Autopsy

AUTOPSY

the cause of death.* It is customary to distinguish between pathological-anatomical autopsies and forensic-medical autopsies. The former are performed on the corpses of persons who died from various diseases in hospital institutions; the performance of such pathological-anatomical autopsies should be a rule for these institutions and, if possible, concern all persons who died in them. Pathological-anatomical autopsies can also include the autopsy of laboratory animals (see). Forensic-medical autopsies are performed by order of judicial authorities on the corpses of persons whose cause of death can be assumed to be related to any violent or criminal acts. Historical data. The first autopsies of corpses date back to the last centuries B.C.; it is known that in Egypt, by order of King Ptolemy, the corpses of criminals began to be handed over to physicians for scientific research. The first anatomical studies of Herophilus date back to this time. However, in the subsequent period, in connection with the development of religious prejudices, the autopsy of corpses ceased; only a few (e.g., Galen, 2nd century A.D.) occasionally dissected animal corpses. In the early Middle Ages, autopsies were viewed as a sacrilegious act, and persons suspected of performing them were subjected to the harshest repressions. During this period, it was only very rarely that anyone managed to perform an autopsy and publish its results (Mundinus in the 13th–14th centuries). After a special 'encyclical' (circular) of Pope Pius IV (16th century), which not only permitted but also recommended autopsies to clarify the causes of death, autopsies gradually began to enter the practice of physicians as a scientific method (Vesalius, 1514–64) and to be practiced for the purposes of anatomy, pathology, and forensic medicine. It should be noted that even in the first half of the 19th century, autopsies were performed very infrequently, and the departments of anatomy existing at that time suffered greatly from a lack of corpses. Usually, almost exclusively the corpses of persons who had no relatives were subjected to autopsy. Subsequently, the number of corpses autopsied in hospital institutions began to increase, and at the beginning of the second half of the 19th century, Virchow was already autopsying 40–45% of all those who died in the Berlin Charité hospital. This figure is slowly increasing, and at the present time, for many medical institutions in Germany, it is equal to 75–80%. In France and England, and especially in America, due to the fact that less importance is attached to pathological anatomy there and in many hospitals there are not even prosectors, this figure is lower (about 65%); in Switzerland, it is equal to 100% due to the fact that about 25 years ago a law was passed there on the mandatory autopsy of persons who died in hospital institutions. In Russia, before the revolution, due to the existing rule that autopsies are performed no earlier than 24 hours after death, and due to the lack of culture of the population, the number of corpses autopsied in hospitals did not exceed 60–65%; the only exceptions were the clinics of Moscow University, in which a rule (existing at the present time) on the mandatory autopsy of all those who died in them had long been established. After the revolution, it can be definitely noted that in the large centers of the USSR, the percentage of corpses autopsied in hospitals has become significantly higher than before. In Moscow, in recent years, it has reached, on average, 85%, and in some Moscow hospitals (e.g., the S. P. Botkin Hospital) — up to 91–92%. All this provides for Moscow about 8,000–9,000 autopsies annually; in other words, about 1/3 of all those who died in Moscow are autopsied. The rules by which the hospital administration and the prosector are guided in the matter of autopsies are not the same in different republics of the USSR. In Moscow, at the present time, the following 'Instruction on the section of corpses in medical institutions of the Moscow Department of Health' dated September 12, 1924 ('Weekly of the Moscow Health Department', 1924), supplemented on January 28, 1925, is applied: '1. In connection with the reorganization of medical affairs in the hospitals of the Moscow Department of Health and its direction towards prevention, a particularly deepened setup of clinical and anatomical research is required, and therefore, if possible, all corpses of those who died in communal medical institutions are subjected to section. Note: To ensure teaching at medical faculties, it is desirable not to subject the corpses of the destitute to section. - 2. An autopsy is performed with the permission of the chief physician of the hospital or medical institution. When authorizing an autopsy, the chief physician of the hospital or medical institution is guided by: a) the requirements of scientific control of hospital affairs; b) the interests of studying occupational diseases and rarely encountered or complex forms of diseases; c) the need to determine initial cases of epidemic diseases. - 3. The autopsy of the body of a person who died in a hospital or medical institution may be canceled upon the petition of relatives no further than the second degree; a statement about this must be made to the chief physician or his deputy. - 4. The autopsy of the body of a deceased person is not subject to cancellation: a) in case of the need to determine initial cases of an epidemic disease; b) for special scientific reasons for a detailed and accurate study of the disease process, according to paragraphs 1 and 2 of the instruction. An autopsy is mandatory and not subject to cancellation in all cases when death occurred after a short stay of the patient, i.e., before the expiration of 24 hours from the moment of the patient's admission to the medical institution (1267-28/1-25). Note: the cancellation of an autopsy in forensic-medical cases depends on the judicial authority. - 5. A pathological-anatomical autopsy of the body cannot be performed earlier than 2 hours from the time of death. Note: for scientific and scientific-practical purposes, it is permissible for clinical and hospital institutions to perform autopsies on corpses before the expiration of 2 hours, but not earlier than half an hour after death, with the prosector specifying in the protocol the reason for the necessity of an early autopsy. - 6. In the presence of bodily injuries, signs of violence, or phenomena depending on other criminal actions in the deceased, the appropriate administrative authority must be notified, and the autopsy is suspended for the transfer of this case to forensic-medical authorities.' - Subsequently, the instruction pursues the goals of distinguishing between the performance of autopsies by pathologists and forensic-medical experts (paragraph 6). The question of injuries and poisonings observed in the order of practical medical activity is of great importance, especially in connection with the widespread use of surgical methods of treatment, complex instrumental examinations, X-rays, intravenous infusions of various medicinal substances, etc. In all cases of death associated with such interventions (for example, anesthesia, encephalography, injection of salvarsan, etc.), if they were performed in a normal clinical or hospital setting and do not bear traces of clearly negligent or criminal actions, the autopsy is performed in the general order, i.e., pathologically-anatomically. It is especially important to emphasize the necessity of observing paragraph 6 of the instruction in relation to abortions: all cases of death after abortions performed outside the walls of institutions authorized for these operations are unconditionally subject to forensic-medical autopsy. In individual cases, when the decision on the direction of the corpse to one or another instance cannot be given with certainty, joint participation in the autopsy by both a pathologist and a forensic-medical expert is necessary; the autopsy itself is conducted with careful observance of the relevant rules guaranteeing the socio-legal side of the matter. Pathological-anatomical autopsies of corpses in non-clinical institutions are always performed by written order of the chief physician or director of the institution. The significance of an autopsy is very great and diverse. First of all, one can emphasize the already mentioned role of autopsy in the development of correct materialistic views on the structure of the human body, its functions, and the essence of disease processes. Autopsies are, in addition, the main base for developing the problems of so-called thanatology, or the study of death. Furthermore, autopsies play a very large role in teaching. Autopsies also have great sanitary-epidemiological significance, since often, thanks to autopsies, the appearance of certain infectious diseases, which could be the beginning of an epidemic, is established. In hospital institutions, through autopsies, control over the activity of their departments is carried out in the sense of the correctness of diagnosing and treating diseases. The enormous significance of autopsies in this regard is revealed by comparative-statistical data obtained by comparing clinical (resp. hospital) and anatomical diagnoses. Firstly, only as a great exception is a case observed where an autopsy would not introduce something new to the antemortem diagnosis of a disease, and in 16–25% of all autopsies (depending on the qualifications of the institutions, the workload of the staff, etc.), there is even a complete discrepancy of diagnoses concerning the underlying disease; in an even greater percentage of cases, there are unrecognized or incorrectly recognized concomitant ailments. - The significance of forensic-medical autopsies lies in the fact that they detail the cause of death of the subject, and also establish or reject the role of certain violent influences in the fatal outcome; these data have a very important, often decisive significance in judicial terms. Pathological-anatomical autopsy. The methodology of autopsy has developed and improved gradually; only at the beginning of the second half of the 19th century R.

Virchow was the first to indicate a definite and most rational order for the autopsy of a corpse. This Virchow method is to this day the most widespread and serves as the basis for all other methods (Heller-Zenker, Chiari, Letulle), which differ from it only in details. Pathological-anatomical autopsies are performed in specially adapted institutions existing at hospitals and clinics. In medical faculties, such an institution is the pathological-anatomical institute, to which the corpses of those who died in university clinics are sent. In hospitals (see), autopsies are usually performed in special premises—anatomical theaters or prosectoriums, serviced by special physicians-pathologists, called prosectors (see), and assistants to the prosectors. Forensic medical autopsies in cities that have medical faculties and medical institutes are performed for the most part at the departments of forensic medicine by a professor and the instructors of this subject; in other cities, by special forensic medical experts in so-called morgues (see). In medical districts remote from cities, autopsies, both pathological-anatomical and sometimes forensic medical, have to be performed by district physicians. In pathological-anatomical institutes, prosectoriums, and morgues, there are special dissection halls or rooms with dissection tables for autopsies. In the absence of a specially adapted room, autopsies are performed on a simple table, on some boards, etc. Special dissection instruments are used for autopsies. The person performing the autopsy puts on a gown and an oilcloth apron over their clothes, and protects their hands with rubber gloves; in the absence of gloves, the hands are greased with fat, for example, a mixture of petroleum jelly and lanolin. An autopsy must be performed in daylight, since with artificial lighting it is difficult to make correct conclusions about changes in the color of the skin and organs of the corpse. The corpse for the autopsy is placed on its back, with the head facing the window; a block (or log) is placed under the corpse; a vessel with water is placed at the feet of the corpse. The person performing the autopsy remains at the side of the table, at the right side of the corpse, throughout the entire autopsy, and only when opening the skull and extracting the brain does he stand at the head of the corpse. For a pathological-anatomical autopsy of a corpse, the general order is as follows. The autopsy itself is preceded by familiarizing the prosector and those present with the clinical course of the disease and the antemortem diagnosis by reading the medical history or by an oral report from the physician who observed the course of the disease. After this, the prosector performs an external examination of the corpse, noting data on sex, age, body dimensions, physique, constitutional appearance, nutrition, condition of the skin (color, postmortem lividity, rashes, hemorrhages, wounds, ulcers, scars, bedsores, swelling and edema of the skin, etc.), rigor mortis, and cadaveric odor. The external examination is followed by an incision and separation of the skin and the opening of the body cavities; for this, a main incision of the skin is made, most often running from the chin to the pubis; some use incisions of a different type; following the incision, the skin is separated to the sides from the midline, which opens the abdominal cavity and exposes the thoracic cage. The latter is opened by cutting the cartilaginous parts of the ribs near the place of their transition into the bony parts. After opening the cavities, a detailed examination of them is performed, clarifying the peculiarities in the position and relationship of the organs, the presence of accumulations, adhesions, etc., and then the extraction of organs from the corpse begins. The order of extracting organs from the corpse and examining them can be different depending on the peculiarities of the case; in general, for each autopsy, it is customary to individualize the course of the autopsy and, based on the data of the medical history and the results of the examination of the organs in situ, to make a departure from the main method. As for the main method of extracting and examining organs, it is different in various pathological-anatomical institutions, in connection with tradition, the peculiarities of the school, or the personal habit of the director, representing certain deviations from the Virchow scheme. In some pathological institutes, various organs are extracted one by one, cutting them off from their connection with others; in others, it is preferred to extract complexes of organs; some pathologists consider it rational to perform incisions of organs in situ, i.e., before their extraction; in the Moscow school, proceeding from the desire to not separate organs and parts of anatomical-physiological systems as much as possible, the organs of the neck and thoracic cavity are usually extracted as a general mass, then the intestine separately, the liver, stomach, and duodenum together, the kidneys, urinary tract, and genital organs together; in Leningrad, those performing autopsies for the most part use the method of complete evisceration, developed by Shor, which consists in the fact that the organs of the neck, thoracic cavity, abdominal cavity, and small pelvis are extracted as one continuous complex, and furthermore, the organs are not separated from each other, but are examined in their mutual connection. The organs extracted from the corpse by one method or another are studied in terms of their size, weight, shape, surface condition, color, and consistency, after which incisions of the organ are made and the surface of the incision and the condition of the cavities are examined, if it concerns a hollow organ. To open the skull and examine the brain, an incision of the scalp is made from one ear to the other across the crown, the scalp is separated from the incision forward and backward, and a circular sawing of the skull and removal of the skull cap are performed; after separating the dura mater, the brain is removed. The spinal cord is extracted after an incision of the skin along the line of the spinous processes and the opening of the vertebral canal by sawing through the posterior arches of the vertebrae. The opening of the skull and vertebral canal may precede the opening of the body cavities or follow it, depending on the peculiarities of the case. The limbs are opened last, if there is data for this; in the limbs, the condition of the muscles, bones and bone marrow, joints, vessels, and nerves is examined. During the autopsy of newborns, a longitudinal sawing of the lower epiphysis of the femur is mandatory; with the help of this sawing, the condition of the lines of enchondral ossification (the border between the epiphysis and diaphysis) is clarified, which is important in relation to congenital syphilis, and the presence and size of the epiphyseal ossification center (see Beclard's ossification center) are also established. Upon completion of the autopsy, the person who performed it briefly summarizes the detected changes and reports the anatomical diagnosis. After this, he makes a comparison of the detected findings with the antemortem manifestations of the disease and explains, from the point of view of the detected data, everything concerning the development and manifestation of the main disease, its complications, and the causes of death. The examination of the autopsied corpse does not end there, since material is taken from its organs and tissues for microscopic study; in addition, it is often necessary to perform a bacteriological examination of the corpse (see below), and sometimes serological reactions with its blood. The final act of the autopsy is the cleaning of the corpse, consisting of placing the organs back into the cavities, suturing the incisions, washing the corpse, and dressing it. Due to the fact that no incisions are made on the exposed parts of the body during an autopsy, there are no visible signs of the performed autopsy on the dressed corpse. One should not perform partial autopsies, for example, only of the abdominal cavity or the cranial cavity, etc., as this can yield completely incorrect results. It is most correct to record the autopsy protocol during the autopsy under the dictation of the person performing it. In the absence of appropriate personnel, as well as if it is necessary to explain the detected changes in detail during the autopsy, the protocol can be written after the autopsy from memory. Each autopsy protocol consists of a descriptive part, representing a strictly objective and accurate description of the observed pictures, and a concluding part, or anatomical diagnosis, which represents the definition of the essence of the detected changes by means of brief pathological-anatomical terms. Sometimes the prosector, in addition, adds an explanatory conclusion to such a protocol, highlighting the essence of the main disease and its complications, the role of the changes that preceded the given disease, etc.; considerations about the cause of death can also be given here. One should not limit oneself to just an anatomical diagnosis when recording an autopsy, as this lacks the extremely important description of the altered organs and does not record information about the condition of those organs that did not present definite changes to the naked eye. At the end of the protocol, space is left for recording the results of the microscopic (and bacteriological) examination. Shor recommends dividing the pathological-anatomical diagnosis into four categories: 1) constitutional anomalies, 2) distant diseases and conditions, 3) recent diseases and conditions, 4) immediate diseases and conditions. Such a diagnosis is followed by a "thanatological conclusion," containing considerations about constitutional anomalies, signs of conditional and unconditional disability, wear and tear of organs and systems, the presence of nutritional disorders and poisoning, and data on the nature of death (gradual fading of life, accelerated death, sudden death); such a thanatological conclusion ends with an indication of the "dynamics of death." Copies of autopsy protocols are issued only at the request of the militia and judicial authorities.