Whenever required, the scene of death should be visited by a doctor and all features of the scene as well as the body documented, using photography, sketch or diagram.
The following Protocol should be followed during the autopsy in addition to the procedures described under Autopsy procedure.
a. Serial photographs reflecting the course of the external examination must be included. Photograph the body prior to and following undressing, as well as before and after washing, cleaning and/or shaving.
b. Photographs should be comprehensive and must confirm the presence of all demonstrable signs of injury or disease recorded in the autopsy report.
c. X-ray should be considered in case of charring of body and/or gunshot wounds.
- Documentation of injuries is the most crucial aspect of autopsy examination. All injuries should be documented, fresh or old, recording the following:
- Location (related to anatomic landmarks)
- Depth and structure involved
- Photograph all injuries should be photographed with unique identification number and scale, oriented parallel or perpendicular to the injury.
- In addition, the following should be documented and photographed:
- Areas of keloid formation
- Areas of increased or decreased pigmentation
- Anything distinctive or unique e.g. birthmarks
- In addition to the normal injury documentation, bruised should be incised and their extent delineated.
Head and neck:
- Hair should be shaved, where necessary, to help visualise the surroundings of an injury. Photographs should be taken before and after shaving as well as after washing the site.
- Examine the teeth and note their condition. Record any findings such as absent, loose or damaged teeth as well as all dental work (restorations, fillings, etc). Check the inside of the mouth and note any evidence of trauma, injection sites, needle marks or biting of the lips, cheeks or tongue. Note any objects or substances in the mouth.
- In cases of suspected sexual assault, collect a swab for semen analysis. (Swabs taken at the tooth-gum junction and samples from between the teeth provide the best specimen). Dry the swabs quickly with cool, blown air if possible, and preserve them in clean plain paper envelopes.
- Examine the nose and ears and note any evidence of trauma, haemorrhage or other abnormalities.
- Examine the neck externally on all aspects and note any contusions, abrasions or petechia.
Chest and abdomen:
- Note any bite marks; these should be photographed to record the dental pattern, swabbed for saliva testing (before the body is washed). Bite marks should ideally be analyzed by a forensic odontologist, if possible.
- Back and buttocks must be systematically examined for deep soft tissue injuries using the Fourth incision method (described by A.J. Patowary).
- Note any puncture wounds or marks of injection and excise the skin, a few cms on all sides, for toxicological evaluation.
- Examine all surfaces of the extremities, in particular for the presence of ‘defence wounds’ – arms, forearms, wrists, hands, legs and feet
- Note any broken or missing fingernails. collect and document finger nail clippings and any under-nail tissue (nail scrapings), as required.
- Examine the beds of fingernail and toenail for trace evidences or evidence of injuries
- Wrists and ankles must be systematically incised to look for deep soft tissue injuries
- The shoulders, elbows, hips and knee joints must also be incised to look for ligamental injury
- The soles of both feet must be carefully examined, noting any evidence of injury. The extent of injury should be delineated by incising the soles. The palms and knees should be carefully examined for glass shards or lacerations.
- The external genitalia should be routinely examined for the presence of any foreign material or semen stains
- The inner thighs and peri-anal areas should also be carefully examined to look for injuries.
- In suspected cases of sexual assault, all potentially involved orifices should be swabbed, for semen analysis (acid phosphatase and spermatozoa), before being carefully examined. Swabs should be dried in cool, blown air if possible, and preserve them in clean plain paper envelopes. A speculum may be used to examine the vaginal walls.
- The pubic hair should be combed with a new comb and all loose hair collected. A control sample of the deceased’s hair (pubic) should also be collected.
- Be systematic in the internal examination as mentioned in autopsy procedure.
- The internal examination should clarify the extent of injuries and/or assist in developing a relation of causality between the external injuries and internal findings.
- Deep incision of soft tissue over the palms, soles, back, buttocks, as well all four extremities should be performed to demonstrate soft tissue injuries.
- After completion of the autopsy, All specimen collected should be recorded and labelled with the name of the deceased, the autopsy identification number, the date and time of collection, the name of the doctor as well as a brief description of the contents. It may be necessary to collect dual sets of samples, especially in cases of alleged violation of gross human rights and torture, for validation of laboratory findings.
- The specimen should be carefully preserved and chain of custody, with appropriate release forms, maintained.
- Appropriate ancilliary investigation should be performed, if possible, or a request made to a higher center for the same.
The Fourth incision by Amarjyoti Patowary
- (A.J Patowary, The Fourth incision – A cosmetic Autopsy Incision Technique. Am J Forensic Med Pathol. Vol 31 (1) 2010 – pp 37 – 41)
- (A.J Patowary, The Fourth Incision – A Few Modification in Autopsy Incisions. J Indian Acad Forensic Med. Vol 32(3) – pp 234 – 238)
It is recommended that AJ Patowary’s ‘Fourth Incision’ be used for maximum exposure of soft tissue of the entire body. The procedure is as follows:
- Steps of Incision
- Exposure of the posterior aspect:
- Positioning the body –
- Body is placed in prone position with a wooden block under the shoulder, so that the neck is flexed anteriorly.
- Incision on the back –
- A scalp incision is made from the mastoid of one side to the mastoid of the other side in coronal plane through the vertex as in the conventional methods.
- From the mastoid process, the incision is extended to the posterior aspect of acromion process through the posterior border of the sternocleidomastoid and then through the posterior border of the trapezius bilaterally
- A curved incision is made bilaterally from the tip of acromion up to the mid axillary line just below the axilla through the medial border of the posterior aspect of the shoulder joint which is then extended up to the iliac crest through the mid axillary line bilaterally.
- Reflection of the posterior flap:
- The posterior flap of the scalp is reflected back up to the occiput and anteriorly up to the supra-orbital ridges. The posterior flap is then reflected back making superficial strokes by the scalpel on the subcutaneous tissues and continued through the neck, then the chest and back of the abdomen up to the superior border of sacrum. In this way, the whole flap of the skin is reflected back up to the superior border of the sacrum exposing the whole of the back of the head, neck, chest and abdomen simultaneously.
- Positioning the body –
- Exposure of the anterior aspect
- Positioning the body
- After completion of the examination of the posterior aspect, the flap of the skin is reflected back and the body is turned back to the supine position with a wooden block under the shoulder to keep the neck in extended position.
- Incision in the front:
- A curved incision is made from the acromion process through the medial border of the shoulder joint to the mid axillary line bilaterally, as was made posteriorly.
- Another incision is made from the mid axillary line on the iliac crest bilaterally over the inguinal ligament, to meet at the symphysis pubis .
- The skin with the superficial tissue flap is reflected up, up to the root of the neck and then to the inferior margin of the mandible bilaterally taking care not to injure the neck structures and the rectus sheath.
- This way, the whole of front of the neck chest and abdomen is exposed.
- Opening the abdominal cavity:
- To open the abdominal cavity, a para-medial incision is made on the rectus near the symphysis pubis, which is extended upward by keeping the index and the middle fingers as guard up to the xiphoid process using a scissors or enterotome.
- Opening the thorax:
- The sternum is removed by cutting at the costochondrial junction and then separating the sterno-clevicular joint. Now after separating the diaphragm, the whole of the thorax and abdomen can be examined.
- Positioning the body
- Exposure of the posterior aspect:
- Closing the incisions
- The sternum is replaced back to its position. The abdomen is closed by stitching the rectus. Now the flap of the skin is replaced back. The incision over the inguinal ligament is stitched first then the bilateral mid axillary incisions up to the axilla. Then the stitches are continued in the front on the curved incision in the medial border of the shoulder. The body is then turned back to stitch the curved incision on the medial margin of the shoulder joint in the back and then on the incisions on both sides of the posterior aspect of the neck up to the mastoid process and then continued to close the scalp incision.