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The decomposed cadaver
MINI-SYMPOSIUM: AUTOPSY PATHOLOGY
The decomposed cadaver
straight forward and should be approached with caution. As part of the police investigation, some form of scene imaging may be undertaken with the use of still photographs or body worn video camera footage. Reviewing the images can provide the pathologist with a better understanding of the circumstances, body position and general environment in which the body was located. If the images are not available prior to the examination, it may still be worthwhile to request them for review after the autopsy to assist in the interpretation of the findings and completion of the post-mortem report. The degree of putrefactive change seen on a body at the locus may differ to that observed in the mortuary at the time of the autopsy, due to factors such as a delay in body recovery, transportation to the mortuary and refrigeration. A delay between body recovery from the locus and the instruction or undertaking of the autopsy may result in further decomposition of the body. There are a number of factors which can accelerate or retard the process of decomposition (listed in Table 1) and these should also be taken into consideration.
SallyAnne Collis Christopher Paul Johnson
Abstract The examination of a decomposed cadaver is inherently difficult with varying degrees of decomposition encountered and the possibility of predation related damage then masking or hampering assessment of injuries and underlying pathology. These cases should be approached with caution and require a full autopsy examination to obtain the maximum amount of information, be that positive findings or the absence of significant injuries. It is advised that if at any point during the post-mortem examination concerning findings are encountered then the examination should be stopped with further information, clarification or advice sought. Despite the presence of putrefactive change and tissue autolysis, additional investigations are potentially useful with histology and toxicology considered important in such cases to reach a conclusion in the cause of death, be that unascertained.
Identification Before the autopsy, identification of the deceased is usually attempted, although it may be appropriate for the autopsy to be requested and performed without positive identification depending on the policies and procedures in different areas of the country. The identification may be regarded “as presumed to be .. ” with ongoing enquiries. Autopsy findings may provide further information to assist with the identification process. A significant delay whilst awaiting formal identification could result in loss of material as the process of decomposition and possible predation associated damage by insects (e.g. maggots) continues, even if a body is adequately refrigerated. The use of fingerprints may still be an option and if there is early mummification change of the hands then water can be injected into the pulp of the finger tips to enhance the ridge detail. A GP summary or hospital notes of the ‘presumed’ deceased may provide documentation of previous surgical procedures or implants (Figure 1) which can assist with identification. Specialists, such as forensic odontologists and genetic identification, may be required in certain cases to formally determine the identification of the deceased. If an odontologist is instructed then it may be more advantageous to perform the autopsy first as the process of exposure of the teeth can sometimes involve incision into tissues of the face, which could make interpretation of potential injuries in that area difficult.
Keywords autopsy; decomposition; histopathology; odontology; predation related damage; putrefaction; toxicology
Introduction The process of decomposition starts from the moment of death. It is not uncommon for pathologists to be requested to undertake an autopsy of a body in a state of decomposition in order to attempt to address the questions of who the person was, when the person died and what led to their death be it natural, un-natural or unascertained. The degree and extent of decomposition seen on a body can vary. Galloway (1989)1 classified human remains into five categories: fresh, early decomposition, advanced decomposition, skeletalisation and decomposition of skeletal material. It is quite frequent for the stages to overlap in the same body. Potential scenarios where such a case is encountered may include: an individual found deceased at home, or exposed to the external elements either on land or in water, with the time from death to discovery being variable and often unknown.
Initial investigations On finding a body in a state of decomposition, an initial police investigation should be instigated to ascertain the circumstances leading up to the discovery of the body and potential features that may assist in identification of the deceased. Even if such a case is deemed by the police and Coroner/Procurator Fiscal to be non-suspicious the post-mortem examination is by no means
The autopsy Although the autopsy would have been instructed as a ‘nonsuspicious’ case, at each stage of the examination the pathologist should determine if they are willing to proceed. Elements may be identified that raise concern, such as ‘un-natural’ circumstances in which the body was found (e.g. concealment of the body), potential for third party involvement (e.g. neglect, physical, financial or mental abuse or previous history of violence towards the deceased) or the body being discovered in an incomplete state. The decision to conduct and proceed with the post-mortem examination ultimately rests with the pathologist undertaking the examination; but if there is concern regarding the circumstances of the case, or with findings identified on external examination, then advice should be sought either from colleagues
SallyAnne Collis BN MBChB FRCPath DMJ Consultant Forensic Pathologist, Forensic Pathology, Nine Edinburgh Bioquarter, Edinburgh, UK. Conflicts of interest: none declared. Christopher Paul Johnson MD FRCPath DMJ Consultant Forensic Pathologist and Home Office Pathologist, Forensic Unit Liverpool, Royal Liverpool University Hospital, Liverpool, UK. Conflicts of interest: none declared.
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Ó 2019 Published by Elsevier Ltd.
Please cite this article as: Collis S, Johnson CP, The decomposed cadaver, Diagnostic Histopathology, https://doi.org/10.1016/ j.mpdhp.2019.07.008
MINI-SYMPOSIUM: AUTOPSY PATHOLOGY
Factors which can affect the rate of decomposition Location of the body Environmental temperature at the time of discovery and in the preceding time interval Thawing of frozen body Exposure to predators Clothing or coverings over body Body size Ante-mortem injuries and blood loss Underlying pathology (e.g. infection) Table 1
or a local forensic pathologist, and further discussion should be had with the Coroner or Procurator Fiscal. In some cases, additional police investigation may also be required and the autopsy referred on to a forensic pathologist for completion, particularly if there is the potential for subsequent criminal proceedings.
Figure 2 Skin discolouration, venous marbling, areas of skin slippage with parchmented change and bloating of the abdomen due to putrefactive gases.
External examination The published literature outlines the process of decomposition and features commonly encountered at autopsy.2,3 Early decompositional changes include green skin discolouration which usually starts over the abdomen, venous marbling, skin slippage, bloat, purge fluids emanating from the nose and mouth and drying of the extremities (Figure 2). With advancing putrefaction there is insect activity, areas of skin loss and exposure of the underlying bone. In drier conditions mummification often predominates. The final stage is skeletonization in which greater than 50% of the bone is exposed. The formation of adipocere (a greasy or wax-like substance) may occur in some circumstances. The extent and pattern of decomposition may vary depending on the environment, body position at the locus and size of the body. In order for a thorough autopsy examination to be performed the body must be removed from the body bag. It is not uncommon for very decomposed bodies to be recovered from the locus with items such as carpet or bedding wrapped around the deceased in an attempt to preserve the body’s integrity. Ideally
any clothing should be left in situ for the pathologist to examine as necklaces or clothing such as a shirt collar or elasticated areas around wrists or ankles, may leave marks on the skin which could be misinterpreted as having been caused by a ligature. If the clothing was removed at the locus by police then scene images may assist in interpretation of any such markings. The clothing or coverings should then be removed and examined. It is recommended to check the pockets as this may not have been done at the locus due to the state of the body. An initial external examination of the body should note the degree and distribution of putrefactive and mummification change, the presence, type and location of any insects as well as associated activity and injuries (Figure 3). Should the type of insects present and stage of development be considered an important factor then an entomologist may be required; such a case is usually best undertaken by a forensic pathologist. Photography can be helpful in recording findings of the post-mortem examination and facilitate future discussions, for example, with colleagues. It should be noted that the external examination is often hampered by skin discolouration, insect activity and areas of associated skin loss, which could mask potentially significant injuries and pathology. Predator damage from animals or insects may result in additional ‘injuries’ to the body (Figure 4), alteration of ante-mortem injuries and the separation of body parts and organs from the main body mass. Such damage can occur indoors or outdoors and it is worth enquiring if there were any animals (including household pets) or signs of rodent infestation at the locus. Establishing which defects are ante-mortem rather than due to post-mortem change or predation can be difficult, with potential features such as scalloped edges, absence of haemorrhage, and the presence of other predation associated damage providing some assistance. Correlation with the overlying clothing is also helpful. Post-mortem imaging, in the form of X-rays, fluoroscopy or CT scanning, may be available in some areas of the UK. Imaging may prove a useful adjunct in cases where there are suspected bony injuries, the presence of advanced decomposition or
Figure 1 A metal surgical implant identified on one of the metatarsal bones with identification numbers present that could then be checked against medical records for identification purposes.
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Please cite this article as: Collis S, Johnson CP, The decomposed cadaver, Diagnostic Histopathology, https://doi.org/10.1016/ j.mpdhp.2019.07.008
MINI-SYMPOSIUM: AUTOPSY PATHOLOGY
intervention. This process is best achieved by using a macerator/ bone washing table. It is acknowledged that this process can be time consuming and may not be deemed necessary in the majority of cases. Internal examination Evisceration can be carried out using the method deemed most appropriate by the pathologist. However, in decomposed cases, it is recommended that the pathologist perform the evisceration themselves or observes closely whilst an experienced technician performs the procedure. It is also advised that a ‘Y’ incision is undertaken to allow a thorough examination of the neck, as external injuries may have been masked by putrefactive change. Evidence of previous surgical intervention may be identified (e.g. burr holes in the skull) or sometimes significant trauma, even if there was no suggestion in the history or on external examination. Effusions in the chest or abdominal cavities of differing consistencies are commonly encountered in decomposed bodies. The nature of the effusion should be documented and a sample potentially retained for toxicology. Decomposition affects the internal organs in different ways and to varying degrees; some organs may shrink or others liquefy which can alter the organ weight when compared to standard reference tables and potentially significant pathology may be masked. Attempts must be made to identify and examine all the internal organs, including the brain, and despite autolytic change some pathology may still be discernible e.g. calcification and atheroma of the coronary arteries, myocardial fibrosis, intracerebral haemorrhage, cirrhosis of the liver, gastrointestinal erosions or unknown disseminated malignancy. Occasionally an embalmed body may require an autopsy. The embalming process can result in variable degrees of tissue preservation and result in embalming related artefacts but the autopsy process should be the same. Special consideration of some organ systems is required in decomposed cases. As mentioned previously, careful examination of the neck structures using a layered dissection technique is vital to exclude injury to the voice box which can occur in cases associated with external compression of the neck. Whilst identification of haemorrhage in the strap muscles may be hampered by putrefactive change, a voice box fracture with associated bleeding may still be recognizable and histology can confirm the findings. The potential for iatrogenic injuries associated with body recovery must also be considered especially in cases of advanced decomposition and skeletonization and careful handling is vital. Examination of the skeleton, including the
Figure 3 Skin discolouration with insect associated damage around the ankle and small maggots visible.
absence of body parts4,5 but is not considered by the authors to be a suitable alternative to a full post-mortem examination. If the pathologist is faced with a disrupted body and the circumstances in which the deceased was found raise some concern, the authors would advise caution and discussion with a local forensic pathologist for advice. Removal of any skin slippage, blistering or insects with standard washing up liquid can facilitate identification of scars, tattoos or injuries. If the nature of an area of skin discolouration is difficult to determine, then incision into the area may be considered appropriate with the absence of any underlying haemorrhage favouring post-mortem artefact. Penetrating defects such as incised wounds, lacerations or gunshot wounds may be preserved in decomposed cases; however, post-mortem predation and putrefaction can alter their size and appearance. If the body is partially skeletonized then methodical identification of the body parts present is required and can be made easier by using two adjacent tables (or a table and a trolley) to lay out the body parts in correct anatomical locations (Figure 5). In such cases, a more detailed examination could be undertaken by removing any remaining flesh (once the internal examination has been completed), thereby facilitating the identification of potential bony injuries, skeletal anomalies or previous surgical
Figure 4 Post-mortem predation related damage to the ear (a) and trunk (b) in a more mummified case and to the hand (c) in a body recovered from water.
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Please cite this article as: Collis S, Johnson CP, The decomposed cadaver, Diagnostic Histopathology, https://doi.org/10.1016/ j.mpdhp.2019.07.008
MINI-SYMPOSIUM: AUTOPSY PATHOLOGY
Figure 5 Body parts individually examined, subsequently cleaned and laid out with a fracture identified in the calcaneus. Teeth or samples of bone can be used for DNA identification.
skull, spine, chest, pelvis and limbs assists in the exclusion of potential bony injury and trauma (Figure 6). If imaging has been conducted prior to the autopsy then a further targeted examination of the area of injury can be conducted if necessary. Further dissection of the facial tissues and skeleton may also be appropriate in certain cases, although this would not be considered a routine procedure.
muscle, liver, bile, brain, bone and maggots can be utilized by some laboratories. Hair can also be useful to indicate a chronic history of drug use. Discussion with your local toxicology laboratory is advised prior to submission of any samples. It must be noted that interpretation of drug concentrations may vary depending on the substrate sent for analysis due to post-mortem redistribution and decompositional changes.7 The benefit of microbiology may be limited in decomposed cases due to postmortem bacterial translocation but virology could be an option depending on the degree of decomposition. If there is vitreous available, not required for toxicology, then biochemistry could be considered in appropriate cases but the post-mortem interval may make interpretation of the results difficult. There will be cases in which the identification of the deceased is still uncertain so samples of tissue (e.g. blood, muscle, heart, spleen, bone and fingernails) for potential DNA identification may be requested. Again, prior discussion with your local laboratory who will be handling the DNA extraction process, will assist in deciding which their preferred tissue is.
Further investigations Autolysis of the organs should not preclude sampling tissues for histology and complete sampling of the major organs is recommended. Histology may identify potentially relevant pathology such as inflammation, fibrosis or malignancy. Fixation prior to sampling may assist in block selection if the tissues are very soft and the use of special stains can highlight the underlying architecture and disease process of certain tissues, e.g. cirrhosis of the liver and myocardial fibrosis. In the majority of decomposed cases it is advisable to retain some samples for toxicology even if no concerns about drug or alcohol misuse have initially been raised,6 as additional information may come to light after the post-mortem examination. Blood, urine and vitreous are the ideal substrates for analysis; however, these may not be available in decomposed cases so samples of effusions, gastric contents,
Interpretation of findings The post-mortem report should incorporate information from the scene, circumstances, any past medical history, the post-mortem findings including the degree and distribution of putrefactive change as well as pertinent negative findings, along with the results of any further investigations performed. It is important to note the possibility of missed findings and pathology due to putrefaction and how confident you can be in your conclusions. Once all of the information has been collated, the pathologist then needs to decide if in their opinion that it is possible to offer a cause of death ‘on the balance of probabilities’ or if the death is best regarded as unascertained due to the inability to exclude potentially significant factors, such as injury, chronic disease or drug intoxication. Discussion of the case with colleagues can be useful in this regard.
Conclusion Despite the difficulties involved in the examination of a decomposed cadaver, a thorough and complete autopsy can not only provide information as to identification but also reveal significant pathology potentially sufficient to identify a cause of death.8,9
Figure 6 Evidence of haemorrhage around the ankle in a case with mummification change but no fracture was demonstrated.
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Please cite this article as: Collis S, Johnson CP, The decomposed cadaver, Diagnostic Histopathology, https://doi.org/10.1016/ j.mpdhp.2019.07.008
MINI-SYMPOSIUM: AUTOPSY PATHOLOGY
Throughout the examination the pathologist must be prepared to stop the procedure if there is evidence of significant trauma or other concerning pathology not accounted for in the history provided. In a small number of cases, further police investigation into the case may be required with the autopsy examination being referred to a forensic pathologist for completion of the case. If this does occur then attempts should be made to preserve evidence as much as possible e.g. retaining the brain or voice box by placing them in formalin or in a separate bag away from the other main organs. The post-mortem interval is a question often asked; however, in cases where decomposition is involved it must been remembered that the environment in which the body is found, any trauma or concurrent systemic pathology and how the body was subsequently stored, can significantly impact on the rate of decomposition.10,11 For these reasons caution is advised when considering whether to offer a possible postmortem time interval.12
8 Byard RW, Farrell E, Simpson E. Diagnostic yield and characteristic features in a series of decomposed bodies subject to coronial autopsy. Forensic Sci Med Pathol 2008; 4: 9e14. 9 Ambade VN, Keoliya AN, Deokar RB, Dixit PG. Decomposed bodies e still an unrewarding autopsy? J Forensic Leg Med 2011; 18: 101e6. 10 Zhou C, Byard RW. Factors and Processes causing accelerated decomposition in human cadavers e an overview. J Forensic Leg Med 2011; 18: 6e9. 11 Cockle DL, Bell LS. The impact of trauma and blood loss on human decomposition. Sci Justice 2019; 59: 332e6. 12 Madea B. Estimation of the time since death. 3rd edn. Boca Raton: CRC Press, 2016.
Practice Points
Potential cause of death opinions/statements 1a. Unascertained 1a. Mixed drug intoxication 1a. Gastrointestinal haemorrhage 1b. Cirrhosis of the liver 1a. ‘on the balance of probabilities’ Ischaemic heart disease
C
C C
C
A
C
REFERENCES 1 Galloway A, Birkby WH, Jones AM, Henry TE, Parks BO. Decay rates of human remains in an arid environment. J Forensic Sci 1989; 34: 607e16. 2 Saukko P, Knight B, eds. Knight’s forensic medicine. 4th edn. Boca Raton: CRC Press, 2015. 3 Rutty GN. Post-mortem changes and artefacts. In: Rutty GN, ed. Essentials of autopsy practice, vol. 1. London: Springer, 2001; 63e95. 4 Ruder TD, Thali MJ, Hatch GM. Essential of forensic post-mortem MR imaging in adults. Br J Radiol 2014; 78: 1e13. 5 Levy AD, Harcke HT, Mallak CT. Postmortem imaging. MDCT features of postmortem change and decomposition. Am J Forensic Med Pathol 2010; 31: 12e7. 6 The Royal College of Pathologists. Guidelines on autopsy practice: scenario 3: suspected illicit drugs. London: Royal College of Pathologists, 2005 [Currently under review)]. 7 Dinis-Oliveira RJ, Carvalho F, Duarte JA, et al. Collection of biological samples in forensic toxicology. Toxicol Mech Methods 2010; 20: 363e414.
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Obtain as much information as possible regarding the circumstances of the case. If available, review any images taken at the locus. A full post-mortem examination should be conducted and will often include further investigations (e.g. histology and toxicology). Be prepared to stop the examination and discuss or refer back to the Coroner or Procurator Fiscal, if any concerning findings are noted. Local forensic pathologists may also be a useful source of advice in decomposed cases.
Multiple choice question Which of the following substrates would be the most useful for postmortem toxicology? a) Liver b) Vitreous humour c) Pleural effusion d) Muscle e) Gastric contents Answer: B, Vitreous humour
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Please cite this article as: Collis S, Johnson CP, The decomposed cadaver, Diagnostic Histopathology, https://doi.org/10.1016/ j.mpdhp.2019.07.008
The decomposed cadaver
straight forward and should be approached with caution. As part of the police investigation, some form of scene imaging may be undertaken with the use of still photographs or body worn video camera footage. Reviewing the images can provide the pathologist with a better understanding of the circumstances, body position and general environment in which the body was located. If the images are not available prior to the examination, it may still be worthwhile to request them for review after the autopsy to assist in the interpretation of the findings and completion of the post-mortem report. The degree of putrefactive change seen on a body at the locus may differ to that observed in the mortuary at the time of the autopsy, due to factors such as a delay in body recovery, transportation to the mortuary and refrigeration. A delay between body recovery from the locus and the instruction or undertaking of the autopsy may result in further decomposition of the body. There are a number of factors which can accelerate or retard the process of decomposition (listed in Table 1) and these should also be taken into consideration.
SallyAnne Collis Christopher Paul Johnson
Abstract The examination of a decomposed cadaver is inherently difficult with varying degrees of decomposition encountered and the possibility of predation related damage then masking or hampering assessment of injuries and underlying pathology. These cases should be approached with caution and require a full autopsy examination to obtain the maximum amount of information, be that positive findings or the absence of significant injuries. It is advised that if at any point during the post-mortem examination concerning findings are encountered then the examination should be stopped with further information, clarification or advice sought. Despite the presence of putrefactive change and tissue autolysis, additional investigations are potentially useful with histology and toxicology considered important in such cases to reach a conclusion in the cause of death, be that unascertained.
Identification Before the autopsy, identification of the deceased is usually attempted, although it may be appropriate for the autopsy to be requested and performed without positive identification depending on the policies and procedures in different areas of the country. The identification may be regarded “as presumed to be .. ” with ongoing enquiries. Autopsy findings may provide further information to assist with the identification process. A significant delay whilst awaiting formal identification could result in loss of material as the process of decomposition and possible predation associated damage by insects (e.g. maggots) continues, even if a body is adequately refrigerated. The use of fingerprints may still be an option and if there is early mummification change of the hands then water can be injected into the pulp of the finger tips to enhance the ridge detail. A GP summary or hospital notes of the ‘presumed’ deceased may provide documentation of previous surgical procedures or implants (Figure 1) which can assist with identification. Specialists, such as forensic odontologists and genetic identification, may be required in certain cases to formally determine the identification of the deceased. If an odontologist is instructed then it may be more advantageous to perform the autopsy first as the process of exposure of the teeth can sometimes involve incision into tissues of the face, which could make interpretation of potential injuries in that area difficult.
Keywords autopsy; decomposition; histopathology; odontology; predation related damage; putrefaction; toxicology
Introduction The process of decomposition starts from the moment of death. It is not uncommon for pathologists to be requested to undertake an autopsy of a body in a state of decomposition in order to attempt to address the questions of who the person was, when the person died and what led to their death be it natural, un-natural or unascertained. The degree and extent of decomposition seen on a body can vary. Galloway (1989)1 classified human remains into five categories: fresh, early decomposition, advanced decomposition, skeletalisation and decomposition of skeletal material. It is quite frequent for the stages to overlap in the same body. Potential scenarios where such a case is encountered may include: an individual found deceased at home, or exposed to the external elements either on land or in water, with the time from death to discovery being variable and often unknown.
Initial investigations On finding a body in a state of decomposition, an initial police investigation should be instigated to ascertain the circumstances leading up to the discovery of the body and potential features that may assist in identification of the deceased. Even if such a case is deemed by the police and Coroner/Procurator Fiscal to be non-suspicious the post-mortem examination is by no means
The autopsy Although the autopsy would have been instructed as a ‘nonsuspicious’ case, at each stage of the examination the pathologist should determine if they are willing to proceed. Elements may be identified that raise concern, such as ‘un-natural’ circumstances in which the body was found (e.g. concealment of the body), potential for third party involvement (e.g. neglect, physical, financial or mental abuse or previous history of violence towards the deceased) or the body being discovered in an incomplete state. The decision to conduct and proceed with the post-mortem examination ultimately rests with the pathologist undertaking the examination; but if there is concern regarding the circumstances of the case, or with findings identified on external examination, then advice should be sought either from colleagues
SallyAnne Collis BN MBChB FRCPath DMJ Consultant Forensic Pathologist, Forensic Pathology, Nine Edinburgh Bioquarter, Edinburgh, UK. Conflicts of interest: none declared. Christopher Paul Johnson MD FRCPath DMJ Consultant Forensic Pathologist and Home Office Pathologist, Forensic Unit Liverpool, Royal Liverpool University Hospital, Liverpool, UK. Conflicts of interest: none declared.
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Please cite this article as: Collis S, Johnson CP, The decomposed cadaver, Diagnostic Histopathology, https://doi.org/10.1016/ j.mpdhp.2019.07.008
MINI-SYMPOSIUM: AUTOPSY PATHOLOGY
Factors which can affect the rate of decomposition Location of the body Environmental temperature at the time of discovery and in the preceding time interval Thawing of frozen body Exposure to predators Clothing or coverings over body Body size Ante-mortem injuries and blood loss Underlying pathology (e.g. infection) Table 1
or a local forensic pathologist, and further discussion should be had with the Coroner or Procurator Fiscal. In some cases, additional police investigation may also be required and the autopsy referred on to a forensic pathologist for completion, particularly if there is the potential for subsequent criminal proceedings.
Figure 2 Skin discolouration, venous marbling, areas of skin slippage with parchmented change and bloating of the abdomen due to putrefactive gases.
External examination The published literature outlines the process of decomposition and features commonly encountered at autopsy.2,3 Early decompositional changes include green skin discolouration which usually starts over the abdomen, venous marbling, skin slippage, bloat, purge fluids emanating from the nose and mouth and drying of the extremities (Figure 2). With advancing putrefaction there is insect activity, areas of skin loss and exposure of the underlying bone. In drier conditions mummification often predominates. The final stage is skeletonization in which greater than 50% of the bone is exposed. The formation of adipocere (a greasy or wax-like substance) may occur in some circumstances. The extent and pattern of decomposition may vary depending on the environment, body position at the locus and size of the body. In order for a thorough autopsy examination to be performed the body must be removed from the body bag. It is not uncommon for very decomposed bodies to be recovered from the locus with items such as carpet or bedding wrapped around the deceased in an attempt to preserve the body’s integrity. Ideally
any clothing should be left in situ for the pathologist to examine as necklaces or clothing such as a shirt collar or elasticated areas around wrists or ankles, may leave marks on the skin which could be misinterpreted as having been caused by a ligature. If the clothing was removed at the locus by police then scene images may assist in interpretation of any such markings. The clothing or coverings should then be removed and examined. It is recommended to check the pockets as this may not have been done at the locus due to the state of the body. An initial external examination of the body should note the degree and distribution of putrefactive and mummification change, the presence, type and location of any insects as well as associated activity and injuries (Figure 3). Should the type of insects present and stage of development be considered an important factor then an entomologist may be required; such a case is usually best undertaken by a forensic pathologist. Photography can be helpful in recording findings of the post-mortem examination and facilitate future discussions, for example, with colleagues. It should be noted that the external examination is often hampered by skin discolouration, insect activity and areas of associated skin loss, which could mask potentially significant injuries and pathology. Predator damage from animals or insects may result in additional ‘injuries’ to the body (Figure 4), alteration of ante-mortem injuries and the separation of body parts and organs from the main body mass. Such damage can occur indoors or outdoors and it is worth enquiring if there were any animals (including household pets) or signs of rodent infestation at the locus. Establishing which defects are ante-mortem rather than due to post-mortem change or predation can be difficult, with potential features such as scalloped edges, absence of haemorrhage, and the presence of other predation associated damage providing some assistance. Correlation with the overlying clothing is also helpful. Post-mortem imaging, in the form of X-rays, fluoroscopy or CT scanning, may be available in some areas of the UK. Imaging may prove a useful adjunct in cases where there are suspected bony injuries, the presence of advanced decomposition or
Figure 1 A metal surgical implant identified on one of the metatarsal bones with identification numbers present that could then be checked against medical records for identification purposes.
DIAGNOSTIC HISTOPATHOLOGY xxx:xxx
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Ó 2019 Published by Elsevier Ltd.
Please cite this article as: Collis S, Johnson CP, The decomposed cadaver, Diagnostic Histopathology, https://doi.org/10.1016/ j.mpdhp.2019.07.008
MINI-SYMPOSIUM: AUTOPSY PATHOLOGY
intervention. This process is best achieved by using a macerator/ bone washing table. It is acknowledged that this process can be time consuming and may not be deemed necessary in the majority of cases. Internal examination Evisceration can be carried out using the method deemed most appropriate by the pathologist. However, in decomposed cases, it is recommended that the pathologist perform the evisceration themselves or observes closely whilst an experienced technician performs the procedure. It is also advised that a ‘Y’ incision is undertaken to allow a thorough examination of the neck, as external injuries may have been masked by putrefactive change. Evidence of previous surgical intervention may be identified (e.g. burr holes in the skull) or sometimes significant trauma, even if there was no suggestion in the history or on external examination. Effusions in the chest or abdominal cavities of differing consistencies are commonly encountered in decomposed bodies. The nature of the effusion should be documented and a sample potentially retained for toxicology. Decomposition affects the internal organs in different ways and to varying degrees; some organs may shrink or others liquefy which can alter the organ weight when compared to standard reference tables and potentially significant pathology may be masked. Attempts must be made to identify and examine all the internal organs, including the brain, and despite autolytic change some pathology may still be discernible e.g. calcification and atheroma of the coronary arteries, myocardial fibrosis, intracerebral haemorrhage, cirrhosis of the liver, gastrointestinal erosions or unknown disseminated malignancy. Occasionally an embalmed body may require an autopsy. The embalming process can result in variable degrees of tissue preservation and result in embalming related artefacts but the autopsy process should be the same. Special consideration of some organ systems is required in decomposed cases. As mentioned previously, careful examination of the neck structures using a layered dissection technique is vital to exclude injury to the voice box which can occur in cases associated with external compression of the neck. Whilst identification of haemorrhage in the strap muscles may be hampered by putrefactive change, a voice box fracture with associated bleeding may still be recognizable and histology can confirm the findings. The potential for iatrogenic injuries associated with body recovery must also be considered especially in cases of advanced decomposition and skeletonization and careful handling is vital. Examination of the skeleton, including the
Figure 3 Skin discolouration with insect associated damage around the ankle and small maggots visible.
absence of body parts4,5 but is not considered by the authors to be a suitable alternative to a full post-mortem examination. If the pathologist is faced with a disrupted body and the circumstances in which the deceased was found raise some concern, the authors would advise caution and discussion with a local forensic pathologist for advice. Removal of any skin slippage, blistering or insects with standard washing up liquid can facilitate identification of scars, tattoos or injuries. If the nature of an area of skin discolouration is difficult to determine, then incision into the area may be considered appropriate with the absence of any underlying haemorrhage favouring post-mortem artefact. Penetrating defects such as incised wounds, lacerations or gunshot wounds may be preserved in decomposed cases; however, post-mortem predation and putrefaction can alter their size and appearance. If the body is partially skeletonized then methodical identification of the body parts present is required and can be made easier by using two adjacent tables (or a table and a trolley) to lay out the body parts in correct anatomical locations (Figure 5). In such cases, a more detailed examination could be undertaken by removing any remaining flesh (once the internal examination has been completed), thereby facilitating the identification of potential bony injuries, skeletal anomalies or previous surgical
Figure 4 Post-mortem predation related damage to the ear (a) and trunk (b) in a more mummified case and to the hand (c) in a body recovered from water.
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Please cite this article as: Collis S, Johnson CP, The decomposed cadaver, Diagnostic Histopathology, https://doi.org/10.1016/ j.mpdhp.2019.07.008
MINI-SYMPOSIUM: AUTOPSY PATHOLOGY
Figure 5 Body parts individually examined, subsequently cleaned and laid out with a fracture identified in the calcaneus. Teeth or samples of bone can be used for DNA identification.
skull, spine, chest, pelvis and limbs assists in the exclusion of potential bony injury and trauma (Figure 6). If imaging has been conducted prior to the autopsy then a further targeted examination of the area of injury can be conducted if necessary. Further dissection of the facial tissues and skeleton may also be appropriate in certain cases, although this would not be considered a routine procedure.
muscle, liver, bile, brain, bone and maggots can be utilized by some laboratories. Hair can also be useful to indicate a chronic history of drug use. Discussion with your local toxicology laboratory is advised prior to submission of any samples. It must be noted that interpretation of drug concentrations may vary depending on the substrate sent for analysis due to post-mortem redistribution and decompositional changes.7 The benefit of microbiology may be limited in decomposed cases due to postmortem bacterial translocation but virology could be an option depending on the degree of decomposition. If there is vitreous available, not required for toxicology, then biochemistry could be considered in appropriate cases but the post-mortem interval may make interpretation of the results difficult. There will be cases in which the identification of the deceased is still uncertain so samples of tissue (e.g. blood, muscle, heart, spleen, bone and fingernails) for potential DNA identification may be requested. Again, prior discussion with your local laboratory who will be handling the DNA extraction process, will assist in deciding which their preferred tissue is.
Further investigations Autolysis of the organs should not preclude sampling tissues for histology and complete sampling of the major organs is recommended. Histology may identify potentially relevant pathology such as inflammation, fibrosis or malignancy. Fixation prior to sampling may assist in block selection if the tissues are very soft and the use of special stains can highlight the underlying architecture and disease process of certain tissues, e.g. cirrhosis of the liver and myocardial fibrosis. In the majority of decomposed cases it is advisable to retain some samples for toxicology even if no concerns about drug or alcohol misuse have initially been raised,6 as additional information may come to light after the post-mortem examination. Blood, urine and vitreous are the ideal substrates for analysis; however, these may not be available in decomposed cases so samples of effusions, gastric contents,
Interpretation of findings The post-mortem report should incorporate information from the scene, circumstances, any past medical history, the post-mortem findings including the degree and distribution of putrefactive change as well as pertinent negative findings, along with the results of any further investigations performed. It is important to note the possibility of missed findings and pathology due to putrefaction and how confident you can be in your conclusions. Once all of the information has been collated, the pathologist then needs to decide if in their opinion that it is possible to offer a cause of death ‘on the balance of probabilities’ or if the death is best regarded as unascertained due to the inability to exclude potentially significant factors, such as injury, chronic disease or drug intoxication. Discussion of the case with colleagues can be useful in this regard.
Conclusion Despite the difficulties involved in the examination of a decomposed cadaver, a thorough and complete autopsy can not only provide information as to identification but also reveal significant pathology potentially sufficient to identify a cause of death.8,9
Figure 6 Evidence of haemorrhage around the ankle in a case with mummification change but no fracture was demonstrated.
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Please cite this article as: Collis S, Johnson CP, The decomposed cadaver, Diagnostic Histopathology, https://doi.org/10.1016/ j.mpdhp.2019.07.008
MINI-SYMPOSIUM: AUTOPSY PATHOLOGY
Throughout the examination the pathologist must be prepared to stop the procedure if there is evidence of significant trauma or other concerning pathology not accounted for in the history provided. In a small number of cases, further police investigation into the case may be required with the autopsy examination being referred to a forensic pathologist for completion of the case. If this does occur then attempts should be made to preserve evidence as much as possible e.g. retaining the brain or voice box by placing them in formalin or in a separate bag away from the other main organs. The post-mortem interval is a question often asked; however, in cases where decomposition is involved it must been remembered that the environment in which the body is found, any trauma or concurrent systemic pathology and how the body was subsequently stored, can significantly impact on the rate of decomposition.10,11 For these reasons caution is advised when considering whether to offer a possible postmortem time interval.12
8 Byard RW, Farrell E, Simpson E. Diagnostic yield and characteristic features in a series of decomposed bodies subject to coronial autopsy. Forensic Sci Med Pathol 2008; 4: 9e14. 9 Ambade VN, Keoliya AN, Deokar RB, Dixit PG. Decomposed bodies e still an unrewarding autopsy? J Forensic Leg Med 2011; 18: 101e6. 10 Zhou C, Byard RW. Factors and Processes causing accelerated decomposition in human cadavers e an overview. J Forensic Leg Med 2011; 18: 6e9. 11 Cockle DL, Bell LS. The impact of trauma and blood loss on human decomposition. Sci Justice 2019; 59: 332e6. 12 Madea B. Estimation of the time since death. 3rd edn. Boca Raton: CRC Press, 2016.
Practice Points
Potential cause of death opinions/statements 1a. Unascertained 1a. Mixed drug intoxication 1a. Gastrointestinal haemorrhage 1b. Cirrhosis of the liver 1a. ‘on the balance of probabilities’ Ischaemic heart disease
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REFERENCES 1 Galloway A, Birkby WH, Jones AM, Henry TE, Parks BO. Decay rates of human remains in an arid environment. J Forensic Sci 1989; 34: 607e16. 2 Saukko P, Knight B, eds. Knight’s forensic medicine. 4th edn. Boca Raton: CRC Press, 2015. 3 Rutty GN. Post-mortem changes and artefacts. In: Rutty GN, ed. Essentials of autopsy practice, vol. 1. London: Springer, 2001; 63e95. 4 Ruder TD, Thali MJ, Hatch GM. Essential of forensic post-mortem MR imaging in adults. Br J Radiol 2014; 78: 1e13. 5 Levy AD, Harcke HT, Mallak CT. Postmortem imaging. MDCT features of postmortem change and decomposition. Am J Forensic Med Pathol 2010; 31: 12e7. 6 The Royal College of Pathologists. Guidelines on autopsy practice: scenario 3: suspected illicit drugs. London: Royal College of Pathologists, 2005 [Currently under review)]. 7 Dinis-Oliveira RJ, Carvalho F, Duarte JA, et al. Collection of biological samples in forensic toxicology. Toxicol Mech Methods 2010; 20: 363e414.
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Obtain as much information as possible regarding the circumstances of the case. If available, review any images taken at the locus. A full post-mortem examination should be conducted and will often include further investigations (e.g. histology and toxicology). Be prepared to stop the examination and discuss or refer back to the Coroner or Procurator Fiscal, if any concerning findings are noted. Local forensic pathologists may also be a useful source of advice in decomposed cases.
Multiple choice question Which of the following substrates would be the most useful for postmortem toxicology? a) Liver b) Vitreous humour c) Pleural effusion d) Muscle e) Gastric contents Answer: B, Vitreous humour
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Ó 2019 Published by Elsevier Ltd.
Please cite this article as: Collis S, Johnson CP, The decomposed cadaver, Diagnostic Histopathology, https://doi.org/10.1016/ j.mpdhp.2019.07.008