AUTOPSY PROTOCOL

ORLEANS PARISH CORONER'S OFFICE

No. W67-2-255 .


Name:         David W. Ferrie                                         Age:       Color:       W         Sex:    M    

Date and Time of Death:                   2-22-67 at 1:00 P.M.                                                      

Date and Time of Autopsy:                          2-22-67 at 3:00 P.M.                                     


FINAL DIAGNOSES



1. Rupture of berry aneurysm of Circle of Willis with massive left subdural hematoma, subarachnoid hemorrhage, and secondary pontine hemorrhages.

2. Hypertensive cardiovascular disease.

3. Pulmonary edema and congestion.





Classification of Death: Natural


Nicholas J. Chetta, M.D.

Coroner


Autopsy Protocol
David Ferrie
W/M

EXTERNAL EXAMINATION: The body is that of a well developed white male measuring 5 ft. 9 in. in length and weighing 182 lbs. There are no external marks of violence on the body at any point. The face is heavily cyanotic, as are the shoulders and portions of the back. Livor mortis appears posterior. The scalp is covered with a false wig, which is easily removed. There are no evidences of trauma or contusions to the scalp at any point. A few residual normal hairs are still present, particularly around the right occipital region and along both sideburn areas. There is a small 1/32 in. residual unshaven beard on the inferior aspect of the chin but the overall body hair is markedly absent. There are false eyebrows present. These are easily removed leaving a shiny skin. There is absence of axillary hair and pubic hair. No hair is present on the arms or legs. The pupils are equal. The ears, nose and mouth show no abnormlities. There is a small area of dryness of the inner aspect of the upper lip on the right side. This area measures in. in length and is somewhat reddish brown in color. There is a less well defined area on the lower lip immediately inferior to the lesion in the upper lip. Both areas show no deep hemorrhages or swellings. The mouth is edentulous in the upper area. The lower front teeth are present but in a poor state of condition. There are no burns or hemorrhages in the oral cavity. The neck is symmetrical. There are no contusions in the neck. The chest is slightly increased in its anterior posterior diameter. The abdomen is not protuberent. The external genitalia are normal male. The upper and lower extremities show no abnormalities. There are no venipuncture marks at any point in the extremisties on the body. Rigor mortis is just beginning in the distal aspects of the extremities. The body is tagged with NOPD identification tag #1440.

BODY CAVITIES: The usual Y-shaped incision is made. The viscera lie in their usual positions. There is no abnormal accumulation of blood or fluid.

CARDIO-VASCULAR SYSTEM: The heart is enlarged and weighs 490 grams. The coronary arteries show only mild to moderate atherosclerosis. There is no significant narrowing at any point, nor is there any occlusion. Sections through the myocardium demonstrate marked hypertrophy of the left ventricle measuring 3 cm. in thickness at its mid level. There is no evidence of infarction, old or recent. The valves are normal. The coronary ostia are patent. The aorta shows mild to moderate atherosclerosis.

RESPIRATCRY SYSTEM: The neck contents are carefully removed. There is no evidence of hemorrhage in the musculature of the neck. There are no hemorrhages in he tongue, hypopharynx or pharyngeal mucosa. There are no fractures of the hycid bone, thyroid cartilage or criccid bone. There are no hemorrhages in the mucosa of the trachea or larynx. The thyroid gland is nodular on both sides and weighs 35 grams. There is one large nodule in the left lobe of the thyroid measuring 1 cm in diameter. It is firm and gray-white in color and appears poorly encapsulated. The left lung weighs 650 grams. The right lung weighs 700 grams. Both lungs show marked congestion with increased fluid on cut section. There are no emphysematous blebs demonstrable. The mainstem bronchi cortin a rather abundant mucus. The pulmonary arteries are normal.

GASTRO-INTESTINAL SYSTEM: The esophagus is intact. There is no hemorrhage or ulceration of the esophagus. The stomach contains approx. pt. of a brownish turbid fluid in which particles of vegetable matter are still identifiable. There is no hemorrhage or ulceration of the stomach mucosa, although the fundus of the stomach is showing early greenish discoloration from post mortem digestion. The duodanum, small intestine and colon shows no hemorrhage or ulceration.


David Ferrie

The liver is red-brown in color and weighs 2400 grams. There are slight mottled areas of yellowish change beneath the capsule. On cut section the overall coloration is red-brown with mild congestion. The gall bladder and pancreas are normal.

SPLEEN: The splean is congested and weighs 300 grams. On cut section the pulp is very soft.

ADREANALS: These show no hemorrhage or nacrosis or adenomas or tumors.

GENITO-URINARY SYSTEM: The left kidney weighs 230 grams. The right kidney weighs 240 grams. Both kidneys are somewhat larger than normal, and congested. They have a granular cortical surface. On cut section they show congestion. There is no hemorrhage or infection. The ureters are normal. The bladder contains 200 cc of clear straw colored urine. The prostate is normal.

CENTRAL NERVOUS SYSTEM: The scalp is reflected and the calvarium is removed in the usual manner. There are no contusions in the scalp. There is no fracture of the calvarium. The dura is stretched tightly over the left cerebral hemisphere and a large subdural hematoma is visible beneath the dura at this area. The right cerebral hemisphere is markedly compressed and flattened. The total volume of the subdural hematoma on the left side is measured at 95ml. The brain is removed and weighs 1480 grams. Dissection of the Circle of Willis demonstrates a small berry aneurysm at the anterior communicating artery between the two anterior cerebral vessels. This ansurysm measures 1/8 in. in maximum diameter. There is a frim blood clot adherent to it, and a much larger fresh blood clot lying between the frontal lobes communicating with the area of the aneurysm. Multiple sections through the brain show no evidence of contusion foci in the contex. The white matter is normal. The basal ganglia shows no changes. The lateral ventricles are slightly compressed. There is a marked edema and flattening of the right cerebral convolutions. There is uncinate herniation on the left side. There are numerous hemorrhages in the rostral pons and thalamic region. Therse hemorrhages lie mostly in the tegmental area of the pons but some are in the basilar substance in the midline. The medulla and cerebellum show no changes. The dura is stripped from the base of the skull and no fractures are found.

PROVISIONAL ANATOMICAL DIAGNOSIS:

1. Rupure of berry aneurysm of Circle of Willis with massive left subdural hematoma, subarachnoid hemorrhage, and secondary pentine hemorrhages.

2. Hypertensive cardiovascular disease.

3. Pulmonary edema and congestion.

ADDENDUM TO EXTERIAL EXAMINATION: On the right leg on its lateral aspect overlying the head of the fibula there is a pigmented ovoid area measureing 1 1/4 x 1 in. in diameter that shows a grid like stippling. This does not appear recent.


[Signature]
Ronald A. Welsh, M.D., Pathologist
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