The document provides guidance on performing an external examination during an autopsy. It emphasizes that the external exam is important for establishing identity, determining cause and manner of death, and looking for natural disease. It describes examining the entire body, including identification marks, clothing, jewelry, height, weight, rigor mortis, livor mortis, drying, edema, cyanosis, and hands and feet. Proper documentation of all findings is stressed.

1. External Examination in
Autopsies with Pro forma
Presenter :
Dr. Varughese George
Moderator :
Dr. Bhavani K

2. Introduction
• Prior to undertaking the evisceration & internal
examination, the pathologist should perform a systematic
external examination.
• Many pathologists are of the impression the external
examination is of less importance than the internal
examination.
• This often results in cursory and poorly documented
external examinations with lots of errors.

3. The importance of an external
examination
• to ensure that the person is dead.
• yields information about the natural diseases that the
deceased suffered from in life.
• To know the identification of the deceased.
• To know the time of death.
• To know the place of death.
• To know the cause of death.
• To know the manner of death.

4. Ideal external examination
• must be started prior to cleaning the body as critical
evidence can be lost at this point.
• should include both the front and the back of the body.
• best performed by turning the body completely over so
that it is lying prone.
• must be documented in writing on to a pro forma.
• must use lay words to record descriptions.
• Must record findings on the body by digital
photography and surface body scanners.

5. PRELIMINARIES
 Consent (hospital administrator
(RMO/coroner) and relatives)
 Identification of body
 Clinical details

6. Should have a statement pertaining to retention
of body parts/ organs
Get specific permission for an unusual
examination (removal of eyes/limbs) even if
signed as NO RESTRICTIONS
Make sure the case is not medicolegal, like
delayed accidents, homicides, deaths after
abortions, occupational diseases, suspicious
cases of poisoning, deaths on table.

9. Dictate as follows
 Autopsy no, date and time
 Pathologists Name and designation
 Patient’s age (look for disparity) and sex
 State of body (built and nourishment)
 State any restrictions
 Final clinical diagnosis
 Clinical summary
 Height (crown to heel)
 Weight

10. Dictate as follows
 Rigor mortis
 Livor mortis
 Algor mortis
 Post mortem drying
 Body built
 Nourishment
 Edema
 Cyanosis
 Skin
 Nails

11. Identification
• Determination of the individuality of a person based
on certain physical characteristics.
• Before starting an autopsy the pathologist must be
satisfied that the body about to be examined is that
of the deceased.
• No matter how the identification of the body is
established, the means, location, time and date of
the identification should be recorded within both the
autopsy notes and report

12. Identification
Known individuals
• In the majority of cases the identity of the deceased will be
known.
• The body will have been booked into the mortuary under
this name and often allocated a unique identifying number,
the details of which will be recorded on at least one
identification band usually secured to the wrist or ankle
area.
• The autopsy examination should not proceed until the body has
been identified.

13. Identification
Unknown individuals
• The pathologist may be faced with one or more individuals
whose identification at the time of the autopsy is unknown.
• This can be made worse if the body is disrupted,
decomposed, skeletonised or comingled with parts from
other bodies.
• In these circumstances the pathologist assists in the
gathering of information that will be used to identify the
deceased.

14. Identification
Means can be used to assist in the identification of an
individual :
• primary – a characteristic considered unique to the
individual that can be used on its own to identify an
individual.
e.g. fingerprints, odontology, DNA, prosthesis etc.

15. Identification
Means can be used to assist in the identification of an
individual :
• secondary – a characteristic that is not unique but
can be used in combination with another secondary
or primary characteristic to identify an individual.
e.g jewellery, personal effects, distinctive marks,
distinctive scars, X-rays, physical disease, blood
grouping, tissue identification etc.

16. Identification
Means can be used to assist in the identification of an
individual :
• assistance – a characteristic that is not unique to an
individual but can be used to assist identification in
combination with a primary or secondary
characteristic or only on its own as a matter of last
resort.
e.g. photographs, body locations, clothing, etc.

17. Identification
• More specialist means can be engaged at times,
including for example podiatry, pollen, anthropology,
facial reconstruction and isotopic/elemental tracing .
• If these systems are unfamiliar, the pathologist
should seek specialist advice or refer to specialist.

18. Clothing
• Most bodies will arrive naked or in a shroud or
hospital gown which should be documented.
• If the body is within a body bag, this should be
documented, including the colour of the bag and
whether the bag is sealed.
• If sealed, the nature of the seal and any unique
identification number should all be recorded.
• In the case of mass fatalities, a unique number and
scene book should have been attached to the
outside of the bag and should be removed and
checked prior to the opening of the bag.

19. Dressed bodies
• If the body arrives dressed in the deceased’s own
clothing, each article of clothing should be
examined before and after its removal from the
body.
• Type, make and size of a piece of clothing should
be recorded.
• Pockets should be examined with forceps(sharps)
and any personal effects documented.
• Cutting of pockets is permitted provided a record
is kept.

20. Undressed bodies
• If the body was undressed prior to the pathologist’s
arrival, consideration should always be given to obtaining
the clothing and examining it.
• Particular importance in cases of sudden infant death, as
children are often redressed prior to going to the
mortuary and the clothing they are presented in may not
be the clothing they died in.
• Most infants pass urine prior to or at the time of death,
so it may not be possible to collect a urine sample for
metabolic screening from the bladder

21. Jewellery
• The presence or absence, site and type of all
jewellery should be carefully documented to
prove that it has not been removed by a member
of staff for any purpose other than the autopsy
examination.
• Simple descriptions of metal (e.g. ‘a yellow metal
ring was present to the ring finger of the left
hand’).
• In police cases, jewellery should be handed to the
exhibits officer and processed as for clothing.

22. General examination
Cleanliness
• Examine for unwashed body.
• Examine for faecal or urinary incontinence.
• Examine for presence of head lice.
• Examine for presence of scars or decubitus ulcers noted.
• Examine for features seen in case of possible maltreatment
or neglect.

23. General examination
Height and weight
• All bodies should have their naked length and weight
recorded.
• Length (height) should be measured from the heel to
the vertex of the skull, not from the toe (coffin size) in SI
units.
• A weight is important for the estimation of the time
since death using temperature-based algorithms, the
interpretation of toxicological results and the
interpretation of apparently enlarged organs.

24. General examination
Height and weight
• If available, the weight should be recorded in kilograms,
or the last known body weight recorded in life obtained
from the hospital notes and reported in SI units.
• Body mass index (BMI) can be calculated using the
formula BMI = kg/m2 where kg is a person's weight in
kilograms and m2 is their height in metres squared.
• Body mass index (BMI) is useful if the deceased appears
to be malnourished or obese.
• Death may have been in part due to morbid obesity only
if the body mass index > 40 kg/ m2

25. Fluids, blood and exogenous material
• Distribution, colour and constituency of any fluid
(gastric contents or pulmonary oedema , froth)
should be recorded.
• The presence of blood should be recorded and
sampled in consideration as to whether it is the
victim’s or the offender’s blood.
• Other exogenous material( oil from vehicle, ink)
noted.
• Other biological and non-biological evidential
material – gunshot residue, paint, fibres, glass,
semen, saliva (both human and animal) or third-
party DNA – may be present to the external surface
of the body.
General examination

26. General examination
Gender, age and race
• The colour of the skin may also offer clues to potential
• natural or unnatural diseases.
• A careful examination of the external genitalia and anus
should be performed.
• Gender of individual may be obvious.
• Individuals can be described in broad terms as fetuses,
neonates, infants, children, young adults, middle-aged
adults and elderly adults.
• Specialist examinations can assist in more precise ageing
estimates
– radiology for dental eruption and epiphyseal fusion.
– anthropological examination of bones such as the ribs
and pelvis.

27. General examination
Congenital and dysmorphic features
• The presence of congenital or dysmorphic features
should be recorded.
• Should include anything from an extra digit and
accessory nipples to spina bifida or syndromic facies.

28. RIGOR MORTIS
Rigor is tested by trying to lift eyelids, trying to depress
the jaw and bending the neck and various joints of the
body

29. RIGOR MORTIS
 Primary flaccidity (till ATP remains) – rigor
– secondary flaccidity
 Secondary flaccidity due to onset of
putrefaction
 Mechanism (4-8 hrs, 24-48hrs)
 NYSTEN’S rule – doesnot appear in all
muscles simultaneously and both voluntary
and involuntary muscles affected
 Contraction of erector pilae – cutis
anserina/goose flesh

30. RIGOR MORTIS
 Commences in the heart (LV-RV-atria) , in
sytole
 Diaphragm
 Skeletal musculature – first jaw, neck, face,
arms, lower extremities, last ankle joint
 Passes off in the same order
 Contraction of tracheal muscles causes white
dots on mucosa
 Postmortem intususception
 Iris – dilatation (postmortem) and then
contraction (rigor)
 Handling causes loss of rigor – patchy
distribution

31. Factors affecting rigor
 Age – absent in fetus, early and milder in
children and old
 Early onset, short duration – wasting
diseases, strychnine poisoning
 Late onset – asphyxia, hemorrhage,
pneumonia, paralytic diseases
 Increased duration – CO poisoning
 Less duration – bacterial infection d/t
early putrefaction
 Environment – cold – late onset, more
duration, heat – early onset, less
duration

32. CADAVERIC SPASM / INSTANTANEOUS RIGOR /
CATALEPTIC RIGIDITY

33. CADAVERIC SPASM
 Muscles that were contracted during
life become rigid immediately after
death without passing into a stage
of primary relaxation
 Affects single group of voluntary
muscles, frequently hands
 Sudden death, excitement, severe
pain, convulsions, strychnine
poisoning

34. LIVOR MORTIS

35. LIVOR MORTIS
Hypostasis
 Initially intravascular (can blanch), then
extravascular
 Begins 30 to 45 mins after death in
dependent parts, max in 6-12 hrs
 Can enlarge the extent of subcutaneous
hemorrhages, can mimick suboccipital
hemorrhage
 Initially cut on the area of livor shows
delicate hemorrhagic dots showing
transected congested vessels.
 Not possible to distinguish from
antemortem cyanosis

36. BLANCHING TEST

37.  Colour is a shade of blue
 No livor – hemorrhage, anemia,
wasting diseases
 Red in bodies kept in moist
refrigeration – higher affininty for
O2
 Cherry red – cyanide, CO
 Methemoglobinemia – smoky green,
brown
 Hydrogen sulfide – black

38. Tardieu spots develop in areas of lividity, such as this
individual's shoulder area, as decomposing capillaries
rupture.

39. ALGOR MORTIS
 Rectal temp falls @ 1 deg/hr
 Also inferior surface of
liver/EAC/nasal passages
 Time of death =
n body tem – rect t / rate of cool
 Post mortem caloricity – stroke,
convulsions, strychnine poisoning,
septicemia

40. POST MORTEM DRYING
develops when the eyelids are not completely shut, the areas of the sclera
exposed to the air dry out, which results in a first yellowish, then brownish-
blackish band like discoloration zone
cholera, wasting dis
(Tache noire)

41. DRYING
 Skin is wrinkled and leathery
 Loosening of hair, apparent
lengthning of finger nails due to
shrinkage of finger tips

42. Body built and nourishment

43. BODY BUILT
 Gigantism –
•Hereditary/endocrine
•Proportioned/dysproportioned
 Endocrine –
 Pituitary
 d/t excess GH acromegaly, gigantism
 Hypogonadism
 Eunuchoid – Klinefelter‘s Syndrome

47. BODY BUILT
 DWARFISM – hereditary / endocrine
perfect/imperfect
 Hereditary – pygmies (primordial)
sporadic (mutation)
achondroplasia
 Endocrine –
 Hypothyroidism – cretinism
 Pituitary dwarfism – GH deficiency
 Gonadal dwarfism – Turner’s syndrome

48. TURNER SYNDROME

49. Spinal deformities
Old age
Chronic
emphysema
Rickets
Osteomalacia
Acromegaly
Tuberculosis

50. NOURISHMENT
 OBESITY
 Exogenous – food intake
 Double chin and abdominal
 Endogenous - glandular
 Cushing’s – truncal – moon face, buffalo hump,
protuberant abdomen, thin extremities
 Hypothyroidism – non pitting myxedema –
eyelids, hands and tibia – hyaluronic acid
infiltrn

51. NOURISHMENT
 CACHEXIA
 Cancer
 TB
 Thyrotoxicosis
 Addison’s disease
 Anorexia nervosa
 Starvation

52. EDEMA
 Generalized and localized
 Pitting and non pitting
(lymphedema/myxedema)

53. GENERALISED/ LOCALISED
 GENERALISED
 Congestive heart failure
 Nephrotic syndrome
 Hypoproteinemia
 Cirrhosis
 LOCALISED
 Filariasis
 Post operative
 Insect bites
 Vena caval syndromes

54. CYANOSIS

55. CYANOSIS
 CENTRAL
 Conjunctive, mouth, nose, lips
 Pneumonia, chronic bronchitis, fallot’s,
shunts as in cirrhosis
 Associated with clubbing
 PERIPHERAL
 Extremities, not associated with
clubbing
 Localised obstruction to blood flow like
raynaud’s, arterial obstruction, varicose
veins

57. Hands and Feet

58. General examination
Hands and feet
• The dorsal and volar surfaces of the hands, feet and the
digits should be examined for evidence of natural or
unnatural disease.
• The presence/absence of normal creases is noted
particularly in children.
• The state, length and colour of the nails (including the
presence or absence of nail polish, decorations and
extensions) are recorded as well as the presence of
injuries.

59. General examination
Hands and feet
• Nails may give clues as to the presence of natural
disease
e.g clubbing, leuconychia, koilonychia, yellow nails, pitting or splinter
haemorrhages.
• Digits can be used for identification purposes by their
prints, and the nails can be used for toxicology, DNA,
and geometric fingerprinting techniques.

60. KOILONYCHIA

61. General examination
Hands and feet
• The assistance of a forensic podiatrist may be
considered in mass fatality investigations.
• In police cases, a careful inspection for the presence of
trace evidence (e.g.fibres or hairs) must be undertaken.
• Any evidence should be photographed prior to lifting
with adhesive tape.
• The interdigital webspaces may contain needle
puncture marks in individuals dying from drug
overdoses.

62. SKIN PIGMENT DISTURBANCES
 Hyperpigmentation
 Generalised
 Jaundice, Addison’s, Hemochromatosis,
chronic malaria
 Localised
 Chloasma, Acanthosis nigricans
 Hypopigmentation
 Albinism, vitiligo
 Fungal disease (tinea vericolor,
pityriasis alba), leprosy

64. HAIR AND FACE

65. General examination
Hair
• Assessment of whether they are present and whether
they are the body’s own.
• The distribution of hair (male and female patterns) to the
entire body should be noted.
• Hair may be lost from the body by natural disease or by
shaving, e.g from the legs, pubic area, armpits or chest.
• The presence/absence of head hair (male balding
pattern), its colour (natural or dyed), length (measured)
and style should be recorded.
• Natural hair can also be used for race determination,
toxicology (for drug and poison analysis) and DNA
testing.
• The presence and make of a wig should be noted.
• Injuries to natural or false hair should be recorded.

66. HAIR
 Loss – debilitating illness, malignancy,
typhoid, male pattern baldness, alopecia,
ringworms, thallium poisoning
 Female distribution in male – portal
cirrhosis, after castration
 Hirsuitism – Male pattern hair in female –
Cushing’s, ovarian tumors
 Thinning and drying of scalp hair –
myxedema

67. Cicatrical alopecia male pattern baldness

68. FACE
 Hippocratic facies - A pinched expression of
the face, with sunken eyes, hollow cheeks
and temples, and relaxed lips, observed in
one dying after an exhausting illness
 Moon face – cushing’s
 Potter facies - oligohydramnios
 Mask like facies - parkinsonism
 Leonine facies - lepromatous leprosy

69. •Potter's facies.
•Parrot-beaked nose. Recessed chin. Epicanthic folds. micrognathia
•Low set ears (helices often folded).
•Hypertelorism.

70. EYES

71. EYES – POST MORTEM
CHANGES
 Loss of corneal reflex – not reliable
 Opacity of cornea – cholera, wasting
diseases
 Flaccidity of eyeball – sunken
 Pupils – dilatation then constriction
 Retina – Kevorkian sign – shunting/tracking
of blood due to fall in bp
 Steady rise in potassium values of
vitreous upto 100 hrs

72. EYES
 Exophthalmos
 Hyperthyroidism, myopia
 Enophthalmos
 Cachexia, Horner’s syndrome
 Cornea –
 Ulceration, opacity, Arcus senilis, Kayser-
Fleischer ring
 Sclera –
 Icterus
 Blue sclera (osteogenesis imperfecta,
marfan’s)

73. General examination
Ears
• The presence or absence, placement, shape and size of
the ears can be recorded.
• They should be examined for diseases, such as
– blood within the external auditory process (which may
indicate a basal skull fracture)
– petechial haemorrhages behind the pinna.
– gouty tophi or lobar creases associated with cardiac disease.
• Ear morphology may be unique to individuals and can
be used for identification purposes

74. General examination
Teeth
• The absence of teeth/dentures at the time of the
autopsy does not preclude a dental identification.
• If charting of the teeth is required, the assistance of a
dental practitioner or forensic odontologist is
advisable.
• The pathologist should not put fingers into the
mouth except under direct vision as this is a sure way
to receive a glove puncture injury from broken teeth,
projecting bone or foreign objects which can be
placed maliciously into the mouth.

75. Tongue
• Geographic tongue – Vitamin B12
deficiency.
• Protuberant tongue – Cushing’s
Syndrome.
• Macroglossia and fissured tongue
– Down’s Syndrome

76. ORIFICES

77. NECK

78. NECK
 Look for neck veins
 Prominence indicates RVF

79. LYMPH NODES – NECK,
AXILLA AND INGUINAL

80. CHEST

81. CHEST
 Pectus carinatum aka alar chest
 Prominence of vertebral border of sternum
 Pigeon Chest
 Nasopharyngeal obstruction, respiratory
disease
 Barrel Chest
 Emphysema, chronic bronchitis
 Pectus excavatum
 Occupational deformity, cobblers
 Rachitic Chest
 Pigeon breast, keel breast, Harrison’s sulci,
Verical grooves, Rickety rosary

82. RIBS

83. LIVER AND SPLEEN

84. Signs of liver failure

85. UMBILICUS

86. Detailed examination
Once the general examination has been undertaken,
the body is examined in detail for
• Presence of signs of natural disease & modifications.
• Medical intervention.
• Drug misuse.
• Injuries (both fresh and historical).

87. Detailed examination
Body modifications
• A wide range of permanent and non-permanent
modifications can be made to the body which can
• used for identification purposes.
• result in disease and death due to complications of procedures
• Includes tattoos, piercings, brandings,scarification,
non-surgical and surgical modifications

88. Detailed examination
Body modifications - Tattoos
• can be found anywhere on the skin and occasionally
on the internal aspects of the body.
• can be unintentional/related to the occupation of
the individual
e.g
– coal miner’s tattoos,
– amalgam tattoos related to dental restoration
– ballistic tattooing from gunshot residue.

89. Detailed examination
Body modifications - Tattoos
• Intentional tattoos can be
• Artistic - expensive, complex, colourful, professional
tattoos, or simple, monochrome, home-made or prison
tattoos, tattoos made with inks that fluoresce under
ultraviolet light.
• Therapeutic - related to beam areas used in radiotherapy.
• Non-permanent henna tattoos are prevalent within some cultural
groups.
• Non-permanent tattoos produced with black ink are commonly
associated with surrounding skin irritation
• The nature, size and site of tattoos on the body should be
recorded.

90. Detailed examination
Body modifications - Tattoos
• Tattoos may be found
inside the mouth
particularly the mucosa of
the lips.
• Tattoos may be altered or
even removed - this can
result in one or more
tattoos at one site or a
tattoo scar.

91. Detailed examination
Body modifications - Piercings
• not confined to the ear and
may be seen at a multitude
of sites on the body.
• The site and nature of the
jewellery should be noted
Body piercings on the ear.

92. Detailed examination
Body modifications –
Brandings and scarification
• involves scratching, etching,
burning / branding, or
superficially cutting designs,
pictures, or words into
the skin as a permanent body
modification.
• tend to occur in specific
countries like the US
especially in college age
group.

93. Detailed examination
Body modifications
• Non-surgical
• e.g. cosmetics, hair treatments, nail extensions and
dermabrasion.
• Surgical
• e.g. dental treatment and filing (to produce animal-like
teeth), surgical implants, prostheses and gender
reassignment

94. Detailed examination
Medical intervention
• Acts of medical intervention may have been
performed on the deceased prior to death even if
they have not died in hospital
e.g. bystanders or a paramedic ambulance crew.
• Presence and location of all tubes, catheters and operation
sites should be documented.
• Craniotomy scars or intracranial pressure monitor sites may
be present and may be sutured or stapled, closed with Steri-
Strips or covered by dressings.
• Nasogastric and endotracheal tubes may be present.

95. Detailed examination
Medical intervention
• ECG monitor pads may be present, as may automated
defibrillator pads and external pacing wires,
• The site and correct placement of automated
defibrillation pads should be checked and noted, may be
associated with shaving of chest hair to ensure close
contact of the pads with the skin.
• If tracheostomies, gastrostomies, colostomies or urinary catheters
are done, they should be documented.

96. Detailed examination
Drug misuse
• This should alert the pathologist to the possibility of
a toxicological death, so that additional precautions
should be taken during the autopsy procedures.
• Needle marks, both fresh and old, of differing sizes
depending on the calibre of needle used may be
seen not only on the external surface of the body.
• Knowledge of any medical intervention is essential
for the interpretation of needle marks to the neck,
bend of the arm, wrist and groin areas.

97. Detailed examination
Drug misuse
• The use of a ligature may leave a mark at a level above
the needle mark should be recorded.
• Perforated nasal septum and sinuses in the groins should
be recorded.
• Tablet dye residue can sometimes be found on the palm
of the hand in those that have taken a ‘handful’ of
tablets.
• Scars resulting from self-inflicted injuries can be found in
those who misuse drugs.
• A careful search of the mouth, foreskin, vagina and anus
should be undertaken for concealed drugs.

98. Detailed examination
Injuries
Each injury is characterized by its:
• i. Type/nature of injury.
• ii. Size (length, breadth and depth).
• iii. Shape.
• iv. Site (in relation to two external anatomical landmarks).
• v. Direction of application of the force.
• vi. Margins, edges and base.
• vii. Distance of the wound from the heel.
• viii. Time of infliction of the injury should be studied from
inflammatory and color changes.
• ix. Vital reaction.
• x. Foreign materials, e.g. hair, grass, fibers, etc.

99. Detailed examination
Injuries
• After full preliminary
examination and
forensic sampling the
area is cleaned, shaved
if necessary, and
photographed with a
scale adjacent to the
injuries.

100. Detailed examination
Injuries
• Where there are
numerous similar
injuries, it assists the
clarity of the autopsy
report if numbers used
during photography
match those listed in
the autopsy protocol.

101. When an individual has external marks/injuries these should be drawn onto the
pro forma or onto separate anatomical diagram sheets

102. Special procedures utilized during
external examination
• Photography for the purposes of identification and
documentation.
• Infrared and UV photography will enhance trace materials,
tattoos, bruises and patterned injuries.
• High contrast black-white photography or computer
directed image enhancement can be used to enhance
patterned injuries.
• Autopsy radiology: In well equipped hospital where
radiographic facility is available, radiological examination
should be done in select cases before starting the autopsy
• X-ray examination assists in identification, locating foreign
objects such as projectiles and documenting old and recent
bony injury.

103. Indications of radiological examination
• Identification and dentistry
• Mutilated/charred remains
• Gunshot wounds
• Air embolism
• Sharp force wounds
• Barotrauma
• Explosives deaths
• Child abuse
• Decomposed body

105. Example of a concise report

106. References
• Ludwig J. Handbook of autopsy practice. Springer Science &
Business Media; 2002.
• Waters BL. Handbook of autopsy practice. Springer Science &
Business Media; 2010.
• Finkbeiner WE, Connolly AJ, Ursell PC, Davis RL. Autopsy Pathology:
A Manual and Atlas E-Book. Elsevier Health Sciences; 2009
• Burton JL, Rutty GN. The hospital autopsy. Arnold; 2001.
• Saukko P, Knight B. Knight's forensic pathology. CRC press; 2004