Autopsy
(Post Mortem Examination)
What is an autopsy?
An autopsy is the examination of a dead body and is performed primarily to determine the cause of death and to identify disease states present. It is also known as a post mortem examination. In academic institutions, autopsies are also requested for teaching and research purposes. Forensic autopsies are cases with legal implications and are performed to determine if a given death was an accident, homicide, suicide, or a natural event. The word autopsy is derived from the Greek word autopsia: "to see with one's own eyes."
How is an autopsy performed?
The extent of an autopsy can vary from a single organ such as the heart or brain to a very extensive examination. Examination of the chest, abdomen, and brain is probably considered by most as the standard autopsy and one technique is briefly described below.
The autopsy begins with a complete external examination. The body weight and height are recorded, and identifying marks such as scars and tattoos are documented.
The internal examination begins with the creation of a Y or U- shaped incision from both shoulders joining over the sternum and continuing down to the pubic bone. The skin and underlying tissues are then separated to expose the rib cage and abdominal cavity. The front of the rib cage is removed to expose the neck and chest organs. This opening allows the trachea (windpipe), thyroid gland, parathyroid glands, esophagus, heart, thoracic aorta and lungs to be removed. Following removal of the neck and chest organs, the abdominal organs are cut (dissected) free. These include the intestines, liver, gallbladder and bile duct system, pancreas, spleen, adrenal glands, kidneys, ureters, urinary bladder, abdominal aorta, and reproductive organs.
To remove the brain, an incision is made in the back of the skull from one ear to the other. The scalp is cut and separated from the underlying skull and pulled forward. The top of the skull is removed using a vibrating saw. The entire brain is then gently lifted out of the cranial vault. The spinal cord may also be taken by removing the anterior or posterior portion of the spinal column.
In general, pieces of all of the major organs mentioned above are converted into thin sections of tissue that can be placed on slides and studied under a microscope. The organs may be returned to the body or may be retained for teaching, research, and diagnostic purposes.
At the end of an autopsy, the incisions made in the body are sewn closed. Performance of an autopsy does not interfere with an open casket funeral service, as none of the incisions made are apparent after embalming and dressing of the body by the mortician.
What other special studies may be done as part of the autopsy?
After the organs are removed from the body, they are usually separated from each other and further cut up to reveal any abnormalities, such as tumors, on the inside. Small samples are typically taken from all organs to be made into slide preparations for examination under a microscope. Pictures of findings may be taken for future reference. Special studies may include cultures to identify infectious agents, chemical analysis for the measurement of drug levels or metabolic abnormalities, or genetic studies. Tissue may be frozen for future diagnostic or research purposes. Organs are then stored in formalin for further examination, sampling for microscopy, presentation at conference, or archiving for medical student training.
What is the autopsy report?
After all studies are completed, a detailed report is prepared consisting of the autopsy procedure and microscopic findings, a list of diagnoses, and a summary of the case. The report emphasizes the relationship or correlation between clinical findings (the doctor's examination, laboratory tests, radiology findings, etc.) and pathologic findings (those made from the autopsy).
Why is the autopsy rate declining?
Beginning in the 1950s, hospital autopsy rates started falling from an average of around 50% of all deaths to 10% in the late 1990s. In 1970, the Joint Commission for Accreditation of Hospitals dropped the requirement that a hospital needed an autopsy rate of 20% to be accredited. To some, this decline represents a crisis in medical education, research, and practice, and deprives decedents' families, physicians, and society of the many benefits of an autopsy.
Multiple factors are believed to contribute to the declining autopsy rate.
Family factors: Certainly the relationship between patients and their doctors has changed dramatically over the past 50 years due to factors such as specialization, managed care, and the disappearance of the "house call." Physicians no longer are "family doctors" and do not have the same rapport with patients and their families as in past years. This change in the basic doctor-patient relationship would seem to make it increasingly difficult to obtain consent for an autopsy, as issues of trust are most certainly involved.
Concerns over disfigurement of the remains or delays in funeral arrangements may prevent a vast majority of families from consenting to an autopsy. In reality, however, the visual examination of the body and the removal of tissues and/or organs for microscopic examination can be completed in a few hours. Furthermore, there are no visible external changes that would preclude an open-casket funeral service.
In the majority of cases and certainly at academic medical centers, there is currently no charge to the family. More recently, though, some institutions have started to charge and private autopsies at the request of family members that are performed outside of the hospital may cost several thousand dollars.
Clinician Factors: The perceived and experienced hostility of patients' families towards medical providers may also have an impact on the physician's practice regarding the autopsy. Most physicians are generally uncomfortable requesting an autopsy because it is not an easy or pleasant task. If, in addition, a physician feels that a given family is dissatisfied with the caregiver, the physician may be further dissuaded from requesting an autopsy that might prove the family correct. During the first half of the century, physicians requested autopsies with the hope of uncovering errors or missed diagnoses that would serve to improve future patient care. This practice may still occur, but sometimes at the price of a lawsuit.
Many individuals in medicine feel that modern technology has made the autopsy outdated or obsolete. With modern imaging studies and laboratory tests, it is thought that the autopsy is unlikely to reveal any conditions that were not detected clinically. The accuracy of the clinical diagnosis has been the subject of numerous research studies. These studies have consistently shown that in 20% to 40% of autopsied patients, there were important, treatable conditions that were detected at autopsy that were not diagnosed clinically. This consistent and significant discrepancy between clinical and pathologic diagnoses is probably the most compelling argument for continued efforts to revive the autopsy as the "gold standard" in evaluating the quality of medical care.
Pathologist Factors: Some doctors express dissatisfaction with the quality of an autopsy if the pathologist does not provide answers regarding the case. Unfortunately, an autopsy does not guarantee that the cause of death, for example a heart arrhythmia, will be identified.
Autopsy pathology is a vanishing subspecialty, which, for the most part, has been relegated to a secondary position. At the turn of the century, most of the pathologist's activities revolved around the autopsy. Since that time, laboratory medicine and surgical pathology (examining tissue biopsies from living patients) have become the major activities of practicing pathologists.
In addition, the autopsy is not one of the favorite activities among the majority of pathologists. For many pathologists, an autopsy is an extra burden with no compensation during a busy day.
What are the benefits of autopsies?
Benefits for Families: For families, the autopsy has both tangible and psychological benefits. Uncertainty regarding the cause of an individual's death can delay payment of insurance benefits. The autopsy can also uncover genetic or environmental (for example, a bacterium or fungus) causes of disease that could affect other family members. Psychologically, the autopsy provides closure by identifying or confirming the cause of death. The autopsy can demonstrate to the family that the care provided was appropriate, thereby alleviating guilt among family members and offering reassurance regarding the quality of medical care. Lastly, the autopsy is a mechanism that enables the family to participate in medical education and research.
Benefits for the Clinician and Hospital: The procedure can confirm the accuracy of the clinical diagnoses and the appropriateness of medical care. The autopsy findings can be utilized to educate physicians, nurses, residents, and students, thereby contributing to an improved quality of care.
Benefits to Society: Many of the benefits of the autopsy are experienced by society as a whole. The autopsy aids in the evaluation of new diagnostic tests, the assessment of new therapeutic interventions (drugs, devices, surgical techniques), and the investigation of environmental and occupational diseases. Autopsy data are useful in establishing valid mortality statistics. Data derived from death certificates in the absence of autopsy data have repeatedly been shown to be notoriously inaccurate. New medical knowledge on existing diseases that is derived from autopsy based research is clearly important for everyone. Remarkably, new diseases continue to emerge, such as AIDS, Legionnaire's disease, and toxic shock syndrome, which can only be fully investigated by autopsy.
Who pays for autopsies?
Presently, there is no direct funding to hospitals or doctors for autopsies. As part of the federal government's Medicare funding to hospitals, reimbursement for autopsies is theoretically included in fixed payments that hospitals receive. Thus, the federal government contends that it is paying for autopsies. Since these funds are not specifically ear-marked for autopsies, they may not reach the pathology department or pathologist. Managed care organizations consider the autopsy to be built into their hospital contracts. However, these organizations have stated that they are willing to reimburse for autopsies if and when they are convinced of their value. Ultimately, the family may more often be called upon to absorb the cost of the autopsy. In our litigation oriented society, a growing proportion of private-pay autopsies are motivated by distrust, anger, and a desire to sue the potentially responsible physician(s) and hospital. Several groups of pathologists and business persons throughout the country are marketing their autopsy services through direct mail, newspapers, funeral homes, and online. Whether the quality and objectivity of these private autopsies will match those of general hospitals and academic medical centers remains to be determined.
What is the history of the autopsy?
The earliest anatomists and pathologists could be considered ancient hunters, butchers, and cooks who had to recognize organs and determine if they were suitably edible. In ancient Babylon, perhaps as early as 3500 BC, autopsies on animals were performed not for the study of disease, but rather for the practice of predicting the future by communicating with divine forces. The intestines and liver were believed to contain messages from divine spirits.
Galen (131-200 A.D.), a disciple of Hippocrates practicing in ancient Greece, performed surgical dismantling (dissection) of animals and humans. He determined that Hippocrates' theory that disease was due to four circulating humours (phlegm, blood, yellow bile, and black bile) was correct. Galen was a highly respected, powerful, and dogmatic individual who dominated the medical thinking of his time and for hundreds of years to follow. It is said that the four humour doctrine paralyzed medical science for about 1400 years.
In general, before 1700 there was a negative attitude regarding dissection of the human body. Egyptians, Greeks, Romans, and Medieval Europeans performed dissections for religious reasons or to learn anatomy, but this was not done in any systematic fashion. There were, however, some notable exceptions. In the late 1200s the law faculty dominated the University of Bologna and would order autopsies to be performed to help solve legal problems. Thus, some of the earliest autopsies were medicolegal cases. In the late 1400s in Padua and Bologna, Italy, the sites of the world's first medical schools, Pope Sixtus the IV issued an edict permitting dissection of the human body by medical students. Before such edicts from religious leaders, it was considered a crime to dissect the human body and criminal prosecutions for "body snatching" by students of anatomy date back to the early 1300s.
By the 1500s, the autopsy was generally accepted by the Catholic Church, marking the way for an accepted systematic approach for the study of human pathology. While a number of "giants" around this time, such as Vesalius (1514-1564), Pare (1510-1590), Lancisi (1654- 1720), and Boerhaave (1668-1738) advanced the autopsy, it is Giovanni Bathista Morgagni (1682-1771) who has been considered the first great autopist. During his 60 years of observations, Morgagni insisted upon correlation of pathological findings with clinical symptoms, marking the first time that autopsies made major contributions to the understanding of disease in medical science.
Some historians say that the power of the autopsy in medical education peaked during the 1800s. In the beginning of that century the Allgemeine Krankenhaus in Vienna was considered the premiere medical center of the Western World, in large part because of the stature of its Pathology Institute which was headed by Karl Rokitansky (1804-1878). Almost every patient who died was taken to the Rokitansky Institute, which still exists in Vienna, for autopsy. Rokitansky is said to have supervised 70,000 autopsies, and personally performed over 30,000, averaging two a day, seven days a week, for 45 years. Rokitansky stressed a systematic, almost ritualistic, approach to the autopsy with every patient receiving the same detailed examination. For the sake of objectivity, Rokitansky, unlike Morgagni, did not care to know the clinical history of the patients. Because of this style and his disinclination to apply microscopy in a routine fashion, many of Rokitansky's theories about diseases proved to be incorrect.
Rudolph Virchow (1821-1902), an eminent German statesmen and pathologist, was a younger contemporary and competitor of Rokitansky. Unlike Rokitansky, he grew up with the microscope, and was most influential in the systematic application of microscopy to study disease. Virchow advanced the doctrine which held that cellular pathology was the basis of disease, finally laying to rest the humoural theory of Hippocrates and Galen. In many ways, Virchow could be considered the first molecular biologist. Under Virchow, Berlin replaced Vienna as the premier center of medical education.
Many clinicians, upon returning from study in Berlin, became leaders in North American medicine. The most notable of these physicians was the legendary Sir William Osler who worked in Canada and the US. Osler was inarguably the most respected and revered North American physician of his time. He studied with Rokitansky and Virchow and relied heavily on autopsy studies for his own education. Osler not only performed autopsies himself and taught others from autopsies, but also left detailed instructions for his own autopsy. In speaking of himself, Osler told a friend: "I've been watching this case for 2 months and I'm sorry I shall not see the postmortem." As expected, the autopsy showed that all of Osler's diagnoses were correct.
In 1910, Abraham Flexner reported the sorry state of medical education in the United States at that time. The Cabot report issued from the Massachusetts General Hospital in 1920, based on approximately 3000 autopsies performed, revealed astonishing diagnostic inaccuracies on the part of clinicians. Resulting medical reforms included the placement of autopsy pathology as a central, integral component of medical education.
Should the autopsy be revived?
Government agencies that regulate the accreditation of hospitals and nursing homes are deeply concerned about the decline in autopsy rates. For example, recent surveys have indicated that less than 1% of nursing home patients who die are autopsied. The U.S. general accounting office, which pays for some nursing home services, recently attempted to prove that particular nursing homes were substandard. Such efforts were thwarted by the lack of hard evidence. The allegations could not be proven because the patients in question were not autopsied and the actual causes of death could not, therefore, be confirmed.
Some information can only be acquired during an autopsy. The information autopsies can provide benefits society, the medical profession, and families. The autopsy should be revived. Whether or not it will be remains to be seen. - An autopsy is the examination of a dead body.
- An autopsy may be restricted to a specific organ or region of the body.
- Autopsies are performed to determine the cause of death, for legal purposes, and for teaching and research.
- The body is opened in a manner that does not interfere with an open casket service.
- The autopsy rate has dropped from 50% to 10% over the past fifty years.
- The autopsy is the cornerstone of modern medicine and benefits families, doctors, and society in many ways.
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