NOTES
Autopsy ( auto = self , opis = view) - to see for oneself.
Types of autopsies
-Conducted for disease causing death , efficacy of treatment , transplantation purposes
Medico-legal autopsy or Forensic autopsy
-Medico-legal autopsy carried for suspicious and unnatural death for legal purpose
Anatomical or academic autopsy
-carried out for teaching anatomy to medical students.
Performed under authorized person
Identification is important
Should be conducted only in the mortuary and as far as possible in daylight.
Should be performed as soon as possible after requisition
Inquest report , case sheet , accident register should be read thoroughly
Non authorized person are not allowed to watch autopsy
All cavities must be opened
Even mutilated ,fragmented or decomposed body , an autopsy is performed
After autopsy body is handed to policeman
The person responsible for handling, moving, and cleaning the body is often called a diener (German, servant).
Instruments and equipment useful for postmortem examinations
• Scalpel and disposable blades of 22 sizes. • Toothed forceps: Teeth lend strength in gripping the skin and organs. • Rib cutters: Small pruning shears are used to cut through the ribs before lifting off the chest plate. • Enterotome: Large scissors used for opening the intestines. • Scissors used for opening hollow organs and trimming off tissues. • Bone cutter: This is used to cut the ribs and has curved blades. • Councilman rib shear/cutter: Small pruning shears are used to cut through the ribs before lifting off the sternum. • Vibrating saw (Stryker saw): Instrument of choice for most autopsy surgeons for removing the brain. • Bone saw: The hand saw can be used to see through the skull, but it's very slow-going compared to the vibrating saw. Infections from aerosols being thrown up are other disadvantages.• Virchow skull breaker or chisel: After scoring the calvarium with the vibrating saw, the chisel is used to separate the top of the calvarium from the lower skull, thus exposing the brain and the meninges.• Hammer with hook is used with the chisel to separate the calvarium from the lower skull. • Brain knife: Long knife used to smoothly cut solid organs into slices for examination. • Hagedorn's needle is used for sewing up the body after an autopsy. Other instruments that should be available: are probe, small rule, and plastic-coated measuring tape.
External examination
Clothing
General condition
Injuries
Medical scars ,non medical identification marks
Appearance of body and changes during the course of death
Face , neck ,eyes examination
Natural orifices
Internal examination
Primary incision
I shaped (most common )
Y Shaped (especially for females)
modified Y shaped ( hanging , strangulation)
Methods of dissection
Virchow's method ( individual organ removed , organ dissection)- quick
Rokitansky method ( organ dissection in situ)-infected bodies , children
Letulle (En masse dissection & organ separation , organ dissection )- organ inter-relationship
Ghon method (separate block dissection , organ dissection)- easier handling
Cardiovascular examination
Gastrointestinal examination
Genitourinary examination
Respiratory system examination
Nervous system examination
Preliminary autopsy data includes
Medical Records.
Consultation with the doctor.
Statement of family members.
Investigation of the area where the person died.
Circumstances surrounding the death .
Consultation with public
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MEDICOLEGAL AUTOPSY
Introduction
Autopsy ( Gk. Auto = self, opis/opsis = view ) is also known by many other terms like necropsy, post mortem examination, autopsia cadaverum means to see with one's own eyes or in other sense - means a medical examination of the dead body. A medico-legal autopsy is a scientific examination of a dead body carried out under the laws of state or requisition of legal authority ( usually a police officer ) for the investigation of sudden, suspicious, violent, and unnatural deaths.
Natural and unnatural death
Death may be defined as the permanent and irreversible cessation of three interlinked vital systems of the body called the tripod of life, namely - the nervous, circulatory and respiratory systems. Natural death includes deaths due to a cause that is incompatible with life. Such deaths are not preceded by medicolegal autopsies. Unnatural death includes the suspicious, uncommon cause of death that might have caused comorbidities but was not enough to precipitate death without the involvement of another person. Under a requisition of an authorized person, such cases can be involved to perform autopsies and finding out the cause of death for the justice of the deceased person.
Cause , Mechanism and Manner of death
The cause , mechanism and manner of death explanation is what we seek after an autopsy is performed . Cause of death is any injury or disease producing physiological derangement, briefly or over a prolonged period and which results in the death of the individual.The cause of death can be either traumatic or non traumatic .Mechanism of death is the physiological derangement produced by the cause of death that results in death, e.g. hemorrhage, septicemia, metabolic acidosis or alkalosis, ventricular fibrillation, and respiratory paralysis. tic.To better explain the case, the Mechanism of death must be enlightened. The Mechanism of death should properly explain and distinguish it from natural death.Manner of deaths includes if the death was natural or unnatural . If unnatural- was it a homicide, suicide, accidental or undetermined, or may be pending also.
The Pre Autopsy requirement
This includes authorization and consent. Medicolegal autopsies in Nepal are carried out following a request made by a legal authority which is usually the police who leads all death investigations. The consent from the family is not necessary however one can inform the family members.Some protocols should be followed before an autopsy is carried out. This includes visits to a crime scene (done by the police themselves),transportation, registration, and storage of corpses.
External examination
The general condition of the body like height, weight, nutritional status, condition of skin and hair, decomposition, and medical interventions are noted. The clothing of the deceased should be examined with its nature, condition, tears , cut, holes, loss of buttons, or any derangements. The clothes are removed without tearing them and if they can't be removed, are cut with careful manners. Blood stains, seminal fluid, grease, etc. Should be noted.If it's a sexually assualated victim, vaginal and anal swabs are taken. skin is examined thoroughly and the presence of blood, mud , vomit faeces are noted. presence of any signs of disease are noted. Face and eyes are examined for any pallor, petechiae hemorrhage. bruises , fingernails, abrasion, ligature marks can be checked on the neck.other examination of thyroid, lymph nodes, thorax, breasts, abdomen, back, and external genitalia is observed for any deformities.all the natural orifices like mouth, nose, ears, vagina, etc. Should be examined . external injuries like abrasions , bruises, laceration , burns , scalds etc . Should be examined with their details like length, breadth , direction, position, margins, base, and extent are noted.We should also determine if they were caused before or after the death or their time of inflection.
Internal examination : Abdominal organs
The condition of the abdominal cavity and organs is observed before anything is disturbed or altered, to find out if there is any blood, pus, or fluid in the cavity perforation, or damage to any organ. If blood, pus or any other fluid is present, its quantity is measured . Every organ’s external appearance and weight are noted.The stomach is ligated and any abnormalities of the mucosa ,ecchymosis, haemorrhage , or ulcerations are noted. the gastric contents are studied to if they can explain the cause of death.Both intestines are removed along with mesentery and are ligated. Small intestine is opened longitudinally Along the mesenteric border while large intestine along the anterior tenia and their contents and mucosa are studied.Contents can be preserved in case of poisoning.Organs like the spleen, kidneys ,liver are studied and explained in the report. They may be preserved for chemical analysis.extra Abdominal structure like testes , genitalia are studied.
Internal examination : chest organs
The examination includes study of lungs , heart and associated structure and coverings.A bone saw is used to cut the front of the chest plate.The chest plate is removed , exposing the pleura and pericardial sac.The heart is extracted by cutting the inferior vena cava , pulmonary vein, pulmonary artery ,aorta ,and the superior vena cava. The dissection of the heart is done and the most common method mentioned is the inflow-outflow method.For the extraction of lungs , a long bladed knife is placed under the hilum and is cut . The lungs are cut from apex to base by a, Large bladed knife , held parallel to the board.
Internal examination : Head & Neck
The head examination includes incision of scalp,removal of skull cap , removal of brain and it's dissection.The neck is extended by putting a wooden block to allow the head to fall back .Neck is best dissected by modified Y- shaped incision.The signs of trauma is detected in all the five layers .viz 1. platysma , 2.sternocleidomastoid , 3. omohyoid & digastric. 4.sternohyoid . 5. Sternothroid ,thyrohyoid. Structures like thyroid gland , common carotid are observed. Oesophagus , larynx , trachea are mobilized and pulled away from the prevertebral tissue by blunt dissection which are later examined by cutting and opening them from the posterior surface.
All the organs and tissue must be returned to the body unless permission is given by family to retain any tissue for further investigation.
The possible ancillary investigation
These include certain tests like vitreous analysis , DNA testing , microbiology, toxicology , diatom testing, imagining and some other biochemical testing which can aid to find the cause of death and explain it more vividly.
The autopsy report
The autopsy report summarizes and reviews the overall autopsy findings correlated with historical information , imagining studies , lab results , diagnosis. The report contains three parts .
A. Introductory part ( pre-amble)
B. Body ( findings)
C. opinion (post amble)
The introductory part consists of date , identification , case , brought by, date and hour of death , date and time of examination, information by police.Body consists of complete description and findings on external and internal examination of the dead body. All negative findings are also to be mentioned in the heading. Post amble includes opinion regarding the cause , manner of death and the time since death based on the findings observed during autopsy. It is very important that the report contains adequate findings and well documented without presenting biases involving concealing or erasing the findings