Autopsy 342334 225647925 2008-07-14T18:48:55Z SmackBot 433328 Date the maintenance tags or general fixes {{about|the medical procedure||Autopsy (disambiguation)}} {{redirect|Post-mortem}} [[Image:Rembrandt Harmensz. van Rijn 007.jpg|thumb|right|220px|The ''[[Anatomy Lesson of Dr. Nicolaes Tulp]]'', by [[Rembrandt]], depicts an autopsy]] An '''autopsy''', also known as a ''post-mortem examination'', ''necropsy'', or ''obduction'', is a [[medical procedure]] that consists of a thorough [[examination]] of a [[Dead body|corpse]] to determine the cause and manner of [[death]] and to evaluate any [[disease]] or [[injury]] that may be present. It is usually performed by a specialized medical doctor called a [[pathology|pathologist]]. Autopsies are either performed for legal or medical purposes. 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 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. The prefix 'auto-' means 'self', and so '''autopsy''' means 'to see for oneself'; it is used more broadly of personal examination of an object, as well as its specific usage for the post-mortem examination of a human corpse. ==History== The [[Egyptians]] were one of the first civilizations to practice the removal and examination of the internal organs of humans.[http://www.mnsu.edu/emuseum/prehistory/egypt/dailylife/medicine.html] ==Value of autopsy in medicine== Autopsies are important in clinical medicine as they can identify [[medical error]] and assist [[continuous improvement]]. A study that focused on [[myocardial infarction]] (heart attack) as a cause of death found significant errors of omission and commission,<ref>{{cite journal |author=Ravakhah K |title=Death certificates are not reliable: revivification of the autopsy |journal=South. Med. J. |volume=99 |issue=7 |pages=728–33 |year=2006 |pmid=16866055 |doi=10.1097/01.smj.0000224337.77074.57}}</ref> i.e. a sizable number cases ascribed to myocardial infarctions (MIs) were not MIs and a significant number of non-MIs were actually MIs. A [[systematic review]] of studies of the autopsy calculated that in about 25% of autopsies a major diagnostic error will be revealed.<ref name="pmid12783916">{{cite journal |author=Shojania KG, Burton EC, McDonald KM, Goldman L |title=Changes in rates of autopsy-detected diagnostic errors over time: a systematic review |journal=JAMA |volume=289 |issue=21 |pages=2849–56 |year=2003 |pmid=12783916 |doi=10.1001/jama.289.21.2849}}</ref> However, this rate has decreased over time and the study projects that in a contemporary US institution, 8.4% to 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.<ref>{{cite journal |author=Roulson J, Benbow EW, Hasleton PS |title=Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review |journal=Histopathology |volume=47 |issue=6 |pages=551–9 |year=2005 |pmid=16324191 |doi=10.1111/j.1365-2559.2005.02243.x |doi_brokendate=2008-06-20}}</ref> Also, it is thought that over one fifth of unexpected findings can only be diagnosed [[histology|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. ===Value of autopsy in intensive care unit=== One study found 32% major diagnostic errors (Class I and Class II) with the leading missed diagnoses being "Autopsies revealed 171 missed diagnoses, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli, and 9 endocarditis, among others".<ref name="pmid14980989">{{cite journal |author=Combes A, Mokhtari M, Couvelard A, ''et al'' |title=Clinical and autopsy diagnoses in the intensive care unit: a prospective study |journal=Arch. Intern. Med. |volume=164 |issue=4 |pages=389–92 |year=2004 |pmid=14980989 |doi=10.1001/archinte.164.4.389}}</ref> Focusing 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 examination of the abdomen were considered unremarkable in most patients, and the symptom was not pursued".<ref name="pmid1992186">{{cite journal |author=Papadakis MA, Mangione CM, Lee KK, Kristof M |title=Treatable abdominal pathologic conditions and unsuspected malignant neoplasms at autopsy in veterans who received mechanical ventilation |journal=JAMA |volume=265 |issue=7 |pages=885–7 |year=1991 |pmid=1992186|doi=10.1001/jama.265.7.885}}</ref> == General information == The term "autopsy" derives from the [[Greek language|Greek]] for "to see oneself". "Necropsy" is from the Greek for "seeing a dead body". There are three main types of autopsies: *''Forensic'': This is done for medical-legal purposes, and is the one that is normally seen on [[television]] or in the [[news]]. This type depict an extensive methodology and tends to be complete and comprehensive. No [[family]] permission is required to complete this type of autopsy{{Fact|date=July 2008}}. *''Clinical/academic'': This is usually performed in [[hospital]]s for [[research]] and study purposes. Prior to the start, of a clinical autopsy, a cause of death must have already been established, and a death certificate completed. This usually is as comprehensive as it needs to be adequate. To complete this type of autopsy, permission from the deceased's legal next of kin is required. *''Coroner's'': In Great Britain this type of autopsy encompasses cases where no medical cause of death is readily available. Cause, manner and mechanism of death are in question. Eventually, the prosectors will identify whether the cases deserve comprehensive forensic autopsy or a routine postmortem. In the United States, each state has a set of guidelines defining a "coroner's case" for autopsy, for example: hospital deaths occurring within 24 hours of admission or within 24 hours of a major surgical procedure, with any history (current or remote) of illegal drug or alcohol abuse by the deceased, patients with certain communicable diseases (HIV, hepatitis C virus, etc.), patients with any previous history of violent injury (e.g., gunshot wound many years before death). These cases may or may not be also considered "forensic" in nature. They may be done by the hospital pathologist with the legal permission of the coroner or medical examiner for that county/parish and do not require permission from the deceased's legal next of kin. While [[dissection]] of human remains for medical reasons has been practiced irregularly for nearly a millennium since [[Ibn Zuhr|Avenzoar]] and [[Ibn al-Nafis]], the modern autopsy process derives from the [[anatomist]]s of the [[Renaissance]]. The two great [[19th century|nineteenth-century]] medical researchers [[Rudolf Virchow]] and [[Carl von Rokitansky]] built on the Renaissance legacy to derive the two distinct autopsy techniques that still bear their names. Their demonstration of correspondences between [[pathological]] conditions in dead bodies and [[symptoms]] and illnesses in the living opened the way for a different way of thinking about [[disease]] and its treatment. In [[China]], the office of [[coroner]] and forensic autopsy have a history nearly two thousand years old. == Forensic autopsy == A forensic autopsy is used to determine the cause of death. [[Forensic science]] involves the application of the sciences to answer questions of interest to the legal system. In [[United States]] law, deaths are placed in one of five manners: *[[Death by natural causes|Natural]] *[[Accidental death|Accident]] *[[Homicide]] *[[Suicide]] *Undetermined In some jurisdictions, the Undetermined category may include [[Death in absentia|deaths in absentia]], such as deaths at sea and missing persons declared dead in a court of law; in others, such deaths are classified under "Other". Following an in-depth examination of all the [[evidence]], a medical examiner or [[coroner]] will assign a manner of death as one of the five listed above; and 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 [[Pathology|pathological]] processes and determine what factors contributed to a patient's death. More importantly, autopsies are 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 only be carried out 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. == The process == [[Image:Cadaver dissection table - long shot.jpg|thumb|right|200px|[[Cadaver]] dissection table. Similar to those used in medical or forensic autopsies.]] The body is received at a medical examiner's office or hospital in a [[body bag]] or evidence sheet. A brand 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 alternate way to transport the body. An evidence sheet is a [[sterilization (microbiology)|sterile]] sheet that the body is covered in when it is moved. If it is believed there may be any significant [[residue]] on the hands, for instance [[gunpowder]], 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]], [[Medical test|biochemical test]]s and/or [[genetic testing]] often supplement these and frequently assist the [[pathologist]] in assigning the cause or causes of death. ===External examination=== The person responsible for handling, cleaning and moving the body is often called a ''diener'', the [[German language|German]] word for ''servant''. In the UK this role is performed by an Anatomical Pathology Technologist who will also assist the pathologist in eviscerating the deceased and reconstruction after the autopsy. After the body is received, it is first [[Photography|photographed]]. The examiner then notes the kind of clothes 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]], [[Nail (anatomy)|nail]]s and the like are taken, and the body may also be [[X-ray|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. The [[Weighing scale|scale]] used to weigh the body is often designed to accommodate the [[cart]] that the body is transported on; its weight is then deducted from the total weight shown to give the weight of the body. If not already within an autopsy room, the body is transported to one and placed on a table. A general description of the body as regards [[ethnicity]], [[sex]], age, [[hair color]] and length, [[eye color]] and other distinguishing features ([[birthmark]]s, old [[scar]] [[Biological tissue|tissue]], [[Mole (skin marking)|mole]]s, etc) is then made. A handheld [[voice recorder]] or a standard examination form is normally used to record this information. In some countries e.g. France, Germany and Canada to name but a few, an autopsy may comprise an external examination only. This concept is sometimes termed a "view and grant". The principles behind this being 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=== <!-- Deleted image removed: [[Image:modern autopsy.jpg|thumb|right|220px|A modern autopsy showing the exposed organs of a specimen. The [[intestines]] are fairly visible.]] --> If not already in place, a plastic or rubber brick called a "body block" is placed under the back of the body, causing the arms and neck to fall backward whilst stretching and pushing the [[chest]] upward to make it easier to cut open. This gives the [[prosector]], a pathologist or assistant, maximum exposure to the [[Torso|trunk]]. After this is done, the internal examination begins. The internal examination consists of inspecting the [[internal organs]] of the body for evidence of [[physical trauma|trauma]] or other indications of the cause of death. For the internal examination there are a number of different approaches available: * a large and deep Y-shaped [[incision]] can be made starting at the top of each shoulder and running down the front of the chest, meeting at the lower point of the [[sternum|breastbone]]. This is the approach most often used in forensic autopsies so as to allow maximum exposure of the neck structures for later detailed examination. This could prove essential in cases of suspected strangulation * a T-shaped incision made from the tips of both shoulder, in a horizontal line across the region of the collar bones to meet at the sternum (breastbone) in the middle. This initial cut is used more often to produce a more aesthetic finish to the body when it is re-constituted as stitching marks will not be as apparent as with a Y-shaped incision * a single vertical cut is made from the middle of the neck (in the region of the 'adam's apple' on a male body) In all of the above cases the cut then extends all the way down to the [[pubic bone]] (making a deviation to the left side of the navel). [[Bleeding]] from the cuts is minimal, or non-existent, due to the fact that the pull of [[gravity]] is producing the only [[blood pressure]] at this point, related directly to the complete lack of cardiac functionality. However, in certain cases there is anecdotal evidence to prove that bleeding can be quite profuse, especially in cases of drowning. An electric [[saw]] dubbed a "Stryker saw" after a common [[Stryker Corp.|manufacturer of the tool]], is most often used to open the [[chest cavity]]. However, in some cases, due to the large amount of dust created when the bone is cut by the saw, shears are used to open the chest cavity. It is also possible to utilise a simple scalpel blade. The prosector uses the [[tool]] to saw through the ribs on the lateral sides of the chest cavity to allow the [[sternum]] and attached ribs to be lifted as one chest plate; this is done so that the heart and lungs can be seen [[in situ]] and that the heart, in particular the [[pericardial sac]] is not damaged or disturbed from opening. A [[scalpel]] is used to remove any soft tissue that is still attached to the posterior side of the chest plate. Now the [[lungs]] and the heart are exposed. The chest plate is set aside and will be eventually replaced at the end of the autopsy. At this stage the [[organ (anatomy)|organ]]s are exposed. Usually, the organs are removed in a systematic fashion. Making a decision as to what order the organs are to be removed will depend highly on the case in question. Organs can be removed in several ways: The first is the en masse technique of letulle whereby all the organs are removed as one large mass. The second is the en bloc method of Ghon. The most popular in the UK is a modified version of this method which is divided into four groups of organs. Although these are the two predominant evisceration techniques in the UK variations on these are widespread. One method is described here: The pericardial sac is opened to view the heart. Blood for chemical analysis may be removed from the inferior vena cava or the pulmonary veins. Before removing the heart, the pulmonary artery is opened in order to search for a blood clot. The heart can then be removed by cutting the inferior vena cava, the pulmonary veins, the aorta and pulmonary artery, and the superior vena cava. This method leaves the aortic arch intact, which will make things easier for the embalmer. The left lung is then easily accessible and can be removed by cutting the bronchus, artery, and vein at the hilum. The right lung can then be similarly removed. The abdominal organs can be removed one by one after first examining their relationships and vessels. Some pathologists, however, prefer to remove the organs all in one "block". Then a series of cuts, along the vertebral column, are made so that the organs can be detached and pulled out in one piece for further inspection and sampling. During autopsies of infants, this method is used almost all of the time. The various organs are examined, weighed and tissue samples in the form of slices are taken. Even major [[blood vessel]]s are cut open and inspected at this stage. Next the [[stomach]] and intestinal contents are examined and weighed. This could be useful to find the cause and time of death, due to the natural passage of food through the bowel during digestion. The more area empty, the longer the deceased had gone without a meal before death. [[Image:Streptococcus pneumoniae meningitis, gross pathology 33 lores.jpg|right|175px|thumb|A brain autopsy demonstrating signs of [[meningitis]]. The [[forceps]] (center) are retracting the [[dura mater]] (white). Underneath the dura mater are the [[leptomeninges]], which appear to be [[edema]]tous and have multiple small hemorrhagic foci.]] The body block that was used earlier to elevate the chest cavity is now used to elevate the head. To examine the [[brain]], an incision is made from behind one ear, over the crown of the head, to a point behind the other ear. When the autopsy is completed, the [[incision]] can be neatly sewn up and is not noticed when the head is resting on a pillow in an open casket [[funeral]]. The [[scalp]] is pulled away from the [[skull]] in two flaps with the front flap going over the face and the rear flap over the back of the neck. The skull is then cut with an [[electric saw]] to create a "cap" that can be pulled off, exposing the brain. The brain is then observed in situ. Then the brain's connection to the cranial nerves and [[spinal cord]] are severed, and the brain is then lifted out of the skull for further examination. If the brain needs to be preserved before being inspected, it is contained in a large container of [[formalin]] (15 percent solution of [[formaldehyde]] gas in buffered [[water]]) for at least two but preferably four weeks. This not only preserves the brain, but also makes it firmer allowing easier handling without corrupting the tissue. == Reconstitution of the body == An important component of the autopsy is the reconstitution of the body such that it can be viewed, if desired, by relatives of the deceased following the procedure. After the examination, the body has an open and empty [[chest cavity]] with chest flaps open on both sides, the top of the skull is missing, and the skull flaps are pulled over the face and neck. It is unusual to examine the face, arms, hands or legs internally. In the UK, following the Human Tissue Act 2004 all organs and tissue must be returned to the body unless permission is given by the family to retain any tissue for further investigation. Normally the internal body cavity is lined with cotton wool or an appropriate material, the organs are then placed into a plastic bag to prevent leakage and returned to the body cavity. The chest flaps are then closed and sewn back together and the skull cap is sewed back in place. Then the body may be wrapped in a [[shroud]] and it is common for relatives of the deceased to not be able to tell the procedure has been done when the deceased is viewed in a [[funeral home|funeral parlor]] after [[embalming]]. == Other information == The principal aim of an autopsy is to determine the [[cause of death]], the state of health of the person before he or she died, and whether any medical [[diagnosis]] and treatment before death was appropriate. In most [[Western countries]] the number of autopsies performed in hospitals has been decreasing every year since 1955. Critics, including [[pathologist]] and former ''[[Journal of the American Medical Association|JAMA]]'' [[editing|editor]] [[George D. Lundberg|George 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 learned. When a person has given permission in advance of their death, autopsies may also be carried out for the purposes of teaching or medical research. An autopsy is frequently performed in cases of sudden death, where a doctor is not able to write a death certificate, or when death is believed to be due to an unnatural cause. These examinations are performed under a legal authority (Medical Examiner or [[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]]. == See also == * [[Forensic science]] * [[Disposal of human corpses]] * [[Pathology]] * [[John Tonge Centre]] * [[Gunther von Hagens]] ==References== <references/> ==External links== {{commonscat|Autopsies}} *[http://www.autopsycam.com Autopsy] - Autopsy - Who gets autopsied?, Autopsy permission, Autopsy technique * [http://www.pathguy.com/autopsy.htm Autopsy] - a detailed description by a [[pathologist]] complete with cartoon figures. * [http://www.le.ac.uk/pathology/teach/va/welcome.html The Virtual Autopsy] - a site from the [[University of Leicester]] where one examines the patient, looks at the (medical) history and gets a try at the diagnosis. * [http://www.hbo.com/autopsy/index.html ''HBO's Autopsy''] - a series on [[HBO]] about forensics and autopsies. * [http://news.bbc.co.uk/1/hi/health/2493291.stm ''BBC News - Controversial Autopsy goes ahead''] - news story about Prof. [[Gunther von Hagens]] performing the first public autopsy in the UK in 170 years. *[http://health.howstuffworks.com/autopsy.htm How Stuff Works - Autopsies] *[http://www.expertwitness.com/autopsy Autopsies - Forensic] * [http://members.aol.com/RVSNorton1/Lincoln60.html President Abraham Lincoln's Autopsy.] * [http://www.autopsyvideo.com www.autopsyvideo.com]- This site offers autopsy documentaries, one produced with the aid of The LA County Coroner's Office. * [http://www.montrealsciencecentre.com/autopsy/ ''Autopsy of a Murder''] - An interactive exploration of a murder scene and the science involved in a criminalistic investigation: autopsy and laboratory expertise. Produced by the Montreal Science Centre for its namesake exhibition. *[http://www.icfmt.org/vol1no1/riskfactors.htm ''Prevention of Infection during autopsy''] It lists the risk factors and prevention strategies during post mortem examination. *[http://www.aaptuk.org] - The official organisation for Anatomical Pathology Technologists in the UK {{pathology}} {{Death}} [[Category:Death]] [[Category:Pathology]] [[Category:Forensics]] [[bs:Autopsija]] [[bg:Аутопсия]] [[cs:Pitva]] [[da:Obduktion]] [[de:Leichenschau]] [[el:Νεκροψία]] [[es:Autopsia]] [[eu:Autopsia]] [[fr:Autopsie]] [[gl:Autopsia]] [[id:Otopsi]] [[iu:ᑐᖁᖓᔪᒥᒃ ᖃᐅᔨᓴᕐᓂᖅ/tuqungajumik qaujisarniq]] [[it:Autopsia]] [[he:נתיחה שלאחר המוות]] [[hu:Autopsia]] [[nl:Autopsie]] [[ja:検死]] [[no:Obduksjon]] [[pl:Sekcja zwłok]] [[pt:Autópsia]] [[ru:Аутопсия]] [[sk:Pitva]] [[sr:Аутопсија]] [[fi:Ruumiinavaus]] [[sv:Obduktion]] [[th:การชันสูตรพลิกศพ]] [[tr:Otopsi]] [[yi:פאלמעסונג]]