Autopsy Practices Dhaneshwar Lanjewar, Pradeep Vaideeswar
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Autopsy: Introduction and History1

Dhaneshwar Lanjewar
 
INTRODUCTION
Since the evolution, human beings have struggled for survival and knowledge. In earlier ancient time, the first systematic cadaveric dissection was performed on animals by hunters, butchers and cooks to find edible organs. The observations of animal dissection fascinated human beings and stimulated them to know structure of human body. The work on anatomy by Andreas Vesalius (De humani corporis fabrica, 1543), which initiated a concept of pathologic anatomy, confirms that anatomy is the beginning of pathology; more importantly it emphasized that pathology is best studied on the autopsy table.1 The word ‘autopsy’ is derived from Greek words, autos means oneself and opsis means sight or view), i.e. to see for oneself.2 The word ‘autopsy’ has been used since 17th century. Necropsy (necros means dead, opis means to view) means viewing of the dead body. Necropsy is most accurate term for the investigative dissection of the dead body, but the term autopsy is commonly used and is more popular. Other synonyms include postmortem, postmortem examination and autopsia cadaverum. Autopsy procedure comprises thorough examination of the corpse to determine cause and manner of death and to evaluate any disease. It is considered as akin to a ‘surgical’ operation performed by a specialized medical doctor, which is either a pathologist or a forensic medicine expert.
 
TYPES OF AUTOPSIES
Autopsies are classified into two types.1,3 Medicolegal or Forensic or coroner's autopsy is ordered by law whenever there is violent, suspicious or sudden death which may be a criminal matter (see Chapter 7). On the other hand, clinical, medical or pathological autopsies are performed to know cause of death or for research purpose and are carried out with the consent of the family of deceased person. If the 2person does not have next of kin or legal heir to give consent, then information has to be given to nearest police station in whose jurisdiction the hospital is located and consent is obtained from the Investigating Officer (IO). Usually IO would conduct a police inquest. It is performed by the pathologist in tertiary care centers (ideal), but in most of the places in India, it is performed by medical officer, start who may not always be a postgraduate in pathology. The aim of these autopsies is to determine, clarify or confirm medical diagnosis that was not known prior to the death of patient and to confirm a doubtful diagnosis. Clinical autopsies gain more insight into pathological process and determine factors that contributed to the patient's death and extent of natural disease. It helps to identify the pathological changes that has taken place in different organs during disease processes and its progress or deterioration following treatment. It ensures the standard and care in hospital. Autopsy remains important for quality assurance of clinical work. It identifies medical error and also teaches how patient's death can be prevented in future. In autopsy, it is mandatory to carry out detailed examination of all the organs; this is called as complete autopsy. However, in reality a complete autopsy is not possible because examination of some organs/structures such as eyes, mouth, face and the extremities is not permitted. In some cases, when the clinician is of the opinion that the patient has died due to localized disease involving one or two organs, there is a request for partial or restricted autopsy. In such situations, examination of the skull, thoracic and/or abdominal cavities is performed. To perform partial autopsy, there is also a need of obtaining consent of the family of deceased person.
Anatomical dissection (considered by some as another type of autopsy) performed by medical students for understanding normal anatomy cannot be considered autopsy, as anatomical dissection is not carried out for knowing cause of death. Here, usually the unclaimed or unidentified dead bodies are dissected by the anatomist or the medical student to gather detail knowledge of the normal structures of different external and internal organs and structures of the human body. The consent for such autopsy is also given by the person when he was alive or his legal heir/next of kin after his death who have consented for body donation. No separate consent from any legal authority is required in such cases. Though consent is not required, permission ought to be taken from the government authority for such purpose when such donated bodies have to be transported from one place to the medical college where the body is required for dissection purpose by medical students. In some institutes, MRI and CT scan of dead bodies are performed to determine lesions in various organs, a procedure termed as virtual autopsy.
 
HISTORY OF AUTOPSY
The beginning of autopsy was from anatomy; hence initial history of autopsy is related to anatomical dissection. The first dissection was probably performed in ancient Babylon (Hillah-Iraq) around 3500 BC. In this time period, the organs of animals were examined to obtain messages from divine spirit.4 Another practice of 3hepatoscopy or haruspicy was also prevalent in ancient time. In this practice examination of liver and intestine of sacrificed animals was carried out for foretelling the future. This practice has a religious background and had no relation for understanding of disease.
In the Egypt around 3000 BC, a technique of mummification was practised, where the embalmers of ancient Egypt used to give incision on left hypochondrium and through this incision intestine, stomach, liver, spleen, pancreas, kidneys and lungs were removed. The brain used to be removed through nostrils, but the heart used to be retained in the body. In this practice, even though organs were removed, their observation were never made and this dissection was not related for identification or understanding of any disease process.1,5 However, as time passed, the techniques of hepatoscopy or haruspicy and embalming played a major role in the progress of autopsy.
The Greek doctor, Galen of Pergamum (131–200 BC) dissected humans and animals to know pathology and he was the first to correlate the patients' symptoms and signs on the basis of findings of diseased organs.6 His observations eventually led to autopsy and broke an ancient barrier for progress of medicine.7 Herophilus and Erasistratus of Chalcedon dissected bodies (3rd century BC) of live criminals to teach anatomy and pathology.1,8 In 44 BC, an official autopsy was carried out on Julius Caesar who was murdered by rival senator.8, 9 By around 150 BC, ancient Roman legal practice had established parameters for autopsies.1 As early as 1200, the dissection of humans used to be performed with regularity to become skillful in dissection.6 In England, during the thirteenth century, dissection of dead bodies to determine the cause of death was largely unknown. By the mid-14th century, dissections had become part of the medical curriculum in many Italian Universities.4 Table 1.1 shows world leaders and their contribution in advancement in pathology through autopsy studies. Antonia Benivieni, a Florentine physician (1443–1502) used to obtain permission for postmortem from next of kin of decease in interesting clinical cases.10 He performed autopsies, recorded their brief description and correlated findings of autopsy with prior symptoms of the deceased. His autopsy records of 20 autopsies were published by his brother in 1507 as “The Hidden Causes of Disease”, one of the earliest publications of autopsy work. 11
Andreas Vesalius (1514–1564) used to do anatomical dissection meticulously and skillfully. He moved in Padua in 1537 where he made interesting observations therefore, understanding of anatomy became easier.12 His observations described in De humani corporis fabrica (1543) made it possible to distinguish pathologic anatomy of aortic aneurysm from the normal aorta.1
Giovanni Battista Morgagni (1682–1771), a keen academician, a physician and professor at the University of Padua, was trained under Antonio Valsalva. The autopsy examination in its modern form began in Padua with his work. He meticulously performed and described findings in 700 autopsies and produced the first exhaustive work on pathology “The Seats and Causes of Disease Investigated by Anatomy” in 1761.13 He was the first to correlate clinical symptoms with pathologic lesions and with him, the science of pathology reached new heights.
4
TABLE 1.1   Contributions of world leaders in autopsy
S. no.
Name
Period
Place and country
Significant contribution
1.
Antonio Benivieni
1443–1502
Florentine (Italy)
Correlated clinical symptoms with autopsy findings; Publication of autopsy records in 1507—“The hidden causes of diseases”
2.
Giovanni Battista Morgagni
1682–1771
Padua (Italy)
Performed and described 700 autopsies and produced the first exhaustive work on pathology in 1761—“The Seats and Causes of Disease Investigated by Anatomy”;
“Founder of Pathologic Anatomy”
3.
Marie Xavier Bichat
1771–1802
Paris (France)
Identified 21 types of tissue with the help of physical and chemical tests and without the help of microscope wrote monograms and books which describes his experiences with tuberculosis, pneumonia, typhoid and gastroenteritis; “Father of Histology”
4.
Carl von Rokitansky
1804–1878
Vienna (Austria)
Performed 30, 000 autopsies and supervised 70,000 autopsies; described autopsy technique based on the in-situ examination of viscera; Publications: “Handbook of pathological anatomy” and “Defects in the septa of the heart; “Father of Modern Autopsy”
5.
Rudolf Ludwig Carl Virchow
1821–1902
Berlin (Germany)
Developed simple autopsy technique and published as “Method of performing post-mortem Examinations in the Dead House”;
Thorough the use of microscopic examination and demonstrated that demonstrated that the cellular pathology is the basis of disease; published a book “Cellular Pathology”; first to give names to diseases such as leukemia, embolism, thrombosis, ochronosis, etc; terms named after him—Virchow's node, Virchow-Robin space, Virchow-Seckel syndrome and Virchow triad; “Father of Modern Pathology”
6.
William Osler
1849–1919
Montreal (Canada)
A giant of clinical medicine and pathology; Brought autopsy at the center of medical education; first to note that aneurysm of aorta was a complication of syphilis; on the basis of his autopsy data published a book “The Principles and Practice of Medicine”
5He convinced physicians that if they want progress of medicine, then autopsies should be performed and clinicopathological correlation should be achieved. Morgagni is truly a “Founder of Pathologic Anatomy.”
Marie Xavier Bichat (1771–1802), an anatomist and leading physician of Paris had a great interest in autopsy. In the year he died, he allegedly performed 600 autopsies.14,15 He was analytical, and in addition to dissecting the organs he used to carry out physical and chemical tests on the organs. With the help of these tests, he identified 21 types of tissues and this was done without using microscope. He strongly argued that tissues are damaged in diseases. His observations were important milestones in the history of medicine.16 Bichat wrote monograms and books which describes his experiences with tuberculosis, pneumonia, typhoid and gastroenteritis.
Carl von Rokitansky (1804–1878) was a great physician of Vienna and is considered as father of modern autopsy. He was of the opinion that the autopsy will be of great help for physicians. In earlier time when autopsy examination of only diseased organs was performed, Rokitansky described a technique of systematic examination of organs.14 He not only examined the diseased organ meticulously but also paid attention towards examination of all organs one by one systematically. In a span of 45 years of his career, he himself performed 30,000 autopsies and supervised 70,000 autopsies. He had collection of tens of thousands of pathologic specimens. Rokitansky described entities such as acute yellow atrophy of liver to massive hepatic necrosis. His notable contributions are congenital heart disease, bacterial endocarditis, lobar and lobular pneumonia and pulmonary complications of typhoid. Vienna school of medicine was worldwide recognized because of scientific contributions of Rokitansky; his contribution was published as “Handbook of Pathological Anatomy and Defects in the Septa of the Heart.17,18
Rudolf Ludwig Carl Virchow (1821–1902 was a great pathologist of Berlin (Germany), biologist, prolific writer, and editor and is known as “The Father of Modern Pathology.” When he was appointed as assistant to prosector in the Chariate Hospital, Berlin, he noticed that the working in the autopsy room was disordered. No systematic method for performing autopsy was available. Young untrained surgeons used to perform autopsy and they were not making notes during autopsy. Therefore, for the benefits of beginner in autopsy Virchow developed simple autopsy technique which was subsequently published in 1876.19 He studied diseased tissue by microscopic examination and demonstrated that cellular changes are responsible for development of disease and cellular pathology is the basis of disease. Through microscopy, he made significant contribution for development of pathology and brought autopsy and pathology to recognizable state. His most important work in the “Cellular pathology” published in 1858, as a collection of lectures is regarded as the root of modern pathology.20 A number of terms are named after him, Virchow's node, Virchow-Robin space, Virchow-Seckel syndrome also known as “bird-headed dwarfism” and Virchow triad.21 He was first to describe and give names to diseases such as leukemia, embolism, thrombosis and ochronosis, etc.
6Sir William Osler (1849–1919), the giant of clinical medicine was initially trained for 3 months in Berlin under Virchow and for 5 months in Vienna with Rokitansky.22,23 In his era, pathology and autopsy attained the highest position. He performed 800 autopsies, and published papers on autopsy.24,25 At McGill University, Montreal, he curated and mounted museum specimens and used this data while writing his textbook “The Principles and Practice of Medicine.”24 He highlighted the importance of pathology for better understanding medicine. He was among the first to note that aneurysm of aorta was a complication of syphilis.25 He was among the earliest to show micrococci in the etiology of endocarditis; he also contributed significantly to our understanding of cardiac pathology.
 
HISTORY OF AUTOPSY IN INDIA
The medical science is one of great antiquity in India.26 Kautilya's Arthashastra (Kautilya also known as Chanakya, 2nd century AD) describes the necessity of autopsy in establishing the cause of death.27 In the 1st century BC in India, Sushruta Samhita, the first Indian written medical book, instructed how to prepare the human body for the autopsy.28 The observations in Charak Samhita described bones, muscles, and the structure of the heart.29
The first medicolegal autopsy in Indian empire was performed on 28th August 1693, when Mr. James Wheeler (Member of Council, Sea Customer and Chief Justice of Choultry) died in Chennai.30 The progress of pathology in India during British Era began much earlier in preindependence era. The first Bengal medical school was established in 1822 in Calcutta (now renamed as Kolkata) which was converted into a Bengal Medical College (now renamed as Kolkata Medical College) in 1835.31 In Bengal Medical College records of creation of the “Pathology Museum” in early 1840 are available. Dr Allen Webb, Professor of Descriptive and Surgical Anatomy was the main person behind creation of museum. In those days civilian medical students and medical students of army who passed as graduates, used to perform autopsies and collect specimens of diseased organs. The specimens were collected from the West, the East, from Aden and Singapore, from Moulmein and Lahore and from the southern confines of the Madras Residency to the Himalayan range. The British Government provided the preservation facility and transportation facility to bring the specimens to Kolkata Medical College to create a pathology museum in 1840. This museum is the central depot of pathological contributions from every part of the British Empire. The descriptions of the specimen are written by Dr Allan Webb, after exposition of parts in the dissecting room, and by the civilian and army doctors. The vast collection of morbid anatomy specimens in the museum, thoroughness of the study and recorded descriptions are simply fascinating. This pathology museum during that time was known to be “one of the finest pathology museums” in the world. Professor Allen Webb subsequently published a book Pathologia Indica: ‘Anatomy of Indian Diseases’ in 1848 (Fig. 1.1A).32,33 This book contains autopsy notes with short clinical details and treatment prescribed and also has comments on historical and pathophysiological aspects of diseases of different systems of the body. 7The review of first edition of the book on the subject of diseased heart and arteries among the native, Parsees and Hindus, mentions that aneurysm appears to be, if not altogether unknown, a disease of rare occurrence. Hence, remarks as “Are natives of India exempt from aneurysm”?
In Southern part of India, Madras Medical College was established in 1835,31 while in the West, the Grant Medical College was established in Bombay (now renamed as Mumbai) in 1845.34 The first postmortem at the Grant medical College, Mumbai was performed in 1882 and this institute has preserved old autopsy records of 18578 patients. These records are hand written, contains meticulous descriptions and hand drawings of the pathologic lesions. Dr MN De, Indian pathologist from Kolkata Medical College, studied and published autopsy findings in “Tropical Splenomegaly” (1932) and Pathology of Spleen in malaria” (1938, Fig. 1.1B) and pathologic aspects of “Epidemic Dropsy” in 1933.35,36 In post-independence period (1947–2000) clinical autopsies were performed in all the Government run medical colleges and postgraduate institutes. Significant pathological data on general pathology, liver diseases, diseases of nervous system and cardiovascular diseases was published.37–42
Currently there are more than 400 medical colleges in India and autopsy program is nonexistent in 380 medical colleges.
zoom view
Figs 1.1A and B: Pathologia Indica: Anatomy of Indian Diseases; (B) Publications of Dr MN De
8In some institutes where autopsy program is existent, young untrained pathology residents who are not aware systematic method of conducting autopsy procedure are performing autopsies. No notes are made during autopsy and therefore, valuable information cannot be obtained from such autopsies; therefore there is a need of reviving autopsy program.
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