The Autopsy: More than you ever wanted to know

THE AUTOPSY:

MORE THAN YOU EVER WANTED TO KNOW

Kenneth V. Iserson, M.D.

On doit de égards aux vivants; on ne doit aux morts que la vérité.

We owe respect to the living, but the dead we owe only the truth.

Voltaire. Première Lettre sur Oedipe. Oeuvres (1785), vol. 1, p. 15n.

The Autopsy: More Than You Ever Wanted To Know

By Kenneth V. Iserson, M.D.

The SMASHWORDS Edition

Of a Galen Press, Ltd. Publication

Copyright © 1994-2012 by Kenneth V. Iserson.

Galen Press, Ltd. License Notes

This ebook is licensed for your personal enjoyment. It may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each person you share it with. If you are reading this book and did not purchase it, or if it was not purchased for your use only, then you should return to the same bookseller and purchase your own copy. Thank you for respecting the author’s work.

Original art of the Corpse Cooler is by David Vandenberg, Tucson, Arizona, for Galen Press, Ltd. Reprinted with permission.

Autopsy in the Form of an Elegy by John Stone reprinted by permission of Louisiana State University Press from The Smell of Matches: Poems, by John Stone.

This publication is designed to provide a comprehensive overview of the subject matter. It is not intended as a substitute for professional, legal, or medical advice and is sold with the understanding that neither the Author nor the Publisher is engaged in rendering such services through this boo. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.

TABLE OF CONTENTS

Chapter 1. Being Dead

Chapter 2. What Is a Morgue and How Long Will My Body Be There?

Chapter 3. Why Are Some Morgues Overcrowded?

Chapter 4. How Do Nurses Prepare Bodies for the Morgue?

Chapter 5. What If I Die at Home?

Chapter 6. What Is an Autopsy and Who Performs It?

Chapter 7. How Have Autopsies Evolved over Time?

Chapter 8. Why Perform Autopsies?

Chapter 9. Are There Discrepancies between Clinical and Autopsy Diagnoses?

Chapter 10. What New Diseases Have Autopsies Uncovered?

Chapter 11. Will I Have an Autopsy?

Chapter 12. Why Have Autopsy Rates Decreased?

Chapter 13. What Does an Autopsy Cost?

Chapter 14. What Is a Private Autopsy?

Chapter 15. Who Gives Permission for a Non-Forensic (Medical) Autopsy?

Chapter 16. How Is an Autopsy Done?

Chapter 17. How Do Autopsy Techniques Vary?

Chapter 18. Are Autopsies Harmful to Pathologists?

Chapter 19. After an Autopsy, Can I Still Be Embalmed?

Chapter 20. What Is a Virtual Autopsy?

Chapter 21. What Is a Verbal Autopsy?

Chapter 22. What Are Medical Examiners and Coroners?

Chapter 23. For Which Deaths Is the ME/C Responsible?

Chapter 24. How Do ME/C Offices Investigate Deaths?

Chapter 25. What Are Medical Examiner/Coroner Systems?

Chapter 26. What Are Coroners?

Chapter 27. What Are Medical Examiners/Pathologists?

Chapter 28. How Long Have Physicians Been Doing Medicolegal Autopsies?

Chapter 29. What Is Special about a Medicolegal (Forensic) Autopsy?

Chapter 30. How Have U.S. Medical Examiner Systems Evolved

Chapter 31. Why Is an Autopsy Done on a Decomposing or Dismembered Body?

Chapter 32. How Can a Person Be Identified from Partial or Decomposed Remains?

Chapter 33. What Happens If They Cannot Identify My Body?

Chapter 34. How Is the Time of Death Determined?

Chapter 35. What Role Does Forensic Entomology Play?

Chapter 36. What Happens to the Organs, Tissues, and Medical Devices Examined at Autopsy?

Chapter 37. What Happens to Miscarried Fetuses and Stillborn Infants?

Chapter 38. When and How Are Autopsies Done on Exhumed Bodies?

Chapter 39. When Have Exhumations Helped Investigate Historical Deaths?

Chapter 40. What Are Common Religious Views about Autopsies?

Chapter 41. What Is an Autopsy Report?

Chapter 42. How Do I Get an Autopsy Report?

Chapter 43. How Can I Understand the Autopsy Report?

Chapter 44. What Are Death Certificates and How Are They Used?

Chapter 45. What Forensic Careers Are Available?

Appendix A. Model Postmortem Examinations Act

Appendix B. When Is an Autopsy Required?

Appendix C. Forensic Autopsy Protocol: Indiana

Appendix D. Famous Autopsies

Appendix E. U.S. Standard Certificate of Death

Appendix F. Death Certificate—Al Capone (mobster)

Appendix G. Federal Trade Commission Funeral Rule

References

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CHAPTER 1. BEING DEAD

Being dead is a mutilating experience. What happens to corpses is, for the most part, unspoken and sometimes considered unspeakable. Post-death activities have long been enveloped by a mystical shroud. This alone exacerbates the fear people have about death.

The Bible says, As one dies, so dies the other. They all have the same breath, and man has no advantage over the beasts . . . all are from the dust, and all turn to dust again.(1) Whether we believe that death is a part of life, the end of life, or the start of a new life, we must acknowledge the fact that everyone eventually dies. In the United States alone, about one out of every 135 people die each year.(2) In personal terms, this means that most of us will have to deal with the deaths of friends and relatives during our lifetime.

As a population’s size and average age increase, so do the number of deaths. In the United States, for example, the population in 2012 was about 312 million. Of these, more than 2.3 million will die—a rate of 7.41 per 1,000 people per year. An increase in death rate is not predicted until approximately 2020, when the progressive aging of the U.S. population will trigger steady growth—rising to 9.7 by 2045–2050 (Table 1.1).

Table 1.1: Projected U.S. Population and Deaths

Sources: Bell FC, Miller ML: Life Tables for the United States Social Security Area 1900–2100. Actuarial Study No. 120. Washington, DC: Social Security Administration, 2005; and Statistics. National Funeral Directors Association. www.nfda.org/media-center/statisticsreports.html. Accessed 15 December 2011.

This book, though, is not about death. Rather, it is about some of the unseen after-death activities that go on within our living world: autopsies, death investigation, and exhumations. The act of dying is universal and personal, but it is only the first act in a complex social play.

What do we do with our dead?

Societies around the world and over time have used myriad ways to dispose of their dead. As Habenstein and Lamers state in The History of American Funeral Directing:

Assume that we are confronted with the dead body of a man. What disposition shall we make of it? Shall we lay it in a boat that is set adrift? Shall we take the heart from it and bury it in one place and the rest of the body in another? Shall we expose it to wild animals? Burn it on a pyre? Push it into a pit to rot with other bodies? Boil it until the flesh falls off the bones, and throw the flesh away and treasure the bones? Such questions provoke others which may not be consciously articulated, such as: What do men generally think this body is? And, What do they think is the proper way of dealing with it?(3)

Who should know the answers to these questions?

Physicians? My experience is that they have only a partial understanding of even the medical procedures related to dead bodies, such as autopsy, anatomical dissection and organ donation. They have no better information about other aspects of corpse disposal than does the general public.

Morticians? Their knowledge also centers only on their own practices.

Perhaps the only people who really know what happens to the dead are a few anthropologists specializing in corpses.

It is always disturbing when important areas of human existence are hidden away from public view. For centuries the taboo subject was sex. William Butler Yeats had the right idea when he wrote, I am still of the opinion that only two topics can be of the least interest to a serious and studious mood—sex and the dead.(4) The new taboo topic is death—or more particularly, the dead.

When the National Funeral Directors Association placed a series of newspaper advertisements throughout the country, to grab the audience, they titled these ads What Subject Bugs People More Than Sex? The answer, of course, was death.

Why don’t we know more about what happens to dead bodies? One answer is that the funeral industry itself helps us hide death. Until 100 years ago, people in Western cultures saw their relatives die at home and, usually took care of them in the process. Then modern medical institutions and the funeral industry began to hide the dead, making death a medical experience, orchestrating funeral rites, and depersonalizing the process of parting from loved ones.

A fear of the dead and the belief that corpses pollute the living are ancient beliefs, common among nearly all people. The Sacred Book of the Persians regarded the corpse as taboo, since it was supposed to be saturated with danger for mortals. Biblical priests (Kohanim) were not allowed to touch the dead, and biblical injunctions against those handling the dead were severe: Whosoever is unclean by the dead shall be put outside the camp, that they defile not the camp in the midst whereof the Lord dwells.(5) The ancient Roman high priests (pontiffs) performed funerals from behind curtains, never even seeing the dead. Among the Shuswap Indians of British Columbia and the Thompson River Indians, those touching a corpse had to sleep on thorny branches for a year. Even today in the Fiji Islands, anyone touching someone who has died a natural death cannot touch food with his hands for several days; if he has dug a chief’s grave, he is considered unclean for a year. In southern China, those who handle the dead are social pariahs, and in India, as long as a Hindu body remains in the house, neither members of the household nor neighbors can eat, drink or work.(6) In present-day America, the dying are sent to hospitals and corpses are disguised to appear alive during the funeral. Reminders of death are not appreciated, perhaps because all men think all men mortal but themselves.(7) One grave marker amplified this, saying:

Remember me as you draw nigh

As you are now, so once was I.

As I am now, so must you be,

Prepare for death and follow me.(8)

An American colonial epitaph reinforced that thought:

All ye who read with little care,

Who walk away and leave me here,

Should not forget that you must die

And be entombed, as well as I.(9)

As a society we are generally ignorant of what goes on after death. Many Americans have never attended a funeral or burial, let alone seen an autopsy, attended a wake, or participated in other rites for the dead. It is not because we cannot, but rather because of a committed stance towards ignoring the whole issue. Acknowledging the dead would mean accepting one’s own mortality.

When we do acknowledge the dead, it is often with an avowed lack of attention and concern. Modern society often treats funerals and burials as disagreeable events to be handled as quickly and perfunctorily as possible. Ceremonies are abbreviated, and drive-through visitation at some funeral homes now limits involvement even further. Yet, as Leon Kass said,

One of the most unsettling—yet for the thoughtful man, also interesting—things about confronting cadavers, dead bodies, or the question of organ transplantation is that we are by practice forced to decide who or what we think we are . . . How to treat dead bodies may seem to be a trivial moral question . . . But . . . few are as illuminating of our self-conception and self-understanding.(10)

If this intentional ignorance regarding our dead merely led to the manipulation of grieving survivors by the death industry, it would be unfortunate but not catastrophic. This disregard and misunderstanding, however, has caused the living to suffer and even die as well.

Relatives, in order not to mutilate the body of the decedent, have repeatedly resisted donating their organs and tissues—unwittingly causing thousands of potential recipients to die. Likewise, medical professionals have also been blocked from practicing, teaching and experimenting on dead bodies—and unknown numbers of live patients have been used for these purposes instead.

Elisabeth Kübler-Ross, in her ground-breaking book On Death and Dying (MacMillan, 1969), began to remove the stigma from discussing death. Many books, articles, conferences, and educational courses subsequently appeared to help people measure, discuss and rationalize their attitudes and fears about the topic. While this allowed the public to feel proud of their openness, it is not clear whether the self-congratulatory attitude was appropriate. Geoffrey Gorer suggests that "death has become more and more ‘unmentionable’ as a natural process . . . The natural processes of corruption and decay have become disgusting . . . the art of the embalmers is an art of complete denial.(11) And Enright asks pointedly whether death is a dirty little secret, a thing of shame, the last taboo in an otherwise totally uninhibited world?(12) As Philippe Ariès wrote, When people started fearing death in earnest, they stopped talking about it, starting with clergymen and doctors; death was becoming too serious."(13)

Richard Selzer, a surgeon and author, aptly described this situation, in which the reflexive distaste for one poorly understood medical procedure, the autopsy, is compared to another poorly understood, yet accepted procedure, embalming:

SHE: Is he dead, then?

HE: I am sorry.

SHE: Oh, God.

HE: I should like to ask . . . because of the circumstances of your husband’s death, it would be very helpful . . . to do . . . an autopsy.

SHE: Autopsy? No, no, not that. I don’t want him cut up.

Better to have agreed, madam. We use the trocar [a very large hollow needle] on all, autopsied or merely embalmed. You have not heard of the suction trocar? Permit me to introduce you to the instrument.(14)

Information about treatment of the body after death has been hard to obtain, though the material is there, albeit hidden on medical library shelves and in professional funeral manuals, scholarly books and academic articles. But the topic has been, for the most part, kept out of mainstream literature. Fiction writers have accessed bits and pieces to spice up horror stories and other macabre tales, but no one source has provided a comprehensive picture. For a complete, detailed view of everything that can happen and has happened to bodies after death, see Death to Dust: What Happens to Dead Bodies? (Galen Press, Ltd.; www.galenpress.com).

This book focuses on the autopsy, a procedurally difficult, painstakingly complex, and often enlightening examination of a decedent’s body. Often done to help physicians discover the cause of death, autopsies are viewed by the public as a macabre practice performed in the darkest corner of the hospital basement, called a morgue.

A little more (often intentionally grisly) light has been shed on the practice as forensic autopsies have become routine fixtures in police and crime television shows, movies, and novels. This book lays out, in laymen’s terms, the history, technique and benefits of both the routine hospital autopsy and the arcane world of the medical examiner. How and on whom are autopsies performed? What special techniques do pathologists and medical examiners use? Can the pathologist really determine an accurate time of death? What do pathologists really do at the scene of a major disaster? How do individuals get copies of autopsy reports?

Why don’t we begin by shedding a little light into the morgue?

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CHAPTER 2. WHAT IS A MORGUE AND HOW LONG WILL MY BODY BE THERE?

The Morgue, derived from a French term meaning ‘to look at solemnly,’ was originally an area within the Châtelet, a stone fortress in Paris. From the fifteenth to the eighteenth century, the Châtelet was used to display corpses, often murder victims, for public identification. (Street murders in eighteenth-century Paris were common.)(15) Subsequently, morgues were called dissection houses and used for education. Until the twentieth century, French citizens could stroll through the morgue just as they could attend a public hanging.

Today, bodies are stored in morgues located in hospitals and medical examiner/coroner (ME/C) facilities until their final dispositions are decided. For convenience, hospitals usually place their morgues adjacent to the autopsy room. When a hospital patient is pronounced dead, they immediately become bodies, shrouded and quickly removed through a back elevator or hall, out of the sight of non-hospital persons.(16)

While the original morgue-type corpse cooler (see Figure 2.1), patented by Charles Kimball in 1868, was a large refrigerator with one compartment for the body and the other for ice, the modern morgue is a large room with tile floors, tile wrapped at least halfway up the walls, stainless-steel tables, operating room sinks, and refrigerators. These refrigerators are built into the wall with stainless steel doors and trays that slide out so that bodies can be easily loaded, unloaded, and exhibited for identification. Morgue refrigerators are kept at 2°C to 8°C (35.6°F to 46.4°F) so that corpses do not visibly deteriorate for four days or longer. Due to limited space, both hospitals and medical examiners encourage morticians to remove bodies quickly, since death continually provides new bodies.

Figure 2.1: Corpse Cooler

Thomas Lynch, a poet–mortician, described a friend who came to rest in the morgue:

Milo’s room is called PATHOLOGY. . . . [He] is downstairs, between SHIPPING & RECEIVING and LAUNDRY ROOM, in a stainless-steel drawer, wrapped in white plastic top to toe, and—because of his small head, wide shoulders, ponderous belly, and skinny legs, and the trailing white binding cord from his ankles and toe tag—he looks, for all the world, like a larger than life-size sperm.(17)

When U.S. funeral home workers remove a corpse from a hospital morgue, the pathology assistant opens the morgue and identifies the correct body. Before the days of individual pagers and cell phones, these hospital personnel, then known as morgue attendants, were often audibly paged as Mr. Post (as in postmortem).

Disasters that cause multiple deaths often require temporary morgues, which may take many forms. During the 1977 Beverly Hills Supper Club fire in northern Kentucky, rescue workers laid 150 bodies dressed in their evening finery in a temporary morgue on the grass of the outdoor wedding chapel. They had to be moved again when the still-raging fire threatened to engulf them. After airplane crashes, disaster workers commonly use airplane hangars as morgues, often with adjacent refrigerated trucks (sometimes from food wholesalers) to preserve the bodies while they are processed.(18) Hangers provide the forensic teams with the large areas they need to process bodies and pieces of bodies. They use the morgue to x-ray the parts, do dental and fingerprint examinations for identification, autopsy bodies, and embalm them when possible. After large disasters the accumulated bodies can quickly overrun official morgues. After the devastating Haiti earthquake in 2010, for example, the Port-au-Prince morgue quickly overflowed and filled the parking lot out front.(19)

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CHAPTER 3. WHY ARE SOME MORGUES OVERCROWDED?

Even without disasters, morgues are often overcrowded, usually because bodies go unclaimed when no survivors can be identified or those that can will not pay for burial or cremation.

The Washington, DC, city morgue fell victim to the city’s financial woes when the crematorium broke in 1996, creating a 74-body backlog, not to mention a waiting list of 200 autopsies and 400 toxicology analyses. The Washington Post reported that the autopsy room’s floors were sticky with blood and other fluids, the air conditioning was broken, and body bags filled with corpses were ripped, making for a most unusual odor.(20)

During the infamous heat wave of 1995, when triple-digit temperatures baked Chicago, so many bodies filled the Cook County morgue that refrigerator trucks were brought in to store them. Trying to eliminate the backlog, pathologists averaged 13 autopsies an hour—about one every 4 ½ minutes. In early 2011, and without any unusual event, the Cook County morgue was again so crowded that bodies were doubled-up on trays. According to Cook County Medical Examiner Dr. Nancy Jones, We had this huge upswing in deaths right at the end of the year, and with the holidays being on Saturday, it really created a backlog because the funeral directors weren’t coming in. But, she added, My rule is, if you have two bodies on a tray, you have to have two thin bodies. We’ve been doubling people up for decades.(21) Sounds sort of like packing bodies into sardine cans.

The Los Angeles County morgue also experienced unprecedented overcrowding in 2006. The morgue, designed to hold up to 350 bodies, had 447 bodies at one point, prompting workers to stack them on top of one another and to remove some of them from refrigerated storage and