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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 really 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. In doing around 800+ autopsies, I have
always found something worth knowing that
wasn't known during life. Even at major
hospitals, in about one case in four we find
major disease which was unknown in life.
Giving families
the explanations they want
is one of the most satisfying
things that I do.
A pathologist is a physician with a specialty
in the scientific study of body parts. This
always includes a year or more learning to do
autopsies.
Under the laws of most states, autopsy can be
ordered by the government. A 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, autopsy
can be ordered when there is some public health
concern, i.e., 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.
When a loved one dies, a family can ask the
hospital to perform an autopsy. The hospital
pathologists are supposed to be independent,
and often there's no affection between them and
the clinicians who treated the patient. This
service is generally free. 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.
If autopsy is not required by law, the
legal next-of-kin
must sign an autopsy permit.
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
Muslim
prefer not to
autopsy. If you have a question, check with
your own religious advisor.
No hospital where I have practiced has ever charged for an autopsy
on a patient who was treated there.
I have been aware of a couple of cases in which a hospital,
already concerned about possible liability, discouraged families
from requesting an autopsy by telling them there was a fee.
(Most recently, a visitor told me that
a Louisiana hospital listed a charge of $2000 plus transportation.)
The idea of a hospital charging a family for an autopsy
is opposed to my training, and in any case the charge should should be modest.
Please remember that some small hospitals lack autopsy facilities,
so a mortuary may need to be rented, and a special technician paid
perhaps $200 for the day's work. Some pathologists are paid by the case,
and the hospital might pass the pathologist's reimbursement along to the family,
though this seems wrong to me.
At a large hospital with full-time salaried pathologists and
technicians, I am surprised to hear of anyone being charged.
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 help 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. 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 sewed back up, it will be concealed by the
pillow on which the dead person's head rests.
The
pathologist uses a scalpel for these incisions. There is
almost no bleeding, since a dead body has no blood pressure
except that produced by gravity.
The incisions are carried down to the skull, the rib cage and
breastbone, and the cavity which contains the organs of the
abdomen. The scalp and the soft tissues in front of the chest
are then reflected back.
Again, the pathologist looks around for any abnormalities.
Here, one pathologist is preparing to open the skull,
using a special vibrating saw that cuts bone but not
soft tissue. This is an important safety feature.
Another pathologist is cutting 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 folks.
The third pathologist is exploring the abdominal cavity.
The first dissection in the abdomen is usually freeing
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 sewed back together.
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 in this picture is cutting along the
attachment using a scalpel.
The top of the skull is removed, and the brain is
very carefully cut free of its attachments from inside
the skull.
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 uses
a very large hypodermic needle and syringe.
He 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. This team
will use the method of Virchow, 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 believed 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. Again, this pathologist has decided to
use 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. The pathologist
has found something important. It appears that
this man had a fatty liver. It is too light, too
orange, and a bit too big. Perhaps this
man had been
drinking heavily for a while.
The pathologist has decided 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 liver in this case
weighs much more than the normal 1400 gm.
The lungs are almost never normal at autopsy.
These lungs are pink, because the dead man was
a non-smoker. The pathologist will inspect
and feel them for areas of pneumonia and
other abnormalities.
The liver is cut at intervals of about a centimeter,
using a long knife. This enables the pathologist
to examine its inner structure.
The pathologist weighs both lungs together, then each
one separately. Afterwards, the lungs may get inflated
with fixative.
The rest of the team is continuing 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 is holding 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 is holding 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.
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.
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.
It is the pathologist's decision as to whether to open the small
intestine and/or colon. If they appear normal on the outside,
there is seldom significant pathology on the inside. I usually open them.
The last pathologist is preparing
the big needle and thread used to
sew up the body.
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. The skull and trunk
incisions are sewed shut ("baseball stitch").
The body is washed and is then ready to go
to the funeral director.
These pictures do not show all the steps of an autopsy,
but will give you the general idea. Exercising
my artistic license, I have omitted
the pathologists' gloves and other safety
equipment. And of course, in real life, there may be photographers,
evidence technicians, police, hospital personnel, and others.
These pathologists will submit the tissue
they saved to the
histology lab tomorrow, to be made into microscopic
slides. When these are ready, they 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.
You might enjoy the animated version
of this little cartoon essay. Use the "return" button
of your browser to come back here.
If you like
my work, help yourself. If you share, it must always be given
freely, and
if you use it for some good purpose, please
mention that "Ed, the pathology guy", made it.
If you place it on your own website, please place a link
to one of my pages (your choice).
If I can do anything for you, E-mail me at
scalpel_blade@yahoo.com.
If you are in Missouri or Kansas, and want to talk about an autopsy, phone
816-283-2208 anytime.
I prefer to work with my longtime friends Tammy and Cameron Schenk
at Midwest Autopsy.
You can phone 816-941-3200 (Mon-Fri 7am-7pm) or page the technician
at 816-868-4127.
I'm glad to help those who can afford
my standard fee, and those who cannot. I can usually
be with you within a few hours at the most.
I'm also available to review the work of other
pathologists, especially for attorneys. I have a policy
of not taking money from the pockets of innocent people.
To include this page in a bibliography, you may use this format:
Friedlander ER (1999) Autopsy Retrieved Dec. 25, 2003 from http://www.pathguy.com/autopsy.htm
For Modern Language Association sticklers, the name of the site itself
is "The Pathology Guy" and the Sponsoring Institution or Organization
is Ed Friedlander MD.
Site includes history of forensic autopsies
The best photos are Scott Wagner's "Color Atlas of the Autopsy" (December 2003).
You can purchase this online for about $200.
How Much Do Organs Weigh?
AAMC -- so you want to be a pathologist?
Jack the Ripper
By Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com
Victorian Institute
Andrea
Campbell on Forensic Science
JonBenet's autopsy
Ronald Goldman's
Autopsy
Virtual Autopsy. This is
just now coming into its own, thanks to innovations in radiology.
It is unlikely to replace the classic pathology autopsy, but is certain
to be a useful adjunct and sometimes a suitable substitute.
Especially, 3D reconstructions in cases of trauma are helpful for
demonstration. See Radiology 240: 522, 2006.
Autopsy Videos --
"Through the Eyes of Death's Detectives"
College of American Pathologists -- Would you like to be a pathologist?
Ed Uthman MD -- tips for screenwriters
Ed Uthman MD -- autopsy tools
American Society of Clinical Pathologists -- Would you like to be a pathologist?
PathMax -- Shawn E. Cowper MD's
pathology education links
Autopsy Diagrams -- AFIP
Mount Sinai Morgue -- controversial paintings
commissioned by the chief pathologist; site by the artist, who is one of my cyberfriends
Pushin' Daisies
-- novelty site
BlueLips -- novelty site offering autopsy videos
Tadaaki Hiruki -- nice discussion, fan site
Postmortem Studio Rentals -- the people
who do the props for the autopsy scenes in the movies.
B J Winslow -- cyberfriend who makes props
for autopsy scenes
Schools Where You Can Study Forensics
Anna Nicole Smith -- autopsy report.
If you want to know what an autopsy report looks like, click here. Or click here.
Autopsy photo -- ruptured carcinoma of the ascending
colon
Autopsy photo -- breast cancer encasing the lung
Ed's Home Page
Estimating the Time of Death
Need my help?
Ed's Students
Ed's
Franciscan Notes
Ed's
Fraternity Lambda Chi Alpha
Morgagni's Autopsy Series 1761
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