Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
In this Article
- What is an autopsy?
- Who determines whether an autopsy is performed?
- How is an autopsy performed?
- What other special studies may be done as part of the autopsy?
- What is the autopsy report?
- Why is the autopsy rate declining?
- What are the benefits of autopsies?
- Who pays for autopsies?
- What is the history of the autopsy?
- Should the autopsy be revived?
- Autopsy At A Glance
Who pays for autopsies?
Presently, there is no direct funding to hospitals or doctors for autopsies. As part of the federal government's Medicare funding to hospitals, reimbursement for autopsies is theoretically included in fixed payments that hospitals receive. Thus, the federal government contends that it is paying for autopsies. Since these funds are not specifically earmarked for autopsies, they may not reach the pathology department or pathologist. Managed care organizations consider the autopsy to be built into their hospital contracts. However, these organizations have stated that they are willing to reimburse for autopsies if and when they are convinced of their value. Ultimately, the family may more often be called upon to absorb the cost of the autopsy.
In our litigation-oriented society, a growing proportion of private-pay autopsies are motivated by distrust, anger, and a desire to sue the potentially responsible physician(s) and hospital. Several groups of pathologists and business persons throughout the country are marketing their autopsy services through direct mail, newspapers, funeral homes, and online. Whether the quality and objectivity of these private autopsies will match those of general hospitals and academic medical centers remains to be determined.
What is the history of the autopsy?
The earliest anatomists and pathologists could be considered ancient hunters, butchers, and cooks who had to recognize organs and determine if they were suitably edible. In ancient Babylon, perhaps as early as 3500 BC, autopsies on animals were performed not for the study of disease, but rather for the practice of predicting the future by communicating with divine forces. The intestines and liver were believed to contain messages from divine spirits.
Galen (131-200 A.D.), a disciple of Hippocrates practicing in ancient Greece, performed surgical dismantling (dissection) of animals and humans. He determined that Hippocrates' theory that disease was due to four circulating humours (phlegm, blood, yellow bile, and black bile) was correct. Galen was a highly respected, powerful, and dogmatic individual who dominated the medical thinking of his time and for hundreds of years to follow. It is said that the four humour doctrine paralyzed medical science for about 1400 years.
In general, before 1700 there was a negative attitude regarding dissection of the human body. Egyptians, Greeks, Romans, and medieval Europeans performed dissections for religious reasons or to learn anatomy, but this was not done in any systematic fashion. There were, however, some notable exceptions. In the late 1200s the law faculty dominated the University of Bologna and would order autopsies to be performed to help solve legal problems. Thus, some of the earliest autopsies were medicolegal cases. In the late 1400s in Padua and Bologna, Italy, the sites of the world's first medical schools, Pope Sixtus the IV issued an edict permitting dissection of the human body by medical students. Before such edicts from religious leaders, it was considered a crime to dissect the human body and criminal prosecutions for "body snatching" by students of anatomy date back to the early 1300s.
By the 1500s, the autopsy was generally accepted by the Catholic Church, marking the way for an accepted systematic approach for the study of human pathology. While a number of "giants" around this time, such as Vesalius (1514-1564), Pare (1510-1590), Lancisi (1654- 1720), and Boerhaave (1668-1738) advanced the autopsy, it is Giovanni Bathista Morgagni (1682-1771) who has been considered the first great autopsist. During his 60 years of observations, Morgagni insisted upon correlation of pathological findings with clinical symptoms, marking the first time that autopsies made major contributions to the understanding of disease in medical science.
Some historians say that the power of the autopsy in medical education peaked during the 1800s. In the beginning of that century the Allgemeine Krankenhaus in Vienna was considered the premiere medical center of the Western World, in large part because of the stature of its Pathology Institute which was headed by Karl Rokitansky (1804-1878). Almost every patient who died was taken to the Rokitansky Institute, which still exists in Vienna, for autopsy. Rokitansky is said to have supervised 70,000 autopsies, and personally performed over 30,000, averaging two a day, seven days a week, for 45 years. Rokitansky stressed a systematic, almost ritualistic, approach to the autopsy with every patient receiving the same detailed examination. For the sake of objectivity, Rokitansky, unlike Morgagni, did not care to know the clinical history of the patients. Because of this style and his disinclination to apply microscopy in a routine fashion, many of Rokitansky's theories about diseases proved to be incorrect.
Rudolph Virchow (1821-1902), an eminent German statesman and pathologist, was a younger contemporary and competitor of Rokitansky. Unlike Rokitansky, he grew up with the microscope, and was most influential in the systematic application of microscopy to study disease. Virchow advanced the doctrine which held that cellular pathology was the basis of disease, finally laying to rest the humoural theory of Hippocrates and Galen. In many ways, Virchow could be considered the first molecular biologist. Under Virchow, Berlin replaced Vienna as the premier center of medical education.
Many clinicians, upon returning from study in Berlin, became leaders in North American medicine. The most notable of these physicians was the legendary Sir William Osler, who worked in Canada and the US. Osler was arguably the most respected and revered North American physician of his time. He studied with Rokitansky and Virchow and relied heavily on autopsy studies for his own education. Osler not only performed autopsies himself and taught others from autopsies, but also left detailed instructions for his own autopsy. In speaking of himself, Osler told a friend: "I've been watching this case for 2 months and I'm sorry I shall not see the postmortem." As expected, the autopsy showed that all of Osler's diagnoses were correct.
In 1910, Abraham Flexner reported the sorry state of medical education in the U. S. at that time. The Cabot report issued from the Massachusetts General Hospital in 1920, based on approximately 3000 autopsies performed, revealed astonishing diagnostic inaccuracies on the part of clinicians. Resulting medical reforms included the placement of autopsy pathology as a central, integral component of medical education.
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