Medicolegal autopsy

2. Pathological or clinical autopsies are performed by the pathologists or clinicians to diagnose the cause of death, where diagnosis could not be reached during treatment, or to confirm diagnosis where the same was doubtful.This also helps the pathologists to know the pathology of organs due to some diseases.

3.Medicolegal autopsiesIn unnatural and suspicious circumstances of death, dissection of the dead bodies and their examination is compulsory by law. The purpose of medicolegal autopsies is to find out the cause of death and help disbursement of justice if any crime is involved in the circumstance of the death.

1.To know the exact cause of death 2. To find out the circumstances of death. 3. To find out the time passed after death. 4. In case of unidentified dead body, to establish identity of the deceased or to help to do so.

5. In case of death due to injury or poisoning, the period for which the deceased survived after sustaining the injuries or exposure to poison. 6. To know the nature of death, whether it is a case of natural death or a case of suicide, homicide or accident. 7. What type of weapon or which poison was used?

8. Whether one or more than one person was/were involved, in case of homicide. 9. Whether any natural disease process contributed in any way, to cause the death. 10. Whether any other offence was related with the death e.g., rape. 11Is the injury which has caused death, expected to cause death in ordinary course of nature

12 Whether the dead body was disturbed sometime after death. 13. What was the place of disposal of the dead bodyWhether the body has been shifted from original place of disposal. 14. To know whether more than one method or more than one weapon were used.

Autopsy or postmortem examination isperformed on dead bodies with the following purposes 1. AcademicDead bodies are dissected by the students of Anatomy for academic purposes to know details about the different external and internal organs and structures of the human body.

15. Whether the deceased received any treatment before death. 16. Whether there is anything on or with the dead body which may help identification of the assailant. 17. In case of death due to assault, the relative positions of the victim and the assailant/s.

Procedure to conduct medicolegal postmortem examination For conduction of medico-legal post-mortem examination certain formalities have to be observed. 1. It can be conducted only on the strength of a requisition received from an authorised person. (Ordinarily a police officer, a magistrate or a coroner is authorised to issue a requisition for conduction of medicolegal post-mortem examination).

With the requisition, a copy of the inquest or the preliminary investigation report, a dead-body challan and any other paper of importance, should accompany. 2. Medicolegal P. M. examination can be performed only in an authorised centre. 3. All registered medical practitioners in Govt. service can conduct the examination. 4. A police officer or any other authorised person should identify the dead body in connection with the concerned case, before the autopsy surgeon.

5. Conduction of medicolegal P. M. examination does not require any consent from the relatives or friends of the deceased 6. The dead body should preferably be dissected with the help of natural sunlight. But under special circumstances of urgency, it may be carried on at night, with the help of artificial light. If feasible, the body may once be examined (external), when it first reaches the mortuary, if it reaches at night.A detail examination should be undertaken in the next day when sufficient natural light is available.

7. The mortuary should have cooling chambers for preservation of dead bodies. The doors and windows of the mortuary should be fly proof. There should be plenty of water supply in the mortuary for proper cleaning and washing purposes. The mortuary should have facilities for disposal of dead bodies

It should have dissection table, instruments and other equipments and articles. When a dead body reaches the mortuary, the date and hour of its arrival and then the date and hour of conduction of the P. M. examination should be recordedIt is recommended that, the autopsy surgeon should himself dissect the dead body with the help of an assistant and his other assistant will write down the findings dictated by him.

Before starting the P. M. examination proper, the doctor should go through the inquest report and the requisition and must get the body identified by the accompanying police personnel.

P. M. Examination Proper 1. The description of the dead body should first be noted with the wearing apparels in situ.Then the wearing apparels should be removed from the body, disturbing the body and the wearing apparels minimum.

2. Detailed examination of the dress and other wearing apparels should then be made in respect of their number, make, design, stains on them, old and recent tears, cuts with their dimensions. These may have to be examined once more after conduction of the P. M. examination, to compare the tears, cuts and blood stains on them with injuries on the body. The tears and cut marks should be measured and their placements noted. After P. M. examination these should be sun-dried, packed, sealed and handed over to the police authority.

3. Examination of the dead body A. External examination The following points should be recorded. (a) Body length (b) Body weight (c) Built, complexion (d) Scalp hair--length, colour, recent hair cut, part shaved, use of any dye, singeing, whether wet, presence of dust, mud, stains, if partly fallen off, vermilion mark, baldness, sharp cut on hair, crushing of hair bulb due to injury

(e) Description of beards and moustaches in their length, colour, trimming, shaving, absence (f) Vermilion mark on the forehead (g) Any tattoo mark, moles or mentionable scars, deformities in the body

(h) Condition of the eyes--closed or open, corneas--hazy or clear, condition of the pupils--shapes and sizes of both the sides. Any congenital or acquired deformity or disease, prosthetic eye, scar on cornea, petechial or subconjunctival haemorrhages, cataract.

i Any discharge from mouth or nostrils frothy, blood stained, dribbling of saliva, suspected poisonous stain. (j) Protrusion or biting of the tongue. (k) Congestion, petechial haemorrhages. (l) Cyanosisfingertips or elsewhere.

(m) State and distribution of post-mortem staining, its colour. (n) Blood, mud or other stain on the body. (o) State and distribution of rigor mortis. (p) Cadaveric spasm, content of the hand. (q) Cutis anserina.

(r) Any foreign material any where in the body including the nail beds. Mud or sand stain on the soles. (s) State of decomposition. (t) Maggots. (u) Any adepocere or mummification change. (v) Condition of the prepucecircumcised or not, condition of the scrotum and testicles.

(w) Female breasts--parous, gravid. (x) Discharge per vagina, any other findings. (y) Any antemortem injury anywhere in the body including inside of nose, inside of lips, inside of mouth, over female breasts, private parts of females including inner aspect of thigh, hvmen, vagina.

(zAny suspected stain (poison, seminal fluid) on lips, hands, mons veneris private parts, vaginal wall. (zz) Any ligature mark on the neck or elsewhere, its position, dimension, direction, position of the knot.

If the ligature material is present in situ, then it should be taken out by tying the knot with a thread and then cutting the ligature material at a point opposite to the knot. The ligature material should then be examined in terms of, which material it is made of, the design, length of the part encircling the neck, length of the remaining part, breadth of the ligature material, how many rounds it is twisted around the neck, type of the knot, whether the ends of the ligature material bear any recent cut mark, the strength of the material

The ligature material should then be packed, levelled, sealed and handed over to the police of the concerned police station. Any stains on any part of the body should be scrapped out, preserved without any preservative.

Examination of External Injuries All external wounds should be recorded in all their details, on the following headings (a) Type of injury (b) Size (c) Shape (d) Site, in relation to two external anatomical landmarks. (e) The weapon of infliction or the mode of causation (usually not mentioned in the P.M. report).

(f) The direction of application of the force. (g) For the fatal wounds, the distance of the wound from the same side heel may be recorded. This may help to reconstruct the incident. hThe time and date of infliction of the injury should be studiedThis can be done from inflammatory, healing changes and also from the colour changes.

(i) The vital reaction should be noted, presence of which differentiates antemortem injuries from the postmortem ones. (j) Presence of defence cuts or injury at the expected sites prove the homicidal nature of injury and death. (k) Marks of resistance in the form of minor injuries on the non-vital parts of the body has the same significance.

(1) Concealed punctured wounds are homicidal in nature and search should be made for their presence. (m) Split laceration inflicted on the forehead, scalp or some other areas, against a bony prominence looks like incised woundHence, such doubtful injuries at these sites should be examined carefully with the help of a hand lens. (n) Burn injuries should be recorded in all details of their extent and other features.

(o) It should be kept in mind that, abrasions can be caused on a dead body due to rough and careless shifting of the body, from the place of death to the mortuary. (p) In dead bodies, removed from rivers or ponds, P. M. injuries caused by fish or aquatic animals, may be present. Similarly, P. M. injuries due to gnawing by other animals, starting from dog to rodents, may be present in other bodies. Post-mortem injuries in the form of abrasion, may be caused by ants or cockroaches. (q) Injection marks and other signs of treatment given, should be searched for and recorded.

B. Internal Examination
For internal examination, the different body cavities are to be opened in a planned way. A single incision is given for opening of the thoracic and abdominal cavity both. To open the cranial cavity two incisions are recommended. To expose the structures of the neck, three different incisions are recommended

(a) To open the chest and abdominal cavities, one single incision, starting from the sternal notch above, to the symphysis pubis below, through the right side of the, umbilicus is applied. If there is any injury on the right side then, left paramedian incision can be applied

1.StomachThe stomach is first taken out by placing two ligatures at the cardiac end of the oesophagus and two ligatures below the pylorus end of the stomach. The stomach is removed by cutting between the double ligatures at both the ends. The stomach is opened along the lesser curvature.

The wall of the stomach is thoroughly examined. Presence of any stain, congestion, haemorrhagic points, desquamation, ulceration, sloughing or perforation should be notedThe content of the stomach is noted in respect of quantity, nature of material/food, state of digestion, colour, smell, any evidence of haemorrhage etc.

2. The liver should be removed and any injury or pathology in it should be notedIt should be weighed. A part of the liver (minimum 500 gm.) should be taken out for preservation for chemical analysis. In case, any pathology is suspected in its gross appearance then, a small portion from the suspected area is dissected out along with bordering healthy tissue and preserved in 10% formol saline.

For macroscopic examination of inside of the liver, multiple transverse incision at 1 cm. apart should be given. The gall bladder is dissected out along with the liver. Any pathology or stone formation inside is noted

3. The kidneys are taken out along with the adrenal glands, after tying the ureters along with the vessels at least one inch away from the hilum of each kidney. The surface of the kidneys along with the covering capsules should be examined for presence of congestion, haemorrhage and injury. The capsules and the adrenals are separated

The kidneys are bisected transversely along the longitudinal axesAny pathology, congestion, haemorrhage or injury should be noted with exact mention of the sight and extent. In case of possible pathology, suspected part along with marginal healthy tissue should be preserved in 10% formol saline.

4. The urinary bladder may be examined in situ. Before opening the bladder, if it contains urine, that should be syringed out, or can be taken out with the help of a clean spoon after incising the bladder, avoiding all chances of contamination by blood or any other material. The bladder should be examined for any pathology, haemorrhage, congestion or injury.

5. Both the ureters should be opened along their long axes. 6. The spleen is then taken out and pathology or injury noted 7. The intestine is dissected in its entire length. It is particularly important to look for any injury or reaction due to the effect of poison or presence of a foreign body like a bullet. Curling ulcer is a phenomenon noticed in the duodenum after about 7 to 10 days of sustaining extensive burn' injury. Ulcerative colitis like lesions are noticed in case of poisoning with mercuric chloride.

8. In penetrating wounds of the abdomen, the intra-abdominal vessels may be injured and there may be excessive intra-abdominal haemorrhageExcessive intra-abdominal haemorrhage also occurs due to gross injury to abdominal organs like liver, kidneys and spleen. 9. The pancreas and the adrenal glands are to be examined. If necessary, tissue from these glands are to be preserved for histological examination.

10. The uterus and its appendages should first be examined in situ and then removed enmass along with the vagina. The uterus should be examined in respect of its dimensions, weight, whether gravid, parous or nulliparous or whether there is any pathology in it.

In case of gravid uterus, condition of the whole product of conception should be noted down. Any evidence in support of abortion or attempted abortion with remains of any part of the product of conception inside the cavity should also be recorded.

If there is evidence of attempted abortion then, the endometrial surface should be thoroughly examined in respect of colour, erosion or any other damage including ulceration or perforation of vaginal canal (particularly near the fornices) or of the uterine wall. Foreign body in the form of root, bark (for that purpose any material which might have been used locally to cause abortion) may be present inside the uterine cavity.

Smell and nature of the fluid present inside the uterine cavity may be further indicative in this regard. Death in occasions may occur due to other causes (pathological), preceeded by haemorrhage locally, or systemic effect indirectly. Evidence of use of instruments may be present in the Cervix or in os.

11Rupture of an ovarian cyst may be a very rare cause of death, sometimes associated with history of traumaThe ovaries should be searched for presence of corpus luteum. Fallopian tubes and ovaries have special medicolegal significance in cases of deaths due to their rupture in ectopic pregnancies.

To open the chest cavity, after retraction of the skin sidewise, the cartilaginous parts of the ribs are cut on both sides and the manubrium isseparated from the clavicles at the sternoclavicular joints. The sternum and the marginally attached cartilaginous ribs are removedThe position of the intra-thoracic organs is observed. But, for detailed examination they should be taken out of the chest cavity. Before that, the neck should be dissected and the structures there are examined

The intra-thoracic organs should be taken out along with the neck structures namely, larynx, trachea, oesophagus and also the tongue. Before examining these organs, the chest cavity is examined for haemorrhage or haematomas, injuries including fracture of ribsFractures of ribs are better examined by dissecting the intercostal muscles.

1. After taking out the thoracic structures they are once inspected before separation. 2. The heart is separated after applying double ligatures at the base of the heart over each large vessels and then dissecting them in between the two ligatures of each vessel. The size and weight of the heart is notedThe walls of the heart may be hypertrophied or dilated

The condition of the valves and presence and degree of atheroma, noticed in the valves and the intima of the large vessels, are noted Aneurysm or other pathology in the vessels should be kept in mind, in some cases of death. Any ischaemic lesion, old or new infarction, should be searched for. The patency of the coronary vessels and intravascular clotting in the coronary vessels may be looked for. For the purpose of examination of the coronary vessels, probe of suitable size can be used

Others prefer multiple transverse incisions on the vessels, while some others prefer longitudinal incisions along the length of the vessels. Presence of subendocardial haemorrhagic spots should be searched for in some poisoning cases or pathological conditions. Patent foramen ovale may be noticed, particularly in young individuals, though very rare

To examine the myocardium, transverse incisions are better. The cavities can be opened by longitudinal or transverse incisions. Any septal defect, haemorrhage at any site or injury anywhere can thus be clearly seen.

For confirmation of any suspected pathology, tissue should be preserved for histological examination. Presence of clotted or liquid blood or froth or air bubbles in the chambers of heart should be noted with mention of the quantity, which can be either due to antemortem or postmortem causes.

3. The pericardium should be examined for presence of any pathology or injury. The content of the pericardial sac and its quantity should be notedPericardial effusion, cardiac tamponade, subpericardial haemorrhage, constrictive pericarditis etc. should be looked for.

4. Both the lungs are to be separated from the mediastinal structures after tying the vessels and the bronchioles. The condition of pleura, any sign of pleurisy or pleuritis or pleural adhesion, subpleural petechial haemorrha-ges, injury to pleura, condition of the pleural space (effusion, haemothorax, pneumothorax, pyothorax etc.) should be noted.

5. The lungs are examined for disease, injury and some other findings. In asphyxial deaths the surface of the lungs, particularly, the interfaces of the lobes will show the presence of tardieu's spots, and there will be congestion of both the lungs, with oedema sometimes. In case of death due to drowning, there won't be any tardieu's spot on the surface of the lungs. But the lungs will be more oedematous. The cut section exudes frothy bloodtinged fluid.

The lungs of submerged body may show evidence of emphysema aquosum or oedema aquosum change. Punctured or lacerated wounds cause collapse of the particular lobe. In case of blunt force injury, wound of the lung corresponds with the fractured end of a rib. In case of any pathology in the lungs, tissue may be preserved for histological test. Thymus should be examined and the tissue from the gland preserved, if necessary.

Examination of the structures of the neck The internal structures and tissues of the neck should be examined thoroughly, in case of death due to constriction of the neck or injury or any pathology. For exposure of the structures of the neck, ordinarily, the upper end of the main incision at the sternal notch is extended upto the symphysis mentii.

Skin, subcutaneous tissue, muscles and other structures are examined layer by layer. But, when a more detail examination is necessary or exposure of a wider area of the neck is necessary, then a different type of incision is preferred to.

(a) A 'V' shaped incision is given, the apex being at the sternal notch, with the two wings extending upwards and iaterany uvto the mastoid processes of both sues. The skin is flapped up upto the margin or the mandible.

(b) A third variety of incision exposes still wider area of the neck. Here, actually two incisions are requiredOne incision extends from sternal notch to the symphysis mentii. The other extends from the acromion process of the clavicles of one side to the same point of the other side. The skin is flapped upward and outward

Irrespective of the type of the incision, most autopsy surgeons like to examine the neck structures, before removal of the thoracic organs so that the tongue, larynx, trachea and oesophagus can be taken out along with the lungs. This helps examination of the whole of the upper respiratory tract in its continuity.

In case of death due to alleged constriction of the neck, there may be fracture of hyoid bone or thyroid cartilage with extravasation of blood in the tissue and injury to carotid arteries, sterno-mastoid muscles or platysma. Compression of the neck with hard materials may cause injury to the cervical vertebrae and the corresponding part of the spinal cord. Level and extent of other mechanical injuries on the neck should be cautiously examined to know the type of injury and organs or structures injured causing the death.

Exposure of the Cranial Cavity One of the two conventional incisions can be used. (a) A circular incision around the head at a level 1above the eyebrow, extending sidewise upto the occipital protruberance, keeping the scalp over the protruberance intact. The scalp is flapped out posteriorly. Any haematoma in the soft tissue of the scalp is noted. The periosteum is removed and any fracture in the skull bone is recorded as to its type, position and extent.

(b) The other type of the incision extends from just above the attachment of one ear to the joint just above the attachment of the other ear. In this incision, the skin is f1apped out both anteriorly and posteriorly. Rest of the procedure is same. Many prefer the second variety of the incision due to its cosmetic value, as because this incision does not distort the facial appearance.

The cranial cavity is finally exposed by sawing and chiselling out the skull vault at a level 1 above the eyebrow in front and about the level of the occipital protruberance at the back. Some dissectors feel comfortable with manual saw, while others use electric or battery operated saw.

Any injury to the dura and extra-dural haemorrhage is noted. With a criss-cross incision the dura is removedAny subdural or subarachnoid haemorrhage or injury to deeper meninges or surface of the brain or any evidence of any disease is noted at this stage. The meninges may be congested due to asphyxia, apoplexy or other intra-cranial lesions. The brain is dissected out at its stem, along with the roots of the cranial nerves. The whole brain is taken on a clean enamel tray.

Haemorrhage and fracture at the base of the skull is searched out. Before dissecting the substance of the brain the circle of willis is examined for any aneurysm and rupture of the aneurysm. All the ventricles are opened and examinedThe cerebral hemisphere is dissected out along with base and the cerebellum. Both side cerebral and cerebellar hemispheres are sectioned, first, longitudinally and then transversely. In this way most of the parts of the brain substance will be exposed.

Any haemorrhage, injury, congestion or pathology is noted. Haemorrhage in the pons and base of the brain of any amount is most important. In case of gunshot injury the projectile may be present in the brain substance or inside the cranial cavity. The track of the projectile or the wound should be noted in case of gunshot and stab wounds. The pituitary fossa should be examined specifically and cautiously.

Examination of the Spinal cord When there is no indication, the spinal cord need not be exposed. When necessary, it should be exposed from the back. A midline incision is given on the back along the entire length of neck and trunk. The skin is flapped out sidewise or laterally 1on either side. The vertebral column is chiselled along the medial margins of the transverse processes of the vertebrae. The whole length of the spinal column can be taken out in this way without causing any P. M. trauma.

Scrotal SacTo open the scrotal sac and examine the testicles and other organs, some prefer two lateral incisions, though it can be done by one midline incision also. Examination of the scrotal sac is a must when the sac is enlarged, tense in look or deformed in appearance. Injury, haemorrhage or pathology should be noted

Apart from these, to confirm a bruise, to confirm and examine a fracture, to trace the track of a wound, to recover a foreign body e.g. pellet or bullet, to examine the site of an injection mark and to examine any deformity or pathology, incisions may have to be given at any place on the body surface.

In relation to medicolegal postmortem examinations, preservation of some organs, some viscera or some other materials is necessary or even essential in some cases.