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.
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:
- Medical diagnosis is excellent and diagnostic machines almost infallible; an autopsy is unnecessary.
- If the physician could not save the patient, he or she has no business seeking clues after that failure.
- The patient has suffered enough.
- Body mutilation occurs.
- An autopsy takes a long time and delays final arrangements.
- Autopsy results are not well communicated.
- 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.
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.
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KENNETH V. ISERSON