External autopsy procedure Examination
The external autopsy procedure examination will provide most of the substance of the report, where death occurred due to trauma. It is important in interpretation, e.g. in a case of a pedestrian involved in traffic accident, in which the vehicle involved has not been identified or where due to lack of witnesses, the circumstances of the accident are obscure. Both the issues might be clarified by a good description of the surface injuries.
The following autopsy procedure should be noted:
(1) The clothing should be listed and examined, and described with regard to type of garment, its color and consistence, tears, loss of buttons or disarrangement indicating a struggle, as each item is removed from the body. The clothes should be removed carefully without tearing them to avoid confusion of signs of struggle. If they cannot be removed intact, they should be cut in an area away from any bullet hole or objects, along a seam in the garment.
Clothing removed from the victim should not be thrown on the ground or floor or otherwise discarded or destroyed. They should be handled as little as possible and without any deliberates shaking or dusting. Cuts, holes or blackening from firearm discharges should be noted and compared with the injuries on the body. Blood stains, seminal stains, grease stain, etc, should be described.
Stains due to poison, vomit, etc. should be kept for analysis. Wet clothing should be hung up to dry, but should not be heat dried. Stained and unstained areas of clothes should not be allowed to come in contact to avoid additional soiling, and as such clothes should not be folded while stains are wet.
The clothes should be placed into clean plastic bags or other suitable clean containers. This is an important autopsy procedure. Separate bags or containers should be used for each article. List the ornaments. Describe the type, design and color of each (yellow or white metal; white, red or green stones, etc.).
(2) Nail scraping should be taken. Any visible fibers or other matter in the hand or adherent to it should be removed and placed in envelopes. Ten small envelopes are labelled, one for each finger. A matchstick is cut, or the apex of a twice-folded filter paper is run under the nail. The finger is held over the envelope marked with its number as the material is removed, and then the scraper is dropped into the envelope, which is sealed. Contamination of the specimen with the epithelium or blood of the deceased should be avoided.
(3) Height and weight of the body, and general state, body build, (fat, strong, medium, thin), development and nourishment. If a weighing machine is not available, approximate estimate of the weight of an adult body can be made by measuring the stature and girth of chest and waist while doing the autopsy procedure.
(4) General condition of the skin (rash, petechiae, color, looseness, turgor), asymmetry of any part of the body or muscular wasting.
(5) General description: This includes sex, age, color, race, build, stature, deformities, nutrition, hair, scars, tattoo marks, moles, pupils, skin disease, circumcision, amputations, deformities, etc.
(6) Vaginal and anal swabs are taken and also swabs from areas of suspected seminal staining in all cases of sexual assault. Pubic hair should be combed through. Matted pubic hair should be cut out with scissors and samples of pubic hair taken.
(7) Note the presence of stains on the skin from blood, mud, vomit, faeces, corrosive or other poisons, or gunpowder. They should be described precisely and in detail.
(8) The presence of signs of disease, e.g., oedema of legs, dropsy, surgical emphysema about the chest, skin disease, eruptions, etc., is to be noted.
(9) The time since death should be noted from rectal temperature, rigor mortis, postmortem hypostasis, putrefaction, etc.
(10) The head hair should be examined in autopsy procedure. Any foreign matter should be removed with forceps, and the hair combed through for trace evidence. Samples of both cut and pulled hair from at least six different areas of the scalp should be taken and labelled as to their origin.
(11) The face should be examined for frothy fluid at the mouth and nose, cyanosis, petechial haernorrhages, pallor, etc.
(12) The eyes should be examined for the condition of the eyelids, conjunctivae, softening of the eyeball, color of sclerae, opacity of the cornea and lens, state and color of pupils, artificial eyes, contact lenses, petechiae, and periorbital tissues for extravasation of blood.
(13) The ears should be examined for leakage of blood, or CSF.
(14) The neck must be examined for bruises, fingernail abrasions, ligature marks or other abnormalities. Observe degree of distention of neck vessels.
(15) Thyroid: size, nodularity.
(16) Lymph nodes: cervical, axillary, inguinal.
(17) Thorax: symmetry, general outline.
(18) Breasts: size, masses.
(19) Abdomen: presence or absence of distension or retraction, striae gravidarum.
(20) Back : bedsores, spinal deformity.
(21) External genitalia: general development, edema, local infection, position of testes.
(22) The natural orifices, i.e., mouth; nostrils, ears, vagina, etc. should be examined for injuries, foreign matter, blood, etc in autopsy procedure. If the mouth cannot be opened, the niasseter and temporalis muscles are divided above their insertion into the mandible, to allow the jaw to become mobile. The state of the lips, gums and teeth, marks of corrosion, and injuries to inside of the lips and cheeks should be noted. The state of the tongue, position with relation to the teeth, and the presence or absence of bruising or bite marks should be noted. The presence of froth about the mouth and nostrils and smell of alcohol, phenol, etc., should be noted.
(23) Note the position of all the limbs and particularly of the arms, hands and fingers. The hands should be examined for injuries, defense wounds, electric marks, etc., and if clenched to find out if anything is grasped in them. To open the hand completely, the flexor tendons of the fingers are cut at the wrist. The fingernails must also be carefully examined for the presence of any blood, dust or other foreign matter, indicative of struggle. Note for edema, needle marks, ulcers, gangrene, tumors, digital clubbing, etc in autopsy procedure.
(24) External wounds should be systematically examined taking up each part of the body in turn. The description of wounds should include nature, site, length, breadth, depth, direction, position, margins, base and extremities. The condition of their edges, presence of foreign matter, coagulated blood and evidence of bleeding into nearby tissues noted. Determine whether they were caused before or after death, and their time of infliction.
While doing autopsy procedure Collect foreign materials, e.g., hair, grass, fibers, etc., that may be in the wound. If the injuries are obscured by hair, as on the scalp, the area should be shaved. Deep or penetrating wounds should not be probed until the body is opened. In burns, their character, position, extent and degree should be mentioned. The use of printed body sketches is very useful. Each injury can be drawn in, and measurement noted alongside each and distances from anatomical landmarks recorded. Photographs are useful.
There is no substitute for a good color photograph to preserve the appearance of a wound or injury. If the blood spots or smears on the skin are important, the area should be photographed before and after the skin is cleaned. Excluding stab and firearm wounds, all the injuries should be divided into two broad areas: external and internal. The position of the injuries should be filled in on the skeleton diagrams provided for the purpose.
(25) The limbs and other parts should be examined for fractures and dislocations by suitable movements and by palpation and confirmed by dissection.
(26) While doing autopsy procedure, A list should be made of all articles removed from the body, e.g., clothes, jewelry, bullets, etc. They should be labeled, mentioned in the report and handed over to the police constable in a sealed cover after obtaining receipt.
(27) The report should include all of the surgical procedures, applied dressings and other diagnostic and therapeutic measures found on external examination.
In case of discrepancy between the injuries noted in the inquest report and the findings of the doctor during postmortem examination, the doctor should bring these facts to the notice of the officer who has conducted inquest so that necessary corrections may be done in the inquest report.
Internal Autopsy procedure EXAMINATION
It is convenient to start the examination with the cavity chiefly affected. In a case of suspected cranial injury, the skull should not be opened until the blood has been drained out by opening the heart.
In autopsy procedure, Primary incisions are of three types.
(1) The ‘I-shaped incision, extending from the chin straight down to the symphysis pubis, passing either to the left or right of the umbilicus. The umbilicus is avoided because the dense fibrous tissue is difficult to penetrate with a needle, when the body is stitched after autopsy.
(2) “Y”-shaped incision begins at a point close to the acromial process. It extends down below the breast and across to the xiphoid process. A similar incision is then made on the opposite side of the body. From the xiphoid process, the incision is carried downwards to the symphysis pubis.
(3) Modified ‘Y”-shaped incision: An incision is made in mid line from suprasternal notch to symphysis pubis. The incision extends from suprasternal notch over the clavicle to its centre on both siies awl tkien passes upwards over the neck behind the ear.
The incision must be adapted to the special condition of the case, e.g., in stab wounds of the chest or abdomen, the usual incision may have to be altered to avoid such wounds.
ABDOMEN autopsy procedure
The pathologist should stand on the right side of the body, if he is right-handed. The recti muscles of the abdomen are divided about 5 cm. above symphysis. A small cut is made in the fascia big enough to admit the left index and middle fingers, palmar surfaces up. The fingers are used to protect the underlying structures, arid the peritoneum is cut up to the xiphoid. The thickness of the fat in the abdominal wall is noted.
In fatty people, a ‘few transverse incisions can be made on the inner side of the abdominal wall to divide muscle and fat, which allows lateral flaps to gape widely, and a full view of the abdomen can be had. The condition of the abdominal cavity arid organs is observed before anything is disturbed or altered, to find out if’ there is any blood, pus or fluid in the cavity, or perforation or damage to any organ.
If blood, pus or any other fluid is present, its quantity is measured. If this precaution is not taken, the examiner will be frequently in doubt, as to whether any blood or damage to organs found at a later stage is a result of the opening of the body, or whether it was already present.
Note the amount of fat in the mesentery and omentum. Note abnormalities and position of abdominal organs, adhesions, old operations, pathological processes, injuries and height of diaphragm in relation to the ribs. The peritoneum is examined for adhesions, congestion, inflammation or exudation.
NECK autopsy procedure
A block 12 to 20 cm. high should be placed under the shoulders, to allow the head to fall back and thus extend the neck. The skin is held with a toothed forceps and with a sharp, long-handled scalpel; the dissection is carried out immediately deep to the skin through the platysma. The subcutaneous dissection should be carried up to the lower border of the lower jaw, well laterally on the side of the neck and clavicle.
The deep cervical fascia is incised and reflected from the cervical muscles and the submandibular gland. The sternomastoid muscle is freed from its clavicular and sternal attachments, separated from its underlying fascia and reflected on each side. The omohyoid, sternothyroid, and thyrohyoid muscles are exposed, inspected and reflected on each side.
The thyroid gland and the carotid sheaths are freed by blunt dissection from their investing connective tissue. The larynx, trachea, pharynx and esophagus are mobilized and pulled away from the prevertebral tissue by blunt dissection.
MOUTH autopsy procedure
The mouth is opened, and the tip of the tongue pushed upwards and backwards with a forceps. The knife is inserted under the chin through the floor of the mouth. Cut along the sides of the inaudible to the angle of the mandible, dividing the neck muscles attached to the lower jaw. At the angles of the mandible, turn the blade inward to avoid cutting the carotid artery.
The tongue is pushed down under the mandibular arch with the index and middle fingers. The soft palate is then cut to include the uvula and tonsils with tongue and neck organs to be removed. The knife is carried backwards and laterally on both sides of the mid-line to divide the posterior pharyngeal wall.
The middle finger of the left hand is passed into the larynx and with the scalpel, the pharyngeal tissues are dissected from behind forwards and laterally, and the pharynx is pulled down to the upper part of the neck. The dissection is then carried distally through the prevertebral muscles on the anterior surface of the cervical vertebrae, until the whole of the neck structures are free to the level of suprasternal notch. The great vessels including the carotids should be divided in the neck.
CHEST autopsy procedure
The muscles of the chest are dissected away, keeping the edge of the knife directed inwards towards the ribs, earned back to the midaxillary line, down to the costal margin and up over the clavicles.
Cases of pneumothorax are demonstrated before the chest wall is opened.
(1) A pocket is dissected on the affected side between the chest wall and the skin, and is filled with water, and the wall is punctured with the knife under the water. The scalpel should be twisted a few times to make sure that the wound is open. If air under pressure is present, it will bubble out of the opening through the water.
(2) A wide-bore needle (16- gauge) attached to a 50 ml syringe without the plunger is introduced into s.c. tissue over an intercostal space and the syringe is then filled with water. The needle is pushed to enter the pleural cavity. If air is present it will bubble out through the water.
(3) Chest x-ray.
The ribs, sternum and spine should be examined for fractures, and the chest is opened by cutting the coastal cartilages with a cartilage knife. Begin at the upper border of the second cartilage, keeping very close to the costochondral junctions. The knife should be inclined about 300 to the vertical. In old persons where the rib cartilages are calcified, a pair of rib shears or handsaw is used.
Then, disarticulate the sternoclavicular joint on each side by holding the knife vertically and inserting the point into the semicircular joint. The position of this joint can be made out by moving the shoulder tip with the left hand, which causes the joint capsule to move. To divide the joint capsule, the knife is put in vertically and turned in a circular manner. The diaphragm is divided at its attachment to the lower ribs and sternum up to the spine.
The pleural cavity should be examined before complete removal of the sternum, to prevent leakage of blood from subclavian and jugular veins into the pleural cavity before inspection. Before removal of the thoracic organs, in situ inspection should include:
- Observation of the lumen of the main pulmonary vessels,
- Observation of the right atrium and ventricle for air embolism,
- The state of distension or collapse of the lungs,
- Pleural cavities for the presence of fluid, blood or pus and pleural adhesions,
- Pericardium for cardiac tamponade and
- Collection of blood sample from the heart for toxicological examination.
The pericardial sac normally contains 20 to 50 ml. of straw-coloured fluid and the pericardium is smooth and glistening. White spots (milk spots) on the surface of the heart indicate healed pericarditis.
In acute pericarditis, the sac contains large collections of serous or purulent fluid and fibrin deposits (bread- and-butter pericardium). Hemorrhagic fluid in the sac is seen in malignancy and rarely in tuberculosis, uraemia, bleeding diseases and secondary to myocardial infarction.
This is the general Autopsy procedure followed.