Autopsy: Medical and Forensic Post‑Mortem Examination

Clinical section and forensic section

The term autopsy is usually used for clinical (pathological) dissections and forensic medical dissections.

Clinical autopsies are almost exclusively performed by a pathologist. The pathologist usually works together with a medical dissector (medical dissection and preparation assistant or prosectural assistant). In this process, the cause of death and the previous illnesses of a deceased person are determined by internal medical post-mortem examination. In most cases, the last physician to treat the deceased person submits the request for a post-mortem examination. The prerequisites for a clinical post-mortem examination are that the deceased or the next of kin consent to it and that death occurred from a natural cause (e.g. heart attack, cancer, pneumonia). There is the possibility of a partial autopsy at the request of the next of kin. In such cases, for example, the brain is not removed, which means that no cuts are visible when the body is laid out in public. A good cosmetic result can also be achieved in the head area by means of adapted incisions. Such a procedure is not possible in forensic medicine, where the scope is defined by § 89 StPO. It not only serves the purpose of quality assurance in medicine, but can also be relieving for relatives (e.g. self-reproach for not having noticed symptoms in time). Furthermore, a post-mortem examination can occasionally provide indications of familial risk factors (e.g. cancer or hereditary diseases). It is sometimes performed in the case of insurance issues (e.g. occupational diseases that may have contributed to the death, as well as concealed pre-existing conditions). Last but not least, it is used for the continuing education and training of physicians and medical professionals in the hospital.

Forensic autopsies can be ordered by the public prosecutor's office or by the courts if a non-natural cause of death, i.e. a homicide, suicide or accidental death is suspected or established and further clarification appears necessary. If the cause of death is recorded as "unexplained" on the death certificate, a post-mortem examination is also usually ordered by the court.

In Germany, the authorities must notify the public prosecutor's office or the local court without delay if there are indications that the death was not natural, whereupon the public prosecutor's office decides on the written authorisation for burial (burial certificate) that is then required or on investigations such as the opening of the body and any seizure of the body that may be necessary. If the dissection requires the excavation of a buried body (exhumation), a judicial order is required, of which a relative of the dead person who can be reached without difficulty must be notified The dissection must be carried out by two doctors, at least one of whom is a specialist in forensic medicine; the public prosecutor may be present and a judge must be present at his request. The opening must extend to the opening of the head, thoracic and abdominal cavities and, in the case of newborn infants, shall be devoted in particular to the question of the extent to which the infant was alive and viable at and after birth.

Pathological and forensic medical dissections are very similar in procedure. In the case of pathological autopsies, however, a toxicological examination is dispensed with, as this has generally already been carried out prior to death. The determination of the body temperature of the deceased, which allows the time of death to be inferred, is also omitted. However, differences can be observed in the details of the incision. In forensic medicine, for example, the soft parts of the neck are prepared in artificial bloodlessness.

Duration and costs

Depending on the cause of death and the complexity of the case, an autopsy usually takes two to three hours, or four hours at the most.

An autopsy in forensic medicine costs about 950 euros in Germany. For an external post-mortem examination ordered for the purpose of criminal investigations, the expert receives 70 euros; for such a post-mortem examination, including a report, each of the two post-mortem examiners is entitled to a fee of 460 euros, or up to 800 euros from the public purse in the event of particularly unfavourable conditions due to the condition of the corpse. A post-mortem examination requested exclusively by relatives must be paid for by the person who commissions it.

Frequency of autopsies

In Germany, about one to two percent of the dead are autopsied. There is evidence to suggest that a not inconsiderable proportion of clinically suspected causes of death are false. For example, a study published in the Archiv für Kriminologie in 1997 concluded that of the approximately 900,000 deaths in Germany, about 11,000 non-natural deaths and 1,200 homicides per year would go unrecognized.

Anatomical section

Anatomical dissections ("dissections") are used for the training of medical doctors; anatomists and students perform them together. The deceased to be dissected have usually voluntarily made their corpse available for this purpose during their lifetime, unless it is an animal cadaver for study purposes. The term autopsy is not usually used in this context; instead, one speaks of dissection (formerly also dissection) or the preparation of corpses. However, the term preparation is also used for the preservation of corpses and parts of corpses.

An anatomical dissection is much more detailed. It is not limited to the three body cavities (see below); smaller details are also shown, since all anatomical structures of the body are to be learned during the dissection course. Therefore, an anatomical dissection extends over a whole semester or at least a few weeks. This results in the necessity of embalming the corpse. A reconstruction of the corpse afterwards is no longer possible. In the end, the corpse is usually buried individually and (largely) complete. However, there are also group burials, where all bodies and parts of a course are buried together. This is done anonymously or by name, by cremation or burial, depending on the last will. Particularly successful specimens, however, are kept longer, often for many years or decades, for the purpose of teaching, and only buried later and therefore usually separately from the rest of the body.

Exterior tour

A post-mortem examination begins with a detailed inspection of the corpse. Size, weight, nutritional condition and skin colour are recorded. The location and colour of the death marks and the degree of rigor mortis are documented. Skin changes such as scars, wounds, surgical wounds, pigment spots, tattoos and the like are also described. In forensic autopsies in particular, great importance is attached to a precise external description, which, in addition to any injuries (such as bullet or stab wounds), also includes clothing and other objects (for example: jewellery, wristwatch, etc.). Examination of clothing, effects, body size, and dental status is particularly important in identifying unidentified deceased persons. In addition, conclusions about external effects etc. can be drawn from the external inspection.

Inner tour

The internal post-mortem examination is divided into an opening of the cranial, thoracic and abdominal cavity. In a post-mortem examination ordered under German criminal procedure law, all three body cavities (cranial cavity, thoracic cavity and abdominal cavity) must be opened and thus the organs exposed. The organs are assessed for size, shape, colour, consistency and coherence, with any changes that deviate from the norm being recorded in the descriptive section of the autopsy report. Morphologically visible organ changes have a correspondence in pathological-anatomical diagnoses, which in turn correspond to certain clinical pathologies. The technique of dissection is adapted to the clinical findings reported. For example, in the case of certain previous findings, it may be necessary to visualize leg vessels. Small samples of important organs are preserved for further light microscopic and possibly also microbiological examinations. For forensic medical reports, blood and urine of the deceased are also obtained for the purpose of toxicological examinations.

The Y- or T-cut

This incision has either the Y-shape, in which case the incision is made from both collarbones diagonally to the sternum and from there straight to the pubic bone. Alternatively, a slightly curved cut is made from shoulder to shoulder across and then in a second cut centrally downwards to the pubic bone, the T-cut. Through these incisions, the pathologist or forensic pathologist can access all organs of the chest and abdominal cavity (after removal of the sternum and adjacent ribs).

Aftercare

Following the internal inspection, the organs are placed back into the body cavities of the deceased, whereby removed organs or parts of organs may be processed and archived for clinical or scientific purposes. If larger amounts of tissue are missing as a result, these are replaced with cellulose, for example, in order to approximately restore the external shape of the body. The skin incisions are roughly sutured and the corpse washed. This makes it possible to say goodbye in an open coffin.

Further procedure

Later, the samples obtained are examined microscopically and microbiologically. In a forensic necropsy, drugs and possibly toxins and drug levels are determined toxicologically. Occasionally, special examinations such as DNA analyses, entomological (insectology) and radiological procedures are also used. The various reports are only sent to the client of the section.

Recently, new measuring methods have increasingly been used in necropsy (strip light topometry, CT).

Autopsy report

The autopsy report consists of a descriptive part, which leaves no room for interpretation and is similar in nature to a pictorial description. Accordingly, the descriptive part is an objective description of the organ systems, which ideally should be so accurate that an expert can subsequently read out all pathological-anatomical diagnoses from the report and revise them if necessary. This description is accompanied by a list of the causes of death and the individual pathological-anatomical diagnoses.