Autopsy

Autopsies, also known as necropsies or postmortem examinations, are performed by anatomic pathologists who dissect corpses to determine the cause of death and to add to medical knowledge. "Autopsy," from the Greek autopsia, means seeing with one's own eyes.

Greek physicians performed autopsies as early as the fifth century b.c.e.; Egyptian physicians used them to teach anatomy between 350 and 200 b.c.e.; and doctors with the Roman legions autopsied dead barbarian soldiers. In 1533 the New World's first autopsy supposedly determined whether Siamese twins had one soul or two. In 1662 the Hartford, Connecticut, General Court ordered an autopsy to see if a child had died from witchcraft (she died of upper airway obstruction). Into the early twentieth century, many physicians performed autopsies on their own patients, often at the decedent's residence.

In the twenty-first century, pathologists perform nearly all autopsies. After at least four years of pathology training (residency), anatomic pathologists spend an additional one to two years becoming forensic pathologists. These specialists are experts in medicolegal autopsies, criminal investigation, judicial testimony, toxicology, and other forensic sciences.

While autopsies are performed primarily to determine the cause of death, they also ensure quality control in medical practice, help confirm the presence of new diseases, educate physicians, and investigate criminal activity. Modern medicine does not ensure that physicians always make correct diagnoses. More than one-third of autopsied patients has discrepancies between their clinical and autopsy diagnoses that may have adversely affected their survival. By identifying treatment errors, autopsies also helped clinicians develop the methods in use today to treat trauma patients. Society also benefits from autopsies; for example, between 1950 and 1983 alone, autopsies helped discover or clarify eighty-seven diseases or groups of diseases.

Who Gets Autopsied?

Whether or not people are autopsied depends on the circumstances surrounding their deaths, where they die, their next of kin, and, in some cases, their advance directives or insurance policies. For many reasons, pathologists in the United States now autopsy fewer than 12 percent of nonmedicolegal deaths. Less than 1 percent of those who die in nursing homes, for example, are autopsied.

Medical examiners perform medicolegal, or forensic, autopsies. The 1954 Model Post-Mortem Examination Act, adopted in most U.S. jurisdictions, recommends forensic examination of all deaths that (1) are violent; (2) are sudden and unexpected; (3) occur under suspicious circumstances; (4) are employment related; (5) occur in persons whose bodies will be cremated, dissected, buried at sea, or otherwise unavailable for later examination; (6) occur in prison or to psychiatric inmates; or (7) constitute a threat to public health. Many also include deaths within twenty-four hours of general anesthesia or deaths in which a physician has not seen the patient in the past twentyfour hours. They can order autopsies even when deaths from violence are delayed many years after the event.

Not all deaths that fall under a medical examiner's jurisdiction are autopsied because they generally work within a tight budget. Approximately 20 percent of all deaths fall under the medical examiner/coroner's purview, but the percentage that undergoes medicolegal autopsy varies greatly by location.

In the United States, medical examiners autopsy about 59 percent of all blunt and penetrating trauma deaths, with homicide victims and trauma deaths in metropolitan areas autopsied most often. Some states may honor religious objections to medicolegal autopsies, although officials will always conduct an autopsy if they feel it is in the public interest. In 1999 the European Community adopted a comprehensive set of medicolegal autopsy rules that generally parallel those in the United States.

Autopsy Permission

While medical examiner cases do not require consent, survivors, usually next of kin, must give their permission before pathologists perform a nonmedicolegal autopsy. A decedent's advance directive may help the survivors decide. Survivors may sue for damages based on their mental anguish for autopsies that were performed without legal approval or that were more extensive than authorized; monetary awards have been relatively small.

Autopsy permission forms usually include options for "complete postmortem examination," "complete postmortem examination—return all organs" (this does not include microscopic slides, fluid samples, or paraffin blocks, which pathologists are required to keep), "omit head," "heart and lungs only," "chest and abdomen only," "chest only," "abdomen only," and "head only." Limitations on autopsies may diminish their value.

U.S. military authorities determine whether to autopsy active duty military personnel. Some insurance policies may give insurance companies the right to demand an autopsy, and Workman's Compensation boards and the Veterans Administration may require autopsies before survivors receive death benefits.

Consent is not required for autopsies in some countries, but families may object to nonforensic autopsies. When individuals die in a foreign country, an autopsy may be requested or required upon the body's return to their home country (even if it has already been autopsied) to clarify insurance claims or to investigate criminal activity.

College-educated young adults are most likely to approve autopsies on their relatives. Contrary to popular wisdom, the type of funeral rite (burial vs. cremation) a person will have does not affect the rate of autopsy permission, at least in the United States. Although most people would permit an autopsy on themselves, the next of kin or surrogate often refuses permission based on seven erroneous beliefs:

1. Medical diagnosis is excellent and diagnostic machines almost infallible; an autopsy is unnecessary.
2. If the physician could not save the patient, he or she has no business seeking clues after that failure.
3. The patient has suffered enough.
4. Body mutilation occurs.
5. An autopsy takes a long time and delays final arrangements.
6. Autopsy results are not well communicated.
7. An autopsy will result in an incomplete body, and so life in the hereafter cannot take place.

Increasingly, however, survivors contract with private companies or university pathology departments to do autopsies on their loved ones because they either could not get one done (e.g., many hospital pathology departments have stopped doing them) or they do not accept the results of the first examination.

Religious views about autopsies generally parallel attitudes about organ or tissue donation. They vary not only among religions, but also sometimes within religious sects and among co-religionists in different countries. The Bahá'í faith, most nonfundamentalist Protestants, Catholics, Buddhists, and Sikhs permit autopsies. Jews permit them only to save another life, such as to exonerate an accused murderer. Muslims, Shintos, the Greek Orthodox Church, and Zoroastrians forbid autopsies except those required by law. Rastafarians and Hindus find autopsies extremely distasteful.

Autopsy Technique

Complete autopsies have four steps, including inspecting the body's exterior; examining the internal organs' position and appearance; dissecting and examining the internal organs; and the laboratory analysis of tissue, fluids, and other specimens. In medicolegal cases, an investigative team trained in criminal detection first goes to the death scene to glean clues from the position and state of the body, physical evidence, and the body's surroundings. They also photograph the body, the evidence, and the scene for possible use in court.

The first step in the autopsy is to examine the corpse's exterior. Pathologists carefully examine clothing still on the body, including the effects of penetrating objects and the presence of blood or body fluid stains, evidence most useful in medicolegal cases. They use metric measurements (centimeters, grams) for the autopsy records and the U.S. system of weights and measurements for any related legal documents. Disrobing the body, they carefully examine it for identifying marks and characteristics and signs of injury or violence. They scrape the corpse's nails, test the hands for gunpowder, and collect any paint, glass, or tire marks for future identification. The pathologist also tries to determine the number, entry, and exit sites of gunshot wounds. Radiographs are frequently taken.

In the second step, pathologists open the thoracoabdominal (chest-belly) cavity. The incision, generally Y-shaped, begins at each shoulder or armpit area and runs beneath the breasts to the bottom of the breastbone. The incisions join and proceed down the middle of the abdomen to the pubis, just above the genitals. The front part of the ribs and breastbone are then removed in one piece, exposing most of the organs. Pathologists then examine the organs' relationships to each other. They often examine the brain at this stage. To expose the brain, they part the hair and make an incision behind the ears and across the base of the scalp. The front part of the scalp is then pulled over the face and the back part over the nape of the neck, exposing the skull. They open the skull using a special high-speed oscillating saw. After the skull cap is separated from the rest of the skull with a chisel, the pathologist examines the covering of the brain (meninges) and the inside of the skull for signs of infection, swelling, injury, or deterioration.

For cosmetic reasons, pathologists normally do not disturb the skin of the face, arms, hands, and the area above the nipples. For autopsies performed in the United States, pathologists rarely remove the large neck vessels. However, medical examiners must examine areas with specific injuries, such as the larynx, in possible strangulation cases. In suspected rape-murders, they may remove reproductive organs for additional tests.

In the third step, pathologists remove the body's organs for further examination and dissection. Normally, pathologists remove organs from the chest and belly either sequentially or en bloc (in one piece, or "together"). Using the en bloc procedure allows them to release bodies to the mortician within thirty minutes after beginning the autopsy; the organs can be stored in the refrigerator and examined at a later time. Otherwise, the entire surgical part of an autopsy normally takes between one and three hours. During the en bloc procedure, major vessels at the base of the neck are tied and the esophagus and trachea are severed just above the thyroid cartilage (Adam's apple). Pathologists pinch off the aorta above the diaphragm and cut it and the inferior vena cava, removing the heart and lungs together. They then remove the spleen and the small and large intestines. The liver, pancreas, stomach, and esophagus are removed as a unit, followed by the kidneys, ureters, bladder, abdominal aorta, and, finally, the testes. Pathologists take small muscle, nerve, and fibrous tissue samples for microscopic examination. Examining and weighing the organs, they open them to check for internal pathology. They remove tissue fragments anywhere they see abnormalities, as well as representative pieces from at least the left ventricle of the heart, lungs, kidneys, and liver.

Pathologists remove the brain from the skull by cutting the nerves to the eyes, the major blood vessels to the brain, the fibrous attachment to the skull, the spinal cord, and several other nerves and connections. After gently lifting the brain out of the skull and checking it again for external abnormalities, they usually suspend it by a thread in a two-gallon pail filled with 10 percent formalin. This "fixes" it, firming the tissue so that it can be properly examined ten to fourteen days later. (Bone is rarely removed during an autopsy unless there is suspected to be injury or disease affecting it.) Pathologists then sew closed any large incisions.

Step four, the most time consuming, consists of examining minute tissue and fluid specimens under the microscope and by chemical analysis. Medical examiners routinely test for drugs and poisons (toxicology screens) in the spinal fluid, eye fluid (vitreous humor), blood, bile, stomach contents, hair, skin, urine, and, in decomposing bodies, fluid from blisters. Pathologists commonly test infants with congenital defects, miscarried fetuses, and stillborns for chromosomal abnormalities, and fetuses and infants, as well as their placenta and umbilical cords, for malformations suggesting congenital abnormalities.

After an autopsy, pathologists usually put the major organs into plastic bags and store them in body cavities unless they have written permission to keep them. Medical examiners must keep any organs or tissues needed for evidence in a legal case. Medical devices, such as pacemakers, are discarded. They routinely keep small pieces of organs (about the size of a crouton) for subsequent microscopic and chemical analysis. National standards require that "wet tissue" from autopsies be held for six months after issuing a final autopsy report, tissue in paraffin blocks (from which microscope slides are made) must be kept for five years, and the slides themselves along with the autopsy reports must be retained for twenty years.

After completing the autopsy, pathologists try, when possible, to determine both a "cause of death" and the contributing factors. The most common misconception about medicolegal investigations is that they always determine the time of death. The final autopsy report may not be available for many weeks. The next of kin signing a routine autopsy authorization need only request a copy of the report. In medical examiners' cases, if they do not suspect suspicious circumstances surrounding the death, next of kin need to request the report in writing. When the autopsy results may be introduced into court as evidence, a lawyer may need to request the report.

Forensic pathologists also perform autopsies on decomposing bodies or on partial remains to identify the deceased and, if possible, to determine the cause and time of death. Pathologists usually exhume bodies to (1) investigate the cause or manner of death; (2) collect evidence; (3) determine the cause of an accident or the presence of disease; (4) gather evidence to assess malpractice; (5) compare the body with another person thought to be deceased; (6) identify hastily buried war and accident victims; (7) settle accidental death or liability claims; or (8) search for lost objects. In some instances, they must first determine whether remains are, in fact, human and whether they represent a "new" discovery or simply the disinterment of previously known remains. This becomes particularly difficult when the corpse has been severely mutilated or intentionally misidentified to confuse investigators.

See also: Autopsy, Psychological; Buried Alive; Cadaver Experiences; Cryonic Suspension

Bibliography

Anderson, Robert E., and Rolla B. Hill. "The Current Status of the Autopsy in Academic Medical Centers in the United States." American Journal of Clinical Pathology 92, Suppl. 1 (1989):S31–S37.

Brinkmann, Bernard. "Harmonization of Medico-Legal Autopsy Rules." International Journal of Legal Medicine 113, no. 1 (1999):1–14.

Eckert, William G., G. Steve Katchis, and Stuart James. "Disinterments—Their Value and Associated Problems." American Journal of Forensic Medicine & Pathology 11 (1990):9–16.

Heckerling, Paul S., and Melissa Johnson Williams. "Attitudes of Funeral Directors and Embalmers toward Autopsy." Archives of Pathology and Laboratory Medicine 116 (1992):1147–1151.

Hektoen, Ludvig. "Early Postmortem Examinations by Europeans in America." Journal of the American Medical Association 86, no. 8 (1926):576–577.

Hill, Robert B., and Rolla E. Anderson. "The Autopsy Crisis Reexamined: The Case for a National Autopsy Policy." Milbank Quarterly 69 (1991):51–78.

Iserson, Kenneth V. Death to Dust: What Happens to Dead Bodies? 2nd edition. Tucson, AZ: Galen Press, 2001.

Ludwig, Jurgen. Current Methods of Autopsy Practice. Philadelphia: W. B. Saunders, 1972.

Moore, G. William, and Grover M. Hutchins. "The Persistent Importance of Autopsies." Mayo Clinic Proceedings 75 (2000):557–558.

Pollack, Daniel A., Joann M. O'Neil, R. Gibson Parrish, Debra L. Combs, and Joseph L. Annest. "Temporal and Geographic Trends in the Autopsy Frequency of Blunt and Penetrating Trauma Deaths in the United States." Journal of the American Medical Association 269 (1993):1525–1531.

Roosen, John E., Frans A. Wilmer, Daniel C. Knockaert, and Herman Bobbaers. "Comparison of Premortem Clinical Diagnoses in Critically Ill Patients and Subsequent Autopsy Findings." Mayo Clinic Proceedings 75 (2000):562–567.

Start, Roger D., Aha Kumari Dube, Simon S. Cross, and James C. E. Underwood. "Does Funeral Preference Influence Clinical Necropsy Request Outcome?" Medicine Science and the Law 37, no. 4 (1997):337–340.

"Uniform Law Commissioners: Model Post-Mortem Examinations Act, 1954." In Debra L. Combs, R. Gibson Parrish, and Roy Ing eds., Death Investigation in the United States and Canada, 1992. Atlanta, GA: U.S. Department of Health and Human Services, 1992.

Wilke, Arthur S., and Fran French. "Attitudes toward Autopsy Refusal by Young Adults." Psychological Reports 67 (1990):81–91.

KENNETH V. ISERSON

Autopsy

Autopsy means “see for yourself.” It is a special surgical operation, performed by specially trained physicians, on a dead body. Its purpose is to learn the truth about the person’s health during life, and how the person died.

There are many advantages to getting an autopsy. Even when the law does not require it, there is always something interesting for the family to know. Something worth knowing that wasn’t known during life is often found. Even at major hospitals, in approximately one case in four, a major disease is found that was unknown in life. Giving families the explanations they want is often stated as one of the most satisfying things that a pathologist does. A pathologist is a physician with a specialty in the scientific study of body parts. This specialty always includes a year or more learning to do autopsies.

Under the laws of most states, an autopsy can be ordered by the government. The job of coroner is a political position, while a medical examiner is a physician, usually a pathologist. Exactly who makes the decisions, and who just gives advice, depends on the jurisdiction. Autopsies can be ordered in every state when there is suspicion of foul play. In most states, an autopsy can be ordered when there is some public health concern, for example a mysterious disease or a worry about the quality of health care. In most states, an autopsy may be ordered if someone dies unattended by a physician (or attended for less than 24 hours), or if the attending physician is uncomfortable signing the death certificate. If autopsy is not required by law, the legal next-of-kin must sign an autopsy permit.

When a loved one dies, a family can ask the hospital to perform an autopsy. If the family prefers, a private pathologist can do the autopsy in the funeral home. It does not matter much whether the body has been embalmed first. Whoever does the autopsy, there should not be a problem with an open-casket funeral

afterwards. This is true even if the brain has been removed and the dead person is bald. The pillow will conceal the marks.

Most religions allow autopsy. If the body is that of an Orthodox Jew, pathologists are happy to have a rabbi present to offer suggestions. Many Muslims prefer not to autopsy.

Here’s how an autopsy is done. In this example, there are three pathologists working together.

The body has already been identified and lawful consent obtained.

The procedure is done with respect and seriousness. The prevailing mood in the autopsy room is curiosity, scientific interest, and pleasure at being able to find the truth and share it. Most pathologists choose their specialty, at least in part, because they like finding the real answers. Many autopsy services have a sign, “This is the place where death rejoices to teach those who live.” Usually it is written in Latin: Hic locus est ubi mors gaudet succurrere vitae. Autopsy practice was largely developed in Germany, and an autopsy assistant is traditionally called a “diener,” which is German for “servant.”

The pathologist first examines the outside of the body. A great deal can be learned in this way. Many pathologists use scalpels with rulers marked on their blades. The body is opened using a Y-shaped incision from shoulders to mid-chest and down to the pubic region. There is almost no bleeding, since a dead body has no blood pressure except that produced by gravity. If the head is to be opened, the pathologist makes a second incision across the head, joining the bony prominences just below and behind the ears. When this is sewed back up, it will be concealed by the pillow on which the dead person’s head rests.

The incisions are carried down to the skull, the rib cage and breastbone, and the cavity that contains the organs of the abdomen. The scalp and the soft tissues in front of the chest are then folded back. Again, the pathologist looks around for any abnormalities.

One pathologist prepares to open the skull using a special vibrating saw that cuts bone but not soft tissue. This is an important safety feature. Another pathologist cuts the cartilages that join the ribs to the breastbone, in order to be able to enter the chest cavity. This can be done using a scalpel, a saw, or a special knife, depending on the pathologist’s preferences and whether the cartilages have begun to turn into bone, as they often do in older people. The third pathologist explores the abdominal cavity. The first dissection in the abdomen usually frees up the large intestine. Some pathologists do this with a scalpel, while others use scissors.

The skull vault is opened using two saw cuts, one in front, and one in back. These will not show through the scalp when it is sewed back together. The top of the skull is removed, and the brain is very carefully cut free of its attachments from inside the skull.

When the breastbone and attached rib cartilages are removed, they are examined. Often they are fractured during cardiopulmonary resuscitation. Freeing up the intestine takes some time. The pathologist carefully cuts along the attachment using a scalpel.

The chest organs, including the heart and lungs, are inspected. Sometimes the pathologist takes blood from the heart to check for bacteria in the blood. For this, he or she uses a very large hypodermic needle and syringe. The team may also find something else that will need to be sent to the microbiology lab to search for infection. Sometimes the pathologist will send blood, urine, bile, or even the fluid of the eye for chemical study and to look for medicine, street drugs, alcohols, and/or poisons.

Then the pathologist must decide in what order to perform the rest of the autopsy. The choice will be based on a variety of considerations. One method is the method of Virchow, which is removing organs individually. After the intestines are mobilized, they are opened using special scissors. Inspecting the brain often reveals surprises. A good pathologist takes some time to do this. The pathologist examines the heart, and generally the first step following its removal is sectioning the coronary arteries that supply the heart with blood. There is often disease here, even in people who assumed their hearts were normal.

After any organ is removed, the pathologist will save a section in preservative solution. Of course, if something looks abnormal, the pathologist will probably save more. The rest of the organ goes into a bio-hazard bag, which is supported by a large plastic container.

The pathologist weighs the major solid organs (heart, lung, brain, kidney, liver, spleen, sometimes others) on a grocer’s scale. The smaller organs (thyroid, adrenals) get weighed on a chemist’s triple-beam balance. The next step in this abdominal dissection will be exploring the bile ducts and then freeing up the liver, usually using a scalpel. After weighing the heart, the pathologist completes the dissection. There are a variety of ways of doing this, and the choice will depend on the case. If the pathologist suspects a heart attack, a long knife may be the best choice.

The liver has been removed. In our example of a fictitious autopsy, the pathologist finds something important. It appears that this man had a fatty liver. It is too light, too orange, and a bit too big. It is possible that this man had been drinking alcohol heavily for a while. The liver in this case weighs much more than the normal 49.4 ounces (1, 400 gm).

The pathologist decides to remove the neck organs, large airways, and lungs in one piece. This requires careful dissection. The pathologist always examines the neck very carefully. The lungs are almost never completely normal at autopsy. These lungs are pink, because the dead man was a non-smoker. The pathologist will inspect and feel them for areas of pneumonia and other abnormalities. The pathologist weighs both lungs together, then each one separately. Afterwards, the lungs may get inflated with fixative. Dissecting the lungs can be done in any of several ways. All methods reveal the surfaces of the large airways, and the great arteries of the lungs. Most pathologists use the long knife again while studying the lungs. The air spaces of the lungs will be evaluated based on their texture and appearance.

The liver is cut at intervals of about a centimeter, using a long knife. This enables the pathologist to examine its inner structure.

The rest of the team continues with the removal of the other organs. They have decided to take the urinary system as one piece, and the digestive system down to the small intestine as another single piece. This will require careful dissection. One pathologist holds the esophagus, stomach, pancreas, duodenum, and spleen. He will open these, and may save a portion of the gastric contents to check for poison. Another pathologist holds the kidneys, ureters, and bladder. Sometimes these organs will be left attached to the abdominal aorta. The pathologist will open all these organs and examine them carefully.

Before the autopsy is over, the brain is usually suspended in fixative for a week so that the later dissection will be clean, neat, and accurate. If no disease of the brain is suspected, the pathologist may cut it fresh.

The kidneys are weighed before they are dissected.

When the internal organs have been examined, the pathologist may return all but the portions they have saved to the body cavity. Or the organs may be cremated without being returned. The appropriate laws and the wishes of the family are obeyed.

The breastbone and ribs are usually replaced in the body. A pathologist prepares a large needle and thread used to sew up the body. The skull and trunk incisions are sewed shut (“baseball stitch”). The body is washed and is then ready to go to the funeral director.

The pathologists will submit the tissue they saved to the histology lab, to be made into microscopic slides. When the slides are ready, the pathologists will examine the sections, look at the results of any lab work, and draw their final conclusions.

The only finding in this imaginary autopsy was fatty liver. There are several ways in which heavy drinking, without any other disease, can kill a person. The pathologists will rule each of these in or out, and will probably be able to give a single answer to the police or family.

A final report is ready in a month or so. The glass slides and a few bits of tissue are kept forever, so that other pathologists can review the work.

See also Crime scene investigation; Forensic science.

Ed Friedlander, M.D.

autopsy In a moment made familiar by television dramas and films, a detective views a dead body, turns to the doctor examining the corpse, and asks for the cause of death. The doctor inevitably remarks, ‘Ah, we'll have to wait for the autopsy to be sure.’ An autopsy is a standardized biomedical procedure during which trained medical pathologists examine the exterior of the body, dissect the corpse, view the vital organs for any obvious abnormality and weigh them, and collect specimens of tissues and fluids for further analysis. The procedure takes 2–4 hours and ends with the body being prepared either for storage until it can be released, or to go to the undertaker for embalming and burial or cremation. After additional laboratory work on the tissues and fluid specimens to detect the presence of drugs and/or coexisting medical conditions, the pathologist forms an opinion on the cause of death.

A typical autopsy begins with a Y-shaped incision from each shoulder to the lower end of the sternum and in a single incision from there to the pubic bone. The pathologist retracts the skin and superficial muscles from the chest and abdomen, and cuts the cartilages holding the ribs to the sternum, which is then removed. The pathologist removes, weighs and inspects the heart and lungs, often taking a sample of blood from the heart; the abdominal organs are also inspected, removed, and weighed, taking fluid samples as appropriate. The skull is opened by making an incision through the scalp on the back of the head and detaching it from the bone to lie over the face. The skull is then cut through with a bone saw, the bone removed and the brain extracted. Throughout these steps (which can occur in a different order) the pathologist removes sections of tissues to be preserved, with particular attention to those that appear diseased or injured. Photographs may be taken of parts of the body or of organs still in place or after removal. The flaps from the Y-incision are laid back over the thorax and abdomen and loosely sutured; the removed section of skull is replaced and the skin drawn back, which usually means that the face may be viewed during the funeral.

There are two basic kinds of autopsy: the forensic autopsy and the medical autopsy. A forensic autopsy, as the name implies, is one performed to satisfy the law. In most Western nations, an autopsy must be performed if a person died in suspicious circumstances, was unexpectedly found dead, died without having recently seen a physician who can attest to a cause of natural death, or is suspected of having had a disease that possibly threatens the public's health. In these circumstances, the state requires an autopsy and does not need permission from the deceased's relatives to perform one. If murder is suspected, the autopsy is required to establish the cause of death, to determine if the findings support the suspected crime, and to provide as much evidence as possible about how, when, and where such a crime might have occurred.

The medical autopsy has different goals. In these cases, physicians are already satisfied that the person died a natural death. Pathologists then use the autopsy to investigate the details of that natural death. Sometimes they seek additional information about the treatment that the patient had received, such as internal healing after a surgical procedure or evidence of a response to medications, even if these had nothing directly to do with the death. The medical autopsy also serves researchers studying a disease process such as cancer or bone deterioration, and who need specimens from a patient for whom they have a clinical record. Most medical autopsies require the consent of the immediate family, which normally includes permission for the pathologists to take and to preserve organs and specimens of use to medical science.

The word ‘autopsy’, comes from the Greek terms meaning ‘seeing (or seen) for oneself’. The medical and legal use of ‘autopsy’ to mean anatomical dissection to discover the cause of death carries with it that sense of personal inspection and, when necessary, personal testimony, in court or at a case conference about what the observer saw within the body. ‘Post-mortem’ (Latin: ‘after death’) is often used as a synonym for ‘autopsy’, but post-mortem examination is actually a general term for inspection of a corpse that does not necessarily include dissection.

History and cultural issues

Most cultures have historically had a strong aversion to mutilating the dead human body or to dissecting it simply to learn normal anatomy. Yet the world's ancient and classical civilizations had equally strong prohibitions against murder. In India, in China, and around the Mediterranean, the ruling orders developed legal systems that defined murder and established procedures in which witnesses testified that external marks on the body, or other visible signs, distinguished suicides, accidental deaths, and natural deaths from murder. In medieval Europe, twelfth-century legal scholars first extended the common practice of viewing the external signs on a body to identify probable cause of death, to examining the internal marks of violence or disease. The question of which wound corresponded to the fatal blow, for instance, could be crucial for picking out the murderer from those involved in a group assault. Poison, too, was thought to leave visible marks in the stomach that an expert might identify. Opening the body to serve justice thus outweighed distaste for such procedures. Early autopsies were likely to be quite short and minimally defacing because the inspection was limited to the area of the thorax or abdomen under particular scrutiny. The history of the autopsy in Western Europe and Great Britain is thus closely tied to the evolution of legal systems and court procedures. In English (and later American) law, the development of the duties of the coroner, a lay person, kept the decision to order a medical inspection, whether external or internal, out of the hands of medical experts until the nineteenth century.

Forensic autopsy procedures antedated the introduction of lawful human dissection into medical schools, which first emerged in medieval universities in the early fourteenth century. It is important to distinguish autopsies, where legal officials sought the cause of death, from anatomical dissections, where anatomists and, much later, medical students, learned normal anatomy. The former had a legal purpose; the latter only seemed to satisfy human curiosity. When dissection was introduced into universities and surgical guilds throughout the late medieval and early modern periods, secular rulers only permitted dissections of executed criminals. The continued association of dissection with mutilation and post-mortem punishment helped to maintain cultural aversion to autopsies.

Medical autopsies, where the body is opened simply to determine the cause of a natural death, emerged in Europe only after the rise of the study of normal anatomy in the sixteenth century. Even then, physicians and elite surgeons performed such inspections only sporadically until the eighteenth century, primarily because the dominant theory of the humours, which explained both health and disease in terms of individualized balances of the body's main fluids, accounted for the visible marks of pathology on organs as being the effects of underlying disease imbalances. Such hidden signs, usually inaccessible to the physician, were not considered particularly useful for understanding or treating disease in the living. In the eighteenth century, however, especially with the publication of Giovanni Battista Morgagni's De sedibus et causis morborum per anatomen indigatis (1761), practitioners began to investigate more thoroughly the internal changes associated with diseases, and by the end of the century the study of morbid anatomy was well under way. The early to mid nineteenth century witnessed extensive correlations between the anatomical changes observed at autopsy and the clinical course of diseases in previously living patients, particularly in the bodies of the poor dying in hospitals. With improvements in the microscope, moreover, the enthusiasm for gross pathology shifted to the pathology of tissues and cells, which dominated research in the second half of the nineteenth and well into the twentieth centuries. At the same time, the emergence of biochemistry added chemical investigation of human fluids and tissues to the pathologist's ability to detect both the signs of medical disorders and, eventually, the presence of alcohol and other drugs in a corpse.

Most inhabitants of the industrialized West now see autopsy as a necessary legal and medical protocol. For others, however, an autopsy represents a violation of the spiritual integrity of the recently dead human being. Traditional Hindus prohibit autopsies; Islamic law forbids mutilation of the corpse. While Islamic jurists have long argued that this prohibition does not apply to respectful legal and medical procedures necessary to determine a cause of death, Qur'anic statements about the resurrection of the physical body influence cultural resistance to the procedure. Similarly, modern arguments that humans have ethical obligations to protect life by increasing medical knowledge, and to ensure that justice is done by gathering evidence about crimes, have eased, but not necessarily eliminated, the antagonism towards autopsies held by Orthodox Jews and traditional Christians. As important as autopsies are in the abstract for law and medicine, they will continue to carry important cultural and emotional meanings as humans face the deaths of relatives and friends.

Susan Lawrence

Bibliography

Forbes, T. R. (1985). Surgeons at the Bailey: English forensic medicine to 1878. Yale University Press, New Haven.
Encyclopedia of Bioethics (1995). Macmillan, New York.

Autopsy

Autopsy means "see for yourself." It is a special surgical operation, performed by specially trained physicians, on a dead body. Its purpose is to learn the truth about the person's health during life, and how the person died.

There are many advantages to getting an autopsy. Even when the law does not require it, there is always something interesting for the family to know—something worth knowing that wasn't known during life is often found. Even at major hospitals, in approximately one case in four, a major disease is found that was unknown in life. Giving families the explanations they want is often stated as one of the most satisfying things that a pathologist does. A pathologist is a physician with a specialty in the scientific study of body parts. This specialty always includes a year or more learning to do autopsies.

Under the laws of most states, an autopsy can be ordered by the government. The job of coroner is a political position, while a medical examiner is a physician, usually a pathologist. Exactly who makes the decisions, and who just gives advice, depends on the jurisdiction. Autopsies can be ordered in every state when there is suspicion of foul play. In most states, an autopsy can be ordered when there is some public health concern, for example a mysterious disease or a worry about the quality of health care. In most states, an autopsy may be ordered if someone dies unattended by a physician (or attended for less than 24 hours), or if the attending physician is uncomfortable signing the death certificate. If autopsy is not required by law, the legal next-of-kin must sign an autopsy permit.

When a loved one dies, a family can ask the hospital to perform an autopsy. If the family prefers, a private pathologist can do the autopsy in the funeral home. It does not matter much whether the body has been embalmed first. Whoever does the autopsy, there should not be a problem with an open-casket funeral afterwards. This is true even if the brain has been removed and the dead person is bald. The pillow will conceal the marks.

Most religions allow autopsy. If the body is that of an Orthodox Jew, pathologists are happy to have a rabbi present to offer suggestions. Many Muslims prefer not to autopsy.

Here's how an autopsy is done. In this example, there are three pathologists working together.

The body has already been identified and lawful consent obtained.

The procedure is done with respect and seriousness. The prevailing mood in the autopsy room is curiosity, scientific interest, and pleasure at being able to find the truth and share it. Most pathologists choose their specialty, at least in part, because they like finding the real answers. Many autopsy services have a sign, "This is the place where death rejoices to teach those who live." Usually it is written in Latin: Hic locus est ubi mors gaudet succurrere vitae. Autopsy practice was largely developed in Germany, and an autopsy assistant is traditionally called a "diener," which is German for "servant."

The pathologist first examines the outside of the body. A great deal can be learned in this way. Many pathologists use scalpels with rulers marked on their blades. The body is opened using a Y-shaped incision from shoulders to mid-chest and down to the pubic region. There is almost no bleeding, since a dead body has no blood pressure except that produced by gravity. If the head is to be opened, the pathologist makes a second incision across the head, joining the bony prominences just below and behind the ears. When this is sewn back up, it will be concealed by the pillow on which the dead person's head rests.

The incisions are carried down to the skull , the rib cage and breastbone, and the cavity that contains the organs of the abdomen. The scalp and the soft tissues in front of the chest are then folded back. Again, the pathologist looks around for any abnormalities.

One pathologist prepares to open the skull using a special vibrating saw that cuts bone but not soft tissue. This is an important safety feature. Another pathologist cuts the cartilages that join the ribs to the breastbone, in order to be able to enter the chest cavity. This can be done using a scalpel, a saw, or a special knife, depending on the pathologist's preferences and whether the cartilages have begun to turn into bone, as they often do in older people. The third pathologist explores the abdominal cavity. The first dissection in the abdomen usually frees up the large intestine. Some pathologists do this with a scalpel, while others use scissors.

The skull vault is opened using two saw cuts, one in front, and one in back. These will not show through the scalp when it is sewn back together. The top of the skull is removed, and the brain is very carefully cut free of its attachments from inside the skull.

When the breastbone and attached rib cartilages are removed, they are examined. Often they are fractured during cardiopulmonary resuscitation. Freeing up the intestine takes some time. The pathologist carefully cuts along the attachment using a scalpel.

The chest organs, including the heart and lungs, are inspected. Sometimes the pathologist takes blood from the heart to check for bacteria in the blood. For this, he or she uses a very large hypodermic needle and syringe. The team may also find something else that will need to be sent to the microbiology lab to search for infection. Sometimes the pathologist will send blood, urine, bile, or even the fluid of the eye for chemical study and to look for medicine, street drugs, alcohols, and/or poisons.

Then the pathologist must decide in what order to perform the rest of the autopsy. The choice will be based on a variety of considerations. One method is the method of Virchow, which is removing organs individually. After the intestines are mobilized, they are opened using special scissors. Inspecting the brain often reveals surprises. A good pathologist takes some time to do this. The pathologist examines the heart, and generally the first step following its removal is sectioning the coronary arteries that supply the heart with blood. There is often disease here, even in people who assumed their hearts were normal.

After any organ is removed, the pathologist will save a section in preservative solution. Of course, if something looks abnormal, the pathologist will probably save more. The rest of the organ goes into a biohazard bag , which is supported by a large plastic container.

The pathologist weighs the major solid organs (heart, lung, brain, kidney, liver, spleen, sometimes others) on a grocer's scale. The smaller organs (thyroid, adrenals) get weighed on a chemist's triple-beam balance. The next step in this abdominal dissection will be exploring the bile ducts and then freeing up the liver, usually using a scalpel. After weighing the heart, the pathologist completes the dissection. There are a variety of ways of doing this, and the choice will depend on the case. If the pathologist suspects a heart attack, a long knife may be the best choice.

The liver has been removed. In our example of a fictitious autopsy, the pathologist finds something important. It appears that this man had a fatty liver. It is too light, too orange, and a bit too big. It is possible that this man had been drinking alcohol heavily for a while. The liver in this case weighs much more than the normal 49.4 ounces (1400 gm).

The pathologist decides to remove the neck organs, large airways, and lungs in one piece. This requires careful dissection. The pathologist always examines the neck very carefully. The lungs are almost never completely normal at autopsy. These lungs are pink, because the dead man was a nonsmoker. The pathologist will inspect and feel them for areas of pneumonia and other abnormalities. The pathologist weighs both lungs together, then each one separately. Afterwards, the lungs may get inflated with fixative. Dissecting the lungs can be done in any of several ways. All methods reveal the surfaces of the large airways, and the great arteries of the lungs. Most pathologists use the long knife again while studying the lungs. The air spaces of the lungs will be evaluated based on their texture and appearance.

The liver is cut at intervals of about a centimeter, using a long knife. This enables the pathologist to examine its inner structure.

The rest of the team continues with the removal of the other organs. They have decided to take the urinary system as one piece, and the digestive system down to the small intestine as another single piece. This will require careful dissection. One pathologist holds the esophagus, stomach, pancreas, duodenum, and spleen. He will open these, and may save a portion of the gastric contents to check for poison. Another pathologist holds the kidneys, ureters, and bladder. Sometimes these organs will be left attached to the abdominal aorta. The pathologist will open all these organs and examine them carefully.

Before the autopsy is over, the brain is usually suspended in fixative for a week so that the later dissection will be clean, neat, and accurate. If no disease of the brain is suspected, the pathologist may cut it fresh.

The kidneys are weighed before they are dissected.

When the internal organs have been examined, the pathologist may return all but the portions they have saved to the body cavity. Or the organs may be cremated without being returned. The appropriate laws and the wishes of the family are obeyed.

The breastbone and ribs are usually replaced in the body. A pathologist prepares a large needle and thread used to sew up the body. The skull and trunk incisions are sewed shut ("baseball stitch"). The body is washed and is then ready to go to the funeral director.

The pathologists will submit the tissue they saved to the histology lab, to be made into microscopic slides. When the slides are ready, the pathologists will examine the sections, look at the results of any lab work, and draw their final conclusions.

The only finding in this imaginary autopsy was fatty liver. There are several ways in which heavy drinking, without any other disease, can kill a person. The pathologists will rule each of these in or out, and will probably be able to give a single answer to the police or family.

A final report is ready in a month or so. The glass slides and a few bits of tissue are kept forever, so that other pathologists can review the work.

see also Anatomical nomenclature; Body Farm; Coroner; Death, cause of; Death, mechanism of; Decomposition; Identification; Medical examiner; Pathology; Pathology careers; Rigor mortis; Time of death; Toxicological analysis.

Autopsy

Definition

An autopsy is a postmortem assessment or examination of a body to determine the cause of death. An autopsy is performed by a physician trained in pathology.

Purpose

Most autopsies advance medical knowledge and provide evidence for legal action. Medically, autopsies determine the exact cause and circumstances of death, discover the pathway of a disease, and provide valuable information to be used in the care of the living. When foul play is suspected, a government coroner or medical examiner performs autopsies for legal use. This branch of medical study is called forensic medicine. Forensic specialists investigate deaths resulting from violence or occurring under suspicious circumstances.

Benefits of research from autopsies include the production of new medical information on diseases such as toxic shock syndrome, acquired immunodeficiency syndrome (AIDS ). Organ donation, which can potentially save the lives of other patients, is also another benefit of autopsies.

KEY TERMS

Acquired immunodeficiency syndrome (AIDS)— A group of diseases resulting from infection with the human immunodeficiency virus (HIV). A person infected with HIV gradually loses immune function, becoming less able to resist aliments and cancers, resulting in eventual death.

Computed tomography scan (CT scan)— The technique used in diagnostic studies of internal bodily structures in the detection of tumors or brain aneurysms. This diagnostic test consists of a computer analysis of a series of cross-sectional scans made along a single axis of a bodily structure or tissue that is used to construct a three-dimensional image of that structure

Creutzfeld-Jakob disease— A rare, often fatal disease of the brain, characterized by gradual dementia and loss of muscle control that occurs most often in middle age and is caused by a slow virus.

Hepatitis— Inflammation of the liver, caused by infectious or toxic agents and characterized by jaundice, fever, liver enlargement, and abdominal pain.

Magnetic resonance imaging (MRI)— A diagnostic tool that utilizes nuclear magnetic energy in the production of images of specific atoms and molecular structures in solids, especially human cells, tissues, and organs.

Postmortem— After death.

Precautions

When performed for medical reasons, autopsies require formal permission from family members or the legal guardian. (Autopsies required for legal reasons when foul play is suspected do not need the consent of next of kin.) During the autopsy, very concise notes and documentation must be made for both medical and legal reasons. Some religious groups prohibit autopsies.

Description

An autopsy can be described as the examination of a deceased human body with a detailed exam of the person's remains. This procedure dates back to the Roman era when few human dissections were performed; autopsies were utilized, however, to determine the cause of death in criminal cases. At the beginning of the procedure the exterior body is examined and then the internal organs are removed and studied. Some pathologists argue that more autopsies are performed than necessary. However, recent studies show that autopsies can detect major findings about a person's condition that were not suspected when the person was alive. And the growing awareness of the influence of genetic factors in disease has also emphasized the importance of autopsies.

Despite the usefulness of autopsies, fewer autopsies have been performed in the United States during the past 10-20 years. A possible reason for this decline is concern about malpractice suits on the part of the treating physician. Other possible reasons are that hospitals are performing fewer autopsies because of the expense or because modern technology, such as CT scans and magnetic resonance imaging, can often provide sufficient diagnostic information. Nonetheless, federal regulators and pathology groups have begun to establish new guidelines designed to increase the number and quality of autopsies being performed.

Many experts are concerned that if the number of autopsies increases, hospitals may be forced to charge families a fee for the procedure as autopies are not normally covered by insurance companies or Medicare. Yet, according to several pathologists, the benefit of the procedure for families and doctors does justify the cost. In medical autopsies, physicians remain cautious to examine only as much of the body as permitted according to the wishes of the family. It is important to note that autopsies can also provide peace of mind for the bereaved family in certain situations.

Preparation

If a medical autopsy is being performed, written permission is secured from the family of the deceased??

Aftercare

Once the autopsy has been completed, the body is prepared for final arrangements according to the family's wishes??

Risks

There are some risks of disease transmission from the deceased. In fact, some physicans may refuse to do autopsies on specific patients because of a fear of contracting diseases such as AIDS, hepatitis, or Creutzfeld-Jakob disease.

Normal results

In most situations the cause of death is determined from the procedure of an autopsy without any transmission of disease.

Abnormal results

Abnormal results would include inconclusive results from the autopsy and transmission of infectious disease during the autopsy.

Resources

ORGANIZATIONS

American Medical Association. 515 N. State St., Chicago, IL 60612. (312) 464-5000. 〈http://www.amaassn.org〉.