Medico-legal Autopsy

Introduction: -

John George Haigh took Mrs. Olive Durand Deacon, a rich widow to Crawlye in his car, on 18-2- 1949. There, he took her into a store shed, shot her through the back of the head, removed her Persian lamb coat & jewellery & put her fully clothed in a steel tank & filled with strong sulphuric acid. After 3 days, he removed some fat & bones floating in sludge in the tank, & then pumped some more acid into the tank. On the next day, he poured off the contents of the tank on the ground opposite the door. Several fragments of tissues, bones, intact upper & lower acrylic dentures & gallstones, were found in the acid sludge. A London dentist recognized the dentures as made for Mrs. Durand Deacon. Bloodstained lamb coat & jewellery were also identified. Haigh was arrested, charged with murder & convicted.

Two women, Mrs. Isabella Ruxton, wife of Dr. Ruxton, aged 35 years & Mary Rogerson, their maid, aged 20 years, disappeared from the house of Dr. Ruxton in Lancaster on 15-9-1935. A quantity of human remains (70 portions) was found in a ravine near Moffat, about 107 miles from Lancaster. The remains consisted chiefly of two heads, thorax, pelvis, segments of upper & lower limbs, three breasts, portions of female external genitals, & the uterus & its appendages. The disarticulation had been carried out without damage suggesting the anatomical knowledge of the persons. Both bodies had been mutilated to remove all evidence of identity & sex. All the remains were assembled & found to represent two female bodies, aged about 35 to 45 years & 18 to 22 years, respectively. Casts of the left feet of the two women fitted perfectly shoes belonging to Mrs. Ruxton & her maid. Superimposition of photographs of the skull on life-size photographs of the heads of two women was found to tally in every respect. The fingernails of the younger were scratched & her fingerprints tallied with prints found on many articles in the house of Dr. Ruxton. The newspapers & certain garments found with the bodies were useful in identification. The parts assigned to Mrs. Ruxton showed signs of asphyxia & fracture of the hyoid bone, suggesting strangulation. In the body assigned to Mary Rogerson, there was a fracture on the top of skull. A number of human blood stains were found in the bathroom & on the stair carpets & pads, in the house of the accused. Fragments of human tissue were found in the drain traps & a suit of clothes of the accused was contaminated with blood. Dr. Ruxton was found guilty of murder & sentenced to death.

Autopsy/Necropsy:

Autopsy means complete, thorough, systemic & scientific examination of a dead body, carried out under the law of the state to determine the cause of sudden, suspicious, unexpected & medically unattended death or pathological conditions.

Or,

Autopsy refers to the systematic examination of a dead person for medical, legal &/or scientific purposes.

Fig.: Autopsy instruments

▶ Types of autopsy:

Medico-legal/ Forensic
Clinical/Pathological/ diagnostic/ hospital
Academic/anatomical

1) Medico-legal autopsy: When autopsy is compulsory by law & done in unnatural & suspicious circumstances of death, to find out the cause of death, then it is called medico-legal autopsy.

Or,

Legal in Bangladesh.
It is the systemic & scientific dissection & elaborate examination of the dead body both externally & internally to find out the cause of death, manner of death, time elapsed since death, and sometimes for identification in case of sudden, suspicious, unexpected & medically unattended, or pathological death.

2) Clinical autopsy: When the autopsy is performed by a pathologist or a clinician to diagnose the cause of death, where diagnosis could not be reached during treatment, or to confirm diagnosis where it was doubtful, then it is called clinical autopsy.

3) Academic autopsy: When dead bodies are dissected by the students of anatomy for academic purposes, to know details about the different external & internal organs & structures of human body, it is called academic autopsy.

▶Aims/objectives of medico-legal autopsy:

To find out the cause of death whether natural or unnatural.
To find out how the injuries occurred.
To find out the manner of death, whether accidental, suicidal or homicidal.
To find out the time since death.
To establish identity when not known.
To collect physical evidence in order to identify the object causing death & to identify the criminal.
To retain relevant organs & tissues as evidence.
In newborn infants to determine the question of live birth & viability.

▶Rules of medico-legal autopsy:

The body should be labeled as soon as possible as it arrives in the mortuary.
The autopsy should be conducted in a mortuary & not in a private room.
It should be conducted only when there is an official order authorizing the autopsy, from the police or magistrate.
It should be performed as soon as possible after receiving requisition, without undue delay.
The medical officer should first read the inquest report carefully & find out the apparent cause of death & obtain all the available details of the case from case sheet, accident register, etc., so how that attention may be directed to the significant points, while doing the P.M. examination.
The examination should be conducted in day light as far possible, because color changes, such as jaundice, changes in bruises, changes in P.M. staining, etc. cannot be appreciated in the artificial light.
The body must be identified by the police constable who accompanies it.
No unauthorized person should be present at the autopsy.
As the autopsy is conducted, details of examination should be noted verbatim by an assistant, & sketches made of all the important injuries.
Nothing should be erased & all alternations should be initialed in the report.
Even if the body is decomposed, autopsy should be performed as certain important lesions may still be found.
Both positive & negative findings should be recorded.
After completion of autopsy, the body is handed over to the police constable. 14) P.M. report should not be issued to the party.

▶Pre-requisites of medico-legal autopsy:

Requisition from the authorized person (Chalan)- 2 copies.
2 copies of inquest report.
In case of hospital death- Death certificate.
Command certificate (CC) from police.
Identification of the dead body before medical officer by the police officer.
Autopsy should be conducted in day light. (sunlight) 8AM - 5PM in summer. 8AM-4PM in winter
It should be performed in authorized mortuary having-

Well ventilation.
Drainage system.
Instruments.

▶Picture of an ideal mortuary:

An ideal mortuary should have the following facilities-

Good ventilation.
Sufficient water supply.
Sufficient instruments.
Modern dissection table,
Disinfectants.
Sufficient cooling facilities.

▶Authorized persons to perform medico-legal autopsy:

Professors & lecturers of forensic medicine department of Govt. medical colleges.
Civil surgeons in District hospitals.
RMO (Residential Medical Officer) under the supervision of civil surgeons.

📙Conditions in which a medical officer can refuse to hold autopsy:

1) Absence of pre-requisite & relevant papers-

Inquest report.
Chalan
Relevant papers, e.g., Medical/death certificates in case of hospital death.

2) Incomplete inquest-

Omission of name & code number of the police constable who will identify the dead body.
Absence of signature of the I.O. (investing officer) & the witness.

3) Absence of police constable who is supposed to identify the dead body.

4) Death from infectious diseases, e.g., AIDS, hepatitis B virus, tuberculosis, tetanus, etc.

Negative & obscure autopsy

✶Negative autopsy: When gross & microscopic examination, toxicological analyses & laboratory investigations fail to reveal a cause of death, the autopsy is considered to be negative as negative autopsy.

✶ Incidence: 2-5% of all autopsies are negative.

✶ Causes of negative autopsy:

1) Inadequate history: Deaths from-

⏩Vagal inhibition.
⏩Status epilepticus.
⏩Hypersensitivity reaction.
⏩Laryngeal spasm in drowning, etc.

2) Inadequate external examination, e.g., fresh & old needle marks, snake bites.

3) Inadequate or improper internal examination, e.g., Air embolism & pneumothorax.

4) Insufficient laboratory examinations.

5) Lack of toxicological analysis.

6) Lack of training of the doctor.

Obscure autopsy:

Obscure autopsies are those which do not show a definite cause for death, in which there are minimal, indefinite or obscure findings, or even no positive findings at all.

They are a source of confusion to any pathologist.

⏩ Causes of obscure autopsy:

1) Natural diseases, e.g., Epilepsy, paroxysmal fibrillation, death precipitated by emotion, work stress, etc.

2) Biochemical disturbances, e.g., Uremia, diabetes, potassium deficiency, etc.

3) Endocrine disturbances, e.g., Adrenal insufficiency, thyrotoxicosis, etc.

4) Concealed trauma, e.g., Concussion, blunt injury to the heart, etc.

5) Poisoning, e.g., delayed sub toxic or narcotic poisoning, plant poisoning, etc.

6) Miscellaneous, e.g., allergy, drug idiosyncrasy, etc.

Incisions & procedure of autopsy

⏩ Incisions given during autopsy:

A) To open the cranial cavity:

A transverse incision across the vertex is made from one mastoid process to another mastoid process.
After reflecting the scalp, anteriorly up to the orbits & posteriorly up to the external occipital protuberance, a circular cut is made to remove the skull cap.

B) Skin incisions:

"I"-shaped incision: A straight incision extending down from the chin to the pubic symphysis, passing either to the right or to the left of the umbilicus (Commonly used).
"Y"-shaped incision: To similar incision, from the point close to the acromial process of each clavicle, extend down below the breast to the xiphoid process where they unit. From xiphoid process, it is carried downwards to the pubic symphysis.
Modified "Y"-shaped incision: An incision is made in midline from suprasternal notch to symphysis pubis. The incision extends from suprasternal notch over the clavicle to its center UDK on both sides & then passes upwards over the neck behind the ear. This incision is also known as Princelayer & Gardon incision.

Figure: Incision for removal of scalp

Figure: -Incisions for opening thoracic & abdominal cavities

⏩ Procedure of medico-legal autopsy:

Preliminary requirements
P.M. examination proper: The description of the body in inquest report should be read out before examination.

⏩ External examination: -

A) Examination of clothes for-

Any burn, hole, blackening, custom rents.
Stains of blood, semen, grease, vomit, or faces.
Stains or mud, tear.

B) In case of hanging- Ligature material should be examined.

C) General examination-

Height, weight.
Age.
Scalp hair.
Hands.
Condition of the eye.
State & distribution of P.M. staining, rigor mortis, cadaveric spasm.
State of decomposition.
Female breast.
Natural orifices, e.g., Nose, mouth, anus, urethra, vagina, etc.
External injury-

Site.
Mud
Shape.
Nature.
Type.

Preservation of viscera

⏩Viscera commonly preserved for chemical analysis:

A) In case of dead (In all cases): -

Stomach, with whole of its contents- Tie at the two 2 ends
Longitudinal half of each kidney.
Right lobe of liver, at least one pound. In case of children, whole of the liver.

⏩Preservatives-

Saturated solution of common salt (NaCl).
Rectified spirit (absolute alcohol)

⏩ Other organs or materials may have to be preserved in some specific cases-

Heart
Spinal cord
Brain
Lungs- Hydrocyanic acid, alcohol& chloroform poisoning.
Scalp hair- Chronic arsenic poisoning.
Uterus- Criminal abortion.

B) In case of living-

Blood- 30 ml (Minimum 10 ml).
Urine- 30 ml.
Vomit.
Stomach wash.
Feeces.

⏩Procedure of preservation & dispatch of viscera:

Ideally 3 plastic pots are used, but we use single pot to preserve the viscera.
The bottles should be clean, wide mouthed, white & fitted with glass stopper.
The quantity of the preservatives should be equal to the viscera in bulk.
Only 2/3rd of the bottle should be filled up with the viscera & preservatives to avoid bursting of the bottle.
The stoppers of bottles should be well-fitted, covered with a piece of cloth, & tied by tape or string & the ends sealed.
The bottles should be labeled with the name of the victim, age, sex, autopsy number, police station, crime number, the organs it contains, the date & place of autopsy, preservative used & signature.
A sample of preservative used should be kept in a separate small bottle for analysis, to exclude the possibility of any contamination.
The sealed bottle is kept into a box, which is locked & the lock is sealed.
A copy of the inquest report, p.m. report & authorization from the Magistrate are sent to the Forensic Science Laboratory along with the viscera.
The viscera box is handed over to the police constable after taking a receipt, who delivers it personally in the office of the chemical examination after obtaining a receipt for the same.

⏩Preservatives commonly used to preserve to viscera:

Saturated solution of common salt (NaCl).
Rectified spirit.
10 mg/ml of sodium or potassium fluoride (prevents glycolysis, inhibits enzyme enolase, inhibits bacterial growth) & 3 mg of potassium oxalate. (anti-coagulant)

⏩Ideal preservative:

Super saturated solution of common salt.

⏩Mutilated body:

Mutilated bodies are those which are extensively disfigured, or in which a limb or a part is lost but the soft tissues, muscles & skin are attached to the bones. Sometimes, only a part of the body, such as head, trunk or a limb may be found.

P.M. examination of mutilated bodies or fragments:

Information obtained from the bones/femur:

Autopsy of AIDS patients

⏩Precautions for doing autopsy in AIDS case:

All infected bodies should be wrapped & tied in double layer tough plastic bag, with a red color tag mentioning "Biologically hazardous". The label should mention the name, age, sex, registration number, etc.
Workers who have exudative lesions or weeping dermatitis or external injury should not handle AIDS victims.
Wearing of heavy autopsy gloves over surgical gloves.
Wearing of cap, face mask, goggles, shoe covers.
Avoidance of accidental pricks & cuts during handling sharp instruments.
Used instruments, e.g., syringe, needles should be placed in puncture resistant container.
Gloves should be worn during handling specimen for laboratory examinations.
Disposal of used instruments: They should be dipped in 2% glutaraldehyde (cidox) for half an hour, washed with soap or detergent & water, dried & then rinsed in methylated spirit & air dried.
Disinfectants- 1:10 dilution of common household bleach or a freshly prepared sodium hypochlorite solution is recommended.
After completing autopsy, hands & face should be washed with soap & water & rinsed in 70% methylated spirit.
In case of accidental injuries, with sharp instruments, the wound should be immediately disinfected & the incident should be reported to the proper authority.