MULTIPLE CHOICE QUESTIONS
Clause 3: Prenatal diagnostic techniques should be used in pregnant women, if any of the following conditions
Q. What was the time of death?
The probable time since death may be determined from the condition of parts and decomposition changes. The appearance of bones, unless they are very recent, is
much more dependent upon the environment in which they have lain, than the passage of time. Bones left in a dry environment, such as sand, will last far longer than bones in a damp, acidic situation.
• If soft tissues, like fascia and ligaments are still attached with the bone, then death might have occurred within about 2 weeks to 2 months back.
• If no soft tissue is attached, but the bone is still not completely dry then, death might have occurred about 1-3 months back.
• If the bone is completely dry, but has a putrid smell, death has occurred within the last 3 months.
• If the bone is dry with no putrid smell, but has retained its normal color, then the time passed after death is between 3 months to 1 year.
• After 30-40 years, the bone tends to become lighter as the organic matrix is lost and the softer parts of the bone begin to crumble.
Dating of skeletal remains
• Total nitrogen content is > 4-5 g% in bones less than 50 years old. Between 50-100 years, it is about 3.5 g%, and 2.5 g% when the bones are 350 years old.
• The number of amino-acids (initially about 15, glycine and analine are predominant) diminishes with age and hydroxyproline and proline tend to disappear after 50 years. A bone > 100 years old will contain 7 amino acids.22
• Blood pigment tests using bone dust remain positive for upto 100 years.
• Eluted bone dust solution tested for immunological activity against a human anti-Coombs serum, test positive for 5-10 years.
• UV fluorescence: The sawn shaft of a long bone such as a femur is examined under an UV lamp; fresh bone will fluoresce across the whole surface from periosteum to marrow cavity. As time lengthens, the fluorescent zone narrows, breaks up and finally vanishes between 150- 300 years.
• Estimation of radioactive carbon (C-14): Radioactive carbon gets deposited in living tissue. After death, there is no further deposition and its concentration gradually decreases in the organic substances. Estimation of C-14 in bones may give some idea as to when the person died. There is no significant fall of C-14 during the first century after death.
Exhumation
Definition: It is the lawful digging out of an already buried body from the grave.
• It is a situation where a previously-buried dead body is 'dug up,' 'unearthed,' or 'disinterred'.
• Usually it involves a body (of any age group) that was not originally autopsied but which, for some reason, must be exhumed in order for an autopsy to be performed.23
Reasons
i. Criminal cases
• Establishing the cause and manner of death in suspected homicide disguised as suicide.
• Death as a result of criminal abortion and criminal negligence.
• Retrieving some vital object which may throw light on the case, e.g. bullet from the dead body, if the person was killed by a firearm.
ii. Civil cases: Identification of the deceased for accidental death claim, insurance, workmen's compensation claim, liability for professional negligence, survivorship and inheritance claims, disputed identity, separation overseas, and burial of the wrong body inadvertently or by fraud.
Authorization: The body is exhumed only when, there is a written order from the First Class Magistrate (judicial or executive); police cannot order exhumation.24 Procedure
i. It should be done and completed in broad daylight, for which it should be started during the morning hours of the day.
ii. The body is exhumed under the supervision of a medical officer and Magistrate, in the presence of a police officer.
iii. Before opening the grave, it should be positively identified from location of burial plot, headstone and gravemarker, so that wrong body is not disinterred.
iv. Soil from above, below and two sides of the body or the coffin should be preserved in separate glass jars, with identification tags.
v. Disinfectants/pesticides should not be sprinkled on the body as it might interfere later with the determination of poison in the body.
vi. The doctor should examine the body inside the grave or the coffin regarding its position and appearance. A drawing of the grave and body or skeleton should be made, noting all the details, whether the face is up, or to the right, arms are extended, or the lower limbs are flexed.
vii. The grave or the coffin with the body should be photographed.
viii. If decomposition is not advanced, a plank or a plastic sheet should then be lowered to the level of the earth on which the body rests.
ix. After this, the body is lifted and sent for postmortem examination, along with a requisition and a preliminary investigation report which contains the brief history of the case. In the mortuary, postmortem examination on the body is performed as in all other cases.
x. In highly putrefied bodies, an attempt should be made to establish the identity. Viscera should be preserved for chemical analysis. If the body is reduced to skeleton, the bones should be examined.
Time limit
In India, there is no time limit for ordering of the exhumation, but many western countries have well- defined time limit upto which exhumation can be done.25 For example, in France, the time limit is 10 years and in Germany, the time limit is 30 years. Thus in France, after 10 years of death, if some facts are found which may reveal foul play, even then the body cannot be exhumed.
MULTIPLE CHOICE QUESTIONS
1. B 2. C 3. D 4. B
1. The dead body of a murdered person is brought for preservation in mortuary. Statement NOT correct is:
AIIMS 04 A. The body should be stored averagely at 4°C.
B. The body can be embalmed before postmortem.
C. The body should be never undressed before the forensic doctor has seen it.
D. The body can be stored at -20°C to preserve it for long duration.
2. The temperature ideally preferred to preserve the body
for autopsy is: JIPMER 03
A. -10°C B. 0°C
C. 4°C D. 10°C
3. Last structure to be autopsied in asphyxial death:
AIIMS 07, 08
A. Head B. Thorax
C. Abdomen D. Neck
4. True about subendocardial hemorrhages are all, except:
AIIMS 10; UPSC 11 A. May be seen after head injury
B. Involves the right ventricular wall C. Continuous pattern
D. Flame shaped hemorrhages
Medico-legal Autopsy 103 5. In autopsy, spinal cord is opened through which
approach: AIIMS 11
A. Anterior B. Posterior
C. Lateral D. Anterolateral
6. Underwater autopsy of the heart is done in cases of:
DNB 09 A. Myocardial infarction B. Pulmonary embolism C. Air embolism D. Pneumothorax 7. Brain is preserved in all of the following, except:
AIIMS 06 A. OPC poisoning
B. Alkaloid poisoning C. Heavy metal poisoning D. Volatile organic poisoning
8. To confirm diagnosis of rabies on postmortem:
FMGE 09 A. Find negri bodies in saliva
B. Find negri bodies in corneal scrapings C. Anti-rabies antibodies in blood D. Negri bodies in brain
9. Sample of spinal cord is preserved in suspected
poisoning with: JIPMER 10, 11
A. Oleander B. Alcohol
C. Strychnine D. Arsenic
10. CSF sample is preserved for which poisoning:
FMGE 10 A. Heavy metal B. Alphos
C. Organophosphates D. Alcohol
11. Vitreous humor is preserved in suspected poisoning
with: FMGE 08
A. Carbon monoxide B. Anthrax
C. Alcohol D. Morphine
12. Lung is NOT preserved in which poisoning: UP 05
A. HCN B. Chloroform
C. Organophosphate D. Kerosene
13. Blood is stored at what temperature: FMGE 10
A. 4°C B. -20°C
C. -70°C D. Room temperature
14. CSF is stored at: Kerala 11
A. 4°C B. -20°C
C. Room temperature D. -70°C
15. Specimens for toxicological studies are preserved in:
UP 04; DNB 09; Maharashtra 11 A. 10% of formaldehyde
B. Alcohol
C. Saturated solution of common salt D. Normal saline
16. Rectified spirit is NOT used as preservative in case of:
WB 11
A. Phenol B. Cyanide
C. Insecticides D. Alphos
17. Preservative used for blood: UP 10 A. Sodium fluoride
B. Thymol
C. Potassium oxalate
D. No preservative is needed
18. Viterous humor is preserved in: AIIMS 07
A. HCl B. Fluoride
C. Formalin D. Xylol
19. Sodium fluoride is added to: CMC (Ludhiana) 11 A. Prevent glycolysis
B. Prevent glucogenolysis C. Prevent coagulation
D. Prevent growth of microorganisms
20. Fluoride, used in the collection of blood samples, inhibits the enzyme: AI 05; AP 06; WB 07;
PGI 08; FMGE 10, 11 A. Glucokinase B. Hexokinase
C. Enolase D. Glucose-6-phosphatase
21. Tissue biopsy for histopathological examination should
be sent in: DNB 09
A. Normal saline B. Formalin C. Rectified spirit
D. Saturated solution of saline
22. With respect to dating of a bone, a bone more than 100
years old contain: Karnataka 11
A. 7 amino acids B. 9 amino acids C. 6 amino acids D. 8 amino acids
23. Exhumation is done in which age group: FMGE 10
A. 18 years B. 16 years
C. 21 years D. All ages
24. An order for exhumation can be given by:
Maharashtra 08 A. District collector
B. Additional district magistrate C. Sub-collector
D. Any of the above
25. Exhumation can be done in India:
Maharashtra 09; AP 09 A. After 7 years B. After 2 years
C. After 10 years D. At any time
5. B 6. C 7. C 8. D 9. C 10. D 11. C 12. C 13. A 14. A
15. C 16. A 17. A 18. B 19. A & D 20. C 21. B 22. A 23. D 24. D
25. D
It has long been recognized that the autopsy room is a potential source of infection and that the forensic pathologists and other persons in close proximity to an autopsy are at higher risk of contracting infectious diseases from the dead bodies. These personnel have a greater exposure to blood-borne viruses and other infections including human immunodeficiency virus (HIV), hepatitis B (HBV), non-A non-B hepatitis (C, D and E viruses), tuberculosis, Creutzfeldt Jakob disease, herpes and human T-cell lymphotropic virus type I.
Infections in autopsy room may be acquired by any one of the following routes:
• A wound resulting from an object (e.g. scalpel) contaminated with blood or body fluids or needle- stick injury.
• Splash of infected blood or other body fluids onto an open wound or area of dermatitis.
• Contact of blood or other body fluids with mucous membranes of the eyes, nose or mouth.
• Inhalation and ingestion of aerosolized particles.
Commonly Acquired Infections
• Hepatitis B is the most transmissible of the blood- borne viruses, but its transmission is preventable by vaccination. Increased risk of HBV infection has been found among health care workers, especially those having frequent contact with blood and/or exposure to needles or sharp instruments. Among the physicians, pathologists have been recognized as a high-risk group for occupationally acquired HBV infection, because of their greater exposure to blood.
• Persons associated with postmortem examination and other health care workers experiencing needle stick injuries are at a considerable risk of acquiring hepatitis C infection (HCV).
• Autopsies on persons who have died of viral hemorrhagic fever (VHF) pose even greater risk. Many pathologists and their assistants have died of autopsy transmitted Ebola, Marburg and Lassa hemorrhagic fevers.
• Autopsy is an efficient method of transmitting tuberculosis from the dead body to those present in the autopsy room. The risk for infection does not vary with the distance from the autopsy table. In our country, where tuberculosis is still the most fatal respiratory disease affecting the lower socioeconomic group and where unidentified vagabonds constitute a significant percentage of the autopsy population, the percentage of unrecognized tuberculosis cases is substantial.
Airborne droplets, usually from sputum positive cases transmit tuberculosis. Embalming itself has been shown to produce active tuberculosis aerosols.
• The risk of HIV infection among medical and laboratory personnel, including mortuary workers, is considered low when compared with other blood- borne viruses, such as HBV and HCV, but resembles the rates for single contact heterosexual transmission.
Deep injury, visible blood on the device causing the injury, injury with a needle used in a vessel and injury with hollow-bore needle (compared to a solid needle)—all increases the likelihood of a larger innoculum of blood entering the recipient. HIV infection should be suspected, if the body is of:
i. Male homosexual ii. Intravenous drug abuser
iii. Hemophiliac who has received repeated blood transfusions
iv. Female prostitute v. Victim of sexual abuse.
Risk of transmission from single percutaneous exposure to blood for:
• HBV: 6-30%
• HCV: 3%
• HIV: 0.3%1
Autopsy of HIV Positive and HBV Patients One school maintains that all autopsies should be carried out with total precautions against infective risk.
However, this is almost impracticable to achieve in the present set-up. The other school advocates pre-autopsy testing of blood-sample for HIV and other infective agents.
Autopsy Room Hazards 7
Autopsy Room Hazards 105 A simple and rapid test (10-minute test carried out by
a manual HIV test-kit) is available for mortuary use in the developed countries. This test is also applicable to urine—a more cost-effective specimen and safer than blood collection.
Pre-preparation: The body should be transported to the mortuary by duly plugging all the natural orifices and sites of the IV drip. It should be wrapped and tied in double layer, tough plastic bag, with a red color tag mentioning 'Biologically Hazardous'. The label should mention the name, age, sex and registration number.
Universal Work Precautions
• No unauthorized person should be admitted in the autopsy room, so as to minimize exposures. Only experts and workers who are trained in handling the infected material should be allowed.
• Immunosuppressed or immunodeficient individuals and individuals who have uncovered wounds, oozing skin lesions or dermatitis should not perform the autopsy.
Clothing: Autopsy personnel should wear protective clothing—full sleeves overalls, head cap, N95 particulate masks, goggles if eye glasses are not worn, double gloves (heavy autopsy gloves over surgical gloves) and waterproof rubber gumboots of knee length with shoe covers. A plastic visor will protect the eyes and mucosal surfaces from splash injury.
Handling sharp instruments: Minimum instruments as needed should be kept. Scissors with slightly blunt ends should be used and sharp ones are used, only if needed.
Wherever possible, the use iof needles should be avoided.
Needlestick injuries are entirely preventable, blunt needles and bulb syringes should be used to aspirate fluids.
Needlestick accidents occur during disposal of needles, they should never be recapped after use.
Accident cuts, particularly to the distal thumb and index and middle fingers are the most frequently injured by forensic pathologists.
Examination of organs: It is better to leave some organs in situ in the cadaver rather than eviscerating en masse.
Another method is to fix lungs and other organs as a whole after removal, rather than slicing them before fixation.
To minimize aerosol splatter, cranium may be opened with an electrical oscillating saw attached to a vacuum dust exhaust and filter or with a handsaw under a transparent anti-splash cover.
Handling specimens for laboratory examination: They should be properly labeled and fixed with 10% formalin solution and should be handled with gloved hands.
Disposal of used instruments: They should be dipped in 2% glutaraldehyde (Cidex) for 30 minutes, washed with soap and water, dried and then rinsed in methylated spirit and air dried or autoclaved.
• All soiled gauze and cotton should be collected in a double plastic bag for incineration.
• Disposable needles and syringes, scalpel blades and other sharp items should be placed in a puncture- resistant containers.
• Laundry material, e.g. aprons and towels should be soaked in 1% bleach for half-an-hour, washed with detergent and hot water, and autoclaved.
Clean-up procedure: Small spatters and spills of blood and other body fluids should be wiped up with disposable tissues or towels which are discarded in special biohazard bags and properly disposed. The autopsy table and floor should be cleaned with 1% bleach solution, followed by washing with soap and water.
The health care workers should wash thoroughly with soap and water before dressing.
Disinfectants: 1:10 dilution of common household bleach or a freshly prepared sodium hypochlorite solution is recommended. Liquid chemical germicides commonly used in health care facilities and laboratories are effective against HIV.
The most common method of exposure includes being pricked with a used needle or other contaminated material. To prevent this, body-sewing needles and staples may be avoided and the mortician's stitches may be replaced by suture-free closure using tapes.
After that, the body should be wrapped in double layer plastic sheet bag and secured properly, so that there is no leakage. A tag should be attached for identification.
Universal precautions apply to blood, semen and vaginal secretions, as well as to CSF, synovial, pleural, pericardial, peritoneal and amniotic fluid, but they do not apply to feces, nasal secretions, sputum, sweat, urine and vomitus, unless they contain visible blood.
In case of accidental injuries or cuts with instruments, contaminated or not with blood or body fluids, while working on a body, the wound should be immediately washed thoroughly under running water, bleeding encouraged and the wound disinfected.
It must be reported to the authorities and immediate, proper measures instituted. Blood sample should be taken from the source of exposure and tested for HIV and HBV. The individual should be advised that he/
she could possibly have been infected by the needle- prick and counseled appropriately. HIV-testing should be done there, and then after an interval of 3 and 6 months to trace the possible introduction of the virus to the related event, so as to evaluate the ensuing claims, if need be.
Autopsy and Disposal of Radioactive Corpse
• If the amount of radioactivity is < 5 millicuries, no precautions are necessary.
• If the body contains between 5-30 millicuries of radioactive material, the doctor must wear heavy rubber gloves, plastic aprons, shoe covers and spectacles to reduce radiation. Instruments with long handles should be used during the autopsy. Organs that are most radioactive should be removed first and
placed in covered glass jars, labeled and examined for radioactivity from time to time. Fluid of the pleural and peritoneal cavity should be flushed copiously with running water and drained off directly into the sewer. Contaminated clothing should be thoroughly cleaned with soap and water, for suitable decay of the radioactive material before being sent to laundry.
Instruments can be brought to a safe limit by soaking them in water with soap. Contamination of the floor of the autopsy room should be avoided.
Organs may be removed and detailed dissection is done away from the body, or placed in a glass jar and preserved in a fixative or kept in cold storage for later examination when radioactivity has fallen to a safer level.
• If the body contains more than 300 millicuries activity after autopsy, it should be embalmed in the hospital mortuary. The presence of a cardiac pacemaker must be recorded, especially if it is one which might contain a radioactive substance.