At this time, if fingerprints have not been taken, they should be. In
addition, it is strongly recommended that identification photos, with the
number of the case, be taken.
If there is injury to the body, it should now be described in the next
section, entitled “Evidence of Injury.” All recent injuries, whether minor or
major, external or internal, should be described in this section. There is no
need to repeat the description of these injuries in the subsequent “Internal
Examination” section or to describe them in the “External Description.” The
age of the lesions should be described, if possible, at least in a general way.
There are many ways to handle the “Evidence of Injury” section. Exclud-
ing gunshot and stab wounds, it is easiest to divide it into two broad areas:
In these sections, one would give organ weights (not necessary for adrenal
and pancreas) as well as a brief description of the organs with pertinent
negatives. With the pancreas, adrenals, and spleen, if there are no positive
findings, using the term “unremarkable” as the sole description is acceptable.
Do not use the term “normal” as organs are rarely normal – whatever that is.
The next section is the “Microscopic Examination.” Microscopic slides
should be made when indicated. Samples of tissue from all major organs
should be saved, but are often not needed in forensic cases, especially in
trauma cases.
Next is the “Toxicology Section” where the results of the toxicological
analyses are listed.
The next section is “Findings.” This, and the last section, “Opinion,”
should be on a separate page. List the major findings in order of importance.
It is not necessary to list every minute, often extraneous finding, as is done
in some hospital autopsies. This autopsy will most likely be seen by nonphy-
sicians, and having spent a half hour trying to explain acute passive conges-
tion of the liver to a jury in a gunshot death, we feel the inconsequential
observations should not be listed in “Findings.”
The last section is “Opinion.” This should briefly describe the cause of
death in language as simple as possible, as well as stating the manner of death.
This section is intended for the public, not for physicians Thus, for example,
one can say, “… died of a heart attack due to coronary atherosclerosis (‘hard-
ening’ of the blood vessels that supply blood and oxygen to the heart muscle).”
Or “…died of massive internal bleeding due to a gunshot wound of the aorta
(the major blood vessel of the body).”
Speculation as to circumstances surrounding the death should be absent
or kept to a minimum.