External Examination of the Corpse

Abstract

The autopsy and the external examination of the corpse become a decisive instance when resolving issues of various matters related to an individual. Its aim is not only to establish a diagnosis, but also to provide information about facts related to an illness or legal proceedings. The main tasks of this analysis are firstly to establish death and then to determine the cause and manner of death.

1. Introduction

The external examination of the corpse is a procedure that can provide information on the examination of the body when the identity is unknown, provides guidance on cause of death, unnatural, or unexplained manner of death, and determines conditions, for example, time of death [1].

The external examination of the body must be accurate and must be performed by trained people with many years of experience in the field, as sometimes medical work is combined with the forensic work.

During the external examination, definitive signs of death (temperature, lividity, rigor, or advanced postmortem changes) should be considered. In the procedure, all areas of the naked body should be analyzed and photographed, and all visual evidence and findings, such as scars, traumatic changes, tattoos, deformities, syringe marks, should be reported [2].

Unnatural deaths are those with external influence, due to physical aggression, accident, homicide, poisoning, suicide, and in those death, the external examination is very important, because it can provide information about the cause, with indicators on the body such as conjunctival hemorrhages, livor mortis color, signs of injury, among others [1].

For these reasons, the external examination of the corpse is of great importance, as it allows to:

• To provide the elements of identification.

• Plan the steps to be followed in an autopsy, for which it is necessary to determine the autopsy technique to obtain results according to the needs of the case.

• Document any pathological findings from the outset.

• Support a medico-legal case if a full autopsy is not possible (which has happened due to health regulations in the context of the COVID-19 pandemic).

• Provide evidence in cases of allegations of lack of timely and adequate obstetric care.

• Document cases of neglected of elderly, disabled adults, and young children in the care of third parties.

2. External examination of the corpse

2.1 Identification elements

In addition to fingerprints, there are other elements accessible for external examination that can be valuable in determining or also confirming the identification of the deceased, such as dental features and tattoos [3]. In the case of dental features, age, sex, habits, cultural characteristics can be determined (Figure 1) in addition to the identification of the individual by comparison with dental records [4]. In the case of tattoos, it is important as a complement for identification (Figure 2), as it can provide information for relatives or a tour of tattoo shops which can narrow down the search field [5].

Figure 1.

Denture with missing pieces and poor care conditions.

Figure 2.

Oversized and eye-catching tattoo.

2.2 Autopsy step plan

Before performing an autopsy, it is ideal is to obtain as much information as possible, such as the place where the body or remains were discovered, the circumstances of death, the postmortem interval, the history of previous illnesses, and whether it was a witnessed death.

But if this is not possible, elements of external examination may be useful to:

• Take extreme precautions in the use of personal protective equipment if infection is suspected.

• Establish where the incisions will be placed, so as not to compromise internal structures (Figure 3).

• Establish before starting the autopsy procedure, which complementary tests may be necessary, to have the appropriate containers (e.g., Petri dishes with culture media, fixatives for electron microscopy studies) or to establish coordination with other laboratories, in cases that require quickly processing.

• The existence of entry points for skin infection, such as pressure ulcers (bed sores), suggests that sepsis may be present (Figure 4). Staining for microorganisms such as Gram stain and Lactophenol Blue needs to be considered [6, 7].

Figure 3.

Large umbilical hernia, with a median infra-umbilical laparotomy scar. The autopsy incision should be lateralised to visualize the underlying structures without interrupting them.

Figure 4.

Decubitus ulcer (pressure or bed sores). It is a starting point for skin sepsis.

2.3 Documenting any pathological findings from the outset

Many external signs in the ocular conjunctiva, mucosa of the lips, teeth, ears, or skin, among others, may suggest the underlying disease, or be a key in differential diagnoses.

Internal examination findings only have an impact on the clinicopathological picture, causing or contributed to death.

Alterations in skin color, focal such as petechiae or ecchymosis (Figures 5 and 6) or diffuse such as jaundice, the presence of edema (Figure 7), suggest from external examination of the body that it will be necessary to study certain organs and systems, both macroscopically and through complementary tests, like imaging, histopathology, forensic histopathology, or molecular biology.

Figure 5.

Petechiae on the chest and left flank. Thrombocytopenic purpura.

Figure 6.

Extensive ecchymoses on the abdomen, pubic and genital region. Coagulopathy by anticoagulants.

Figure 7.

Jaundice and generalized edema. Stillborn with Rh incompatibility and isoimmunization.

An example of this is how histology and forensic histopathology can be of great use in the diagnosis of skin alterations, which can give us an understanding of lesions or postmortem changes in the structure of the skin [8].

In congestive heart failure and myocardial infarction, vasodilation and congestion are observed, especially in the mucous membranes and conjunctivae, due to their transparency (Figure 8).

Figure 8.

Conjunctival congestion. Acute myocardial infarction.

When pallor is severe, massive hemorrhage must be presumed. Occasionally, the source of bleeding is an external injury, as well as the gastrointestinal or respiratory tract (Figure 9).

Figure 9.

Conjunctival pallor. Cutting wound.

2.4 Support a medico-legal case if a full autopsy is not possible

In response to the COVID-19 pandemic, many countries have adapted their regulations on the examination of the deceased, reducing and eventually banning clinical autopsies [9, 10].

Forensic services, for their part, have restricted forensic autopsies, subjecting them to autopsy in case of a negative PCR for COVID-19, or even leaving the decision to prosecutors who do not usually handle technical criteria.

Therefore, forensic autopsies of potential cases and especially of confirmed cases, especially those without signs of violence, should be kept to a minimum and performed only when necessary, and internal examination of the body should be carried out only when necessary [11].

As it is necessary to have a cause of death to initiate a legal process and bring the case to justice, we can use the alternatives at our disposal to support the decision whether to do an autopsy and take certain samples.

In cases of sudden death, there is usually no history, so an autopsy and other complementary tests will be necessary, such as histopathology.

Deaths caused by trauma, asphyxia, and poisoning are classified as violent. A thorough external examination may be sufficient to document a case of violent death, for example:

• In cases of traumatic death, where the offending element is often external to the body, it is essential to document the type, size, location, and relationship between external injuries. And non-invasive imaging tests may be useful.

• If the presence of cyanosis suggests asphyxia, manual asphyxia and all lessons accompanied by constriction of the neck should be documented by photographs of the respective groove, fingerprints, nail stigmata, lividity studies, and lividity arrangement in cases of incomplete suspension.

• Only if there are doubts about submersion asphyxia, it is necessary to prove the presence of a foreign body in the airway, which may require an internal examination.

• In the case of poisoning, it should be borne in mind that for analysis and demonstration, it is necessary to isolate the toxic substance from the tissues or fluids of the corpse, for which it is essential to take a good sample. Although toxic substances produce what is called “asphyxia,” visible changes on external examination may be of value: Lividity of colors, other purplish spots, miosis, increased facial congestion are characteristic of some poisonings.

In cases of gunshot wounds, it is very important to determine the distance of the shot, the angle of the shot, the position in which the victim was when the projectile hit, and the entry and exit orifices (Figures 10 and 11).

Figure 10.

Close-range shot, with concentric equimotic-erosive halo and gunshot residue encrustation on its periphery.

Figure 11.

Long distance shot, no residue, with eccentric equimotic-erosive halo.

In cases of asphyxia due to aspiration of gastric contents, in addition to cyanosis, the cause of death may be evident on external examination (Figures 12 and 13).

Figure 12.

Patient found dead at home. Morbid obesity with complicated umbilical hernia, and intestinal volvulus.

Figure 13.

The same patient with severe cyanosis. Foamy hemorrhagic coming out of the mouth and nose.

2.5 Evidence in cases of allegations of lack of obstetric care

Autopsy of newborns can provide information to physicians and families about the cause of death and the accuracy of the antemortem clinical diagnosis [12].

Some women have given birth to a newborn. These deaths are attributed to excessive delay in obstetric care and lack of control of the fetoplacental unit. It is essential to record the external features of the stillbirth body to establish the approximate date of death in utero and the gestational age [13, 14].

Routine external examination includes body measurements (at least: body weight, crown-rump length, crown-heel length, foot length, occipitofrontal circumference).

Detailed external examination, including nutritional status/soft tissue and muscle volume; the presence of edema (localized/generalized), pallor, meconium staining, jaundice or the presence of trauma, location of thoracic drains and vascular cannulae, and other iatrogenic lesions (Figures 14 and 15) [15].

Figure 14.

Premature stillbirth. With skin. Sloughing.

Figure 15.

Term newborn. Fully developed pinna.

The report should include a description of the external morphology specifically mentioning fontanelles, eyes, ears, nose, choanal patency, palatal fusion, spine, extremities, fingers, palmar creases, external genitalia, anal patency, umbilical cord [15]. It is used to diagnose, why some fetuses die in the prenatal period due incompatible life malformations (Figures 16–18) [16].

Figure 16.

Premature and macerated fetus with large omphalocele.

Figure 17.

Term newborn, with multiple head and body malformations.

Figure 18.

Term newborn, with foot malformations.

Examination of the ovarian adnexa may also clarify the causes of death, such as large retroplacental clots (premature detachment of the placenta), opaque ovarian membranes (indicating ovarian infection), or true knots in the umbilical cord (Figure 19) [17, 18].

Figure 19.

Malformation of the foot secondary to oligohydramnios. This condition is associated with polycystic kidney or renal agenesis.

2.6 Document cases of neglected of elderly, disabled adults, and young children in the care of third parties

Malnutrition, soiling, bed sores and colonization by insects on living persons [19, 20] are located on the conjunctivae, ulcers, genitalia, or other wounds (Figure 20). These are the elements that in a judicial process that allow proving the crime of abandonment or neglect of vulnerable people by their relatives or caregivers. An example of poor care is best illustrated by the diagnosis of marasmus and cachexia. These diseases were frequently diagnosed. They were only rarely cited as a cause of death [21].

Figure 20.

Elderly adult male, living in a nursing home. Malnutrition, dirt, and dermatophytosis.

3. Conclusions

Despite the evolution of imaging techniques, the postmortem examination has maintained a key role in the clinical and forensic analysis. To obtain reliable information on the types of death and to allow a better understanding of the phenomenon, it is useful to study the results of clinical and forensic autopsies that start with the external examination of the corpse.

The search for and documentation of seemingly small details in the external examination of corpses help to resolve difficult situations surrounding medico-legal deaths, such as the identification of undocumented victims, the cause and manner of death, the postmortem interval, differential diagnoses of the cause of death, or the regulation of not performing complete autopsies during health crises.