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Examining Wounds During Autopsy

One of the greatest challenges of an autopsy is examining the wounds. The essence of the medical examiner’s job is to use his or her skill and experience to determine the true nature and cause of a particular wound. Depending on the type of wound or weapon used, this can get difficult. Dr. Kiesel talks about those difficulties:

” [When] they weren’t shot once, they were shot 13 times or 20 times … you’ve got to sort out paths of all these bullets. You’ve got to figure out where each bullet went. The old way of doing it was, ‘Well, he’s got 10 holes on the front, there are eight holes on the back, and there’s two bullets inside, we’re done.’ [The] legal system won’t accept that anymore”

Homicide cases have to be examined carefully and thoroughly. A part of a medical examiner’s job includes testifying in court. Medical examiners are often called upon to explain their findings on the stand. Their findings can have a large impact on the lives of all those who are part of the case.

Dr. Kiesel explains how wounds have patterns that help to determine their origins:

“Bludgeoning, where you have someone who’s been physically assaulted and beaten, you’ve got a lot of different injuries. Sometimes these injuries have patterns. Sometimes the injury patterns give you a clue as to what weapon may have been used. Sometimes there’s more than one weapon. I had a case where a person was done in by one individual, but that individual used at least four different weapons. So we had four different types of patterned injuries on that person.”

Through years of education and experience, the medical examiner learns to recognize these patterns and the types of trauma with which they are associated.

(Dr. Kiesel is the Deputy Chief Medical Examiner of Fulton County)

Common Changes of Post-Mortem Chemical Values

(from The Handbook of Autopsy Practice)

Examining Wounds During Autopsy

One of the greatest challenges of an autopsy is examining the wounds. The essence of the medical examiner’s job is to use his or her skill and experience to determine the true nature and cause of a particular wound. Depending on the type of wound or weapon used, this can get difficult. Dr. Kiesel talks about those difficulties:

” [When] they weren’t shot once, they were shot 13 times or 20 times … you’ve got to sort out paths of all these bullets. You’ve got to figure out where each bullet went. The old way of doing it was, ‘Well, he’s got 10 holes on the front, there are eight holes on the back, and there’s two bullets inside, we’re done.’ [The] legal system won’t accept that anymore”

Homicide cases have to be examined carefully and thoroughly. A part of a medical examiner’s job includes testifying in court. Medical examiners are often called upon to explain their findings on the stand. Their findings can have a large impact on the lives of all those who are part of the case.

Dr. Kiesel explains how wounds have patterns that help to determine their origins:

“Bludgeoning, where you have someone who’s been physically assaulted and beaten, you’ve got a lot of different injuries. Sometimes these injuries have patterns. Sometimes the injury patterns give you a clue as to what weapon may have been used. Sometimes there’s more than one weapon. I had a case where a person was done in by one individual, but that individual used at least four different weapons. So we had four different types of patterned injuries on that person.”

Through years of education and experience, the medical examiner learns to recognize these patterns and the types of trauma with which they are associated.

(Dr. Kiesel is the Deputy Chief Medical Examiner of Fulton County)

John Wayne Gacy’s Brain

On May 10, 1994, about 3 a.m., Dr. Helen Morrison received word: John Wayne Gacy, who prowled the Chicago streets preying on lonely runaways and murdered 33 young men and boys, had been executed.

Dr. Morrison headed out to a nearby hospital where she donned scrubs and Latex gloves to assist in Gacy’s autopsy.

For Morrison, it was a strange final chapter to her 14-year history with the clown-turned-killer. The forensic psychiatrist had interviewed Gacy many times, listening to his rants, raves, lies, boasts, explanations and evasions.

Now she was back for something else: Gacy’s brain. Morrison had made arrangements to have the brain examined to see if there was anything — tumors, scars, disease — that made it abnormal.

When the autopsy was over, Morrison drove home with Gacy’s brain in a glass jar on the passenger seat of her Buick.

It took several calls to find a pathologist who would do the tests, and a few weeks later an express-mail envelope arrived at her office. She was not surprised by the summary.

“Just one simple line,” she says. “Normal brain.”

Autopsy Procedure: External Examination

• The body is received at a medical examiners office or hospital in a body bag or evidence sheet. If the autopsy is not performed immediately, the body will be refrigerated in the morgue until the examination. A brand new body bag is used for each body. This is to ensure that only evidence from that body is contained within the bag. Body bags are closed and sealed to prevent any contamination or evidence loss during transportation. Evidence sheets are an alternate way to transport the body. An evidence sheet is a sterile sheet that the body is covered in when it is moved. Just like the body bags, investigators use brand new sheets for every corpse.
• The body is moved in the bag or sheet to the examination suite. The person responsible for handling the body is often called a diener. The diener is a morgue attendant who is responsible for moving and cleaning the body and, in some cases, assisting in the autopsy. The diener will also clean the exam suite after the autopsy is over. This job may vary from facility to facility.
• When the body is received in a body bag, the seals of the bag are broken and the body is photographed inside the bag. In a forensic autopsy, it is important at this stage for the medical examiner to note the clothing of the deceased and the position of the clothing. This is because once the clothing is removed for the examination, any evidence pertaining to the position of the clothing cannot be documented.
• Evidence is collected off of the external surfaces of the body. Hair samples, fingernails, gunshot residue (if present), fibers, paint chips or any other foreign objects found on the surface of the body are collected and noted.
• If it is a homicide investigation, the hands of the deceased will be placed in bags at the scene. The medical examiner will open the bags and take residue and fingernail samples. Then the bags are removed, folded and submitted with the samples as part of the evidence.
• In some cases, a special UV radiation is used to enhance secretions on the skin or clothes. The radiation causes the secretions to fluoresce so that they may be collected for samples.
• If protocol dictates, the body will be x-rayed while still in the body bag.
• Once the evidence is all collected, the body is removed from the bag or sheet and undressed, and the wounds are examined. This is done before the body is cleaned up.
• After the body is cleaned, the body is weighed and measured before being placed on the autopsy table for reexamination. The autopsy table is typically a slanted, aluminum table with raised edges that has several faucets and drains used to wash away collecting blood during the internal investigation. The types of table used vary from facility to facility. The body is placed face up on the table, and a body block is placed under the patient’s back. A body block is a rubber or plastic “brick” that causes the corpse’s chest to protrude forward while the arms and neck fall back. This position makes the chest easier to cut open.

• At this point, a general description of the body is made. All identifying features are noted including: Race, Sex, Hair color and length, Eye color, 
  Approximate age, Any identifying features (scars, tattoos, birthmarks, etc.) 

• These features are noted on a handheld voice recorder or a standard exam form. In addition to all normal features, any external abnormalities are noted in these reports

Autopsy Procedure: Internal Examination

• The internal examination starts with a large, deep, Y-shaped incision that is made from shoulder to shoulder meeting at the breast bone and extends all the way down to the pubic bone.

• The next step is to peel back the skin, muscle and soft tissue using a scalpel. Once this is done, the chest flap is pulled up over the face, exposing the ribcage and neck muscles.

• Two cuts are made on each side of the ribcage, and then the ribcage is pulled from the skeleton after dissecting the tissue behind it with a scalpel.  During this dissection, the various organs are examined and weighed and tissue samples are taken. These samples take the form of “slices” that can be easily viewed under a microscope. Major blood vessels are also bisected and examined.

• With the organs exposed, a series of cuts are made that detach the larynx, esophagus, various arteries and ligaments. Next, the medical examiner severs the organs’ attachment to the spinal cord as well as the attachment to the bladder and rectum. Once this is done, the entire organ set can be pulled out in one piece and dissected for further investigation.

• The examiner opens the stomach and examines and weighs the contents. This can sometimes be helpful in figuring out the time of death (more on time of death later).

• The examiner will then remove the body block from the back and put it behind the neck like a pillow, raising the patient’s head so that it’s easier to remove the brain.

  The examiner makes a cut with a scalpel from behind one ear, across the forehead, to the other ear and around. The cut is divided, and the scalp is pulled away from the skull in two flaps. The front flap goes over the patients face and the rear flap over the back of the neck. The skull is cut with an electric saw to create a “cap” that can be pried off, exposing the brain. When the cap is pulled off, the dura (the soft tissue membrane that covers the brain) remains attached to the bottom of the skull cap. The brain is now exposed. The brain’s connection to the spinal cord and tentorium (a membrane that connects and covers the cerebellum and occipital lobes of the cerebrum) are severed, and the brain is easily lifted out of the skull for examination.

• Throughout this whole process, the medical examiner is looking for evidence of trauma or other indications of the cause of death. The process varies based on the nature of the case and is incredibly detailed — the forensic pathologist has to adhere to an intricate, in-depth process to ensure the proper collection and documentation of evidence.

After the examination, the body has an open and empty chest cavity with butterflied chest flaps, the top of the skull is missing, and the skull flaps are pulled over the face and neck. To prepare the body for the funeral home:

• The organs are either put back into the body or incinerated.
• The chest flaps are closed and sewn back together.
• The skull cap is put back in place and held there by closing and sewing the scalp.

John Wayne Gacy’s Brain

On May 10, 1994, about 3 a.m., Dr. Helen Morrison received word: John Wayne Gacy, who prowled the Chicago streets preying on lonely runaways and murdered 33 young men and boys, had been executed.

Dr. Morrison headed out to a nearby hospital where she donned scrubs and Latex gloves to assist in Gacy’s autopsy.

For Morrison, it was a strange final chapter to her 14-year history with the clown-turned-killer. The forensic psychiatrist had interviewed Gacy many times, listening to his rants, raves, lies, boasts, explanations and evasions.

Now she was back for something else: Gacy’s brain. Morrison had made arrangements to have the brain examined to see if there was anything — tumors, scars, disease — that made it abnormal.

When the autopsy was over, Morrison drove home with Gacy’s brain in a glass jar on the passenger seat of her Buick.

It took several calls to find a pathologist who would do the tests, and a few weeks later an express-mail envelope arrived at her office. She was not surprised by the summary.

“Just one simple line,” she says. “Normal brain.”

The vibrating electric Stryker saw is used in autopsies, to cut into the skull without damaging the brain. 

Examining Wounds During Autopsy

One of the greatest challenges of an autopsy is examining the wounds. The essence of the medical examiner’s job is to use his or her skill and experience to determine the true nature and cause of a particular wound. Depending on the type of wound or weapon used, this can get difficult. Dr. Kiesel talks about those difficulties:

” [When] they weren’t shot once, they were shot 13 times or 20 times … you’ve got to sort out paths of all these bullets. You’ve got to figure out where each bullet went. The old way of doing it was, ‘Well, he’s got 10 holes on the front, there are eight holes on the back, and there’s two bullets inside, we’re done.’ [The] legal system won’t accept that anymore”

Homicide cases have to be examined carefully and thoroughly. A part of a medical examiner’s job includes testifying in court. Medical examiners are often called upon to explain their findings on the stand. Their findings can have a large impact on the lives of all those who are part of the case.

Dr. Kiesel explains how wounds have patterns that help to determine their origins:

“Bludgeoning, where you have someone who’s been physically assaulted and beaten, you’ve got a lot of different injuries. Sometimes these injuries have patterns. Sometimes the injury patterns give you a clue as to what weapon may have been used. Sometimes there’s more than one weapon. I had a case where a person was done in by one individual, but that individual used at least four different weapons. So we had four different types of patterned injuries on that person.”

Through years of education and experience, the medical examiner learns to recognize these patterns and the types of trauma with which they are associated.

(Dr. Kiesel is the Deputy Chief Medical Examiner of Fulton County)

Sharon Tate - Autopsy Sheet

Autopsy Procedure: Internal Examination

• The internal examination starts with a large, deep, Y-shaped incision that is made from shoulder to shoulder meeting at the breast bone and extends all the way down to the pubic bone.

• The next step is to peel back the skin, muscle and soft tissue using a scalpel. Once this is done, the chest flap is pulled up over the face, exposing the ribcage and neck muscles.

• Two cuts are made on each side of the ribcage, and then the ribcage is pulled from the skeleton after dissecting the tissue behind it with a scalpel.  During this dissection, the various organs are examined and weighed and tissue samples are taken. These samples take the form of “slices” that can be easily viewed under a microscope. Major blood vessels are also bisected and examined.

• With the organs exposed, a series of cuts are made that detach the larynx,esophagus, various arteries and ligaments. Next, the medical examiner severs the organs’ attachment to the spinal cord as well as the attachment to the bladder and rectum. Once this is done, the entire organ set can be pulled out in one piece and dissected for further investigation.

• The examiner opens the stomach and examines and weighs the contents. This can sometimes be helpful in figuring out the time of death (more on time of death later).

• The examiner will then remove the body block from the back and put it behind the neck like a pillow, raising the patient’s head so that it’s easier toremove the brain.

  The examiner makes a cut with a scalpel from behind one ear, across the forehead, to the other ear and around. The cut is divided, and the scalp is pulled away from the skull in two flaps. The front flap goes over the patients face and the rear flap over the back of the neck. The skull is cut with anelectric saw to create a “cap” that can be pried off, exposing the brain. When the cap is pulled off, the dura (the soft tissue membrane that covers the brain) remains attached to the bottom of the skull cap. The brain is now exposed. The brain’s connection to the spinal cord and tentorium (a membrane that connects and covers the cerebellum and occipital lobes of the cerebrum) are severed, and the brain is easily lifted out of the skull for examination.

• Throughout this whole process, the medical examiner is looking for evidence of trauma or other indications of the cause of death. The process varies based on the nature of the case and is incredibly detailed — the forensic pathologist has to adhere to an intricate, in-depth process to ensure the proper collection and documentation of evidence.

After the examination, the body has an open and empty chest cavity with butterflied chest flaps, the top of the skull is missing, and the skull flaps are pulled over the face and neck. To prepare the body for the funeral home:

• The organs are either put back into the body or incinerated.
• The chest flaps are closed and sewn back together.
• The skull cap is put back in place and held there by closing and sewing the scalp.

Autopsy Findings

FINAL DIAGNOSIS:

I. Ligature strangulation

A. Circumferential ligature withassociated ligature furrow of neck

B. Abrasions and petechial hemorrhages,neck

C. Petechial hemorrhages, conjunctivalsurfaces of eyes and skin of face

II. Craniocerebral injuries

A. Scalp contusion

B. Linear, comminuted fracture ofright side of skull

C. Linear pattern of contusionsof right cerebral hemisphere

D. Subarachnoid and subdural hemorrhage

E. Small contusions, tips of temporallobes

III. Abrasion of right cheek

IV. Abrasion/contusion, posteriorright shoulder

V. Abrasions of left lower backand posterior left lower leg

VI. Abrasion and vascular congestionof vaginal mucosa

VII. Ligature of right wrist

TOXICOLOGIC STUDIES

blood ethanol - none detected

blood drug screen - no drugs detected

CLINICOPATHOLOGIC CORRELATION: Causeof death of this six year old female is asphyxia by strangulation associated with craniocerebral trauma.

John E. Meyer, M.D.

Pathologist

jn/12/27/96

Three Main Types of Autopsy

• medicolegal (forensic) - to determine cause and manner of death, identify the deceased
• clinical or pathological - to diagnose a disease (or clarify diagnosis) or for research purposes
• anatomical/academic - performed by students for the purpose of learning anatomy