SWRHL-35r
PRINCIPLES OF REPORTING POST-MORTEM FINDINGS
by
Ronald E. Engel, D. V. M., Ph. D. , and
Stanley L. Cohen, D. V. M.
Bioenvironmental Research
Southwestern Radiological Health Laboratory
Department of Health, Education, and Welfare
U. S. Public Health Service
National Center for Radiological Health
March 21, 1968
This study performed under a Memorandum of
Understanding (No. SF 54 373)
for the
U. S. ATOMIC ENERGY COMMISSION
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LEGAL NOTICE
This report was prepared as an account of Government sponsored
work. Neither the United States, nor the Atomic Energy Commissionp
nor any person acting on behalf of the Commission:
A. Makes any warranty or representation, expressed or implied,
with respect to the accuracy, completeness, or usefulness of the in-
formation contained in this report, or that the use of any information,
apparatus, method, or process disclosed in this report may not in-
fringe privately owned rights; or
B. Assumes any liabilities with respect to the use of, or for damages
resulting from the use of any information, apparatus, method, or pro-
cess disclosed in this report.
As used in the above, "person acting on behalf of the Commission" in-
cludes any employee or contractor of the Commission, or employee
of such contractor, to the extent that such employee or contractor of
the Commission, or employee of such contractor prepares, dissemin-
ates, or provides access to, any information pursuant to his employ-
ment or contract with the Commission, or his employment with such
contractor.
100
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SWRHL-35r
PRINCIPLES OF REPORTING POST-MORTEM FINDINGS
by
Ronald E. Engel, D.V.M, Ph. D., and
Stanley L. Cohen, D.V.M.
Bioenvironmental Research
Southwestern Radiological Health Laboratory
Department of Health, Education, and Welfare
U. S. Public Health Service
National Center for Radiological Health
March 21, 1968
This study performed under a Memorandum of Understanding
(No. SF 54 373)
for the
U. S. ATOMIC ENERGY COMMISSION
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PREFACE
This report was felt to be necessary because biologists, veterinarians9
physiologists, etc., for the most part, are not well trained in describ-
ing the post-mortem observations made on animals, whether wildlife or
domestic. By distributing this report on a wide scale, it is hoped that
investigations will be of more value> since the report will incorporate
more meaningful descriptions of the post-mortem findings. Although the
principles of post-mortem reporting are somewhat standardized in the
medical disciplines, the average biologist is usually not aware of the
established standards. Unfortunately, in dealing with descriptions of
lesions, the impressions of the observer lend more subjectivity to the
report than one desires. Nevertheless, for most applications adequate
detailed descriptions of lesions will result if the observer follows the
outline given in this report.
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TABLE OF CONTENTS
PREFACE i
TABLE OF CONTENTS 11
INTRODUCTION 1
OBJECTIVE OF PROTOCOL 2
BASIC DESCRIPTIVE WRITING 3
DESCRIPTIVE TERMINOLOGY 7
REFERENCES 11
i
FIELD NECROPSY KIT 12
GLOSSARY 13
Figure 1. Schematic drawing of right lung showing areas of
involvement.
11
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INTRODUCTION
Pathology is defined as that branch of biological science which deals
with the nature of disease, the study of its cause(s), its process, and
its effect(s) together with the associated alterations of structure and
function.* '
A study in determining the nature of pathological lesions in biological
specimens must include data that are complete, descriptive, and accurate.
It is usually necessary to standardize certain phrases and common de-
scriptive words used in pathological anatomy. A standardized method of
preservation for the pathology laboratory should also be adopted. A
need for a modern guide for the performance of post-mortem descriptions
was readily apparent while searching the files of various sources for
necropsy reports on wildlife and domestic animals. Many excellent cases
were unsuitable for inclusion in the survey for common and obscure
pathological lesions in the desert bighorn sheep and beef cattle. In
the vast majority of cases, lack of essential data and inadequate or
poorly prepared tissue resulted in a statement by the pathologist, such
as "extensive post-mortem autolysis" or "inadequate information for
positive pathological diagnosis."
This report will be limited to proper preparation of necropsy protocols,
terms used for describing various lesions, and methods of preserving
biological material for the pathologist. Excerpts from necropsy reports
on. two desert bighorn sheep will be "described using these terms to
demonstrate the usefulness and importance of utilizing descriptions
that are meaningful to the pathologist.
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OBJECTIVE OF PROTOCOL
The necropsy protocol serves as a precise word picture of all observa-
tions made during the post-mortem examination. It is not suggested that
the protocol be rigidly stylized; however, it should be kept in mind
that if an acute observation is made and it is not recorded properly, it
then becomes of little use to the investigator.
The objectives for well-written, accurate protocols are:
a. To act as a stimulant and adjuvant to the investigator in order
to facilitate correlation of field and post-mortem observations.
b. To be a reliable method of preserving information for reports
of individual field cases. ,
c. To serve as an accurate record of facts whenever legal action
is anticipated.
%
d. Jo serve as essential information which will enable the patholo-
gist to make an interpretation of histological findings.
A special form is not necessarily required although it is a tremendous
aid to the proper recording of necropsies. Various types of protocol
forms have been described; all have their advantages and disadvantages.
Regardless of the type of protocol form decided upon by the investigator,
it should include essential facts, such as time and date of necropsy,
species, sex, age, time of death, and field or clinical history.
Me. T. Cowan has described post-mortem procedures for wildlife biologists
stressing methods as well as observations which are of importance in
(3\
describing the field or clinical history/ ' It is recommended that
personnel doing the necropsy become familiar with the proper necropsy
procedures/ ' tissue preparation, ' and methods of recording the
observations of lesions and organs using acceptable pathological anatomi-
cal terminology. Hereafter in this report, any nonpathologist performing
necropsy procedures will be referred to as a prosector realizing that the
definition is not complete in its entirety.
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BASIC DESCRIPTIVE HRITING
As in any descriptive writing, the prosector should be objective. He
should write down what he actually observes, not opinions or impressions.
His interpretations may be summarized and expressed as a diagnosis.
However, it is not proper to include, these in a lesion or organ de-
scription. Ten items or salient features of a lesion or organ are usual-
(2\
ly necessary to fully describe the true observation/ ' Not all items
are applicable in every instance; nevertheless, an attempt to include
all items is important. The description of a lesion or organ should
include:
a. Position. The relation and orientation of the lesion to other
organs and structures should be stated as well as the presence
of adhesions.
b. Size. Measurements should be taken in all dimensions as
accurately as possible. Use of the metric system is suggested.
Whenever measurements are not possible, approximations should
be made.
c. Weight. In the field, accurate measurements of weight are
^usually not possible. If scales are not available, an.attempt
at an estimated weight should be made.
d. Color. Tone, shade, and distribution of color should be de-
scribed. If the prosector is color blind, describing contrasts
between the abnormal and normal in many cases will aid in the
description.
e. Consistency and texture. These features are subjective, depend-
ing on the skill and training of the prosector. Whenever
possible the lesion or organ should be palpated by placing it
between thumb and fingers or both hands under various configura-
tions. However, the specimen should not be squeezed.
f. Odor. This is another subjective judgment which requires experi-
ence in determining significant and distinctive odors of tissues
and contents of lesions, hollow organs or structures. Many
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infectious agents cause a Characteristic odor in the affected
tissue or organ.
g. Cut surface. For adequate description of any lesion or organ,
a cut surface should be exposed, especially for such organs as
liver, spleen, and kidney. Description should be made immedi-
ately. The surface should not be allowed to dry.
h. Shape. The shape or lack of shape should be reported. Accurate
determination of the outline and configuration is sometimes of
importance.
1. Contents. The quantity, color, and consistency of the contents
of such structures as the pleural sacs, gastrointestinal tract,
gall bladder, urinary bladder, abdominal and pericardial cavi-
ties should be recorded.
j. Lumen !of tubular organs. Any abnormality that affects the
function should be described. This will include dilation,
stricture, hypertrophy, atrpphy, or any other condition that
is of significance.
Only slight mention of normal anatomical relationships is made in these
10 items; however, to properly describe the location of the lesion or
organ, more detailed anatomical terms must be known. Admittedly, it is
well to have knowledge of all, but this is not necessary. To present
a "word picture" to the pathologist, the prosector should be acquainted
with the following terms and their definitions as applied to pathological
anatomy. In the explanation of these terms, it is assumed here that they
apply to a quadruped, such as the sheep in a normal stance. The surface
directed toward the plane of support, (the ground) is termed ventral; and
the opposite surface is dorsal, i.e.; the top of the animal. The rela-
tion of parts in this direction are named accordingly. The longitudinal
median plane divides the body into similar halves. Structure B, which
is nearer than structure A to the median plane, is said to be medial to
A. Conversely structure B, which is'further than structure A from the
median plane, is said to be lateral to A. Planes parallel to the median
plane are termed sagittal planes. The head end of the body is termed
4
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cranial, rostral, or cephalad; and the tail end is termed caudal;
relations of structures with regard to the longitudinal axis of the
body are designated accordingly. Certain terms are used in a special
sense as applied to the limbs. Proximal and distal express relative
distances of parts from the attachment to the body; e.g., the head of
the femur is proximal to the stifle (knee joint). The terms superficial
and deep are useful in determining the distances from the surface of
the body. Oblique is a useful term to indicate neither lateral, medial,
ventral, nor dorsal. It is a plane of that portion of the body not
perpendicular to any of the three axes of the body.
Pinpointing an anatomical area or a lesion within this area requires
further refinement. Many times it is necessary to measure exactly the
extent of the lesion and its relationship to another organ. In those
cases where it is either impossible dr impractical to measure the extent
of the lesion, a reasonable estimate;should be made. Practically speak-
ing, mentally dividing the organs into thirds usually suffices, although
halves or quarters may be more explanatory. If a lesion falls in an
area where it may be termed a junction, it is proper to say that such
a lesion, for example, is located at the junction of the distal one-
third and middle one-third. An example of how these terms are applied
to locating a lesion is a case history where a deer was shot by a hunter.
On opening the thoracic cavity, the hunter noticed large red areas in
all lobes of the right lung. An examination was made by a technician
in which tissue was taken and sent tdi a pathologist. The lesion was
located schematically in Figure 1. : •
The description should read as follows: Dark red, well-demarcated, firm
areas are noted in the entire ventral one-half of each lobe of the right
lung. A similar area is observed in the cranial dorsal one-third of the
right apical lobe.
This clearly indicates a lobar distribution in the lungs, therefore lead-
ing the pathologist to look for a systemic disease rather than an isolated
source. Proper description of the location of dissemination lesions will,
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in many cases, be enough information for the pathologist to arrive at
a correct diagnosis. Further histological and laboratory studies will
confirm his diagnosis.
Dorsal Border
Diaphragmatic
Lobe
Cardiac Lobe
Cardiac Notch
Figure 1. Schematic drawing of right lung showing areas of involvement.
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It is the responsibility of the prosector, whether wildlife technicians
research biologist, or veterinarian, to describe what is observed during
a post-mortem examination. The use of terms given in this report will
enhance a systematic approach to the necropsy which will decrease the
chances of overlooking lesions or abnormal organs. An accurate descrip-
tion of the gross observations may be decisive in establishing a diagnosis
or in determining the relative importance of lesions.
Tissues that are taken during the course of the necropsy and removed for
microscopic examination should not measure any greater than 5 mm in
thickness and should be less than 2 ;cm in any dimension. It is important
that the thickness be not too great so that proper fixation will occur
and maximum benefit will be obtained. Special care must be taken with
any tissues containing a large amount of blood, such as spleen and bone
marrow. The structures must be kept extremely thin because fixation of
o
such tissue is extremely slow and penetration may not occur until
autolysis has destroyed the morphology, thus rendering the tissues of
no diagnostic use.
Normally, all tissues that are taken should be fixed in buffered
formalin. The volume of the fixative must be at least 10 times the
volume of the tissue sample. In this respect, it is better to have too
small a tissue sample than a tissue sample that is too large for the
volume of fixative in which the tissue is being preserved. The first
phase of fixation is the rapid killing of tissue. Rapid killing of all
the tissue sample can only occur if the slice of tissue is capable of
being penetrated by the fixative. The tissue should be placed in the
fixative immediately upon removal from the body to preserve the relation
of the tissue elements as they were in life. The second phase, or the
hardening process, should be of such degree that the normal tissue com-
ponents will not be adversely affected by any subsequent procedures.
For the most part, buffered formalin is used because it kills tissue
rapidly, hardens tissue, and is compatible with most stains. The length
of fixation depends on the size of a block; however, if the recommended
size of blocks is used, overnight fixation will result in adequate
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killing and hardening of the tissue. If several special stains are
required, small blocks of tissue should be fixed in the appropriate
(4)
fixative as suggested by Mosby and Me. T. Cowan. '
Tissue specimens to be sent to the pathology laboratory should be
packed in heavy plastic bags. This assures safe arrival of the tissue
specimens and provides ease of handling and storage. The tissue should
be wrapped in gauze or placed in a cotton bag. Before heat sealing,
excess fixative should be decanted leaving a sufficient amount only to
saturate the gauze wrapper or cotton bag. Special attention is required
for handling bone specimens, as sharp edges may rupture plastics if such
specimens are not properly padded with either extra cotton or gauze.
Identification containing information as to species, date, necropsy
number, and contributors should be sealed in a separate upper portion of
the plastic bag. A complete, detailed necropsy protocol should accompany
•the tissue and be addressed to the pathologist.
Excerpts' from two different necropsies of desert bighorn sheep will be
used to illustrate how much pathological anatomy can be written in a
necropsy protocol by biologists who used the rough draft of this report
for a guideline. .
Case 1: General Examination
The body is that of a 14-year-old, male desert bighorn sheep
that has been dead approximately 14 hours. The body is in a
state of poor nutrition. There is a full set of incisors; how-
ever, a very offensive odor is emitting from the oral cavity.
A screw worm larva is found in the left conjunctival sac and in
the mouth amongst the debris stuck between the right upper and
lower molars. The middle one-third of the right horn shows a
marked degree of decomposition. The horny material is black
and in many portions infested with screw worm larvae. The
center of the horn, which is normally honeycombed, is filled
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with light yellowish purulent material. This extends into the
sinuses of the right side of the skull. The condition is mani-
fested by very thickened, gray-colored sinusoidal membranes.
The greatest extent of sinus involvement appears to be in the
dorsal lateral portion of the right side. There is no involve-
ment of the inner calvaria nor is there evidence of inflammatory
changes in the meninges.
Respiratory Tract
There are extensive adhesions of the right cardiac and apical
lobes to the right thoracic cage. The visceral pleura! sur-
faces of these two lobes are involved. The adhesions are
estimated to be at least 2 weeks of age. There is marked
pulmonary edema in the dorsal portion of the left diaphragmatic
lobe manifested as a diffuse light purple color, noncrepitant,
moist lung parenchyma and reddish frothy fluid in the bronchi.
The remaining portions of the lungs are pink, crepitant, and
well filled with air.
Case 2: General Examination
The body is that of a 15-year-old, male desert bighorn sheep
in fair condition. The animal has been dead approximately
24 hours. There is a subcutaneous abscess approximately 2 cm
in diameter on the very ventral portion of the neck at the
junction of the cranial and middle one-third. On cross section,
the abscess is shown to have a capsule approximately 4 mm in
thickness and to contain pale yellow, thick purulent material.
There are two similar-type abscesses on the left hemisphere of
the anus. Each has an approximate diameter of 3 cm and a 4-mm-
thick capsule. Both contain a light yellow purulent material
that is of a cottage cheese consistency.
Respiratory Tract
Extensive pleural adhesions of the right cardiac and apical
lobes to the right thoracic cage are noted. These adhesions
10
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are infiltrated with a yellowish gelatinous material and are
estimated to be 3 to 8 days of age. Both lungs show extensive
post-mortem changes; all lobes of the right lung are filled
with edematous fluid and are noncrepitant and purplish in color.
Vegetative material is noted in the lumen of all major bronchi
of both lungs.
These two cases have been presented to show that the proper terminology
and descriptive writing need not be,confined to the experienced patholo-
gist. The use of this report as a handbook to establish guidelines and
aid in obtaining clearly descriptive words should be obvious. If one
takes full advantage of the detaiIsland methods, one will vastly add to
his knowledge. With proper tissue fixation and a proper description of
the observations, the pathologist will be able to express his opinion in
regard to the histopathology with more confidence which will result in
more meaning to the investigator who did the post-mortem examination.
The inclusion of such information in reports and other documents will
be of value not only to the investigator and his agency but to others
who use these reports in search of definite and definitive pathology
of wildlife and domestic animals.
REFERENCES
(1) Jones, H. W., N. L. Hoerr, and A. Osol. 1949. Blakiston's New
Gould Medical Dictionary. 1st e
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NECROPSY,FIELD KIT
(Minimum List)
1. Pair of rubber gloves.
2. Two knives (for skinning and boning).
3. A pair of scissors with one blunt and one pointed blade. The blades
should be about 6 inches long.
4. Thumb forceps (rat tooth).
5. Dehorning saw (used for sawing ;bone).
6. Scalpel handle and blades (#22).
7. Buffered formalin.
8. Containers which are leakproof.
a. Hard plastic containers with lids or mason jars.
b. Heavy plastic bags.
c. Gauze--4" squares for wrapping the tissue samples before being
placed in fixative.
9. Labels:
a. should be waterproof.
b. both paste on and tie-on.
10. Camera (35 mm with close-up lens).
11. Scale which reads in grams.
12. Steel and sharpening stone.
13. Cutting board (8" x 12").
14. Paper towels.
15. Protocol sheets and two pencils.
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GLOSSARY
1. atrophy: a shrinking, or wasting away, of an organ or tissue to
less than its former and less than its normal size.
2. autolysis: spontaneous post-mortem dissolution or partial destruc-
tion of cells or tissues and organs as a result of enzymes elaborat-
ed in those sites during life.
3. bulbous: bulb shaped.
4. calvaria: the upper, domelike portion of the skull.
5. caseous: degenerative tissue which is dry, crumbly, and cheeselike.
6. conjunctiva: the mucous membrane covering the anterior surface of
the eyeball and lining the inner surface of the eyelids.
7. crepitant: crackling; the sensation imparted to the palpating
finger by gas or air in the subcutaneous tissues.
8. dilation: enlargement of a cavity, canal, blood vessel, or opening;
occurring physiologically, pathologically, or made artificially.
9. discoid: shaped like a disk.
10. edema: an abnormal accumulation of fluid in cells, tissues, or
cavities of the body, resulting in swelling.
11. exudate: a fluid, often coagulable, or formed elements of the
blood, extravasated into the tissues or any cavity.
12. filiform: having the form of a thread or filament.
13. friable: easily crumbled or crushed into powder.
14. fungoid: resembling a fungus; denoting an exuberant morbid growth
on the surface of the body.
15. gelatinous: like gelatin or jelly; having the consistency of
gelatin or jelly.
16. hypertrophy: an abnormal increase in the size of an organ or tissue
caused by enlargement of its cellular components.
17. inflammatory: relating to a diseased condition of some part of the
body, resulting from injury, infection, irritation, etc., and
characterized by redness, pain, heat, and swelling.
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18. Inspissated: thickened by evaporation or absorption of fluid.
19. lesion: a wound or injury.
20. lobar: relating to any lobe or lobes.
21. lobule: a small lobe or one of the subdivisions of a lobe.
22. meninges: the three membranes that envelop the brain and the spinal
cord; dura mater, arachnoid, and pia mater.
23. mottle: marked with blotches, streaks, and spots of different
colors or shades.
24. mucoid: any of a group of substances resembling mucin and occurring
in connective tissue (like mucus).
25. necropsy: examination of a dead body.
26. parenchyma: the essential or functional tissue of an organ as
distinguished from its connective tissue, etc.
27. pleura: a thin, serous membrane lining each half of the chest cavi-
ty and enveloping the lungs.
28. pulmonary: of, like, or affecting the lungs.
29. punctate: marked with dots or tiny spots.
30. purulent: of, like, containing, or discharging pus.
31. rugose: having or full of wrinkles; corrugated.
32. sinusoidal: relating to a blood space in certain organs, as the
spleen, liver, and pancreas.
33. stippled: speckling of a structure with fine dots.
34. stricture: a circumscribed narrowing or stenosis of a passage in
the body.
35. thoracic: relating to the chest; the upper part of the trunk
between the neck and the abdomen.
36. tortuous: full of twists, turns, curves, or windings.
37. turgid: swollen; distended; bloated; inflated.
38. ulcerated (ulcer): an open sore (other than a wound) on the skin
or some mucous membrane, such as the lining of the stomach,
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characterized by the disintegration of the tissue and, often, the
discharge of pus.
39. undulant: having an irregular wavy form, margin, or surface.
40. visceral: relating to an internal organ, especially one of the
large abdominal organs.
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DISTRIBUTION
1 - 20 SWRHL, Las Vegas, Nevada
21 James E. Reeves, Manager, NVOO/AEC, Las Vegas, Nevada
22 Robert H. Thalgott, NVOO/AEC, Las Vegas, Nevada
23 Chief, NOB, DASA, NVOO/AEC, Las Vegas, Nevada
24 D. H. Edwards, Effects Safety Div.s NVOO/AEC, Las Vegas, Nevada
25 Martin B. Biles, DOS, USAEC, Washington, D.CU
26 Bernd Kahn, NCRH, RATSEC, Cincinnati, Ohio
27 - 31 Charles L. Weaver, NCRH, PHS, Rockville, Maryland
32 Northeastern Radiological Health Lab., Winchester, Massachusetts
33 Southeastern Radiological Health Lab., Montgomery, Alabama
34 D. W. Hendricks, Radiological Safety Branch, NVOO/AEC, Las Vegas,
Nevada
35 Mail & Records, NVOO/AEC, Las Vegas, Nevada
36 Paul T. Tueller, University of Nevada, Reno, Nevada
37 V. R. Bohman, University of Nevada, Reno, Nevada
38 Bruce Browning, Calif. Fish & Game Dept.s Food Habit Lab.,
Sacramento, California
39 George Welsh, Arizona Fish & Game Dept., Kingman, Arizona
40 Al Jonez, U. S. Bureau of Reclamation, Boulder City, Nevada
41 District Ranger, U. S. Forest Service, Las Vegas, Nevada
42 District Supervisor, Nevada Fish & Game Commission, Las Vegas,
Nevada
43 Director, Nevada Fish & Game Commission, Reno, Nevada
44 Director, National Park Service, Boulder City, Nevada
45 District Manager, U. S. Bureau of Land Management, Las Vegas,
Nevada
46 Refuge Manager, U. S. Fish & Wildlife Service, Las Vegas, Nevada
47 University of Nevada, Library, Reno, Nevada
48 Southern Nevada University, Library, Las Vegas, Nevada
49 - 50 USAEC Div. of Tech. Inf. Extension, Oak Ridge, Tenn.
51 R. S. Davidson, Battelle Memorial Institute, Columbus, Ohio
52 Gordon C. Solomon, Colorado State University, Ft. Collins, Colo.
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