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/ MEDICOLEGAL AUTOPSIES AND AUTOPSY TOXICOLOGY Medicolegal Autopsiesand Autopsy Toxicology 2 Press Inc., Totowa, N I. ADAMStrial, deposition, wrongful death civil suit, medical malpracticenarrowly defined as an autopsy that is performed pursuant toFORENSIC PATHOLOGISTS, MEDICAL EXAMINERS,In the States and Territories of the United States, medicaldeath investigation systems, and in 11 states, both systems oper-ACTIVITIES RELATED TO MEDICOLEGAL AUTOPSIESFinally, both plaintiff and defense attorneys in the medical mal-ERRORS IN MEDICOLEGAL INVESTIGATIONAlthough nonforensic pathologists generally understand theDEFINITIONS OF DEATH is the disease or injury that sets inand cardiac electrical silence. “Carcinoma of the Pancreas,” and“Gunshot Wound of the Head with Perforation of the Skull and causes of death, is a pseudo-judicial classification of are deathsthe harm inflicted is not intentional. A is death at the is PART I of witnesses, one may infer a ventricular arrhythmia as the mech-. This means that there can be no other reason- that the defense attorney and the pathologist in a case mightdard, one need not eliminate competing reasonable possibili-well-defined, but is generally understood to require a more-likely-meet the standard of reasonable medical certainty. Otherwise, theof facts, or in the presence of conflicting facts, a decedent isentitled to the rebuttable presumption of a natural death for thePRONOUNCEMENT OF DEATHMany findings are self-evident. Ordinary citizens recognize aputrefied body as being dead. Most police patrolmen recognizewill opine death without resorting to a cardiac monitor. However,1.Cessation of respiration. As a slow death approaches, the2.Cessation of circulation. In slow deaths, the lack of aperipheral pulse does not necessarily denote cardiac arrest,voluntary muscle activity, and consciousness all followDEATHS FROM NATURAL CAUSESthat resulted from an underlying traumatic cause of death. TableEVALUATION OF THE SCENE AND CIRCUMSTANCESOF DEATHvation of medicaments, and allow the medical examiner to take / MEDICOLEGAL AUTOPSIES AND AUTOPSY TOXICOLOGY Table 2-1DiseasePossible underlying injury, acute or chronicCentral nervous systemMeningitis; cerebral abscessFracture of skull, jaw, facial bones; injuries to middle ear,anesthetic, roentgenologic, chemotherapeutic, diagnosticIntracerebral hemorrhageCerebral contusion enlarged by alcoholic coagulopathy,Subarachnoid hemorrhageBlunt impact to head or neck; laceration of vertebral arterySubdural hematomaBlunt impact to head from fallCardiovascular systemCoronary artery insufficiencyEmotional or strenuous physical effort related to occupation, or threatRuptured heart valve; aortic aneurysmStrenuous physical effort or blunt impactCongenital anomaliesTeratogenic drugsSeizure disorder, “Vasovagal attacks”Shock; frightPneumothorax; subcutaneous and mediastinalTraumatic intubation, artificial ventilation with bag-mask, aspirationemphysema; hemopneumothorax of foreign body, SCUBA diving, premature putrefaction in thePneumonia; pulmonary embolismTrauma, immobilizationPulmonary fibrosis; mesothelioma; pneumoconiosisExposure to radiation; drugs; asbestos; industrial exposureRuptured viscus; perforated ulcer; peritonitis;Impact to abdominal wall; burns; strenuous physical effort; foreignintestinal obstructionbodies by mouth or rectum, or left at laparotomy; diagnostic orFulminant toxic hepatitis; massive hepatic necrosisExposure to drugs; poison, anesthetic agents; pesticides; shockRenal tubular necrosis; papillary necrosisPoisons; drugs; heavy metals; burns; shock; dehydrationCystitis; pyelonephritis; ruptured bladder; rupturedImpact to abdomen; abortion; injudicious instrumentationHemolytic anemiaIncompatible blood transfusionAplastic anemia; agranulocytosis; thrombocytopenia;Drugs; poisons; pesticides; industrial and laboratory chemicals;leukemiaantibioticsMalnutrition; failure to thriveNegligence; parental cruelty; eccentric or unusual religious beliefs“Crib death”Accidental or homicidal suffocation they are ready for the body to be disturbed. In busy jurisdictions,the medical examiner is summoned after detectives have arrived,rime scene tech-vicinity of the body. In jurisdictions with few homicides, thein cases of industrial accidents. Scene investigation is muchmore apt to yield clues as to the approximate time of death than PART I Pathologists without training or appreciable forensic expe-technicians from large police departments are familiar withESTIMATION OF THE TIME OF DEATHThen, as blood pigment migrates extravascularly, the livid-Rigor Mortis (Postmortem Rigidity)woman with little muscle mass seems to have weak rigor mortis.and if present, whether it is oncoming, fully developed, or passing.in the almost instantaneous onset of muscle stiffening. Rigorthe body and the environment; the body mass in relation to itssurface area; the rate at which air or water moves across theval generally take into account only the temperature gradient.fairly uniform temperatures. In Florida, where outdoor deathscold, or at ambient temperature. In most cases, warm bodies areStomach Contents and State of Digestionconditions, the stomach empties a medium weight meal in approxcraniocerebral trauma can delay gastric emptying for days. Car-solved by swallowed salivary amylase. Vegetable matter and / MEDICOLEGAL AUTOPSIES AND AUTOPSY TOXICOLOGY subtropical sun, or if the skin is near a heat source, slippage cantions. With fully developed putrefaction, the face and genitaliaExsanguination removes the principal nutrient source forand forearms shrivel and darken as the water content evaporatestermed “maggots.” Maggots consume soft tissue, leaving behindbone, cartilage, gristle, and some but not all of the dermis. Thegist working with the signs of decomposition can only give broadIDENTIFICATION OF THE BODYA Polaroid photographone or two printable fingers, and may be identifiable by dentalelements. The head can be identified by dental comparison ordo not roll well because of maceration or desiccation, the finger-pads can be built up with injectable compounds, including for-malin, found on the shelves of all funeral directors with embalm-stored long-term at room temperature, and the tube of blood is PART I Sex determination can be made from most skeletal remainsTo ensure thatcorrected at any time. However, the concerned attorneys mustNo revision of the gross description should be necessary aftermicroscopic studies, the end of communication is best served change if there are changes in circumstantial and historical repeated in the customary sections for external are made metrically or in the English system, and anatomical measurements can be measured metrically or by the English system,at the discretion of the pathologist. The author measures woundssystem, because the parties who use this information are most / MEDICOLEGAL AUTOPSIES AND AUTOPSY TOXICOLOGY Chapter 12). In addition to roentgenographs forauthor routinely takes chest roentgenographs to detect venoustimes raised the question of what lesions might be obscured bynal cases, medicolegal or hospital-derived, the chain of cus-the names of the transport driver, the log-in technician, the log-rization. If possible, a lock should be put on the cooler in whichtrace evidence, and toxicologic specimens. (For the chain of cus- also below under “AutopsyToxicology.”) Such material should be saved in containerslabeled with the case number, the name of the deceased if known, Bullets can be inscribed on the base or nose, but not on theTHE EXTERNAL EXAMINATIONtively. Victims of bludgeoning, brawls, and strangulation shouldbe examined for transferred hairs and fibers before the body istion of the pathologist. For apparent natural deaths, the clothingfor later examination by the pathologist in the unlikely event thatperforations of the scalp are easily obscured. Cutaneous contu-Chest roentgenographs should be obtained in cases of motorof the neck, to detect venous air embolism from torn dural sinuses,unless the victim has lived long enough to have had spontane- under that heading in Part II and below under “Internal Exam-ination.” Pelvic roentgenographs are helpful in traffic fatalities,rib fractures because the autopsy is more sensitive in this regard.Likewise, roentgenographs are less sensitive for the detectionvical derangements in which there is no residual static dislocation.taken with a 35 millimeter camera. Pathologists customarily useEktachrome or Kodachrome transparency film for three reasons:THE INTERNAL EXAMINATIONabdominal, pelvic and neck organs, and the intracranial con-scraping the intercostal muscle off the external aspect of the PART I In cases of third and fourth degree burns, it is usually neces-Layerwise examination of the anterior neck structures is desir- photog-derangement in cases of suspected suffocation in traffic acci-fibrofatty tissue of the epidural compartment. The absence ofFor special procedures for the diagnosis of arterial and venousprior to dissection ( Chapter 1) but others remove organs inmight convince the judge, the jury, and the press that the autopsyThe order of examination of the organs is not critically impor-tant. The pathologist who does only occasional autopsies shouldter into a common carotid artery, usually the right, followingnecessary. Poor perfusion generally results from luminal obstruc-tions of methanol appearing in the gas chromatograph. Technicalthe walls of blood vessels, which then contract around any post-car is used to aspirate any liquids and to inject cavity embalmingthan does the arterial fluid. After trocar embalming, the liver,along the perforations is firm and gray, unlike the tissue fixedembalming fluid. Fixed feces is often found floating in the peri-EXHUMATION AND OTHER SPECIAL PROCEDURESdescribed above only by the presence of colorful growths of moldINVESTIGATION OF CIRCUMSTANCES OF POISONING / MEDICOLEGAL AUTOPSIES AND AUTOPSY TOXICOLOGY Table 2-2). Of particular interest is the. Figure 2-1 shows that this time inter-CONTAINERSTo prevent contamination of specimensadded to containers with preservatives should be inverted sev-Table 2-2Investigative Information Useful for Suspected Poisoning Cases Average time of death after ingestion or inhalation of fatal dose of poison. Solid regions indicate interval in which most PART I ROUTINE SAMPLING OF TOXICOLOGIC MATERIALVacutainer tubes are not used, 250 mg of NaF can be added tobefore incising the dome to facilitate aspiration of the bladderis unnecessary, because the immunoassays detect cocaine metab-the intrapericardial thoracic aorta, pulmonary artery, or venaaspirated from a hemothorax, hemopericardium, hemoperito-be supplemented by peripheral blood, vitreous, or solid tissueof site-dependent variation in concentrations in blood speci-eyes is gently aspirated from the lateral angle of the eye with ainvert the specimen 10 or 12 times to ensure thorough mixing.After removal of the stomach, duod-enum, pancreas, and esophagus, the gastric contents are squeezedout through the esophagus, or through an incision in the stom-ach, into a 1-L container. A representative 50-mL specimen isbefore removing it and draining it into a specimen container.analysis of tissue or body fluids are needed. Analysis of gastriccontent may help to establish suicidal intent and to investigatealso can be Chapter 6) by suboccipital or lumbar puncture is men-tioned only to discourage it. Although pathologists certainlyproduce blood-lined tracks that render the interpretation ofposterior neck and vertebral dissections problematic. Vitreous,intact and the CSF has not run out. The situation most often call-ing for a CSF specimen is the meningitis autopsy with no urinegallbladder is lush and easily becomes ensnared in the needle tip,when the analyte of interest is an opiate or an alcohol. In rapidlyOther Liquid Specimensest concentrations of toxic substances may be found in dialysis / MEDICOLEGAL AUTOPSIES AND AUTOPSY TOXICOLOGY injected, the skin around the needle-puncture site can be excisedTable 2-3.Volatiles by Gas ChromatographyThe analyte most fre-quently tested is ethyl alcohol. Toxicologists in medical exam-chromatography, as part of a general panel designed to captureisopropyl alcohols, and ketones. Tertiary butyl alcohol is oftenDrugs of abuse are commonly detected quantified by EMIT (Enzyme Multiplied ImmunoTechnique),sured by antibody interaction. The panels are selected dependingfication and quantification. Historically, HPLC has been usedby most laboratories for assaying specific classes of drugs suchextraction methods and columns that permit HPLC to be usedas a general screen. HPLC, with its cool injection ports, is oftenmatography/mass spectrometry (GC/MS) (see below), whichuses hot injection ports in the gas chromatograph to volatilizeSpecific Drug Identification and Quantitation by Gascompounds into ionic subunits, whose weights form a bar-graphCarbon Monoxide Testsin most medical examiner toxicology laboratories by visible spec-Heavy metals can be detected by qualitative tests.For example, the Reinsch test primarily detects arsenic, and is aninsensitive test for mercury, antimony, and bismuth. Quantifica- PART I any person in an office or laboratory can smell cyanide. Text-forensic pathologists who can smell the compound state that itWayne Duer, PhD, Chief Forensic Toxicologist for Hills-improvements, and corrected errors in the toxicology section.1.Curran WJ. The status of forensic pathology in the United States.2.Hartmann W. for the American Board of Pathology. Personal com-munication, March 13, 1997.3.Combs DL, Parrish RG, Ing R. Death Investigation in the United4.Moritz AR. Classical mistakes in forensic pathology. Am J Clin5.Wetli CV, Mittleman RE, Rao VJ. Practical Forensic Pathology.Igaku-Shoin, New York, 1988.6.Adams VI. Autopsy techniques for neck examination: I. Anterior7.Adams VI. Autopsy technique for neck examination: II. Vertebral8.U.S. Department of Defense. Army Department: Autopsy Manual.U.S. Government Printing Office, Washington, DC, 1981.9.Davis JH, Wright RK. The very sudden cardiac death syndrome: aTable 2-3Toxicology Specimen Transmittal SheetToxicology Specimen Transmittal Sheet(Address and Telephone Number of Medical Examiner Agency)“Toxicology Testing Not Indicated” / MEDICOLEGAL AUTOPSIES AND AUTOPSY TOXICOLOGY 10.Atlee WL and the Medical Faculty of Lancaster. Report of a seriesbody of Henry Cobler Moselmann, executed in the jail yard of11.Medical Examiners Commission. 1995 Annual Report. Florida12.Medical Examiner Department Computer Database for 1995 and13.Ihm P, Schleyer F. Fehlerkritische Betrachtungen über die Todeszeit-14.Lie JT. Changes of potassium concentration in the vitreous humor15.Bass WM. Human Osteology: A Laboratory and Field Manual, 3rd16.Ubelaker DH. Human Skeletal Remains: Excavation, Analysis,Interpretation, 2nd ed. Teraxacum, Washington, DC, 1989.17.Hirsch CS. The format of the medicolegal autopsy protocol. Am J18.Adams VI, Hirsch CS. Venous air embolism from head and neck19.Churg A. Poison Detection in Human Organs, 2nd ed. Charles C.Thomas, Tallahassee, 20.Moritz AR, Morris CR. Handbook of Legal Medicine, 3rd ed.C.V. Mosby, St. Louis, MO, 1970.21.Moritz AR, Morris CR. Handbook of Legal Medicine, 3rd ed. C.V.22.Pounder DJ, Fuke C, Cox DE, Smith D, Kuroda N. PostmortemBaselt RC, Cravey RH. Disposition of Toxic Drugs and Chemicals inFroede RC, ed. Handbook of Forensic Pathology. College of AmericanWetli CV, Mittleman, RE, Rao VJ. Practical Forensic Pathology. Igaku-Shoin, New York, 1988. PART I