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Autopsy
June 18, 2015
Dr. Sergio Paguio
 Efficacy of new drugs and their potential adverse effects
“Postmortem examinations provide factual, objective  New surgical techniques
information to the decedent’s families that negate their
suspicions and obviate their desire to pursue a lawsuit.”
FACTORS CONTRIBUTING TO DECREASED AUTOPSY
RATES
AUTOPSY
Reservations because of:
 Considered a medical procedure  Religion
 A careful examination of cadaver’s tissues and organs to  Wrong perceptions
determine the cause and manner of death
 Defamation of the corpse
 Disrespectful of the recently deceased
OBTAINING AUTHORIZATION FROM THE RIGHT PERSON
 Bad media exposure
(From 2016 3B)
PRIORITY CATEGORY
EMOTIONAL DISCOMFORTS IN AUTHORIZATION OF AN
1. Spouse
AUTOPSY BY FAMILY
2. Son or daughter
3. Either parent or guardian  Discomfort with cutting the dead body
4. A brother or a sister  Fear of being disrespectful to the dead
5. Grandparent, grandchildren, uncle or aunt, nieces or  Anxiety about offending nature
nephews  Fear of objections from next-of-kin
6. Great grandparent, great uncle or great aunt  Concern about biomedical development
7. Any other next of kin  Resistance to revealing one’s diseases
8. A friend or person charged by law with the responsibility  Anxiety about offending God
for burial  Distrust of doctors and healthcare system
 Apprehension about the funeral being influenced
TYPES OF AUTOPSIES  Fear of not being dead
 A forensic autopsy is more thorough than a hospital autopsy.  Other discomforts
 The crime scene is important and must be preserved .  Discrepancy between clinical diagnosis and autopsy
diagnosis: 10 – 45%
HOSPITAL AUTOPSY
 Aims to establish a certainty regarding the cause of death 4 TYPES OF EVISCERATION TECHNIQUES
 Can confirm clinical diagnosis of death, often revealing 1. En Masse “Le Tulle”
errors of clinical diagnosis 2. En Bloc“Ghon / Zenker”
 Improvement of medical care 3. Virchow’s
4. Rokitansky “In Situ”
FORENSIC AUTOPSY * Evisceration – removal of internal organs
 Special request of judiciary department for situations Description Advantages Disadvantages
stipulated by law, violent death, or undetermined cause EN MASSE “LE TULLE”
 To determine the cause, manner, and time of death  Organs are  Complete  Difficult to
 To recover and preserve evidential material from the body removed as a preservation of handle
 To correlate and interpret all the findings with the single bulky relationships  Requires
circumstances of the case aggregate among organs assistance
HOSPITAL/CLINICAL/ MEDICO-LEGAL/  Done in a  Speed
ACADEMIC FORENSIC training  Organs
 Cause of death  Manner of death institution removed and
 Internal exam more important  External exam stored for later
 With consent from next-of-kin  No consent from kin dissection
 Clinical history  Crime scene EN BLOC “GHON / ZENKER”
 Anatomical pathologist  Forensic pathologist  Maintain  Preserve most  Multiple organ
 To provide a report for the prosecution or defense of persons connection anatomic system
alleged to be involved in the death between relations without involvement
physiologically- unwieldy mass complicates
BENEFITS OF THE AUTOPSY TO THE PUBLIC related organs of organs procedure
 Ex: Thoracic  Skill necessary
 Provides reassurance to the family pluck, coeliac to remove each
 Identification of any contagious or familial disease pluck, intestines, block from body
 Evaluation for insurance benefits and workman’s urogenital pluck intact
compensation benefits
VIRCHOW’S
 All organs  Systemic  Destruction of
BENEFITS OF THE AUTOPSY
individually approach and anatomic
 The autopsy as an educational tool removed and simplicity relationships
 Identification of new or previously unrecognized disease examined
 The autopsy as a quality control tool (to verify if autopsy systematically
coincides with clinical diagnosis) ROKITANSKY “IN SITU”
 Basic Principle:  Practical  Expertise to
THE AUTOPSY AS A QUALITY CONTROL TOOL Disturb (for single recognize
 Keep track of your competence connections practitioner) abnormalities
between organs
 Develop clinical craftsmanship as little as  Capability of
 Sharpen diagnostic skills possible preserving
 Increased diagnostic accuracy  Dissection occurs abnormal
 Check appropriateness of intervention in situ with little anatomic
How can a full evaluation of the following be done without an actual relationship
autopsy? evisceration
 If an abnormality
 Diagnostic techniques and tests
is found regions
 Risks associated with techniques removed intact 

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SURGICAL PATHOLOGY: AUTOPSY
combination of en
bloc and in situ
 Rarely performed
 For external
examination in
medicolegal
autopsies
EVISCERATION – removal of internal organs
MICROBIOLOGICAL STUDIES
 Samples should be obtained as soon after opening the body
as possible, prior to extensive manipulation, esp. the
intestines.
 Cultures should be collected within 15 hours (or earlier) after
death.
LOCAL REGULATIONS
 Code of Sanitation of the Philippines (P.D. 856)
 Implementing Rules and Regulations of Chapter XXI:
Disposal of Dead Persons
DEATH CERTIFICATES
IMPORTANCE
Information provides basis for state and national mortality
statistics used to:
 Assess general health of the population
 Evaluate medical treatment success
 Examine medical problems with higher prevalence in
certain demographics and to identify where medical
research can have the greatest effect
 Identify public health problems and evaluate established
programs to help these problems
 Allocate healthcare services and follow-up studies of infant
and maternal deaths and infectious diseases
 Identify disease cause
 Evaluate diagnostic and therapeutic technique
 Identify leading causes of death
 Identify potential life-years lost to diseases or injury
 Provide information for epidemiologic studies
 Identify geographical areas with increased death rates from
certain causes of death
 Serve as the primary means for evaluating health at the
local level
REQUIREMENTS
 No remains shall be buried or cremated without a death
certificate
 The death certificate must be issued by the attending
government or the private physician
 When no physician is in attendance, it shall be issued by
o City or Municipal Health Officer (MHO)
o Mayor
o Secretary of the Municipal Board
o Councillor of the Municipality where the death occurred
 The basis of the death certificate shall be an affidavit duly
executed by a reliable informant stating the circumstances
regarding the cause of death
 The death shall be reported to the local health officer within
48 hours after death and the death certificate shall be
forwarded to the local civil registrar concerned within 30
days after death for registration.
SHIPMENT OR TRANSFER OF CADAVER
 Death certificate
 Transfer permit from local health authority of point of origin
 Properly embalmed remains
 Transfer permit from places the remains will pass
 Abroad: rules and regulations of the National Quarantine
Office
ETHICAL VALUE OF THE HUMAN CADAVER
 The person is intimately identified with his or her body
 Desire to respect the memory of the deceased
 The cadaver is the material carrier of an amount of
events regarding the deceased person that persist in
our memory
 Moral-religious significance of the human body
 Christian religion
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From Textbook of Forensic Medicine and Toxicology:
th
Principles and Practice, 5 ed by Krishan Vij
EXTERNAL EXAMINATION
 It is preferable to proceed from head to foot so that
nothing escape notice
 In all cases, general description like weight, height, built,
age, sex should be noted.
 After the body has been undressed the wound upon the
body should be photograph.
 Before starting examination properly, samples like hair
from head, pubic region, swabs from mouth, vagina, anus,
glans, etc. must be collected in appropriate cases
 In head wound of the scalp may present difficult in locating
in a thick & long haired person, so hair must be shave &
wound described. The eyes, nose, mouth, ears must be
examined for blood exudates
 In case of unidentified bodies dental charting must done.
 In neck both the front & back should be examined for any
bruises, finger nails, abrasion, ligature marks & other
abnormalities.
 Thorax and abdomen are inspected for any injury or
deformity; axillary regions should not be overlooked.
 Both upper and lower limbs should be inspected for
defense wounds or for any deformities.
INTERNAL EXAMINATION
 A large and deep Y-shaped incision can be made starting
at the top of each shoulder and running down the front of
the chest, meeting at the lower point of the breastbone.
 This is the approach most often used in forensic autopsies
so as to allow maximum exposure of the neck structures
for later detailed examination.
 This could prove essential in cases of suspected
strangulation
 A T-shaped incision made from the tips of both shoulder,
in a horizontal line across the region of the collar bones to
meet at the sternum (breastbone) in the middle.
 This initial cut is used more often to produce a more
aesthetic finish to the body when it is re-constituted as
stitching marks will not be as apparent as with a Y-shaped
incision
 A single vertical cut is made from the middle of the neck
(in the region of the “adam's apple” on a male body)
Types of incision for opening the body (trunk) during post-
mortem examination:
(i) V-shaped incision from mastoids to suprasternal notch and
then straight to pubis
(ii) Shoulders to manubrium sterni and then straight to pelvis
(iii) Standard midline incision – straight from below the chin to
pelvis
NECK
 Exposing structures of neck , I-shaped incision serves the
purpose
 The structures are examined layer by layer as they are
being dissected
 In case of death due to alleged pressure upon the neck,
carefully examine the carotids , hyoid bone and the thyroid
cartilage for any injury or abnormality
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SURGICAL PATHOLOGY: AUTOPSY
THORAX
 After the routine midline incision, reflect the skin and
muscle mass from the thoracic cage laterally
 Cut the rib cartilages on either side obliquely to avoid
cutting the lungs
 Open the pericardial sac by an anterior midline cut
 The intra thoracic organs should then be removed
 The heart is held at the apex and lifted upwards
 The isolated heart is then inspected and cut along
direction of blood flow
 Lungs should be separated and examine the cut surface
for consolidation, edema, emphysema, etc.
ABDOMEN
 Abdomen is opened by a midline incision
 The cavity as such is examined for any pus , blood,
exudation etc.
 The stomach is examined by making a cut while in situ for
the contents
 Both the small and large intestines should be removed by
cutting mesentery and freeing other attachments
 The liver should be cut open by deep incision at several
places, and the color and consistency noted
 The gall bladder , pancreas, spleen should also be
examined
 Kidneys are exposed by incising their capsules
 The bladder is to be examined for congestion,
haemorrhage etc.
 In female bodies, the uterus should always be examined
for its size and shape
SKULL AND BRAIN
 Incise the temporalis muscle about its middle on each
side. The cranium is to be opened by saw cut.
 Examine the dura from outside for extradural
haemorrhage and superior sagital sinus for ante mortem
thrombus.
 Remove the pituitary by chiseling the posterior clinoid
process and incising the diaphragm of sella tursica.
 Cut the brain in serial coronal section at regular intervals
from front to back.
 Cut the cerebellum through the vermis to expose the
fourth ventricle.
Skull showing (a) incision mark on scalp and (b) line of sawing
SPINE AND SPINAL CORD
 Make a middle incision from the base of skull to sacrum.
 Carry out laminectomy by sawing through the entire length
of spine; laminae are then removed with the help of bone
shears which exposes the spinal canal.
 Examine the dura for any pathological condition.
 Separate the cord at the foramen magnum, carefully lift it
from vertebral column and place it on table for
examination.
Key points:
 Medical negligence is based on standard-of-care
issues rather than accuracy of clinical diagnosis.
 Misdiagnosis indicates lack of advanced medical
technology.
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 No significant relationship between accuracy of
clinical diagnosis and outcome of the suit.
USEFUL INDICATORS FOR AN AUTOPSY QUALITY
ASSURANCE PROGRAM
 Discrepancies between pathologic and final diagnosis
 Lack of documentation by x-ray, photography, and other
tests
 Evidence of pathologic misdiagnosis in final autopsy reports
 Specimens with no clinical information sent to Pathology
 Number of:
 Autopsies
 Cases sent to reference autopsy laboratory or registry
 Incident reports
 Patient complaints
 Physician complaints
 Staff complaints
 Outstanding survey deficiencies
 Mislabelled specimens
 Results of family satisfaction questionnaires
 Infection rates
LIABILITIES OF PHYSICIANS
1. Administrative
 “The practice of medicine is service to mankind
irrespective of race, creed or political affiliation. In its
practice, reward or financial gain should be a
subordinate consideration.”
 Filed in PRC
2. Criminal – proof beyond reasonable doubt
3. Civil – preponderance of evidence
 Filed in their respective institutions
Sources of Liabilities of a Physician
1. Ethics of the Medical Profession in the Philippines
2. Medical Act of 1959 as amended
3. Civil Code
4. Revised Penal Code
5. Special laws
Authorized to perform autopsies:
 Health officers – provincial, municipal, city
 Medical officers of law enforcement agencies – PNP, NBI
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