A medicolegal autopsy, an examination of a body after death, is always required in homicide cases. In this chapter, we will look at the purpose of the autopsy and describe the examination. I have also included a brief section on human anatomy to acquaint the investigator with some basic terminology used by the medical profession.

The Medical Examiner/Coroner

The medical examiner's or coroner's office is primarily concerned with the investigation of violent, sudden, unexpected, and suspicious deaths. The procedures used in the official medicolegal investigation of death fall under the supervision of the chief medical examiner or coroner, who is responsible for the evaluation and interpretation of the results of this inquiry. It should be noted that the terms pathologist, coroner, and medical examiner may be, but are not always, synonymous. In some jurisdictions, the coroner is not a physician, but an elected or appointed official responsible for taking legal charge of the body. In other jurisdictions, medical examiners are not pathologists, and pathologists are not necessarily medical examiners.

The recommended standards for a medical examiner system are that the chief medicolegal officer — whether referred to as medical examiner or coroner — be a qualified doctor of medicine who is also a certified pathologist skilled in forensic pathology. In those jurisdictions lacking a forensic pathologist, I recommend that the investigator seek out the services of a pathologist, preferably one with some experience in forensic medicine, and refer this pathologist to the procedures recommended by the National Association of Medical Examiners.1

For purposes of this chapter, the term medical examiner or coroner will be synonymous with forensic pathologist and will refer to the medicolegal authority responsible for conducting the investigation.

The certified pathologist has received advanced training in recognizing and interpreting diseases and injuries in the human body. It is this knowledge that enables the medical examiner/coroner to make significant contributions to the homicide investigation. Practically speaking, forensic experts play an active part in the homicide investigation and should be considered an important part of the

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Figure 18.1 NASSAU COUNTY MEDICAL EXAMINER'S OFFICE. A modern medicolegal facility and state of the art facility in Nassau County, New York, formulated and designed by Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York. (Courtesy of Dr. Lukash.)

Figure 18.2 MODERN MEDICOLEGAL FACILITIES — STORAGE. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

investigative team. If the investigation is to be successful, the homicide detective and the forensic pathologist must work together.

Investigation of Death

An autopsy is always required in homicide cases. However, the chief medical examiner or coroner has the authority to investigate and certify any death which falls in the following categories:

(A) (B)

Figure 18.3 MODERN MEDICOLEGAL FACILITIES. (A) and (B): Autopsy room. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Criminal violence

Suicide

Accident

Sudden death when in apparent good health

Deaths under unusual or suspicious circumstances

Abortion (legal or criminal)

Prisoner and inmate deaths or any death while in legal custody

Deaths when the deceased was unattended by a physician

Poisoning

Unclaimed bodies

Diseases constituting a threat to public health

Figure 18.4 MODERN MEDICOLEGAL FACILITIES. Photography room illustrating photographic equipment. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau

County, New York.)

Disease, injury, or toxic agent resulting from employment

Death associated with diagnostic or therapeutic procedures

When a body is to be cremated, dissected, or buried at sea

When a dead body is brought into a new medicolegal jurisdiction without proper medical certification

The medical examiner takes charge of the body upon notification of death. The medical examiner/coroner or a duly authorized representative should respond to the scene of the homicide to conduct an investigation into the circumstances of death. In order to conduct the investigation properly, he or she must obtain as

Figure 18.5 FAMILY IDENTIFICATION FORM.

Figure 18.6 POLICE IDENTIFICATION FORM.

Figure 18.7 BODY BEING WEIGHED AND MEASURED PRIOR TO AUTOPSY. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.8 MODERN MEDICOLEGAL FACILITIES. X-ray machine for examining body prior to autopsy. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

much information as possible from the homicide investigator at the scene. An investigator fully apprised of all developments of the case should be present later at the autopsy.

In some jurisdictions, only the first officer is required to attend the autopsy and only then to identify the body for the chain of custody. In my opinion, this is not a wise course of action. From an investigative point of view, I recommend that the investigator familiar with the facts of the case be present to brief the pathologist. Many times during the autopsy, questions will arise that only someone who was present at the scene can answer. The investigator present at the crime scene can provide the pathologist with a detailed account of all that transpired from the discovery of the body to the preliminary investigation at the scene and thereby assure that both parties will have the benefit of all available information.

In addition, sometimes certain changes take place in the body during transportation and storage. These changes may be misinterpreted if someone who was present at the scene and observed the body in its original condition is not present at the autopsy to point out these changes. I recall one case in which the deceased's face was flattened, giving the impression that the body had been face down, when in fact the body was on its back when discovered. A heavy piece of furniture placed on the deceased's face by the killer had created this postmortem artifact. The pathologist who performed the autopsy was at first confused by this apparent contradiction. However, because I had been at the scene and observed the body in its original position with the piece of furniture on the face, I was able to explain.

Cause, Mechanism, and Manner of Death

The terms cause, mechanism, and manner of death sometimes prove confusing. The terms are sometimes used interchangeably or inappropriately by persons who have heard them uttered on television or have read them in fictional literature. The appropriate terms and explanations are provided here.

The cause of death is any injury or disease that produces a physiological derangement in the body that results in the death of an individual. Examples of causes of death are gunshot wound to the head, stab wound to the chest, blunt force trauma to the head, strangulation, and coronary arteriosclerosis.

Mechanism of death is the physiological derangement produced by the cause of death that results in death. Examples are hemorrhage, septicemia, and cardiac arrhythmia. An individual can die of massive hemorrhage produced by a gunshot wound, a stab wound, a malignant tumor, etc. Likewise, a cause of death can result in many possible mechanisms of death such as hemorrhage or peritonitis.

The manner of death explains how the death occurred. There are generally four manners of death: homicide, suicide, accidental, and natural. However, the medical examiner has the option of classifying the death as undetermined. This is an important consideration and is used when the medical examiner cannot state with any degree of medical certainty that the death is a homicide or a suicide. In fact, as a professional murder cop, I would prefer that the classification be left undetermined rather then "locking into" a specific classification. The term undetermined actually means that the death cannot be determined without further police and medical investigation. In this textbook, there are clear examples of the application of this principle, especially in equivocal death investigations.

Practical Application of Terminology

If an individual dies of a massive hemorrhage, this is an example of the mechanism of death. If the massive hemorrhage is due to a gunshot wound to the heart, this is the cause of death. The manner of death would be determined by the circumstances, for example:

Someone shot him — homicide

He shot himself — suicide

The gun fell and discharged — accident

One is not sure what occurred — undetermined

Purpose of the Autopsy

The purpose of the medicolegal autopsy is to establish the cause of death and make a medical determination of all the other factors which may be involved in the death. The autopsy provides the forensic pathologist with an opportunity to examine the body externally and internally to determine what wounds and injuries were sustained and to determine the cause of death.

In some instances, the cause of death cannot be determined; however, because of the condition of the body and the circumstances surrounding its discovery, the medical examiner will determine that the death should be considered a homicide. The findings of the autopsy will usually determine whether death is the result of a homicide. This is important because some conditions, which are in fact natural, may sometimes suggest homicidal violence. Such cases can present serious problems for the homicide detective.

For example, a person suffering a cerebral hemorrhage may become convulsive, compelling the police to subdue him or her. Actually, the victim may have suffered a subarachnoid hemorrhage due to a spontaneous rupture of a small aneurysm (dilatation of the wall of an artery) in the brain. The spontaneous nature of this condition is unaffected by the fact that the deceased may have been slapped, punched, or otherwise subjected to physical abuse during any minor argument or restraining activity. The hemorrhage may be rapid or slow. If it is slow, the victim usually remains conscious, but may become disturbed or aggressive and cause a commotion. In certain instances, these persons may die while police are attempting to subdue them, prompting the erroneous assumption that the use of force by the police caused the death. The pathologist's findings during the autopsy will determine that the death was caused by the ruptured aneurysm and not by any physical restraint. Likewise, death from lobar pneumonia is sometimes preceded by delirium or excitement, which may require that police be summoned. This situation may also produce minor injuries totally unrelated to the death.

The death of an alcoholic may at times cause investigators to believe that the death is suspicious or possibly homicidal, based on the general condition of the body. It should be noted that alcoholics may physically deteriorate to a point where they continually fall or cut themselves, resulting in numerous cuts, abrasions, and contusions, which may be fresh or in various stages of healing. Furthermore, such persons are generally untidy and during their delirium may upset furniture, drop things, throw things around, and generally create an appearance of some sort of violent assault, which did not in fact occur.

Investigators should also be aware of the various postmortem changes, as well as the possibility of the presence of postmortem artifacts, which can appear to be wounds or additional injuries on the body. Examples of postmortem artifacts are insect and animal activity and decomposition. Discolorations in the skin may resemble bruises or injuries and may mislead the investigator. All observations at the scene should be recorded in the investigative notes and brought to the attention of the pathologist to assure that he or she can separate antemortem from postmortem conditions.

Conversely, investigators should realize that fatal violence may be inflicted without any external signs of trauma. Poisoning is probably the most obvious type of homicide in which no external wound is present. However, in any number of other circumstances, an injury may not be readily observed, such as a torn spleen from a kick or other trauma to the abdomen, or an asphyxiation where the victim has had a pillow held over the nose and mouth. I remember reading about a series of senior citizen deaths, all of which were thought to have been natural. There was no evidence of a crime, and preliminary medical examination did not reveal any trauma. However, later a suspect was developed after evidence of asphyxia was discovered in a similar case. A review of the other cases by the medical examiner, who ordered the exhumation of certain bodies, and the police, who reopened their investigation, indicated that these "natural" deaths were in fact homicides.

It was later learned that the suspect would enter the bedrooms of the victims and hold a pillow over their faces as they lay in bed, causing suffocation. The suspect would then steal the TV and other small items of value without disturbing the general condition of the scene. In most instances, the bodies had begun to decompose before discovery. Police later located a witness who had observed the suspect leaving the apartment of one of the victims with a TV. Although evidence of this type of trauma could have been identified earlier, the procedures involved in cases of apparent natural death where no suspicion was involved were not sufficient to address this possibility. The jurisdiction involved subsequently changed its policy.

Figure 18.9 HAMMER ASSAULT — INJURIES TO SCALP. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Interestingly, I have been approached often by investigators attending my seminars, who ask me whether a detective should respond to all unattended deaths. Apparently, many police chiefs, who have never been detectives, have attended administrative management classes and have been advised that their agencies could save money and resources by utilizing patrol officers to handle unattended deaths. In my opinion, this is a recipe for disaster. It is imperative that an experienced detective be assigned to investigate all unattended deaths. These deaths could be very well be equivocal in nature or actually be staged crime scenes that would most likely be missed by an inexperienced patrol officer, who is simply preparing an official record or document to facilitate removal of the body.

Determining the mechanism of death obviously requires the expertise of the forensic pathologist. The detective should be constantly aware that things are not always as they appear to be. He or she should keep an open mind, conduct a thorough investigation, and remember that teamwork is essential. Then the two will be able to pool their knowledge to reach a successful conclusion.

Investigative Information Provided by the Autopsy

In addition to supplying the homicide investigator with an official cause of death, the forensic pathologist conducting the autopsy can assist the investigation by answering such questions as:

1. What type of weapon was involved in the death? (A hammer or screwdriver might leave impression-type wounds, for example.)

2. Are the wounds consistent with investigative evidence?

Figure 18.10 HAMMER ASSAULT — INJURIES TO SKULL. Pattern impression of hammer head into skull, which will allow for calculations of shape and dimensions of the hammer used in the attack. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.11 BRAIN WITH HEMORRHAGE. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.12 CONTRECOUP CONTUSIONS. Contrecoup contusions occur in the brain directly opposite to the point of impact. They are seen most commonly in the frontal and temporal lobes. Contrecoup contusions are classically associated with falls. (Courtesy of Dr. Dominick J. DiMaio, former chief medical examiner, City of New York.)

3. Which wound was the fatal wound? (When there are numerous gunshot or stab wounds, this determination frequently cannot be made.)

4. Approximately how long could the deceased have lived after the assault (survival time)?

5. How far could the deceased have walked or run?

6. Was the body dragged or dumped?

7. From what direction was the force applied?

8. What was the position of the deceased at the time of injury (sitting, standing, lying down, etc.)?

9. Are the injuries antemortem or postmortem?

10. Is there any evidence of sexual assault (rape or sodomy)?

11. Was the deceased under the influence of drugs?

12. Was the deceased under the influence of alcohol?

13. Are there any foreign objects in the cadaver (bullets, broken blades, fibers, etc.)?

14. Is there any evidence of a struggle (defense wounds, etc.)?

15. What is the estimated time of death?

It is important to note that most initial injuries do not cause immediate death. There is often a "survival interval" during which the person may engage in considerable activity before collapsing and dying. In fact, instances have been documented in which persons who have been severely injured or who have suffered multiple gunshot wounds have performed unusual physical accomplishments. This type of

Figure 18.13 ILLUSTRATION OF THE CONTRECOUP INJURY. An injury to a part of the body (usually the brain) caused by a blow to the opposite side. (Courtesy of Medical Legal Art. Illustration copyright 2005, Medical Legal Art, www.doereport.com.)

activity before death will be readily observable to the trained pathologist, who will be able reasonably to determine the survival time by noting the condition of internal organs and the forms of hemorrhage in the body cavities or stomach of the deceased. For example, hemorrhage into the chest and heart cavities following a penetrating wound usually indicates that the individual survived for only a short time; bleeding into the stomach or lower abdominal tract indicates a longer survival time.

The presence of a wound on a body does not necessarily mean that someone else inflicted the wound. Suicide must always be considered. It is a common error to believe that certain wounds would have been too painful to be self-inflicted.

Remember: No wound is too painful if the person is determined to take his or her life.

The pathologist considers the location, size, shape, character, and type of wound before the death is determined a homicide. For wounds to be self-inflicted, the locations must be accessible to the deceased. In most suicides, the instrument of death will be nearby. (However, the absence of a weapon is not conclusive evidence that the death is a homicide.)

The number, type, and location of wounds may also provide information to the investigator. Unusual types of wounds — such as mutilation of the body, removal of private parts, or eyes put out — may offer clues. Secondary wounds or "overkill" injuries may indicate extreme emotion.

The pathologist can ascertain how recent a wound is and which wound caused the death. He or she can also distinguish between wounds produced before and after death. Furthermore, in cases where the body has been out of doors or in water, there will be evidence of feeding by wild animals or postmortem injuries due to marine life or boat propellers, which the investigator might mistakenly interpret as being related to the cause of death. The pathologist also looks for defense wounds; these are usually found on the arms and legs of the victim, particularly between and on the insides of the fingers.

In some instances, the autopsy examination will reveal a specific type of weapon. For example, a piece of the knife blade may break off in a victim's body. When the barrel of a gun is pressed close to the skin of a victim, it will leave a mark of the barrel.

The investigator can assist the medical examiner by keeping the crime scene under police control until after the autopsy has been completed. This procedure allows for further search in case additional information is discovered during the autopsy and assures admissibility of any additional evidence.

The Medicolegal Autopsy

The complete medicolegal autopsy or postmortem examination involves the following steps:

Examination of the crime scene

Identification of the body

External examination of the body

Internal examination of the body

Toxicological examination of body fluids and organs

Figure 18.14 STRANGULATION MARKS ON NECK. This photo shows evidence of small contusions and fingernail marks on the front of the victim's neck caused by the assailant's fingers compressing the neck. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.15 HEMORRHAGE IN EYE. Hemorrhage in the eye of a victim who was manually strangled. (Courtesy of Dr. Dominick J. DiMaio, former chief medical examiner, City of New York.)

Figure 18.16 PETECHIAL HEMORRHAGE. Minute (pin-like) hemorrhages that occur at points beneath the skin, usually observed in conjunctivae (the mucous membrane lining the inner surface of the eyelids and anterior part of the sclera). (Courtesy of William K. Brinkhous, investigator, North Carolina Office of the Chief Medical Examiner, Chapel Hill, North Carolina.)

Figure 18.17 FRACTURES OF THE CRICOID CARTILAGE. This photo shows fractures in the ring-shaped cartilage connected to the thyroid cartilage. The larynx, which lies in front of the fourth through sixth cervical vertebrae, is protected only by the skin and thin layer of fibrous connective tissue called the fascia. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.18 ASPHYXIAL DEATH — OBSTRUCTED AIRWAY. Child who was playing with tinker toys was found unconscious. He apparently swallowed one of the pieces, which the medical examiner found lodged in the esophagus obstructing the airway. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.19A ENTRANCE WOUND. Entrance wound in a bizarre shooting case. (Courtesy of Detective James M. Yoghourtjiam, crime scene investigator, Racine, Wisconsin, Police Department.) Continued.

Figure 18.19B INTERNAL VIEW OF THE SKULL SHOWING THREE BULLETS. Two bullets had become lodged in the barrel of the revolver. When the third bullet was fired, all three projectiles entered the skull, producing the single entrance wound depicted in Figure 18.19A with three projectiles. (Courtesy of Detective James M. Yoghourtjiam, crime scene investigator, Racine, Wisconsin, Police Department.)

Figure 18.19C RECOVERED PROJECTILES. Three recovered projectiles with label. (Courtesy of Detective James M. Yoghourtjiam, crime scene investigator, Racine, Wisconsin, Police Department.)

Figure 18.20 RECOVERY OF A BULLET DURING AUTOPSY. Observe the pathologist recovering the bullet that had come to rest subcutaneously in the victim's back. The bullet had entered the chest area and traveled through the ribs, heart, and lungs. It was stopped under the skin on the opposite side. (From the author's files.)

The medicolegal autopsy is ordered by the medical examiner or coroner for the purposes of

1. Determining the cause, manner, mechanism, and time of death

2. Recovering, identifying, and preserving evidentiary material

3. Providing interpretation and correlation of facts and circumstances related to death

4. Providing a factual, objective medical report for prosecution and defense

5. Separating natural death from unnatural death for protection of the innocent in suspicious deaths

It is important to note that an autopsy must be complete if it is to be accurate. The basic principle of homicide investigation is "Do it right the first time; you only get one chance." Theoretically, a body can be exhumed for further examination. However, exhumation is costly and usually unnecessary if the examination was complete the first time. There is no excuse for haphazard or short-cut methods to be taken in this crucial investigative step. Once a body has been embalmed and

Figure 18.21 CLOTHING OF VICTIM OF GUNSHOT WOUND. Clothing of a victim shot in the left chest in a close contact shooting. The clothing has been arranged by the medical examiner to show the path through the outer shirt and undershirt and into the chest. (Courtesy of Dr. Dominick J. DiMaio, former chief medical examiner, City of New York.)

Figure 18.22 BULLET WOUND WITH SHIRT RESIDUE. Close-up view of the gunshot wound into the left chest from Figure 18.21. Note that the rayon shirt material has melted into the wound entrance due to the extreme heat of the muzzle blast. (Courtesy of Dr. Dominick J. DiMaio, former chief medical examiner, City of New York.)

Figure 18.23 STABBING INJURIES. This female victim had received multiple stabbing injuries to her chest and arms by her assailant, who was using a serrated edged blade. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.24 PATTERN INJURY FOR SERRATED KNIFE. This photo shows a scraping type of injury from one of the weapons. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.25 WEAPONS USED IN STABBING. The knives used in the stabbing murder were recovered with the victim's blood still on the blades. The knives were consistent with the pattern of injury on the victim's arm. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.26 MEDICAL EXAMINER LOCATES A FOREIGN PIECE OF METAL IN VIC-

TIM'S BODY. (Courtesy of Detective Mark Czworniak, Chicago Police Department.)

buried, many forms of evidence — especially toxicological and pathological — will be lost forever. Therefore, a systematic routine must be followed in postmortem examinations.

The medicolegal autopsy is much more involved than a general autopsy, which is performed in a hospital. It involves special training, skill, and cooperation between independent organizations, including the police, the prosecutor's office, and specialized personnel such as serologists, toxicologists, anthropologists, and odontologists. Usually, when the autopsy is performed by the pathologist, it is

Figure 18.27 TIP OF KNIFE BLADE USED TO STAB THE VICITM WAS RECOVERED IN VICTIM'S CHEST. The use of macro photography to document the trace evidence. (Courtesy of Detective Mark Czworniak, Chicago Police Department.)

Figure 18.28 FRACTURE MATCH. This photo shows the "fracture match" of the tip of the blade removed from the chest of the victim by the medical examiner to the murder weapon recovered by the police. The only undisputed and conclusive method of identifying a sharpbladed instrument to the actual stab wound is to recover a piece of the weapon within the wound structure and match it to the murder weapon. (Courtesy of Detective Mark Czworniak, Chicago Police Department.)

Figure 18.29 PUGILISTIC ATTITUDE. This photo depicts the position the body assumes as a result of intense heat and fire. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.30 SOOT IN AIR PASSAGE. This photo depicts soot in the air passage, indicating that the victim was alive during the fire. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

impossible to foresee the questions that may arise hours, weeks, or years later. Therefore, if an autopsy is to be done professionally, it must be done completely and all possible information obtained.

Remember: The purpose of the medicolegal autopsy is more than just to establish cause of death. It involves the determination of all the other factors which may or may not be involved.

In order to acquaint the investigator with the requirements of the medicolegal autopsy, I have provided the following guidelines based on the National Association of Medical Examiners' Standards for Inspection and Accreditation of a Modern Medicolegal Investigative System.

Examination of the Crime Scene

In many jurisdictions, a medical investigator, medical examiner, or coroner will respond to the crime scene to ascertain the essential facts concerning the circumstances of death and make a preliminary examination of the body. Once the body has been identified, the examiner looks for and evaluates any external evidence of trauma. Then a more complete examination of such factors as body heat, lividity, rigor mortis, and decomposition is made to determine the approximate time of death. Often a determination of cause of death will hinge on facts or circumstances derived from an examination of the scene.

However, although cause of death can frequently be determined during the scene investigation, particularly in gunshot or stab wound cases, the exact number of bullet or stab wounds cannot usually be ascertained until the autopsy. This is particularly true in cases where the body is clothed or has been covered with blood or dirt. The medical examiner or coroner takes charge of the body, any clothing on the body, and any article on or near the body that may assist the pathologist in determining cause and manner of death.

The crime scene examination does not end at the location of death. If the medical examiner who was present at the scene will not be performing the autopsy, the information from the crime scene investigation must be conveyed to the pathologist who will conduct the autopsy. The homicide detective who conducted the preliminary police investigation and was present at the crime scene should attend the autopsy and provide the medical examiner or coroner with the following:

1. Description of the circumstances of death

2. Description of the scene of death (Complete notes taken at the scene include a description of the deceased, color of any blood, injuries and wounds observed, etc.)

3. Condition of the body when first discovered (rigor mortis, lividity, temperature, putrefaction, decomposition, maggots or other insect activity, etc.)

4. Statements taken from witnesses and/or suspects

5. Police photographs taken at scene (Polaroid photos should be taken in addition to the usual police photos because they are ready for viewing immediately and can be available at autopsy.)

6. Diagrams and sketches of the crime scene

7. Any weapons or articles found at the scene which relate to the death (knives, guns, other weapons, notes, paper, drugs, etc.)

8. Any questions formulated during the initial phase of the investigation (These may be evaluated in light of the medical evidence found by the pathologist.)

Identification of the Body

The body must be properly identified to the medical examiner. The legal identification of the body is one of the requirements in the chain of custody and is vital to the homicide investigation. In criminal cases, a personal and a police identification must be made directly to the medical examiner. These identifications are made on official affidavits, sworn to in the presence of witnesses, with the time and date affixed, and signed by the person or official making the identification.

The police identification is made by an officer who observed the body at the scene, saw where it was found, or saw where the crime was committed. A personal identification is made by a relative or someone who knew the deceased.

The medical examiner assumes responsibility for the proper identification of the dead body. In homicide cases, all available means of identification should be employed to ascertain the identity of the deceased. The various methods of identification are

Personal identification (next of kin, relatives, friends, etc.)

Fingerprints

Teeth

DNA

Scars and/or surgical procedures (medical records)

Tattoos

Body build

Congenital malformations

Comparison x-rays

Identification of clothing on the body and its contents Photographs

If the body is badly decomposed or skeletonized, an additional function of the autopsy will be to identify the remains. The pathologist is in the best position to know which additional experts — odontologists, microbiologists, anthropologists, etc. — may be needed.

External Examination of the Body

The date, time, and place of autopsy should be recorded, where and by whom it was performed, and the identity of any witnesses and/or participants. This recording can be done by a stenographer or by mechanical recording equipment.

Preliminary Procedure

1. The body is examined before the clothing is removed to determine the condition of the clothing and to correlate any tears or other defects with obvious injuries to the body. These observations are then recorded.

2. The clothing, body, and hands of the deceased should be protected from possible contamination prior to the examination. (Hands should have been covered with paper bags at the scene before the body was transported.)

3. Clothing should then be carefully removed by unbuttoning, unzipping, or unhooking, without tearing or cutting. This should be done systematically, and the condition of the clothing including any torn buttons, unsnapped garments, etc. should be recorded so that any necessary cutting is not confused with any tearing or cutting from the weapon or incident which caused death.

4. Clothing should then be laid out on a table so that a relationship can be established between the wounds on the body and the damages to the clothing. This procedure enables the pathologist to determine the position of the body at the time the wounds were inflicted and to know where to look for external and internal damage.

5. Each item of clothing should be properly marked for identification. (If clothing is wet or bloody, it should be hung to air dry in order to prevent any putrefaction.)

The External Examination

1. The body is identified for the record and a complete physical description is taken as follows:

a. Age

b. Height

c. Weight

d. Sex

e. Color of hair and eyes

f. State of nutrition

g. Muscular development

h. Scars

i. Tattoos

j. Detailed description of teeth (number and general condition)

k. Any abnormalities or deformities

l. Evidence of any fractures

2. The body should then be carefully washed to remove any dried blood and/or dirt from the surface. (In gunshot cases, the pathologist should record the presence of any smoke or powder residue prior to this washing.)

3. A detailed description of the injuries should then be recorded, noting the number and characteristics such as size, shape, pattern, and location in relation to anatomic landmarks.

4. Photographs should then be taken of the body for identification and to record specific injuries.

a. Photographs of injuries should include a scale and an identificationnumber.

b. If police have recovered a weapon, this weapon can be photographedalongside the wound. However, the weapon should be held away from the body in order to prevent any contamination of evidence, such as blood or hair being transferred between the body and the weapon.

5. The presence of any bite marks should be noted and these wounds or marks photographed with a 1 × 1 (fingerprint) camera or Polaroid® Spectra CloseUp kit, using a scale and measure along with an identifier label. (If these bite marks were observed prior to the body washing, a saliva swabbing should have been obtained for a possible blood grouping.)

6. X-ray and fluoroscope examination should then be undertaken to

a. Locate bullets, broken blades, or other radio-opaque objects

b. Document any old or new fractures, anatomic deformities, postsurgicalmaterials such as metal plates, screws, or nails.

c. Identify remains where there is no personal identification. (These x-rayscan then be held pending the comparison of any antemortem records when and if located.) (Note: In all decomposition and child-abuse cases, the remains are x-rayed to document past trauma.)

7. During this external examination, a record is made of any postmortem artifacts, such as:

a. Artifacts of decomposition

b. Third-party artifacts, e.g., animal or insect activity, emergency medicaltreatment, deliberate mutilation, or any dismemberment

c. Artifacts of storage and/or transportation prior to autopsy

8. The hands, wrists, and arms should be examined for evidence of defense wounds. In addition, in certain types of homicides, the pathologist will clip the fingernails to obtain trace evidence from the deceased's fingers, which may include tissue and blood specimen DNA from the suspect. Hands may also be examined for powder residue by SEM-EDX scanning electronic microscope with atomic absorption analysis.

9. In sex homicides, samples of scalp and pubic hair should be obtained from the body of the deceased. All hair should be plucked to secure the entire hair including the root. The pubic area should first be combed to secure any foreign or loose hairs, which may be compared with the suspect's hair. Other samples that represent different parts of the body should be obtained. In addition, oral, nasal, vaginal, and anal swabs should be taken for further DNA examination.

Internal Examination of the Body

An internal examination of the head, neck, cervical spine, thorax, abdomen, and genitalia is then performed by the pathologist. The examination records the course of wounds through the various structures, and any evidentiary items such as bullets, pieces of weapons, pellets, and foreign material are preserved. Their particular point of recovery is noted for the record, and each item is labeled for proper identification. The internal examination generally proceeds as follows.

The Head

1. The exterior of the scalp is first examined for any injuries hidden by the hair. 2. The eyes and eyelids are then examined for any petechiae in the conjunctivae. (This is a pathological condition caused by asphyxia. Tiny hemorrhages in the form of specks are seen on the mucous membrane lining the inner surface of the eyelids.)

3. The ear canals are then examined for evidence of hemorrhage.

4. The interior of the mouth, lips, and cheeks are examined for evidence of trauma.

Figure 18.31 CORONAL MASTOID INCISION — HEAD INCISION. (Courtesy of Dr. Leslie

I. Lukash, former chief medical examiner, Nassau County, New York.)

5. The teeth are then examined for any injury or breakage. The pathologist can use a dental chart to identify each tooth, its condition, location of fillings, evidence of injury, etc.

6. A coronal mastoid incision is then made across the head. The scalp is pulled back exposing the cranium. The interior of the scalp is examined for any evidence of trauma, and the cranium is examined for fractures. The calvarium is then removed, exposing the dura and the brain.

Figure 18.32 HEAD INCISION. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.33 SEPARATING THE SCALP. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

7. The brain is removed and examined for any injury or disease.

8. The brain is weighed.

9. A slice of brain tissue is taken for later examination.

10. The dura is then stripped from the cranial cavity and the interior of the skull is examined for any fractures or injury.

Figure 18.34 SCALP BROUGHT FORWARD. The scalp is brought forward to expose the cranium. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.35 OPENING OF THE SKULL CAVITY. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.36 OPENING THE SKULL. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.37 CALVARIUM REMOVED. The calvarium, or top of the skull, is removed, exposing a hemorrhaged brain. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.38 BRAIN BEING REMOVED FROM SKULL. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.39 SKULL CAVITY — BRAIN REMOVED. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

The Chest

1. An incision is then made across the chest of the subject. This incision is called the thoracoabdominal incision, more commonly referred to as the "Y" or primary incision.

2. The chest is then examined for any fractures of ribs, noting their specific anatomic location. In cases where an ambulance crew has attempted resus-

Figure 18.40 THE THORACOABDOMINAL OR "Y" INCISION. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.41 THE THORACOABDOMINAL OR "Y" INCISION. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.42 CHEST AND RIBS EXPOSED. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.43 REMOVAL OF CHEST PLATE. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.) citation, additional injuries to the body may not be properly evaluated if the medical examiner is not given this information. I cannot overemphasize that an investigator assigned to the case should be present during the autopsy so that the pathologist can be briefed about what transpired at the scene.

3. The breast plate is then removed by cutting through the ribs, exposing the heart and lungs for examination.

4. A sample of blood is then taken directly from the heart, after opening the pericardial sac, for determining blood type and for later toxicological examination.

Figure 18.44 BREAST PLATE REMOVED. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.45 INTERNAL ORGANS EXPOSED FOR AUTOPSY. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

Figure 18.46 CONTAINERS OF SPECIMENS. Containers of physiologic fluids and organs to be sent for further toxicologic examination. (Courtesy of Dr. Leslie I. Lukash, former chief medical examiner, Nassau County, New York.)

5. The heart and lungs are then removed, weighed, and examined and a slice of tissue taken for later examination.

6. The quantity of fluids in the pericardial and pleural cavities is measured and recorded.

7. The chest flap is then pulled upward to chin level to examine structures of the neck muscles and organs. Any hemorrhage is noted, and the organs of the neck and throat, including the tongue, are removed for further examination.

8. Signs of asphyxia are noted within these structures and the upper chest and in the pericardium and pleurae.

9. The tongue is then examined by lateral dissection for any evidence of trauma. (In many instances, the deceased will bite his or her tongue during strangulation.)

10. The interior of the chest is then examined for any trauma or other injuries along the cervical and thoracic spine.

The Abdomen

1. The abdomen is examined, noting the positions and condition of the organs. 2. The course of injuries is traced and recorded before any organs are removed.

3. All fluids in this cavity are measured and recorded.

4. Each separate organ is weighed and dissected for later toxicological examination after it has been examined for any projectiles. In addition, a section of the intestines is kept for testing.

5. Stomach contents are measured and recorded and a sample kept for toxicology.

6. The fluid in the gall bladder is kept intact for testing.

The Pelvic Cavity

1. The external and internal genitalia are examined for evidence of foreign matter and injury.

2. In sex homicides, vaginal and anal swabs are taken (oral swabs should also be obtained).

3. The urinary bladder is removed and the fluid measured and kept for toxicological examination.

The Protocol

The protocol is the official report of the autopsy by the medical examiner or coroner. It may be dictated to a stenographer or recorded into a mechanical recorder for later transcription. The preparation of this report is the responsibility of the chief medical examiner or coroner. The protocol or autopsy report reflects the entire examination, negative and positive, and gives the official cause of death expressed in acceptable terminology. It contains the following information:

1. External examination

a. Description of the clothing

b. Description of the body

2. Evidence of injury

a. External

b. Internal

3. Central nervous system (head and brain)

4. Internal examination — cardiovascular system, pulmonary system, GI (gastrointestinal) system, stomach, small and large intestines, etc.

5. Anatomical findings

6. Toxicological findings

7. Opinion

The medical examiner at the end of this protocol then reports the official diagnosis of the cause of death. Today, many pathologists use a prepared autopsy form that not only guides the procedure but also assures the completion of the autopsy. If death is determined to be the result of homicide, the pathologist will indicate this by placing the word "homicidal" on the protocol. The opinion will then be expressed in simple, understandable English, avoiding medical terminology and indicating the nature of the injury which caused death and any major complicating factors. For example:

It is my opinion that John Smith, a 30-year-old male, died as a result of a gunshot wound to the chest. The bullet, a .38-caliber which was recovered from the body, passed through the right lung and heart causing massive internal hemorrhage. No other injuries or significant natural disease process was found at the time of autopsy.

The value of the diagnosis and protocol from an investigative point of view is that they provide a factual and medical opinion of the death. This can then be used to determine whether the facts and evidence gathered during the homicide investigation are consistent with the cause of death as determined by the medical examiner.

Summary

The success of the medical examination and the homicide investigation is assured when mutual cooperation exists between the pathologist and the homicide investigator. Teamwork is essential in this phase of the duties and responsibilities so that all parties can benefit from one another's contributions and expertise in the professional investigation of homicide.

Human Anatomy

In order to provide some basic reference material and understanding of the terminology used in medicolegal investigations, I have included this section on human anatomy.2,3 Investigators are not expected to have the medical knowledge of a forensic pathologist. However, they should have a working knowledge of anatomical terminology in order to communicate intelligently with the pathologist and comprehend the final autopsy report. Furthermore, an understanding of the fundamental structures of the human body and the location of vital organs and bones can enable the investigator to make intelligent observations at the scene.

The word anatomy is derived from two Greek words, which mean literally "to cut apart." Through usage, it has come to mean the study of the structure of the body, describing the size, shape, composition, and relative positions of the organs and various parts of the body. In order to describe the structures within the body, medical terminology employs a number of "points of reference," which assist in visualizing each organ's position within the human body. For example, to describe the heart's position, it is necessary to detail what is above, below, to the right and left, and in front and back of it, and where all these positions are located in reference to easily identified points on the outside of the body. In order for these points of reference to be meaningful, there must be a set position of the body known as anatomical position.

Figure 18.47 ANATOMICAL POSITION. (Courtesy of Medical Legal Art. Illustration copyright 2005, Medical Legal Art, www.doereport.com.)

All terminology used in describing the body and its parts is based on this anatomical position, which is that of the body standing erect, arms at the sides, with the palms facing forward and the thumbs to the outside.

Therefore, when studying anatomical plates, such as the figures presented in this section, the right side of the body will be on the left side of the drawing, and the left side of the body will be on the right side of the drawing, as they are when you are looking at a person facing you.

Directional Terms

These are the terms used in anatomy to describe the position of a particular organ in relation to other organs;

1. Superior indicates direction toward the head end or upper part of the body. Hence, the lungs are superior to the liver.

2. Inferior indicates direction further away from the head end of the body or toward the lower part of the body. Hence, the intestines are inferior to the stomach.

3. Anterior (ventral) indicates the front or belly side of the body. Hence, the toes are anterior or ventral.

4. Posterior (dorsal) indicates the back side of the body. Hence, the heels are posterior or dorsal.

5. Proximal indicates nearer to a point of reference, usually the center of the body. Hence, the shoulder is proximal to the elbow.

Figure 18.48 DIRECTIONAL TERMS. (Courtesy of Medical Legal Art. Illustration copyright 2005, Medical Legal Art, www.doereport.com.)

6. Distal indicates farther away from the center of the body. Hence, the elbow is distal to the shoulder.

7. Medial indicates closer to the midline of the body. Hence, the little finger is medial in anatomical position.

8. Lateral indicates toward the side of the body or away from the midline. Hence, the thumb is lateral in anatomical position.

9. Sagittal plane is an imaginary line dividing the body into a right and left portion.

10. Coronal plane is an imaginary line dividing the body into a front and back portion.

Body Cavities

The body is divided into two large cavities called the dorsal (back) and ventral (front) cavities, which are then subdivided into smaller sections.

Dorsal Cavity

This cavity is subdivided into the cranial and vertebral cavities:

Figure 18.49 BODY CAVITIES. (Courtesy of Medical Legal Art. Illustration copyright 2005, Medical Legal Art, www.doereport.com.)

1. The cranial cavity is formed by the skull and contains the brain and the pituitary gland.

2. The vertebral cavity is contained within the vertebral column and houses the spinal cord.

Ventral Cavity

This cavity is subdivided into two major sections, the thoracic cavity and the abdominopelvic cavity. These two sections are divided by the diaphragm and then subdivided into additional cavities as follows:

1. Thoracic cavity: this is the portion above the diaphragm and contains the following cavities:

a. Two pleural cavities: these contain the two lungs.

b. Pericardial cavity: this contains the heart.

c. Mediastinal or interpleural cavity: this contains everything located in the thoracic cavity other than the heart and lungs, including the trachea, bronchi, esophagus, etc.

2. Abdominopelvic cavity: this is the portion below the diaphragm and contains two sections:

a. Abdominal cavity: the upper portion of the abdominopelvic cavity. It contains the stomach, liver, gallbladder, spleen, pancreas, and most of the large and small intestines. The kidneys, ureters, and adrenal glands lie deep in the cavity.

b. Pelvic cavity: the lower portion of the abdominopelvic cavity, which begins roughly on a line with the iliac crests and ends at the inferior end of the abdominopelvic cavity. It contains the urinary bladder, the sex organs, and part of the small and large intestines.

Quadrants

There are additional points of reference to locate precisely the organs in the abdominopelvic cavity because the cavity is large and contains several organs. The medical description divides the cavity into four quadrants:

1. The upper right quadrant contains part of the small intestine, the descending duodenum; the upper ascending colon; most of the liver, gallbladder, and bile ducts; head of pancreas; right adrenal gland; right kidney; and upper part of right ureter.

2. The lower right quadrant contains the lower ascending colon, cecum, appendix, lower right ureter, terminal ileum, part of urinary bladder, and sex organs.

Figure 18.50 QUADRANTS. (Courtesy of Medical Legal Art. Illustration copyright 2005, Medical Legal Art, www.doereport.com.)

Figure 18.51 ANTERIOR AND POSTERIOR VIEWS OF THE THORACIC AND ABDOM-

INAL CAVITIES. (Courtesy of Medical Legal Art. Illustration copyright 2005, Medical Legal Art, www.doereport.com.)

3. Upper left quadrant contains the ascending part of duodenum, upper descending colon, left half of transverse colon, spleen, small part of liver, left adrenal gland, left kidney, and upper part of left ureter.

4. Lower left quadrant: contains descending colon, small intestine (part of ileum), lower part of left ureter, part of urinary bladder, and sex organs.

The Skeletal System

The skeletal system consists of all of the bones in the body. The skeleton provides support, protects certain body organs beneath the bones, and serves as a system of connection for the muscles and ligaments. Practically speaking, it is not necessary for the homicide detective to understand the make-up, development, or detailed structure of the bones. However, the investigator should have some basic knowledge of the anatomical location of certain major bones in the human body, such as the long bones of the arms and legs, the humerus, ulna, radius, femur, tibia, and fibula. In addition, the location of the clavicle, scapula, sternum, vertebral column, ribs, pelvis, and patella may be useful in visualizing a specific portion of the body.

The Heart

The heart is basically a pump that maintains the circulation of blood throughout the human body. It is about the size of a man's fist and is located in the pericardial cavity between the lungs, posterior to the sternum, lying about two-thirds to the

Figure 18.52 THE HEART ANATOMY. (Courtesy of Medical Legal Art. Illustration copyright

2005, Medical Legal Art, www.doereport.com.)

left of midline. The heart is divided into four chambers. The upper two chambers are called atria and the lower two chambers are called ventricles.

The heart is the major organ of the cardiovascular system. The pumping action maintains the circulation of blood to and from the heart through a series of blood vessels:

1. Arteries carry blood away from the heart.

2. Veins carry blood to the heart.

3. Capillaries connect arteries and veins.

The purpose of circulation is to bring the deoxygenated blood from various parts of the body through the veins to the lungs for purification. The oxygenated

Figure 18.53 THE CIRCULATORY SYSTEM — ARTERIES AND VEINS. (Courtesy of Medical Legal Art. Illustration copyright 2005, Medical Legal Art, www.doereport.com.)

blood is then returned to the heart from the lungs for circulation to the body through the arteries.

It is not necessary for the investigator to have an in-depth knowledge of the workings of the heart and cardiovascular system. However, he or she may want to be familiar with the general location of the heart and the major veins and arteries in order to appreciate the trauma or damage that can be done to the body if one of these major blood vessels is injured. The following table lists the major arteries and veins for reference purposes.

Carotid Femoral Jugular Femoral

Subclavian Brachial Subclavian Brachial

Aorta Ulnar Superior vena cava Ulnar

Abdominal aorta Radial Inferior vena cava Radial

Iliac Iliac

Figure 18.54 BONES OF THE SKELETON. (Courtesy of Medical Legal Art. Illustration copyright 2005, Medical Legal Art, www.doereport.com.)

References

1. Lukash, L.I. (chairman) et al. Standards for Inspection and Accreditation of a Modern Medicolegal Investigative System. Wilmington, DE: National Association of Medical Examiners, 1974.

2. Gray, H. Gray's Anatomy. Pickering, T. (Ed.). Philadelphia: Pick Running Press, 1974.

3. Thomas, V. Life Sciences for Nursing and Health Technologies. Long Beach, CA: Technicourse, Inc., 1977.

Selected Reading

Adelson, L. The Pathology of Homicide. Springfield, IL: Charles C Thomas, 1974.

DiMaio, D.J., and V.J. DiMaio. Forensic Pathology, 2nd ed. Boca Raton, FL: CRC Press, 2001.

Fisher, R.S. and C.S. Petty (Eds.). Forensic Pathology: A Handbook for Pathologists. Washington, D.C.: National Institute of Law Enforcement and Criminal Justice Law Enforcement Assistance Administration, U.S. Department of Justice, 1977.

Geberth, V.J., Practical Homicide Investigation: Tactics, Procedures, and Forensic Techniques, 3rd ed. Boca Raton, FL: CRC Press, 1996.

Geberth, V.J. "Autopsy: The Medicolegal Investigation of Death," Law and Order Magazine, 30(7), July, 1982.

Gray, H., Gray's Anatomy. Pickering, T. (Ed.). Philadelphia: Pick Running Press, 1974.

New York City Charter and Administrative Code. Chapter 39 Chief Medical Examiner.

Snyder, L. Homicide Investigation, 3rd ed. Springfield IL: Charles C Thomas, 1977.

Spitz, W.U., R.S. Fisher, and D. Spitz. Spitz and Fisher's Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation, 4th ed. Springfield, IL: Charles C Thomas, 2005.

Thomas, V. Life Sciences for Nursing and Health Technologies. Long Beach, CA: Technicourse, Inc., 1977.