Autopsy

Autopsy

Autopsy means "see for yourself." It is a special surgical operation, performed by specially trained physicians, on a dead body. Its purpose is to learn the truth about the person's health during life, and how the person died.

There are many advantages to getting an autopsy. Even when the law does not require it, there is always something interesting for the family to know—something worth knowing that wasn't known during life is often found. Even at major hospitals, in approximately one case in four, a major disease is found that was unknown in life. Giving families the explanations they want is often stated as one of the most satisfying things that a pathologist does. A pathologist is a physician with a specialty in the scientific study of body parts. This specialty always includes a year or more learning to do autopsies.

Under the laws of most states, an autopsy can be ordered by the government. The job of coroner is a political position, while a medical examiner is a physician, usually a pathologist. Exactly who makes the decisions, and who just gives advice, depends on the jurisdiction. Autopsies can be ordered in every state when there is suspicion of foul play. In most states, an autopsy can be ordered when there is some public health concern, for example a mysterious disease or a worry about the quality of health care. In most states, an autopsy may be ordered if someone dies unattended by a physician (or attended for less than 24 hours), or if the attending physician is uncomfortable signing the death certificate. If autopsy is not required by law, the legal next-of-kin must sign an autopsy permit.

When a loved one dies, a family can ask the hospital to perform an autopsy. If the family prefers, a private pathologist can do the autopsy in the funeral home. It does not matter much whether the body has been embalmed first. Whoever does the autopsy, there should not be a problem with an open-casket funeral afterwards. This is true even if the brain has been removed and the dead person is bald. The pillow will conceal the marks.

Most religions allow autopsy. If the body is that of an Orthodox Jew, pathologists are happy to have a rabbi present to offer suggestions. Many Muslims prefer not to autopsy.

Here's how an autopsy is done. In this example, there are three pathologists working together.

The body has already been identified and lawful consent obtained.

The procedure is done with respect and seriousness. The prevailing mood in the autopsy room is curiosity, scientific interest, and pleasure at being able to find the truth and share it. Most pathologists choose their specialty, at least in part, because they like finding the real answers. Many autopsy services have a sign, "This is the place where death rejoices to teach those who live." Usually it is written in Latin: Hic locus est ubi mors gaudet succurrere vitae. Autopsy practice was largely developed in Germany, and an autopsy assistant is traditionally called a "diener," which is German for "servant."

The pathologist first examines the outside of the body. A great deal can be learned in this way. Many pathologists use scalpels with rulers marked on their blades. The body is opened using a Y-shaped incision from shoulders to mid-chest and down to the pubic region. There is almost no bleeding, since a dead body has no blood pressure except that produced by gravity. If the head is to be opened, the pathologist makes a second incision across the head, joining the bony prominences just below and behind the ears. When this is sewn back up, it will be concealed by the pillow on which the dead person's head rests.

The incisions are carried down to the skull , the rib cage and breastbone, and the cavity that contains the organs of the abdomen. The scalp and the soft tissues in front of the chest are then folded back. Again, the pathologist looks around for any abnormalities.

One pathologist prepares to open the skull using a special vibrating saw that cuts bone but not soft tissue. This is an important safety feature. Another pathologist cuts the cartilages that join the ribs to the breastbone, in order to be able to enter the chest cavity. This can be done using a scalpel, a saw, or a special knife, depending on the pathologist's preferences and whether the cartilages have begun to turn into bone, as they often do in older people. The third pathologist explores the abdominal cavity. The first dissection in the abdomen usually frees up the large intestine. Some pathologists do this with a scalpel, while others use scissors.

The skull vault is opened using two saw cuts, one in front, and one in back. These will not show through the scalp when it is sewn back together. The top of the skull is removed, and the brain is very carefully cut free of its attachments from inside the skull.

When the breastbone and attached rib cartilages are removed, they are examined. Often they are fractured during cardiopulmonary resuscitation. Freeing up the intestine takes some time. The pathologist carefully cuts along the attachment using a scalpel.

The chest organs, including the heart and lungs, are inspected. Sometimes the pathologist takes blood from the heart to check for bacteria in the blood. For this, he or she uses a very large hypodermic needle and syringe. The team may also find something else that will need to be sent to the microbiology lab to search for infection. Sometimes the pathologist will send blood, urine, bile, or even the fluid of the eye for chemical study and to look for medicine, street drugs, alcohols, and/or poisons.

Then the pathologist must decide in what order to perform the rest of the autopsy. The choice will be based on a variety of considerations. One method is the method of Virchow, which is removing organs individually. After the intestines are mobilized, they are opened using special scissors. Inspecting the brain often reveals surprises. A good pathologist takes some time to do this. The pathologist examines the heart, and generally the first step following its removal is sectioning the coronary arteries that supply the heart with blood. There is often disease here, even in people who assumed their hearts were normal.

After any organ is removed, the pathologist will save a section in preservative solution. Of course, if something looks abnormal, the pathologist will probably save more. The rest of the organ goes into a biohazard bag , which is supported by a large plastic container.

The pathologist weighs the major solid organs (heart, lung, brain, kidney, liver, spleen, sometimes others) on a grocer's scale. The smaller organs (thyroid, adrenals) get weighed on a chemist's triple-beam balance. The next step in this abdominal dissection will be exploring the bile ducts and then freeing up the liver, usually using a scalpel. After weighing the heart, the pathologist completes the dissection. There are a variety of ways of doing this, and the choice will depend on the case. If the pathologist suspects a heart attack, a long knife may be the best choice.

The liver has been removed. In our example of a fictitious autopsy, the pathologist finds something important. It appears that this man had a fatty liver. It is too light, too orange, and a bit too big. It is possible that this man had been drinking alcohol heavily for a while. The liver in this case weighs much more than the normal 49.4 ounces (1400 gm).

The pathologist decides to remove the neck organs, large airways, and lungs in one piece. This requires careful dissection. The pathologist always examines the neck very carefully. The lungs are almost never completely normal at autopsy. These lungs are pink, because the dead man was a nonsmoker. The pathologist will inspect and feel them for areas of pneumonia and other abnormalities. The pathologist weighs both lungs together, then each one separately. Afterwards, the lungs may get inflated with fixative. Dissecting the lungs can be done in any of several ways. All methods reveal the surfaces of the large airways, and the great arteries of the lungs. Most pathologists use the long knife again while studying the lungs. The air spaces of the lungs will be evaluated based on their texture and appearance.

The liver is cut at intervals of about a centimeter, using a long knife. This enables the pathologist to examine its inner structure.

The rest of the team continues with the removal of the other organs. They have decided to take the urinary system as one piece, and the digestive system down to the small intestine as another single piece. This will require careful dissection. One pathologist holds the esophagus, stomach, pancreas, duodenum, and spleen. He will open these, and may save a portion of the gastric contents to check for poison. Another pathologist holds the kidneys, ureters, and bladder. Sometimes these organs will be left attached to the abdominal aorta. The pathologist will open all these organs and examine them carefully.

Before the autopsy is over, the brain is usually suspended in fixative for a week so that the later dissection will be clean, neat, and accurate. If no disease of the brain is suspected, the pathologist may cut it fresh.

The kidneys are weighed before they are dissected.

When the internal organs have been examined, the pathologist may return all but the portions they have saved to the body cavity. Or the organs may be cremated without being returned. The appropriate laws and the wishes of the family are obeyed.

The breastbone and ribs are usually replaced in the body. A pathologist prepares a large needle and thread used to sew up the body. The skull and trunk incisions are sewed shut ("baseball stitch"). The body is washed and is then ready to go to the funeral director.

The pathologists will submit the tissue they saved to the histology lab, to be made into microscopic slides. When the slides are ready, the pathologists will examine the sections, look at the results of any lab work, and draw their final conclusions.

The only finding in this imaginary autopsy was fatty liver. There are several ways in which heavy drinking, without any other disease, can kill a person. The pathologists will rule each of these in or out, and will probably be able to give a single answer to the police or family.

A final report is ready in a month or so. The glass slides and a few bits of tissue are kept forever, so that other pathologists can review the work.

see also Anatomical nomenclature; Body Farm; Coroner; Death, cause of; Death, mechanism of; Decomposition; Identification; Medical examiner; Pathology; Pathology careers; Rigor mortis; Time of death; Toxicological analysis.