James Claude Upshaw Downs. Handbook of Death and Dying. Editor: Clifton D Bryant. Volume 1. Thousand Oaks, CA: Sage Reference, 2003.
Pathologists are ghouls, and autopsies are madness.
— Hill and Anderson 1988:173
The term autopsy is self-explanatory (auto = self and opsis = to see), literally “to see for oneself,” and currently is used synonymously with postmortem (after death) and necropsy (to look at the dead) (Hill and Anderson 1988:60). In modern usage, laity and medical professionals alike often misunderstand “the autopsy.” This is a direct consequence of the evolution of the physical process of, and the persons involved in, the examination of deceased human remains over the millennia. The medical practice of the autopsy has developed over time to the present state where physicians specializing in the medical field of pathology study the anatomy and diseases of the dead with the goal of determining how and why someone died.
Pathology
Several different definitions could be given for the medical specialty of pathology; however, the simplest seems appropriate—pathology is the use of the laboratory in the study of disease. Anatomic pathology is primarily the gross (macroscopic) and microscopic study of cells, organs, and tissues, whereas clinical pathology concentrates on bodily fluids and instrumental analyses. The study of pathology can be divided into (a) general pathology, which relates to broad diseases or reactions affecting areas or processes of the entire body to various extents, and (b) systemic pathology, which relates to changes in specific individual organ systems. Autopsy pathology, the medical practice of examining the human body after death, is primarily anatomic pathology in nature and both general and systemic pathology in scope. Over time, the postmortem exam has undergone significant change in procedure, extent, and purpose. The latter has resulted in the two major types of modern autopsy practice: hospital (or medical, clinical, etc.) and forensic (or legal, medicolegal, medical examiner, coroner, etc.)
The History
Antiquity to Premodern Time
Public attitudes toward the examination of the human body after death have evolved over time and between various societies. In particular, concerning medical relevance of the examination, contemporaneous understanding of the basis of disease bore direct relation to how the exam was perceived. In the days of the Greeks, when disharmony of the humors was considered the source of illness, there was little need for or acceptance of the procedure. Despite this, the importance of autopsy-derived information was apparent as early as the 3rd century B.C. when Herophilus and Erasistratus in Alexandria studied disease through human dissection in nonmurder cases (Smyth 1980:18). In 44 B.C., the murdered body of Julius Caesar was externally examined by the physician, Antistius, who concluded that only one of Caesar’s 23 stab wounds was lethal (Hill and Anderson 1988). The physician Galen is credited with the origin of the revolutionary concept of study of the tissues of the dead body and association with physical symptoms in life (known today as clinicopathologic correlation); as such, he can be viewed as the first modern pathologist (Smyth 1980).
The expertise of physicians in matters related to the interface of medicine and the law continued to be recognized, with Justinian law in the 6th century A.D. when despite taboos against incising the body, doctors were called on to render opinions in cases of medicolegal matters involving injury (such as rape) and death (abortion) (Hill and Anderson 1988). Into the middle ages, the East and West independently evolved death investigation systems (see Downs 2003). In 1248, the Chinese publication Hsi Yua Lu (“Instructions to Coroners”) described the proper examination of bodies and classification of deaths. The foundation of modern forensic trace evidence analysis and forensic biology (using DNA) was contained therein: “Everything may depend upon the difference between two hairs” (Smyth 1980:19).
The Western model seems to have been predicated on the needs of law but strongly influenced by Christian religious views. Despite the religious prohibition to routine autopsy in 13th-century Italy, in suspicious deaths (specifically poisonings) the Church allowed court-ordered examinations (Smyth 1980). The Bishop of Bamberg, Germany, in Constitutio Bambergensis Criminalis (1507) addressed medicolegal testimony—specifically, examination and documentation of injuries by a physician (Smyth 1980). Constitutio Criminalis Carolina (1533), under Emperor Charles V, permitted the internal correlation of the organ pathology (wound depth, direction, and extent) to external injuries through exploration of wounds (Smyth 1980). Although this was an early form of limited modern autopsy, it did not require or necessarily encourage a complete autopsy. Discouragement of autopsies by the Church in the Middle Ages was far from absolute; Pope Clement VI mandated examinations on plague victims in 1548, the first autopsies related to a mass disaster (Smyth 1980:15-31). Similar evaluations were being performed in Palermo, Rome, and France. Even in the New World, postmortem examination was a tool used by the Church to answer the theological question of the number of souls present in the bodies of conjoined (“Siamese”) twins (Hill and Anderson 1988:38). The first official death inquiry in the United States, an external examination in 1635 in New Plymouth Colony, New England, concluded that the death was not a homicide (Fisher 1993:6).
The stigma of dealing with the dead hindered the practice of the autopsy and limited the advances in understanding the natural progression of diseases and the effectiveness of various therapies.
Historically, the ability to dissect the human body and to examine it after death required the overcoming of societal taboos, but this has been an important factor in the development of modern scientific medicine. The autopsy became established in much of the Western world as a central component of good medical practice. (Hill and Anderson 1988:xiii)
The mid to late 1700s to the early 1800s were a watershed period for pathology, particularly forensic pathology. In Padua, Italy, Giovanni Battista Morgagni believed that the postmortem examination with “careful observation and the correlation of clinical symptoms with anatomic findings would lead to an understanding of the relation between disturbed function and abnormal structure” (Hill and Anderson 1988:21); in 1761, he published Seats and Causes of Disease, the first medical textbook to correlate macroscopic pathology with morbidity (Hill and Anderson 1988:21; Smyth 1980:15-31; Weber, Fazzini, and Reagan 1973:ix). Shortly after, in Paris, Marie Francois Xavier espoused the basis of cellular pathology: The tissues forming the organs were “the key to understanding normal and diseased function” (Hill and Anderson 1988:24). In the United Kingdom, John Hunter formulated “an uncertain but visionary synthesis of surgery, medicine, and pathology, all the while insisting on the search for pathogenesis” (Hill and Anderson 1988:24). Medical jurisprudence was taught by Sir Andrew Duncan in 1791 at the University of Edinburgh (Fisher 1993:5). In 1793, Matthew Baille produced what is considered “the first modern textbook of pathology” (Hill and Anderson 1988:25).
The key to understanding disease was to be found in this emerging field of pathology and particularly the scientific study of the changes in the tissues causing death. “From 1800 through the first decades of the 1900s discovery and understanding in medical science thrived on autopsy” (Hill and Anderson 1988:20). Andrew Duncan, in 1801 at Edinburgh University, and James S. Stringham, in 1804 at Columbia College, New York, were early pioneers in didactic medicolegal training (Smyth 1980:15-31). In 1807, Andrew Duncan II became the first forensic medicine professor, and six years later, James S. Stringham assumed the first university chair in the new field of medical jurisprudence at Columbia College (Smyth 1980:15-31). One of the basic premises of forensic pathology was stated in 1878 by Alexandre Lacassaque in Précis de Medicine: “One must know how to doubt” (Smyth 1980:15-31). Thus the foundations of modern autopsy pathology were in place but needed a champion or two to become institutionalized. “It was above all autopsy study that ushered in the modern era [of medicine], in which the causes of disease can be pursued meaningfully” (Hill and Anderson 1988:37).
All the advances and medical interest in pathology in the 1800s are symbolized by the two fathers of autopsy pathology, Rokitansky and Virchow. In Vienna, Karl Rokitansky (1804-1878) established the Pathology Institute dedicated “to the investigation of the seats and causes of disease.” As one of the pioneer full-time pathologists, and through discipline and routine, Rokitansky radically altered how the autopsy was performed, leading the charge in establishing the subspecialty of autopsy pathology by eliminating the then common practice of clinical attending physicians conducting postmortems on their own patients. This shift was a two-edged sword in that it allowed much needed independence but also had the unintended effect of isolating the pathologist from his fellow physicians. There was now a doctor whose practice of medicine dealt not with the living, but with the dead and tissues. The autopsist’s “purpose was ‘first…sorting out the facts scientifically on a pure anatomic basis.'” The key to Rokitansky’s method was in improving the process of the autopsy by creating a disciplined routine involving “thorough, systematic dissection and careful observation” (Hill and Anderson 1988:27). Rokitansky’s success was impressive, achieving a staggering near 100% autopsy rate on all the hospitalized patients he treated who died while under his care while personally performing over 30,000 examinations. His en bloc technique for organ removal with subsequent organ system dissection is one of the two major evisceration procedures used in the modern autopsy (Weber et al. 1973:x).
Berlin’s Rudolph Virchow (1821-1902) expanded on Rokitansky’s efforts and is considered the father of modern pathology (Weber et al. 1973:ix). His text, Die Allgemeine Cellulare Pathology espoused that disease resulted from aberrations at the cellular level (Weber et al. 1973:ix). Virchow’s integration of the sciences of structure (histology), function (physiology), and morbidity (microbiology) with pathology created modern scientific medicine and the field of cellular pathology (Hill and Anderson 1988:32). He practiced detailed observation and study of each organ as a separate entity. The other modern autopsy procedure, the Virchow method, wherein organs are removed from the body and examined in isolation, still bears the name of its creator.
William Osler (1849-1919), an internist, radically altered the state of American medicine by stressing the importance of physician’s correlation of clinical morbidity with anatomic lesions. Such vision was sorely needed as suggested by the state of American forensic medicine in 1894, when the subject was being taught in over 100 U.S. medical schools with no mention of pathology, pathologists, or autopsy (Hill and Anderson 1988:115). This was to change through the efforts of Abraham Flexner. The report from the Flexner Commission in 1910 clearly demonstrated the sad state of American medical education (Hill and Anderson 1988:35). Two years later, Richard C. Cabot of Massachusetts General Hospital pioneered the concept of the autopsy as a cornerstone of medicine (Hill and Anderson 1988:35-36, 68, 89-90); because of an extraordinarily high diagnostic error rate, common diseases were misdiagnosed in over half of all cases (Hoyert 2001:1).
Autopsy training became a necessity for physicians: “At least a year of study of pathologic anatomy was included in the medical training of all American physicians aspiring to leadership positions” (Hill and Anderson 1988:19). The golden age of the autopsy was not long-lived.
Modern Practice
Despite its lengthy past and major contribution to modern medicine, the autopsy has faded from the forefront of health care. There are many explanations for this decline in stature: lack of interest (both medical and lay), lack of purpose, lack of qualified or interested pathologists, and lack of resources.
The argument against the autopsy goes that all major diseases have already been clarified, but “the list of diseases discovered or elucidated in the course of autopsy studies is endless” (Hill and Anderson 1998:49). Diseases clarified by autopsy since 1950 include congenital heart disease, dissecting aneurysm, mitral valve prolapse, cardiac conduction system abnormalities, cardiac surgery sequelae, oxygen toxicity, industrial dust inhalation, Legionnaire’s disease, viral hepatitis, vinyl chloride relation to hepatic angiosarcoma, transfusion-related disease, adverse renal effects of diethylene chloride as a medicinal carrier vehicle, Cruetzfeld-Jacob disease, various toxins, autoimmune disorders, acquired immunodeficiency syndrome, various environmental pathogens, fetal alcohol syndrome, hypervitaminosis, and sudden infant death syndrome. Medical examiner input was a major factor in the universal adoption of automobile safety devices, such as seat belts and air bags. Obviously, much has been and is yet to be learned from the process of the autopsy.
As new therapies are created and as diseases appear and naturally evolve, the postmortem exam allows the best opportunity to observe the effects or lesions associated with treatment and death and to then clearly delineate the association between symptoms and pathology. Some, laity and physicians alike, believe that with advances in medical imaging studies, there is little to be gained from direct observation that is not already obtained prior to death. Despite the availability and ready use of such techniques, some 15% of major cancers and 34% of metastatic cancers are not diagnosed prior to death (Steigman 2002). Even in the present era, major diagnostic discrepancies are still discovered in one-third of autopsies (Steigman 2002), a situation little changed from the heyday of the autopsy into the mid 1900s.
Significantly, the investigation of the deaths of trauma patients treated in major trauma centers (where the lethal injury is or should be fairly obvious) uncovers diagnostic errors in over 28% of patients; almost one-third of autopsies yielded information of potential significance to families, such as existing heart disease and lung cancer (Forsythe et al. 2002). The treating trauma physician mind-set underestimates the value of the autopsy to the detriment of his or her practice and the patient’s family.
To focus on the very narrow recognition of physical injury ignores the many purposes of the autopsy, including determination of the cause, manner, and mechanism of death; course and progression of major diseases; diagnosis of all existing diseases; disease-pathology-anatomy correlation; assessment of therapy; collection of health information important to the public and the family (infectious disease, sudden death explained, etc.); research; education and training; and quality assurance, to which the forensic autopsy adds evidence collection and medicolegal correlation (Adelson 1974:33-109). Public health concerns are additionally served by investigating certain types of deaths. “Nothing can equal the thoughtful medicolegal autopsy as a teacher of the amazing variability of human responses to disease and injury” (Hill and Anderson 1988:118). The ability of an autopsy to reveal the previously undiagnosed or undisclosed condition of the patient adversely affects its acceptance of and use in typical medical practice. No one, particularly a physician charged with caring for a patient, wants to deal with “the disturbing fact that medicine is not an exact science … errors will occur” (Hill and Anderson 1988:59). Interestingly, although the fear of malpractice suits may tend to hinder treating physician autopsy requests (for fear of uncovering clinical errors), research shows that autopsy findings, whether favoring plaintiff or the treating physician in malpractice suits, “are not the crux of a successful legal argument for either side” (Bove, Iery, and the Autopsy Committee, College of American Pathologists 2002). Some research suggest that autopsies reduce the risk of financial loss from malpractice suits. Autopsies eliminate suspicion and provide reassurance to families. Autopsy findings replace conjecture with facts and allow defendants to construct a better defense. Autopsies have also been shown to reduce the number of capricious malpractice legal actions (Steigman 2002).
Monetary concerns, however, remain a major disincentive to performing autopsies. This largely results from lack of budgetary and time resources because of failure to provide a funding avenue for the autopsy (see later). Pathologists do not charge for the autopsy; rather, it is considered an operating expense of the medical center or, in cases of public interest, a governmental service (provided by the medical examiner). Hospitals may charge for examinations requested by the next of kin of persons who died while not inpatients of the facility. In addition to this financial challenge, funeral homes may charge more for their services because preparation of autopsied bodies is more time-consuming (Hoyert 2001:15). The expense for the exam itself can be significant, with the cost per forensic case averaging $2,844 (range $228 to $10,886) (Weedn 2002).
The autopsy is being relegated to the role of quality control instrument. Although true in the most simplistic sense, such a view has as its corollary the denigration of all the basic medical sciences. Worse, it ignores all the obvious benefits of competent postmortem examinations to families, physicians, and society. Quality assurance is not an exciting or popular activity; because it fails to stimulate public imagination or interest and it increases workload for the practitioners, it is often viewed as little more than book-keeping or inventory. “The autopsy is the moment of truth for all medical care and the time of reckoning to improve the care of the patient” (Hill and Anderson 1988:66).
The Autopsy Procedure
The Players
The participants in the examination include the active participants (the prosector and assistant[s]) and the observer(s). The prosector is the person who actually performs the exam. Ideally, this is a physician trained in autopsy, forensic pathology, or both. Different terms refer to physicians at different levels of training and experience. An attending pathologist, a fully trained doctor who is board qualified (able to sit for the certifying examinations) or preferably board certified (passed the examinations) in anatomic pathology or anatomic and forensic pathology, is singularly the most qualified to perform an autopsy; however, insufficient numbers exist to examine all sudden, unexpected deaths, let alone all hospital deaths. Less experienced physicians may also perform autopsies: an intern is a physician in the first year of postgraduate training following medical school, a resident physician is one in postgraduate training Years 1 through 4, and a fellow is a physician who (typically) has completed residency and is spending an additional year in postgraduate training in a subspecialty such as forensic pathology. All three of the latter are less qualified, and as such, their work should be closely supervised and scrutinized by the attending pathologist. Regrettably, such is often not the case, particularly in poorly run training programs where the least experienced physicians are thrust into autopsy duty with little or no experience or supervision.
Other active participants include a lay assistant, also called a technician, Diener (German for helper), or physician’s assistant. The assistant facilitates the physical procedure of the examination for the physician by anticipating needs and helping the doctor with the procedure, much like a nurse would assist a surgeon. Other less qualified assistants are crime scene investigators and rotating medical students. The active collaboration and consultation with the clinical team is tremendously advantageous to both the pathologist and the clinician because it provides immediate gross pathology correlation with symptoms and disease. Attendance of the autopsy by the treating clinician is rare because of scheduling demands, thus compromising the information gleaned at autopsy and its relevance to the final diagnosis.
On rare occasions, other witnesses might attend an autopsy, particularly in questionable deaths and in forensic cases. Most often, these witnesses are the law enforcement officials working on the case. In cases where litigation is likely, a physician (preferably a pathologist) might be present to represent the family, either by consent or by court order. Other health care professionals, both practicing and in training, might attend the exam for reasons related to patient care or training. Other attendees are discouraged because of potential biohazard risks and concerns for the dignity and confidentiality of the patient.
Knowing who is physically present at the exam is an important part of interpreting the report. Even more crucial is knowing who actually performed the procedure. The attending pathologist should be in the autopsy room and an active participant in the entirety of the examination. Anything less is substandard and difficult to justify.
The Purpose
“The essential features of the medicolegal autopsy are [these]: (1) to perform a complete autopsy; (2) to personally perform the examination and observe all findings so that interpretation(s) may be sound; (3) to perform a thorough examination and overlook nothing which could later prove of importance; (4) to preserve all information by written and photographic records; and (5) to provide a professional report without bias” (Fisher and Petty 1977:1). All these apply equally well to the nonforensic autopsy. Medical and forensic postmortems differ in that both ask very specific questions, but the extent and significance of the answers are disparate. In practice, the distinction may not be obvious. Both require prosector diligence and accuracy. On one hand, both types of autopsy reports are frequently the basis for civil litigation and are subject to public scrutiny and courtroom presentation. On the other, the medical records (including the autopsy report) are used in patient care by physicians.
In a medical autopsy, the major purpose of the examination is to answer a specific question, either examining the entire body (full or complete autopsy) for determination of the cause and mechanism of death or looking at a specific organ or area of the body (limited, restricted, or partial autopsy) for clarification of a particular issue. A forensic autopsy is conducted to determine the cause and manner of death. In either procedure, an additional benefit is the discovery of any additional disease process or medical condition of importance to other parties. The focus of the examination differs: In forensic pathology, the process is often confirmatory (e.g., obvious trauma) and evidentiary, whereas in hospital pathology, the autopsy is more for correlation, like a conventional lab test (Wetli, Mittleman, and Rao 1988:1).
In both the forensic and medical autopsy, one goal is finding the cause of death (that process eventuating in the cessation of life). For the purposes of both the medical and the forensic pathologist, the cause of death can be further parsed into the primary or proximate or underlying cause of death (that disease state or injury that acted through an unbroken chain of events to end life). The secondary or intervening cause (or mode or mechanism) of death is that disease or injury through which the primary cause acted. For example, in an individual who was stabbed in the chest, causing a massive loss of blood and eventual cardiac standstill, the primary cause would be sharp force injury (stab wound) to chest with exsanguination as the mechanism and cardiac arrest as the mode. In someone with sickle cell disease who loses (by autoinfarction) their spleen as a consequence of the illness and becomes infected with the bacterium Pseudomonas, as a result developing overwhelming systemic infection, including florid pneumonia, the primary cause is sickle cell disease, the intervening cause is Pseudomonas sepsis, and the mode is respiratory failure. If someone dies from pneumonia, the death may be simply due to a community-acquired infection and thus a natural death, or it may be a complication resulting from paraplegia following a gunshot wound years earlier and thus a homicide. The time interval is irrelevant in determining causation as long as an unbroken chain of events can be documented between injury and death.
The medical autopsy tends to be most concerned with elucidating a mechanism and mode of death, particularly if the clinical course is well established. This fundamental difference is often not well understood and occasionally misunderstood by parties interested in the outcome of the examination. Hospital physicians are usually well cognizant of the patient’s clinical course and tend to be interested in effects of disease states on the tissues at varying stages of the illness. Their interest is in details of the examination, which may not be available for weeks, if at all. The medical autopsist may be unable to closely correlate severely damaged tissues to specific points in the course of disease, particularly without active consultation and communication with the attending clinicians. Such a chain of medical disease progression, the clinicopathologic correlation, is tremendously valuable for medical education while also being resource intensive and time-consuming. Major benefits for the entire body of medical knowledge, most directly subsequent patient care, are to be had when the autopsy uncovers an unusual or unexpected cause or mechanism of death or effect of therapy. Regrettably, outside pathology training programs, the continued lack of respect for the autopsy (as evidenced by the continued lack of funding) has resulted in clinical attending physicians and even hospital pathologists showing little interest in performing, much less finalizing, autopsy reports that they believe will never be read.
The forensic autopsy is focused on the actual primary cause of death. The importance is that the medical examiner considers all information, including scene information and circumstances surrounding death to determine how the death came to be, also known as the manner of death (homicide, accident, suicide, natural, or undetermined). “Whereas the hospital pathologist often performs a complete autopsy on all cases, searching for tidbits of ‘interesting’ or marginally relevant information, the forensic pathologist focuses attention narrowly on matters concerning the legal problem” (Hill and Anderson 1988:121). Medical examiners are far more experienced in autopsy pathology than their hospital counterparts. Thus the forensic pathologist is more knowledgeable about determining the course of disease as reflected in autopsy-derived tissues and better able put that into a context useful to interested parties, whether family members or attorneys.
The Case History
An old pearl learned early in medical school is that 90% of medical diagnosis is the history. The same is true for the autopsy—medical and forensic. The source of information differs; however, its scope should be similar—the succinct summation of all available information. In the world of the medical examiner, investigators and law enforcement officials interview witnesses at the scene of injury or death and conduct vigorous searches for evidence of criminal activity related to the fatality. In hospital pathology (and those in forensic cases surviving to reach the hospital), reams of medical records in the hospital chart serve as the primary information source, often filtered through consultation with the treating doctors. Again, the best information is that obtained and documented early—memories fail and recollections fade with the passing of time.
The Consent
All autopsies require authorization. Medical autopsists must receive explicit consent to conduct an examination from the decedent’s next of kin. The progression of next-of-kin authority is usually delineated by statute but in general progresses from spouse to adult child(ren) to parent(s) to adult sibling(s) to guardian to responsible party to the State. In addition to permission to perform the autopsy, the hospital pathologist must have permission regarding the extent of the exam, which may be limited to certain organ(s) or area(s) (e.g., head only, head excluded, chest only, heart only, etc.). In addition, such consents should list any restrictions, tissue collection and disposition, witnesses, and consenter’s signature and relationship (Weber et al. 1973:3-9). In most medical examiner systems, authorization is given by statutory authority to investigate deaths; thus the next of kin cannot usually prevent or limit an exam. Rare jurisdictions do allow next of kin to limit or restrict examination.
Myriad, sometimes overlapping, societal beliefs limiting postmortem exams include diagnostic infallibility, anger (one shot to find the answer), “they’ve suffered enough,” mutilation, the delay of burial, noncommunication of results, denial of corporeal intactness (quasi-religious), and emotional and financial cost (Hill and Anderson 1988: 165-66). All these, save cost and religion, can be overcome by knowledgeable and compassionate requests for consent. Personnel trained to approach families should be available to accurately address their concerns. A consistently documented link exists between the skill of the requester and obtaining consent.
The medical examiner may encounter religious objections to an autopsy. Despite clear legal authority to ignore family wishes, “It behooves the medical examiner to determine whether there is a possible religious objection to an autopsy, and if so, to proceed only where there is a compelling need” (Bierig 1998:147). There are no absolutes; however, in general, no prohibition against autopsy examination exists in Roman Catholic, most Protestant, and Reform Judaism faiths. Possible religious objections to postmortem exams may be encountered with most conservative Jews, orthodox Jews, fundamentalist Christians, certain Eastern faiths, Greek Orthodox adherents, and Muslims (Bierig 1998; Gawande 2001). The Jewish objections are traced to Rabbi Ezekiel Landau in 18th-century Prague who interpreted an Old Testament book of Deuteronomy passage (“His body shall not remain all night upon the tree, but you shall bury him the same day, for a hanged man is accursed by God,” Deuteronomy 21:23, RSV) to mean that autopsy is permissible only to save a human life (Weber et al. 1973:5; Hill and Anderson 1988:167). Although there are no clear rules, in general,autopsies are permitted to comply with the law of the land (e.g., in homicides), to determine cause of death if otherwise impossible, or to save a life (e.g., in organ donors or hereditary disease); (Wetli et al. 1988:12). Medical examiners and other physicians are concerned about recently enacted “‘religious exemption laws that may complicate criminal investigation and prosecution for abuse or neglect of children” (Cina 2001:9). Legally, a medical examiner’s overriding family objections has been deemed protected by sovereign immunity in negligently performed examination and organ harvesting but has been found liable in cases of lack of consent and in religious objection without sufficient societal benefit (Bierig 1998).
The Procedure
Medical autopsies can be performed by request on any deceased individual but are typically limited to cases in which the treating physician or the decedent’s next of kin have questions about diagnosis, treatment, or both. Forensic cases are usually limited to sudden, unnatural, unexpected deaths but, at a minimum, should include homicides, suspected foul play, anticipated future criminal prosecution, deaths in custody (police and institutional), and potentially obscured trauma (decomposition or fire) (Wetli et al. 1988:10-11). An effective rule of thumb is that “it is better to do an autopsy and obtain the necessary answers than to open the door to needless speculation and inquiry (which will take up much more time at a future date than an autopsy)” (Wetli et al. 1988:11).
The time required for an autopsy varies with the extent of disease and complexity of the case; it may be 1 hour for a straightforward single gunshot wound or heart attack to a day (or longer) for a complicated medical case with extensive pathology, a multiple wound sexual homicide, or a child abuse autopsy. One thing is certain—the examiner should spend sufficient time to study diseases present, adequately document these, and relate findings to others. The time spent in advance is most beneficial to all parties concerned because the amount of time spent in the exam is inversely proportional to errors and oversights. No one—prosector, clinical physician, next of kin, or court—wants to have a case where
[The] autopsy lasted a total of seven minutes, during which the pathologist violated every rule … The autopsy report consisted of fourteen pages of single-spaced type which described in detail all the procedures which were performed at the autopsy, even though the procedures described were a figment of the pathologist’s imagination….The pathologist, however, spent several days on the stand admitting to the many errors. (Ogle 1997:63)
Bad autopsies share several features: exceedingly rapid examination, procedural shortcomings, and resultant poor testimony (Ogle 1997).
“Usually … it is impossible to foresee the questions which may arise hours, weeks, or years later” (Geberth 1990:429). Despite this, such caution is the mission of the autopsist, particularly in the forensic setting. The procedure of the autopsy can be divided into two broad portions, the external exam and the internal exam. The extent, scope, and duration of each of these sections depend on several factors. The single most significant variable is the purpose of the examination. Other obvious factors include skill of the prosector, extent of terminal disease, length of hospitalization, other diseases present, and age of decedent. The examiner is cautioned that “things are not always as they appear to be…. [One should] keep an open mind, conduct a thorough investigation, and remember that teamwork is essential” (Geberth 1990:426).
What caseload is considered too much? As a general rule, it is suggested that in a pure autopsy practice, over 350 autopsies per year is too many and that up to 250 autopsies per year is ideal (National Association of Medical Examiners 2002a:3.A.7-3.A.8), which averages to 8.3 hours per case in a 52-week work year. In practice, the average number of autopsies per forensic pathologist is 227, with a range of 4 to 537 (Weedn 2002). The goal for case completion is 1 month in routine cases and 2 months in complicated cases; however, certain high-profile cases rightfully demand expediency (Jentzen and Ernst 1998:310) and other more complicated deaths mandate more lengthy review.
The Examination
An autopsy must be complete if it is to be accurate … [D]o it right the first time, you only get one chance. (Geberth 1990:xxii, 429)
Because the autopsy is a medical procedure, to be legitimate and admissible in court, it must be performed by a pathologist (Adelson 1974:7; Riddick et al. 2001; Wetli et al. 1988:16-17). Regrettably, such may not be the case in both medical examiner and hospital autopsies, because of lack of resources, reimbursement, and interest. To understand the quality of the autopsy procedure and resultant report, one should have a clear understanding of who actually performed the examination.
An attending physician must personally perform medical procedures for reimbursement by a third-party payor (insurance company, health maintenance organization, governmental entity, etc.). Because the nonforensic autopsy is typically performed as a pro bono service by a hospital, there is a strong financial incentive to perform the examination as cost-effectively as possible. The temptation is to have a lay assistant (in medical or forensic pathology) or investigator (in forensic pathology) eviscerate the organs, examine them for lesions, collect any additional samples indicated, prepare microscopic slides, and so on, all independent of the medical practitioner. In a perfect world, with adequate funding, this level of examination would be abolished as medical malpractice on the part of the physician and as practicing medicine without a license on the part of the lay examiner. The pathologist must be physically present, must actively participate, and must make all medical decisions regarding the process (Riddick et al. 2001; National Association of Medical Examiners 2002b:7.8-7.11). To shun active medical participation is to relegate the practice of autopsy pathology to little more than meat cutting, more suited to a butcher. Unfortunately, as reprehensible as this practice seems, continued shortcomings in budget allocation by (ir)responsible governmental or medical funding entities force such measures to continue.
The forensic examination conducted purely by a layman virtually assures the adage garbage in, garbage out. In addition to this falling into the category of practicing medicine without a license, the lay examiner lacks the depth and breadth of the pathologist’s training. In addition to the standard 4 years of medical school, the pathologist must successfully complete the identical medical boards as non-pathology colleagues merely to obtain a medical license. A pathologist must complete a minimum 4 years of approved residency training to be eligible to sit for specialty board examination—a year more than many other specialties, including internal medicine, family practice, pediatrics, and obstetrics. The extent of training required indicates that autopsy pathology is “doing much more than taking out the organs for an interested clinician” (Rezek and Millard 1963:ix). For a pathologist to delegate the performance of the examination—in its entirety—to a less qualified individual is to equate the practice of autopsy pathology to the level of said lay examiner. In so doing, the pathologist, intentionally or not, sends the message to all that this is the standard to which pathology is to be held—a far cry from the early 20th century when doctors were admonished that modern medicine is “not only diagnosis and autopsy, but the treatment and care of patients” (Hill and Anderson 1988:18). Again, this may be out of the pathologist’s hands, because limitations imposed by funding entities force continuation of such practices. As such, this is an indictment of the budgeters rather than the physicians. One funds what one values. A sad reality for the future of the autopsy is that the dead do not vote, thus in a medical field chiefly funded by elected officials, the patients have no voice.
An old adage is that 90% of cases are routine and could be performed by just about anyone, whereas 10% are complicated and require a true expert; the problem lies in knowing in advance into which category a particular case falls. Given that the autopsy is the final opportunity to study a disease process in situ and that the examination process is inherently destructive, it is ill advised to take the process lightly. Mistakes of omission or commission in the suboptimal performance of the autopsy routinely go undetected—after all, the evidence is buried with the body. Only particularly egregious errors are brought to light. These situations are not limited to the unqualified/inadequate lay examiner but may involve experienced autopsy pathologists who, for whatever reason, fail to do their jobs by either not performing all or part of an autopsy that they said they did (perjury in a legal setting) or by committing malpractice.
Another point to keep in mind is that the extensive training and passing of specialty and subspecialty medical boards is no guarantee of competence or quality. One must bear in mind that such qualifications represent a snapshot of a point in time and prove that only a minimum level has been achieved. The same is true for recertification examinations (not presently required in pathology).
External Examination
As with other medical disciplines, that portion of the diagnosis not readily apparent from the history will be revealed in the physical examination of the patient. In other specialties, the examining physician can ask the patient to clarify certain points of medical history or examination to better focus the examination to answer a specific question while that step is underway. The autopsist is afforded no such luxury. As a result, the observations and interpretations of the prosector become critical. As such, the oft-overlooked corollary, the documentation of those observations, is paramount. The accurate, complete, and timely recording of the physical findings at autopsy is the essence of the autopsy. Following the principles of Rokitansky, the exam should be consistent and complete. In the forensic setting, the decedent’s clothing can hold clues such as gunshot residue useful in determining range of fire, paint chips useful in determining the vehicle involved in a hit and run fatality, and other trace evidence. The medical examiner will often go to great lengths to ensure that the clothes worn at the time of the lethal event are received by the lab. This is most important in cases of sudden trauma deaths (e.g., car crashes) where emergency medical personnel cut the clothing away from the body to better visualize the injuries and render aid. Garments are of little concern to treating physicians.
The examiner conducts a complete and systematic head-to-toe viewing of the external body surfaces, front and back, documenting both positive and negative physical findings, including postmortem changes. General descriptive information such as hair color, eye color, dentition, fingernails, scars, and so on is also recorded. The goal is to record data in sufficient detail to allow general identification of the deceased and to note any externally obvious disease or trauma.
Internal Examination
Once the outer body has been completely examined and pertinent findings documented, the internal autopsy begins. The examiners employ universal precautions because all patients are potential carriers of biohazardous agents. Personal protective equipment is required for those present at the exam if there is a good chance that the persons will be exposed to potential biohazards. This gear might include a covering outer gown, shoe covers, latex gloves, and a face shield. In addition, a face mask or respirator may be worn if there is potential for exposure to inhalational pathogens. Decontamination and sterilization of equipment and areas may involve numerous chemical agents, depending on the pathogen(s) believed present.
The prosector makes a shallow “U” or “V” incision on the anterior chest, extending from shoulder to shoulder with the base over the mid to inferior sternum. A contiguous vertical incision extends from the base to the lower abdomen, just above the mons pubis. The corresponding skin is reflected as three flaps (two lateral and one superior) from the soft tissues anterior to the subjacent rib cage with sharp dissection along fascial planes. The muscles may be reflected en bloc with the attached skin or as individual layers, depending on the preferences of the examiners, the findings in the autopsy, and the circumstances of the case. The front of the rib cage and abdominal contents are thus exposed. The breastplate is cut away with a saw, blade, or shears. The hemithoraces (sides of the chest), pericardial sac, and peritoneum (abdominal cavity) are evaluated for abnormal fluid collections or lesions. The procedure continues with collection of fluids (blood, urine, and bile) for toxicology and bacteriological cultures if necessary. In general, the organs are then eviscerated by one of two procedures, the Virchow or the Rokitansky method. Many forensic pathologists prefer the former, whereas medical autopsy practitioners favor the latter.
The Rokitansky procedure consists of removal of all the thoracoabdominal organs en bloc from the level of the trachea to that of the internal anogenital area. First the small and large bowel are dissected from the mesentery, opened along their length, and cleaned. The bowel contents may or may not be examined in detail. The major blood vessels in the neck (carotid arteries and jugular veins), upper extremities (subclavian vessels), and lower body (the iliac and femoral vessels) are identified and tied off with string. This allows the embalmer to readily identify these vessels, possibly facilitating the embalming process. The upper airway should be removed from the level of the tongue to the middle of the trachea above the thyroid gland (depending on the case and type autopsy). Unfortunately, in many hospital autopsy settings, the mouth, the tongue, and even the neck structures are not examined at all. The dissection continues inferiorly with reflection of the various organs free from their soft tissue attachments to the anterior spine. On reaching the area of the anus and internal genitalia, the distal rectal tissues are tied off with string and transected at the maximal attainable internal limit. The entire mobilized contents of the chest and abdomen are then removed as a unit. The surgeon then proceeds to carefully dissect and examine each individual system and organ. The entire evisceration requires about 15 minutes, depending on the skill of the eviscerator and the complexity of the case (i.e., the amount of disease present).
The Virchow method is similar in scope but differs in that organs are examined for important anatomic relationships and lesions in situ. In contrast, with the Rokitansky method, these relationships are studied after the organ block has been removed from the body (inherently altering the relationships). Once the examiner commences with the evisceration of organs, each is taken individually—typically, each as a single sample: in turn, the heart, each lung, liver, spleen, stomach with esophagus, pancreas with or without attached duodenum, each kidney, each adrenal, and internal genitalia with urinary bladder and rectum as dissected. In contrast to the alternate procedure, the soft tissues of the abdomen and hemidiaphragms may be left in place. The aorta and inferior vena cava are also opened longitudinally in situ or may be removed. If the great vessels are left anatomically undisturbed, there is no need to tie them off. This evisceration procedure is substantially quicker, requiring between 5 and 10 minutes total time for a skilled practitioner in an uncomplicated case lacking significant trauma or gross pathology.
In most autopsies, the brain is removed after the other organs. An incision is made at the back of the head, from ear to ear. The scalp is then gradually peeled off the skull and flipped inside out, exposing the outer surface of the top of the skull. The skullcap is then sawed off on the sides and removed, exposing dura mater and underlying brain. The brain is removed by gentle traction posteriorly, exposing the orbital plates on the floor of the skull. The various cranial nerves and internal carotid arteries are cut. The dura mater overlying the cerebellum is cut, exposing the brainstem, which is then transected somewhere between the level of the medulla oblongata and the upper cervical spinal cord; with the cutting of the adjacent vertebral arteries, the brain is freed.
In cases of suspected strangulation, the procedure employed is modified slightly so that the neck structures are examined after all the other organs have been eviscerated. The rationale is that any bleeding into the neck structures could be an important clue to the prosector. To eliminate any potential artifactual blood accumulation, the thoracoabdominal and cranial organs are removed and any remaining intravascular blood allowed to drain. The dissection then proceeds with a layer-by-layer examination of the individual neck muscles (“strap muscles”) on each side. The hyoid, thyroid, and cricoid cartilages (which become increasingly calcified with advancing age) are evaluated for fractures and other trauma indicating assault.
Following evisceration, each organ is independently evaluated with weight, size, shape, color, consistency, and other pertinent findings (positive and negative) noted. A triad of organs is ultimately responsible for life and thus most sudden deaths: the lungs, the heart, and the brain. The reason being that life is based on adequate oxygen exchange. The lungs provide the absorptive surface, the heart provides the vector (pumping blood), and the brain drives the system. Any derangement in this triumvirate, for even a brief period, is incompatible with life. An experienced examiner will therefore spend a considerable amount of time in the evaluation of these vital organs, particularly if no other lethal trauma or disease is uncovered to that point.
The lungs may be examined by opening to a greater or lesser extent the pulmonary vessels along their lengths or by cross-sectioning to check for thromoemboli. The lung parenchymae are then assessed for any significant gross lesion, such as pulmonary edema, pneumonia, infarction, and so on. This is accomplished by way of serial parallel incisions (“bread-loafing”) across the entire organ at 1 to 2 cm intervals. The heart is assessed in stages, often commencing with a systematic evaluation of the major coronary arteries. The three major vessels are sequentially sectioned and evaluated for atherosclerotic narrowing, thrombi, or both. The heart itself may then be opened, along the sides of the chambers following the direction of blood flow and/or bread-loafing from the apex toward the valves. The brain is unique and highly complex, with an entire subspecialty (neuropathology) devoted to its study. The dissection typically involves separation and evaluation of the cerebellum, brainstem, and cerebrum, employing serial transverse sections through each. The remaining organs are then examined.
The basic autopsy procedure may be modified based on the requirements of a specific case. In medical autopsies, consent may be granted for only a specific body area or organ (aka a limited, partial, or incomplete autopsy). Morbid anatomy may require alteration of the basic dissection process. The latter is particularly common in cases in which surgery has been previously performed, resulting in reanastomoses and fibrous adhesions (scars). Certain cases, most typically forensic autopsies, demand additional approaches and that examinations be conducted. In suspected child abuse and in-custody or inmate fatalities where there is concern about hidden trauma, the examiner will often examine the soft tissues of the entire back, possibly extending to the upper and lower extremities by literally dissecting the skin away from the remainder of the body, leaving only small axial attachment points.
Depending on the particulars of the case under examination, numerous special procedures and dissection techniques might be used. These might include X-rays (in gunshot wounds), search for air emboli (in diving deaths), genitalia evisceration (in sexual homicide), and many others. In cases where certain organs (most often the brain, heart, or both) are of particular importance, these tissues are saved in formaldehyde and allowed to “fix,” thus allowing time and preservation for a more detailed examination at some later time (ideally, within 2-4 weeks, but in reality, sometimes several months).
The physical process of the autopsy is only a single, relatively brief laboratory test. The experienced practitioner well knows that “the autopsy is not over when the body leaves the autopsy room. At that point, toxicologic and histologic examination has just begun. Investigational data of great correlation may not yet be available to the prosector” (Fisher and Petty 1977:9). Microscopic sections of diseased and apparently normal organs may be examined. The extent of histology varies depending on the type of examination (Hutchins and the Autopsy Committee of the College of American Pathologists 1994; Wetli et al. 1988:125-27), from none in many straightforward medical examiner cases to 30 in hospital practice or even more in a forensic child abuse case. Specimens (fluids and organs) may be analyzed for potential toxins. These additional studies and others account for the weeks (or longer) delay in obtaining the final results of the autopsy. Even when the autopsy is complete, there may be no immediate grossly obvious explanation for the death. In such instances, the pathologist may perform numerous uncommon and exotic analyses to determine the lethal event. “Sudden death and a ‘negative autopsy’ is often the most challenging case faced by a medical examiner” (Wetli et al. 1988:126). In such cases, these additional studies and additional investigation (medical and police) become critical. A complete autopsy requires the physician to integrate all information; a major shortcoming would be to look at only part of the data out of context to the remainder (Geberth 1990:417-47).
The written autopsy report should be succinct, organized, and factual. The only subjective opinions contained therein should be in the form of clearly distinguishable diagnoses and clinical mechanism opinions. “A clinicopathologic summary can be described as an objective correlation of clinical findings with gross and microscopic findings…to describe the death and elucidate the sequence of events leading to death….The pathologist uses…general medical knowledge to produce this synthesis” (Hutchins and the Autopsy Committee 1995:127). As a general principal, “autopsy findings should be recorded in a form that makes them useful for all interested parties…. The written report complements, but cannot substitute wholly for cooperation and open lines of verbal communication among pathologists, clinicians, and all other interested parties” (Hutchins and the Autopsy Committee 1995:123).
The Future
The hospital autopsy is now an underused procedure with the rate having fallen from 50% of in-hospital deaths in the 1940s to 13.2% in the 1980s (Hill and Anderson 1988:41) to 5% in the late 20th century (Steigman 2002). This fall has been attributed to three root causes: lack of reimbursement, lack of consent, and lack of perceived value by hospital physicians (Hoyert 2001:1). In contrast, the forensic autopsy never lost sight of the value of the examination and continues to meet societal needs and expectations (Hill and Anderson 1988:121).
This relates to another interesting observation. Most medical examiner cases are skewed to a population of young males involved with illicit drugs (either homicides or overdoses), whereas most overall deaths are among the elderly, with a larger percentage of females dying at a later age than males. Thus the information available from the largest numbers of autopsies (medical examiner cases) may not accurately represent what the treating physician is likely to encounter. With the significantly increasing age of the U.S. population and a steadily dwindling medical autopsy rate, one can anticipate that this disparity will only increase. “One of the reasons for the sorry state of geriatric medicine is the paucity of autopsies among old people” (Hill and Anderson 1988:121).
A fascinating non sequitur exists at present with tremendous interest in the forensic sciences and medical examiners coexisting with a profoundly low autopsy rate. Public interest in the autopsy process can be traced to 1312, when Italy’s Mondino diLiucci in Bologna conducted the first public dissection (Smyth 1980:18). The use of public autopsy as a medical training technique continued into the mid 20th century when large-group exams were replaced by small groups of health care professionals in didactic sessions. In the early 21st century, the heritage of the teaching autopsy was corrupted into a media and public spectacle (“Dissecting an Autopsy” 2002).
The heritage of the medical practice of autopsy pathology combined with its fundamental foundation of modern medicine and continuing vital contributions to public health would seem to ensure a lofty place in medical practice for this, the “gold standard” of diagnosis. Regrettably, such may not be the case.
The prognosis for the autopsy is grave, and multiple political and financial forces imperil its future … While it is not likely that the autopsy will ever disappear altogether, in the absence of its integration into effective and realistic quality assurance programs and improved reimbursement, it may remain little more than a quaint relic in nonforensic deaths. (Steigman 2002)