1.2. Autopsy
1.2.1. History and definition of terms
The term autopsy also referred to as “post-mortem examination”, “necropsy”, “obduction” and “autopsia cadaverum” originates from the Latin language and denotes to “open, cut/dissect”. Another origin is from two Greek terms “aut” (self) and “opsie” (to see, to conduct a personal inspection) – autopsy therefore, refers to the opening/dissection of a cadaver to see for oneself, through observation, the cause of death or the nature of disease contrary to hearsay. Autopsy practice has been in existence since over 3000 years ago. It however became standardized during the Renaissance period in Europe (1,2) when the link between clinical syndromes and postmortem findings was established by Herman Boerhaave (3).
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The autopsy rates are currently on the decline compared to the 19th and 20th centuries when autopsy practice was at its peak. This can be observed from the current rates of less than 5% of all deaths (4).
A survey by Brinkmann et al. showed that only 46,000 autopsies – 5.3% of all deaths in Germany were autopsied in 1999, making the autopsy rates in Germany lower compared to other European countries such as Great Britain (17.3% in 1999), Sweden (22% in 1992), Finland (31.1% in 1992) and Denmark (16% in 1992) (5). The survey also revealed that between 1994 and 1999, the frequency of clinico-pathological autopsies in Germany decreased from about 4% to 3% of all deaths while the frequency of medico-legal autopsies stood at 2% with marked differences between the different German states. The state of Hamburg particularly, recorded 20,000 deaths between 1994 and 1999, and among these, the autopsy frequency for clinical-pathological autopsies was 12.3% and 6.0% in 1994 and 1999 respectively indicating a 51,3% decrease in the frequency, whereas the rates for medico-legal autopsies were 1.5% and 1.5% in 1994 and 1999 respectively (5). The decline in the autopsy rates has in the past been attributed to lack of clarity about the legal position regarding clinical or scientific autopsies (6). The state of Hamburg introduced a new law in 2000 regulating clinical/scientific autopsies, and currently, three categories of autopsies are differentiated (7) :
• Clinical autopsy
• Anatomical autopsy
• Medico-legal autopsy
Other types such as private autopsies can also be performed in cases where there is particular interest – this can be from the family of the deceased who wish to have the cause of death determined or control of infections by the health authorities, etc.
Anatomical autopsy
Refers to the dissection of a body or body parts in anatomy institutes with an aim of teaching and research purposes concerning the build of the human body. The autopsy should be done under the watch of a qualified physician or the administration of the training institution where the training, teaching or research is being conducted. Importantly, the deceased person should have, before his/her death, consented to the dissection, and in addition, a complete external examination should have been conducted and a natural death confirmed. It should be noted however that, an anatomical autopsy is not meant to establish the cause of death.
Clinical/scientific autopsy
This kind of autopsy serves to establish the cause of death, quality control of the existing diagnostic and therapeutic interventions as well as supporting the medical practice through teaching, research and epidemiology aimed at better care for the survivors. Prior consent from the deceased should have been obtained before death or in other cases; consent can be got from the mandated caretakers of the deceased before such an autopsy can be conducted. It is worth noting that a total of 36646 and 27147 clinical-scientific autopsies were done in Germany in 1994 and 1999 respectively (5)
Medico-legal autopsy
A medico-legal autopsy is done at the request of the local state prosecutor’s office in death cases in which foul play or involvement of another party in the death of an individual is suspected. In all cases in which the cause of death cannot be determined, a medico-legal autopsy is done. In a nutshell, a medico-legal autopsy serves to help explain a legal question surrounding the death in question e.g. is the manner of death natural, unnatural or unascertained? Was someone else involved? What were the circumstances leading to death? Therefore, in addition to the results and findings of the autopsy, other findings such as those from the crime scene also play a big role in helping to determine what might have caused the death.
The medico-legal autopsy report should be as detailed as possible so as not to miss even the slightest of findings, which may later play a big role in determining the case. It is for this reason that standardized autopsy procedures as well as autopsy protocols have been devised.
The procedures for a medico-legal autopsy according to national and international guidelines should always include:
• External examination: This part involves the complete and systematic examination of the body. It should clearly detail features on the body such as clothing, age, height, skin color, body build and special characteristics such as tattoos and scars. It should also describe the post-mortem changes like rigor mortis and post mortem lividity, putrefaction or other environmentally-induced changes. Visible injuries on the body should be detailed, clearly documenting any foreign material seen on the body as well. Swabbing of body orifices should also be done prior to commencing the autopsy for the recovery and identification of biological trace evidence. Where necessary, complementary investigations such as imaging should also be done prior to dissection of the body.
• Internal examination: the internal examination should follow a systematic layer by layer opening of all the body cavities i.e. head, thorax and abdomen, and where need arises, the vertebral canal and joint cavities should also be examined. It should be emphasized that, once the body cavities have been opened, all organs and soft tissues should be sliced according to established guidelines and all findings clearly described in detail. The weight of all major organs should also be recorded. Sampling is case-dependent even though samples for histology, peripheral blood (for drug, alcohol and genetic identification analyzes), urine and gastric contents should be collected at the minimum, for every case.
The autopsy report, once the autopsy has been completed, should entail all the findings in a “clear, accurate and permanent document”, and should be comprehensible not only to doctors but also non-medical readers. Evaluation of the significance of the findings should also be given at the end of the autopsy in a medical-legal expert opinion (8).
