Procedures and Standards

Short Historical Overview Anatomical dissection

The prerequisite for the whole idea of an autopsy or necropsy was the knowledge of human anatomy, and the history of autopsy shows three, partly overlapping, paths of development. The first of them lasted almost 2000 years, from the first known school of anatomy in Alexandria around 320 BC, where human dissections were carried out, until the publication of the great text topic of anatomy De Humani Corporis Fabrica in 1543. Written by Andreas Vesalius (15141564), the ‘father of anatomy’, this marked the overthrow of traditional galenic anatomy. The possibility of dissecting human bodies varied greatly at times. In Vienna the first anatomical dissection took place in 1404, and in Prague somewhat later in 1460. Felix Platter I, the famous anatomist in Basle, was said to have performed more than 300 autopsies since 1559.

Medicolegal autopsy

The medicolegal investigation of deaths was introduced relatively early as a result of the requirements of the judicial system. According to Singer, the earliest of medicolegal dissections took place at the University of Bologna, Italy between 1266 and 1275. In France, Ambroise Pare; performed the first medicole-gal autopsy in 1562.
Our knowledge of old autopsy procedures is rather scanty. With few exceptions, detailed written autopsy records are relatively recent. Such exceptions are the reports of the autopsy of Emperor Maximilian II (1576) and of Markgrave Jakob III of Baden (1590).
The principles of modern medicolegal investigation were based on the codes of sixteenth century Europe:
The Bamberg code (Constitutio Bambergensis)in 1507, the Caroline Code (Constitutio Criminalis Carolina) in 1532 and later the Theresian Code (Constitutio Criminalis Theresiana) in 1769.
The Austrian decree of 1855 contains very detailed instructions, in 134 paragraphs, as to the performance of medicolegal autopsy, and is still legally valid today in Austria. Similar, although not as detailed, is the Prussian edict of 1875. Both of these instructions can be considered as the culminating point of legislation dealing with the performance of medicolegal autopsy.

Clinical autopsy

The clinical autopsy, as we understand it today, took much longer to develop and first became meaningful after the introduction of modern concepts of patho-genesis of disease, by Carl von Rokitansky (18041878), and cellular pathology, by Rudolf Virchow (1821-1902).
At the beginning of the nineteenth century increased attention was paid to the actual autopsy technique. Prost, a French physician, insisted in 1802 that all organs of the body should be examined, and declared that 3 hours was the minimum time for a postmortem examination. In 1846 Rudolf Virchow, then prosector in Berlin, insisted on regularity and method and definitive technique. The classical techniques, which are still in use today, are more or less modifications of those introduced by Rokitansky, Virchow, Ghon and Letulle, among others.
In 1872 Francis Delafield’s A Handbook of Postmortem Examination and Morbid Anatomy was published in New York, and German and English editions of Rudolf Virchow’s topic on autopsy technique were published in 1876.

Present Use of the Autopsy

Medicolegal autopsy

Further development of medicolegal autopsy has been characterized and greatly influenced by the judicial system adopted in any given country, the main emphasis being in the detection and investigation of criminal and other unnatural or unexpected deaths. Due to different legislation and practices, there exists great variation in medicolegal autopsy rates between the countries. In addition to national measures to create guidelines and to harmonize medicolegal autopsy, there has been increasing international interest in achieving harmonized and internationally recognized rules on the way autopsies should be carried out. This has become imperative, especially from the point of view of human rights. The mass killings in Cambodia, Rwanda, Bosnia and Kosovo should have made it quite clear, even to the general public, what implications a medicolegal investigation, or the lack of it, may have upon human rights.
In May 1989 the UN Economic and Social Council adopted, in its resolution 1989/65, the Principles on the Effective Prevention and Investigation of Extra-Legal, Arbitrary and Summary Executions, that had been created by cooperation with intergovernmental and nongovernmental organizations, especially the Minnesota Lawyers International Human Rights Committee. In 1991 the General Assembly of the United Nations endorsed the Model Autopsy Protocol of the United Nations.
The European Council of Legal Medicine (ECML) is an official body that sits in Cologne and deals with scientific, educational and professional matters at a European level. It has delegates nominated by the national medicolegal associations from all European Union and European Economic Space (EES) member countries. Since the early 1990s the ECLM has also been active in this field and its document Harmonisation of the Performance of the Medico-Legal Autopsy was adopted by the General Assembly in London in 1995.
The Council of Europe is an intergovernmental organization whose aims among others are to protect human rights and pluralist democracy. It should not be confused with the European Union. The two organizations are quite distinct; however, all the 15 European Union States are also members of the Council of Europe, which currently has a total of 41 member states. In its 43rd Ordinary Session, the Parliamentary Assembly of the Council of Europe adopted a Recommendation 1159 (1991) for the harmonization of autopsy rules. Following this recommendation, a working party of international experts in legal medicine and law, with representation from Interpol and the International Academy of Legal Medicine, was established in 1996 under the Committee of Bioethics to make a proposal for the Autopsy Rules. One of the guidelines used in the work was the Autopsy Rule produced earlier by the
ECLM. The working party finished its work in November 1998 and this new paneuropean recommendation No. R (99) 3 on the harmonization of medicolegal autopsy rules and its explanatory memorandum was adopted by the Committee of Ministers on 2 February 1999 at the 658th meeting of the Ministers’ Deputies. Although the document is a ‘recommendation’ by nature, and hence strictly speaking not legally binding, it has legal implications because all 41 Council of Europe member countries have agreed to incorporate these principles in their national legislation.

Clinical autopsy

Despite the advent of more sophisticated investigative and imaging techniques, the clinical autopsy has been shown to have maintained its value and remained an essential factor in the quality assurance of medical care. Regardless of this, there has been a progressive decline in autopsy rates throughout the world. The mandatory 20% autopsy rate required for accreditation of postgraduate training in the United States was withdrawn in 1971, on the grounds that each institution should set its own rate but that it should ideally be close to 100%.
According to World Health Organization (WHO) statistics published in 1998, total autopsy rates varied in Europe in 1996 between 6% (Malta) and 49% (Hungary) and, in other parts of the world reported to the WHO, between 4% (Japan) and 21% (Australia) (Table 1).
The reasons for this decline are many and complex: overreliance on the new diagnostic techniques, low appreciation of autopsy work, poorly performed autopsies by inexperienced trainees without proper supervision, long delays in the production of autopsy reports, economic factors, fear of malpractice litigation, etc., to name just a few.
The standardization and harmonization of clinical autopsy has taken place primarily at national level. The quality of health care and quality assurance and audit have become increasingly important and have been extended from laboratory medicine to encompass autopsies.

Objectives of Autopsy

An autopsy is a detailed systematic external and internal examination of a corpse, carried out by a pathologist or one or more medicolegal experts, to ascertain the underlying and possible contributing causes of death and, depending on the jurisdiction, also the manner of death. Before the pathologist can begin the examination he or she must be sure that the autopsy has been authorized. An assessment of possible risks that may be involved with the autopsy must be considered, and necessary health and safety precautions taken. The autopsy and all related measures must be carried out in a manner consistent with medical ethics and respecting the dignity of the deceased.

Table 1 Reported information on autopsy rates 1996

An autopsy is performed to achieve one or more of the following objectives:
• To identify the body or record characteristics that may assist in identifying the deceased.
• To determine the cause of death or, in the newborn, whether live birth occurred.
• To determine the mode of dying and time of death, where necessary and possible.
• To demonstrate all external and internal abnormalities, malformations and diseases.
• To detect, describe and record any external and internal injuries.
• To obtain samples for any ancillary investigations.
• To obtain photographs or retain samples for evidential or teaching use.
• To provide a full written report and expert interpretation of the findings.
• To restore the body to the best possible cosmetic condition before the release.
In addition to the anatomical dissection, there are basically two main types of autopsy:
• The clinical autopsy is carried out to investigate the extent of a known disease and the effectiveness of treatment, and it is sometimes also performed for medical audit or research purposes. Almost invariably the consent of relatives is needed unless the deceased has given consent ante mortem.
• The medicolegal or forensic autopsy, which is ordered by the competent legal authority (a coroner, medical examiner, procurator fiscal, magistrate, judge or the police) to investigate sudden, unexpected, suspicious, unnatural or criminal deaths. Unidentified bodies or deaths occurring in special circumstances, such as deaths in police custody or during imprisonment, are also often subjected to a medicolegal autopsy. In most jurisdictions permission of the relatives is not required.

Autopsy Techniques

Both clinical and medicolegal autopsy may involve different strategies and techniques, depending on the questions they are expected to answer. Autopsy technique in adults is generally somewhat different from pediatric autopsies.
The scope of medicolegal autopsy is much often broader than that of clinical autopsy and may also include the investigation of the scene of death. All background information on the circumstances of death are of paramount importance in choosing the right approach. In medicolegal autopsy the examination of the clothing is often an essential part of the external examination, whereas in clinical autopsy it is generally not. Both types of autopsy should consist of full external and internal examination of the body, including the dissection and investigation of all three body cavities.

External examination

External description of the body includes the age, sex, build, height, ethnic group and weight, nutritional state, skin color and other characteristics of the deceased, such as scars or tattoos; description of postmortem changes, including all essential details relating to rigor mortis, hypostasis and decomposition; careful investigation and description of all body surfaces and orifices including color, length, density and distribution of hair, color of irises and sclerae, presence or absence of petechiae or any other abnormalities or injuries. The examination should be carried out systematically and include head, neck, trunk, upper and lower extremities and the back.

Internal examination

Examination of the body cavities includes the description of the presence of gas (pneumothorax), fluids (effusions or exudates) or foreign bodies and the measurement of their volume, appearance of the internal surfaces and anatomical boundaries as well as location and external appearance of organs.
The classical autopsy techniques vary mainly in the order in which the organs are removed:
• The organs may be removed one by one (Virchow technique).
• Cervical, thoracic, abdominal and pelvic organs can each be removed as separate blocks (Ghon technique).
• They may be removed as one single block, which is then subsequently dissected into organ blocks (Letulle technique).
• All organs are dissected in situ (Rokitansky technique)
All organs have to be dissected, the outer appearance as well as the cut surfaces described and the weight of major organs recorded. The hollow organs have to be opened and their content described and measured. All relevant vessels, arteries and veins as well as ducts have to be dissected. All abnormalities must be described by location and size.

Sampling

Histological examination of the main organs should be performed in all autopsies. The need for further ancillary investigation may depend on whether the cause of death has been established with the necessary degree of certainty, and, if not, additional samples have to be taken for toxicological or other investigations. For toxicology this may include peripheral blood, vitreous humor, cerebrospinal fluid, bile, hair samples or other relevant tissues. When retaining tissues one has to take into consideration possible restrictions, depending on national legislation.

Special procedures

Sometimes special procedures and modifications of normal dissection techniques are necessary. Chest X-ray has to be performed before the autopsy if there is suspicion of air embolism. Where neck trauma is suspected, the brain and the organs of the chest cavity have to be removed before the dissection of the neck to drain the blood from the area to avoid artifactual bleeding. Postoperative autopsies may present various problems with medicolegal implications, such as complications of anesthesia, surgical intervention or postoperative care. Detailed description of these special dissection procedures and techniques is beyond the scope of this presentation.

Autopsy Report

The report is an essential part of the autopsy. It should be full, detailed and comprehensive. Medico-legal autopsy reports, in particular, should also be comprehensible to the nonmedical reader. In addition to the factual, positive and negative gross, microscopical and analytical findings, the pathologist should conclude with a discussion of the significance of the findings. Where the findings are of uncertain nature and there are several competing causes, the pathologist should try to give an opinion as to their probability.