THE AUTOPSY
RODELIA V. NICOLAS, MD, MMHOA
POSTMORTEM EXAMINATION
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also known as, autopsy or necropsy.
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The word autopsy means self-examination
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In the terminology postmortem, word post means after and mortem
means death, thus postmortem examination means examination after
death.
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Necros of necropsy means death and opis meaning view, thus, the word
necropsy means viewing after death.
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DEFINITION
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Postmortem examination or autopsy is a scientific and systemic study of a dead
body
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Autopsies are of three types
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(i) clinical or pathological autopsy
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(ii) medicolegal autopsy
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(iii) anatomical autopsy
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Clinical/Pathological/Academic Autopsy
To determine the disease causing death. A Pathologist performs it with consent of the
relative of the deceased.
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Medicolegal Autopsy
To solve mysterious unnatural death.
A forensic pathologist or medicolegal expert preferably does it.
However, in India, due to lack of adequate qualified experts, all registered medical
practitioners can also perform this with an authorisation by State.
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Anatomical Autopsy
To learn the normal structure of the human body by medical students.
It is usually done on an unclaimed dead body, handed over to
anatomy department by municipal or such other governmental
authority.
It is also performed on the voluntarily donated dead body.
CONSENT FOR AUTOPSY
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Clinical autopsy: Obtain consent from the relatives.
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Medicolegal autopsy: No consent is required but legal permission or
authorisation (requisition from police) is a must.
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Anatomical autopsy: Here permission must be obtained from government
authority and the dead body is mostly an unclaimed. In a voluntarily donated
dead body consent from the legal heirs is essential prior to the dissection.
MEDICOLEGAL AUTOPSY
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A special type of autopsy or postmortem examination, ordered by the
government/legal
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authorities in all unnatural deaths, such as homicide, suicide,
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accident, etc.
Objectives of medicolegal autopsy are definite and they are basically to
establish:
• Identity of the deceased
• Time since death
• Cause of death
• Live birth, period of viability,
Place of Performing Autopsy
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Preferably done in an equipped mortuary
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Autopsy is also done at site of recovery of the cadaver in cases of
exhumation and putrefied body.
Qualifications
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Minimum qualifications render a doctor qualified for this work is that he or she should have
MBBS degree and that he or she must be a registered medical practitioner.
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Specialist qualifications vary and include any one of the following qualification:
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MD (forensic medicine)
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DNB—forensic medicine (diplomat of national board— forensic medicine)
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DFM (diploma in forensic medicine)
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DMJ (diploma in medical jurisprudence) from UK.
Other specialist qualifications
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MD (pathology)
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MS (anatomy/surgery)
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Any other specialists may also be allowed to do the autopsy in India on account
of shortage of subject specialists.
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However since 1985 MCI insists to recruite only MD (forensic medicine) qualified
only to be appointed in forensic medicine departments of a medical college
allowing all those who are already in profession to continue.
Medicolegal Autopsy Guidelines
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Avoid unnecessary delay in performing autopsy
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Do not allow unauthorised person into the mortuary. If allowed
record a statement from him or her giving reasons for his or her
presence and signature for being present during the autopsy.
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The investigating officer (IO) may be allowed, if desires.
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Prepare the PM notes during autopsy or arrange to tape record the
dictation.
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Prepare the PM report immediately and sign it duly.
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Handover this report and viscera (if preserved for chemical analysis)
only to an authorised police officer/constable maintaining the ‘Chain of
custody’
Autopsy Procedure
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Procedures vary and depend on the skill and experience of forensic expert. A checklist for postmortem examination can be given under the
following headings in general
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External Examination
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It is the most important part of the medicolegal autopsy procedure as most of the information gathered at this stage can always help a lot
in solving the most mysterious deaths. This includes examination of:
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Clothes
Stains of mud, blood, urine, stool, etc.
Identity
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Body orifices
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Finger/toe-nails
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Injuries/surgical intervention
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Rigor mortis
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Postmortem staining
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Decomposition/other changes.
Internal Examination
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This includes dissection and examination of the three major body cavities and their
contents, namely:
Skull/cranial cavity
Thoracic cavity
Abdominal cavity.
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No autopsy is completed until all parts of the body are dissected and examined in detail.
Forensic Autopsy
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Cause of death,
Hospital Autopsy
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manner and time of death
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The dead body belong to the state.
Cause of death, effectiveness of
therapy,extent of disease
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Consent shall be obtained from next
of kin
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The identity of the body is already
known
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Consent obtained from next of kin or from an
authoritative agent.
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Involves positive identification of the body
Forensic Autopsy
▪ External examination is
frequently important
- description of entrance
and exit gunshot
wounds
▪ Photography is a key
component.
▪ Toxicology and
Radiography often
required
Hospital Autopsy
▪ External examination is
relatively unimportant,
more on internal
findings
▪ Photography is
optional
▪ Toxicology and
Radiography are not
necessary
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Complete and Partial autopsy
Autopsy Techniques
▪ Virchow
▫ Organs are removed one by one
▪ Rokitansky
▫ In situ dissection, combined with the removal of
organ blocks
▪ Ghon
▫ En bloc removal,
▪ Letulle
▫ En masse removal
DISSECTING THORACIC AND ABDOMINAL CAVITIES
The procedure includes several steps and they are:
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Incisions
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Removing the abdominal and thoracic viscera enmass (Letulle’’s method)
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Closing the body
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Handing over the body
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Preserving/dispatch of viscera to FSL or to other laboratories.
However, only three types of incision are in practice routinely and described initially, followed by
uncommon ones.
Types of incisions:
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I-shaped incision
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Y-shaped incision
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Modified Y-shaped incision
I-Shaped Incision
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Extends from symphysis mentii to symphysis pubis taking curve
towards left around umbilicus.
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Indication: It is used routinely in practice.
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Advantages: It is simple and convenient.
Y-Shaped Incision
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Commence at angle of mandible above on either side and the incision from
both sides brought forwards, downwards to meet at the suprasternal notch
and then run downwards as in “I” shape incision to symphysis pubis.
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Indication: This is preferred when a detailed study of neck structures
required, e.g. asphyxial death due to neck compression.
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Advantage: It has a better exposure and allows study of neck structures.
Modified Y-Shaped Incision
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Commences at anterior axillary fold on the chest on either side, runs
downwards and anteriorly beneath the breasts as to meet at xiphisternum in
the midline and then run downwards as in I-shaped incision to symphysis
pubis
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Indication: Preferred in females—
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Advantages: It prevents cutting of the chest skin in midline and also allows
detailed study of neck structures.
Elongated X-shaped Incision
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This is a aspecial incision used to dissect out subcutaneous structures
in the back to identify and evaluate the extent of blunt injuries, which are
usually missed where superficial imprints are faint, particularly when
present on skin not overlying bone
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This is helpful in reconstruction of events prior to death and should be
practiced in causes of custodial death.
NEGATIVE AND OBSCURE AUTOPSY
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It is a fact that a medicolegal autopsy result may not be favorable in
deciding every case.
Negative Autopsy
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An autopsy, which fails to reveal the cause of death with gross, microscopic, toxicologic and other
laboratory investigations is defined as negative autopsy.
Causes
Various causes are enumerated as follows.
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Inadequate history especially in cases of death due to vagal inhibition, hypersensitivity, etc.
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Lapses in external examination as in case of death due to snake bite, other insect stinging, etc.
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Inadequate or improper internal examination, e.g. air embolism or pneumothorax missed.
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Insufficient laboratory examination.
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Lack of toxicological analysis
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Lack of proper training to perform an autopsy properly.
Obscure Autopsy
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An autopsy done meticulously, properly and perfectly, but may present
with no clear-cut findings as to give a definite cause of death, leading to
perplexity of the forensic pathologist
Causes
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Causes of obscure autopsy are usually unexplainable.
1. Natural causes such as:
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Obscure morbid anatomy
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Obscure histopathology
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Emotional causes
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Paroxysmal fibrillation, etc.
2. Biochemical disturbances like uremia, diabetes, etc.
3. Concealed trauma, such as concealed punctured wound.
4. Endocrine disturbances such as conceded fimctired wound.
5. Poisoning due to:
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Anaesthetic over-dosage
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Delayed narcotic poisoning
6. Miscellaneous—such as putrefied body.