AUTOPSY: INTERNAL EXAMINATION

INTERNAL EXAMINATION
It consists of:
1. Incising the body
2. Inspecting the various organs
3. Examining the cavities systematically
4. Weighing and measuring the organs
5. Checking for any pathology
6. Putting all the organs back in and padding
7. Suturing the body

1. ‘I’ shaped Incision: It is a straight line incision
extending from the chin to the symphysis pubis.
2. ‘Y’ Shaped Incision: This type of incision starts
near the acromian process and progresses
downwards towards the xiphoid process. The
incision is then extended till the symphysis pubis.
Also, a similar incision is made on the opposite side
of the body.
3. Modified ‘Y’ Shaped: A ‘Y’ shaped incision is
made from the suprasternal notch to symphysis
pubis. It extends from the suprasternal notch over
the clavicle
to its center on both sides and passes upwards
over the neck, behind the ear.

REMOVAL OF ORGANS
1. Virchow’s Technique: Head  Thorax 
Abdomen
2. Rokitansky’s Technique: in situ dissection in
parts combined with en block removal.
3. Letulle’s Technique: Cervical  Thoracic 
Abdominal  Pelvic Organs  Removed en
masse and dissected as organ block.

ORDER OF EXAMINATION
VIRCHOW’S TECHNIQUE 
Head
Thoracic (Cervical)
Abdominal Organs

HEAD
• The neck is extended by placing a
wooden block under the shoulders.
• Fix head using a head rest.
• Intermastoidal incision is made i.e. from
the mastoid process behind one ear to
the vertex and again to the mastoid
process of the other ear.
• Scalp flap is reflected forward to the
superciliary ridge and backwards to the
occipital protuberance.

HEAD
• With the help of a saw, ‘V’ shaped cut is made
so that the skull fits back correctly after
autopsy.
• This ‘V’ shaped cut passes through: the center
of the forehead  base of the mastoid
process  occipital protuberance  the base
of the other mastoid process and back to
the center of the forehead.

CAUTION
• Care must be taken to avoid any damage to the
meninges or the brain during the process of skull
removal.
• Therefore, chisel and hammer should never be
used.
• Instead, a chisel should be inserted and twisted
at various points in order to remove the skull flap.
• By doing so, superior longitudinal sinus can be
exposed.

BRAIN
• Dura is incised along the lines of the incision
of the skull  folded to the midline  falx
cerebri is freed from the cribriform plate 
dura is pulled back.
• 4 fingers of the left hand are inserted into the
frontal lobe and the nerves and vessels are
cut.
• Tentorium is also cut along the posterior part
of the petrous bone.

BRAIN
• A knife is then inserted into the occipital foramen
and the cervical cord  cervical nerves and the
vertebral arteries are cut as far as possible.
• With the right hand the cerebellum is grasped
and examined.
• Any signs of hemorrhage, injury or any other
disease should be carefully seen.
• Vessels, especially the Circle of Willis, should be
checked for any arteriosclerosis or aneurysm etc.

FIXATION
Brain will start to deteriorate as soon as the
blood supply is interrupted. This deterioration is
rapid and therefore, it is of utmost importance
to arrest this procedure.
This process of preservation of the brain is called
fixation.
There are 2 main methods of fixation:
1. Freezing
2. Prefusion

FIXATION OF THE BRAIN
Brain is fixed in 10% formalin for
at least 1-2 week(s).
To help with the penetration of
the preservative, lateral fissures
are made through, which tear
open the pia and the arachnoid
mater.
A long sagittal cut is made
through the corpus callosum so
as to allow the formalin to pass
into the ventricles.

AFTER FIXATION
 Brain is placed on a board and the
cerebellum along with the pons and the
medulla are removed.
 Straight cut is made to expose the fourth
ventricle.
 Thereafter an oblique cut is made to
expose the dentate nucleus.
 Entire stem is sectioned at a few
millimeters distance and examined for any
pathology.
 Cerebellum is examined by making a series
of sagittal cuts beginning from the frontal
pole passing backwards to the occiput.
 Sequentially cuts are made and serially
placed aside in the same order for later
identification.

SPINAL CORD
• Not examined unless there is an indication.
• In prone position, wooden block is placed
under the chest and the head is bent
downwards.
• Mid-line incision from the occipital
protuberance to the L4 vertebra is made.
• Muscles are dissected all the way.
• Atlas is disarticulated.
• With the help of a double bladed saw, the
laminae are sawed through the entire length
and separated by a chisel.

SPINAL CORD
• Dura is cut open and checked for
haemorrhage, inflammation, tumours, pus
etc.
• Nerves are cut from below as they pass
though the spinal formaina.
• And the cord is separated from the
foramen magnum.
• Cord is then sectioned transversely and
serially.
• Lastly, the vertebral column is examined
for any fractures or dislocations.

THORAX
• Chest muscles are dissected away.
• Chest is opened by cutting the costal cartilages
with the help of a cartilage knife.
• In case of elderly subjects, the costal cartilage may
be calcified, hence, a bone saw or a rib shear is
used to cut it out.
• Thereafter, both the sternoclavicular joints are
disarticulated and the chest is opened.

HEART
 Held at the apex and lifted
upwards so that the
pulmonary vessels, SVC &
IVC and the ascending
aorta can be examined.
 The pulmonary artery is
palpated and then the
vessels are cut open.
Pericardium is incised
and examined for any
blood or fluids.
Heart, opened in the
direction of the blood flow
i.e. (Inflow-outflow
method).

HEART
 The enterotome is inserted into the:
 RA  Tricuspid valve  RV  Pulmonary Trunk
 Pulmonary vein  LA  Mitral Valve  LV 
Ascending aorta.
 Both the auricular appendages are examined for
thrombi.
 Heart should eventually be weighed and the
various measurements of the circumference of
the valves or the thickness of the ventricles etc.
are taken.

CORONARY ARTERY
 Examined by making serial cross sections to check
for ante mortem clots.
 To check for infarction and fibrosis, muscles of the
right and the left ventricles are incised.
SUBENDOCARDIAL HAEMORRHAGE:
 Flame shaped, confluent, patchy, haemorrhages
may be seen in the LV on the left side of the inter
ventricular septum.
 Seen in severe hypotension, intracranial damage,
death due to ectopic pregnancies, arsenic
poisoning etc.

LUNGS
• Anterior surface is faced upwards 
PA is identified and cut as far as
possible using small scissors  check
for atherosclerosis, thrombi or emboli.
• Steps are re-traced via PV  check for
thrombi.
• At hilum, a long bladed knife is placed
with the blunt end facing upwards 
pierced into the hilum and the knife is
turned upwards so that the sharp end
now faces upwards  Sawing motion
 hilum is cut.

LUNGS
• Lungs are mounted on a board or held in
the left hand incision is made from
the apex to the base.
• Hence, producing an antero-posterior
slice.
• Cut sections are then examined for
consolidations, edema, atelectasis,
congestion, emphysema, Tardieu spots,
emboli etc.

If PENUMOTHORAX
is suspected:
• Pocket dissection on affected side
between the chest wall and the skin 
filled with water  wall is punctured
under water.
• If bubbles are present  Pneumothorax.
• 16 gauge needle attached to a syringe
without its plunger is inserted into the
subcutaneous tissue over the ICS 
water is filled in the syringe  needle is
pierced into the pleural cavity if water
bubbles are seen  Pneumothorax.
• Thereafter, X-ray is done.

If AIR EMBOLISM
is suspected:
• In such cases, before touching the thoracic
organs, the pericardium and the heart should
be examined.
• The heart is lifted up and cut open at the
apex.
1. Left ventricle is filled with frothy blood if air
is present is good amount.
2. If right ventricle is filled with air, the heart
will float in water.

If AIR EMBOLISM is suspected:
1. Pericardial sac is filled with water  heart is punctured with
a scalpel and twisted  if bubbles are present  AIR
EMBOLISM.
2. A wide bore needle is attached to a syringe and water is
filled in it  it is inserted in to right ventricle  if air is
present bubbles are seen.
3. PYROGALLOL TEST: 4 mL of 2% freshly prepared pyrogallol is
taken in two 10 mL syringes.
In one of the syringes, 0.5 M NaOH is added. Gas is aspirated
from the right heart and the needle is retracted and
removed. A stopper is fixed to the syringe and the syringe is
shaken. If the aspirate contains air, the colour of the solution
would turn brown.
4. Air in the IVC can be demonstrated by puncturing it
underwater.
5. Lastly, X-ray is done.

NECK
• Identify the oesophagus  incise it from the posterior
aspect up till the cardiac end of the stomach 
inspected for capsules, tablets or powders.
• Larynx, trachea and the bronchi are also cut from the
posterior aspect and checked for foreign bodies, blood,
mucous, tumours, inflammation etc.
• Thyroid is removed and examined.
• The carotid arteries are examined for thrombi, esp. at
their bifurcation.
• Later, the hyoid bone, cricoid and the thyroid
cartilages are examined.

ABDOMEN

ABDOMEN
• 5 cm above the symphysis pubis the rectus
muscles are divided and a small cut is made.
• Middle and the index fingers are then inserted
and spread in a ‘V’ shape.
• Sharp braded knife is inserted between them
and the peritoneum is cut up to the xiphoid
process.

ABDOMEN
• Firstly, inspection is done and if any
damage, free fluid, perforations etc.
are seen then these are noted.
• Also, note should be made about the
abnormalities, positions, abdominal
organs, adhesions, pathology (if any),
injuries etc.

STOMACH
After applying double ligatures, the stomach is
opened along the greater curvature  from the
cardiac to the pyloric end  size of the pyloric ring
is noted.
Contents are examined for any nature of food
which might be present & its state of digestion,
smell, colour, character, the presence of foreign
bodies or any other suspicious matter etc.
Mucous membrane is examined for congestion,
haemorrhage, ulcerations or any other abnormality.

INTESTINES
• Note the colour, consistency, adhesions,
herniae, haemorrhage, serosal surface etc.
• Small intestine is opened along its line of
mesenteric attachments.
• Large intestine is opened along the anterior
taenia coli.
• Examined for inflammation, congestion,
erosions, perforations etc.

LIVER
• Either liver is removed by itself or attached to
the stomach and the duodenum.
• It is examined for its weight, size, consistency
and for the presence of any other pathology /
injury.
• It is cut along the long axis into 2 cm thick
slices.

SPLEEN
• It is removed by itself.
• Size, weight, consistency, capsule condition,
rupture injuries or any pathology is noted.
• This is also sectioned along its long axis and
the character of the septa and the
parenchyma are noted.

PANCREAS
• Along the long axis cuts are made at right
angles.
• Examined for fat necrosis.

KIDNEYS
• Size and weight are noted.
• Capsules are excised and
examined carefully.
• Kidney is sectioned
longitudinally the convex
border of the hilum so that
it splits into half and opens
the pelvis.
• Checked for calculi,
inflammation etc.
• Ureter is cut into and
examined.

BLADDER
• Incision is made from the
fundus and carried to the
urethra.
• Wall condition, amount
and character of urine is
noted.

PROSTATE & TESTES
• Examined for enlargement and malignancies.
• Vertical cross-sections are made through the lateral
and median lobes and the prostate is split open for
examination.
• Inguinal canal is incised from the peritoneal aspect
and the loop of the vas deference is pulled to free it
from the internal inguinal ring.
• The testes is pushed with one hand and pulled out of
the scrotum easily by the other.
• These are cut longitudinally and checked for any
clotted blood inside the scrotum and in the testis.

FEMALE GENITALIA
• Vagina and the uterus are cut either
anteriorly or posteriorly upto the fundus.
• Two short incisions are made at the fundus
from the main incision towards each cornu so
as to expose the endometrium.
• Ovaries are sectioned longitudinally and the
fallopian tubes are cut longitudinally.
If the uterus contains a foetus, its age should
be determined.

AFTER COMPLETING
INTERNAL EXAMINATIONS
• Body cavities should be cleaned and made free from
blood, fluids etc.
• Organs are placed back in and excess space is packed
with cotton/cloth etc. (esp. in the pelvis and the neck
regions.)
• Dissection flaps are closed and sutured with thin
twine.
• Skull is filled with cotton and absorbent material and
the skull cap is placed back in and the scalp is stitched.
• Body is washed with water, dried, covered with
clothes and handed over to the police officials.