Medicolegal Autopsy

Abstract

The word autopsy is formed from two Greek words, Autos and Optos. The meaning of the word Autos is self and the word Optos is seen. Thus, autopsy means seeing of self. An autopsy is of two types. Medicolegal Autopsy and Histopathological or Clinical Autopsy. In this chapter, we mainly focus on the Medicolegal autopsy, what is the aim of the autopsy. What are the prerequisites of the autopsy? Where medicolegal autopsy can be carried out? Who can carry out the autopsy. What are the different incisions of doing a medico-legal autopsy? We also discuss which viscera are to persevere in different autopsy procedures and which trace elements are to be collected in common medicolegal autopsies. How viscera and trace evidence collected from the dead body are preserved. We will also discuss, in brief, the preservatives used.

1. Introduction

The word Autopsy is formed from two Greek words, Autos and Optos. The meaning of the word Autos is self and the word Optos is seen. Thus, autopsy means seeing of self. It is also commonly known as postmortem examination. An autopsy is of two types:

1. Medicolegal Autopsy/Forensic Autopsy.

2. Histopathological Autopsy/Clinical Autopsy.

Medicolegal Autopsy is done in deaths due to unnatural causes and in natural cases also, where the cause of death is not certain or brings dead cases [1]. The aim and objective of the medicolegal autopsy are to help the law enforcement agencies to ascertain the identity of the deceased, cause of death, type of weapon used, Time since death, manner of death and to collect any trace evidence. The registered medical practitioners are only legally allowed to do the autopsy in India in the medicolegal case at the request of the investigating officer, along with inquest papers at the authorized place only. The consent of relatives is not required. However, relatives are required for the identification of the deceased before starting a postmortem examination. After completing the postmortem, the body of the deceased is handed over to the police/Investigating officer along with numbered and initial inquest papers and a medicolegal autopsy report. While, in the Clinical Autopsy, the autopsy is to be done by a Pathologist after taking the consent of the relatives for autopsy and investigation if any is required. Before starting a clinical autopsy, it should be insured or verified that it is not a medicolegal case. It is done at the request of clinical doctors and after authorization from the head of the hospital, to know the disease process which was going on in the deceased body, to further augment the knowledge of medicine. The pathologist may or may not share the autopsy report with the relatives. In a medicolegal autopsy, the background information is minimal, maybe distorted or non-scientific as per the knowledge available with the investigating police official while in the histopathological autopsy, the detailed events of disease, case sheets made by well-educated staff are available. The report of the medicolegal autopsy will be crossed by a defense lawyer in the court of law while the histopathological autopsy is crossed by peer review in case discussion meetings [2].

The Medicolegal Autopsy is studied under the following heads

• Preliminary Examination of Inquest Papers.

• Gross/External Examination of the body

• Internal examination of the body.

  • Skin incisions

  • Methods of removal of organs

  • Samples to be collected

• Preservatives used for various samples

2. Preliminary examination of inquest papers

Medicolegal Autopsy is done on the orders of legal authorities like Police, Magistrate, or Coroner. In India, in most cases, a Medicolegal autopsy is ordered by the police, Hence known as Police Inquest. In a few medicolegal cases like dowry death, custodial death under armed forces, etc. are ordered by Magistrate, Hence, it is known as Magistrate Inquest. In the western world, Inquests are done by the coroner also. Hence, it is known as Coroner Inquest.

Inquest means Inquiry or Investigation. The officer who is authorized to do an inquest is known as Investigation Officer. The investigating officer may be a Police official, Magistrate, or Coroner depending upon the case to be investigated according to local laws. A medicolegal autopsy is usually done in sudden, unexplained, or unnatural deaths. In India, the investigating officer requests a Registered Medical officer (RMP) with an application for autopsy along with inquest papers. In India, an investigation is done by Police officials under sections 174 and Magistrate under Section 176 of the Criminal Procedure Code, 1973 to inquire in cases of suicide and suspicious deaths whereas, under Section 174 [3], deaths related to dowry or cruelty by in-laws were investigated [3].

After completion of the investigation report by the Police officer, he/she will have to submit an Inquest report in Form 25.35 [1] A, B, C for natural causes, violence, and poisoning cases respectively. The inquest report should mention the apparent cause of death, description of any mark or marks of violence which may be found on the body, and description of the alleged weapon used. The Inquest report should contain the plan of the scene of death, the inventory of the clothing, etc. A list of the articles on and with the body, a list of the articles sent for medical examination, if any, and a copy of police information (PI) from the Hospital, Hospital record along with a death summary [4].

3. Gross/external examination of the body

Before starting the postmortem examination, the registered medical practitioner (Medical officer) note down the preliminary data related to the deceased in the computerized format like name, father name, age sex, the residence, report number, date, name of investigating officer with belt number and police station, names, and signatures of two relatives who identify the body of deceased on autopsy table before starting of postmortem examination.

Gross examination of the deceased is one of the important steps in doing an autopsy. In medicolegal cases, like a road traffic accident, homicide, suicide, burns, vitriolage, firearm, etc., gross examination gives valuable information to augment internal examination. During the gross or external examination, we record the following parameters from the body of the deceased.

1. Height

2. Weight

3. Clothes

4. Skin (injuries, tattoos, moles, and any disease)

5. Eyes (Injuries, Tardieu spots, Hemorrhages)

6. Mouth (externally) including lips

7. Nose (injury, deformity, blood, etc.)

8. Face, Ears, and neck (injuries, nail marks, ligature, injection marks)

9. Palpate Chest, abdomen and testis

10. Back of the body and lower and upper limbs (injuries, nail marks, ligature, injection marks)

After noting down the above parameters, photography should be done before removing or handling the body. Clothes are removed from the body with most precaution. All the clothes should be preserved and photographed separately. It should be ensured that any cuts, and tears on clothes are not distorted while removing the clothes from the body. In case of homicide and cases where the investigating officer requested for sealing of the clothes, it should be labeled with the postmortem number, signed along with the date, and sealed in a packet with seals as specified, with a proper label, signature, and stamped for finally handing over to the investigating officer. Any trace evidence recovered during removal of clothes from the body like nails parts, firearm projectile lying loose should be preserved separately in a packet, labeled, sealed, signed and stamped, and handed over to investigating officer after completion of autopsy after taking receipt to maintain the chain of custody of the evidence.

4. Internal examination of the body

After doing a gross or external examination and removal of clothes from the body of the deceased, Again examination of the deceased body is to be done to look for any injuries, biological material like semen, saliva, and any foreign body. With Gross examination, we had already made a preliminary road map to proceed further. There are three cavities in the body, Abdominal or peritoneal cavity, Thoracic cavity, and cranial cavity. Depending upon the nature of the case, we open the cavity where we see more injuries. But as a routine, we open the skull first followed by the abdomen and chest. After opening the skull first, all the blood was drained out from the neck. Thus, we got a clear bloodless view of neck tissues. So, the case of asphyxia like hanging and strangulation is well appreciated.

But on gross examination, we found injuries to the abdomen and thorax, then we opened the abdomen and thorax first followed by the cranial cavity.

5. Skin incisions used for opening cavities during autopsy

A cranial incision is the most common incision given on the scalp starting from the mastoid process of one side of the skull going superiorly passing through the vertex of the cranial cavity and ending on the mastoid process of another side. The scalp is reflected up to the frontal eminence on the front and the occipital protuberance on the back of the skull. Then the cranial vault is opened with a skull opening machine by giving a V or Z-shaped incision on the outside of the skull. V and Z-shaped cut in the cranial vault help in a tight fit on stitching the scalp after placing the cranial vault.

There are mainly three conventional skin incisions used in most of the world on the thorax and chest while doing the autopsy. These are as follows:-

5.1 I-shaped incision

This incision is widely used while opening the abdominal and thoracic cavity. I-shaped incision starts from just below the chin and reaches up to the pubic symphysis, curving around the umbilicus laterally. The umbilicus is left as such to maintain the cosmetic effect and technically, it consists of dense fibrous tissue, it is difficult to cut through it and later on difficult to stitch (Figures 1–3).

Figure 1.

Showed I-shaped incision on the front of the body of the deceased in the supine position. The figure showed an incision starting from the suprasternal notch of Manubrium going downwards in midline curving around the umbilicus up to symphysis pubis in the supine position. This incision is extended upwards up to the chin in the midline to complete the I-shaped Incision.

Figure 2.

Showed I-shaped incision on the body of the deceased in the supine position. The figure showed I-shaped incision starting from the suprasternal notch of the manubrium to symphysis pubis along with soft tissue dissection to raise the flaps for further dissection.

Figure 3.

Showed I-shaped incision on the body of the deceased in the supine position. The figure showed I-shaped incision starting from the suprasternal notch of the manubrium to symphysis pubis to raise the flaps of skin on either side of the abdomen and then opening of the abdominal cavity in the midline and below the subcostal margins and then retracting the abdominal muscular flaps to either side for the internal dissection of the abdominal organs.

5.2 Y-shaped incision

This incision is the next common incision given while opening the abdominal and thoracic cavity. The Y-shaped incision starts from just below the mastoid process on both sides as two limbs of Y, descends anterior-inferiorly and meets in the midline at the level of the suprasternal notch and then proceeds downwards up to the pubic symphysis, curving around the umbilicus laterally similar to I-shaped skin incision. This type of incision is used in medicolegal cases of autopsy where layer by layer dissection of the neck is required to demonstrate neck injuries as well as ligature marks e.g. In asphyxia due to neck compression-like Hanging, Strangulation, etc. In the neck region, the large neck veins are present superficially. So, there are chances of artifactual air embolism (Figures 4–6).

Figure 4.

Showed a Y-shaped skin incision on the body of the deceased in the supine position. The Y-shaped incision started from just below the mastoid process on both sides as two limbs of the Y, descends anterior-inferiorly and meets in the midline at the level of the suprasternal notch and then proceeds downwards up to the pubic symphysis, curving around the umbilicus laterally similar to I-shaped skin incision.

Figure 5.

Showed a Y-shaped skin incision on the neck and the chest of the deceased in the supine position. The flap of the skin is retracted superiorly up to the level of the chin and the lower border of the mandible as a V-shaped flap. This will give a clear field for dissection at the neck.

Figure 6.

Showed a Y-shaped incision on the body of the deceased in the supine position. The figure showed Y-shaped incision starting from each mastoid process and merging in the midline at the level of the suprasternal notch of the manubrium further proceeded to symphysis pubis curving the umbilicus along with the soft tissue dissection to raise the flaps on the front of the chest, abdomen and neck area for further dissection.

5.3 Modified Y-shaped incision

This incision is the third most common incision given while opening the abdominal and thoracic cavity. It is usually given in females and VIP cases, where the body is to be kept for the last homage to the public to avoid disfigurement and public outrage. Modified Y-shaped incision starts from the acromion on both sides of the shoulder, then descends downwards curving the outer shoulder joint anteriorly, reaching to the anterior axillary folds and curving below both breasts and meets in the midline at the xiphisternum level and then proceeds downwards up to the pubic symphysis, curving around the umbilicus laterally (Figures 7–10).

Figure 7.

Showed a Modified Y-shaped skin incision on the body of the female deceased. Modified Y-shaped incision starts from the acromion, then descends curving around the outer side of the shoulder, then reaching anterior axillary folds and curving below both breasts and meets in the midline at the xiphisternum level and then proceeds downwards up to the pubic symphysis, curving around the umbilicus laterally.

Figure 8.

Showed a Modified Y-shaped skin incision with underlying soft tissue dissection on the body of the female deceased. Modified Y-shaped incision along with underlying soft tissue dissection is done to raise the abdominal flaps and mammary flaps.

Figure 9.

Showed a Modified Y-shaped incision with underlying soft tissue and abdominal wall dissection on the body of the female deceased. Modified Y-shaped incision with underlying soft tissue dissection is done to raise the abdominal flaps and mammary flaps. The abdominal wall is opened in the midline and below the sub-costal cartilage to raise the abdominal wall flaps on each side of the abdomen to open the abdominal cavity.

Figure 10.

Showed stitched modified Y-shaped incisions on the body of the female deceased. The Modified Y-shaped incision is stitched to retain the anatomical appearance of the body of the deceased. The neck and face are cosmetically preserved due to dissection of underlying tissue after raising the flaps.

There are few more incisions, other than these three conventional incisions which are used by different autopsy surgeons as per convenience.

5.4 Fourth incision

All the conventional incisions as described above are on the front of the neck, chest, and abdomen, Hence, it was difficult to tell about injuries on the back of the neck, chest, and abdomen. In India, It is also routine practice to replace all the dissected organs in the abdominal cavity and thoracic cavity in one single incision as mentioned above. So, there are chances of seepage of the blood from this single incision. So, to overcome this problem, another incision named the fourth incision as per the author [5] was advised. The incision is also cosmetically better appealing to immediate legal heirs before the last rituals. For the anterior approach, the body is kept in a supine position with a block under the shoulder to extend the neck. The incision is started from one side of the mastoid process to the other side passing through the vertex in the coronal plane. The scalp is reflected up to occipital protuberance in the back and frontal eminence in front, thus exposing the skull bone for further dissection. The incisions on both sides of the mastoid process are extended downwards up to the acromion process and pass in front of the chest outside the shoulder joint to the midaxillary line below the axilla and then further extended to the anterior superior iliac spine, then turning to the middle along with inguinal ligaments to meet each other in midline. Now, the flap is raised by superficial dissection up to the root of the neck furthering up to the lower border of the mandible. Then, the abdominal cavity is opened by giving a midline incision. The dissection is further preceded, as usual, then again, the body is stitched in the midline and then skin incision is stitched starting from the inguinal region on both sides and then sideways. To do dissection on the posterior side of the body, it is kept in a prone position with a block under the chest to raise it and flex the neck. Now again, the incision is extended from the right acromion posteriorly, curving the outer side of the shoulder on both sides reaching up to the midaxillary line, and further extended to the anterior superior iliac spine on both sides. Now the scalp flap raised to occipital protuberance is further extended through the neck, back of the chest, and lower back and raised inferiorly. Now, the underlying dissection was done. The stitching on the back is done after replacing the flap superiorly with an anteriorly replaced scalp flap. Afterward, later sidewall stitching is done.

Few authors also advised fifth or another incision [6] to reduce the time taken for suturing and disfigurement of the body of the deceased. The body is kept in a supine position with a block under the back of the chest to extend the neck. This incision starts from the right mastoid process and goes towards the left mastoid process in the coronal plane on the scalp. From the right mastoid process, the incision moves on the front of the neck to reach the left incision on the left mastoid process just two fingerbreadths inferior to the lower border of the chin. The incision from the right mastoid process goes down on the lateral side of the neck up to the right acromion process. Then from the right acromion process, the incision is curved in front of the medial end of the right shoulder to reach the level of the mid-axillary line of the fourth rib, from here it goes down up to the right anterior superior iliac spine, then move towards the left side on the front of the abdomen near inguinal ligament and reaches up to the left anterior superior iliac spine. Now, dissection of the underlying tissues is done horizontally to raise the flap of skin on the front of the chest and abdomen. Now, to open the abdominal cavity, a muscular incision is started just above the right anterior superior iliac spine which extends towards the left anterior superior iliac spine along the inguinal canals, then extends superiorly up to the level of tenth rib costal cartilage and then again extends towards right side till right costal margin near the midaxillary line. After this incision, the flap of the muscular abdominal wall is raised towards the right side. After doing dissection, the flap is replaced without stitching and then the body is stitched starting from the skin incision near the left anterior superior iliac spine to the right mastoid process. If dissection is required on the back of the body, then the body is kept in a prone position with a block below the chest to flex the neck. Starting from the incision made in an anterior approach, the incision is extended posteriorly on the outer side of the right shoulder from the right acromion process up to the right mid-axillary line meeting the incision already given in the anterior approach. From the anterior superior iliac spine, the incision has to be extended along the upper convex borders of the buttocks from the right to the left anterosuperior spine. Now dissection is done tangentially and the flap on the backside of the chest and lower back is raised on the left side separating the underlying muscles and body attachments after dissection of the back, the skin is sutured from the left anterosuperior spine to the right acromion process. The length of this incision is less than the fourth incision as discussed above, but more than the conventional I, Y, and Modified Y-shaped incisions, and thus suturing can be done early as compared to the fourth incision. However, similar to the fourth Incision, it is cosmetically appealing and avoids seepage of contents as occurred in the conventional skin incisions.

6. Methods of removal of organs during autopsy

There are four conventional methods known to remove organs from the body of the deceased during autopsy [7].

6.1 Rokitansky’s technique or method of removal of organs

As the name suggests, this technique was devised by a German pathologist named Carl Rakitansky (1804–78). In this technique, Autopsy dissection is done in situ. Advantages: Easy to do in infected bodies as well in children. Disadvantage: This technique is difficult to perform in adults.

6.2 Virchow’s technique or method of removal of organs

As the name suggests, this technique was performed by a German pathologist named Rudolph Virchow (1821–1902). In this technique, organs are removed one by one and studied as separate entities. Advantages: Easy to study each organ. Disadvantage: The relationship between organs is lost. Thus valuable information may be lost.

6.3 Letulle’s technique or method of removal of organs

As the name suggests, this technique was performed by a French pathologist named Maurice Letulle (1853–1929). In this technique, organs are removed together in one mass from tongue to prostate.

Advantages: In this technique, interpersonal relationships are well maintained. Relationships to vessels, lymphatic and nerves are well preserved.

Disadvantage: This is a cumbersome technique and all organs are difficult to manage.

6.4 Ghon’s technique or method of removal of organs

As the name suggests, this technique was performed by an Austrian pathologist named Anton Ghon (1866–1936). In this technique, organs are removed in 3 separate blocks. This technique accommodates both Virchow’s and Letulles’s techniques in one setting. This technique is also known as the Enbloc Method.

Advantages: Since organs are removed in 3 blocs. So, the interrelationship between organs in each block is well maintained. Handling of organs is easy as compared to Letulle’s technique where organs are removed en masse.

Disadvantages: Interrelationships are difficult to study if the disease extends across the blocs.

7. Viscera/samples to be collected with preservatives used for medicolegal cases

In Medicolegal cases, various samples are collected depending on the case to case [8].

7.1 Stomach

The entire stomach is tied on above and below the stomach opening and contents are poured into a Jar (preferably a glass jar with a tight lid) by giving an incision at the greater curvature. The stomach wall is inverted and mucosa is examined for congestion, ulceration, and sticky material. The contents of the stomach are also examined for consistency, odor, and color. The stomach and entire contents of the stomach are preserved for detection of poisons in a saturated solution of common salt in suspected common poisons. Rectified spirit is used as a preservative in acid poisoning except for carbolic acid.

7.2 Small intestine and large intestine

Part of the small intestine and large intestine are preserved similar to the stomach as mentioned above in a Jar (preferably a glass jar with a tight lid) for detection of poisons.

7.3 Spleen, kidneys, and liver

Part of the spleen, half of each kidney in the coronal plane, and part of the liver from each lobe or suspected area are also preserved similar to the stomach as mentioned above in a Jar (preferably a glass jar with a tight lid) for detection of poisons. For Microbiological examination, Blood swabs are taken from the spleen. The spleen is kept straight on the autopsy table. The wide base hot sterilized knife is taken and then touched to the spleen twice. This will sterilize the spleen on the outside. Now, the cross incision is given on the sterilized surface of the spleen. The blood swabs are taken from the cuts on the spleen and sent for microbiological examination.

7.4 Gallbladder

The entire gallbladder is preserved and sent for chemical examination along with part of the livers as mentioned above. This is used for the poisons which are excreted through the Biliary System. The Bile can be excreted by giving a cut to the gallbladder wall and collecting bile in the container inserting a needle of the syringe and aspirating bile or collecting bile by squeezing the gallbladder through the cystic duct.

7.5 Blood

After removal of viscera, 10–20 ml of blood should be collected. The femoral vein is the most preferred site for the collection of blood, followed by the iliac vein and Subclavian vein. Never take bloody fluid directly from the heart or scoop it out of thoracic or abdominal cavities. No preservative should be used, when we are sending blood for the detection of common poisons. For Microbiological examination, a Blood culture vial is used to preserve the blood. For Dengue serology and other serological tests, Blood should be preserved in Red Vacutainer. For Alcohol estimation, Blood should be preserved in Sodium fluoride and potassium oxalate solution; else we can also use Phenyl mercuric chloride or Sodium Azide. For blood grouping or DNA/RNA analysis, drops of blood are preserved in an FTA Card [9].

7.6 Anal swabs

These are taken when anal intercourse is suspected. Two sterilized swabs in glass test tubes labeled A and B are taken. A – Swab is taken from deep inside the anal canal. B-Swab is taken from outside the anal canal or as such as control. After taking the swabs, the respective slides are made swabs are kept in respective test tubes and all are kept aside and air-dried, labeled before packaging and sealing for onward transmission.

7.7 Vaginal swabs

These are taken when sexual intercourse is suspected. Two sterilized swabs in glass test tubes labeled A and B are taken. A – Swab is taken from deep inside the vagina preferably posterior fornix. B-Slide is taken from outside the vagina or as such as control. After taking the swabs, the respective slides are made, swabs are kept in respective test tubes and all are kept aside and air-dried, labeled before packaging and sealing for onward transmission.

Both anal and vaginal swabs are preserved for the detection of spermatozoa.

7.8 Saliva/bite marks

In medicolegal cases, if we come across bite marks then we suspect dried saliva. A cotton swab moistened with saline solution is taken and rotated on the bite mark then the swab is kept aside for drying and then kept back in a glass test tube. Saliva is useful in the detection of Blood group (if secretors) and DNA analysis from mucosal cells in saliva.

7.9 Urine

It is usually preserved when we suspect that poison is excreted through urine. The preservative used for Urine is Thymol or Sodium benzoate solution.

7.10 DNA analysis

Long bones are preserved free from skin and muscle tissue preferably in dry ice for DNA Analysis.

7.11 Diatom test

The sternum is preserved to detect diatoms in the bone marrow in suspected cases of drowning.

7.12 Feces

For detection of protozoal and helminthic infestation, 5 to 10 g of feces is collected. In Autopsy cases, it is rarely collected these days.

7.13 CSF

CSF is collected by using a needle and syringe from cisterna magna.

7.14 Vitreous humor

Vitreous Humor is withdrawn from each eye 1 to 5 ml in quantity. It is used to determine the time since death from the potassium etc. level in the vitreous humor [10] and aqueous humor.

For Histopathological examination, the Suspected pathological part of the Lungs, Brain, Kidney, Spleen, Liver, and Skin tissue is collected and sent. These should be preserved in a 10% Formalin solution. The Pieces should be small. Thus formalin can penetrate the tissues quickly and to more areas. Thus the problem of autolysis due to unpreserved tissue is restricted.

8. Conclusions

It is always said that Justice delayed is justice denied. Medico-Legal Autopsy is a process to help law enforcing agencies to understand the cause of death etc., to give justice to the deceased as well as their near and dear ones. So, we should continuously update our knowledge and concepts to help our law enforcement agencies to deliver justice in time.

Acknowledgments

We want to thank open source Intech Publishers and the editor of the book, “Autopsy - What Do We Learn from Corpses?” Who invited us to write a chapter in this book by granting a waiver? We also want to thank all the authors whose articles and literature were referenced to make our knowledge and understanding rich. We are also thankful to the entire staff, especially postgraduate students of the Department of Forensic Medicine, BPS Government Medical College for Women, Gohana, Haryana, India for helping and encouraging us in completing this project in time. This concept of open-source publication is very encouraging. This is our effort to reproduce the work of all the referenced authors and editors in our language for a better understanding of our readers. Thanks.

Conflict of interest

No conflict of interest is present with anybody.