An autopsy is the systematic and internal examination of a body to establish the presence or absence of disease by gross and microscopic examination of body tissues. . . . Medicolegal autopsies are conducted to determine the cause of death; assist with the determination of the manner of death as natural, suicide, homicide, or accident; collect medical evidence that may be useful for public health or the courts; and develop information that may be useful for reconstructing how the person received a fatal injury.
—Strengthening Forensic Science in the United States: A Path Forward, 2009
THE FIELD of forensic medicine covers everything of a medical nature that might be discussed or argued in a court of law. The responsibilities of a medical examiner are myriad, but generally speaking he or she is charged with determining the cause of death, the time of death, and the identity of the decedent.
The specialized knowledge required to answer these often complex questions is immense. Forensic pathologists are responsible for determining the cause of death when someone dies suddenly, unexpectedly, or violently; at autopsy they look for the presence or absence of disease, injury, or poisoning; they collect medical evidence such as trace evidence and secretions; they document sexual assault and determine how injuries to the body were inflicted. Some forensic pathologists also have a working knowledge of toxicology, wound ballistics, trace evidence, forensic serology, and DNA technology.
The earliest known person who might be said to have practiced what we think of today as forensic medicine was Imhotep, counselor to the pharaoh Zoser who ruled Egypt five thousand years ago. Imhotep, who was both the chief justice of the kingdom and physician to the pharaoh, was a polymath—an early Egyptian combination of Leonardo da Vinci, Thomas Jefferson, and Louis Pasteur. He earned an impressive collection of titles: Chancellor of the King of Lower Egypt, Doctor, First in Line after the King of Upper Egypt, Administrator of the Great Palace, Hereditary Nobleman, High Priest of Heliopolis, Builder, Chief Carpenter, Chief Sculptor, and Maker of Vases in Chief.
Imhotep designed the first Egyptian pyramid, the so-called step pyramid at Saqqara. He improved the manufacture of papyrus scrolls and wrote the earliest known treatise on the surgical treatment of traumatic injuries. The Edwin Smith Papyrus, written a thousand years after Imhotep but believed to be based on his work, lists forty-eight different traumatic injuries and gives advice on their treatment and prognosis. It is notable for its pragmatic, nonmagical approach—only a few magical incantations are called for. In it, Imhotep wrote of the heartbeat in the extremities of the body and of taking a pulse, but mainly he concerned himself with injuries—wounds that might be acquired in combat. A few sample case headings are: a wound in the head penetrating to the bone; a gaping wound in the head with a compound comminuted fracture of the skull; a gaping wound at the top of the eyebrow, perforating to the bone.
In each case, instructions are given as to how to diagnose the wound and then how best to treat it. Some sad cases are labeled “An ailment not to be treated.”
The Romans gave some thought to the problems of forensic medicine, and due to the necessities of the battlefield their physicians were skilled in the treatment of wounds. When Julius Caesar was assassinated in 44 B.C., the physician Antistius determined that of the twenty-three stab wounds Caesar had suffered, only the second one had been decidedly fatal. The Romans also had some knowledge of poisons due to the popularity of their use among the nobility.
The Code of Justinian, first issued in 529 A.D. and revised in 534, specified that a medical expert at a trial should not appear for either side but should be appointed to assist the judge impartially—a good idea that might be followed with profit today. Later, in the sixth century, St. Gregory of Tours wrote A History of the Franks in which he confirmed that physicians were indeed often called as expert witnesses by the courts.
In 1209 Pope Innocent III accepted testimony from doctors in an ecclesiastical court as to the lethality of a particular wound. This established an important precedent that eventually opened all European courts to such testimony. In 1497 Dr. Hieronymus Brunschwig of Strasbourg published the first known description of gunshot wounds.
In 1532 the Holy Roman Emperor Charles V devised the Caroline Code of criminal law, which advised that a medical doctor should be consulted in all deaths of a violent or unnatural nature. These included death by wounding, poisoning, hanging, drowning, murder, manslaughter, infanticide, abortion, and many other circumstances involving injury to the person. Doctors were required to testify in cases of malpractice and to keep written records of their autopsy findings.
In 1547 Antonius Blancus wrote On the Indications of Homicide, in which he questioned the reliability of a Germanic tribal custom that was still in use as a method to establish a murderer’s guilt. Known as ius cruentationis, it required the suspect to touch the corpse of the victim. If the corpse began to bleed at the touch, the suspect was guilty. Despite Blancus’s doubts, the use of the custom continued in some German courts until the mid-eighteenth century.
In 1670 the medical faculty of the University of Prague decided that their expert opinion on the subject of any wound would be given only after the joint consultation of the dean, one professor, three barber-surgeons, and two barbers.
Dr. Theodoric Romeyn Beck, a lecturer on medical jurisprudence in the College of Physicians and Surgeons of Western New York, published the two-volume Elements of Medical Jurisprudence in 1823. It covered questions of rape, impotence, sterility, pregnancy and delivery, infanticide and abortion, legitimacy, presumption of survivorship, identity, mental alienation, wounds, poisons, persons found dead, and feigned and disqualifying diseases. For the next half-century the book was the standard reference on forensic medicine. It was republished several times and translated into German and Swedish.
For the power of his deductive abilities, Dr. Joseph Bell (1837–1911) became the model for Arthur Conan Doyle’s Sherlock Holmes. A surgeon at the Royal Infirmary in Edinburgh and a lecturer at the University of Edinburgh Medical School (where Conan Doyle received his medical degree), Bell amazed his students with the accuracy of his deductions about patients. And not merely concerning their medical symptoms. “This man is a left-handed cobbler,” he once said, startling not only his students but the cobbler in question. “The worn places on his trousers,” he continued, “could only have been made by resting a lapstone between his knees. The right side is more worn than the left because he hammers the leather with his left hand.”
A story that Bell liked to tell on himself concerned a particular patient that he had decided would provide a good example of his methods. “Here is an interesting case for us,” he began. “This man, I should say, is a recently discharged soldier who was probably in the Royal Scots and had a good deal of service in the East. In the Army he was probably in the band, and, I have no doubt played a brass wind instrument.”
When his students looked suitably impressed, Bell explained his methods. When the patient entered the room he had stood rigidly to attention. No civilian does that. Neither would a soldier who has been discharged for any length of time. Hence Bell’s deduction about the recent discharge. The deep tanning on the patient’s face and neck suggested that he served in a hot climate, and the tattoo on his arm suggested it was in the East. His belt buckle was from a Royal Scots regiment. As he was smaller than the usual infantrymen, there was a good chance that he had served in the band. His narrow chest and shallow breathing were the marks of emphysema, possibly caused by playing a large wind instrument for many years.
Bell turned to the patient to verify his deductions.
“Now, my man, have you been a soldier?”
“Yes, sir.”
“For a long period?”
“Twenty years, sir.”
“You have seen service in India?”
“Yes, sir.”
“You played in the band?”
“Yes, sir.”
“And can we take it that you played the euphonium or a similar instrument?”
Well, four out of five isn’t bad.
The office of Coronae Custodium Regis, “Keeper of the King’s Pleas,” was established in England when King Richard the Lion Hearted was captured by Leopold of Austria in 1192. The original function of the office was to collect taxes, particularly death duties, to be used for Richard’s ransom. The functions of the coroner gradually expanded and the tax-collecting aspect disappeared, but the connection with death remained.
“Crowners,” as they became known, were charged with keeping track of convicted felons and, if the sentence was death (and almost every felony was a capital offense), with seeing to it that the executed felon’s worldly goods were properly confiscated by the crown.
By the time the post of coroner was brought to the United States, its function had narrowed to the investigation of suspicious deaths. There were no special qualifications for holding the job, which was often an elective office. Often the local mortician would be appointed or elected since he was the only one with the facilities to handle dead bodies. The coroner, and in some places a coroner’s jury, would hold a legal proceeding known as an inquest or postmortem to determine if a crime had been committed and, if so, whether there was probable cause to say who had committed it. The rules of conduct in the coroner’s court were set by the coroner. Witnesses had no right to have an attorney present and might be forced to answer questions that would not be allowed in a formal court of law. The decisions were binding on the victim but not on the suspect, if any. That is, the coroner’s findings could be used to settle estate or insurance questions, but it would take an indictment by a grand jury or a preliminary hearing before a trial judge to bring someone to trial on a felony charge.
In New York City in the late nineteenth century, the office of coroner reached a level of corruption and malpractice that was truly creative. Since the coroner was paid a set fee per inquest, he would often hold three or four inquests over the same body. Some coroners let it be known that for an extra $10 they would change the official cause of death from suicide to accidental death, thus assuaging the family’s feelings and making it possible for them to collect on the deceased’s life insurance. For $50, some would change a finding of homicide to one of accidental death, a cheap enough price to pay to get away with murder.
In 1897 a Brooklyn coroner had the body of a drowned man dragged from spot to spot along the East River waterfront. At each spot he would hold an inquest over the body. Even though the morgue held only one body, he billed the city for $10,000 in fees. The next year, when Brooklyn joined Manhattan and the other three boroughs to officially form the City of New York, the fee system for coroners was done away with and the job was made a regular salaried position. Twenty years later, in 1918, the position of coroner was abolished and the modern medical examiner system was installed.
Shortly before the New York City coroner’s office closed, it handled one of its more unusual cases. A husky, six-foot businessman named Murray Hall had died in bed. The coroner’s physician determined that the cause of death had been a heart attack and that Hall’s gender was actually female, a fact that even Hall’s niece, who lived in the same apartment, had not known. The jury’s verdict: “We find that Murray Hall came to his death by natural causes. We find that he was a lady.”
It takes about two hours to do an uncomplicated autopsy on a person who died of a stroke or a heart attack. Bullet wounds take longer. Mafia killings always take more time because of the number of bullet holes. We have to check each injury to see whether it contributed to the death.
—Michael M. Baden, Confessions of a Medical Examiner, 1990
The first step in the forensic examination of a body is a positive identification by a family member or close friend. Morgues handle this in various ways, from the ritual drawing back of the sheet to New York City’s practice of showing a photograph of the deceased.
Then comes the autopsy, where it is the job of the medical examiner or one of his assistants to determine the actual cause of death. Ideally, one of the homicide detectives working the case is present at the autopsy. This gives the detective a chance to ask questions and to have them answered immediately and in plain language. There is a chance too that this will spare the medical examiner a day in court, since the detective can then testify to what was found at autopsy.
If the case is a prominent one, the district attorney will probably send an investigator to the autopsy. This is a signal to the medical examiner that every cut, every assay, and every statement will be reviewed at trial. Pictures will (or should) be taken at every step of the autopsy. If there are questions afterward (or even years later), the possibility then exists of obtaining an answer.
On July 4, 1850, Zachary Taylor, four months into his second year as the twenty-second President of the United States, attended the groundbreaking ceremony for the Washington Monument and fell ill shortly afterward. It was explained that he had eaten too many cucumbers and cherries while standing in the hot sun. Five days later, after suffering extreme diarrhea, fever, and stomach cramps, the sixty-five-year-old president suddenly died.
For political reasons having to do with the slavery question, Taylor had made many strong enemies in his year and a half in office. The official cause of his death was gastroenteritis, but for more than 150 years rumors have circulated that he was poisoned, probably with arsenic.
On June 17, 1991, at the request of his closest living relative, Taylor’s remains were exhumed and taken to the offices of the chief medical examiner of Kentucky. Samples of his hair, fingernails, and tissue were taken, and he was reburied with appropriate honors.
The samples were subjected to neutron-activation analysis, which revealed the presence of arsenic, but at levels that were hundreds of times lower than they would be if he had been poisoned. Arsenic had probably leached into the body from the soil he was buried in.
But conspiracy theories never die. In his 1999 book History as Mystery, Michael Parenti suggests that the neutron-activation analysis was performed incorrectly. He asserts that Taylor was poisoned by arsenic after all.
When President John F. Kennedy was assassinated in 1963, everything about the killing and its aftermath assumed great importance. In the national effort to come to terms with the facts of this terrible event, one of the most critical pieces of information would be the results of the president’s autopsy. It was conducted at Bethesda Naval Hospital by three examining pathologists. One of them, Dr. James Humes, a navy commander, wrote in the autopsy report, “The complexity of these fractures and the fragments thus produced tax satisfactory verbal description and are better appreciated in photographs and roentgenograms [x-ray pictures] which are prepared.” Unfortunately the FBI agent in charge on the scene decided that the corpsman who was trained to take the pictures had no “clearance” to be present at the autopsy. The only other photographer, an FBI agent who presumably did have clearance, was not trained in photographing postmortem gunshot wounds. As Dr. Michael M. Baden puts it in Unnatural Death:
His pictures showed it. A proper photograph would have shown the injury first as it was and then cleaned off, next to a ruler to give perspective on its size and position in the body. None of his pictures clearly defined the entrance or exit wounds. The photographs of the body’s interior were out of focus. You have to know at what level you want to shoot—the chest is deep. He didn’t take pictures of any internal organs. These are the pictures Humes proposed to rely on, his own descriptive powers having failed him.
The lack of adequate autopsy photographs is at least part of the reason why the death of President Kennedy remains for many a mystery, and why various conspiracy theories refuse to fade away.
The standard incision for opening the body for internal autopsy examination is in the shape of a Y. It extends from each shoulder to the pit of the stomach and then down and through the pelvis. The internal organs—heart, lungs, spleen, liver, and so on—are removed, weighed, and inspected for physical signs of damage. Tissue samples are then taken and set aside for chemical and toxicological testing. The stomach is removed, its contents examined, and samples taken. The state of digestion of any food present may help determine the time of death.
Any fluid in the thoracic (chest) cavity or in other body cavities is siphoned off and saved for analysis. Any urine present in the bladder will also be preserved for analysis. Drugs that may have been ingested by the decedent can be detected in the urine.
The head is usually examined last. The exterior is closely examined for tiny scratches or wounds, the skull is examined for fractures, and the area around the eyes is examined for petechiae—pinpoint hemorrhages that might indicate strangulation or hanging. The top of the scalp is incised, and a flap is pulled down in front of the face. The skull is then sawed open and the brain is removed for examination. (This is a gruesome and disturbing sight if you are not used to it. But when the section of the skull is replaced and the skin flap is pulled back into place, the face and head can be prepared for a funeral such that the damage is invisible to the viewer.)
The complex and thorough procedures of the medical examiner may seem a waste of time if the cause of death is obvious—say, a gunshot wound or drowning. But many times it has been shown that the seemingly obvious cause of death is only a contributing factor and sometimes not the true cause at all. Even when no surface wound was visible, people have been found to have been shot or stabbed.
If the body was found in the water but there is no water present in the lungs or stomach, the victim was probably dead before entering the water, though there is a condition called laryngospasm, or “dry drowning.” In these cases the victim’s larynx closes and he is unable to draw water into his lungs. About 10 percent of drownings are dry drownings. If the body was found in the ocean but the water in the lungs is fresh water, the death would most certainly be regarded as suspicious.
If the victim supposedly died in a fire but there are no carbon particles in the lungs and no sign of carbon monoxide poisoning in the system, the fire may have been started to cover up a murder.
When the physical part of the autopsy is completed, the internal organs are placed back inside the body cavity. The body is then sewn back together, the head is reassembled, the face is made to look once more like a face, and the body is placed in cold storage. Chemical and biological tests may take weeks to complete and may be performed at laboratories thousands of miles from the autopsy site. When the cause of death has been officially determined, a death certificate is issued and the body is released to the family.
One of the great myths of forensic science, perpetuated in weekly television shows, is that it is possible to tell the time of death down to the quarter-hour.
“I can say that Mr. Fleishwhacker died sometime between 7 and 8:30 in the morning on Tuesday.”
“Can’t you pin it down any better than that, Dr. Kildare?”
“Well, you’ll be fairly safe if we call it between 7:30 and 7:45.”
It certainly would be useful to the homicide detectives to have the time window narrowed down so precisely. And in real life, forensic pathologists do more than their best to oblige. But in truth it is seldom possible to pin down the time of death so closely. And the longer ago the death, the more difficult the task.
The three major markers of time of death are rigor mortis, livor mortis, and algor mortis—the stiffening of the body, the settling of the blood, and the decrease in body temperature. These processes occur at the same time but at different rates. The figures for these rates are given in pathology textbooks and are presented as averages.
At or very shortly after death, all the muscles in the body relax completely. This is called “primary flaccidity.” Rigor mortis—the stiffening of the body—usually begins from two to six hours after death. It starts at the eyelids, neck, and jaw and proceeds down the body to the larger muscle groups until all the body’s muscles, even the heart, are stiffened. The body stays in rigor for twenty-four to seventy-two hours; then rigor passes in roughly the same order that it arrived.
Livor mortis, also known as postmortem lividity and hypostasis, describes the settling of the blood after death. Since it is no longer being pumped through the body, the blood settles at the lowest points it can reach given the position of the body. This pooling is evident in the skin, where it causes a purplish-red discoloration. It can begin at any time from half an hour to three hours after death. As the blood congeals, it becomes fixed and so can serve as a rough guide to time of death and as an indicator of whether or not the body has been moved. Lividity will always present at the lowest part of the body, so if it is evident throughout the body, it is a sign that the body has been shifted. Often this is due merely to the fact that the paramedics (or whoever found the body) rolled the deceased over in order to check for signs of life.
Algor mortis, Latin for the coolness of death, is the body’s path from the average 98.6 degrees Fahrenheit of life to the temperature of inanimate objects. There are different formulas for the rate of cooling, but the commonly accepted one is that the body cools only slightly during the first hour after death, presumably because the metabolic processes are still shutting down. Thereafter it cools at the rate of about one and a half degrees per hour. The temperature of the corpse is best taken rectally or from one of the internal organs. Usually at a crime scene a meat thermometer is inserted into the body on the right side just under the rib cage so that the tip penetrates the liver. It is left in for about five minutes before the reading is taken.
On a hot day in midsummer the temperature of the body might stay the same for quite a while or might even rise. On a very cold day the body temperature might fall comparatively quickly. If the deceased died while in the throes of a high fever, the rate would have to be adjusted accordingly. And there are many factors that can intervene—the deceased’s body weight, the amount of physical exertion right before death, and fluctuations in the external temperature—so that the readings are not always dependable. By roughly six hours after death, any temperature readings are absolutely untrustworthy.
Another consideration in determining time of death is that a person who is fatally injured and who should, according to everything we know of medical science, fall dead right then and there might live for quite a while. Thus the time of death and the cause of death are widely separated. In the Police Journal in 1943, the British pathologist Sir Sidney Smith told of the case of a man, whom he identified as “an elderly professional,” who left his residence hotel in Edinburgh one winter evening and stayed away all night. The next morning at half past seven he returned and was let in by the maid. He was, she noticed, wearing his overcoat and hat and had his umbrella over his arm. His face appeared to be covered with blood. Before she could call anyone he said, “Don’t worry. I will just go upstairs and have a wash.” After placing his umbrella in the hall stand, and hanging up his hat and coat, he went upstairs to the bathroom. The maid found him there a few minutes later, collapsed and unconscious.
When the police were called, the old gentleman was taken to the hospital, where he died a short while later. The cause of death was a self-inflicted bullet wound to the head. He had held the gun under his chin and fired. The bullet passed through his brain and came out on the left side of the frontal bone of his skull, leaving an exit hole an inch and a quarter in diameter.
By following the blood trail, the police were able to piece together the night’s events. At some time before six in the morning, the man had been sitting on a sheltered bench in a garden across the way from his hotel when he shot himself. He then got up and walked in a wide circle for about 165 yards and returned to his bench. Then he rose again and wandered around the garden for a while before once again settling on the bench. Finally he returned to the hotel. A fresh coating of snow on the ground showed clearly that there had been no one else near him, and letters received by relatives the next day put it beyond question that his death was a suicide.
Bits of the gentleman’s brain were found clinging to the top of the shelter over the bench. Not knowing the facts of the case, and just seeing the body, any pathologist would be willing to state that the wound would have caused instant unconsciousness and rapid death. But the man had lived, walked, and talked for at least two hours after shooting himself.