Introduction_and_principles_of autopsy
- 2. MEDICOLEGAL ▪ In cases of violent ,suspicious or sudden deaths ▪ Deaths without medical assistance or during surgical procedure PATHOLOGICAL ▪ Performed to diagnose a particular disease or for research purpose ▪ Aim to determine clarify or confirm medical diagnosis that remained unknown or unclear prior to the patients death
- 3. COURTS OF LAW ▪ CIVIL Court ▪ CRIMINAL Court - Supreme court High court Sessions court Juvenile court
- 4. ▪ Ultimate medical audit ▪ Five different rulings for manner of death: natural, accident, homicide, suicide, or undetermined ▪ AUTOPSY (NECROPSY)- Postmortem examination of body
- 5. HISTORY …. ▪ 460–370 B.C. No autopsies yet. Greek physician Hippocrates reasoned that diseases had natural rather than supernatural causes.He establishes the humoral theory ▪ 44 B.C- first recorded autopsy , when Antistius examines Julius Caesar’s body after his assassination, determining which of the 23 stab wounds proved fatal.
- 6. ▪ GALEN(129-201 AD)-Performed dissections on animals,primates ▪ FREDERICK II (1194-1250)-Authorised human dissection ▪ Karl rokitanski(1804-1878)-Performed more than 30,000 autopsies
- 7. TECHNIQUE OF R. VIRCHOW ▪ Organs are removed one by one ▪ Used most widely, often with some modifications ▪ First step was to expose the cranial cavity and, from the back, the spinal cord, followed by the thoracic, cervical, and abdominal organs
- 8. ADVANTAGE ▪ Quick ▪ Suitable for beginners DISADVANTAGE ▪ Difficult to evaluate interrelationship between organs
- 9. TECHNIQUE OF C. ROKITANSKY ▪ Characterized by in situ dissection, in part combined with the removal of organ blocks ▪ Connections between organs disturbed as little as possible
- 10. ▪ ADVANTAGES To limit spread of infections such as hepatitis B,HIV (infected bodies) ▪ DISADVANTAGE Organs cannot be studied in detail
- 11. ZENKERS TECHNIQUE ▪ Connection between physiologically related organs were maintained ▪ Separation may occur only when a closer view of pathological changes is otherwise not possible or found technically too difficult
- 12. TECHNIQUE OF M. LETULLE ▪ Thoracic, cervical, abdominal,and pelvic organs are removed as one organ block (“en masse” removal) and subsequently dissected into organ blocks
- 13. ADVANTAGE ▪ Preservation of connection between organ and organ system DISADVANTAGE ▪ Organ mass is awkward to handle
- 14. OBJECTIVES OF AUTOPSY 1.BENEFITS TO PHYSICIAN / HEALTH CARE ORGANISATION ▪ Goldstandard for evaluating treatment outcome and therapy ▪ Alert hospital inspections ▪ Decrease hospital and physician malpractise risk 2.BENEFITS TO FAMILY OF DECEASED ▪ Identify hereditary or contagious diseases ▪ Genetic counselling ▪ Determination of insurance benefits or workers compensation
- 15. 3. BENEFIT TO PUBLIC HEALTH ▪ Detection of contagious diseases ▪ Identification of environmental hazards ▪ Accurate vital statistics 4.BENEFIT TO MEDICAL EDUCATION 5.BENEFIT TO MEDICAL DISCOVERY AND APPLIED CLINICAL RESEARCH
- 16. 6.EVALUATION OF TOXIC EFFECTS OF DRUGS,EFFICACY OF NEW THERAPIES 7.BENEFITS TO LAW ENFORCEMENT AND JURISDICTION
- 17. TYPES OF AUTOPSY ▪ Immediate autopsy ▪ Needle autopsy ▪ Endoscopic autopsy ▪ Post operative autopsy ▪ Virtual autopsy
- 18. IMMEDIATE AUTOPSY ▪ For the preservation of cytological detail or growth in tissue culture ▪ Postmortem interval is very short ▪ FIRST PHASE -modified “Y” incision mini-incisions
- 19. NEEDLE AUTOPSIES ▪ Used to obtain tissue samples when , more invasive procedures, as described under “immediate autopsies,”are not possible. ▪ May be the case in tropical countries if proper infection precautions cannot be taken ▪ All efforts to obtain permission for a regular autopsy fail but the next of kin agree to multiple sampling by needle. ▪ Inferior to conventional autopsies
- 20. ENDOSCOPIC AUTOPSIES Indications may be the same as those for needle autopsies
- 21. POSTOPERATIVE AUTOPSIES▪ Pathologist is rarely familiar with all operative techniques that may have been used, the complications that were encountered Following general guidelines should be observed: 1. Most experienced autopsy pathologist should do postoperative cases 1. Surgeon or one surgical assistant who participated in the operation should attend the autopsy 1. Autopsy technique should be changed as required by the specific situation
- 22. VIRTUAL AUTOPSY(VIRTOPSY) ▪ Employs imaging methods that are also used in clinical medicine such as computed tomography (CT), magnetic resonance imaging (MRI), etc 1. Alternative to standard autopsies for broad and systemic examination of the whole body as it is less time consuming, 2. Aids better diagnosis, 3. Renders respect to religious sentiments
- 23. THE AUTOPSY ROOM.. ▪ Should have at least two mortuary tables preferably of stainless steel with arrangements for free drainage of a constant flow of water from top to bottom ▪ A proper vent and duct system needs to be installed for exit of foul smelling gases and entry of fresh air. ▪ There should be large charts depicting weights and measurements of viscera, bones etc. for quick reference for autopsy surgeon
- 24. ▪ The floors should be constructed of materials like granite and walls with epoxy which facilitate easy cleaning with a slope to a main drain ▪ There should be X-ray view boxes in these rooms for seeing x-ray film ▪ Portable x-ray machine should be available.
- 26. INSTRUMENTS
- 28. OTHER MATERIALS ▪ Glass slides ▪ Coplin jar with fixatives for cytology ▪ Spirit lamp/spatula ▪ Culture broth ▪ Swabs ▪ Weighing scales
- 29. PRELIMINARY EXAMINATION ▪ Identification ▪ Signs of death – Cessation of respiration,heart beat and functional activity of nervous system ▪ ALGOR MORTIS ▪ LIVOR MORTIS ▪ RIGOR MORTIS
- 30. ALGOR MORTIS ▪ Progressive chilling of the body ▪ Body becomes cold within 8-17 hours ▪ This may be noted in the uncovered parts of body within 4-5 hours ▪ Immediate surroundings of body and outside temperature influences
- 31. LIVOR MORTIS ▪ Postmortem accumulation of blood in the dependant parts ▪ 20-30 minutes after death ▪ Not permanent at first,shifts with change in position of body ▪ After 3-4 hours livor spots become stationary ▪ Pressure points- shoulder girdle,buttocks and heels do not show livor mortis (supine body) ▪ Lead blue in color ▪ Light red in CO poisoning and cyanide poisoning
- 32. RIGOR MORTIS ▪ Rigidity or stiffness of muscles ▪ 2-4 hours after death ▪ Head,face ,neck>Thoracic and abdominal muscles>upper extremity>lower extremity ▪ Completed in 6-8 hours ▪ Disappears after 12-48 hours (jaw and neck>lower extremity) ▪ Early appearance-fever,strychnine/pilocarpine/atropine poisoning, deaths due to lightning or severe haemorrhage
- 33. INSPECTION OF BODY ▪ Height /Weight ▪ Chest circumference ▪ Abdominal circumference ▪ Leave indwelling central lines/endotracheal tubes/feeding tubes/urine catheters to confirm their location ▪ Signs of external injury /laceration/gunshot/strangulation
- 34. ▪ Edema ▪ Jaundice ▪ Petichae-Blood dyscrasia,asphyxia or septicemia
- 35. SKIN DISEASES ▪ Sections to be taken from skin lesions and put in 10% formalin ▪ Bullae in palms and soles in newborns – congenital syphilis ▪ Acute dermatitis,boil around nails may be source of septicaemia or pyaemia ▪ Chancroid/granuloma inguinale present as ulcers in inguinal region and genitals ▪ Psoriasis-dry papules covered by fine silvery scales ▪ Lichen planus – shiny violaceous papules
- 36. ▪ Tattoo marks ▪ Lipomas/angiomas ▪ Keloids ▪ Skin tumors
- 37. ▪ Lower limb deformities ▪ Clubbing ▪ Eye-artificial eye/petechial haemorrhages/cataract/pupils ▪ Teeth-artificial dentures ▪ Neck- position of trachea,size and consistency of thyroid gland ▪ Lymph nodes-neck,axilla,inguinal ▪ Caput medusae
- 38. ODOR ▪ Foul odor-gangrene and putrefaction ▪ Urine odour in lungs-uraemia ▪ Diabetes-Sweet odor ▪ Cyanide and nitrobenzol poisoning- bitter almond smell ▪ Phosphorous poisoning – onion smell
- 39. OPENING THE BODY ▪ Before opening- A wooden block should be placed under the lower portion of spinal column ▪ INCISION- Y shaped incision ▪ This incision makes the axillary region and neck organs easily accessible
- 42. ▪ Breasts-should be cut from within ABNORMALITIES OF BREAST ▪ Malformations ▪ Lactating breast ▪ Abscess ▪ Acute mastitis/cysts ▪ Haematoma/fat necrosis ▪ Lipoma/papilloma/carcinoma/sarcoma ▪ Tuberculosis ▪ Fibroadenoma
- 43. PERITONEAL CAVITY ▪ Inspect peritoneal cavity and omentum ▪ Peritoneal surface – smooth glistening and transparent ▪ Smooth – absence of acute inflammatory exudate ▪ Glistening – normal continuity of lining cells ▪ Transparency – absence of foreign tissue between lining cells and underlying tissue
- 44. ▪ Measure and charecterise ascitic fluid ABNORMALITIES OF PERITONEUM ▪ Ascites ▪ Hemoperitoneum ▪ Inflammation of peritoneum ▪ Foreign bodies /fat necrosis ▪ Congenital anomalies – meckels diverticulum/adhesions/fibrous strands/mesentry length ▪ Pseudomelanosis
- 45. CHECKING FOR PNEUMOTHORAAX ▪ Fill the space between ribs and thoracic skin flap with water ▪ Cut through first intercostal space
- 46. ▪ Cut cartilaginous portion of the ribs with a rib knife,cut should be somewhat parallel to the costochondral junctions
- 48. PLEURAL CAVITY ▪ Adhesions – torn with ease or difficulty ▪ Inspect thoracic duct ▪ Hydrothorax ▪ Haemorrhage ▪ Pneumothorax ▪ Acute pleuritis ▪ Healed pleuritis ▪ Empyema/TB ▪ Tumors
- 49. PERICARDIAL CAVITY ▪ Note position of heart and relation to lungs ▪ Open pericardial sac with scissors by cutting a triangular flap starting from the apex of the heart ▪ Blood culture can be taken ▪ Normally 20-50 cc of fluid present in the pericardial cavity ▪ Dissect thoracic duct by lifting up the right lung and placing it over the heart
- 50. ▪ The brachiocephalic,left common carotid and left subclavian arteries are ligated close to their points of origin and a long segment of ligature to be exposed
- 51. REMOVAL OF ORGANS FREEING OF RECTUM
- 52. CUTTING THROUGH THE LEFT PORTION OF DIAPHGRAM
- 53. CUTTING THROUGH LEFT PORTION OF DIAPHRAGM
- 54. REFERENCES ▪ Handbook of autopsy practise , Jurgen Ludwig, 3rd edition ▪ Autopsy diagnosis and techniques ,Otto Saphir ,4th edition ▪ Synopsis of forensic medicine and toxicology, KSN Reddy,29th edition
- 55. THANK YOU