Professional Documents
Culture Documents
Autopsy Saukko2009
Autopsy Saukko2009
Autopsy Saukko2009
from nonexistent to well-functioning organizations resonance imaging (MRI) clinical autopsy has been
with sophisticated autopsy practices. Generally the shown to have maintained its clinical, educational,
lack of forensic and medicolegal services is a char- and epidemiological value and remained an essential
acteristic of developing countries, usually including a factor in the quality assurance of medical care [13]. In
poor judiciary and educational system, but the aware- spite of this, there has been a progressive decline in
ness of the importance of high standard medicolegal autopsy rates in recent decades in most industrialized
autopsy for the protection of individual rights varies countries on all continents [14–16].
a lot even in industrialized countries due to historical In 1971, the Joint Commission on Accreditation
and/or political reasons. of Hospitals (JCAH) in the United States ended its
Most countries have not provided laws to regulate requirement for minimum rates of autopsy for certifi-
the actual performance of medicolegal autopsies. cation. Until then, a mandatory 20% autopsy rate had
There exist both international recommendations and been required for accreditation of postgraduate train-
national guidelines by the competent authorities or ing. The idea had been that each institution should
professional bodies such as the Royal College of set its own rate but the dropped requirement seems
Pathologists in the United Kingdom or minimum to have had a negative impact on autopsy rates and,
standards by individual forensic institutes. according to an estimate, the national autopsy rate
Various international bodies have been interested of nonforensic deaths may have fallen roughly to
in achieving harmonized and internationally recog- 5% [17].
nized rules concerning the performance of medicole- There are several reasons for this decline and
gal autopsies. In Europe the “Sevilla Working Party the emphasis of contributing factors varies according
on the Harmonization and Standardization of Foren- to the country. Clinicians may be too reliant on
sic Medicine (SWP)” was established in 1985 by the new diagnostic techniques and poorly motivated
Professor Luis Frontela Carrerras of Seville, Spain, to obtain consent from the relatives to perform
carrying out groundwork and collaborating with the an autopsy. Pathologists are less enthusiastic, and
Council of Europe to create minimum standards for owing to low autopsy rates, less experienced to
autopsy protocols. The Minnesota Lawyers Interna- perform autopsies and this task is often delegated to
tional Human Rights Committee had taken the initia- inexperienced trainees. Further factors that probably
tive to draft international standards for the investiga- have contributed to the decline of autopsies are
tion of suspicious deaths, including autopsy. In May fear of malpractice litigation, if errors in clinical
1989, UN Economic and Social Council adopted in judgment are detected, and cost-cutting pressures,
its resolution 1989/1965 “the Principles on the Effec- when autopsies do not produce income [18, 19].
tive Prevention and Investigation of Extralegal, Arbi-
trary, and Summary Executions”, which had been
created by cooperation with intergovernmental and Objectives of Autopsy
nongovernmental organizations. In 1991, the General
Assembly of the United Nations endorsed the Model Autopsy is a detailed systematic external and internal
Autopsy Protocol of the United Nations. SWP’s work examination of a corpse carried out by a pathologist
was continued by the European Council of Legal or one or more medicolegal experts to ascertain
Medicine (ECLM), whose document “Harmonisation the underlying and possible contributing causes of
of the Performance of the Medicolegal Autopsy” was death and, depending on the jurisdiction, also the
adopted by the General Assembly in London in 1995 manner of death. Before the pathologist can begin
and which largely served as basis for the Pan Euro- the examination, he must be sure that he has been
pean, Council of Europe – Recommendation No. authorized to perform the autopsy on that particular
R (99) 3 On the Harmonisation of Medico-Legal body. As infection risks are common in mortuary
Autopsy Rules and Its Explanatory Memorandum, and autopsy may involve also other risks, such as
which was adopted by the Committee of Ministers electrical, chemical, and radiological hazards, these
in February 1999 [12]. must be assessed and necessary health and safety
In spite of the invention of new medical imaging precautions taken. The autopsy and all ancillary
techniques such as computed tomography (CT), mul- investigations must be carried out in compliance
tislice computed tomography (MSCT), or magnetic with the relevant legislation and possible national
4 Autopsy
guidelines in a manner consistent with medical ethics jurisdictions, permission of the next of kin is not
and respecting the dignity of the deceased. required [20–22].
An autopsy is performed to achieve one or more
of the following objectives: Autopsy Techniques
• to identify or record characteristics that may assist The basic technique of autopsy has remained the
in identifying the deceased; same since 1850s but various imaging techniques
• to determine the cause of death or, in the new- such as CT, MSCT, MRI, percutaneous needle biop-
born, whether live birth occurred; sies, or endoscopic techniques have been applied,
• to determine the mode of dying and time of death, either for preautopsy screening purposes, or as so
where necessary and possible; called “minimally invasive autopsy” if full autopsy
• to demonstrate all external and internal abnormal- is not possible.
ities, malformations, and diseases; Both clinical and medicolegal autopsy may
• to detect, describe, and record any external and involve different strategies and techniques depending
internal injuries; on the questions they are expected to answer and
• to obtain samples for any ancillary investigations; pediatric autopsy technique is generally somewhat
• to obtain photographs or retain samples for evi- different from the one in adults. The Royal College
dential or teaching use; of Pathologists (the United Kingdom) has published
• to provide a full written report and expert inter- a set of Guidelines on Autopsy Practice and
pretation of the findings; and scenarios for specific types of death, to facilitate the
• to restore the body to the best possible cosmetic improvement of the standards of autopsy performance
condition before the release. and reporting [23].
In addition to the anatomical dissection, there are The scope of medicolegal autopsy is often broader
basically two main types of autopsy and, although than that of clinical autopsy, with special emphasis
in principle, a single standard should be applicable on all information concerning the circumstances of
to all autopsy examinations, this is not the case in death, often necessitating a visit to and investigation
practice, owing to different traditions and structures of the scene of death. Both types of autopsies should
in education of medical specialists and wide variation consist of full external and internal examination of
in autopsy practices, from partial autopsy to full the body including the dissection and investigation
examination of all body cavities including ancillary of all three body cavities.
investigations such as histology of all major organs,
depending on the country and jurisdiction. The External Examination
The clinical or hospital autopsy must, in most
jurisdictions, be consented by the deceased person, In medicolegal autopsy, the examination of the cloth-
before death, or the next of kin after death. It is ing is often an essential part of the external examina-
usually performed to investigate details of a known tion, whereas in clinical autopsy it is generally not.
disease process, e.g., the exact type or spread of a The description of the body includes age, sex,
malignant disease or the effectiveness of therapy. It build, height, ethnic group and weight, nutritional
can also be performed for medical audit or research state, color of the skin as well as other characteristics
purposes. of the deceased including color of irises and sclerae,
The medicolegal or forensic autopsy necessitates, presence or absence of petechiae; color, length,
owing to legal issues involved, the highest possible density and distribution of hair, or any abnormalities
standards of practice. It is ordered by the compe- such as scars or tattoos. All injuries must be described
tent legal authority (a coroner, a medical examiner, a in detail, measured, and photographed. Postmortem
procurator fiscal, a magistrate, a judge, or the police) changes relating to rigor mortis, hypostasis, and
to investigate sudden unexpected, suspicious, unnat- decomposition should be described in detail. The
ural, or criminal deaths. Also unidentified bodies or examination should be carried out carefully and
deaths occurring in special circumstances such as systematically and include head, neck, trunk, upper
deaths in police custody or during imprisonment are and lower extremities, and the back and description
often subjected to a medicolegal autopsy. In most of all body orifices.
Autopsy 5
[4] Rabl, R. (1952). Die Wertung der Sektionen im Wandel [19] Hasson, J. & Schneiderman, H. (1995). Autopsy training
der Zeiten, Virchows Archiv 321, 142–162. programs. To right a wrong, Archives of Pathology
[5] Jimenez, F.A. (1978). The first autopsy in the New Laboratory Medicine 119(3), 289–291.
World, Bulletin of the New York Academy of Medicine [20] Saukko, P. & Pollak, S. (2000). Postmortem exami-
54(6), 618–619. nation: procedures and standards, in Encyclopedia of
[6] Tz’u, S. (1981). The Washing Away of Wrongs, The Forensic Sciences, J.A. Siegel, P.J. Saukko & G.C.
University of Michigan Center for Chinese Studies, Ann Knupfer, eds, Academic Press, San Diego, Vol. 3, pp.
Arbor. 1272–1275.
[7] Cunha, F. (1941). William of Saliceto – The School of [21] Saukko, P. & Knight, B. (2004). Knight’s Forensic
Bologna, American Journal of Surgery, 52, 144–149. Pathology, Edward Arnold, London.
[8] O’Neill, Y.V. (1976). Innocent III and the evolution of [22] Saukko, P. & Pollak, S. (2005). AUTOPSY, procedures
anatomy, Medical History 20(4), 429–433. and standards, Encyclopedia of Forensic and Legal
[9] Siraisi, N.G. (1977). Taddeo Alderotti and Bartolomeo Medicine, Elsevier, Oxford, p. 166.
da varignana on the nature of medical learning, Isis [23] The Royal College of Pathologists (2002). Guidelines
68(1), 27–39. on Autopsy Practice, The Royal College of Pathologists,
[10] Maksymowicz, K. (2008). Forensic medicine in Poland, London, p. 34.
in Forensic Medicine in Europe, B. Madea & P. Saukko,
eds, Schmidt-Römhild, Lübeck.
[11] Ludvig, J. (2002). Principles of autopsy techniques, Further Reading
immediate and restricted autopsies and other special
procedures, in Handbook of Autopsy Practice, J. Ludvig, Lu, G.D. & Needham, J. (1988). A history of forensic medicine
ed, Humana Press, Totowa, p. 592. in China, Medical History 32(4), 357–400.
[12] Nancy, G. Siraisi (2000). Council of Europe, Recom-
mendation no. R (99) 3 of the Committee of Ministers
to member states on the harmonization of medico-legal Related Articles
autopsy rules. Forensic Sci Int, 111(1–3), 5–58.
[13] Burton, J.L. & Underwood, J. (2007). Clinical, edu-
cational, and epidemiological value of autopsy, Lancet
Cardiac and Natural Causes of Sudden Death
369(9571), 1471–1480. Crime Scene Documentation
[14] Svendsen, E. & Hill, R.B. (1987). Autopsy legislation
Gunshot Wounds
and practice in various countries, Archives of Pathology
and Laboratory Medicine 111(9), 846–850. Histology
[15] Sugiyama, T., Fujimori, T. & Maeda, S. (1991). Autopsy Natural Causes of Sudden Death: Noncardiac
rates in medical schools and hospitals in Japan, IARC
Scientific Publications (112), 245–252. Report Writing for Courts
[16] Jeganathan, V.S., Walker, S.R. & Lawrence, C. (2006). Shaken Baby Syndrome
Resuscitating the autopsy in Australian hospitals, ANZ
Journal of Surgery 76(4), 205–207. Species Determination of Osseous Remains
[17] Shojania, K.G. & Burton, E.C. (2004). The persistent Toxicology: Analysis
value of the autopsy, American Family Physician 69(11),
2540–2542. Wounds: Sharp Injury
[18] Yesner, R. (1986). Quality assessment of the autopsy,
American Journal of Clinical Pathology 86(2), 250. PEKKA J. SAUKKO AND STEFAN POLLAK