Autopsy

Forensic Medicine & Toxicology, NMC

 01 Defining Autopsy

LEARNING OUTCOMES
02 Major types of autopsy

03 Special forms of Autopsy

04 Protocol of medicolegal Autopsy

05 Instruments used in Autopsy

06 Exhumation

07 Postmortem Artefacts
 01
Defining Autopsy
 Autopsy

Autopsy (Greek autos: self, opis: view)—to see for oneself; also called necropsy (Greek necros:
dead, opis: view) or post-mortem examination (post: after, mortem: death)

Scientific examination of external surfaces and internal contents of

a dead body along with sample collection for medical, scientific and
legal purposes

The words autopsy, necropsy and post-mortem examination are synonymous, although
post-mortem examination can have a broader meaning encompassing any examination
made after death, including a simple external examination.
 02
Major types of autopsy

The first autopsy was done in 1302 AD by Sir William in Italy

 Major types of autopsy
Autopsy, based on the purpose, can be classified into 3 major types

1. Academic autopsy

2. Pathological or clinical autopsy

3. Medico-legal autopsy
 Academic Autopsy

o Performed 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 other governmental authority.

o Consent:
− Unclaimed body : Permission from government authority
− Voluntarily donated body : Permission from legal heirs

o Purpose / Objective:
− To study human anatomy
 Pathological/ Clinical Autopsy

o Performed to arrive at the diagnosis of cause of death where diagnosis

could not be reached during the treatment or to confirm diagnosis where
it was doubtful.
− Here the autopsy may be complete or incomplete (partial) depending upon
the consent obtained for that part of body.

o Consent:
− Permission from relatives

o Purpose / Objective:
− To study course of disease
− To study effects of therapy
− To co-relate clinical diagnosis with autopsy findings
− To understand cause of death
 Medicolegal Autopsy

o Scientific examination of a dead body carried out under the laws of the
State, where the basic purpose is to establish the cause and manner of
death in cases of sudden, suspicious or unnatural deaths
− In medicolegal cases always complete autopsy is performed

o Consent:
− No permission from relatives is required
− Legal permission and authorization is given by the state

o Purpose / Objective:
− To determine cause, manner and mode of death
− To estimate time since death
− To establish identity of deceased when not known
− To collect evidence and document injuries
− To retain relevant organs/viscera and tissues as evidence
 03
Special forms of autopsy

I will always bear in mind that I am a truth seeker, not a case maker and
that it is more important to protect the innocent than to convict the guilty
 Special forms of autopsy

1. Psychological autopsy

2. Virtopsy

3. Negative autopsy

4. Obscure autopsy
 Psychological Autopsy

o An investigative procedure of reconstructing a person’s state of mind

prior to death, undertaken in alleged cases of suicide
− Information is gathered from personal documents, police and medical
records and interviews with survivors of the deceased - family and friends
− Important in life insurance claims that are void if death was suicidal

Virtopsy

o Minimally invasive procedure to examine a body for cause of death

− Utilizes imaging techniques (CT and MRI) and 3-D optical measuring
techniques to get a reliable, accurate geometric presentation of all findings
(the body surface as well as the interior).
 Negative Autopsy

o The cause of death remains unknown, even after all laboratory

examinations including biochemical, microbiological, virological,
microscopic and toxicological examination
− Occurs in 2-5% cases
o Reasons :
− Inadequate history especially in cases of death due to vagal inhibition,
hypersensitivity, etc.
− Inadequate external examination and internal examination
− Insufficient laboratory examinations
− Lack of toxicological analysis
− Lack of training of the doctor
 Obscure Autopsy

o An autopsy done meticulously, properly and perfectly, but may present

with no clear-cut findings as to give a definite cause of death
− Occurs in almost 20% cases
o Causes :
− Natural diseases: Epilepsy, paroxysmal fibrillation.
− Concealed trauma: Concussion, reflex vagal inhibition.
− Poisoning: Anesthetic overdose, narcotic, neurotoxic poisoning.
− Biochemical disturbances: Uremia, diabetes.
− Endocrinal disturbances: Adrenal insufficiency, thyrotoxicosis.
− Miscellaneous: Allergy.
 04
Protocol of medicolegal autopsy
 Protocol of medicolegal autopsy

1. Guidelines and Precautions

2. External examination

3. Internal examination

4. Sample collection and preservation

5. Autopsy report
1. Guidelines and Precautions
 Guidelines and Precautions

o Authorization: autopsy should be conducted only on receiving official order

(requisition letter) from the competent authority (i.e. police or magistrate)

Type of case Authorizing officer

Accident, Suicide, Homicide etc. Police up to ASI (Assistant Sub Inspector)
Exhumation Magistrate
Death in Prison Magistrate
Death in Police custody Magistrate
Death in Police firing Magistrate

o Body for medicolegal autopsy should be accompanied by a dead body

challan and an inquest report.
− A dead body challan is a requisition submitted to doctor by investigating officer and
contains name, age, sex, address along with probable date and time of death.
− An inquest report is preliminary investigation to ascertain the matter of fact, the details
of body, presence of any injury etc.
o All Registered Medical Practitioners in Government Service are authorised
to conduct the autopsy.
o Preferable for the doctor performing autopsy to visit crime scene.
o Identification of the deceased:
− Known body - Confirm identity by the police officer or the relatives or legal heirs
− Unknown body - the marks of identification, race, religion, sex, age, dental formula,
photographs, fingerprints, tailor’s label on clothes if present should be noted
o No unauthorized person should be present at the autopsy
o The medico-legal autopsy should be conducted in an authorized centre
o Autopsy should be performed as soon as possible after receiving the
requisition, without undue delay
o Autopsy should be conducted in daylight since it is said that colour changes,
such as jaundice, changes in bruises and postmortem staining cannot be
appreciated in the artificial light.
o If the body is received in the mortuary at night, it is preserved at 4°C after
noting the date and exact time.
− A preliminary examination is done to note external appearances, body (rectal)
temperature, extent of postmortem staining and rigor mortis. The actual postmortem is
conducted on the next day.
o Both positive and negative findings should be recorded.
o Chain of evidence: It is absolutely essential to preserve the chain of
evidence by identifying the body and maintaining absolute control of
specimens removed at autopsy.
− Chain of evidence/custody requires that from the moment the evidence is collected,
every transfer of evidence from person to person be documented and be provable that
nobody else could have accessed or tampered that evidence which can compromise the
case of the prosecution.
o List of articles: A list is made of all the articles removed from the body, e.g.
clothes, jewellery, bullets, etc. They are labelled, sealed, mentioned in the
report and handed over to the police constable after obtaining a receipt
o Prepare the postmortem notes during autopsy
o Prepare the autopsy report immediately and sign it duly
o After completion of autopsy, the body is stitched, washed and restored to
the best possible cosmetic appearance, and then handed over to the police
o A doctor should better not take up the autopsy, which he does not feel
competent to carry out.
o Autopsies and cause of death investigations are performed under the
Section 174 and Section 176 of Criminal Procedure Code (CrPC) Pakistan
o SECTION 174:
− Inquiry by Police into cause of death:
1. The officer incharge of a police-station or some other police-officer specially
empowered by the Provincial Government in that behalf, on receiving information that
a person:
a) has committed suicide, or
b) has been killed by another, or by an animal, or by machinery, or by an accident, or
c) has died under circumstances raising a reasonable suspicion that some other person
has committed an offence, . .
shall immediately give intimation thereof to the nearest Magistrate empowered to
hold inquests, and, unless otherwise directed by any rule prescribed by the Provincial
Government, shall proceed to the place where the body of such deceased person is,
and there, in the presence of two or more respectable inhabitants of the
neighbourhood, shall make an investigation, and draw up a report of the apparent
cause of death, describing such wounds, fractures, bruises and other marks of injury as
may be found on the body, and stating in what manner, or by what weapons or
instrument (if any), such marks appear to have been inflicted.
2. The report shall be signed by such police officer and other persons, or by so many of
them as concur therein, and shall be forthwith forwarded to the [concerned]
Magistrate.
3. When there is any doubt regarding the cause of death or when for any other reason the
police-officer considers it expedient so to do, he shall, subject to such rules as the
Provincial Government may prescribe in this behalf, forward the body, with a view to
its being examined, to the nearest Civil Surgeon, or other qualified medical man
appointed in this behalf by the Provincial Government, if the state of the weather and
the distance admits of its being so forwarded without risk of such putrefaction on the
road as would render such examination useless.
o SECTION 176:
− Inquiry by Magistrate into cause of death:
1. When any person dies while in the custody of the police, the nearest Magistrate
empowered to hold inquests shall, and in any other case mentioned in Section 174,
clauses (a), (b) and (c) of sub-section (1), any Magistrate so empowered may hold an
inquiry into the cause of death either instead of, or in addition to, the investigation
held by the police-officer, and if he does so, he shall have all the powers in conducting
it which he would have in holding an inquiry into an offence. The Magistrate holding
such an inquiry shall record the evidence taken by him in connection therewith in any of
the manners hereinafter prescribed according to the circumstances of the case.
2. Power to disinter corpses: 'Whenever such Magistrate considers it expedient to make
an examination of the dead body of any person who has been already interred, in order
to discover the cause of his death, the Magistrate may cause the body to be disinterred
and examined.
2. External Examination
 External Examination

1. Examination of clothes

2. Examination of body

3. Examination of external injuries

 Examination of clothes

o They are listed and their number, labels and laundry marks, design, stains,
tears, loss of buttons, cuts, holes or blackening from firearm discharges with
their dimensions should be noted.
− Trace evidence like hair, fibres, insects, glass fragments etc. are collected and labelled
− Jewellery, medicines or drugs of abuse and personal papers in the pockets may help in
identification
− 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 cuts, along the seam of the garment.
− Examination of clothes is done on the body and off the body
− After autopsy, wet clothing (decomposes evidence) should be air-dried, packed, sealed
in paper bags and handed over to the police.
− Examination of clothes gives information about: Identity of the deceased, Nature of
assault and Manner of infliction
 Examination of body

o Whole surface of the body should be carefully examined before and after
washing from head to foot, and back and front, and the details noted
o General description: deformities, scalp hair, beard, scars, tattoo marks,
moles, skin disease, circumcision, amputations, surgery marks etc.
o Time since death: Rectal temperature, rigor mortis, postmortem staining,
putrefaction, maggots, stomach contents, etc.
o Skin including scalp: General condition - rash, petechiae, colour etc. The
presence of stains from blood, mud, vomit, faeces, corrosive or other
poisons, or gunpowder is noted.
o Face: Cyanosis, petechial hemorrhages, pallor, protrusion or biting of the
tongue, state of lips, gums, teeth, marks of corrosion or injuries inside the
lips and cheeks.
o Eyes: Condition of the eyelids, conjunctivae, softening of the eyeball, colour
of sclera, state and colour of pupils, contact lenses, petechiae, opacity of the
cornea and lens
o Natural orifices: nose, mouth, ears, urethra, vagina and anus should be
observed for any discharges, injuries and foreign body. Samples of leakage of
blood or CSF from ears, mouth or nostrils is collected on swabs
o Neck: Bruises, fingernail abrasions, ligature marks etc.
o Thorax: Symmetry, general outline, and injuries if any
o Abdomen: Presence or absence of distension , striae gravidarum
o Back: Bedsores, spinal deformity, or injuries
o External genitalia: General development, edema, local infection, and position
of testes.
o Hands: Injuries, defence wounds, electric marks, and in clenched hands if
anything is grasped.
o Fingernails: Presence of tissue, blood, dust or other foreign matter may be
indicative of struggle
o Limbs and other parts: Fracture and dislocation

Indications of radiological examination

 Examination of external injuries

o The final stage of external examination is the documentation of injuries,

either by grouping them according to injury type and anatomical location,
or by numbering them, without implying an order of infliction or ranking
of severity
o Each injury is characterized by its:
− Type/nature of injury
− Size (length, breadth and depth)
− Shape
− Site (in relation to two external anatomical landmarks)
− Direction of application of the force
− Margins, edges and base
− Distance of the wound from the heel
− Time of infliction of the injury should be studied from inflammatory and colour changes
− Foreign materials, e.g. hair, grass, fibres, etc.
o If the injuries are obscured by hair, it should be shaved
o Deep or penetrating wounds should not be probed until the body is opened
o In burns, their character, position, body surface area involved, and degree
should be mentioned
o The position of the injuries should be pictographically depicted on the
diagrams
o Photographic documentation of major injuries is now considered as standard
practice
o Identifying markers bearing the unique autopsy number, with a
measurement scale should be included to ensure that the photos correspond
to the specific case
3. Internal Examination
 Internal Examination

1. Basics of internal examination

a) General rules
b) Skin incisions
c) Evisceration/ Autopsy techniques

2. Examination proper
a) Dissecting Cranial cavity
b) Dissecting Spinal cord
c) Dissecting Neck
d) Dissecting Thoracic cavity
e) Dissecting Abdominal and Pelvic cavity
1. Basics of Internal Examination
a) General rules
a) Skin incisions
b) Evisceration/ Autopsy techniques
 a) General rules

o Dissection and examination of all three major cavities of the body i-e Cranial,
Thoracic and Abdominal cavities, and their contents should be carried out.
Spinal cord is routinely not opened
o The choice as to which part of body is to be opened first — skull or the body
cavities is left to the dissector

o However, some surgeons suggest to start autopsy by opening the cavity least affected
so as to create a blood-less field in the affected area e.g. in case of strangulation,
cranium and chest cavity to be opened first so that the excess of blood is drained out
from the neck
 b) Skin incisions

Major skin incisions used to open the cranial, thoracic and abdominal cavities:
o For cranial cavity:
− Intermastoid Inverted U-Shaped incision

o For thoracic and abdominal cavities:

− I-Shaped incision
− Y-Shaped incision
− Modified Y-Shaped incision

o For back:
− Elongated X-Shaped incision
o Intermastoid inverted U-shaped incision
− Incision starts behind one ear (at mastoid process) passes across the scalp just behind
the vertex and ending behind the other ear (at mastoid process).
− Only common incision used to open skull
− Indication: Opening of cranial cavity
o I-shaped incision
− Straight incision is made from the chin (symphysis mentis) to pubis (symphysis pubis),
avoiding umbilicus (because the dense fibrous tissue is difficult to penetrate with a
needle, when the body is stitched after autopsy)
− Indication: Most common type of incision
− Advantage: Simple and convenient

o Y-shaped incision
− Straight incision from suprasternal notch to pubis is made, avoiding umbilicus. Now this
incision is extended from suprasternal notch to the mid-point of clavicle and then
upwards towards the neck behind ear. Similar incision is made on opposite side
− Indication: When a detailed study of neck structures is required, e.g. strangulation
− Advantage: Better exposure and allows study of neck structures
Green : I shaped incision Red : T shaped incision
Brown : Modified Y shaped incision Blue : Y shaped incision
o Modified Y-shaped/ Continental incision
− It begins at a point close to acromial process and extends down below the breast and
then medially across the xiphoid process. A similar incision is made at opposite side of
the body and from xiphoid process the incision is carried downwards in a straight line to
the pubis
− Indication: Preferred in females
− Advantage: Prevents cutting of the chest skin in midline and also allows detailed study
of neck structures

o Elongated X-shaped incision

− Special 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
− Indication: Practiced in custodial deaths
 c) Evisceration/ Autopsy techniques

o Four different techniques are used to remove contents of the body during
autopsy:
− Technique of Virchow / Individual organ removal and dissection
− Technique of Rokitansky / In situ dissection
− Technique of Ghon / En bloc removal and dissection
− Technique of Letulle / En mass removal and dissection
o Technique of Virchow
− Removal of individual organs one by one with subsequent dissection of that
isolated organ
− Quick and effective method, if the pathological interest is in a single organ
o Technique of Rokitansky/ In situ dissection
− Rarely performed, involves dissecting the organs in situ with little actual
evisceration being performed prior to dissection
− Method of choice in patients with highly transmissible diseases

o Technique of Ghon/ En bloc removal

− Thoracic, cervical, abdominal and urogenital system organs are removed
separately as organ blocks.

o Technique of Letulle/ En masse removal

− Cervical, thoracic, abdominal and pelvic organs are removed En-masse and
subsequently dissected into organ blocks.
− Rapid technique for removing the organs from the body although the
ensuing dissection is the lengthiest. It has the advantage of leaving all
attachments intact.
2. Examination proper
a) Dissecting Cranial cavity
b) Dissecting Spinal cord
c) Dissecting Neck
d) Dissecting Thoracic cavity
e) Dissecting Abdominal and Pelvic cavity
 a) Dissecting Cranial Cavity

o Dissection of cranial cavity includes five steps

1. Scalp incision
− Intermastoid inverted U-Shaped incision
− Bring the anterior flap up to superciliary ridge and posterior flap up to
occipital protuberance
2. Removing the skull cap
− Incise the temporalis muscle and cut it along its origin and reflect down on
both sides
− Saw the skull bone a little above superciliary ridges in front and occipital
protuberance behind
− Now, let both lines meet at an angle of 120° above mastoid process and
then remove the skull cap using chisel, exposing dura mater
A: Inverted U incision B: Reflect the flaps C: Cut temporalis muscle

D: Saw the skull E: Remove the skull cap

3. Opening the dura mater
− Using sharp pair of scissors it is cut along the line of detached skull cap and
pulled gently from front to back while cutting falx cerebri, and examined for
subdural and subarachnoid hemorrhages.
4. Removing the brain
− Insert four fingers of left hand between frontal lobes and skull.
− Draw the lobes backwards gently and cut optic nerve and then other nerves
and vessels with right hand as they emerge out from the skull.
− Cut the tentorium cerebelli along its attachments in posterior cranial fossa.
− Cut spinal cord, first cervical nerves and vertebral arteries as low as possible
through foramen magnum.
− Support the brain in left hand and remove with the cerebellum.
F: Cut open the dura mater G: Brain exposed

H: Cut optic nerves I: Remove the brain on cutting spinal cord

5. Dissection of brain and its parts.
− The brain is weighed (normally 1.3 to 1.4 Kg) and then examined for any
swelling, softening, shrinkage or herniation, upper and lateral surfaces of
the brain for asymmetry or flattening of the convolutions. The cerebral
vessels is looked at for arteriosclerosis, embolism and aneurysms
− Brain is dissected by two methods:
• Dry dissection: Less common; Dipped in 10% formalin which makes the tissue firmer
without altering its histological characteristics
• Wet dissection: More common; Fresh brain dissection without using any fixative
− The brain is placed on a board with frontal pole away from dissector.
− Cut the brain in serial coronal sections at regular intervals (about 1cm apart)
from front to back or cut obliquely at the intracerebral fissures exposing
basal ganglia, lateral ventricles and white matter.
− Features to look for:
• The cortical ribbon, white matter, basal ganglia and lateral ventricle should be
examined for any asymmetry or brain shift that would indicate space occupying
lesion—abscess, large hemorrhage, recent infarction or either metastatic or
primary tumors.
• Dilatation of lateral ventricle may indicate atrophy
• Shrinkage of cerebral cortex (grey matter) is common in chronic alcoholics
• Petechial hemorrhages in the white matter are commonly found in death from
anaphylactic shock.
• In head injury, edema is seen in the white matter around or deep to contusions,
lacerations or ischemic lesions.
• If there is any injury to the brain, successive sections parallel to the wounded
surfaces should be made till the whole depth of the wound is revealed.
 b) Dissecting Spinal cord

o The spinal cord can be removed from an anterior or posterior approach

o If there is no indication, the spinal cord need not be exposed

1. Anterior approach
− All the organs of abdomen and thorax are removed first
− Spinal cord is then exposed by cutting the vertebral bodies from anterior
− The anterior approach is more difficult but has the advantages of not
requiring the body to be turned and allowing the nerve roots and dorsal
ganglia to be dissected
2. Posterior approach
− The posterior approach is both quicker and easier, but best performed
before the full postmortem, to avoid the mess
− In this approach, a midline incision is given, extending from base of the head
to the sacrum dissecting away soft tissue from the spines and arches of
spinal cord
− With the help of saw and chisel, cut through and remove lamina and spinal
processes to expose dura mater
− Examine the dura for any pathological condition, such as inflammation,
haemorrhage, crushing, infection, etc.
− Separate the cord at the foramen magnum, carefully lift it from vertebral
column, and place it on table for examination
− The dura is then opened with the help of forceps and scissors to examine
the cord itself
− Samples may be taken for histology, if needed.
 c) Dissecting Neck

o The neck structures are examined before removal of the thoracic organs so
that the tongue, larynx, trachea and esophagus can be taken out along with
the lungs.
o For exposing the structures of the neck, ordinarily, the I-shaped incision is
used; however, when wider view is necessary, neck structures should better
be exposed by a Y-shaped incision
o In case of death due to alleged constriction of the neck, there may be
fracture of hyoid bone or thyroid cartilage with extravasation of blood into
the tissues, and injury to carotid arteries, sternomastoid muscles or
platysma.
o Compression of the neck with hard materials may cause injury to the cervical
vertebrae and the corresponding part of the spinal cord
o Neck when dissected is also checked for presence of any foreign body
 d) Dissecting Thoracic cavity

o Chest is opened by midline incision

o The skin, subcutaneous and soft tissues in the neck and chest are then
reflected sideward
o Now cut along the costochondral junction, and reflect the chest plate
o Introduce the hands into pleural cavities and explore and look for
blood/fluid collection
o Disarticulate the sternoclavicular joints on either side, cut the cartilage of
first rib and separate the chest plate and remove it
o In situ inspection is done before removal of thoracic organs which includes
observation of the atrium and ventricle for air embolism, distension or
collapse of lungs, the chest cavity for fluid, hemorrhage or pus, pleural
adhesions, injuries including fracture of ribs.
o Demonstration of Air embolism :
− Usual indications for air embolism are
• Suspected criminal abortion
• Open wound of the neck, central venous catheterization etc
− Principle: To demonstrate air in the vascular system, i.e. heart.
− Procedures:
• Heart is exposed by routine autopsy incisions and sternal plate is removed with ribs up
to the costochondral junction. The pericardial sac is now incised anteriorly, and the
edges are grasped with haemostats on either side and held firmly. Now fill the sac with
water till the heart is submerged. Invert water filled measuring glass cylinder (300 ml)
over the heart, with the mouth of cylinder under pericardial water column. The right
side of the heart is then punctured with a scalpel under the water level. The gas will
escape from heart into the cylinder, displacing the water in it
• Another method is by inserting a water-filled syringe (minus plunger) connected to a
needle into the right ventricle, the syringe chamber observed for the presence of
bubbles
o Demonstration of Pneumothorax :
− Pure form of pneumothorax is rare. It is usually associated with injury to lung,
resulting in blood in the pleural cavity or haemopneumothorax. Thus every
case of chest injury is an indication for checking for the presence of air or
pneumothorax .
− Principle: To demonstrate air in the pleural cavity.
− Procedure:
• Incision of the body as in any routine medicolegal autopsy examination and
the skin and muscles on the injured side are reflected and dissected to form
a pocket. This pocket is then filled with water. Invert now water filled
measuring glass cylinder over the pocket, with the mouth of cylinder under
water in the pocket. A scalpel is then introduced under water level into the
costodiaphragmatic sinus through an intercostal space. If air is present in the
pleura, bubbles will come out from the wound and get collected into the
glass cylinder and directly measure the amount of air in the pleural cavity.
• Another method is possible before any incision is made. This involves
introducing a wide bore needle attached to a 50 ml syringe into the
subcutaneous tissue over an intercostal space into the pleural space. The
plunger should be removed previously and the syringe filled with water. The
water is observed for the presence of any bubbles. A similar procedure is
then followed on the other side.
• A third method involves postmortem chest X-ray, and assessment in a
manner similar to detection of a pneumothorax in the living patient.
o Examination of Heart :
− The heart is held at the apex, lifted upwards and separated from other thoracic
organs by cutting the vessels entering and leaving it (inferior and superior vena
cava, pulmonary vessels, and ascending aorta) as far away as possible from the
base of the heart
− The size and weight of the heart is noted. Adult heart weighs about 250–300 g
− The myocardium is examined for fibrosis or recent infarct. If an infarct is
identified, sections from its central and peripheral zones are useful in dating the
onset of ischemic damage and determining any recent extension.
− The extramural coronary arteries are examined by making serial cross-sectional
incisions about 3–5 mm apart, in order to evaluate for atherosclerotic narrowing,
the common site being 1 cm away from the origin of the left coronary artery
− The extent of coronary artery atherosclerosis is categorized based on the
approximate percentage stenosis, caused by the plaque. Anything < 50% is
considered mild, while 50–75% is considered moderate and > 75% is severe.
− Pulmonary embolism may be detected by opening pulmonary artery before any
other part of the heart is opened.
• It is important to differentiate between antemortem embolus, that originates
from deep veins of the leg, from postmortem clots that are formed in stagnant
blood
• An embolus is firm, has transverse ridges, often coiled upon itself and generally of
the size of femoral vein. Postmortem clots, which form after death in stagnant
blood, are soft, smooth, shiny and purplish or yellowish
• For confirmation of antemortem embolus, deep veins in the calf muscles can be
incised which will reveal firm solidly structured thrombi which pops out as
sausages when the vein is transacted.
− Heart is dissected by Inflow - outflow method or following the direction of
blood flow --- right atrium, right ventricle, pulmonary arteries, pulmonary veins,
left atrium, left ventricle, and aorta.
• First, the right atrium is opened, followed by the tricuspid valve, and then the
pulmonic valve
• Next, the left atrium is opened, followed by the mitral valve and the aortic valve
• During opening, the valves should be examined before being cut and valve orifice
measured (The circumference of mitral valve is 8–10.5 cm (mean 10 cm) and
admits two fingers; tricuspid valve is 10–12.5 cm (12 cm) and admits three fingers;
aortic valve is 6–8 cm (7.5 cm) and pulmonary valve is 7–9 cm (8.5 cm). The
decrease in circumference is suggestive of stenosis whereas increased
circumference could be due to regurgitation or incompetent valves )
• Special sections can be taken at this point to evaluate the conduction (electrical)
system of the heart
o Examination of Lungs :
− Normal lungs weigh 250–400 g each in an adult, but may weigh > 1 kg in
cases of severe cardiac failure or diffuse alveolar damage
− The condition of pleura, any sign of pleuritis, petechial hemorrhages, injury,
effusion, hemothorax, pneumothorax or pyothorax is noted
− It is conventional to cut open from large to small airways, from medial to
lateral to include all lobes and segments opening along the branches as they
are encountered.
− Impression of the parenchymal appearance and texture is noted. The
parenchyma is squeezed and any pus or fluid expressed is noted.
− It is preferable to make large horizontal slices through the whole lung rather
than opening the airways and vessels in cases of large mass lesion (e.g.
carcinoma).
 e) Dissecting Abdominal and Pelvic Cavity

o Abdomen is usually opened by a midline I - shaped incision

o Care being taken not to injure the intestines underneath. To accomplish this,
a small puncture may be made in the peritoneum and a finger inserted to lift
it away from the intestines.
o The knife then may be directed outwards cutting along the length of
abdomen and preventing penetration into the intestines.
o The cavity as such should be examined for any pus, blood, exudation, etc.
Then the individual organ should be examined as under
o Stomach:
− Two ligatures are applied at the cardiac end of the esophagus and two ligatures below
the pyloric end of the stomach. The stomach is removed by cutting between the double
ligatures at both ends, and is opened along the greater curvature.
− The mucous membrane is examined for the presence of any stain, congestion,
hemorrhage, desquamation, ulceration, or perforation
− The content of the stomach is noted in respect to quantity, nature of material/food,
state of digestion, colour and smell
o Intestine:
− Dissected in its entire length. Any injury or reactions due to poison or presence of
foreign body, e.g. a bullet, is noted
− Ulcerative colitis like lesions is noticed in case of poisoning with mercuric chloride

o Liver:
− Removed along with gall bladder and its weight,
size, colour, consistency and presence of any
pathology or injury is noted.
− Normal liver weighs about 1300–1550 g in an adult.
− Inflammatory or neoplastic processes often cause
hepatomegaly, but fibrotic conditions such as
cirrhosis will cause a shrunken organ.
− For macroscopic examination of the liver, multiple
transverse sections at 1–2 cm apart are given from
one side to the other
− The gallbladder should be opened, and the presence or absence of bile stones and the
character and quantity of the bile should be noted.
− In some cases, bile may be required for analysis as in morphine or chlorpromazine
poisoning

o Spleen:
− The spleen is removed by cutting through its pedicle;
its size, weight (130-170g), consistency and
condition of capsule, and rupture, injuries or disease
is noted. Hilum should be inspected for splenunculi
before dissecting the spleen
− In case of septicemia, the spleen will often be soft
and liquefied, and slicing may be impossible

o Pancreas:
− The pancreas is removed along with the stomach and duodenum. It is sliced by multiple
sections at right angles to the long axis to expose the ductal system.
o Kidneys:
− Removed along with adrenal glands after tying the ureters along with the vessels at
least 1 inch away from the hilum.
− The surface of the kidneys along with the covering capsules should be examined for
texture, congestion, hemorrhage and injury
− An adult kidney weighs about 150 g
− The kidney is sectioned longitudinally through the convex border into the hilum. The
pelvis is examined for calculi and inflammation
− With chronic renal parenchymal disease such as
nephrosclerosis, ischemia or infection there may
be fine or coarse scars
− Renal infarcts are pyramidal or wedge-shaped
lesions with the base at the cortical surface and
the apex pointing to the medullary origin of the
arterial supply
o Urinary bladder:
− Examined in situ for any pathology, hemorrhage, congestion or injury
− If bladder contains urine, it is syringed out before opening to avoid any chances of
contamination by blood or any other material.
− Both the ureters should be opened along their long axes

o Female genitalia:
− The uterus and its appendages should first be examined in situ and then removed en-
masse along with the vagina
− The uterus is examined and its dimensions, weight, whether gravid, parous or
nulliparous, or any pathology present is noted.
− It should be opened longitudinally, and mucous membrane and walls should be
examined.
− In old age, it becomes atrophied, and paler and denser in texture. If the uterus contains
a fetus, the age of its intrauterine life should be determined.
− The ovaries and fallopian tubes should also be examined. The vaginal canal should be
opened from below upwards and examined for the presence of a foreign body or marks
of injury. The condition of the cervix and any marks from instruments should be noted.

o Prostate and Testes:

− These should also be sectioned and examined wherever necessary
− Prostate is examined for enlargement or malignancy. In prostatitis, it is firm and in
carcinoma, it is hard and granular
4. Sample Collection and
Preservation
a) Collection of Samples and Viscera
b) Preservation of Samples
c) Samples for Lab Investigations
 a) Collection of Samples and Viscera

o Blood: Before autopsy, 10–20 ml of blood can be drawn from the femoral
(best sample), jugular or subclavian vein by a syringe. Due to loss of
cellular barrier after death, samples of blood collected from other places will
lead to erroneous results.
o CSF: May be collected by lumbar puncture or by direct aspiration from the
lateral or third ventricle after removal of the brain
o Vitreous Humor: 1–2 ml of crystal clear fluid from each eye is aspirated by a
hypodermic needle (20 gauge) inserted through the outer canthus into the
posterior chamber of the eye.
− Water/saline is re-introduced through the needle to restore the tension in
the globe for cosmetic reasons
o Urine: Collected in a suitable sterile or non-sterile ‘universal container’ for
either microbiological or toxicological analysis by suprapubic puncture or
when the bladder is opened.
− Before dissection, urine can be collected via catheter
o Bone: About 200 g is collected. It is convenient to remove about 10–15 cm
of the shaft of the femur
o Hair: Sample of head and pubic hair should be removed by plucking along
with roots, and not by cutting, and preserved in separate containers (0.5 g
for DNA analysis, up to 10 g for analysis of heavy metals)
o Maggots: Dropped alive into boiling absolute alcohol or 10% hot
formalin which kills them in an extended condition (to disclose the internal
structure of the larvae).
− If time of death is an issue, some larvae/maggots should be preserved alive
for examination by an entomologist. Maggots may reveal the presence of
drugs/poisons in decomposed bodies.
o Nails: All the nails (fingers and/or toes) should be removed in their entirety
and collected in separate envelopes
o Skin: If there is needle puncture, the whole needle track and surrounding
tissue should be excised. Control specimens should be taken from same area
on the opposite side of the body and preserved in a separate container
− In firearm cases, a portion of skin around the entrance and exit wounds
should be preserved
o Viscera should be preserved in cases of:
− Suspected death due to poisoning
− Deceased was intoxicated or used to drugs
− Cause of death could not be found after autopsy
− Accidental death involving driver of a vehicle or machine operator
− Death due to burns (if needed)
− Advanced decomposition (When the body is too decomposed to collect any fluids,
collect at least 100 g of muscle from thigh, liver, brain, fat and kidneys)
− Any case, if requested by the Magistrate.
o Some practical points to remember:
− Blood is the most useful sample because toxins present in this can be best related to a
physiological effect, and can be used to assess the likelihood of recent exposure to
poisons/drugs.
− Urine is the second most important specimen collected. However, the disadvantages
are: it is unavailable in half the cases (since it is voided after dying) or poison may be
already metabolized by the body
− Vitreous Humor is the preferred specimen for postmortem confirmation of alcohol
ingestion, since postmortem formation of ethanol does not occur to significant extent
in vitreous, and hence useful even in decomposing bodies. It is recommended that this
specimen is included routinely in sudden death investigations.
− Whole stomach is preserved since it allows the analyst to dissolve any poison adhering
to the sides of the walls
− Specimen from liver is taken from its right lobe. Liver is quite important due to high
concentration of toxins, and availability of large database of liver drug concentrations.
However, majority of drugs are detected readily in the blood, and it is not necessary to
rely on the liver nowadays. Also, lives decomposes faster as compared to blood.
− Bile has been collected historically, but its usefulness is limited. It may be show the
presence of number of drugs including morphine/heroin, benzodiazepine, cocaine,
methadone, glutathione, many antibiotics and tranquillizers and heavy metals (in
chronic poisoning)
− Brain, kidney and spleen are used to determine and interpret the concentration of
toxins, i.e. overall assessment of the body burden of a toxin.
− Spleen is useful as a specimen for toxins, such as carbon monoxide (CO) and cyanide
that binds to hemoglobin. If septicemia is suspected and the cause of it is not
obvious, spleen should be cultured.
− The viscera should be refrigerated at about 4°C, if not sent to the laboratory. They can
be destroyed either after getting the permission from the Magistrate or when the IO
informs that the case has been closed
 b) Preservation of Samples

o The ideal samples are the ones in which no preservative has been added and
sent to Forensic Science Lab within few hours.
o The specimen is preserved at 4°C until they are analysed. For long-term
storage, it has to be kept in freezer (–10°C)
o In order that putrefaction may not set in and render chemical analysis difficult,
certain preservatives are used.
1. Viscera
− Most commonly used preservative is saturated solution of Common Salt
− The best preservative for preservation of viscera is rectified spirit. However,
it is not used in cases of suspected poisoning with: ---- Alcohol --- Chloroform
---- Kerosene ---- Ether ---- Phosphorus --- Formaldehyde -----
Paraldehyde ---- Acetic acid
2. Blood
− Blood for toxicological analysis is preserved in sodium or potassium fluoride
at the concentration of 10 mg/ml of blood and anticoagulant potassium
oxalate, 30 mg/10 ml of blood
− Heparin and EDTA should not be used as anticoagulants, since they interfere
with detection of methanol
− If blood is required only for grouping, no preservative is necessary
− In case of suspected CO poisoning, a layer of 1–2 cm of liquid paraffin is
added immediately over the blood sample to avoid exposure to atmospheric
oxygen.
− If solvent abuse and anesthetic death is suspected, the glass container should
have a foil-lined lid to prevent gas from escaping (as gas can permeate rubber)
and the container is completely filled to prevent gas from escaping in ‘dead’
air space.
3. Urine
− Urine is persevered by adding small amount of phenyl mercuric nitrate or
thymol
− Fluoride should be added to urine if alcohol, cyanide or cocaine is suspected
in the sample
4. Vitreous humor is preserved using sodium fluoride (10 mg/ml)
5. For bones, hair and nails, preservative is not required. It has to be dried in
normal temperature and sealed in plastic bag.
6. Bone marrow is preserved in a test tube containing 4–5 ml of 5% albumin-
normal saline solution and stored at 4°C.
o Procedure of Preservation
− For preservation of viscera, a clean, transparent and preferably sterile glass jar (one
litre capacity) with a wide mouth and stoppers should be used. The size of the jar
should be such, that at least 1/3rd of the container remains empty after being filled
with the preservative to allow for accommodation of the gas which will evolve out
of the organs preserved. However, the preservative should completely immerse the
viscera after the contents are well shaken.
− The stomach, small intestine and its contents are preserved in one bottle, part of
liver along with gallbladder, spleen and kidneys in another bottle and urine in the
third bottle. The stomach and intestines are opened before they are preserved. The
liver and kidneys are cut into small pieces to ensure penetration of the preservative.
Blood should be sent in a vial(s)
− A sample of the preservative used (sodium chloride or rectified spirit) is separately
preserved and sent for analysis to rule out any poison being present as a
contaminant
− The stoppers of the bottles should be well fitting, covered with a piece of cloth and
tied by tape or string, and the ends sealed using a departmental seal. Each bottle
should be suitably labelled with the autopsy number, name of the deceased, name
of the organ, date, time and place of autopsy, followed by signature of the doctor
who performed the autopsy.
− The sealed bottles are then put in a viscera box which is sealed. The viscera box
along with a specimen of the seal used (put in a separate envelope and sealed) is
handed over to the police constable, in return for a receipt. All these precautions
are necessary to maintain the chain of evidence.
− Along with the viscera box, the following documents are also sent:
I. Copy of the inquest papers, brief facts of the case and the case sheet.
II. Copy of autopsy report.
III. Letter requesting the chemical examiner to examine the viscera and inform the
medical officer of its findings.
 c) Samples for Lab Investigations

o Histopathological examination: Sections of various internal organs (1.5 × 1.0 ×

1.0 cm) in case of suspected abnormality are preserved in 10% formalin or
95% alcohol
o Bacteriological/serological examination: Blood should be kept in sterile
container using sterile syringe from the right ventricle of the heart or from
some large vessel, such as femoral vein or artery. It may also be used for
biochemical examination.
o Virological examination: A piece of tissue is collected and preserved in 50%
sterile glycerine
o Enzymatic studies: Small pieces of tissues are collected into a thermos
containing liquid nitrogen
 05
Instruments used in Autopsy
 06
Exhumation
 Exhumation
(‘Ex’ means ‘Out’, ‘Hume’ means ‘’Earth’)

Definition: Lawful digging out of an already buried body from the grave
for postmortem examination

o Usually, it, involves a body (of any age group) that was not originally
autopsied but which, for some reason, must be exhumed in order for an
autopsy to be performed
o Authorization: The body is exhumed only when, there is a written order from
the Magistrate and is done under CrPC Section 176, Subsection 2
o Reasons/ Objectives:
1. Criminal cases
− Establishing the cause and manner of death in suspected homicide disguised
as suicide
− Death as a result of criminal abortion and criminal negligence
− Retrieving some vital object which may throw light on the case, e.g. bullet
from the dead body, if the person was killed by a firearm
2. Civil cases
− Identification of the deceased for accidental death claim, insurance,
inheritance claims, disputed identity, and burial of the wrong body
inadvertently or by fraud
o Procedure and Protocol:
− Exhumation should be done and completed in broad daylight
− The body is exhumed under the supervision of a medical officer and
Magistrate, in the presence of a police officer
− Before opening the grave, it should be positively identified through
relatives and from headstone and grave markers
− Soil from above, below and two sides of the body or the coffin should be
preserved in separate glass jars to rule out postmortem imbibition
− Disinfectants should not be sprinkled on the body as it might interfere
later with the determination of poison in the body
− The doctor should note the position and appearance of the body inside
the grave or the coffin. A drawing of the grave and body or skeleton should
be made, noting all the details
− The grave or the coffin with the body should be photographed
− If decomposition is not advanced, a plank or a plastic sheet should then be
lowered to the level of the earth on which the body rests
− After this, the body is lifted and sent for postmortem examination, along
with a requisition and a preliminary investigation report. In the mortuary,
postmortem examination on the body is performed as in all other cases
− In highly putrefied bodies, an attempt should be made to establish the
identity. Viscera should be preserved for chemical analysis. If the body is
reduced to skeleton, the bones should be examined.
o Time limit:
− There is no time limit for ordering of the exhumation in Pakistan, but many
Western countries have well defined time limit up to which exhumation can
be done. For example, in France, the time limit is 10 years and in Germany,
the time limit is 30 years.
o Postmortem imbibition:
− Process by which poisons or metals percolate into body from surrounding
medium through passive diffusion after death
− For example, if Arsenic is found in dead body, it may be due to poisoning or
postmortem imbibition from surrounding soil. To confirm this, surrounding
soil is collected and checked for presence of Arsenic.
 07
Postmortem Artefacts
 Postmortem Artefacts
(Latin arte: art, factum: something made)

Definition: Postmortem artefact is any change or new feature introduced

into the body after death, and such feature or change posses’ difficulty in
interpreting the autopsy findings

o Ignorance and misinterpretation of such postmortem artefacts leads to:

− Wrong cause/ manner of death
− Undue suspicion of criminal offence
− A halt in the investigation of criminal death
− Unnecessary wastage of time and effort, as a result of misleading findings
− Miscarriage of justice
o Postmortem artefacts can be classified into:
1. Artefacts due to postmortem changes
2. Third party artefacts
3. Environmental artefacts
4. Other artefacts
1. Artefacts due to Postmortem Changes
o Rigor Mortis: Existing rigor mortis may be broken down while removing the
body from the scene of crime to the mortuary which may cause error in
interpretation of time since death.
o Postmortem Lividity: Isolated patches of postmortem lividity may be
mistaken for bruises. Such patches on the front and sides of the neck may be
mistaken for bruising due to throttling. Lividity of the internal organs may be
mistaken for congestion due to disease.
o Autolysis: Autolysis leads to discoloration of skin and viscera, like
gallbladder, pancreas, liver, kidney, and brain, where it may simulate injury or
disease. Pancreas is one of the first organs to undergo autolysis because of
proteolytic enzymes within it, which can be mistaken for acute hemorrhagic
pancreatitis. Perforation of the stomach due to autolysis have to be
distinguished from that due to corrosive acid or peptic ulceration.
o Putrefaction: Postmortem bloating due to putrefaction may give false
impression of antemortem obesity
− Escape of sanguineous fluid from the mouth and nose in case of pulmonary
edema may give impression of hemorrhage
− False strangulation groove (deep groove simulating ligature mark of
strangulation) may appear on the neck if the deceased was wearing tight
collar shirt or some other beaded threads or ornaments around the neck
− The bulging of eyes, protrusion of tongue and discharge of red stained froth
from mouth and nose may be mistaken for signs of throttling
− Putrefactive blisters may be confused with blisters from burns
− Splitting of skin may give a false impression of antemortem lacerations or
incised wounds
− Gas bubbles in the blood and air in the right side of the heart may be
mistaken for air embolism
2. Third Party Artefacts
o Artefacts due to Animal and Insect Activity: Rats and rodents gnaw away
the tissue over localized areas mimicking incised or lacerated wounds
− Bodies recovered from water may show gnawing by fish, crabs and other
aquatic animals, giving false impression of lacerated wounds
− Flies, maggots and larvae may alter the wounds
o Therapeutic Artefacts: External cardiac massage, especially in elderly
patients is associated with the fracture of ribs (3rd-5th) and sometime
fracture of the sternum which can create an impression of antemortem
violence
− Regurgitation and aspiration of gastric content into the air passages may
give a false impression of choking
− Investigative procedures, like carotid angiography may result in bruising of
the neck muscles giving a false impression of constriction of the neck
o Autopsy Induced Artefacts: During the opening of the skull by forceful
sawing or by using a chisel and a hammer, an existing fracture of the skull
may become extensive or fresh fractures may be caused
o During pulling of the dura, air may enter the blood vessels. This may lead to
an erroneous diagnosis of air embolism
o The handling of organs and the incision of the vessels may result in
extravasation of blood into the tissues
o The removal of the neck structures en-block as in routine autopsies may
produce artefacts in the neck tissues which resemble bruises (as seen in
throttling)
o While removing neck structures, the hyoid bone and thyroid cartilage may be
fractured, especially in old persons which may be mistaken for being
antemortem in origin
o Collection of the viscera in a single bottle or use of contaminated bottles/
instruments/ preservatives may result in wrong analysis of poisons.
3. Environmental Artefacts
o Heat Effects: Heat applied to the skin of a dead body may loosen the
epidermis from the dermis and produce a postmortem blister
− An unburnt groove around the neck due to a tight collar may resemble a
ligature mark
− Heat ruptures may resemble lacerated or incised wounds
o Postmortem Corrosion: Dead bodies exposed or lying in kerosene, water or
gasoline show chemical injuries. The epithelium detaches while handling the
body, and then the underlying dermis turns yellow to brown which may be
misinterpreted as antemortem chemical injury or abrasion or burns
4. Other Artefacts
o Artefacts due to Refrigeration: Pink postmortem staining is seen in bodies
kept in cold storage. If the bodies are kept in a cold storage immediately
after death, goose skin may develop
o Artefacts due to Mishandling of the Body: During the process of transfer
of the body from the scene of crime to the mortuary, abrasions may be
produced over the back or bony prominences, clothes may get bloodstained
or torn
− Fractures of the ribs or long bones or cervical spine may occur by rough
handling of the bodies, especially in the elderly or debilitated, during
attempts to straighten limbs which are contracted due to rigor mortis
− Contusion may occur over occiput due to bumping of the head on hard
surface. Undertaker’s fracture may be seen which is a subluxation of the
lower cervical spine due to tearing of the intervertebral disc at about C6-C7
 01 Defining Autopsy

02 Major types of autopsy

DO YOU HAVE
03 Special forms of Autopsy

QUESTIONS? 04 Protocol of medicolegal Autopsy

THANKS 05 Instruments used in Autopsy

06 Exhumation

07 Postmortem Artefacts