction system if pos-
sible), skin, subcutaneous tissue, liver, kidney, thymus,
brain, and diaphragm.
Representative sections of placenta that include
both decidual and fetal surfaces, and sections of cord
and membrane roll are submitted for histological exam-
ination, too. The samples can be obtained from fresh or
fixed placenta. Histological examination should include
two rolls of membranes, at least two sections of umbili-
cal cord, and at least three full-thickness blocks, plus
focal lesions of placental disk. Fixation of routine blocks
in 10% buffered or alcoholic formalin is recommended.
Samples of placenta: The general characteristics of
the internal structure of the placenta are approached
by performing serial sections of the whole organ with
a long flat knife along its major axis, at intervals of
approximately 1.0–1.5 cm, extending from the fetal to
the maternal surface; these sections should be from
the central region, rather than from the margin, which
is often nonrepresentative (Figure 3.81). One section
must cross through the point of umbilical cord inser-
tion. These samples of the villous parenchyma should
be taken to include the full thickness of the placenta,
including fetal and maternal surfaces. The sections of
the villous tissue should be taken away from the mar-
gin of the placenta, as the perfusion is not consistent
throughout the placenta and abnormalities exist in
the peripheral areas of poor perfusion that may not be
reflective of the remainder of the specimen. Sections
of the fetal surface with chorionic vessels should be
included in those sections of villous tissue.
Samples of membranes: Membranes can be sec-
tioned with the rollmop method. They’re wrapped
around a forceps and then cut into disks with scissors,
or wrapped around the cord as a rolling mechanism in
145
Figure 3.81 Serial sections of placenta.
order to prepare a section, which in the center we have
the umbilical cord specimen and around the membranes.
Samples of cord: At least three pieces of the
umbilical cord should be taken for histological sec-
tion, one near the placental end, one closer to the
fetus, and one in the middle. These should be away
from the sites of trauma like that of cord clamping.
Any unusual lesions should also be sampled. Sites
of in utero cord blood sampling identified should be
examined.
Additional sections should be always taken in case
of abnormalities or pathological findings.
3.7.1 Case Study #1
Liberto A, Di Nunno N, De Palma A.
A 38-day-old infant was found dead in the crib. The
body displayed no external injuries or other abnor-
malities. The radiological study with chest X-ray
showed a massive pneumothorax of the left thorax
(Figure CS-1.1a and b).
3.7.1.1 Autopsy
All the thoracic organs were in situ solitus, and no
fluid was found in the pleural spaces. The autopsy
was carried out according to Letulle technique.
The lungs showed many emphysematous air bub-
bles on pleural surfaces with diffuse crackling to
the touch. The gross section of the lungs showed a
brownish and diffusely porous parenchyma because
of the many air bubbles up to 0.4 cm in diameter
(Figure CS-1.2a–c).
146 Forensic and Clinical Forensic Autopsy

3.7.1.2 Histological Assessment Key Points

The histological examinations performed on the lung
tissue samples using hematoxylin and eosin staining
(H&E) revealed focal pleural fibrosis, large pleural air
bubbles bounded by thickened septi, at atelectatic and
collapsed parenchyma alternating with areas of acute
and chronic emphysema, characterized by alveolar
cavities (Figure CS-1.3). The exitus was attributed to
an acute respiratory failure caused by the left sponta-
neous pneumothorax congenital cystic adenomatoid
malformation (CCAM)-induced.
• CCAM of the lung is an uncommon cause of
respiratory distress in neonates and babies
due to a development anomaly of the terminal
respiratory structures.
• A complete forensic approach by means of
autopsy and histopathological examinations
to diagnose CCAM plays an irreplaceable rule
to study these cases to explain the cause of the
death.

Figure CS-1.1 (a and b) Chest and abdomen radiograph Antero-Posterior (AP) view shows large left-sided pneumo-
thorax with compression of the collapsed lung.

Figure CS-1.2 (a–c) Macroscopic aspects of lungs. Both lungs appeared to be diffusely enlarged, and the consistency
was firmer than usual. Externally, a brownish coloration was noted diffusely distributed on every lobe. The cut sur-
face was solid. The combined weight of the lungs (39 g) was slightly below normal.
Pediatric and Fetal Autopsies 147

Figure CS-1.3 Low magnification of the cystic lesion. The cysts were lined by columnar epithelium in the absence
of smooth muscle or striated muscle in the walls of the cysts. Focal pleural fibrosis, atelectasis of parenchyma, alter-
nating with areas of acute and chronic emphysema, characterized by alveolar cavities. (H&E x 40).

3.7.2 Case Study #2 gynecological counseling and routine blood analysis,

P. Malandrino, S. Franco, P. Mazzeo, A. Piscopo
Miscarriage occurred at the 15 week of gestation dur-
ing monochorionic diamniotic pregnancy. After the
onset of severe abdominal pain and vaginal blood loss,
a woman went to the emergency department. After
the woman spontaneously aborted two male fetuses.
3.7.2.1 Autopsy
The external examination showed a partially initial
maceration process of the anterior face of chest and
abdomen in both fetuses (Figure CS-2.1).

Figure CS-2.1 A complete external examination of both fetuses is required to exclude macroscopic malformations.
148 Forensic and Clinical Forensic Autopsy

The autopsy was carried out using Letulle tech-

nique. No abnormalities were found in both fetuses.
The gross examination of placenta was also per-
formed (Figure CS-2.2).

3.7.2.2 Histological Assessment

The histological examinations of both fetuses’ samples
using H&E revealed substantial normality. Instead,
the placenta and the villous structures showed a mas-
sive white blood cell infiltration. Similar evidences can
be identified in subamniotic and chorionic structures
compatible with a diagnosis of an infective chorioam-
nionitis (Figure CS-2.3a–d).

Key Points
• A complete autopsy allowed us to exclude any
fetal abnormalities.
• The histological examination was fundamen-
tal to diagnose the chorioamnionitis that was Figure CS-2.2 Placental gross examination performed
the cause of death of both fetuses. before sampling.

Figure CS-2.3 (a–b) Placental microscopic examination, with massive white blood cell infiltration. (c–d) Amniotic
and chorionic structures’ microscopic examination with evidences of similar infiltration.
Pediatric and Fetal Autopsies
3.7.3 Case Study #3
G. Cocimano, F. Casella, F. Colosimo
A 30-day-old female baby was found dead in her
house. After stabbing her husband’s ear, the mother
grabbed the baby from her knees, banging the baby’s
head on the floor several times.
No traumatic injuries were visible (Figure CS-3.1),
except for three bluish and oval-shaped ecchymotic
areas on the left knee (Figure CS-3.2). Palpation of the
skull showed a slight swelling of pericranial tissues
and preternatural motility of the cranial bones.
3.7.3.1 Radiological Examination
The total-body CT, MRI, and X-ray scan analyses were
performed before autopsy. Images showed the features
of severe traumatic brain injuries: right orbital roof
fracture, right coronal and sagittal suture fractures,
intracerebral hemorrhagic contusions, subarachnoid
hemorrhages and hemorrhagic infiltrate of pericranial
tissues, diffuse brain swelling, and cerebral white mat-
ter injuries (Figure CS-3.3a–c).
Figure CS-3.1 No visible traumatic injuries.
Figure CS-3.2 Bluish ecchymotic areas can be seen.
149
3.7.3.2 Autopsy
Dissection by anatomical layers was carried out.
A classic bimastoid scalp incision was performed.
During skin incision, blood associated with brain
fragments came out (Figure CS-3.4). The bones
of the cranial vault presented sutural diastasis.
Inspection showed hemorrhagic infiltrate of pericra-
nial tissues, right coronal, and sagittal suture injuries
(Figure CS-3.5), bilateral parietal and orbital roof frac-
tures, subarachnoid hemorrhage (Figure CS-3.6), lep-
tomeninges, and cerebral white matter injuries. The
Letulle technique (en masse) was performed.
After formalin fixation, the examination of the
organs allowed us to appreciate subarachnoid hemor-
rhages and cerebral injuries (Figure CS-3.7).
Key Points
• An accurate external examination must
always be carried out.
• Even if skin injuries are not evident, bone
fractures must always be searched.
150 Forensic and Clinical Forensic Autopsy

Figure CS-3.3 (a–c) Indications of severe traumatic brain injuries.

Pediatric and Fetal Autopsies
Figure CS-3.7 Subarachnoid hemorrhages and cerebral
injuries.
Figure CS-3.4 Blood associated with brain fragments.
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Figure CS-3.5 Hemorrhagic infiltrate of pericranial
tissues, right coronal and sagittal suture fractures.
Figure CS-3.6 Bilateral parietal and orbital roof frac-
tures, subarachnoid hemorrhage.
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Postmortem Radiology
and Digital Imaging
From Traumatic Injuries to Natural Death
GIUSEPPE BERTOZZI AND FRANCESCO PIO CAFARELLI
University of Foggia
ANDREA GIOVANNI MUSUMECI
Policlinico - Vittorio Emanuele Hospital, Catania
GIULIO ZIZZO AND GIAMPAOLO GRILLI
Ospedali Riuniti Hospital, Foggia
CRISTOFORO POMARA
University of Catania
Contents
4.1 Conventional X-ray
4.2 Computed Tomography
4.3 Magnetic
 Resonance
4.4 Angiography
4.5 Microimaging
4.6 Conclusions
4.7 Case Study #1
4.8 Case Study #2
4.9 Case Study #3
4.10 Case Study #4
4.11 Case Study #5
References
The relevance for dealing with “evidence” in the
medical “system” is supported by the need of a mod-
ern, shared, and standardized reflection on the
contribution from eidologic science in necroscopic
practice for forensic purposes. Radiological science,
indeed, toward a broader definition of the technical
parameters, is meant to study the details of the human
body and its components, both in an anatomical–
structural and in a physiological–physiopathological
sense, which brought the two disciplines (radiology
and forensic pathology) closer together during past
years. Both are easily toward research purposes: One
geared toward radiology and the need of a faster
answer with therapeutic–operational implication,
and the other geared toward forensic medicine and
the ascertainment of items of law. Of course, the abil-
ity of radiology to provide evidence is characterized
not only by high diagnostic credibility but also by
important documentary power-seduced medicolegal
ascertainers.
153
4
154
154
158
159
161
163
163
164
166
168
169
171
The methodological and operational approach
between the two disciplines has roots dating to the
first uses of traditional radiology for the study and
report of foreign bodies retained in the corpse. Back in
the 1970s in the United States, the American College
of Pathologists signaled the importance of the cor-
rect use of a preventive radiographic inquiry in some
deaths and, concurrent with its introduction, studied
the use of eco-guided techniques of anatomical sam-
pling. In 1982 in Italy, Pierucci edited a handbook for
the correct use of radiography in the study of deaths
by firearms, which immediately gained credibility
for the discipline. Then, this shared path between the
two disciplines was clearly ratified with the Swedish
“Virtopsy® project.” The aim was to detect the find-
ings in corpses using 3D photogrammetry, computed
tomography (CT), and magnetic resonance imaging
(MRI), and to confront them with autoptical results. In
2002, the expression “virtual autopsy” was strength-
ened by Thali et al. A virtopsy can be configured as
154
an observer-independent instrument, which does not
alter the reality of the corpse and, since it is digitized
and archived, is always repeatable and objectified,
even if time has passed. The Institute of Forensic
Medicine in Bern strongly pursuits this value; in fact
in 2007, it developed the first Virtobot. This “robotic
system” was able to perform a complete 3D surface
scanning through an optical surface scanner and
CT-guided needle introducer for tissue and biological
fluid sampling, so that thinking of digital autopsy did
not seem so futuristic. Six years later, Virtobot 2.0 was
introduced to the forensic community. Implemented
issues consisted of (i) automatic surface scanning,
generating 3D data with geometric characteristics
helpful for crime scene reconstructive purposes; and
(ii) minimally invasive tissue and fluid sampling and
placement of guide wire in order to focus on specific
suspected areas for the subsequent autopsy.
Although this, nowadays, postmortem imag-
ing preceded autopsy in many forensic institutes as
a routine practice, the field of forensic radiology is
suggested to evolve to an autonomous subspecialty
between forensic medicine and radiology. Thanks to
this spread and availability, it could be said that the
current use of different imaging techniques for cadaver
examination follows the principle: The more clinical
radiology progresses, the more forensic radiology bor-
rows. In general, as in clinical radiology, the different
techniques used in forensic pathology can be classified
as follows: “basal” methods (without contrast medium
use) – accounting for conventional X-rays, CT, MRI –
and complementary methods like postmortem angi-
ography, only performed in elite centers. Ultrasound
is a residual technique in forensic evidence because of
its operator-dependent subjectivity and image altera-
tion by postmortem gas.
4.1 Conventional X-ray
When in this previous edition the need to have
a radiology table or a potable X-ray machine was
advocated, it would never have been thought that
only a residual space remained for this technique.
However, according to the past, due to its wide
availability, conventional radiography is the most
important application employed in forensic pathol-
ogy. Radiographs, indeed, allow us to visualize
skeletal injuries: Traumatic, lytic, inflammatory,
degenerative, and developmental lesions of bones
and joints are well revealed by radiographs, even
in cases of skeletal abnormalities in cases of fetal
autopsies. Moreover, this oldest technique keeps its
Forensic and Clinical Forensic Autopsy
utility in (i) revealing the presence and localization
of radipaque foreign bodies (like gunshots), but in a
two-dimensional plane; (ii) recognizing anthropo-
metric features by bone analysis, linked to age defini-
tion; and (iii) helping person identification mainly by
means of orthopantomography, for example, in cases
of unknown or burned cadavers.
4.2 Computed Tomography
CT uses X-rays to obtain transverse (axial) images
of body sections. The tube rotates around the longi-
tudinal (z)-axis of the cadaver lying on the CT table,
transmitting radiation through the body from many
angles. X-rays are absorbed according to the different
radiographic densities of tissues. The many profiles
measured during one rotation are used by the com-
puter to calculate a density map of the body section
with discrete absolute density values of all image ele-
ments (voxels). Modern multidetector row scanners
(multislice computed tomography (MSCT) scanner)
can acquire information for several slices during one
rotation, which can be used to improve z-axis, volume
coverage, or speed. The slice thickness obtained from
the images will then be calculated from those data at
any selected z-axis position within the volume, accord-
ing to the reconstruction interval chosen. This gives a
resolution that is equivalent to isotropic imaging; vox-
els have similar dimensions in all three axes. Isotropic
voxels are ideal for image postprocessing using multi-
planar reformation to obtain images in sagittal, frontal,
or oblique planes, or even three-dimensional presen-
tation methods (multiplanar reconstruction (MPR),
maximum intensity projection (MIP), and volume ren-
dering (VR)). For these characteristics, postmortem CT
(PMCT) is the most used imaging technique in foren-
sic field, thanks to high resolution, rapid examination
times (scanning of a whole body in a short period of
time, only few seconds), and its ability to adapt study
parameters to each case and reconstruct images.
PMCT application in the postmortem studies
allows forensic pathologists to reconstruct skeletal
system injuries (i.e., traffic fatalities, mass disaster,
falls). PMCT, in fact, can detect neurocranial and facial
fractures. Furthermore, this technique diagnoses intra-
cranial hematomas as a hyperdense collection in every
localization: epidural, subdural, subarachnoid, or intra-
ventricular hemorrhages as well as intraocular hemor-
rhages, associated with orbital or skull base fractures.
Performing CT imaging before autopsy, especially in
cases of traumatic injury with open skull fractures, can
detect pneumocephalus and cerebral venous and arterial
Postmortem Radiology and Digital Imaging
gas emboli. These evidences are barely detected during
postmortem examination unless a modified technique
opening the body under water is performed. In these
cases, PMCT can provide information to plan the most
correct autoptical approach. However, differential diag-
nosis with postmortem putrefactive gas accumulation
has to be made. As normal putrefaction process, indeed,
bacterial metabolism produces gas formation, which
is usually thought to begin in bowels and then spread
through the whole body. However, a distinction has to
be made between pathological premortem gas accumu-
lation and postmortem decomposition gas. The former
is most frequently associated with fractures (e.g., in head
after cranial trauma) or invasive surgical procedures
(e.g., in hepatobiliary ducts after Endoscopic Retrograde
Cholangio-Pancreatography) and appears to be focally
localized; instead, the latter shows the presence of diffuse
gas in different body segments and different locations,
and not necessarily with traumatic injuries.
In order to provide the solution to the age-old
question of discriminating between putrefactive gas
accumulation and the premortal one, Egger et al.
proposed a link between the grade of gas in the right
heart and that in the liver. Indeed, putrefactive gas in
the heart appeared earlier than in parenchyma and
preferentially in the right cavities. Deep digestive
system-linked abdominal vessels were the second site
of putrefactive gas development, with no preference
for either veins or arteries. Only in later putrefactive
phases, gas appeared in subcutaneous fat.
Thus, an explanation based on grading of putre-
factive gas simultaneously present in these anatomi-
cal compartments was proposed. The presence of large
quantities of gas in the heart cavities (Egger–Grabherr
grade III) associated with no or lower than moderate
gas (Egger–Grabherr grade II) in the hepatic paren-
chyma indicated a non-putrefactive genesis.
PMCT also uncovers bone cervical injuries which
can result from a blunt cervical trauma (e.g., hyper-
extension injury). Atlanto-occipital or atlanto-axial
fracture, and dislocation and lower cervical vertebral
fractures with spinal canal encroachment can be easily
detected, which is an indirect sign of medullar com-
pression resulting in the cause of death; the compres-
sion can be determined by traumatic pneumorachis.
Furthermore, imaging provides a few informa-
tion in cases of suspected blunt or penetrating chest
trauma or ascertained at cadaver external examina-
tion, including the possibility to diagnose chest wall
injuries; pneumothorax; pneumopericardium; hemo-
thorax; hemopericardium; and lung, cardiac, aortic,
or vascular injuries. Fractures of sternum, ribs, or ver-
tebrae are easily recognized in PMCT as well as their
155
complications such as waste pneumothorax (tension
pneumothorax is usually associated with chest wall
trauma as primary cause of death or with both pneu-
morachis and pneumocephalus as secondary causes
of death) or pneumopericardium and hemothorax,
which if massive represents a well-documented cause
of death. This latter is associated with the “vanishing
aorta” sign, a PMCT finding due to fatal hemorrhages
with bloody diversion other than vessel location, and
in collapse of the vessel walls. The simultaneous pres-
ence of massive hemothorax and “vanishing aorta”
sign is suggestive of aortic rupture.
Lung lacerations are also diagnosed with PMCT,
through consolidation. Ground-glass areas are ambigu-
ous signs with difficult interpretation, which are recon-
nected to postmortem hypostasis, or lung contusions,
hemorrhages, infective pneumonia, or pulmonary
edema due to fluid overload or cardiac failure or even
drowning. This is a clear example in which a multidisci-
plinary approach between legal medicine and radiology
could provide the most appropriate interpretation.
Furthermore, blunt traumas like car accidents
can cause immediate or delayed intra-abdominal
organs’ herniation into the pericardial sac or pleural
space, leading to cardiac tamponade or failure for left
ventricle compression or respiratory failure. PMCT
examination can reveal diaphragm laceration and
the anomalous localization of the abdominal organs.
Moreover, imaging applied to the abdomen is useful in
diagnosing intra-abdominal bloody collection follow-
ing blunt or penetrating traumas, such as perihepatic
and perisplenic blood and perirenal fluid extended to
perirenal fat, or massive hemoperitoneum at PMCT.
PMCT, in addition, can reveal the presence of signifi-
cant pneumoperitoneum allowing suspecting a bowel
injury (Figure 4.1). PMCT, even in this segment, still
remains the best imaging technique to detect lumbar
vertebral and pelvic fractures, even associated with
hemorrhage and PMCT signs of exsanguination suf-
ficient to cause death, for example, abdominal aorta
laceration following blunt or penetrating traumas.
Traumatisms are mostly detected using PMCT:
PMCT is also used to identify every type of foreign
bodies, such as bullets (firearm fatalities) or surgi-
cal materials (surgical liability). As far as projectiles
are concerned, PMCT can provide information about
number, form, dimensions, localization, and trajectory.
Gunshots penetrating injuries often affected the
head segment because of its vital content in cases of
suicide or homicide: The latter, for example, in cases,
is characterized by the presence of the so-called coup
de grace. Bullets can be easily found using CT imag-
ing as hyperdense foreign bodies, thus located, and
156
Figure 4.1 PMCT enlightening the presence of a pneumoperitoneum, observable as localized stratification of supra-
hepatic air (albeit in the presence of air in the bilio-portal vessels, index of putrefaction) likely due to two hyperdense
foreign bodies.
Figure 4.2 Coronal MIP documenting the presence of
left parietal fracture with bone fragments detected in the
cerebral tissue underlying the bone gap. Concomitance
of extra-axial hematoma with small hyperdense frag-
ment, referred to as a foreign body.
described in terms of number, shape, dimensions,
and integrity; furthermore, thanks to the structure of
cranial bone, the enter hole can be identified or imag-
ined by penetrating the bone fragment going from the
internal bone layer into encephalic parenchyma as a
wake following the channel excavated by bullet trajec-
tory (Figures 4.2 and 4.3).
In CT imaging, parenchymal laceration usually
assumes a conical shape with the basis at the entrance
wound. Similar considerations can be made about the
exit hole. Moreover, the entry hole is characterized by
an inner cortical bone layer, which is more commi-
nuted than the outer layer; on the contrary, the exit hole
in cases of perforating injuries is characterized by an
outer layer, which is more comminuted than the inner
layer. Stab wounds, on the other hand, are uncommon
Forensic and Clinical Forensic Autopsy
Figure 4.3 MPR oblique paraxial scan allows us to
clearly realize the channel from the left parietal bone
bruise, as enter hole, through the cerebral parenchyma,
identified by multiple hyperdense fragments, up to ante-
rior cranial fossa where a metallic body is found in the
periclinoid region of the left sphenoid.
affecting the body parts, because of natural protection
and resistance opposed by the cranial table to severe
instruments. Knives, screwdrivers, scissors, pencils,
ice picks, and stilettoes are usually involved in casual-
ties, leading to death for vessel lacerations with mas-
sive intracranial hemorrhages or brainstem or vital
brain damage. PMCT, which is useful in identifying
fractures, hemorrhages, trajectory, and encephalic or
thoracic areas affected by these lesions, is limited only
by metal artifact/high-density foreign material artifact.
Besides, in gunshot, PMCT allows localizing and
identifying an ingested object, lodged just above the
narrow cricopharyngeal sphincter.
Postmortem Radiology and Digital Imaging 157

PMCT, indeed, exhibits a high sensitivity in the
diagnosis of laryngohyoid fractures, with an eas-
ier visualization than the classic autopsy in cases of
strangulation.
At least, its shorter time of execution, allowing
a rapid inside inspection of the whole lesion pattern,
renders this technique applicable to the investigation
of mass catastrophes victims, reporting even the
presence of medical implants or peculiar body char-
acteristics (anthropometric parameters to estimate
age and gender), which are useful in victim iden-
tification. An unusual application of CT in foren-
sic pathology is in the anthropologic study of body
remains (Figure 4.4).

Figure 4.4 VR reconstruction showing skeletal segment (left ankle and footbones) in “running” shoe with loose
laces. Furrows of the sole were also appreciable, referable to slight/modest signs of wear, more pronounced at the
heel level, on the postero-external side (tendency to supination?). The subcutaneous soft tissues at the level of the
ankle–proximal leg are no longer to be appreciated; on the other hand, the subcutaneous soft tissues at the mid-
posterior plantar region was appreciable, with a fluid/superfluid density (5-10 HU), and a 21 mm maximum thickness
(adipocere?). No morpho-structural alterations referable to bone lesions of a past or recent traumatic nature were
detected. Instead, inversion of the plantar arch at the level of the metatarsal heads was reported. Incipient degenera-
tive manifestations were highlighted at the level of first metatarsophalangeal joint with osteophytotic head, small
geodic-similar cystic lacunae and static subluxation of sesamoids as for possible mild valgus. There was no absence
of conjugation cartilages. In relation to the conservation conditions of the exhibit, the sample could probably belong
to a subject aged between 40 and 50 years.
158
4.3 Magnetic Resonance
Since MRI had been considered as a further and
higher-level technique of imaging, deserving to be
used only in specific condition, and as a powerful
diagnostic tool, there are not enough studies about
its application in the forensic field. Thanks to its mul-
tiplanar and multiparametric characteristics, MRI
could give a big support to forensic investigation.
Postmortem MRI (PMMRI) underuse should blame
first of all to the lack of MRI machine in countries,
the long time of acquisition for the examination (sec-
onds to few minutes for CT, several minutes to hour
for MRI), the costs, absence of communal acquisition
protocols, and no conspicuous data about postmortal
changes and MR signals. In addition, other consider-
ations should be made, for example, before PMMRI; a
CT scan of all body parts has to be made, in order to
prevent the possible access of metal foreign bodies to
enter in the magnetic field of the MR space, becoming
a potentially life-threatening bullet.
Several differences are found between PMCT and
PMMRI; the main one is the physical mechanism base
which is used to acquire information; indeed, by means
of ionizing radiation, it is possible to study tissues
and organs with different densities. The advantage of
MRI, instead, is that it utilizes different amounts and
mobilities of magnetic field and radiofrequency (RF)-
sensitive atoms and molecules. To investigate human
body, this imaging technique was proposed in order
to focus the attention on hydrogen ions (H+), which is
largely found in the body.
It is possible to simplify the functioning of MRI,
thinking about the H+ as little needle of a compass
(spin), which, after entering in a strong magnetic field
(usually 1.5 Tesla) with a precise vector, are all obliged to
acquire the same direction of the magnetic field vector.
In this forced static condition, an RF is applied to influ-
ence the movement of the spins. After stopping the RF,
the time that spins employ to come back in the initial
condition acquired by the MRI magnetic filed, called
“relaxation time”, is read by the machine as an “echo,”
and then transformed from electrical signal to grayscale
value to depict an image with different signal intensity.
As the amount and mobility of spins is strictly
linked with biochemical and physical properties of
tissues, MRI can give several pieces of, sometimes
unexplored, information due to the different relax-
ation times, thus leading to an excellent tissue con-
trast. Unlike CT, even MRI can acquire images in
3D, examinations are usually set in one plane at a
time; and to have a high-quality image, PMMRI has
normally a longer acquisition time than live person.
Forensic and Clinical Forensic Autopsy
However, movement artifacts are totally absent. For
these reasons, PMMRI is mostly performed in one
anatomical region of specific interest and cannot be
used as a screening method like PMCT. Further stud-
ies about the postmortem semeiotics are needed since
several conditions, such as vascular stasis and, in par-
ticular, venous stasis, gas presence, and temperature
of the body, surely influence the known contrast MR
image. Moreover, like in PMCT, the absence of circu-
lation makes impossible to use the dynamic clinical
MR sequences (arterial or venous), but some special
sequences could give a pivotal information, concern-
ing above all potential vascular diseases (dilatations:
aneurysms, ectasia; occlusion and stenoses) without
contrast medium injection, providing also several
additional clues that can help the autopsy, and/or
address the autopsy to confirm or exclude a specific
cause of death.
As proposed, an ideal protocol should include
T1- and T2-weighted sequences, in all main three axes
of the space, but unfortunately there is no univocal
consensus about the acquisition protocol.
Potentially, PMMRI beyond the high-contrast
resolution and anatomical details could be used to
identify the specific tissue characteristics and, for
example in case or hemorrhage, to establish the tem-
poral evolution of the pathological process; on this
basis, postmortem cardio-MR (PMCMR) is a develop-
ing field of interest due to its potential role in distin-
guishing acute, subacute, and chronic infarction.
As in clinical radiology is pivotal the contribute
that MRI could offer in soft-tissue pathology, PMMRI
due to its great ability to identify different tissue char-
acteristics is the modality of choice to investigate
postmortem fetuses and pediatric forensic cases. Even
in this specific field, there are several publications
handling nonlegal cases with parental objection to
autopsy. About this purpose, the first large prospective
study about the role of PMMRI as potential alterna-
tive to full conventional autopsy in fetuses and chil-
dren was the MRI Autopsy Study (MaRIAS), clearly
demonstrating PMMRI advantages.
However, the need to compare PMMRI with his-
topathology has led to some studies. Absinta et al.,
in fact, have shown that compared to standard sec-
tioning, the use of a PMMRI of whole brains fixed in
formalin in order to drive the subsequent sampling
has improved the speed, quality, and accuracy of the
radiological–pathological correlations. Furthermore,
the use of magnetic resonance elastography (MRE) for
noninvasive evaluation of the viscoelastic properties
of brain tissue demonstrates no or minimal significant
difference between in vivo and 24 hour postmortem.
Postmortem Radiology and Digital Imaging
A further step forward is represented by, like in
PMCTA (postmortem computed tomography angi-
ography), the use of contrast agent during the MRI
examination, to get an angiography study with the
additional vascular data to the characterization of tis-
sues. This technique is called “PMMR angiography”
(PMMRA). Several techniques were described to per-
form PMMRA; even recently, Ruder et al. used a mix-
ture of iodinated contrast medium diluted in a PEG
(polyethylene glycol) solution to obtain high-quality
image T1-weighted with and without fat saturation,
obviously reducing, as possible, the time between con-
trast mixture injection and MRI acquisition. More
recently, the use of oil agent to make a coronarogram
by means of PMMRA was also proposed.
Other techniques such as diffusion-weighted
imaging (DWI), proton magnetic resonance spectros-
copy, and chemical study of the postmortem decom-
position were also proposed.
Compared with PMCT, PMMRI, even in its
forerunner method, seems to be very promising, but
shared and standardized protocols should be estab-
lished and new developments can be awaited in this
field during the coming years.
4.4 Angiography
Although PMCT has shown its usefulness in a large
number of cases, as previously reported, evident limits
are in the visualization of soft tissues, but above all of
the vascular system, limiting the diagnostic capacity
of postmortem imaging in advance to traumatology.
To overcome this limit, in 2005, Jackowski et al.
reported the preliminary results of a minimally inva-
sive technique of total-body PMCTA, resorting to
cannulation of the femoral vessels of one side of the
body and to injection of meglumine ioxitalamate,
as a contrast medium. This and other experiments
led, however, to the conclusion that, in order for the
PMCTA to be carried out excellently, a postmortem
circulation that could allow the diffusion of the con-
trast agent had to be reproduced in the cadaver. A first
study by Grabherr et al. was conducted on an animal
model, using perfused diesel oil and a rotating pump
as a perfusion instrument, and confirmed the hypoth-
eses, allowing the sequential visualization of the arte-
rial, parenchymal, and venous system. This method
was later adapted to a human model by changing the
perfusion fluid and the injection technique.
The resulting method called “two-step postmor-
tem angiography” was conducted as follows: A post-
mortem perfusion was conducted as a first step and
159
the injection of contrast medium with the acquisition
of sequential images as a second step, using a modified
heart lung machine as a perfusion tool. Furthermore,
while Jackowski et al. had applied an aqueous solution
as a contrast agent, the methods of Grabherr et al. had
commonly applied the injection of an oily perfusate.
This method was followed by numerous angio-
graphic studies investigating the variations in con-
trast media and injection techniques. In order to
systematize all these observations, in February
2012, the TWGPAM (Technical Working Group
Post-mortem Angiography Methods) was founded,
consisting of nine participating centers located in
six European countries, including the Department
of Legal Medicine of the University of Foggia. The
Center of Forensic Medicine of the University of
Lausanne developed, therefore, the protocol for the
multiphase postmortem computed tomography angi-
ography (MPMCTA), which consisted of (i) perform-
ing a native CT scan, followed by three angiographic
stages (arterial, venous, and dynamic); (ii) injecting
a specific contrast agent, Angiofil® (Fumedica AG,
Muri, Switzerland); (iii) introduced via the cannula-
tion of the femoral vessels of one side of the body; (iv)
using specific parameters of injection (injection time,
pressure, volume, flow); (v) ensuring perfusion with
a heart-lung machine (Virtangio® (Fumedica AG)),
which allows the visualization of the whole vascular
system of head, thorax, and abdomen.
The oily contrast medium has been preferred to
other hydrophilic contrast agents because the latter
rapidly diffuse to the tissues, thereby causing edema
and deforming artifacts. In addition, the injection of
an oily mixture could take away the postmortem clots.
In the first experimental studies, perfusion was
carried out with the initial injection of paraffinum
perliquidum, as an oily medium, in order to remove
the postmortem clots and the remaining blood, and
Lipiodol Ultrafluide®, as an oily contrast agent. This
technique, however, was associated with the loss of
oily material in the stomach and intestine, caused by
the presence of one or more loci minoris resistentiae,
which were created due to the combination of bacte-
rial decomposition and the autolytic processes that
occur precociously at the gastrointestinal tract. This
problem was subsequently obviated by the introduc-
tion of a new contrast agent, Angiofil® (Fumedica,
AG), which was mixed with paraffin oil to a higher
viscosity than previously used agent (paraffinum liq-
uidum instead of paraffinum perliquidum).
In order to guarantee the complete filling of the
whole vascular system, it was necessary to proceed
with an arterial and a venous phase. Although it is
160
possible to visualize the venous system through the
arteries, and specifically by exploiting arterio-venous
anastomosis, this modality has proved to be less
effective than direct filling by the cannulation of the
venous vessels, reducing the appearance of artifacts
in which the technique would incur with only arterial
access. Moreover, the two phases, arterial and venous,
must be carried out with different volumes of perfu-
sion, in order to opacify the whole vascular tissue in
an optimal manner. The difference in the volumes
needed to visualize the arterial and venous system can
have different physiological bases. First, the venous
system contains a greater volume of blood than the
arterial system. Second, the average diameter of a
single venous vessel is greater than that of the arterial
system. Finally, the vessels of the arterial system are
relatively rigid, while those of the venous system are
much more dilatable.
To conclude, a third angiographic phase called
“dynamic phase” is performed. The particularity of
this phase is that the data acquisition is performed
during a continuous circulation of the contrast mix-
ture, and consequently, the entire vascular system is
under the pressure of perfusion, with the aim of simu-
lating a vital intravascular circulation during the CT
scans. This phase allows the most complete and effec-
tive visualization of the cases, improving the quality
of the image and facilitating its interpretation. In fact,
it has been proposed that an alteration must be present
in at least two of the three phases; otherwise, it can be
interpreted as an artifact.
The standardized procedure establishes that the
femoral vessels on one side of the body must be used
as an entry point to the vascular system. This site for
infusion of the mixture guarantees the visualization
of the vascular network of the cephalic, thoracic,
and abdominal segments, but excludes the opacifica-
tion of the vessels below the insertion of the cannu-
lae. As a consequence, the anatomy, morphology, and
functionality of the vascular tree of the lower limbs
are difficult to study, and some injuries may remain
unrecognized. An example is the high incidence of
pulmonary thromboembolism in the forensic investi-
gation and the difficulty of postmortem diagnosis of
the same, which has its origin, much more frequently,
in the thrombosis of the superficial and deep venous
circle of the lower limb, which is difficult to view with
the cannulation site provided for by the protocol.
At the Department of Legal Medicine of the
University of Foggia, Pomara et al. have experimented
with a new approach to MPMCTA, in order to better
visualize the vascular axis of the lower limbs, espe-
cially in cases where the examination of the venous
Forensic and Clinical Forensic Autopsy
axis of these districts appear with a marked medical–
legal relevance, like the deaths which are suspected
through a diagnosis of pulmonary thromboembolism.
This new approach first involves the isolation of
the artery and axillary vein on one side of the corpse
and then the insertion of the cannulae into the afore-
mentioned axillary vessels.
Another method for PMCTA uses a high-viscosity
contrast agent solution containing 65% PEG, through
the cannulation of the femoral artery to reach the aortic
root. The distribution of the contrast agent was gener-
ally limited to the arterial system, except for the brain,
the left ventricular myocardium, and the renal cortex.
However, postmortem tissue edema constituted a sig-
nificant artifact with such minimal angiography.
In England, TCA (targeted coronary angiography)
using surgical access through the left common carotid
artery uses a 14-Fr silicone male catheter (Bardia Foley
catheter), with a ≥30 ml balloon inserted into the
ascending aorta, just above the aortic valve. The first
scan without contrast is performed in three overlap-
ping blocks of “head and neck,” “chest, abdomen and
pelvis,” and “pelvis and legs.” The angiographic steps
include five sequences: the first three using air (nega-
tive contrast), followed by two sequences of Urografin®
150 mg/ml (Bayer Healthcare, positive contrast) diluted
1:10. Initially, a manual injection is carried out with a
standard 60-ml bladder syringe with a “constant” man-
ual pressure, then with a Medrad Stellant double-head
pump injector system (Medrad UK Ltd, UK).
PMCTA could be used to avoid an invasive
autopsy. The gold standard of postmortem investiga-
tions should include both PMCT and invasive autopsy.
In Japan, PMCTA is performed with cardiopul-
monary resuscitation (CPR). Sakamoto et al., indeed,
inject a contrast agent into a peripheral vein immedi-
ately after the ascertainment of death, already on the
CT bed. Diffusion is guaranteed by direct pressure on
the chest as it occurs during CPR, in order to mimic a
small cardiac output.
Finally, Shao et al. by a biopsy core needle con-
ducted a percutaneous puncture in the left ventricle
under CT guidance. Following the injection of con-
trast medium, composed of diatrizoate meglumine
and normal saline (0.9%) at 1: 2 ratio, CT sequence
was performed. With this method, the visualization
of the systemic arteries has been reached.
This technique, overcoming PMCT, also allows
detecting damage to soft tissues or parenchymal organs.
MPMCTA, in fact, allows us to clearly identify the pres-
ence of hemorrhagic collection and to study cerebral
vessels, like Willis polygon in cases of either natural or
traumatic deaths (Figure 4.5). Furthermore, recently,
Postmortem Radiology and Digital Imaging
Figure 4.5 MIP reconstructions (images on the left) with the presence of extravasation of the contrast medium in
the territory of distribution of the lenticolous-striated arterial vessels and with integrity of the average cerebral arter-
ies better studied in VR (right image).
with extravascular and external local application of
contrast media, the reconstruction of stab directions
and documentation of the inflicted wounds depth have
been possibly demonstrated, so that this technique has
been compared to the conventional autopsy. This tech-
nique demonstrated high sensitivity in detecting causes
of sudden cardiac death (SCD), guaranteeing knockout
of coronary arteries, and identifying vascular obstruc-
tion or source site of fatal hemorrhages.
Therefore, PMCTA revealed its biggest break-
through in the study of cases of SCD with a higher
autoptical-like sensitivity: (i) Coronary stenosis could
be detected and the degree of occlusion was quanti-
fied, even in cases of grafted vessels, without inevitable
autoptical alteration; (ii) lacerations of the coronary
arteries are easily revealed by the extravasation of con-
trast agent; (iii) hemopericardium is a consequence
of myocardial rupture as consequence of myocardial
ischemia, with the CT sign of “hyperdense armored
heart” (Figure 4.6); (iv) myocardial thickening is a
161
sign of chronic infarction; or (v) hemothorax sug-
gests a thoracic aortic dissection. Moreover, in cases
of thromboembolism, using MPMCTA technique,
Pomara et al. demonstrated a high diagnostic capacity
in the identification of suspicious thrombotic lesions
in the lower limb; this method is limited to the identi-
fication of lesions suspected for embolism (whose cer-
tainty remains; however, histological analysis helps in
differentiating embolus and postmortal clot), in order
to plan the next autopsy.
4.5 Microimaging
The term “microimaging” includes micro-CT (micro-
computed tomography) and micro-MRI (micro-
magnetic resonance imaging) techniques. The
micro-CT, which can be called as “high-resolution
CT”, allows the virtual reconstruction of micrometer-
sized structures, as the name suggests. The micro-CT,
162
Figure 4.6 MPMCTA examination with staining to highlight the arterial vessels. There is a pericardial blood col-
lection with the sign of the “hyperdense armored heart,” better documented in VR (image above).
in turn, is, using a very small X-ray source, particu-
larly useful for the study of bone structures with the
great limit, of limited soft tissue definition. Micro-
MRI responds to the same conventional clinical MRI
procedures with a definition of 106 times smaller voxel
then clinical imaging. Exactly like its clinical coun-
terpart, the micro-MRI maintains its high diagnostic
accuracy in the evaluation of soft tissues.
As already mentioned, the particular use of these
methods in the study of bones also translates into the
study of bone composition and its trabeculation in order
to provide important information not only in the pres-
ence of a fracture but also related to the time of repair
of a fracture. In detail, calcifications at the bone or soft
tissue level can be assessed by measuring tissue volume,
calcification volume, and calcified tissue percentage, to
detect fractures or dislocations, as well as healing fol-
lowing trauma. Furthermore, it is possible to document
the presence of the subtlest fracture lines, for example,
on the upper horn of the thyroid cartilage and on the
hyoid bone in cases of strangulation. To these, it can be
added the use of micro-MRI which allows a detailed
evaluation of the contours and the position of each com-
ponent of the laryngeal structure, that is, on cartilages,
joints, ligaments, intrinsic muscles, and vocal cords.
As regards the study of internal organs, the micro-
MRI allows a minimally invasive visualization of the
brain structures before the histological sampling,
preserving a spatial resolution close to the histology,
allowing, for example, to document microhemor-
rhages and rearrangement associated with age, also in
the hippocampal site, which are the result of cranial
traumas. Furthermore, microimaging could virtually
allow the reconstruction of nerve circuits of any part
of the brain, potentially analyzing neuronal loss.
Forensic and Clinical Forensic Autopsy
The mechanical properties of the myocardium
and the orientation of the measuring fibers were
determined.
A combination of micro-MRI with micro-CT,
which is used for the nondestructive reconstruction
of fiber orientation, has been successfully used to cre-
ate a three-dimensional computational model of the
sinus node. Micro-CT is an important tool for vascu-
lar examination with a resolution at the micron level,
a three-dimensional view of the entire microvascular
structure, the volumetric blood vessel caliber infor-
mation, and the morphometric analysis of human
plaque. Micro-CT, indeed, can also correctly identify
the amount of mineralization, and consequently, dif-
ferential diagnoses of atherosclerosis was made, simi-
larly to histological classification as fibrous plaques,
calcified lesions, fibro-atheromasia, and lipid lesions.
Furthermore, micro-CT is a promising method
to visualize the architecture of renal vasculature and,
above all, to separate the cortex and marrow for the
visualization of glomeruli and their afferent and effer-
ent arterioles.
The thoracic micro-MRI, in addition to the defini-
tion of traumatic injury to the lungs and heart, would
allow the reconstruction of the orientation of the myo-
cardial fibers, in order to create a three-dimensional
model of the sinus node. Furthermore, micro-CT is an
interesting tool for studying vessels, allowing a three-
dimensional visualization of the entire microvascular
tree. It is also possible to analyze the morphometry
of atherosclerotic plaque with the quantification of
mineralization, and consequently, the differential
diagnosis of fibrous plaques, calcified lesions, fibro-
atheromasia, and lipid lesions was usually made by
histological examination.
Postmortem Radiology and Digital Imaging
In fetal autopsies, microimaging has shown its
usefulness in the study of the placenta, resorting to a
contrast agent reaching the measurement of the total
placental volume as well as the estimation of the approx-
imate surface of the placental vasculature, with the relief
that the decrease in blood flow was associated with a
decrease in fetal weight. In personal identification, the
micro-CT examination of enamel, dentin, and pulp
cavity can contribute to the determination of age.
Finally, the high-resolution micro-CT is able to
detect the radiopaque particles in the gunshot wounds
at the entrance, in the cutaneous and subcutane-
ous sites, also covered by tissues, as well as altered by
putrefaction, fire or water, allowing the reconstruc-
tion of three-dimensional spatial distribution of par-
ticles, with high reliability to the differential diagnosis
between entry and exit wounds.
4.6 Conclusions
In the range of such auxiliary grafts to the main inves-
tigation (autopsy), the eidologic–forensic investigation
rises to a new dimension, which can be counted with
full rights among the means of research for scientific
evidence (such as legitimate and repeatable).
The awareness of the need for a great guarantee of
validity (the best in a technical sense) and the capa-
bility to refer to more objective technical–scientific
backups have influenced coroners’ sensitivity during
the past few years. In forensic medicine, the need for a
description as objective, straight, controllable as pos-
sible has grown so the eventual laboratorial controls
must be reported within the whole results, the images
must be enclosed, the clinical objectification must be
complete and detailed, and still more the morpho-
logical surveys (postmortem, histological, and so on)
should be recorded.
Nevertheless, the ultimate impetus to the imple-
mentation of radiological application in forensic
medicine came surely from the evolution of the imag-
ing instruments. The application of radiology in the
practice of forensic medicine during a necroscopic
examination is an extraordinary benefit, including
the possibility to proceed to new evaluations, to verify
at a later time, and to have multidisciplinary consults
for complex investigations, even after the classic post-
mortem procedures are closed. The possibility also
exists to use this instrument when religious or general
cultural contexts do not allow traditional postmortem
procedures. Digital autopsy can provide surveys that
could escape even the most careful and tried obser-
vation (a minuscule bony splinter, for instance, can
163
easily avoid direct observation). Moreover, it is use-
less to deny the great evolution, represented by the
PMCTA and PMMRI. Despite its limitations, further-
more, PMCTA allowed forensic radiology to switch
from the detection of trauma-related injuries to the
identification of alterations related to natural causes
of death.
However, advanced putrefaction or extensive
lacerations (e.g., mass disaster), because of the wide
number of destroyed vessels, may heavily affect post-
mortem angiography inapplicable. Furthermore, the
arrhythmogenic cause of sudden and unexpected
death (whatever the source is) cannot be diagnosed
yet. The lack of a specific expertise in forensic radiol-
ogy impedes a universal interpretation of findings. In
addition, the availability, economical and logistic, rep-
resents another limitation; in fact, CT and MRI scan-
ners are shared between forensic and clinical units.
For all these reasons and for the same need of dis-
covering the true, the autopsy can be improved upon,
but not replaced by forensic radiology yet. Autopsy
remains irreplaceable when it comes to the value of mac-
roscopic features such as margins, edges, and auras, at
the external and internal layers even at different organs
and it is indispensable for a correct framing of the death
(not just as the causative moment, but the information
pertinent to the modus and time of the death).
4.7 Case Study #1
During an ambush made by the Gargano mafia, a man
was killed inside his car while he was going to work.
At the external examination, the involvement of more
than one ammunition was suspected. An X-Ray scan
was performed in order to detect the presence of foreign
bodies: number, shape, and size. Skull examination was
not remarkable. Instead, thoracic imaging revealed the
presence of two different hyperdense foreign bodies.
Another hyperdense foreign body surrounded
by multiple high-density fragments was seen in the
abdomen, which is of different shape and dimen-
sions compared to the other two found in the thorax
(Figure CS-1.1).
Moreover, imaging of the left lower limb showed
a compound, probably multi-fragmentary, fracture
of the left femur, whose dominant line showed a per-
trochanteric direction. Another compound multi-
fragmentary fracture of the femoral diaphysis was
detected. Surrounding that fracture, multiple hyper-
dense fragments were noticed (Figure CS-1.2).
During the autopsy, it was difficult to recover
the fragments identified at the RX. Indeed, despite
164
Figure CS-1.1 Another hyperdense foreign body sur-
rounded by multiple high-density fragments.
the ability to identify foreign bodies of metallic con-
sistency, the limit represented by this method is the
impossible spatial location of the same. Instead, the
ability to identify traumatic bone injury resulted
undisputed.
4.8 Case Study #2
A 30-year-old woman was traveling as car anterior
passenger when the driver lost car control and fron-
tally crashed into another car. Despite the intervention
Figure CS-2.1 D4-D5 fracture luxation with misalignment of the corresponding vertebrae and abnormal
enlargement of the corresponding intervertebral space.
Forensic and Clinical Forensic Autopsy
Figure CS-1.2 Imaging the left lower limb revealed
another compound multi-fragmentary fracture of the
femoral diaphysis, surrounded by multiple hyperdense
fragments.
of the emergency doctors, she died. Prior to autopsy,
a PMCT was performed; it showed D4-D5 fracture
luxation with misalignment of the corresponding
vertebrae and abnormal enlargement of the corre-
sponding intervertebral space (Figure CS-2.1); mul-
tiple bilateral costal fractures occur: left V and VI
costs; from the 2nd to the 12th on the right, with cos-
tal volet aspects in relation to the presence of bifocal
fractures; fracture of right ileus branches and pubic
Postmortem Radiology and Digital Imaging
ischium (better  visualized with MIP reconstruc-
tions (Figure  CS-2.2)); bilateral pleural effusion with
a right wide pneumothorax and a left moderate one
(Figure CS-2.3); a displaced fracture of the base of the
right acromion (better seen with MIP reconstructions,
Figure  CS-2.4); and comminuted and decomposed
fracture of the right scapula (Figure CS-2.5).
Figure CS-2.2 Fracture of right ileus branches and pubic
ischium (better visualized with MIP reconstructions).
Figure CS-2.3 Bilateral pleural effusion with a right
wide pneumothorax and a left moderate one.
165
Figure CS-2.4 A displaced fracture of the base of the
right acromion.
Figure CS-2.5 Comminuted and decomposed fracture
of the right scapula.
As shown in Figure CS-2.3, the absence on one
side, of a hepatic gas grade II and concomitant right
heart gas grade III, according to Grabherr, and the
presence, on the other side, of an air collection imme-
diately below costal fracture, let undoubtedly conclude
for the evidence of premortal pneumothorax.
These findings were confirmed on the autopsy
examination, performed the same day. In addition, the
autopsy examination documented the presence in the
166 Forensic and Clinical Forensic Autopsy

left pleural cavity of 150-cc frankly hematic fluid, and in

the right pleural cavity of about 225-cc frankly hematic
fluid. The left lung measured 21.5 × 15 × 5.5 cm and
weighed 220 g. In correspondence with the mediastinal
face of the inferior lobe, there were several areas of blu-
ish color, occupying an area of the overall dimensions
of 6 × 2 cm, in which multiple tears of the pleura were
inscribed. The right lung measured 20.5 × 11.5 × 5 cm,
weighed 265 g, and appeared to be widely affected by
bluish discoloration, most evident in the upper lobe.
Moreover, at the rib face of the upper lobe, there were
multiple lacerations of the visceral pleura, occupying
an area of overall dimensions of 3 × 1 cm.
So the cause of death was identified as acute
respiratory failure.

4.9 Case Study #3

A 52-year-old man was involved in a shooting of Gargano
mafia, have being reached by several gunshots, that is
either Kalashnikov-single bullet either rifle-multiple pel-
lets. In a real true cruel execution, the man was hit mainly
at level of the skull and of his cervical spine, determining
the cause of death. In particular, Figure CS-3.1 shows a
CT scan visualized with bone window, and relative MIP
reconstruction (Figure CS-3.2) with the presence of mul-
tiple bullets and fragments in the maxillofacial bones.
MIP reconstruction allows us to identify the high-density
fragment and can facilitate the fracture lines; in this case,
it is possible to recognize an almost complete destruction
of the splanchnocranium, with several fractures that
involve the base of the skull, interestingly above all the
posterior and middle cranial fossa.
Figure CS-3.2 The presence of multiple bullets and
fragments in the maxillofacial bones.
Figure CS-3.3 shows the precise localization of a
bullet in the vertebral canal at level of C6, with evi-
dent posterolateral entry hole. This bullet determines
a complete section of the spinal cord at that level.
To confirm its position, MPR reconstruction was used
to have a correct orthogonal visualization either in
coronal and in sagittal plane; each reconstruction was
then accompanied by relative MIP (Figures CS-3.4a
and b, CS-3.5a and b) to enhance the demonstration
of other bullets, fragments, and bone lesions. Indeed,
Figures CS-3.5a and b, CS-3.6a and b demonstrate the
presence of at least six bullets, two of them in the right
cheek, next to the omolateral mastoid process, and the
ascending branch of the right mandible.

Figure CS-3.3 A bullet in the vertebral canal at level of

Figure CS-3.1 A CT scan visualized with bone window. C6, with evident posterolateral entry hole.
Postmortem Radiology and Digital Imaging 167

Figure CS-3.4 (a and b) Visualization in coronal plane.

Figure CS-3.5 (a and b) Visualization in sagittal plane.

Figure CS-3.6 (a and b) A VR with the demonstration of deep depression of the right hemiskull.
168
Figure CS-3.6a, moreover, shows a previous man-
dible fracture, synthesized by means of metal prosthesis
for a further gunshot lesion; this MPR reconstruction
was very useful during the recognition operations. In
sagittal MPR reconstruction, the cranial disintegration
with almost complete brain material leakage was clear.
CT was used, above all in its first phase of usage,
to study the surface of body. Figure 4.16a and b shows
a VR with the demonstration of deep depression of
the right hemiskull, caused by comminute, multi-
fragment, compound fracture as well evidenced in
Figures CS-3.6b and Figure CS-3.7.
Figure CS-3.7 External visualization.
Figure CS-3.8 (a and b) Bone 3D-VR reconstruction.
Forensic and Clinical Forensic Autopsy
Suggestive, often useful, bone 3D-VR reconstruc-
tion can be used to quickly visualize the location
of any bullets or foreign bodies that can be helpful
during autopsy (CS-3.8a and b).
4.10 Case Study #4
A 52-year-old man, without any criminal records, was
involved in a shooting of Gargano mafia. The PMCT
performed before the autopsy revealed the presence of
multiple foreign bodies of different shapes and dimen-
sions (Figure CS-4.1).
Figure CS-4.1 The presence of multiple foreign bodies.
Postmortem Radiology and Digital Imaging
Figure CS-4.2 The presence of a bullet in the vertebral canal.
Figure CS-4.3 Image of the thorax.
In particular, this 3D-VR allows us to notice the
channel wound, passing through the posterior arch
of the right 12th coast (fractured), right transverse
apophysis of L2 (fractured), and the left iliac wing
(decomposed fracture with bone fragments on the
external side out of the hip).
MPR reconstruction even in this case allows
to localize precisely a bullet in the vertebral canal
(Figure CS-4.2).
The study of the thorax also allowed us to visual-
ize the abundant right hemothorax (80HU) with strat-
ification of hematocrit (from bottom to top) and a left
layer of hemothorax (Figure CS-4.3).
Blood was also detected at the right paracolic gut-
ter level associated with the so-called vanishing aorta
sign (Figure CS-4.4).
169
Figure CS-4.4 Blood collection was also been observed
at the right paracolic gutter level.
4.11 Case Study #5
A man was found dead by his wife in his covered park-
ing under the building in which he lived. At the exter-
nal examination, the corpse presented multiple bruises,
excoriations, and irregular wounds at the frontal, pari-
etal, and occipital regions of the head, whose palpation
allowed us to notice the presence of underlying frac-
tures, compatible with blunt injuries. Moreover, the
neck showed stab wounds on its left, anterior, and right
sides. The left hand presented the same stab wounds.
Within 72 hours, autopsy was performed. Before
it, the MPMCTA with femoral access was realized.
During the so-called dynamic phase, thanks to
MIP reconstructions, a lesion of the right internal
170 Forensic and Clinical Forensic Autopsy

jugular vein was detected, with spreading of contrast
medium between the adjacent soft tissues according to
the decubitus (Figure CS-5.1).
This lesion was better revealed by comparing the
right internal jugular vein to the left one with VR
reconstruction (Figure CS-5.2).
Then, MIP reconstruction was used to study the
skull revealing multiple cranial fractures with decom-
posed and slightly introflected bone fragments, with
the underlying areas of SAH (subarachnoid hemor-
rhage) (Figure CS-5.3a and b).
Skull fractures and their mutual position were better
seen with volume bone reconstruction (Figure CS-5.4).
These findings were confirmed on the autopsy.
The lesion of the right jugular internal vein measured
1.2 × 0.5 cm, with the presence of numbers of erythro-
cytes in the context of the muscular and elastic fibers
of the vessel wall.

Figure CS-5.1 MIP reconstructions showing a lesion of the right internal jugular vein, with spreading of contrast
medium between the adjacent soft tissues according to the decubitus.

Figure CS-5.2 VR reconstruction illustrating the lesion.

Postmortem Radiology and Digital Imaging 171

Figure CS-5.3 (a and b) Multiple images of the skull.

The cause of death was established to be an

acute anemia secondary to the wound of the right
jugular vein affecting a subject with severe cranio-
encephalic injuries. All of these were found using
MPMCTA.

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Forensic Genetics and Genomic
FRANCESCO SESSA AND FRANCESCA MAGLIETTA
University of Foggia

ALESSIO ASMUNDO
5
University of Messina

CRISTOFORO POMARA
University of Catania

Contents
5.1 Introduction 177
5.2 Nonhuman Forensic Genetics 178
5.3 Molecular Application in Human Forensic Investigation 179
5.3.1 Identification 179
5.3.2 Searching the “Causa Mortis” 180
5.3.3 Understanding Manner of Death 182
5.3.4 Pharmacogenetics: How Death Could Be Influenced 183
5.3.5 Gene Expression: The Central Dogma 183
5.4 Future Perspectives 184
5.5 Case Study #1 184
5.5.1 The External Examination 185
5.5.2 Autopsy Findings 185
5.5.3 Genetic Analysis 185
5.5.3.1 Discussion 186
5.5.3.2 Ethical Approval and Consent to Participate 187
5.5.3.3 Consent for Publication 187
References 187
Case Report 192

5.1 Introduction to forensic science, such as forensic odon-

The forensic science is a multidisciplinary system of
knowledge that involves biology, physics, mathemat-
ics, medicine, chemistry, etc. Due to the highly com-
plex nature of forensic science, forensic scientists are
most often skilled in a particular area of forensic sci-
ence, such as latent prints, questioned documents,
trace evidence, or firearms, just to name a few.
Forensic scientists can be divided into three major
groups:
• Forensic pathologists: These include medical
examiners and other professionals who oversee
autopsies and clinical forensic examinations.
• Forensic scientists: These include forensic
professionals working in law enforcement,
government, or private forensic laboratories.
• Associated scientists: These include scien-
tific professionals lending their knowledge
tologists, forensic botanists, and forensic
anthropologists.
The application of molecular genetics technologies to
the forensic field is becoming very important, dem-
onstrating a pivotal role in cases that have to do with
civil and criminal law, family law, as well as in cases
of catastrophes with numerous victims (natural, acci-
dents, wars, terrorist attacks).
Genetic testing is usually named as a medical
investigation with the aims to identify changes in
chromosomes, genes, or proteins (Holtzman et al.,
1997). It is possible to distinguish several genetic test-
ing methods:
• Molecular genetic tests (or gene tests) study
single genes or short lengths of DNA to iden-
tify variations or mutations that lead to a
genetic disorder.

177
178
• Chromosomal genetic tests analyze whole
chromosomes or long lengths of DNA to see
if there are large genetic changes, such as an
extra copy of a chromosome, which cause a
genetic condition.
• Biochemical genetic tests study the amount
or activity level of proteins; abnormalities in
either can indicate changes to the DNA that
result in a genetic disorder.
Genetic testing could be performed to achieve differ-
ent aims: newborn screening, diagnostic testing, car-
rier testing, prenatal testing, preimplantation testing,
predictive and presymptomatic testing, and foren-
sic testing (Haeusermann et al., 2017; Bonthron and
Foulkes, 2017; Temming and Macones, 2016).
In a strict definition of genetic testing applying to
forensic sciences, it was commonly thought that the
polymorphic DNA sequences were used to identify
an individual for legal purposes. Indeed, the Short
Tandem Repeat (STR) typing has been usually used
to identify crime or catastrophe victims, rule out or
implicate a crime suspect, or establish biological rela-
tionships between people (e.g., paternity) (Jobling and
Gill, 2004; Carracedo et al. 2007).
The general definition that has better defined the
idea of “forensic genetics” has been reported in main
journal of this field (Forensic Science International:
Genetics), who reported it as “the application of genet-
ics to human and nonhuman material (in the sense of
a science with the purpose of studying inherited char-
acteristics for the analysis of inter- and intraspecific
variations in populations) for the resolution of legal
conflicts.”
This chapter aims to analyze the molecular tech-
niques applied to the human and nonhuman forensic
scenario, considering the scientific progress from the
past 30–40 years which has highlighted and continues
to highlight the role of this important tool to solve
forensic casework.
Table 5.1 Most Relevant Applications of Molecular Technologies for Forensic Purposes in Nonhuman Field
Nonhuman Forensic Genetics – Applications
Plants Microorganism
• Bioterrorism • Bioterrorism
• Silent witness of CS • Silent witness of CS
• Patent misappropriates • Outbreaks and
• Identification of endangered transmission of
and exotic species pathogens
• Identification of illegal drugs • Human identification
• Estimation of
postmortem interval
• Geolocation
Forensic and Clinical Forensic Autopsy
5.2 Nonhuman Forensic Genetics
This field of molecular technique application is fre-
quently underevaluated with respect to other fields
in forensic sciences. Contrariwise, the application of
molecular techniques is very important in the non-
human sector, allowing us to solve important foren-
sic problems, supporting undoubtedly the forensic
investigations.
Even if the forensic science applied to nonhuman
samples may not have attained the profile of human
identification, the scale of criminal activity related to
this field of investigation is extensive by any subsector.
It is possible to divide the molecular applications into
four subsectors: animals, plants, microorganisms, and
food (Table 5.1, Arenas et al., 2017).
The invisible line that connects each of these sub-
sectors is an important forensic application: The pres-
ence of one or more elements on a crime scene (CS)
could be used as a silent witness of crimes. For example,
the identification of an animal fur (dog’s hair) or the
presence of a vegetal seed on the victim’s corpse could
be very useful to locate correctly the CS. Considering
the increased interest in the use of nonhuman DNA
typing in forensic science investigations, in 2011,
Linacre et al. with the aim to define the standardiza-
tion of methodologies used in the forensic analysis of
animal DNA or in reporting styles published a paper
with the guidelines on the use of nonhuman DNA in
a forensic science investigation (Linacre et al., 2011).
Moreover, the identification of a particular food or
the presence of specific microorganisms could be very
useful in the forensic investigation: All these nonhu-
man elements could be considered a silent witness of a
CS (Butler, 2010).
Specifically, the knowledge in the molecular field
could be applied in animal subsectors to solve ani-
mal attacks, livestock robbery, illegal fishing, wildlife
crimes, and doping controls, and in the determination
Food Animals
• Bioterrorism • Animal attacks
• Silent witness of CS • Silent witness of CS
• Patent misappropriates • Kinship/pedigree tests
• Identification of allergens • Doping controls
• Identification of genetically • Livestock robbery
modified organisms • Illegal fishing
• Wildlife crimes
Forensic Genetics
of pedigree or kinship (Staats et al., 2016; Johnson,
et al., 2014).
The application of molecular technologies to the
plants is frequently applied to identify illegal drugs:
Solano et al. (2018) described the use of molecu-
lar analysis to support other tests, like sporological
examination, to allow the identification of psychedelic
fungus in a case of illegal drug traffic. They described
an innovative DNA analysis as a reliable method that
can be used as an identification tool for the purposes
of supporting evidence, due to the high variability of
DNA between species. Moreover, these technologies
are very useful in the identification of endangered and
exotic species, patent misappropriations, and for the
bioterrorism. Finally, the molecular tools can be used
in the illegal trafficking of plants: Even if the police
department often confiscated the substances, it needs
a validated tool to identify plants in the illegal trade
(Sharma and Thakar, 2018).
Another important sector in the nonhuman foren-
sic application is related to the analysis of microorgan-
isms. The molecular applications in this field could be
a very useful tool in the bioterrorism fight, outbreaks
and transmission of pathogens, in the estimation of
postmortem interval, and for the geolocation of vic-
tims. Another important application of forensic genet-
ics is related to the human microbiome: It is relatively
untapped resource for human identity testing. A very
interesting study suggests that microbial strain com-
position could be a useful tool for forensic human
identification (Woerner et al., 2019).
Finally, the molecular technologies are frequently
used in the food analysis, helping the forensic inves-
tigation in the identification of food origin and com-
position, in the identification of allergens, in the
identification of genetically modified organisms, and
in the bioterrorism (Arenas et al., 2017).
As previously described, the forensic applications
in the nonhuman field could be very useful, support-
ing the investigations allowing us to collect impor-
tant pieces of evidence to solve complex crimes. These
applications are frequently underestimated and unap-
plied; contrariwise, the knowledge in this field should
be mandatorily used in every crime laboratory.
However, when analyzing food or forensic sam-
ples, the analytical procedure is often challenged by
low amounts of poor-quality template molecules and
complex matrices. This problem is amplified by the
heterogeneous samples worked in nonhuman forensic
test, with interfering matrices, with relevance in food
testing, forensic DNA analysis, bioterrorism prepared-
ness, and veterinary medicine (Hedman et al., 2018).
179
5.3 Molecular Application in Human
Forensic Investigation
The molecular techniques meet the human forensic
fields in several criminal investigations, with com-
pletely different tasks.
5.3.1 Identification
The human genome is organized as 23 pairs of chro-
mosomes: the X and Y sex chromosomes and the
remaining autosomal chromosome pairs, numbered
1–22. The human genome is peppered with regions
of repetitive DNA – hypervariable regions consisting
of a short DNA sequence repeated in tandem. These
regions are polymorphic in that the sequence varies in
the number of copies of the repeat unit. The number
of repeat units is indicated by the allele designation
(Anderson et al., 1981).
Many samples recovered from CSs yield only
nanogram or picogram amounts of DNA that is
sometimes degraded; due to these reasons, PCR (poly-
merase chain reaction)-based STR analysis is of higher
throughput so that more samples can be analyzed in
less time. Ideally, STR loci for forensic use are physi-
cally separated enough so that they are inherited inde-
pendently of each other (i.e., not genetically linked)
(Edwards et al., 1991; Chakraborty et al., 1999; van
Oorschot et al., 2010). Moreover, some polymorphic
regions could be located on sex chromosomes, X-STR,
and Y-STR, which are very useful in several complex
cases, like sexual assault (Tie and Uchigasaki, 2013;
Israr et al., 2014; Kayser, 2017).
While the analysis of nuclear DNA provides full
STR profiles in many situations, ancient or degraded
samples often yield partial profiles or no profile.
In these cases, analysis of mitochondrial DNA
(mtDNA) may provide information where nuclear
DNA analysis cannot (Carracedo et al., 2000; Szibor
et al., 2000).
Moreover, in the past few years, thanks to the new
sequencing tools, the multiplex SNP (single-nucleotide
polymorphism) analysis is becoming the preferred
identification method, especially in the cases with a
small amount of degraded DNA (Budowle and Van
Daal, 2008; Fondevila et al., 2017).
The forensic application of DNA typing not only
involves paternity testing and stain analysis collected
on CS but also involves other cases like specimen
identity of FFPE (formalin-fixed, paraffin-embedded)
tissue, thus determining the possible diagnostic errors
(Ullah et al., 2017).
180
Moreover, the genetic analysis could be used to
predict the origin population of a typed DNA and
for unknown corpse identification; this finality of the
forensic molecular tools is very useful in mass disaster,
for example (Zietkiewicz et al., 2012).
The concept of “identification” could be extended
to the determination of the biological trace. To date,
this is an important step of forensic investigation;
indeed, the identification of DNA profile sampling an
object found during a Crime Scene Investigation (CSI)
without the determination of the biological sources
could produce unstable evidence (Apostolov et al.,
2009).
The biological source identification of DNA pro-
file should be mandatorily performed in every DNA
analysis, with the exception for the case in which
this step could compromise the DNA typing. Indeed,
the conventional methods to identify the sources of
body fluids are immunological, chemical, and enzy-
matic tests. The difficulties linked to these methods
are related to great variability in terms of specificity
and sensitivity, the large amount of required sample,
and not reliable tests for every body fluid (e.g., vaginal
secretion and menstrual blood). In order to address
these issues, different molecular genetic approaches
could be used, such as the methylation, cell-specific
proteins, or RNAs (Forat et al., 2016; Zubakov et al.,
2010; Hanson et al., 2009). To date, these methods are
becoming the preferred tools.
Moreover, the exact identification of the biological
source of DNA typing could avoid the critical issue;
indeed, by developing new forensic technologies, it is
possible to obtain a complete profile starting to few
Figure 5.1 “Causa mortis” identification remains one of the major applications of the forensic sciences. To reduce
the mistakes, several steps are necessary, allowing the right identification of the cause of death.
Forensic and Clinical Forensic Autopsy
cells: In this manner, it could be typed a subject who
has handled an object for a few seconds, both a gar-
ment and other articles (such as weapons). The power
of “touch DNA,” described for the first time in 1997
by van Oorschot and Jones (Van Oorschot and Jones,
1997), has opened an undiscovered world, even if it
is important to know the potential limitations of this
technique (van Oorschot et al., 2019).
5.3.2 Searching the “Causa Mortis”
The “causa mortis” identification remains one of the
major applications of the forensic sciences. Several
steps are necessary to reduce the mistakes, allowing
the right identification of the cause of death. The first
step is the external examination, which is an impor-
tant step, even if is often poorly performed and docu-
mented. Evidence that is crucial to the formulation of
the correct cause of death may be readily overlooked:
If the pathologist fixed the “causa mortis” only with
this step, it could fall in error with a percentage of
70%. The following step is the autopsy: An important
technique allowed reducing the error identification to
30%. Moreover, it is important to underline that the
use of other techniques, such as histological, toxico-
logical, and molecular examinations, let the exact
identification of causa mortis, limiting the errors to
few complex cases or when an error occurs during the
application of these techniques (Madea et al., 2010)
(Figure 5.1).
The top ten global causes of deaths in 2016 defined
by World Health Organization (WHO) are ischemic
heart disease; stroke; chronic obstructive pulmonary
Forensic Genetics
disease; lower respiratory infections; Alzheimer’s dis-
ease and other dementias; trachea, bronchus, lung
cancers; diabetes mellitus; road injury; diarrheal dis-
eases; and tuberculosis (WHO, 2018). In light of these
data, nine of the WHO’s ten leading causes of global
deaths have genetic components, underlying a pivotal
role of the molecular techniques in the identification
of the right cause of death.
The molecular techniques applied to forensic sci-
ence are very important in helping the medicolegal
community in the identification of substrates or con-
causes that could be important in the definition of the
“causa mortis.” Indeed, many human diseases have a
genetic component. A genetic disease is any disease
that is caused by an abnormality in an individual’s
genome. There are several types of genetic disorders:
chromosomal abnormalities, single gene defects,
multifactorial problems, and teratogenic problems.
Genome-wide association studies (GWASs) have iden-
tified hundreds of genetic variants associated with
complex human diseases and traits, and have pro-
vided valuable insights into their genetic architecture
(Manolio et al., 2009). For these reasons, frequently,
genetic substrate could be identified as the main
explanation for the “exitus” of the subject. For exam-
ple, when the thrombosis is correctly identified as the
cause of death, it could be very important to analyze
the genetic characteristics of the subject. The risk of
thrombosis is substantially increased for patients
with multiple genetic risk factors (i.e., the “double hit
hypothesis”), including the prothrombin (G20210A)
gene mutation, Factor V Leiden mutation, hyperho-
mocysteinemia, methylenetetrahydrofolate reductase
(MTHFR)-thermolabile polymorphism, protein C
deficiency, protein S deficiency, and antiphospho-
lipid antibody syndrome(s) (Previtali et al., 2011). For
example, the Factor V Leiden mutation is the most
common variant associated with inherited thrombo-
sis. FV mutation has a high prevalence in the general
population, enhancing the risk of venous thrombosis,
with odds ratios (ORs) of 3–8 in heterozygotes and
30–140 in homozygotes (Bertina et al., 1994).
In light of these considerations, the genetic test-
ing is very useful in the medicolegal activities, both for
identifying the cause of the death and for helping the
relative’s health status, with the early identification of
an unknown disease.
Frequently, in the scientific community, the
“molecular autopsy” is undoubtedly linked with “sud-
den cardiac death” (SCD), especially for the unde-
termined cases. Indeed, the SCDs represent about
the 20% of death caused by cardiovascular diseases
(Wellens et al., 2014). It is estimated that SCD claims
181
∼10 times as many lives as do traffic accidents in the
EU and United States combined. Between 45% and
50% of SCD victims are not previously diagnosed
with heart disease (Pagidipati and Gaziano, 2013;
Myerburg et al., 1992).
Molecular autopsies have been reported to be of
value in case of SCDs, particularly in autopsy-negative
cases. The identification of DNA variations in deceased
individuals could be very important to determine the
cause, which contributed to and/or was likely to have
caused the death.
One of the most important problems linked to
the SCD diagnosis is linked with the number of genes
involved in this kind of pathologies: This problem is
known as “genetic heterogeneity of cardiomyopa-
thies.” Indeed, the key barriers to the identification of
these genetic factors have been restricted sample sizes,
heterogeneity of the associated cardiac substrate, and
the difficulty of ascertaining adequate phenotype
information after cardiac arrest (Kolder et al., 2012).
An in-depth explanation of the concept that
reported all genes involved in the control of ECG
parameters is well summarized in Table 5.2 (Bezzina
et al., 2015).
The new genetics technologies to identify the
mutations have undoubtedly supported this impor-
tant field, like whole-genome sequencing (WGS),
allowing the diagnosis and their associated preven-
tions. Indeed, in the guidelines for autopsy investi-
gation of SCD of 2017 update from the Association
for European Cardiovascular Pathology, the toxico-
logical and molecular pathological analyses of blood
and other adequately collected body fluids are recom-
mended in all victims of unexplained sudden death.
To avoid the use of FFPE tissue which does not allow
us to obtain the exact quantity and quality of DNA,
it is very important to collect an appropriate material
(blood, tissue, or body fluids) for toxicological, micro-
biological, biochemical, and molecular investigations
before the burial (Basso et al., 2017).
Finally, the molecular techniques could be very
useful for the identification of pathogens, in both
viral and bacterial infections. Modern medicine has
successfully used new technologies, particularly in
the molecular field, based on scientific achievements,
to diagnose and treat infectious diseases (Mattick,
2003). In recent years, traditional microbiological
methods such as microscopic or culture-based micro-
biological analysis have been supplemented with new
systems, based on molecular genetic technologies
such as the PCR assays (McLuckie et al., 2018; Zandi
et al., 2010; Chakravorty et al., 2010), multiplex PCR
(Roberts et al., 2011), or real-time PCR (Seaman
182 Forensic and Clinical Forensic Autopsy

Table 5.2 Gene Identified as Modulators of ECG Parameter Thanks to GWASs

Gene Identified as Modulators of ECG Parameter
Heart Rate PR Interval QRS Interval QT Interval
CD34, NKX2.5, CD46, MEIS1, SCN5A, C1orf185, RNF11, CDKN2c, NOS1AP, SCN5A,
CD34, GJA1, PLXNA2, SCN10A, FAF1, NFIA, CASQ2, CACNA1D, SCN10A, PLN, SLC35F1,
CTSS, PLN, MYH7, ARHGAP24, SCN5A, SCN10A, CRIM1, RNF207, CNOT1, LITAF,
LOC644502, EPHB4, WNT11, SOX5, HEATR5B, STRN, LRIG, LIG3, TCEA3, SP3,
SLC12A9, SRRT, BCAT1, NKK2.5, SLC25A26, HAND1, SPATS2L, C3ORF75,
UFSP1, ACHE, HCN4, CAV1, CAV2, SAP30L,TBX20,TBX3, TBX5, SLC4A4, SMARCAD1,
FADS1, GPR133, TBX3, TBX5 PLN, PRKCA, HAND1, SAP30L, GFRA3, GMPR, NCOA2,
SOX5, BCAT1, PI16, CDKN1A, IGFBP3, DKK1, LAPTM4B, AZIN1,
KIAA1755, CCDC141, VTI1A, KLF12, SIPA1L1, GBF1, FEN1, FADS2,
SYT10, GNB4, FLRT2, GOSR2, SETBP1 KLF12, ANKRD9,
CHRM2, GNG11, USP50, TRPM7, MKL2,
B3GNT7, FNDC3B, TTN, CCDC141,
RFX4, CPNE8, TFPI SUCLA2, KCNH2,
KCNQ1, KCNJ2,
KCNE1, ATP1B1, CAV1,
ATP2A2, PRKCA, SRL,
SCL8A1

et al., 2010), enzyme-linked immunosorbent assay
(ELISA) (Lequin, 2005; Cho and Irudayaraj, 2013),
direct sequencing (Bakour et al., 2016; Bertelli and
Greub, 2013), and metabarcoding (Günther et al.,
2018). Although these technologies are efficient, new
platforms for rapid detection and characterization of
microbial pathogens are critically needed to prevent
and treat diseases (Allicock et al., 2018). Indeed, exist-
ing detection technologies are based on the amplifica-
tion of nucleic acid sequences. While these methods
are able to rapidly identify selected pathogens at spe-
cies or even strain level, they cannot be multiplexed to
detect hundreds of species simultaneously. New tools
have been developed such as “DNA chips” or “DNA
microarray,” with an aim to test an arrayed series of
thousands of microscopic spots of DNA oligonucle-
otides, each containing a specific DNA sequence
(“probe”). In this manner, it is possible to detect mul-
tiple pathogens in clinical and environmental samples
(Mäder et al., 2011; Otero et al., 2010). These new tools
could be very useful for the identification of the cor-
rect cause of death, for example, allowing us to ascer-
tain the eventual medical/hospital responsibility.
5.3.3 Understanding Manner of Death
As a definition, the “cause of death” could be kept in
mind as well as the “kind of death.” “Cause of death”
is a term used to indicate the medical cause of death,
identifying the list of the diseases or injuries that
caused death. “Manner of death” is the way to catego-
rize death. The classifications are natural, accident,
suicide, homicide, undetermined, and pending.
In other words, while the “cause of death” repre-
sents the scientific term used to define the “biologi-
cal cause” of a man’s death, the “manner of death”
extends this significance, with the aim to identify the
concealed aspects under the death. In this manner, it
is possible to turn out unnatural as a natural death,
and vice versa. To better understand the fine line that
distinguishes these two similar but different concepts,
it can be used an example.
Traumatic brain injury (TBI) is a leading cause of
death and disability worldwide, hitting all ages and
demographics. Symptoms associated with TBI can
appear immediately following injury or days to weeks
later, and result in wide-ranging physical and psycho-
logical deficits. TBI is classified into three categories,
namely, mild, moderate, and severe (Marshall et al.,
2015; Gregory et al., 2017). It is very interesting to note
that the same brain trauma could be a different con-
sequence: At the base of these differences, there is the
genetic substrate of the subject involved in the acci-
dent. A growing body of literature has attributed to
an important role of genetic factors in the interindi-
vidual variability observed in TBI, and in predicting
functional and cognitive outcomes following brain
injury (McAllister, 2015; Weaver et al., 2014; Wilson
and Montgomery, 2007; Davidson et al., 2015).
Several genes that influence the outcome follow-
ing TBI have been implicated. The genes involved
in TBI can be roughly categorized into those that
influence the extent of the injury (e.g., pro- and anti-
inflammatory cytokines) and those that effect repair
and plasticity (e.g., neurotrophic genes). An additional
category of genes that should be considered are those
Forensic Genetics
that effect pre- and postinjury cognitive and neu-
robehavioral capacities (e.g., catecholamine genes)
(Bennett et al., 2016; McAllister, 2015).
In this regard, several studies conducted on mili-
tary and athletes exposed to brain injury have high-
lighted the pivotal role of the genetic predisposition in
the consequences of the brain trauma (Dashnaw et al,
2012; Saigal, and Berger, 2014; McKee et al., 2014).
These studies have underlined the polygenic
nature of TBI, involving the interaction of numer-
ous genes from multiple pathways. Moreover, the role
of epigenetic mechanisms is very important in dis-
ease and injury, considering that these mechanisms
can effect gene expression without altering the DNA
sequence (Qureshi and Mehler, 2010; Liyanage et al.,
2014).
Considering the importance of the polygenic trait,
it is very important to define the genetic characteris-
tics of the subject dead for brain injury to better com-
prehend the “manner of death.” As extensively treated,
the kind of trauma could bring different consequences
with severe or moderate trauma. In light of these con-
siderations, a trauma caused after physical aggression
could have different legal implications for the offender,
passing by the prosecution for the “attempt to homi-
cide” to “homicide,” and vice versa.
Finally, the genetic characteristics could be con-
sidered in an experimental study on this TBI thematic:
For example, it could be very important to define
the genotype in the formulation of the experimental
group (Neri et al., 2018).
5.3.4 Pharmacogenetics: How Death
Could Be Influenced
Pharmacogenetics is the study of inherited genetic dif-
ferences in drug metabolic pathways (and other phar-
macological principles, such as enzymes, messengers,
and receptors), which can affect individual responses
to drugs, both in terms of therapeutic effect and in
terms of adverse effects (Shah, 2004). Advances in
pharmacogenetics of drug-metabolizing enzymes and
pharmacological targets, together with the prospects
of rapid and inexpensive genotyping procedures, allow
us to individualize and improve the benefit/risk ratio of
therapy with drugs. The main application of pharma-
cogenetics knowledge is warfarin therapy (Mackman,
2008). This is a drug commonly prescribed to prevent
thromboembolism, but it remains a challenging drug
to manage. This is predominate because of its narrow
therapeutic index and the significant interpatient vari-
ability in the dose that produces therapeutic anticoag-
ulation. Indeed, the activity of warfarin is affected by
183
diet and genetic makeup: Polymorphisms in the gene
that encodes vitamin K epoxide reductase and in the
cytochrome P450 gene CYP2C9 account for up to 50%
of the interindividual variability of warfarin dosing
(Krynetskiy and McDonnell, 2007). In light of these
considerations, before warfarin prescription/assump-
tion, the genetic characterization is very important.
In the same manner, other drugs could have different
effects on the user/abuser in consideration of the gen-
otype, causing possible adverse effects, with forensic
consequences.
The medicolegal interest in this field is amplified
not only by the response to the licit or illicit drugs, but
also it is important in distinguishing if the death can
be classified as an accident or suicide. For example, a
drug intoxication could be caused by a hypersensitiv-
ity to the drugs on genetics basis or, alternatively, by a
voluntary assumption like suicide attempt.
Moreover, considering that the drug assump-
tion has direct consequences both for metabolism
responses and by the target organs, emerging genetic
tools, like epigenetic applications, could be very use-
ful in the forensic sciences. Over the past few years,
the micro-RNA (miRNAs) were considered promis-
ing biomarkers for diagnosis and therapeutic targets
of several human diseases, which is becoming one of
the most investigated fields by the scientific commu-
nity (Hur, 2015). The main characteristics of circulat-
ing miRNAs that endorse the use of these prognostic
tools are related to the stability, both at room tempera-
ture and during freeze–thaw cycles, and to the mini-
mal quantity of sample required (Blondal et al., 2013).
Furthermore, the ongoing efforts to incorporate and
discover the potentiality of miRNAs could be very
useful to provide insights into the complex pheno-
type of drug response (Ghasabi et al., 2019; Burgess
et al., 2018). These characteristics highlight the impor-
tant role of miRNAs in the near future as new tools
for forensic application for the identification of illicit
drugs both for hedonistic purpose and in sports activ-
ities, helping undoubtedly the antidoping fight. For
example, an interesting research idea suggested in
a recent article is the use of miRNAs dosage as new
potential molecular biomarkers of anabolic andro-
genic steroid use/abuse (AASs) (Sessa et al., 2018).
In a similar manner, the miRNAs could be used
as less invasive or noninvasive molecular biomarkers
to identify the use of licit or illicit drugs.
5.3.5 Gene Expression: The Central Dogma
Transcription and translation are two processes of
synthesis, which are equalized thanks to two reactions
184
of decay – dilution and degradation of mRNAs and
proteins, setting the steady-state protein abundance.
This concept synthesizes the four basic rates of the
central dogma (Crick, 1970; Hausser et al., 2019). In
other words, the central dogma of biology provides
the basic framework for how genetic information flows
from a DNA sequence to a protein production inside
cells. This process of genetic information flowing from
DNA to RNA to protein is called “gene expression.” To
date, the use of data in the forensic field is undoubtedly
an essential part of the work of the forensic laboratory.
Several papers described the use of gene expres-
sion data (both mRNA and miRNA) to identify the
just time of the death. For example, Sibbens et al.
(2017) in their paper analyzed the roles of melatonin
and cortisol, in order to develop a forensic molecular
clock for postmortem blood samples, using mRNA
transcripts. Moreover, Corradini et al. (2015) reported
the possibility to use four miRNAs as “chronobio-
markers” for the time-of-death determination.
Other works highlighted the use of gene expres-
sion to identify the vitality of the lesion, to solve the
complex case. Bedreag et al. (2015), considering that
tissue injuries are followed by a significant change
in the expression of miRNAs in biological fluids,
suggested their use in the time injury identification.
Moreover, other papers have described the possibility
to establish wound aging using the serum levels of the
cytokines (Ye et al., 2018; He et al., 2018).
Finally, the identification of miRNAs exclusively
detected in the determined tissues has allowed the dif-
ferentiation of the source origin of a biological trace.
For example, the blood mixture could be differentiated
using these miRNAs, thereby allowing the identifica-
tion of the anatomical region of provenience. In other
words, it could be possible to identify if the blood mix-
ture is produced by the blood of the abdominal region
(e.g., identifying the miRNAs exclusively expressed in
the liver) and by menstrual blood (testing the miRNAs
specific for this tissue) (Hanson et al., 2009; Johnson
et al., 2018).
5.4 Future Perspectives
In this chapter was described the pivotal role of the
molecular techniques in the forensic investigation. To
date, the central dogma of biology (DNA->mRNA->
protein) is at the base of the scientific technologies
that could be applied in medicolegal question. The
development of new tools has represented a historical
revolution, thus opening new undiscovered ways of
analysis in the medicolegal vision.
Forensic and Clinical Forensic Autopsy
In a more recent paper, it was demonstrated for
the first time the possibility to use single-cell analysis
to resolve real forensic cases involving the mixtures of
blood from two or even three people. In this experi-
mental study, applying DEPArray technology to both
mock and casework samples, the authors have demon-
strated the possibility to reconstruct from the analysis
of several single cells the clear profiles of all contribu-
tors to the blood mixes. Each single cell has produced
a different level of profile completeness, but always
with 100% concordance (Anslinger et al., 2018).
Current and next challenges in forensic applica-
tions are undoubtedly linked with the massively par-
allel sequencing (MPS) technologies, also termed as
NGS, both in nonhuman and in human applications.
For example, DNA barcoding is an approach that
involves the sequencing of short DNA sequences for
food and wildlife forensic species identification (Staats
et al., 2016). Moreover, these new technologies are
becoming increasingly popular and alternative to STR
typing (Xue et al., 2018). The future challenges for the
scientific community are related to the forensic use of
MPS. Indeed, even if this technology is routinely used
in other genetic diagnostic disciplines (such as oncoge-
netics and clinical genetics), it is still far from being a
routine forensic tools. The main criticisms that should
be resolved in the next future involve the full compre-
hension of the data obtained, the possibility to discuss
the results obtained with MPS in a court, the method
standardization, and which information is necessary
in a forensic investigation report (de Knijff, 2019).
All these considerations confirmed, making
actual and applicable to the forensic sciences, the
Marie Curie sentence: “Nothing in life is to be feared,
it is only to be understood. Now is the time to under-
stand more, so that we may fear less.”
5.5 Case Study #1
G. Bertozzi, P. Mazzeo, A. De Palma
Heritable thrombophilias are a heterogeneous group
of conditions associated with an increased risk of
thromboembolism. Typically, they involve a decrease
or abnormality in anticoagulant proteins, or an
increase in procoagulant factors. Acquired throm-
bophilias like antiphospholipid syndrome have been
associated with stillbirth, fetal growth restriction, and
preeclampsia (Ogishima et al., 2000). Despite the lack
of a clear association, many clinicians routinely screen
for thrombophilias in women with adverse pregnancy
outcomes, including stillbirth (Silver et al., 2016).
Forensic Genetics
Although venous thromboembolism (VTE) has
been observed, the uncommon disorder of pulmonary
embolism (PE) in women before menopause remains
one of the most common causes of sudden death among
apparently young healthy women (Konstantinides
et al., 2014). The absolute risk of PE is low among this
population, but it must be emphasized that the group
affected are young healthy persons (Dinger et al., 2007).
Combined oral contraceptives (COCs) were long ago
reported to induce VTE (Gronich et al., 2011), the
most important determinant of the benefit/risk profile
of contraceptives (Heinemann et al., 2010). With their
use, the risk of VTE may increase six times compared
to nonusers, making the relative risk of thromboem-
bolic complications high (Trenor III et al., 2011).
A 17-year-old female patient was admitted to hos-
pital because of dyspnea, palpitations, chest discom-
fort, weakness, and moderate temperature (37.5). Six
days before, she fell during beach volley match; after the
radiological investigation, a complete left rib fracture
was diagnosed. The medical investigation reported a
pleural effusion around the left lung, near the trauma
area. Radiological and CT examination confirmed
the pleural effusion. The patient’s medical history
was negative for significant disorders, but the patient
declared the use of oral contraceptives. On physical
examination, increased resting heart rate of about 110
per minute was found. ECG revealed sinus tachycar-
dia without other abnormalities. The blood samples
were taken for laboratory routine tests and bacterial
investigations, resulting in normal values. After four
days, the general conditions precipitated: hyperpy-
rexia, dyspnea, tachycardia (140 bpm). Conjecturing
a PE, several medical practices were applied such as
Ambu (auxiliary manual breathing unit) ventilation
and anticoagulant therapy. Nevertheless, despite the
medical procedures, the patient became cyanotic, and
after several resuscitation attempts, she died.
5.5.1 The External Examination
The main signs observed during the external exami-
nation were reported below:
1. Left nasal choana, percolation of the red liq-
uid material (blood?);
2. Oral cavity, presence of red fluid (blood?);
3. Neck, right-side face, presence of a sign of
acupuncture;
4. Left hemithorax, in correspondence with the
middle axillary line, originated a dermo-
graphic pencil mark, placed transversely to
the major axis of the body, which was carried
185
posteriorly in the dorsal region, up to the
paravertebral line, placed at the level of the
lower scapular; a dermographic pencil mark
was present at the level of the inferior rib arch,
arranged transversely to the major axis of the
body;
5. Right deltoid region, the presence of ECG-
graphing patch.
5.5.2 Autopsy Findings
At the autopsy investigation, in the left hemithorax
region, near to parietal pleura, several marks were
noted, which were due to hemorrhagic infiltration,
which extended for an area between the VII and IX
rib following the rear axillary line, with a total size of
7.5 × 6 cm. Finally, the venous tree in the abdomino-
pelvic tract was isolated, taking care to identify and
preserve the integrity of the vascular structures (infe-
rior vena cava, external iliac veins, and internal iliac
veins). In this manner, the main venous branches were
analyzed, opening in situ through the use of pointed
scissors and subsequent exploration of the lumen. In
the left iliac vein, there was a thrombotic formation of
reddish-brownish color (Figure 5.2), adherent to the
vessel wall, which was collected and stored in formalin
for the purposes of subsequent sampling operations to
prepare for histological examination.
Further red-brownish thrombotic formation, not
adherent to the vessel wall, was found at the right iliac
vein (Figure 5.3).
5.5.3 Genetic Analysis
In the postmortem evaluation, a blood sample was
also taken for the diagnosis of possible thrombophilia,
based on genetic factors. Particularly, several SNPs,
Figure 5.2  A thrombotic formation of reddish-brownish
color was found in the left iliac vein.
186 Forensic and Clinical Forensic Autopsy

rare disorder in young individuals without known risk

Figure 5.3 A thrombotic formation of reddish-brownish
color was found in the right iliac vein.
located on Factors II and V genes, were investigated
(Table 5.3).
The genetic investigation was negative, as shown
in Figure 5.4.
The forensic investigation has defined the pres-
ence of:
• Pulmonary thromboembolism;
• Thrombosis of the left iliac vein, undoubtedly
a recent onset on the previous thrombotic
organization; moreover, thrombosis of the
right iliac vein of recent onset was detected.
All data was confirmed by histological exami-
nation: Organ and tissue samples were taken
during autopsy, and massive pulmonary
edema was reported.
In light of these findings, the death of the patient was
caused by PE with emboli starting from a very recent
thrombus organization of the iliac veins, in line with
pharmacological anamnesis positive for the use of a
contraceptive pill.
5.5.3.1 Discussion
Based on genetic test results and clinical presentations,
normal-risk PE was diagnosed in the patient. PE is a
factors for VTE. Few data are available about the young
patients who experience the first episode of VTE dur-
ing contraceptive use. Cigarette smoking, overweight,
and positive family history for DVT were common
among the affected individuals (Trenor III et al., 2011).
Use of COC is common in athletic women since the
agents enhance physical capacity (Patnaik and Moll,
2008). Female athletes have no such risk factors as obe-
sity, immobility, and cigarette smoking; therefore, the
risk of VTE is lower in the population of COC users.
The risk of VTE returns to normal after discontinu-
ation of the treatment (Martínez et  al., 2012). Before
COCs are prescribed, counseling on side effects,
including VTE, is mandatory, and a careful evaluation
of risk factors for VTE and screening for other abnor-
malities, including hypertension, obesity, cigarette
smoking, and positive family history for spontaneous
VTE are recommended. In the case of previous VTE,
either COCs are contraindicated or, as in the case of
persons with risk factors for VTE, including throm-
bophilia, progestogen-only contraception may be an
option. Thrombophilia is the predisposition to form
clots inappropriately. The abnormality may result in
thrombotic disorders in young, apparently healthy
individuals (O’Brien, 2014; Lenicek Krleza et al., 2010).
Inherited thrombophilias have been found in about
30% of patients with PE, for which there are different
guidelines on screening (Ivanov et al., 2008).
In the case of PE in a young individual below
50 years of age, without any known risk factors, such
as immobilization, surgery, malignancies, screening
for thrombophilias is recommended, including muta-
tion of Factor V Leiden, prothrombin, antithrombin
III, protein C, protein S, Factor VIII, and activated
protein C resistance. The use of oral contraceptives
may induce PE in patients with inherited thrombo-
philias (Legnani et al., 2002).
The patient in the presented case was not found
to have an interaction between the genetic predisposi-
tion investigated and the fatal event occurred. These
results are very important because the prosecutors

Table 5.3 Results from the Blood Sample Taken

Gene SNPs Rs Reference Phenotype
FII, 11p11 C20209T Warshawsky et al. (2002) Thrombosis, venous
FII, 11p11 G20210A Poort et al. (1996) Thrombosis, venous
FII, 11p11 T20219A Flaujac et al. (2007) Thrombosis, venous
FII, 11p11 C20221T Wylenzek et al. (2001) Thrombosis
FV, 1q23 aa513 Hiyoshi et al. (1998) Thrombosis, increased risk
FV, 1q23 aa534 Bertina et al. (1994) Thrombosis, increased risk
FV, 1q23 aa1327 Castaman et al. (1997) Thrombosis, increased risk
Forensic Genetics 187

Gene SNPs Patient Electropherogram

C A A T A A A A G T G A C T C T C A G C G A G C T T C A A T G C T C C
C A A T A A A A G T G A C T C T C A G C G A G C T T C A A T G C T C C
rs72550707
FII,11p11 W.T.
C20209T

C A A T A A A A G T G A C T C T C A G C G A G C T T C A A T G C T C C
C A A T A A A A G T G A C T C T C A G C G A G C T T C A A T G C T C C
rs1799963
FII,11p11 W.T.
G20210A

C A A T A A A A G T G A C T C T C A G C G A G C T T C A A T G C T C C
C A A T A A A A G T G A C T C T C A G C G A G C T T C A A T G C T C C
cr072308
W.T.
FII,11p11 T20219A

C A A T A A A A G T G A C T C T C A G C G A G C T T C A A T G C T C C
C A A T A A A A G T G A C T C T C A G C G A G C T T C A A T G C T C C
cr015317
W.T.
C20221T
FII,11p11

A G T G A C G T G G A C A T C M T G A G A G A C A T C G C C T
A G T G A C G T G G A C A T C A T G A G A G A C A T C G C C T
rs140627208
FV,1q23 aa513 W.T.
(AGA>AAA)

G C A G A T C C C T G G A C A G G C G A G G A A T A C A G G T A T T T T G
rs6025 G C A G A T C C C T G G A C A G G C G A G G A A T A C A G G T A T T T T G
FV,1q23 aa534 W.T.
(CGA>CAA)
C T C GG T C A G A T G C C C C T T T C T C C A G A C C C C A G C C A T A C A AC C C T T T C T C T A GA C CT C A G C C A GA C A A A CC T C T CT

aa1327
FV,1q23 (CAT>CGT)
W.T.

Figure 5.4 Each genetic polymorphism was investigated with direct sequencing: The electropherograms highlighted
that the patient does not have genetic mutations.

have hypothesized a medical responsibility in con-
sideration of the fact that the genetic analysis was not
prescribed before the contraceptive use.
Thanks to postmortem genetic investigation,
it was possible to clarify that the cause of death is a
fatality.
5.5.3.2 Ethical Approval and
Consent to Participate
All procedures performed in the study were in
accordance with the ethical standards of the institu-
tion and with the 1964 Helsinki Declaration and its
later amendments or comparable ethical standards.
Informed consent was obtained from the relatives.
5.5.3.3 Consent for Publication
The authors declare to have received written consent
from relatives of all persons involved in this case
report, to publish the article mentioned above in this
book.
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Human Skeletal Remains
A Multidisciplinary Approach
FRANCESCO SESSA
University of Foggia
6
DARIO PIOMBINO-MASCALI
Vilnius University

NICHOLAS MÁRQUEZ-GRANT
Cranfield University

LUIGI CIPOLLONI
University of Foggia

CRISTOFORO POMARA
University of Catania

Contents
6.1 Introduction193
6.2 Crime Scene Investigation195
6.3 Anthropological Investigation197
6.3.1 Sex Estimation197
6.3.2 Age-at-Death Estimation197
6.3.3 Height 198
6.3.4 Ancestry198
6.4 Medicolegal Investigation and Trauma Analysis198
6.5 Personal Identification199
References200

6.1 Introduction Forensic identification of human remains is a legal

This chapter focuses on the analysis and i­dentification
of human remains, in particular those that are
­skeletonised. This work, in most countries, falls under
the remit of forensic anthropology (see Komar and
Buikstra, 2008). More specifically, this chapter deals
with protocols for scene attendance, ­anthropological
analysis in the mortuary and the process of
­identification. Although the information contained
in this chapter relates to a general pattern within
our experience mainly from Italy, we acknowledge
that different countries may have different practices,
systems, and protocols as well as legislation (e.g., see
Kranioti and Paine, 2011; Márquez-Grant and Fibiger,
2011; Ubelaker, 2015).
duty based on the scientific compatibility of information
on missing persons with unidentified human remains.
Positive identification, where possible, requires a mul-
tidisciplinary approach where all ­available scientific
and contextual evidence that could be useful in the
identification process is undertaken.
The first step is to gather as much information as
possible about the missing person, presumed dead,
and the whereabouts of their human remains. The
so-called antemortem information such as general
personal/social  information, physical appearance,
­medical and dental history, distinguishing features,
clothes and other personal items that may have belonged
to the missing person, and any circumstances related
to the disappearance can be considered the basis of the

193
194
identification process: Without this information, the
task cannot be undertaken (Blau et al., 2006; Omanovic
and Orchard, 2008).
It should be considered mandatory, although sub-
ject to consent, to collect biological samples from the
relatives of a missing person (and/or samples from
the individual acquired before his/her disappear-
ance), or alternatively, DNA swabbing from personal
items (e.g., toothbrush) from a missing person. This
is particularly important, for example, if the human
remains are found several years after the disappear-
ance when family members have since died. For this
reason, a database with all DNA profiles of the missing
person’s relatives should be considered (Djuric et al.,
2007; Borovko et al., 2009).
Proper recovery and management of human remains
and associated evidence (e.g., clothes, personal belong-
ings, and other relevant items) are vitally important in
personal identification. By contrast, improper recovery
of remains and inappropriate handling can result in
the loss of relevant data, and thus seriously undermin-
ing the  identification processes (Lee and Ladd, 2001;
Cattaneo and Gibelli, 2012; Ferreira-Silva et al., 2019).
The recovery of human remains involves several
main phases: The search and location of the remains,
a survey and documentation of the deposition site
(whether surface or buried), recovery of the remains and
all relevant information, and the labeling of the remains
(Adams and Byrd, 2008; Schwark et al., 2011). Obviously,
the chain of custody should be respected: For these rea-
sons, the recovery process should be carried out only by
trained professionals (Evans and Stagner, 2003), either
in forensic science, forensic anthropology and, in par-
ticular for clandestine graves, trained in archaeological
Decomposition Putrefaction
Post-mortem
changes
Adipocere
Modified
decomposition
Mummification
Figure 6.1  The postmortem changes: The successful rate of DNA profiling is correlated to the degree of preservation
of the human remains.
Forensic and Clinical Forensic Autopsy
techniques (Hunter and Cox, 2005; Dupras et al. 2012;
Hunter et al., 2013; Groen et al., 2015).
After the remains have been properly recov-
ered, they then need to be submitted to the labora-
tory, mortuary, or medico-legal institute for further
investigation.
If the aim is identification, all data relating to this
such as age at death, sex, height, medical and dental
features, fingerprint or ridge information if available,
DNA results, clothes and personal items, as well as cir-
cumstantial information, should then be compared with
the ­antemortem information of a missing person. The
greater the number of matching or compatible character-
istics between the AMD (antemortem documentation)
and the PMD (postmortem documentation), the greater
the likelihood that the remains are indeed who they are
believed to be (Holmes, 2016; Corradi et al., 2017).
To ascertain positive identification in most legal
contexts the primary identifiers are DNA, dental,
fingerprint or other ridges, and any unique features,
whether anatomical variants or medical devices or
implants and reference samples to compare them to
(Mundorff et  al., 2006; Angyal and Dérczy, 2015).
When human skeletal remains are presented, the
most important methods for establishing identity
include DNA analysis, odontology, comparative X-ray
analysis, and skull–photo comparison. If this does not
work, facial reconstruction may be undertaken where
the image is presented to the media, to seek possible
relatives in order to obtain a reference DNA sample
(Komar and Buikstra, 2008).
As illustrated in Figure 6.1, the human remains
can be found in different degrees of decomposition
(Bardale, 2012). In addition, it is worth noting that
Fossil
formation
Skeletonization
Complete
dissolution
Human Skeletal Remains: A Multidisciplinary Approach
they are also found in different contexts such as sur-
face remains, clandestine graves, fire scenes, and mass
disasters.
Moreover, when human skeletal remains are
found, it is mandatory to medically examine them in
order to pronounce death and, where possible, pro-
nounce the time of death, establish the mode of death,
and determine the cause of death (Dirkmaat, 2009).
In most countries, it is not the forensic anthropologist
that comments on cause and manner of death, but the
forensic pathologist, and ultimately the coroner.
6.2 Crime Scene Investigation
When human remains are found, the first step is the
examination of the scene in cases of either fresh, mum-
mified, burnt, decomposed, and skeletonized bodies.
One of the most important aspects of securing the crime
scene is to preserve the scene with minimal contamina-
tion and disturbance of physical evidence. Obviously,
the scene where the human remains are located is not
always the same as the crime scene because the murder
could have been committed elsewhere, but the precau-
tions should be the same (Kilfeather, 2011).
Although it depends on the country or region
within that country, the first law enforcement officer(s)
who arrives at the scene is usually an “initial respond-
ing officer(s).” He or she approaches the scene in a
manner designed to reduce contamination, and in
particular cases, maximize the safety of workers, vic-
tims, witnesses, and others in the area. Moreover, he
or she should notify supervisory personnel and stop
the unauthorized entry, checking, identifying and
limiting the number of persons who enter the crime
scene (Chisum and Turvey, 2011).
The scene should be cordoned off, allowing access
to only authorized personnel. It should be manda-
tory to set up physical barriers (e.g., tent, ropes, cones,
crime scene barrier tape, available vehicles, ­personnel,
other equipment) or use existing b ­ oundaries (e.g.,
doors, walls, gates) (Daniels and Hart, 2004). All
operations should be executed by a command cen-
ter that is responsible for coordinating media com-
munication, ensuring authorized access to the crime
scene, and providing a central location for crime scene
­investigation activities and assessment of resources
(Crispino, 2008). The activities also relate to ensuring
that other key investigators and forensic scientists are
kept up to date with the investigation and called upon
when needed. At this stage, after the boundaries have
been established, a log should be generated that docu-
ments all the people entering and leaving the scene,
195
controlling the flow of personnel to maintain scene
integrity (Petraco and Sherman, 2005; McInerney and
O’Hara, 2006).
Furthermore, although it is not always the case,
the creation of a buffer area (outer cordon) is strongly
recommended to permit the preliminary opera-
tions before entering the crime scene (Figure  6.2).
Obviously, these are general recommendations and
could be subject to specific differences in the regula-
tions and law of each country.
All activities conducted and observations made
at the crime scene must be documented as soon as
possible after the event to preserve information. Note-
taking should be mandatory during the exploration
of the crime scene for investigative and prosecutorial
purposes: Reporting all activities, decision-making
processes, forensic strategy, time of different tasks
completed, and an assessment of the scene prior to
that determines what kind of documentation is needed
(e.g., photography, video, sketches, measurements,
notes). These notes can be disclosed to the court and
will also help with writing the expert witness report.
After the cordoning of the area, the forensic exam-
iner, especially a forensic pathologist or more impor-
tantly an experienced forensic anthropologist (e.g., see
İşcan and Steyn, 2013), should be able to ­distinguish
between human and animal bones. In the case of
human remains (and if the recovery consists of an
incomplete skeleton or a body part, it is necessary to
explore the nearby area to search for additional bones;
particularly, in other cases, the exploration of any con-
cealed location, such as behind a corner, trees, or waste
containers, should not be excluded. Indeed, when
human remains are found, it may be useful to take
aerial photographs and/or 3D coordinates of a scene
to show spatial relationship between human remains
and items (Rohatgi and Kapoor, 2014; Miller, 2018).
At present, drone use is recommended since it allows
Figure 6.2 A schematic reconstruction of the crime
scene investigation (CSI) coordination.
196
an area to be better explored, and may be ­useful to
identify other body parts or skeletal elements (Smith,
2015). During these search operations, an additional
resource could be supplied by the K-9 unit that is use-
ful in open areas, allowing exploration in only a few
hours (Komar, 2015; Ferrara et al., 2019).
An assessment should made by carefully walk-
ing through the scene to assess the situation, recog-
nize potential evidence and come up with a strategy to
allow recovery of the remains. Moreover, a final survey
should be conducted to ensure that the scene has been
effectively and completely processed. Undoubtedly,
one of the most important factors during the crime
scene investigation is the handling of physical evi-
dence. For example, in the case of human remains,
clothes or pieces of clothing may be recovered: All
items should be collected and preserved in labeled and
tamper-evident containers (Miller and Jones, 2014).
Once the skeletal remains have been identified as
being human, the next step is the identification of the
victim’s characteristics, and the cause and manner of
death (Ortner, 2003; Brues and Krogman, 2006). Some
observations with this regard may be undertaken at
the scene on a preliminary basis only.
The main questions that the medical exam-
iner should be able to answer are summarized in
Figure 6.3.
In the case of recovered skeletal remains, it is
very important to define the species-specific skeletal
­characteristics. This operation starts with a gross
­anatomical examination of the skeletal remains:
Particularly, when bones are recovered, several
parameters such as shape, size, texture, weight, and
Is the material bone?
Are they human bones?
HUMAN
What is the sex of the individual?
What is his/her age at death?
REMAINS
What is the stature?
What is the ancestry?
Figure 6.3  The main questions that the medical examiner should be able to answer after the finding of human
skeletal remains.
Forensic and Clinical Forensic Autopsy
morphology are analyzed to establish anatomical land-
marks (Rösing et al., 2007; Burns, 2018). Usually, this
operation does not pose any difficulty, even if there are
some exceptions, such as small bones, bones covered
by mud, and highly fragmented bones. Furthermore,
the recovery of small bones, ossification centres and
teeth can, in some cases, indicate that the remains are
those of a child. However, preservation and fragmen-
tation may provide a challenge when trying to ascer-
tain if human (non-adult) or animal.
In doubtful cases, a microscopic examination may
be necessary or any other analysis (Tersigni-Tarrant,
2012): For example, hematoxylin/eosin staining is very
useful to highlight the Haversian system and the pres-
ence of osteons. The distinctive traits of human bones
are randomly distributed round, markedly polygonal,
and virtually equally sized osteons and Haversian
canals; however, animal species often show a plexi-
form, occasionally linear arrangement of osteons of
varying sizes.
In addition to identifying the bones as human,
it is also necessary to establish if the bones origi-
nate from one or more individuals. Obviously, the
­discovery of three left-sided ulnae indicates that the
human remains originate from at least three indi-
viduals. However, apart from repeated bone counts,
it is also necessary to take into account age, sex, and
even dimensions. Finally, during these operations, it
could be very important to consider that the skeleton
may present alterations linked to possible pathologi-
cal changes, like paralysis, and so it is important to
collect as much information as possible (Byrd, 2008;
Ubelaker, 2010; Dirkmaat, 2012).
What was the cause of death?
What is th post-mortem interval?
How can identity be established?
Human Skeletal Remains: A Multidisciplinary Approach
6.3 Anthropological Investigation
The identification of human remains is important
for both legal and humanitarian reasons. Forensic
anthropology (sometimes with forensic archaeology)
offers a unique set of skills to examine human skel-
etal remains from a variety of contexts, from natural
deaths, to surface depositions, clandestine burials, and
mass fatality incidents (Tersigni-Tarrant and Shirley,
2012; de Boer et  al., 2018); whether accidental, natu-
ral, suicide or homicide deaths. It also may deal with
a complete skeleton, a partial skeleton, a body part, or
a single bone or bone fragment (Bethard et al., 2018;
Navega et  al., 2018). Dental structures are usually
examined by a forensic odontologist (Krishan et  al.,
2015). For the different roles of a forensic anthropolo-
gist, see Márquez-Grant (2018).
Forensic anthropology can assist in the identifi-
cation of the deceased and assess whether trauma is
present. The identification of course is limited by the
preservation, condition of the bone, fragmentation,
completeness as it is very complicated, for example,
to identify the person through the examination alone
of a body part such as a foot (Cattaneo, 2007; Moon,
2013). Indeed, even if DNA profiling is obtained, it
may not be enough to identify a person.
Estimating the sex, age at death, height, and
­ancestry yields what are considered classical indica-
tions of identity. This information represents a “bio-
logical” profile, which in addition to any unique
identifying features (a healed fracture, surgical inter-
vention, frontal sinus, etc.) helps reduce the list of pos-
sible missing persons (Gökşen et al., 2005; Satoh, 2015).
To this end, a broad spectrum of skills is ­necessary:
For example, when human remains are partially bur-
ied, expertise and skill in archaeological methods are
required. Moreover, forensic anthropology tradition-
ally focuses on forensic osteology, which is mainly
concerned with determining human specificity, post-
mortem interval (PMI), identity, and analyzing evi-
dence of injury. The PMI yields valuable information
in terms of identity: Indeed, bones with a PMI of over
50 years are believed to represent historical bones and,
as such, are no longer justiciable (Sterzik et al., 2016;
Sterzik et al., 2018), but this depends on the country as
it can vary from 20 years to over 100 years (Márquez-
Grant and Fibiger, 2011; Márquez-Grant et  al. 2016;
Bethard et al., 2018; Navega et al., 2018).
6.3.1 Sex Estimation
Morphological sex estimation of skeletons is p
­ erformed
by evaluating sexually dimorphic skeletal traits:
197
These  characteristics are particularly evident in the
pelvis and the skull, considering that the male trait
carriers are generally described as larger, heavier, and
more prominent (White and Folkens, 2005). The diag-
nosis “female”, “male” or “undertermined” is reached
by making an overall assessment of all traits assessed
(Bongiovanni and Spradley, 2012; Luo et al., 2013).
Morphometric methods have also been devel-
oped. Of these, discriminant function analysis is the
best-established method for the estimation of sex. This
approach involves recording measurements in suppos-
edly sexually dimorphic samples and using these to
develop discriminant functions that permit the sex of
the person in question to be estimated (Cabo et al., 2012).
The accepted rule when estimating sex from the
entire skeleton is that features of a female individual
are less pronounced, or smaller traits are indicative
of a female individual (Buikstra and Ubelaker, 1994).
Nevertheless, by using the established morphological
methods, especially around the area of the pubis in the
pelvis, sex estimation is 96–98% accurate when the
entire skeleton is present, even if certain identification
of sex is made via DNA analysis.
6.3.2 Age-at-Death Estimation
The phenomenon of human aging is associated with
morphological changes in bone: Numerous noninva-
sive (macroscopy, dental status, overall appearance,
X-rays) and invasive (chemical and histological analy-
ses of teeth or compact bone in long bones) methods
are available to establish the subject’s biological age
(Limdiwala and Shah, 2013; Márquez-Grant, 2015).
Individual aging is not the only factor that could
cause bone deterioration: Lifestyle, living conditions,
biological factors, and problems with the methods
employed can create discrepancies between chrono-
logical and biological age.
In the same manner of the determination of body
height, it is usually correct to apply several methods
and then specify the estimated age, indicating the error
and the interval of confidence. The current knowledge
is that all known methods, when combined, are able to
provide important information on age, whereby esti-
mations to within ±5 years are possible when technical
methods are used, and even greater accuracy is pos-
sible in younger individuals (Pasquier et al., 1999).
Age at the time of death from single bones or a
skeleton is determined by noting the following: Dental
formation and development, skeletal maturation (e.g.,
ossification of epiphyseal plate); dimensions (in juve-
nile remains), and age-related or degenerative changes
occurring in individual bones or landmarks, such as
198
the sternal rib end, radiographic methods, and histo-
logical methods (Stout and Paine, 1992; Sheuer and
Black, 2000; Mall et al., 2001).
6.3.3  Height
The fact that long bones stand in a linear relation to the
overall body length is used to estimate height. There are
numerous formulas based on the mathematical model of
linear regression, which, by determining primarily the
length of intact or fragmented long bones, permits height
to be calculated (Duyar and Pelin, 2003; Duyar et  al.,
2006). It is widely known that formulas of this kind tend
to be highly population- and sex-specific. Considering
that this kind of evaluation is an estimation, it is cor-
rect to give the margin of error or a statistical confidence
interval. Another important consideration is that when
stature is estimated from a bone, an allowance of 2.5 to
4 cm is added to the calculated stature in order to com-
pensate for the loss of soft tissues (Garmendia et al., 2014;
Nath and Badkur, 2017). Different formulae are used to
estimate stature, whether from complete bones or frag-
mentary bones, but the most employed today are those of
Trotter and Gleser (1977), although there are a number
of other equations (e.g., see Márquez-Grant et al. 2016).
6.3.4 Ancestry
This is one of the most controversial and difficult
parameters in forensic anthropology. The identifica-
tion of whether a skull is “Black,” “White,” “Asian,”
“Hispanic,” etc. is a matter of debate but relies heavily
on the shape and measurements of the skull (Bookstein
et al., 1999; Baab et al., 2012).
Not surprisingly, it is not always possible to clas-
sify a specific skull unequivocally to one of those “cat-
egories” or “groups,” and the ability to differentiate
between skulls will certainly be reduced in the future
by increasing globalization and migration. An in silico
analysis is very helpful in the interpretation of all
results and a number of softwares are available (e.g.,
Fordisc 3.1); moreover, to date, genetic analysis can sup-
ply the anthropological analysis, for example, with the
SNP (single-nucleotide polymorphism) test (Phillips
et al., 2007; Gettings et al., 2014; Ramani et al., 2017).
Finally, further information about the origin of
the subject may be obtained from any dental treatment
(significant national and international differences are
seen in terms of dental treatment) or analyzing the
radionuclides (global concentrations of various radio-
nuclides in food, drinking water, and air vary widely
with respect to the origin and region) and isotope
analysis (Meier-Augenstein, 2018).
Forensic and Clinical Forensic Autopsy
6.4 Medicolegal Investigation
and Trauma Analysis
When human remains (bones or body parts) are
found, it is very helpful to determine the post-mortem
interval (PMI), meaning if the case is of forensic and/
or archaeological interest.
Usually, the recovery of human remains can be
considered forensically relevant with a PMI up to
50 years, although this depends on the country and
even state or region within that particular country as
there is great variation (Ubelaker, 2015): In the evalu-
ation of human remains, changes in the decomposi-
tion processes are very important to define the PMI
(Schwarcz et  al., 2010; Brown et  al., 2018), but also
difficult. The major problem is linked to the fact that
these discernible changes depend on environmental
conditions, which are often difficult to evaluate. A
body lying in the open air in central Europe during the
summer months can skeletonize completely within a
few weeks. Soft tissue remnants may be present even
after decades if extensive natural mummification has
occurred due to the hot, dry weather conditions asso-
ciated with the summer months (Blau and Sterenberg,
2015; Maples, 2015). For these reasons, and this field
of forensic taphonomy is crucial (Haglund and Sorg,
1996, 2001; Pokines and Symes, 2013; Schotsmans
et al. 2017), it is very important to analyze all trans-
formative events on the tissues or bones. In addition
to investigating tissues, appropriate attention needs
to be paid to the scene of discovery and accompany-
ing findings; remnants of clothing, coins, newspapers
and anything datable, tools, and weapons, among oth-
ers, can help to narrow down the temporal horizon.
Indeed, during the recovery operation, the position of
the body, the presence of certain objects, the trace or
evidence for a coffin may help distinguish a normal
burial from the illegal disposal of a body (Fahlander
and Oestigaard, 2008).
Moreover, and especially for this time frame,
­certain analysis can be carried out to ascertain the PMI,
apart from context and any datable items. The most used
techniques on the recovered bones are the radionuclide
methods, such as radiocarbon dating (Ubelaker et al.,
2006; Brock and Cook, 2017). Environmental evidence
may also be able to assist, especially forensic botany and
entomology (Márquez-Grant and Roberts, 2012).
Regarding possible injury (trauma) to the skel-
eton, it is necessary to differentiate between ante-,
peri-, and postmortem injuries. These terms are not
always straightforward and may have different mean-
ings in forensic anthropology compared to other dis-
ciplines or fields. A stepwise procedure is followed
Human Skeletal Remains: A Multidisciplinary Approach
that involves drawing conclusions about the types of
trauma (e.g., sharp or blunt force) and the mechanism
(e.g., blow or stab wound), as well as determining – or
even identifying - the specific weapon or instrument
used (Judd, 2004; Šlaus et al., 2012).
Particularly, it is very important to identify inju-
ries incurred around the time of death (perimortem
injuries), which are generally considered relevant in
terms of cause of death. They need to be differentiated
from injuries incurred during life (antemortem inju-
ries or historical fractures) and the damage produced
after death (like animal predation) (Scheuer, 2002;
Shaw and Mennell, 2009).
In order to diagnose antemortem bone injury,
signs of healing and bone remodeling need to be pres-
ent, such as callus formation following the fracture.
Postmortem changes occur as a result of
­intentional and nonintentional bone modification
or alteration by either animals or humans. When
the human remains have a preserved tissue, it is
very important to analyze the final region to better
­comprehend the vitality of the tissue at the time of
detachment (Schotsmans and Van de Voorde, 2017). It
is also necessary to be able to distinguish fresh or wet
vs dry bone fractures.
When only bones are recovered, the most important
differential diagnostic criterion to identify postmortem
changes is the color of cut or fractured surfaces, which
are usually distinctly lighter compared with other bone
surfaces. In addition, the absence of signs of decompo-
sition on the fractured surfaces, despite visible decom-
position on other bone tissue, suggests a postmortem
origin (Cattaneo and Cappella, 2017).
The most important is the identification of
­perimortem injuries, which could be injuries that
cannot be classified as either ante- or postmortem.
Considering the anatomical region and the severity of
the injury, it is very helpful to understand if it can be
considered a possible cause of death or associated with
death in some other way (Kranioti, 2015).
When an injury is classified as a perimortem
lesion, it should be necessary to identify the underly-
ing mechanism of injury (Moraitis et al., 2008).
They could be related either to possible vio-
lent events linked with the death or to independent
events such as impaired or unusual gait (e.g., a limp),
which could be generated during the individual’s life
(Demirci and Hakan, 2012; Austin et al., 2013).
Post-mortem computed tomography (PMCT)
prior to autopsy is a valuable add-on in the postmor-
tem forensic investigation of human remains for the
detection of hidden signs of trauma, gas collection,
and foreign bodies (de Bakker et al., 2019).
199
Currently, PMCT is an accessible and contempo-
rary tool for forensic investigations. The radiologist
must discern all the contextual divergences with the
forensic history, and must be able to report all the rele-
vant elements to answer the forensic pathologist’s ques-
tions: Are there tomographic features that could help
to identify the deceased? Is there evidence of remnants
of biological fluids in liquid form available for toxico-
logical analysis and DNA sampling? Is there another
obvious cause of death beyond heat-related lesions,
especially metallic foreign bodies of ballistic origin?
Finally, what are the characteristic burn-related inju-
ries seen on the corpse that should be sought during the
autopsy? (Chawla et al., 2013; Luijten et al., 2016; Coty
et al., 2018).
6.5 Personal Identification
Forensic anthropology rarely is able to provide  an
identification, but there are some exceptions (Ubelaker
et al. 2019; De Boer et al. 2020). DNA analysis repre-
sents the gold standard method to identify subjects.
The success of forensic DNA analysis is strictly related
to the changes that occur after death (Higgins and
Austin, 2013). Generally, to obtain DNA profiling
from all the tissue types of the body, the choice is nat-
urally related to the state of preservation (Dettmeyer
et al., 2014). The buccal swab or blood sample is usu-
ally taken from a recently deceased individual as in
living subjects; but DNA analysis could become com-
plex with regard to skeletal remains. Usually, when a
corpse is found in an advanced state of decomposi-
tion, such as in the case of incomplete skeletoniza-
tion, samples should be taken from the compact long
bones, as well as (preferably intact) teeth, and mito-
chondrial DNA analysis may have to be performed
(Hagelberg et  al., 1991; Jeffreys et  al., 1992; Draus-
Barini et al., 2013).
The main aim of DNA analysis is short tandem
repeat (STR) typing that can identify the victim: Only
if this attempt fails, various purification methods,
mtDNA sequencing, or SNP analysis, that are now
available can be employed (Bender et al., 2000; Holland
et al., 2015). Obviously, the identification ­process refers
to identifying an unknown person, and can be applied
only if there are relatives or personal objects of the
suspected decedent (Butler, 2005; Butler et  al., 2007;
Budowle et al., 2009; Templeton et al., 2013).
Generally, if a complete STR profile is obtained,
it can be compared with the profile of the missing
person, which can be performed on different mate-
rials such as saliva-stained stamps, toothbrushes, or
200
razors used by the person while alive. Alternatively,
DNA profiles of relatives may be used: Obviously,
the most used samples belong to parents or children,
while in the cases where these subjects are unavail-
able, other samples can be used (e.g., siblings), but
further investigations are needed (e.g., Y-STR male
lineage testing) (Quintana-Murci et al., 2001; Kayser,
2017).
The main problem of DNA analysis is related
to the state of preservation of the human remains:
Indeed, even if the DNA is obtained from all the tis-
sue types of the body, it is not always possible to obtain
a complete DNA profile, especially with samples in an
advanced state of decomposition (Jakubowska et  al.,
2012; Damgaard et al., 2015). Indeed, the rate of success
in obtaining a complete DNA profile is the condition
of the preservation. It is well known that several condi-
tions such as humidity levels, temperature, and burial
conditions are very important to determine the qual-
ity and quantity of DNA (Imaizumi et al., 2005; Westen
et  al., 2008). For example, early mummification often
seems to be an advantage, while marked adipocere for-
mation is more likely to be a disadvantage. Another
important difference is related to the conditional assess-
ment of burial: Different qualities and quantities of
DNA are obtained from the same sample in relation to
these conditions. Human remains that have been bur-
ied undergo different transformation processes with
respect to remains recovered in seawater or in the sur-
face: PCR (polymerase chain reaction)-inhibitory sub-
stances are responsible for this (Rohland and Hofreiter,
2007; Campos et al., 2012).
The bones used for DNA extraction are usually
the long bones or teeth (Rohland et  al., 2018). The
choice of the sample is strictly made in relation to the
state of the sample, evaluating all external conditions
that can affect DNA quality. It is important that the
­pathologists/anthropologists liaise with the DNA lab-
oratory to discuss sampling preference and protocols.
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Index

“f” indicates material in figures. “t” indicates material in tables. “n” indicates material in footnotes.

A bronchi and, 38, 45 need for, 11f-14f

heart dissection and, 38 preliminaries, 9
Abdomen
in situ exam of, 38, 39f, 52f, 127 prosector positions during, 10
access to, 49
inspection of, 31, 52f, 100f room temperature for, 3
eggshell technique, 16
pulmonary artery and, 29f, 30, 99,
infant, 124t, 126, 128, 129f, 134f,
100f, 101f, 104, 133
146, 146f B
removal of
neck, chest and, 126
Ghon’s technique for, 45–47, Back
parietal peritoneum, 14, 17f, 20f,
47f, 48f spine/spinal cord; See Spine/spinal
21, 49, 61–63, 64n, 66, 128
infant, 135f, 137f cord vertebrae; See Vertebrae
posterior, 17, 50, 51, 54, 57, 59f, 60,
Letulle technique for, 50f-52f Barium nitrate, 113
61, 62n, 63, 63n, 64, 66, 134,
Virchow technique for, 38 Barium sulfate, 113
135f, 146f
thoracic, 29, 29f, 30, 31, 38, 39, 45, 47, Basal ganglia, 125
primary, 10
47f, 50f, 66, 67, 99, 100f, 101f, Basilar artery, 85f
colon; See Colon
102f, 103f, 104, 127, 133, 137f, Bile samples, 59
diaphragm; See Diaphragm
155, 160, 169 Bimastoid incision, 77f, 78, 78f, 84f
dissection of
trachea and, 38f, 39, 45, 46, 47f, 51f Bisacromial incision
Letulle technique for, 50, 50f, 51f,
Arms for abdomen, 18f
52, 52f, 83, 128, 134, 134f-135f-
CT scans of, 88 for arms, 88f, 110
136f-139f, 145, 148, 149
defensive marks on, 3 for chest, 14, 14f, 15f,
adult, 50, 51, 50f-52f
dissection of, 88, 88f, 89, 89f, 92, 93f for face and neck, 77, 77f
infant, 128, 134, 134f-136f, 149
external exam of, 3, 4, 34, 91, 92 posterior, 77f, 84f
Virchow technique for, 37, 38, 53,
x-rays of, 88 Bladder
58, 98, 99, 99f
Arteries inspection of, 49, 63, 63n
external exam of, 20, 51, 146
abdominal, 51f, 52f, 60n, 66, 66f, 67, peritoneum and, 63, 63n
in situ exam of, 49
132, 134, 155 rectum and, 63, 63n
kidneys; See Kidneys
aorta; See Aorta removal of, 58, 63, 63n, 64
large intestines; See Large intestines
basilar, 85f, 88 umbilical arteries and, 63n
liver; See Liver
bronchial, 113 urethra and, 63n
pancreas, 57, 59–61, 61f, 61n, 134, 139f
carotid; See Carotid artery urine samples from, 2
small intestine; See Small intestines
coronary, 2, 30, 31, 59, 99, 100n, 101, uterus and, 63, 63n
spleen, 53, 53f, 54, 54f, 58, 114, 114f,
101f, 102f, 103, 104, 105, 106, vagina and, 63, 63n
133, 134, 139f
132, 160, 161 Blood
stomach; See Stomach
examination of, 52f from arteries, 29
Abrasions, 3, 4, 79
heart dissection and, 99–105 from brain, 99
Adams’s incision, 78
opening and study of, 52f drainage of, 10
Adipose tissue, 14n, 16
peritoneum and, 59, 66n, drug concentrations in, 29
Adrenal glands, 59
pulmonary; See Pulmonary arteries/ from heart, 29
Age of cadaver, 2
veins sodium fluoride and, 29
Air temperature, 2
samples from, 105 Blood clots,; See also Thrombosis
Amyloidosis, 99
umbilical, 15f, 18f, 59n, 63n, 64, 117, Body mass index (BMI), 2
Anemia, 35, 92, 99, 124, 171
122, 123, 123f, 125f, 128, 133f, Body piercing, 2
Aneurysm, 28f, 52f, 73f, 76, 99, 100f, 158
135, 137, 142, 143, 143f, 145, Body temperature, 2
Angiography, 89, 113, 153, 154, 159,
vertebral, 83, 87, 88, 98 Bones
160, 163
Willis polygon, 76, 85f, 97, 97f, 98f, 160, arm, fracture of, 4
Anhydramnios, 123
Asphyxia-related deaths, 3 CT scans of, 21, 22, 43, 51, 66, 67, 76,
Animal remains; See Remains
Autopsy 79, 87, 88, 108, 118, 121f, 158,
Ankles, 157
adult, general principles, 9 160, 166, 166f,
Anus, 122
forensic vs. hospital, 9 humerus, 14, 16, 66, 110
Aorta
infant, general principles, 117 lesions on, 154, 157, 166
abdominal, 51f, 52f, 66, 128, 132,
instruments for; See Instruments ribs; See Ribs
133, 155
length of time for, 9 skull; See Skull
blood samples from, 29

205
206 Index

Brain angiography of, 160 CT; See Computed tomography

access to, 71, 72, 73f cardiac system; See Cardiac system Cuts/slashes, 1; See alsoIncised wounds;
adult, photos of, 72f, 73f, 79f, 81f, 82f, CT scans of, 155 Lacerations; Stab wounds
85f, 97f, 98f diaphragm; See Diaphragm
characteristics of, 75, 82 dissection of
D
dissection of, 79–81 adult, 3, 4, 13, 14, 16, 22, 23, 24f, 25,
dura mater; See Dura mater 32, 38, 47, 112, 155, 160, 185 Deciduas, 144
fixation of, 88, 88f clavicular joint disarticulation Decomposition, 99, 155, 159, 194f,
in situ exam of, 71, 72f, 79 and, 22 198, 199
removal of Ghon’s technique for, 45–47, 47f Defensive wounds, 4, 34
anterior, 72 f, 73f, 83, 85f infant, 118, 122f, 123, 124f, 126, Diabetes, 2, 61, 118, 181
infant, 126 127, 131f, 145, 146f, 147 Diagram sheets, 1
Ludwig method for, 97–99 Letulle technique for, 50f-52f Diapers, 2
posterior, 85, 86, 87f planar approach to, 14–16 Diaphragm
Virchow technique for, 98 Virchow technique for, esophagus; colon and, 58
subdural hematoma, 99, 154 See Esophagus external CT scans of, 155
Breasts, 14, 16 exam of, 4 esophagus and, 38
Bronchi lungs; See Lungs Ghon’s technique and, 47, 47f
aorta and, 38, 45 pleural cavities, 23, 24f, 25, 26f, 48f, histological Sections and, 144
fixation of lungs and, 113 127, 128, 131f, 166 Letulle technique and, 50
lung removal and, 38 ribs; See Ribs liver and, 59
opening and study of, 25, 25f, 26f trachea; See Trachea lungs and, 50, 112,
removal of, 38 Children omentum, peritoneum, and, 61n
Bronchial arteries, 113 external exam of, 118–124, 119f-123f position of, 23, 38, 59, 61n
Butterfly flap dissection, 17, 20f, 133 infant; See Infants small intestines and, 54
technique 133f sexual abuse of, 4 stomach and, 60
Chondrocostal incision, 23 thoracic cavity and, 23, 24f, 131f
Cingulate gyrus, 73 Digastric muscle, 39, 45
C
Circumcision, 4 Dissection, flap, 17, 21f
Calcification, 99, 106, 137, 162 Clamps, intestinal, 54 DNA
Calyx, 11, 15f, 16, 18f, 63, 88, 126, Clavicle, 16, 23, 39n blood for tests, 186t
128f, 129f Cleanliness of body, 2 cardiomyopathy and, 99
Carbon monoxide poisoning, 2 Clothing, 1, 2, 196, 198 formalin and, 179
Carboxyhemoglobin, 2 Collagen, 89 myocarditis and, 99
Cardiac system Colon for PCR, 179, 181, 200
arteries; See Arteries duodenum and, 54 Dorsal and lumbar region, 5
blood samples from, 27, 29, 99, 184, 185 kidneys and, 57 Douglas, pouch of, 58, 64, 65
Ghon’s technique for, 45–47, 47f liver and, 57 Down’s syndrome, 123
heart; See Heart omentum and, 57 Drowning, 107, 155
in situ exam of, 25, 29, 29f, 51f pancreas and, 57 Duodenum
liver and, 60f, 134 peritoneum and, 57, 58 colon and, 57
pancreas and, 61n position of, 57, 58 duodenal-jejunal flexure, 54
in pelvic region, 66, 66f, 100f, 185, removal of, 57, 58 Glisson’s sphincter and, 61
185f, 186, 186f small intestines and, 54 in situ exam of, 60, 61f, 139f
pericardial cavity, 27, 28f, 47, 101f, 101n transverse 54, 56f inspection of, 61f
pericardial sac; See Pericardial sac Computed tomography (CT) omentum and, 60, 61
removal of, 38, 46, 47, 50 in adult autopsy, 154 peritoneum and, 60, 61
veins; See Veins for anthropologic studies, 157, 200 removal of, 54
Virchow technique for, 38 in fetal/pediatric autopsies, 118, 121f Treitz muscle, 54, 60
Carotid artery of gunshot wounds, 155, 156 Dura mater
cranial, 73f, 80, 81 multislice, 154 cauda equina and, 83
dissection of, 42, 42f Congenital heart disease, 99, 117 incision of, 72f, 125
hyoid and thyroid muscles and, 41 Contact lenses, 3 inspection of, 73f
in situ exam of, 42, 42f Contraction band necrosis, 105f removal of, 70, 83, 85f, 124, 125
Cauda equina, 83 Coronary artery, 2, 30, 101f, 102f, 103, subdural hematoma and, 99
Caul, 56f 105f, 106
Cerebellum, 85f, 87, 99, 125 Corpus callosum, 99, 125
E
Cerebrospinal fluid, 71 Cotyledon, 137
Cervix, 4, 64, 64n, 65f Cranial nerves Ears, 3, 123, 124t
Chest “fan rays” technique for, 41, 41f ECG, 181, 182t, 185
access to in situ exam of, 80 Edema, 77, 80, 109, 111, 112, 120, 124, 155,
infant, 126–130, 131f Cricoarytenoid joint, 107 159, 160, 186
posterior, 83, 84f, 86f Cricoid cartilage, 41f, 42, 45 Elastic fibers, 170
primary, 16, 23 Crime scene investigation, 94, 180 Electrical marks, 4
Index 207

Electrocardiograms (ECG), 181, 182t, 185 in dissections scalp; See Scalp

Emphysema, 4, 31, 80, 109, 111, 113, 145, abdomen wall, 17 skull; See Skull
146, 147f Ghon’s technique, 45, 46 throat; See Throat
En bloc removal; See Ghon’s technique mouth area, 45, 46 Heart
En masse removal; See Letulle technique neck, 39, 40, 42 characteristics of, 25, 26, 27, 99
Encephalon 75f; See also Brain thoracic wall, 16, 23 contraction band necrosis, 105
Eosin, 31, 146 for pericardial sac incision, 27 dissection of
Epiglottis, 45, 46 for peritoneum incision, 47 adult, 25, 26, 27, 99, 102
Epithelium, 147f in pulmonary artery exam, 29, 30 base of the heart method, 103
Esophagus in removals blood flow, 99, 132
diaphragm and, 38 bladder, 64 Fineschi and Baroldi method, 99
in situ exam of, 45, 46, 47f heart, 25, 38 four chambers method, 103
inspection of, 45, 46 rib shield, 23 infant, 127, 132, 137
omentum, peritoneum, and, 60 small intestine, 56 enlargement of, 99
opening and study of, 45, 46, 47f, 107f with rubber prongs, 10, 38, 45 fixation of, 99
position of, 38, 60, 60f for sample collection in situ exam of, 25, 26, 27, 28f, 101, 107
removal of, 45, 62 stomach contents, 59 inspection of, 99, 107
External examinations, 1– 5, 10, 20, urine, 64 removal of, 38, 99
27, 30, 32, 43, 51, 62, 65, 66, 75, Formaldehyde, 113 samples from, 99, 102, 103
81, 91, 92, 96, 104, 118, 120, 136, Height of decedent, 2
146, 147f, 155, 163, 185 Hematoxylin
G
Eyes, 3, 120, 124 for embolism studies, 31
Galea capitis, 69f, 70f, 81, 124, 125f in immunohistochemistry, 110
Gallbladder, 49, 59, 61 Hepatopancreatic sphincter, 61
F
Genome, 179 Hesitation marks, 4
Face, 3, 39, 46, 72, 73, 74, 77, 123, 124t Ghon’s technique, 30, 43, 45–47, 47f, Histologic studies
“Face off” technique, 77, 77f, 78f 48f, 50 fixation for; See Fixation
“Fan rays” technique, 41f, 42f, 79 Glasses, 3 immunohistochemistry, 110
Fat tissue, 15f, 88, 134, 155, 159 Glisson’s sphincter, 61 Human remains; See Remains
Feet, 3, 95f, 97, 124t Gums, 120, 123f Humerus, 14, 16, 66, 110
Femoral artery, nerve, and vein, 159, 163 Gunshot residue, 1 Hyoid, 3, 39, 45, 45f, 107, 162
Fetal Gunshot wounds, 1, 20 Hypertension, 2, 61, 99, 113, 118, 186
annexes, 134 injuries 20f, 28f Hypostasis, 3, 155
measurements, 124t cardiac system and, 28f
membranes, 137, 139, 144 clothing and, 1
I
Fetus CT scans of, 155, 163
abnormalities, 120 to the face, 166 Iatrogenic lesions, 10,
brain exams, 124, 125, 127t, 144 in Ghon’s block, 48f Identification cards, 10,
chest exam, 122f, 124t, 127, 144 lungs and, 48f Immunohistochemistry, 110
evisceration methods, 128 planar dissection for, 20f Incised wounds, 3
external exam of, 120, 136, 146, 147f, radiographs of, 155 Incisions
placental exam, 118, 145f to scalp, 166 abdominal, neck and, 10, 11, 14f, 15f,
FFPE, 179, 181 16, 17, 17f-21f
Fibrin, 37, 137 Adams’s, 73, 73n
H
Fibrosis, 31, 99, 105, 144, 147f bimastoid, 69, 69f, 77, 77f, 78, 78f,
Fineschi and Baroldi method, 99 Hair, 3, 4, 68, 178 84f, 149
Fingernails, 4 Hands, 4, 23, 34, 69, 77, 79, 81, 123 bisacromial; See Bisacromial incision
Fingers, 26, 59, 63, 71, 91 Hanging, 4 calyx-shaped 14 -16, 18f, 88, 126,
Fixation Haversian canal, 196 128f, 129f
of aorta, 100f Head chondrocostal, 23
of brain, 98f, 125 brain; See Brain thoracic, 10, 14, 14f, 15f, 18f-20f, 22, 22f
of digestive tract, 51f CT scans of, 155 transverse; See Transverse incisions
of coronary arteries, 106 dissection of T-shaped, 14
formaldehyde for, 113 adult, 68, 69, 80 Y-shaped, 14, 25, 27f, 39, 127
formalin for; See Formalin infant, 118, 122f, 123, 124t Infants
of heart, 30, 100f, 101, 107 ears, 68 brain exams, 125
of Letulle block, 51f, 128, 135f, 136f external exam of, 3, 34, 118 chest exam, 118, 122f, 123, 124t, 126,
of lungs, 112, 113 face, 34, 68, 118 127, 131f
of placenta, 135, 136, 144 hair on, 68 evisceration methods, 128
of uterus, 65f mouth; See Mouth external exam of, 2, 118
Flap dissection, 17, 21f nose, 3 heart exams, 127, 128, 132, 133,
Forceps optic system; See Optic system 137f, 144
anatomic, 12 palpation of, 3 placental exam, 135, 137, 142t, 143,
buttoned, 108 positioning of, 3 143f, 144, 145t, 148f
208 Index

Inflow-outflow method, 99 peritoneum and, 16, 17, 20, 47, 57–65, external exam of, 2, 3, 123f
Injections, 4, 10, 72f, 100, 158–160 128, 130f floor, 45, 46f
Instruments position of, 61, 69, 129 foam in/on, 3, 107
clamps, 29f, 118, 184, removal of, 57, 58 tattoos inside, 2
forceps; See Forceps small intestines and, 54, 61, 133, teeth, 3, 196, 197, 200
knives; See Knives 134, 139f tongue, 45, 46, 46f, 47f, 106, 107f
minimum set of, 12f Larynx, 106, 130, 136f tonsils, 45, 46, 106
pliers, 15, 15f, 16, 16f, 18f, 26f, 27f, 41f Legs, 43, 94 Multislice CT (MSCT), 154
rib shears, 13f, 23 Lesions Myocarditis, 99
rongeur, 83, 87 in arteries, 10, 30, 89f Myocytes, 34
saws, 42, 71 in heart, 101
scalpel; See Scalpels iatrogenic, 10, 30, 32
N
scissors; See Scissors in lungs, 112
staplers, 54 parietal, 11, 13f, 17f, 20f, 21f Narcotic overdose, 3
suture needles, 30, 71f, 81, 149 radiographs of, 154, 157, 168–170 Neck
Intestines on Vertebral arteries, 80, 83, 85f, 87, 98f access to
clamping of, 53, 54 Letulle technique thorax and, 39, 40f
large; See Large intestines for adults, 50, 50f, 51, 51f clavicular joint disarticulation
small; See Small intestines for infants, 128, 134f, 135f, 136f, 139f, and, 23
Iron, 37 144, 146, 149 planar, 39, 40f
Ligature strangulation, 4, 77 posterior, 43
Lipids, 162, 181 bleeding in, 3, 10, 40f, 41f
J
“Listening” method, 113 dissection of
Jaundice, 124 Liver “fan rays” technique for, 41f, 42f, 75
Jewelry, 2 bile sample collection, 58, 59 Ghon’s technique for, 30, 43, 45, 46,
Joints, lesions on, 4, 88, 107, 157f colon and, 54–59 46f-48f, 50f
Jugular vein, 3, 14, 28f, 38f, 41, 42, 42f, 44, diaphragm and, 23, 24f, 34, 38, 47, 50, planar, 39
45, 170, 170f, 171 54, 58–61, 100f, 112, 131f posterior, 38, 39
diseases of, 2 external exam of, 3
dissection of, 114, 114f hyoid, 23, 45, 46
K
Glisson s sphincter and, 61 mobility of, 3
Kaiserling solution, 115 inspection of, 51, 61f positioning of, 10
Kidneys omentum, peritoneum, and, 54 rib shield removal and, 23
amnion nodosum and, 139 removal of, 59 throat; See Throat
colon and, 57 Virchow technique for, 53, 58, thymus, 127, 132f, 144
dissection of, Livor, distribution of, 3 thyroid, 42
fixation of, 113 Lungs Needle marks, 4
inspection of, 51f barium sulfate saturation of, 113 Needles, suture, 154
peritoneum and, 114, 134 characteristics of, 26f, 113 Nerves/nervous tissue
position of, 115f diaphragm and, 23, 24f, 34, 38, 47, 50, cranial; See Cranial nerves
removal of, 62, 63f 54, 58–61, 100f, 112, 131f dissection of, 41, 79
samples from, 140f dissection of, 108f, 112 femoral, 94
toxicological analysis of, 111 inspection of, 25 Nose, 3
vertebrae and, 84, 85f, 155 fixation of, 113 Nutrition, 2
Knives gunshot wounds and, 22, 163
for brain dissection, 125 in situ exam of, 25f, 26f
O
for clavicular joint disarticulation, 22 “listening” method for, 113
for placenta, 136, 143, 144 mounting of sections, 114 Oddi, sphincter of, 61
for lung dissection, 38, 113 removal of, 38, 39f, 45 Omentum
for lung removal, 38 ribs and, 127 colon and, 56f, 57f
scalpels; See Scalpels samples from, 112, 114, 194 diaphragm and, 56f, 57f
storage of, 3 duodenum and, 56f, 61, 61f
Lymph nodes, 59, 88, 134 liver and, 59, 59f
L
Lysosomal-associated membrane protein pancreas and, 59, 61f
Lacerations, 3, 4, 17f, 26f, 32, 96f, 112, 113, 2 in cardiomyopathy, 99 peritoneum and, 59n-61n
155, 156, 161, 163, 166 small intestine and, 54, 56, 57
Ladles, 60 stomach and, 59, 60, 60f , 61f,
M
Large intestines Optic system
duodenum and, 54, 57, 59–61, 60f, 61f Maceration, 118, 123f, 124t, 146 dissection of, 79
inspection of, 126, 134f Mackenroth, ligaments of, 64, 64n, eyes, 79
kidneys and, 62, 63 Magnetic resonance imaging (MRI), 10, in situ exam of, 79
liver and, 61f 153, 161 removal of, 80
omentum and, 49f, 54, 56f, 57, 59–61 Missing person, 193, 194, 199 Orbitonasal injuries, 3
pancreas and, 59–61, 61f Mouth Ovaries, 128, 134
Index 209

P aorta and, 29f, 30, 31, 38, 47, 50f, 52 thoracic wall, 16, 18f
in situ exam of, 29, 29f, 30, 30f, 35, on handling of, 11
Palate, 106, 107f, 118, 120 35f, 36f for incisions
Pancreas, 57, 59–61, 61f, 134, 138f opening and study of, 38 brain, 72, 79, 80, 80f, 98
Paraffin, 159 Virchow technique for, 38, 39, 39f floor of the mouth, 45, 46
Parametrium, 64n Pulmonary embolisms, 38, 112, 185 peritoneum, 47
Parietal lesions, 13f scalp, 70
PCR, 179, 181, 200 thoracic, 14
Pectoral muscles, 16f R
for removals
Pericardial cavity, 27, 47, 101f Race of decedent, 2, 3, 196f bladder, 63
Pericardial effusion, 27 Radiographs brain, 124, 125
Pericardial sac whole body, 118, 154, 155 heart, 100
incision of, 25, 26 x-rays, 154 kidney, 62
in situ exam of, 27f Records liver, 59
rib shield removal and, 23, 38, 38f clinical, 51, 53 rib shield, 23
thymus and, 132f of clothing, 1 small intestines, 54
Peritoneal cavity, 1, 47 identification cards, 10 thyroid, 42
Peritoneal effusion, 49 Rectouterine types of, 13f
Peritoneum cavity 58 Scars, 3
arteries, veins, and, 66, 67 space, 58, 64f Scissors
bladder and, 63n, 64 Rectum, 20f, 58, 58f, 63–65, 63n, 64n, enterotomes, 13f
colon and, 57, 58 133, 133f incisions with
duodenum and, 59, 61, 61f Remains duodenum, 59, 60
esophagus and, 60, 60f age-at-death estimation of, 197–198 gallbladder, 59
incision and detachment of, 16, 17, 17f, ancestry, 198 heart, 101, 101f
128, 130f CT of, 157 pericardial sac, 25
kidneys and, 62 crimescene investigation and, pulmonary artery, 30
liver and, 58, 59 194, 195 stomach, 59
omentum and, 59n-61n decomposition, 194 upper limbs, 89, 90f
pancreas and, 59, 60, 61f DNA extraction, 200 ureters, 63
rectum and, 58 height 198 vascular: nervous bundle, 42
stomach and, 59, 60, 60f, 61f investigation of, 199 types of, 13f
uterus and, 63–65 personal identification of, 194, 199 SCN5A gene, 182t
Petechiae, 3, 131f sex estimation of, 197 Sex of decedent, 2, 197
Pharynx, 46, 106, 107f Renal cavity, 62, 62n, 63 Sex-related deaths, 2, 4
Photographs Renal disease, 63 “Short-axis” method, See Four
during autopsy, 9, 10 Resection tables, 113 chambers 103
of brain, 73f, 97, 125 Retzius, space of, 64 Shoulders, 4, 13, 39, 126
of clothing, 1, 2, 195 Ribs Skin, 2, 4, 14, 16, 17, 20, 22, 39, 40f, 62,
during external exams, 3, 9, 10 age-at-death estimation and, 197 73n, 77, 77f, 78, 89, 90f, 91, 95f,
of skull, 73, 81, 81f, fractures of, 4, 17, 66, 92, 110, 96, 118, 123f, 124, 124t, 125f,
of thoraco abdominal cavity, 28f 155, 185 129f, 130f, 149
Pituitary stalk, 80 inspection of, 16f, 25, 131f Skull
Placenta, 135–150 lungs and, 113 blood in cranial vault, 71f,
Platysma muscle, 129f removal of, 14, 23, 23f, 24f, 127 CT scans of, 83, 154, 163, 166, 166f,
Pleural cavities, 23, 25, 48f, 127 shears, 13f, 23, 23f 170, 171f
Pleural effusion, 25, 165, 165f, 185 Rigor mortis, 3, 99 deformity or fracture of, 3
Pliers, 26f RNA, 183, 184 opening of
Pneumocystis carinii, 112 Rongeur, 83, 87 adult, 69–72, 70f, 71f,
Pneumothorax, 52, 112, 144, 145f, 155, infant, 124–126, 126f, 128f, 149
165, 165f posterior, 87
Poisoning, 59 S
Skeletal Remains, 194, 197
Polymerase chain reaction (PCR), 179, 200 Saws, 42, 71 teeth; See Teeth
Proteins Scalp Slashes, 1; See also Incised wounds;
in amyloids, 99 detachment of, 68, 68f, 69, 69f, 77, 78f Lacerations; Stab wounds
autolysis and, 159 lacerations of, 3 Small intestines
eosin and, 31, 144, 196 surgical suture of, 71f, 81 colon and, 56f,
formalin and, 30, 101, 112–114, 126 Scalpels duodenal-jejunal flexure, 54
in immunohistochemistry, 110 for clavicular joint disarticulation, 23 duodenum; See Duodenum
LAMP2, 99 for dissection in situ exam of, 54, 56f, 62f
in myocytes, 34 abdominal wall, 15f, 17, 126 inspection of, 57f, 61f, 62f
narcotic overdose and, 3 head, 68, 69, 78 omentum and, 54, 56f
Pulmonary arteries/veins heart, 101, 102, 102f peritoneum and, 60, 61
angiographs of, 113 neck, 39 removal of, 54, 56, 56f,
210 Index

Smothering, 3 esophagus; See Esophagus V

Sodium fluoride, 29
Sodium sulfate, 113
Spine/spinal cord
access to, 83,
in situ exam of, 85f, 86f, 87,
removal of, 87, 125, 126
Spleen, 53, 53f, 54, 54f, 58, 67, 113, 114,
114f, 133, 134, 139f
Stab wounds, 1, 20f, 32, 49f, 92, 156, 169
Stains
eosin; See Eosin
hematoxylin; See Hematoxylin
H&E See Hematoxylin; Eosin
immunohistochemical, 37, 109, 111
Masson’s, 37
Perl’s, 37
Staplers, 52
Sternochondrocostal surface, 23
Sternocleidomastoid muscle
face access and, 73, 73n, 74f
infant, 126, 129f, 130f
neck access and, 39, 40, 40f
histological Assessment, 44
Stillbirth, 117, 120, 123, 123f, 124, 184
Stomach
in situ exam of, 59,
inspection of, 49, 60f, 61f, 139f
omentum, peritoneum, and, 60n, 61n
opening of, 60, 60f, 139f
removal of, 59, 60,
sample collection, 60
spleen and, 54, 54f
Strangulation, 3, 4, 41f, 43f, 81, 107,
157, 162
Stryker saw, 70, 72, 83
Subdural hematoma, 99
Subserosa, 62n, 63n
Sudden cardiac death, 106, 161, 181
Sudden infant death syndrome, 2
Suffocation, 3
Suprarenal glands, 62
external exam of, 3, 4
larynx, 41, 45, 46 Vagina
tonsils, 106 atresia, 118
trachea; See Trachea bladder and, 63, 63n, 64
vocal cords, 162 external exam of, 4, 122
Thrombosis, 36, 137, 143, 160, 181, 186, inspection of, 4, 122
186t; See also Blood clots rectum and, 58
Thymus, 127, 132f, 144 removal of, 63, 63n
Thyroid, 41, 42, 42f, 126 uterus and, 65
Time of death indicators Vagus nerve, 39f, 41
body temperature, 2 Vater, ampulla of, 61
drug concentrations in blood, 29 Vater, papilla of, 60
gene expression data, 184 Veins
livor, 3, Angiography and, 160
rigor mortis, 3 abdominal, 50, 66, 155
for stillbirths, 118, 124, 124t, femoral, 159, 160
Tongue, 45, 46, 46f, 47f, 106, 107f inspection of, 14, 16f, 28f, 35, 39f, 40f,
Tonsils, 106 42, 42f, 61n, 65f, 90f, 91, 93f, 94,
Trachea 95f, 96, 134
anatomy, 38 jugular, 28f, 39f, 41, 42, 42f, 44, 45,
aorta and, 45 170, 170f, 171
fixation of lungs and, 113 peritoneum and,
histological Assessment of, 109 pulmonary, 38, 128, 133
in situ exam of, 39f, 47f, 75, 107, 107f thrombotic formation, 185, 185f, 186
opening and study of, 107, 107f, 108f, umbilical, 59n, 128, 133f
130, 136f, 137f Vertebrae
removal of, 45, 47f, 106, 107, 113 access to, 83
Traffic fatalities, 2, 154 arteries, 80, 83, 85f, 87
Transverse incision colon and, 58,
for face and neck, 14, 77, 77f, 78 “Face off” technique and, 77
for lower Limb Dissection, 95f fracture of, 67, 92, 110, 155, 164, 164f,
first, 10 in situ exam of, 83, 86f, 87
in hearts, 104, 101 kidneys and, 62
in kidneys, 114, 140f palpation of thoracic, 4
Treitz posterior approach and, 83, 84f, 87
ligament of, 60, 60n radiographs of, 155, 164, 164f,
muscle, 54 removal of, 83, 85f, 86f
“Triangled” tears, 1 small intestines and, 54
T-shaped incision; See Y-shaped incision Virchow technique, 38, 53, 58
Tumors, 9, 63 “Virtopsy”, 153
Vocal cords, 162

U W
T
Umbilical arteries/veins, 59n, 63n, 122,
Weight of cadaver
Tattoos, 2 128, 132, 133f, 143
adult, 2
Teeth, 3, 196, 197, 199 Umbilical cord, 122, 123, 123f, 135, 137,
fetal, 118, 124t, 142t
Temperature, 2 142–144, 143f
Willis polygon, 97, 97f, 98f, 160
Temporal muscle, 69f, 70, 70f, 124, 125f Urethra, 4, 63, 63n, 122
Wrist, 4, 38, 88, 88f, 91, 110
Testes, 122, 128 Urine samples, 2
Thalamus, 125 Uterus
Thoracic incisions, 14, 22 anatomy of, 64n X
Thoracic wall dissection, 16, 16f, 19f, bladder and, 63, 64 X-rays, 10, 88, 154, 197
Thorax, 11, 15f, 18f, 23f, 45, 46, 118, inspection of, 35, 50f, 65f, 141
124, 126, 129f, 130f, 132f, 159, peritoneum and, 63n, 64
Y
169, 169f rectum and, 58,
Throat removal of, 64, 65, 134, Y-shaped incision, 14, 25, 27f, 39, 127