An autopsy (also referred to as post-mortem examination, obduction, necropsy, or autopsia cadaverum) is a surgical procedure that consists of a thorough examination of a corpse by dissection to determine the cause, mode, and manner of death; or the exam may be performed to evaluate any disease or injury that may be present for research or educational purposes. The term necropsy is generally used for non-human animals.
Autopsies are usually performed by a specialized medical doctor called a pathologist. Only a small portion of deaths require an autopsy to be performed, under certain circumstances. In most cases, a medical examiner or coroner can determine the cause of death.
Purposes of performance
Autopsies are performed for either legal or medical purposes. Autopsies can be performed when any of the following information is desired:
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If it is an infant, determine live birth and viability
For example, a forensic autopsy is carried out when the cause of death may be a criminal matter, while a clinical or academic autopsy is performed to find the medical cause of death and is used in cases of unknown or uncertain death, or for research purposes. Autopsies can be further classified into cases where an external examination suffices, and those where the body is dissected and an internal examination is conducted. Permission from next of kin may be required for internal autopsy in some cases. Once an internal autopsy is complete, the body is reconstituted by sewing it back together.
Etymology
Autopsy
The term "autopsy" derives from the Ancient Greek αὐτοψία autopsia, "to see for oneself", derived from αὐτός (autos, "oneself") and ὄψις (opsis, "sight, view"). The word has been in use since around the 17th century.
The term "post-mortem" derives from the Latin post, 'after', and mortem, 'death'. It was first recorded in 1734.
Necropsy
The term "necropsy" is derived from the Greek νεκρός (nekrós, "dead") and ὄψις (opsis, 'sight, view').
Purpose
The principal aims of an autopsy are to determine the cause of death, mode of death, manner of death, the state of health of the person before they died, and whether any medical diagnosis and treatment before death were appropriate. In most Western countries the number of autopsies performed in hospitals has been decreasing every year since 1955. Critics, including pathologist and former JAMA editor George D. Lundberg, have charged that the reduction in autopsies is negatively affecting the care delivered in hospitals, because when mistakes result in death, they are often not investigated and lessons, therefore, remain unlearned. When a person has permitted an autopsy in advance of their death, autopsies may also be carried out for the purposes of teaching or medical research. An autopsy is usually performed in cases of sudden death, where a doctor is not able to write a death certificate, or when death is believed to result from an unnatural cause. These examinations are performed under a legal authority (medical examiner, coroner, or procurator fiscal) and do not require the consent of relatives of the deceased. The most extreme example is the examination of murder victims, especially when medical examiners are looking for signs of death or the murder method, such as bullet wounds and exit points, signs of strangulation, or traces of poison.
Some religions, including Judaism and Islam, usually discourage the performing of autopsies on their adherents. Organizations such as ZAKA in Israel and Misaskim in the United States generally guide families on how to ensure that an unnecessary autopsy is not made.
Autopsies are used in clinical medicine to identify a medical error or a previously unnoticed condition that may endanger the living, such as infectious diseases or exposure to hazardous materials.
A study that focused on myocardial infarction (heart attack) as a cause of death found significant errors of omission and commission, i.e. a sizable number of cases ascribed to myocardial infarctions (MIs) were not MIs and a significant number of non-MIs were MIs.
A systematic review of studies of the autopsy calculated that in about 25% of autopsies, a major diagnostic error will be revealed. However, this rate has decreased over time and the study projects that in a contemporary US institution, 8.4–24.4% of autopsies will detect major diagnostic errors.
A large meta-analysis suggested that approximately one-third of death certificates are incorrect and that half of the autopsies performed produced findings that were not suspected before the person died. Also, it is thought that over one-fifth of unexpected findings can only be diagnosed histologically, i.e., by biopsy or autopsy, and that approximately one-quarter of unexpected findings, or 5% of all findings, are major and can similarly only be diagnosed from tissue.
One study found that (out of 694 diagnoses) "Autopsies revealed 171 missed diagnoses, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli, and 9 endocarditis, among others".
Focusing on intubated patients, one study found "abdominal pathologic conditions – abscesses, bowel perforations, or infarction – were as frequent as pulmonary emboli as a cause of class I errors. While patients with abdominal pathologic conditions generally complained of abdominal pain, results of an examination of the abdomen were considered unremarkable in most patients, and the symptom was not pursued".
Types
There are four main types of autopsy:
Medico-legal or forensic or coroner's autopsies seek to find the cause and manner of death and to identify the decedent. They are generally performed, as prescribed by applicable law, in cases of violent, suspicious or sudden deaths, deaths without medical assistance, or during surgical procedures.
Clinical or pathological autopsies are performed to diagnose a particular disease or for research purposes. They aim to determine, clarify, or confirm medical diagnoses that remained unknown or unclear before the patient's death.
Anatomical or academic autopsies are performed by students of anatomy for study purposes only.
Virtual or medical imaging autopsies are performed utilizing imaging technology only, primarily magnetic resonance imaging (MRI) and computed tomography (CT).
Forensic autopsy
A forensic autopsy is used to determine the cause, mode, and manner of death.
Forensic science involves the application of the sciences to answer questions of interest to the legal system.
Medical examiners attempt to determine the time of death, the exact cause of death, and what, if anything, preceded the death, such as a struggle. A forensic autopsy may include obtaining biological specimens from the deceased for toxicological testing, including stomach contents. Toxicology tests may reveal the presence of one or more chemical "poisons" (all chemicals, in sufficient quantities, can be classified as a poison) and their quantity. Because post-mortem deterioration of the body, together with the gravitational pooling of bodily fluids, will necessarily alter the bodily environment, toxicology tests may overestimate, rather than underestimate, the quantity of the suspected chemical.
Following an in-depth examination of all the evidence, a medical examiner or coroner will assign a manner of death from the choices proscribed by the fact-finder's jurisdiction and will detail the evidence on the mechanism of the death.
Clinical autopsy
Clinical autopsies serve two major purposes. They are performed to gain more insight into pathological processes and determine what factors contributed to a patient's death. For example, material for infectious disease testing can be collected during an autopsy. Autopsies are also performed to ensure the standard of care at hospitals. Autopsies can yield insight into how patient deaths can be prevented in the future.
Within the United Kingdom, clinical autopsies can be carried out only with the consent of the family of the deceased person, as opposed to a medico-legal autopsy instructed by a Coroner (England & Wales) or Procurator Fiscal (Scotland), to which the family cannot object.
Over time, autopsies have not only been able to determine the cause of death, but have also led to discoveries of various diseases such as fetal alcohol syndrome, Legionnaire's disease, and even viral hepatitis.
Academic autopsy
Academic autopsies are performed by students of anatomy for the purpose of study, giving medical students and residents firsthand experience viewing anatomy and pathology. Postmortem examinations require the skill to connect anatomic and clinical pathology together since they involve organ systems and interruptions from ante-mortem and post-mortem. These academic autopsies allow for students to practice and develop skills in pathology and become meticulous in later case examinations.
Virtual autopsy
Virtual autopsies are performed using radiographic techniques which can be used in post-mortem examinations for a deceased individual. It is an alternative to medical autopsies, where radiographs are used, for example, magnetic resonance imaging (MRI) and computed tomography (CT scan) which produce radiographic images in order to determine the cause of death, the nature, and the manner of death, without dissecting the deceased. It can also be used in the identification of the deceased. This method is helpful in determining the questions pertaining to an autopsy without putting the examiner at risk of biohazardous materials that can be in an individual's body.
Prevalence
In 2004 in England and Wales, there were 514,000 deaths, of which 225,500 were referred to the coroner. Of those, 115,800 (22.5% of all deaths) resulted in post-mortem examinations and there were 28,300 inquests, 570 with a jury.
The rate of consented (hospital) autopsy in the UK and worldwide has declined rapidly over the past 50 years. In the UK in 2013, only 0.7% of inpatient adult deaths were followed by consented autopsy.
The autopsy rate in Germany is below 5% and thus much lower than in other countries in Europe. The governmental reimbursement is hardly sufficient to cover all the costs, so the medical journal Deutsches Ärzteblatt, issued by the German Medical Association, makes the effort to raise awareness regarding the underfinancing of autopsies. The same sources stated that autopsy rates in Sweden and Finland reach 20–30%.
In the United States, autopsy rates fell from 17% in 1980 to 14% in 1985 and 11.5% in 1989, although the figures vary notably from county to county.
Process
The body is received at a medical examiner's office, municipal mortuary, or hospital in a body bag or evidence sheet. A new body bag is used for each body to ensure that only evidence from that body is contained within the bag. Evidence sheets are an alternative way to transport the body. An evidence sheet is a sterile sheet that covers the body when it is moved. If it is believed there may be any significant evidence on the hands, for example, gunshot residue or skin under the fingernails, a separate paper sack is put around each hand and taped shut around the wrist.
There are two parts to the physical examination of the body: the external and internal examination. Toxicology, biochemical tests or genetic testing/molecular autopsy often supplement these and frequently assist the pathologist in assigning the cause or causes of death.
External examination
At many institutions, the person responsible for handling, cleaning, and moving the body is called a diener, the German word for servant. In the UK this role is performed by an Anatomical Pathology Technician (APT), who will also assist the pathologist in eviscerating the body and reconstruction after the autopsy. After the body is received, it is first photographed. The examiner then notes the kind of clothes – if any – and their position on the body before they are removed. Next, any evidence such as residue, flakes of paint, or other material is collected from the external surfaces of the body. Ultraviolet light may also be used to search body surfaces for any evidence not easily visible to the naked eye. Samples of hair, nails, and the like are taken, and the body may also be radiographically imaged. Once the external evidence is collected, the body is removed from the bag, undressed, and any wounds present are examined. The body is then cleaned, weighed, and measured in preparation for the internal examination.
A general description of the body as regards ethnic group, sex, age, hair colour and length, eye colour, and other distinguishing features (birthmarks, old scar tissue, moles, tattoos, etc.) is then made. A voice recorder or a standard examination form is normally used to record this information.
In some countries, e.g., Scotland, France, Germany, Russia, and Canada, an autopsy may comprise an external examination only. This concept is sometimes termed a "view and grant". The principle behind this is that the medical records, history of the deceased and circumstances of death have all indicated as to the cause and manner of death without the need for an internal examination.
Internal examination
If not already in place, a plastic or rubber brick called a "head block" is placed under the shoulders of the corpse; hyperflexion of the neck makes the spine arch backward while stretching and pushing the chest upward to make it easier to incise. This gives the APT, or pathologist, maximum exposure to the trunk. After this is done, the internal examination begins. The internal examination consists of inspecting the internal organs of the body by dissection for evidence of trauma or other indications of the cause of death. For the internal examination there are a number of different approaches available:
