Views on suicide have been influenced by cultural views on existential themes such as religion, honor and the meaning of life. The Abrahamic religions consider suicide an offense towards God due to religious belief in the sanctity of life. In the West it was often regarded as a serious crime. Japanese views on honor and religion led to seppuku (also called hara-kiri), one of the most painful methods of suicide, to be respected as a means to atone for mistakes or failure, or as a form of protest during the samurai era. In the 20th century, suicide in the form of self-immolation has been used as a form of protest, and in the form of kamikaze and suicide bombing as a military or terrorist tactic. Sati is a Hindu funeral practice in which the widow would immolate herself on her husband’s funeral pyre, either willingly, or under pressure from the family and in-laws.
Medically assisted suicide (euthanasia or the right to die) is currently a controversial ethical issue involving people who are terminally ill, in extreme pain, and/or have minimal quality of life through injury or illness. Self-sacrifice for others is not usually considered suicide, as the goal is not to kill oneself but to save another.
CLINICAL AUTOPSY;
Clinical autopsies are necessary for two main reasons
• To gain insight into the factors leading to pathology and death.
• To ensure the standard of care at hospitals.
Autopsies can yield insight into how patient deaths can be prevented in the future. In some countries clinical autopsies can only be carried out with the consent of the family of the deceased person. They are necessary in clinical medicine because they identify the medical errors and help medical personnel for continous improvement.
Fig 7 Photograph TISSUE SHOWING PATHOLOGY
FORENSIC PATHOLOGY:
It is a branch of pathology concerned with determining the cause of death by examination of a cadaver. Here autopsy are performed by the pathologist at request during the investigation of criminal and civil cases. Forensic pathologists are also frequently asked to confirm the identity of a cadaver. Physical examination of the body both external and internal examination is necessary for pathologist in order to assign the cause or causes of death.
Fig 8 Photograph Cadaver dissection table
EXTERNAL EXAMINATION:
Person who will be responsible for handling, cleaning, and moving the bodies are called as DIENER the German word for servant. Once the body is received it has to be photographed. Examiner has to note about the clothes, their position on the body before they are removed. Evidence such as residue, flakes of paint or other material is collected from the external surfaces of the body. Ultraviolet light may also be used to search body surfaces for any evidence not easily visible to the naked eye. Samples of Hair, Nails and the like are taken, and the body may also be radiographically imaged if necessary.
Fig 9 Photograph samples showing dress used by individual when last met
Fig 9a Photograph samples showing Hair sample
Once the external evidence is collected body has to be undressed and careful examination is necessary for injuries /wound present of body surface. If any injury/wound noted complete description is necessary The body is then cleaned, weighed and measured in preparation for the internal examination.
The body is transported to autopsy room and placed on a table. Body regarding ethnicity, sex, age, hair color and length, eye color and other distinguishing features (birthmarks, old scar tissue, moles etc) has to be noted. A standard examination form is normally used to record this information. Countries like in France, Germany and Canada, an autopsy may comprise an external examination only. They consider that medical records, history of deceased and circumstance of death will indicate caus and manner behind death, hence internal examination is not necessary. This concept is sometimes termed a “view and grant”.
Fig 10 external examination suggests death due to blood loss (hemorrhage and Shock.
INTERNAL EXAMINATION;
Before examining the internal organs it is necessary to prepare the body for proper visualization. It can be achieved by placing a plastic or rubber brick ( “body block”) under the back of the body, allowing neck to fall back, pushing chest upward and allowing the arms stretching to make it easier to incise and cut open. This gives the prosector, a pathologist or assistant, maximum exposure of the trunk. Following the exposure internal organs has to be incised and removed inspected carefully for any evidence of trauma or other indications of the cause of death.
Internal examination can be achieved by incising the body. Different approaches available includes,
• Large and deep Y-shaped incision: here incision should be given at the top of each shoulder, running down the front of chest meeting at lower point of sternum. It is often used in forensic autopsies where maximum exposure of structure is necessary for detailed examination. Example in cases of suspected strangulation.
• T-shaped incision: incision is made from the tips of both shoulder, in a horizontal line across the region of the collar bones to meet at the sternum (breastbone) in the middle. This initial cut is used more often to produce a more aesthetic finish to the body when it is re-constituted as stitching marks will not be as apparent as with a Y-shaped incision
• A single vertical cut: it is made from the middle of the neck (in the region of the ‘adam’s apple’ on a male body)
In all of the above cases the cut then extends all the way down to the pubic bone.
Fig 11 Photograph incision given.
During incision bleeding from cut surface may be minimal or absent due to pull of gravity. It can also be directly related to the complete lack of cardiac functionality. However, in certain cases there is undependable evidence to prove that bleeding can be quite profuse, especially in cases of drowning.
An electric saw dubbed a “Stryker saw” is most often used to open the chest cavity. Even shears are used to cut chest cavity to prevent large amount of dust formed due to cut of bone by saw. Simple scalpel blade can also be utilized to cut the bone. Ribs on the lateral sides of the chest cavity and the sternum to be lifted as one chest plate this is done so that the heart and lungs can be seen in situ. In particular the pericardial sac should not be damaged or disturbed from opening. Soft tissue that is attached to posterior side of the chest plate has to be removed by using a scalpel. Lungs and the heart have to be exposed. The chest plate is placed aside which can be replaced at the end of the autopsy. Once the body internal organs are exposed they are removed either in en masse technique of letulle where all organs are removed as one large mass if not by en bloc method of Ghon.
1. The pericardial sac is opened to view the heart. Blood for chemical analysis may be removed from the inferior vena cava or the pulmonary veins. Before removing the heart, the pulmonary artery is opened in order to search for a blood clot. The heart can then be removed by cutting the inferior vena cava, the pulmonary veins, the aorta and pulmonary artery, and the superior vena cava. This method leaves the aortic arch intact, which will make things easier for the embalmer. The left lung is then easily accessible and can be removed by cutting the bronchus, artery, and vein at the hilum. The right lung can then be similarly removed. The abdominal organs can be removed one by one after first examining their relationships and vessels.
2. Some pathologists, however, prefer to remove the organs all in one “block”. Then a series of cuts, along the vertebral column, are made so that the organs can be detached and pulled out in one piece for further inspection and sampling. During autopsies of infants, this method is used almost all of the time. The various organs are examined, weighed and tissue samples in the form of slices are taken. Even major blood vessels are cut open and inspected. Next the stomach and intestinal contents are examined and weighed. This could be useful to find the cause and time of death, due to the natural passage of food through the bowel during digestion. The more area empty, the longer the deceased had gone without a meal before death.
Fig 12 a, b ,c d Photograph Different organ removed during PM
(PALGARISM CHECKED)
RECONSTITUTION OF BODY;
It is an important step which has to be done with an utmost care during autopsy. Reconstitution of the body has to be done so that it can be viewed, if desired, by relatives of the deceased following the procedure. After the examination, the body has an open and empty chest cavity with chest flaps open on both sides, the top of the skull is missing, and the skull flaps are pulled over the face and neck. It is unusual to examine the face, arms, hands or legs internally. All organs and tissue must be returned to the body unless consent is given by the family to retain any tissue for further investigation. Normally the internal body cavity is lined with cotton wool or an appropriate material. The organs are then placed into a plastic bag to prevent leakage and returned to the body cavity. The chest flaps are then closed and sutured back together and the skull cap is placed back in place and flaps are sutured.
Fig 13 Photograph Skull opening
INDICATIONS FOR AUTOPSY:
While a request for autopsy should be made the following criteria indicate situations in which autopsies are particularly warranted,
1. To help explain unknown or anticipated medical or surgical complications.
2. When the cause of death or a major disease is not known with reasonable clinical certainty.
3. To provide reassurance to the family and/or the public regarding the death.
4. When there is unexpected or unexplained death that is apparently natural and not subject to the medical examiner’s jurisdiction.
5. In a natural death possibly subject to, but waived by, the medical examiner, such as person dead on arrival at hospital.
6. In a death in which the patient sustained or apparently sustained an injury while hospitalized.
7. When an unexpected or unexplained death occurs during or following a diagnostic procedure and/or therapy.
8. To disclose a known or suspected illness that may have a bearing on surviving family members or recipients of transplanted organs (e.g., genetic disorders or unsuspected cancer).
9. In death resulting from high-risk infection or contagious disease (for public health concerns).
10. In death known or suspected to have resulted from an environmental or occupational hazard (for compensation or public health aspects).
11. To confirm or further define a prenatally diagnosed condition after termination of pregnancy.
12. In pregnancy loss (miscarriage, spontaneous abortion, or intrauterine fetal demise) or stillbirth.
13. In neonatal (death within 28 days of life) or pediatric death.
14. To correlate anatomic findings with imaging or other diagnostic studies.
15. For educational purposes or in an unusual case.
16. When the patient participated in a clinical trial or protocol.
17. To obtain tissue for research purposes.
While autopsies should be requested in all hospital deaths, certain cases require medical examiner review; by law the coroner can order a post mortem examination in some circumstances, such as accidental death. The coroner’s office will contact you directly about this if it is necessary. Deaths under the jurisdiction of the medical examiner include,
1. Homicide.
2. Suicide.
3. Accidental death (even long after the initial injury).
4. Sudden death in apparent good health.
5. Death unattended by a physician.
6. Suspicious circumstances surrounding the death.
7. Sudden Infant death.
ORAL AUTOPSY:
Similar to general autopsy oral autopsy is a postmortem assessment or examination of an oral cavity. Immediately after registration, all bodies and other evidence found may be brought to the center selected for direct examination. The medical expert performs the general autopsy, often attended by a police officer. The dental expert performs the oral autopsy. His examination should be conducted along particular lines on account of the number of decisive details that he may be able to unveil. Thus, the oral autopsy may require more time than the general autopsy. The first thing is to find and prepare for examination all dental evidence actually present.
If, in a given body, the facial tissues and bones have not been mutilated, dental characteristics may still exist. However, it may prove impossible to force the jaws apart for inspection. This may be the consequence of pronounced rigor mortis or of excessive combustion. It may therefore become necessary to remove a rectangular area of the cheeks, including the lips, in order to expose the facial surfaces of teeth still in position. It may also prove necessary to remove the tongue and the tissues below the mandibular base, in order to be able to move the mandible downward and gain access to the occlusal and oral surfaces of the teeth. When the oral autopsy has been completed, removed parts may be restored to position and fastened with transparent tape. In cases of this type, the teeth themselves are generally clean and can be directly examined and described.
Fig 14 Photograph tongue placed out
If, on the other hand, facial structures and bones are fractured or smashed, it is first necessary to find and to rearrange those parts of the jaws still present. This must be done to see whether there are empty sockets, indicating that the corresponding teeth have been lost. Such teeth must be looked for. They may be lying at some distance or even have been lodged deep in the throat or under the scalp. Single teeth may also have been found lying loose in the accident area and will, consequently, have to be looked for in some separate bag. All teeth that may belong to the body under examination must be tried in their respective sockets to see whether they fit. In this way, remaining parts of the teeth and jaws may be restored to their original positions.
Fig 14 a Photograph Suggestive of antemortem blow on face
ESTIMATING TIME OF DEATH:
Time of death means the exact time where the victim drew his last breath.
different time of death includes,.
• The physiologic time of death, where vital functions of the victim is ceased.
• The legal time of death, is the time that is recorded on death certificate..
• The estimated time of death, is the time that a medical examiner estimates.
Estimated time of death can vary from legal time of death and physiologic time of death. Estimating time of death is necessary for both legal and administrative purpose. When witnesses are not available to the legal authorities for establishing PMI they depend on the medical officers for the approximate establishment of time since death. Determining the time of death is both an art and a science. The medical examiner uses several techniques and observations to make his estimate.
Establishing time of death is important for the investigative officers since it may be helpful in gathering evidence that can support or deny the stated actions of suspects in a crime. Postmortem interval (PMI) is the time elapsed from the moment of death until a corpse is discovered. Time of death and PMI cannot be estimated with 100% accuracy. It can be always a rough estimation, particularly when a body is found in advanced state of decomposition or is recovered from fire, water or ice. Therefore, time of death and PMI are given as estimates, and can vary from hours to days or from months to years, depending on each particular case.
Different methodologies used for establishing postmortem interval can be grouped into,
Visual Method (Conventional method).
Physical Examination.
Histological Examination.
Bio-chemical examination.
DNA & RNA as a marker for PMI.
Forensic Entomology.
Evidence for estimating time of death includes physical evidence present in the corpse (postmortem changes, presence of insects, etc.), environmental evidence such as location where the body was found (indoors, outdoors, buried, burned, in water, etc.), and other evidence found at the crime scene (a stopped wrist watch due to a blow or impact, an answering machine record, phone calls received or made around the time of the assault, etc.), and finally, the historical evidence (habits and daily routine of the victim, relationships, existence of enemies, etc). The knowledge of the internal sequential changes a dead body undergoes in relation to the variations on the rate of their occurrence due to ambient temperature, humidity, and the presence of insects or other predators are all considered when estimating the time of death.
Physical method for estimating time of death includes rate method, where body changes occur which help to measure postmortem (after death) changes that a body undergoes such as cooling rates (algor mortis), stiffening (rigor mortis), initiation and duration, postmortem lividity (discoloration stains), degree of putrefaction, adipocere (body fat saponification), and maceration (tissue softening due to the presence of liquid).
Algor mortis, is the process of body cooling. It is a useful parameter for PMI estimation for first 24hrs after death. generally internal body temperature drops down at known rate. Other factos like temperature, bacterial activity, clothing, body weight, amount of subcutaneous, adipose tissue, surrounding environment has to be considered.
Rigor mortis, or postmortem stiffening and contraction of all muscles occurs after three to four hours after death and can last for approximately 36–48 hours in temperate climates and about 9–12 hours in tropical temperatures. Body position cant be considered as a clue for victim position at the moment of death because body can be moved before rigor begins. Pathologist cannot determine the cause of death during phase of rigor mortis because of changes in internal muscles. For example, rigor mortis dilates the myocardial (heart) muscles, giving it the appearance of cardiac hypertrophy (enlarged heart). Contraction of the iris muscles also dilates the pupils during rigor mortis.
Fig 15 Photograph showing Rigor mortis
Factors that has to be considered while checking for rigor mortis are are temperature, existing antemortem pathologies, age, body muscular mass, and the degree of muscular activity immediately before death. Higher temperatures shorten the time till the onset of rigor mortis and its time of duration. A strong fight or lengthy physical effort before death causes an earlier onset and shorter duration of rigor mortis. Children and older adults have also earlier rigor mortis than younger adults. Generalized infections or long, debilitating diseases also produce earlier onsets and shorter periods of rigor mortis, whereas extensive antemortem bleeding or death due to asphyxia delays rigor mortis onset.
Livor mortis, or postmortem lividity, it is the reddish/purple discoloration of the skin, sometimes with a pink border. When blood circulation ceases, the blood is gradually deposited in the lower internal vessels and in the lower parts of the body, with the signs of livor mortis. It can be noted in first hour following death. in some cases it can appear 2–3 hours after death, and is usually fixed after about 12 hours. Factors considered here are severe anemia and starvation which can delay, but can be present before death in individuals slowly dying from circulatory insufficiency.
Fig 15a Photograph showing Livormortis
Postmortem decomposition/putrefaction includes the destruction of soft tissues by the action of microorganisms present in the body. Any injury or wounds in the body can also provide access to bacteria from the environment. Factors that interfere with process of putrifaction are Obesity, infectious conditions, congestive cardiac failure, or when edema (swelling with fluid) is present. Conversely, extensive external bleeding during death or severe dehydration delays the putrefaction onset. Temperatures may accelerate or delay putrefaction onset and rates.
Brouardel method is a method where gases derived from the putrefaction process are used to estimate time of death. According to this approach, within the first postmortem 24 hours, abdominal gases are not flammable, between the second and the fourth day they are flammable, from the fifth day on, they are not flammable again. Putrefaction stains start to form on the abdominal skin around 24–36 hours after death in temperate climates and in 12–18 hours in tropical regions. These stains are green and gradually appear all over the body between the third and the fifth day after death.
Westernhoffer-Rocha-Valverde method, is a method first applied by Brazilian forensic pathologists Martinho da Rocha and BelmiroValverde to estimate the time of death. it was developed with the principle that as the blood undergoes putrefaction, crystal blades are formed in fragmented or clustered patterns, crisscrossed and colorless. These crystals start forming after the third day and can remain in the blood up to 35 days.
Autolysis within the cell is the self destructive programme achieved by the enzymes present within the cell itself without bacterial interference. Due to the autolysis build up of potassium ions concentrations known as vitreous humor potassium (VHP), are found which can occurs during the first 20 postmortem hours. It can also be used as a one of the adjuvant method for estimating time of death.
Postmortem tissue survival rates can be utilized as an another PMI estimation method. Different tissues lose their vital properties in different moments of the postmortem interval. Example: Sperm cells show motility for about 36 hours after death.
Muscles react to electrical or mechanical stimuli for a postmortem interval of six hours.
Leukocytes, the white blood cells, die at the following PMI rates: 8% during the first 5 hours, 58% within 30 hours, and 95% within 70 hours.
Forensic entomology: in modern days even the insects present on the dead individuals are utilized for establishing time of death. Corpses exposed to outdoor environments attract insects with different behavioral habits and life cycles. It utilizes insects on or surrounding the body, as well as their eggs and larvae, to estimate the amount of time a body has been dead and left in a certain environment. Life cycles of insects are both well known and predictable. In addition, the succession of colonization of a corpse by insects occurs in temporally specific waves of different species.
Bloodstains found at the scene of a crime can also yield clues or confound police. Stains that are recently deposited, or possibly been there for a period of time from events unrelated to the crime under investigation. Many techniques are applied to establish time of death and age of bloodstains.
Decomposition is a mixed process, ranging from cell autolysis due to internal chemical breakdown to tissue autolysis due to liberated digestive fluid. Dr.Gururaj, Dr.Sivapathasundaram showed the initiation of decomposition at cellular level and determined the approximate time of death by histological examination of gingiva in postmortem cases.
Fig 16 Photograph Histology of cell autolysis
In recent days since teeth are more resilient to environmental factors measuring the rate of degradation of nucleic acids (DNA and RNA ) in these tissues has been used as a method for estimating the PMI for longer time intervals, from days and weeks, months and years.
POSTMORTEM PINK TEETH:
Pink teeth phenomenon is a common postmortem finding noted by forensic dentists. It has to be differentiated from the antemortem pinkish discoloration of teeth especially along the cervical portion of the teeth and along the root portion which is commonly associated with decomposition in a moist environment. Exact notification of the pink teeth phenomenon is not known within the literature first explanation regarding pink teeth in victims of hanging or drowning was made by Bell in 1829. Postmortem pink teeth can be made out in people who has dead due to drowning, hanging, knifing, barbiturate poisoning, carbon monoxide and CO2 poisoning, also unknown cause. Usually pink appearance is more pronounced at the region of cemento-enamel junction than other parts of the teeth at the same time this appearance of pink teeth is more intense among anterior teeth than the posterior teeth.
Beely and Harvey conducted biochemical investigation into the nature of the post-mortem occurrence of pink teeth including iso-electric focusing after homogenisation, pH measurements and carbon monoxide detection and concluded that presence of the pink pigment as haemoglobin and/or its derivatives. Kirkham et al in 1977 concludes that Pinkness occurs due to seepage of fluid containing hemoglobin or its degradation products derived from decomposition or liquefaction of the tooth pulp into the dentinal tubules. However exact cause of the pink discoloration remains unexplained few authors suggests that it is due to great physical trauma and moist environment play role in its appearance.