The Hospital Autopsy

A Manual of Fundamental Autopsy Practice, Third Edition

Julian Burton, Guy Rutty

• Publisher: CRC Press
• Year: 2010
• ISBN:
  9780429585821
• Edition: 3
• Topic: Law
• Subtopic: Forensic Science
• Index: Law

Now in full colour, this new and revised edition of The Hospital Autopsy presents a clear and systematic approach to safe and effective modern autopsy practice for pathologists. It begins by discussing issues such as legislation governing autopsies, religious attitudes and ensuring safety, before covering the procedures of external examination, evi

Chapter 1

THE HISTORY OF THE AUTOPSY

Julian L Burton

Introduction

Antiquity

Human dissection in the Dark Ages

The medieval autopsy

The Renaissance autopsy

Autopsies in the seventeenth and eighteenth centuries

The nineteenth century autopsy

The twentieth century autopsy

The twenty-first century autopsy

References

The greater the opportunity that hospitals give us for observing rare diseases – and this applies even more to the commoner diseases – the more often am I obliged to bewail the lot of the ancient physicians, who lacked hospitals … But, if after hospitals began to exist, it had been permitted to investigate diseases not only in sick persons but also in those who had died after every sickness, the advances that the medical profession would have made in the subsequent ten centuries can easily be estimated by considering the advances that have been made since both kinds of examination began to be permitted, about the beginning of the 16th century.

Morgagni (1761)

Introduction

The term ‘autopsy’ means ‘to see for oneself’ and is synonymous with the terms ‘post-mortem’, ‘postmortem examination’ and ‘necropsy’. None of these terms has a specific meaning that allows the extent or precise nature of the investigation to be inferred from their use. In modern practice, an autopsy is usually taken to indicate a detailed examination that includes the external examination of the corpse, and the evisceration and subsequent careful dissection of the contents of the cranial, thoracic, abdominal and pelvic cavities. Nonetheless, examinations restricted to a particular body cavity (either by the relatives’ wishes or because of some infectious hazard), or to the sampling of the organs in the unopened body with a biopsy needle, are also regarded as autopsy examinations. In some countries, such as Scotland, where a ‘view and grant’ system of death certification exists, the term ‘post-mortem examination’ may refer only to the external examination, with no effort being made to examine the internal organs. So-called ‘scan and grant’ virtual autopsies, in which bodies are subjected to imaging rather than dissection, have also emerged in recent years (Rutty, 2007).

We can consider that there are two principal types of autopsy: hospital examinations, performed on the request of a clinician with the consent of the next of kin, and medicolegal autopsies. The latter can be subcategorised into those where there is a criminal or civil interest (forensic autopsies) and those where death is presumed to be due to natural causes (non-forensic medicolegal autopsies).

The variations in the scope of the examination implied by these terms must be remembered in any historical account of the autopsy. Furthermore, other terms have historically been used to describe what we now call ‘autopsy’. Among these, the term ‘dissection’ is now taken to refer solely to the process of cutting apart or separating tissues and organs from one another for further study. ‘Anatomisation’ is a term that has fallen into disuse, but carries the connotation of a degree of dissection that sounds extreme.

Throughout recorded history, humans have felt both revulsion and fascination at the prospect of examination of the human body after death. These attitudes have been inextricably linked with the prevailing religious and political climates of the time, and, further, reflect the epistemological advances in our understanding of medicine and disease. As the nineteenth century French philosopher Auguste Comte (1798–1875) argued, the human mind has progressed from a theological stage, through a metaphysical stage, to a final positive stage. In the theological stage, primitive attempts are made to explain behaviour in terms of spiritual or supernatural entities. The metaphysical stage is a modification of this and explains behaviour in terms of abstractions, essences or forces. The positive stage dispenses with these concepts and turns to observation and reason as a means of understanding behaviour (Cohen and Manion, 1998). Such ‘positivism’ is the underlying principle of the modern scientific method. Thus, the purposes for which post-mortem examinations were performed have evolved from the prophetic, through a search for an imbalance of the humours, to a ‘scientific’ approach to the evaluation of the nature and extent of disease and the cause of death. Modern medicine has an anatomical and physiological attitude underlying most diseases and, even when such causes cannot be proven, we assume that they will someday be elucidated in these terms. Our continuing fascination with the autopsy in the twenty-first century is evidenced by the proliferation of web pages and television programmes discussing autopsies.

What follows is a brief account of the history of the modern autopsy. More detailed discussion is to be found in the excellent commentaries by Porter (1999), Park (1995) and King and Meehan (1973). Any historical account of the subject will lean heavily on their definitive studies.

Antiquity

The ancient Egyptians, whose civilisation rose under the Pharaohs around 3000 BC, practised medicine that had both an empirical and a magico-religious aspect. Human dissection was confined to the process of mummification, in which embalmers attempted to preserve the body intact. The internal organs were removed through small incisions (although the heart, believed to be the seat of the soul, was left in situ) and the brain was removed via the nose using hooks. Once removed, the organs were stored in special Canopic jars. While it was acceptable to tamper with the body of the deceased in this manner, the procedure was performed for entirely magico-religious reasons and no attempt was made to understand disease in the living from an examination of the dead.

In the other great civilisation of the time, that of Mesopotamia (the lands between the rivers Tigris and Euphrates), disease was similarly thought to be due to supernatural intervention. Rather than looking to the human corpse for an understanding of disease, omen-based prognostic practices flourished, including the examination of the liver (hepatoscopy) and entrails (haruspicy) of sacrificed animals (Porter, 1999). Hepatoscopy and haruspicy can be traced back to the time of Sargon I of Babylon (c. 3500 BC). Disease was regarded in an anamistic fashion – i.e. controlled by gods or spiritual forces, whose intentions could be read in the liver by the haruspex (King and Meehan, 1973).

The Greek civilisation began to emerge around 1000 BC, but little is known of their medicine before 500 BC. Hippocrates (c. 460–377 BC), whose work has been deduced from legend, promoted a naturalistic philosophy that disease resulted from ‘natural’ causes. Early Greek physicians had a sound grasp of surface anatomy, but the cultural mores against human dissection limited their knowledge of internal anatomy to that gleaned from the inspection of wounds and the dissection of animals. The use of animal dissection, promoted by Aristotle (384–322 BC), was subsequently used to ground biomedical knowledge in Alexandrian medicine. Hirophilus (c. 330–255 BC), however, is reported to have performed dissections on live humans (probably condemned criminals) and public dissections on human cadavers. It was he who discovered and named the prostate, duodenum (from the Greek for 12 fingers), and the structure that bears his name, the torcular Herophili (the confluence of the intracranial sinuses) (King and Meehan, 1973). That Hirophilus describes the rete mirabile (a network of arteries found at the base of the brain in primates) demonstrates that some of his dissections were also performed in animals; the rete mirabile is not present in humans.

The application of human dissection altered little over the subsequent four centuries. The classical Greeks and their successors were working with an entirely different concept of disease; namely a misbalance of humours. This model gives no particular significance to the physical state of the organs and therefore does not see any particular clinical interest in the autopsy. The work and views of Galen (AD 129–c.216) were to dominate medicine for the next millennium. However, while he prided himself on being an expert clinician, he was also a medical scientist and performed dissections. These were mainly performed on apes, sheep, pigs, goats, and even an elephant’s heart. Human dissection was out of the question, though he told of examining two skeletons observed by chance, one washed from a grave by a flood and another of an unburied thief picked clean by carrion birds (King and Meehan, 1973). Given Galen’s dominance over the medical establishment, his assertions on human anatomy based on comparative anatomy in apes and other mammals were to remain largely unchallenged for 1400 years (Porter, 1999).

Human dissection in the Dark Ages

With the fall of the Roman Empire, the West began its decline into the Dark Ages. Little of what passed for medical practice between 476 and 1000 in the West is known. Human dissections for scientific purposes in the West are unrecorded in this time.

Thanks to a number of writers in the Greek East, we can be certain that the practice of human dissection did continue and that the history of the autopsy is unbroken from ancient times to the modern day. Both Pseudo-Eustathius (c. 325) and Symeon the Theologian (949–1022) report that autopsies intended to search for disease were performed on the dead bodies of criminals (Bliquez and Kazhdan, 1984; Burton, 2005). It is apparent that the practice of human vivisection also continued. As Theophanes (752–818) records:

… an apostate from the Christian faith and leader of the Scameri was captured. They cut off his hands and feet on the Mole of St Thomas, brought in physicians, and dissected him from his pubic region to his chest while he was alive. This they did with a view to understanding the structure of man. In this condition they gave him over to the flames.

(Bliquez and Kazhdan, 1984)

Clearly, the Eastern Church did not have the same mores against human dissection that had plagued the ancient Greeks or that would feature prominently in the West. Moreover, these Byzantine dissections were perhaps the first true autopsies, seeking to understand the nature of disease and not just anatomical structure (Burton, 2005). Such autopsies would not be seen in the West for another 450 years.

The medieval autopsy

In Anglo Saxon England, the Tutonic pagan belief that disease was caused by ‘the worm’, ‘onfliers’, ‘elf-shot’ and contagious magic meant that further investigation of the body was not only fruitless but might also be positively dangerous. The appropriate activity in that context was the proper observance of the ritual of cleansing, disposal and grief with perhaps some vengeance on supposed sources of disease. Elements of these attitudes persist in all cultures, as the expensive procedures of funeral and bereavement rituals attest.

Little is known of autopsy practices in the early Middle Ages. In the early medieval west, dissection of the human cadaver remained closely bound up with the religious beliefs of the time. Dissection for scientific advancement was all but unheard of. Indeed no mention of human dissection for such purposes is to be found in Binski’s (1996) account of medieval death, ritual and representation.

In England, Germany and France, human dissection was limited to the process of ‘division of the corpse’. In general terms, this practice consisted either of the evisceration of the body in preparation for a state funeral or of a complete dismemberment (‘anatomy’). The latter was undertaken largely on the bodies of the saints (Park, 1995; Binski, 1996) and allowed several religious communities to have local access to a part of such an illustrious person. Such relics often consisted of severed body parts and were preserved within the alter or a shrine within the church (Binski, 1996). Division of the corpse was also undertaken to facilitate its transportation for burial when death occurred far from home. Such a practice is clearly exemplified in this account of the division of Henry I of England in 1135:

Although he had died in Rouen, the king wished to be buried in Reading. Accordingly, he was decapitated, and his brain, eyes, and viscera were removed and buried in Rouen. The rest of his body was cut into pieces, heavily salted, and packed into oxhides against the smell, which, according to the chronicler, had already killed the man responsible for extracting the brain. By the time the funeral procession had reached Caen, the corpse was exuding a liquid so foul that its attendants could not drain it without what Henry of Huntington called ‘horror and faintings’.

(Park, 1995)

In contrast, such practices were only rarely adopted in twelfth and thirteenth century Italy. Indeed, division in preparation for burial in Italy was prohibited by Pope Boniface VIII in 1299 and punishable by excommunication – itself a form of social death (Park, 1995).

In thirteenth century England, dissection of the dead to determine the cause of death was largely unknown. Autopsies were not used in early coronial inquests – instead, the jury met with the coroner around the body (Seabourne and Seabourne, 2001). Disease, death and decay were considered to be signs of sin and the will of God. Further, as bubonic plague (and, later, smallpox) ravaged the country there were fears that cadavers were sources of contagion. However, given that the diagnosis of death was often certain, but not always accurate (giving rise to several ‘miracles’ of resurrection), the absence of autopsy practice was perhaps comforting (Horrox, 1999)!

Italy is the birth-place of the examination of the dead that evolved into the autopsy we are familiar with today. The earliest report of such an autopsy dates from 1286 when a doctor in Cremona undertook an autopsy examination to investigate an epidemic (Park, 1995). The chronicles of Fra Salimbene, a Franciscan friar, tell of a physician who opened a hen and found an abscess at the tip of the heart. He then opened a man who had died of apparently the same disease and found a similar lesion. The autopsy was to soon have a place in medicolegal investigations, and the report of Azzolino, who died in Bologna in 1302 in suspicious cir...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Contributors
• Preface to the third edition
• Acknowledgements
• 1. The history of the autopsy
• 2. The future of the autopsy
• 3. The role of the autopsy in medical education
• 4. Autopsies and the law
• 5. Religious attitudes to death and post-mortem examinations
• 6. The safe and healthy autopsy
• 7. Autopsies of people with high-risk infections
• 8. The external examination
• 9. The pathology of wounds and injuries
• 10. The evisceration
• 11. Dissection of the internal organs
• 12. Examination of the nervous system
• 13. Fetal, perinatal and infant autopsies
• 14. The maternal autopsy
• 15. Toxicological and biochemical analyses
• 16. Microbiology of the autopsy
• 17. Investigating possible anaphylactic deaths
• 18. Perioperative and postoperative deaths
• 19. The radiological autopsy
• 20. The decomposed body and the unascertained autopsy
• 21. Reconstruction of the body
• 22. Autopsies and clinical audit
• 23. Reports, documentation and statements
• Appendix forms used in criminal justice cases
• Index