Drsajjad Ul Hadi
Drsajjadmbbs@[Link]
If you need my lecture PPT just contact me through email to inbox
you….
Why are post mortems carried out?
Post-mortems are usually associated with establishing a cause of death - particularly in
Coroners cases. When your consent is being asked for to conduct a post-mortem there is
usually little doubt regarding the cause of death though the underlying disease process may
be poorly understood.
Post mortems have far wider implications for medical education and research generally.
Examining tissue is one of the most important ways in which doctors learn about illness and
how to treat it. Tissue from post-mortems can be used to train medical students and new
doctors, to help experienced doctors continue to learn about new conditions or treatments,
or to teach specialist knowledge. New medical conditions are recognised all the time. If
tissue samples have been retained, it is sometimes possible at a later date to
diagnose these new conditions in cases in which they were previously undiagnosed, or
given a different diagnosis. With your permission, an organ (or part of an organ) might also
be retained for use in medical research or education. If the organ shows a particularly clear
example of a specific illness, it may play an important role in the education of medical
students, doctors and nurses. Tissues/organs can only be retained at post-mortem with the
express consent of the next-of-kin.
Donating organs for transplant is handled separately from the post mortem
procedure.
When do post mortems take place?
The post mortem will be carried out as soon as possible, usually within two to three working
days. It may be possible to arrange it within 24 hours if necessary.
Who carries out post mortems?
Post mortem examinations are done by pathologists, who are medically qualified doctors
who have specialised in the study of tissue diagnosis, with help from trained technical staff.
The examinations take place in the mortuary.
What is involved?
A full post mortem examination involves examination of each of the main body systems
including the brain and all the contents of the chest and abdomen. It will normally include
the removal and retention of small tissue samples for examination under a microscope.
Sometimes whole organs may be retained (with your consent) for closer examination. Small
blocks of tissue and corresponding microscope slides retained during or after post-mortem
will be kept permanently in the hospital pathology laboratory and will form part of a
person’s medical records unless you have specified otherwise. In some cases, organs and
tissues may need to be temporarily retained for the preparation of blocks and slides – you
will be told if this is the case. You may have been asked to give written agreement for a
specified organ or organs to be retained for diagnostic purposes by the pathologist.
If you stipulate it, a hospital post mortem can be limited to one body cavity (for example, the
chest) or organ system (for example, the lungs), but this may not provide all possible
information about the disease or cause of death.
The word “autopsy” origins from the Legal autopsy: is performed to detect the cause
unification of the words “auto” and “opsis” of death, identify the predisposing factors,
and has a meaning as “seeing with one’s own determine the time of death and the injuries
eyes” . The word “autopsy” is widely used resulting in death, clarify the formation of
throughout the world and there is no ambiguity injuries and non-legal diseases and provide
about its meaning. A synonymous word expert reports for the court .
“necropsy” means the dissection and the
examination of the corpse but is less The main objectives of the legal autopsy are
frequently used . The term “post-mortem as the following:
examination” is widely used in the United • Defining whether the remnants belong to a
Kingdom, but this term does not provide any human or an animal.
information about the content of the • Determining the identity, the size and the
examination or whether any dissection is physique of the corpse,
performed after the external examination. • Determining the time of death,
• Determining the cause of death,
Although medical regulations and law systems • Identifying the mechanisms (conditions and
vary across the world, there are 2 basic types form) of death (detection of the findings that
of autopsies as legal and medical autopsies. help to determine the origin),
• Detection of proofs of injury due to assault,
Medical autopsy: is the kind of autopsy that is suicide or accident,
performed to reveal pathological etiologies, to • Defining the proofs that reveal the time
examine the relationship between the clinical between the injury and death,
incidents and anamnesis, to determine the • Defining the order of injuries,
variations and the causes of the variations • Identifying the movements after injury and
(environmental effects, diseases...), to evaluate detecting the
the accuracy, convenience, validity of the duration and the distance of movements,
diagnosis and the treatment, to investigate • Determining the injuries (external and
unknown contagious and genetically diseases internal), describing and sizing the injuries,
and for educational and scientific purposes. • Determining whether fatal injuries occurred
Written informed consent from the family at the scene where the corpse is found,
members of the deceased, is essential for • In case of more than one assaulter,
performing the medical autopsy . identifying which of the suspects committed
the injury,
• Detecting whether the newborn was born
alive or showed any capacity to survive,
• Determining the fatal disease (evaluating deceased and the pre-death treatment
the external and the internal abnormalities documents should be evaluated if possible. In
and malformations). case of child abuse, and for determining the
• Preserving organ and tissue samples for number and location of the foreign bodies, X-
providing further proof (sampling for ray should be performed. Autopsy should begin
toxicological, microbiological, histological after completing the preparations and pre-
examinations and etc.) autopsy information collection.
• Collecting photo and documents which
could be as a proof. External Examination
• Delivering the body to his/her family as
undamaged as possible. 1. If the body is clothed, the corpse should be
• Documenting the findings in full photographed and taken into video in
complement clothes, then clothes should be taken off and
their relationship with the wounds and the
Autopsy should be performed in the detail of clothing should be noted.
following; 2. After taking off all the clothing, the body is
photographed and taken into video as
In all traumatic and suspicious deaths in which completely naked.
no certain cause of death could be determined, 3. Identification of the corpse is performed by
autopsy should be performed. These include; the Prosecutor’s Office by showing the
• Murder or suspicion of murder corpse to the witness.
• Child abuse 4. In the identification the following should be
• Intoxication determined: Age, gender, skin color, weight,
• Asphyxiation due to drowning or hanging height, body structure, hair and eye (both
• Sudden deaths including sudden infant the color of the iris and the sclera, the status
death syndrome of the pupils, the sclera and the
• Suspicion of human rights violation such as conjunctiva), congenital and acquired
torture or maltreatment deformities, tattoos and previous medical
• Suicide intervention findings.
• Malpractice suspect 5. Postmortem changes: rigor mortis, livor
• Transportational, occupational or domestic mortis (distribution, shape, color, intensity),
accidents the temperature of the body (rectal, sub
• Occupational diseases hepatic temperature), putrefaction findings
• Natural-technological disasters are recorded.
• Corpses with no id or corpses found in 6. Environmental changes are noted (e.g.
skeletal form animal bite,
• Deaths in dormitories or hotels
• Deaths in prison, detention cell or during
military activities.
The Autopsy Procedure
Before performing the autopsy, information
about the incident should be gained from the
legal departments, family members of the
environmental temperature, the 5. Temporal muscles on both sides are
environmental state of the incident scene). dissected downwards starting from the
7. In suspicion of any legal incident, upper insertion point of the muscle.
sampling for DNA isolation from 6. A complete and circumferential saw cut is
underneath the nails, the genital and anal made, starting about 2 cm above the orbita
regions is performed. and the auricle on both sides. A
8. Any recent traumatic lesions, their supportive triangular structure is formed
anatomical localization and characteristics via this section, with the occipital bone
(size, width, depth, and margin being the base of the triangle and the
characteristics) are recorded. merging point of the lambdoid and the
9. Detailed examinations of the mouth, the sagittal sutures as being the apex of the
oral cavity, armpits and genital area are triangle.
performed since lesions in these areas are 7. Calvarium is removed by the raspatorium.
easily omissible. 8. Dura is examined and superior sagittal
10. Blood drawn from the femoral vein, sinus is inserted. Dura mater is cut in a
aqueous humor and urine drawn from the parallel fashion to the incision line.
suprapubic region are sampled in 9. CSF sampling from the lateral ventricles
accordance with the varying laboratory can be performed at this stage.
conditions. 10. Tentorium is made accessible by cutting
11. External examination forms for some the olfactory bulbi, optic chiasm, cranial
characteristic cases are shown below. nerves and vessels. By inserting the
bistoury into the petrous part of the
Internal Examination temporal bones, tentorium’s are excised.
The remaining cranial nerves and vessels
For the internal examination, all the organs are cut and passed down through the
which are excised from their anatomical foramen magnum and the spinal cord is
regions should be weighed and their surface transected as far down as possible. Thus the
characteristics should be described. Weight of brain, the cerebellum, the brain stem and
samples, sent for histopathological and the upper segments of the spinal cord are
toxicological examination should also be excised.
noted. 11. The surface characteristics of the brain, the
cerebellum, the brain stem and the upper
Examining The Skull segments of the spinal cord are recorded.
12. Arteries forming the Willis polygon are
1. A circumferential cut connecting the two examined in detail.
auricles is made, 13. The cross-sections of the brain are as the
starting just above the mastoid process. following:
2. Soft tissues between the scalp and the skull • The 1st Cross-Section: is made through the
are dissected by temporal lobe
bistoury in a blunt fashion. • The 2nd Cross-Section: is made through the
3. Scalp is peeled off from the forehead to the optic chiasm
occiput. • The 3rd Cross-Section: is made through the
4. Scalp is peeled off till the eyebrow line and mammillarbodies
peeled back over
the face.
evaluated via pulling the precordium
• The 4th Cross-Section: is made through the upwards with a forceps and making a
anterior part of the pons upside down Y shaped cut. In the presence
• The 5th Cross-Section: is made through the of any fluid, the amount and the
posterior part of the pons characteristics of the fluid are recorded.
14. Dissection per 1 cm is performed on the 10. Organs inside the mediastinum are
brain stem. examined including the inspection and the
15. After examining the dural sinuses and the palpation and blood is drawn from the heart
hypophysis gland, dura is stripped out and if necessary.
the cranium is examined. 11. Main vessels ascending from the heart are
excised with transection being as far from
Examining The Thorax the heart as possible. Heart is weighed. The
external appearance and vascular structures
1. Regarding the first four ribs, the chest wall are examined. The right atria is incised by
along the midclavicular line is punctured tracking the blood flow and the vena cava.
via the needle of the syringe and After opening the right atria, the right
pneumothorax test is performed by ventricular wall is cut across the apex. Right
removing the piston and filling the syringe ventricle wall is cut closely to the apex and
with water. pulmonary arteries are opened. Pulmonary
2. An incision starting from the submental veins are cut across and left atrial appendix
region and ending in the pubic region is is opened. Left ventricle wall is cut till the
made, leaving the umbilicus on the right apex. Transection is widened from right
side of the incision line. under the mitral valve to the ascending
3. Pectoral muscles are flayed off to both aorta. Ostia of the coronary arteries are
sides. A dissection allowing the inspection examined. Left circumflex, left anterior
of the ribs and the sternum is made by descendant and right coronary arteries are
stripping off all the soft tissues over the examined by performing transections. The
chest wall. septum and the anterior wall of the left
4. Careful examinations including the ventricle are transected. Atria’s, ventricles,
inspection and the palpation of the chest valves, papillary muscles, corda tendinous
wall, the sternum and the ribs are and the septum are examined and weighed.
performed. 12. Lungs are removed out of the thoracic
5. Height of the diaphragm is measured. space. Hilar structures are cut and lungs are
6. By using either electrical saw or knife, ribs removed. Lungs are weighed and taken to
are dissected from the bone-cartilage joint, the dissection board. Main bronchi, lobar
with caution not to damage the thoracic bronchi, pulmonary arteries and veins are
organs. cut open. By placing the knife on the
7. Intercostal muscles and diaphragm are cut bifurcation notch of the main bronchi, a
with a knife and the lateral cut is made. Intrapulmonary vessels
sternum is released. and bronchi over the surface of the
8. After removing the sternal valve, the
thoracic cage, the thoracic cavity, the skin
and the subcutaneous tissues are examined.
9. Heart is removed. Presence of any fluid is
cross-section are opened. 1 cm thick slice bone is revealed. A careful examination
cross-sections are taken. Samples are containing inspection and palpation is
collected from each lobe for toxicological performed.
and histopathological examinations 9. Common carotid arteries, internal jugular
veins are released
Removal of the Neck Organs and dissected .
1. A dissection starting from the frenulum is Examination of the Abdomen
performed, teeth and the oral cavity are
examined. Afterwards dissections of the 1. Abdomen is inspected with regards to
skin and the subcutaneous tissue are abdominal organs being in their anatomical
performed starting right below the chin positions and examined for the presence of
and ending on the jugular incisura. After any fluid or blood.
performing careful examination of the 2. By moving the bowels to both sides,
neck muscles, a graded dissection is retroperitoneal region and organs are
performed. examined.
2. During the graded dissection, the 3. Duodenum is opened and its mucosa is
sternocleidomastoid muscle as well as the cleaned and by palpating the
other neck muscles, is pulled from the hepatoduodenal ligament, biliary flow to
nearby tissues with a forceps at one end the duodenum is examined.
and dissected with a bistoury, with caution 4. Falciforme ligament and other ligaments
to preserve its structure. which connect the liver to the diaphragm
3. Through the submental region the floor of are cut.
the mouth is incised by bistoury, the lower 5. Liver is removed by cutting the hepatic
pharynx is removed, the tongue is freed arteries, hepatic veins, the portal vein and
and taken out by hand. the choledoch duct.
4. Neck organs are freed by dissecting the 6. Liver is weighed and placed over the
vertebral column from dissection board. Macroscopic surface
the nearest spot to the end. findings are recorded. Liver is dissected in
5. Esophagus is fastened at its inferior end. 1-2 cm slices.
6. Esophagus is opened using scissors and its 7. Spleen is pulled out and the hilus is cut,
lumen is examined. thus the spleen is freed and removed. A
7. Larynx and trachea are cut upside down deep incision through the axis is made and
with scissors and examined internally. parenchymal characteristics are evaluated.
8. Careful examinations of the hyoid bone 8. The two strings that are tied at the duodenal
and the thyroid cartilage are crucial for the level and stomach is removed by cutting at
autopsy. These structures are especially the half of the strings. Stomach is opened
important in case of any neck trauma. with an incision to integrate both
After freeing the tongue, tongue is sticking sphincters on the minor curvature.
out using the left palma and tissues Stomach content, its characteristics,
connecting the major horns of the hyoid structure, viscosity and liquidity are
bone and the upper horns of the thyroid recorded. Sampling of the content is
cartilage are dissected with the bistoury on performed for the toxicological
the right hand. By deepening the incision, examination.
nearby tissues are dissected and the hyoid
9. Pancreas is dissected and removed from the 14. Spermatic cord is found under the inguinal
surrounding tissue. ligament and testicles are taken out with
10. Kidneys along with the adrenals are care in male cases. Prostate gland is
removed from the retroperitoneal region dissected.
together by a straight blunt dissection. 15. Suprapubic urine sampling from the
11. Small intestines are removed from their bladder is performed for the toxicological
meso and taken out. examination (1,4,5,11,20,24).
12. Insertion points of the large intestines are
cut one by one, starting from the caecum. After the completion of the autopsy, the body
Sigmoid colon is tied using 2 strings and should be reconstructed and organs should be
cut right in the middle and freed. sutured back to their places. After completely
13. Pelvic organs such as uterus, both ovaries, closing and cleaning the body, the corpse is
phallopian tubes and 1/3 upper part of the handed to the family members with an
vagina are removed all together as a “inhumation and transportation license” which
complex, in female cases. is conducted by the Prosecutor’s Office.
Evaluation of the Firearm Injuries
External Examination Findings
(Should be filled separately for every single wound.)
Wound No:
Scopy Examination (The body localization, number of the metallic bodies and their characteristics):
Clothes:
Photography : Distance Shot: Close Shot:
The localization of the wound, its distance to the main anatomical structures, to the apex of the head and to the midline:
Characteristics of the wound: (Size, shape)
Carbon black: Yes No Burnt: Yes No Gunpowder remnants: Yes No
Barret mark: Yes No Tattoos around the entrance wound: No
Yes
Characteristics and the qualities of the medical interventions which are applied to the wound:
Evaluation of the Sharp/Sharp-Penetrating/Penetrating/Sharp-Crushing Object Injuries
External Examination Findings
(Should be filled separately for every single wound.)
Wound No:
Photography : Distance Shot: Close Shot:
Quality of the wound: [ ] Cut [ ] Sharp-Penetrating Object Wound [ ] Sharp Object
Wound [ ] Sharp-Crushing Object Wound
The localization of the wound, its distance to the main anatomical structures, to the apex of the head and to the midline:
Characteristics of the wound: (angle, margin, depth, length, tail, route, its location as
clockwise): Characteristics and the qualities of the medical interventions which are applied to
Evaluation of the bodies which are pulled out of the water
External Examination Findings
Evaluation of the hanging cases
Photography : Distance Shot: Close Shot:
External Examination Findings
Maceration Findings (Especially on the hand and the feet skin):
Conclusion
Photography : Distance Shot: Close Shot:
The characteristics of the rope or the hanging material (color, length, type of the knot, surface characteristic, width etc.):
Goose bumps (Cutis anserine):
Development of standardized
Livor mortis (Especially application methods, are required for medical autopsies to serve in
on hands and feet’s):
accordance withthetheir
White froth around goals.
mouth and These
the nose (color, standardized application protocols would help in making
size and other characteristics):
Ligature
more mark (its location with regards to the thyroid cartilage,
accurate diagnosis as well as lessening the center-origin its distance to both auricles,
bias width, depth,odds
and the color changes
of false around
results.
Sand
the and water plant contamination:
mark):
These developments would also be helpful for performing better supervision. Use of external
examination (Face, finding
Trauma findings:
Petechial forms would help to detect findings easier and provide better retrospective
eyelid, conjunctiva,
data categorization, especially in specialized cases. These forms are designed to be used in both
etc.): Other traumatic findings:
medical and legal autopsies, detailed photography section is included and case- specific
procedures, such as scopy examination in firearm injuries are defined. We believe that by using
standardized forms that fit the national conditions, clearing personal and departmental bias and
increasing the reliability of autopsies via developing better supervision, would be easier.
Good luck for your exams as well your future.
Drsajjad Ul Hadi