Anthropology
Open Access
ISSN: 2332-0915
ISSN: 2332-0915
Research Article - (2013) Volume 1, Issue 1
To date, the whole brain is classically freshly examined during the autopsy, and can be removed in entirety in order to perform a complementary neuropathological examination. Is-it legitimate to bury a corpse without the brain – this symbolic organ – in order to satisfy the physician’s curiosity and/or the scientific necessity? Indeed, brain is an organ with a strong symbolic signification. In order to estimate the accuracy of such post-mortem neuropathological examination of the whole brain, a brief survey was carried out in the Department of Pathology and Forensic Medicine of the R. Poincaré University Hospital (West Paris, France) between 2009 and 2011. On a total of 32 brains (=13.4%) removed on a total of 238 autopsies of adult individuals (in a good state of preservation, without exteriorization of the intra-cranial structures) and get full analysis by a neuropathologist, the final diagnostic of the cause of death given at the end of the autopsy was never changed. However, circumstances of death has been modified and/or completed in almost 62.5% of the cases (n=20). Our hypothesis is that post-mortem examination of the whole brain is scientifically legitimate, but not from a purely ethical point of view. Several practical solutions can be proposed in order not to deprive a human dead body from one of its most symbolic organs (but their efficacy facing neuropathology has to be tested). Indeed, behind this case of full brain sampling is the problem of the introduction of emotions and cultural visions that we have about internal organs; this global problem for all physicians could change their current practice when confronted to the death of their patients.
Keywords: Forensic Nursing; Neuropathological
It is widely accepted by the neuropathological community (including forensic pathologists) that valuable gross dissection of the central nervous system, and microscopy must be performed after formalin fixation, except to provide fresh tissue for microbiological or toxicological studies [1].
To date, the whole brain is classically freshly examined during the autopsy, and can be removed in entirety in order to perform a complementary neuropathological examination [2]. In the later case, the brain, fixed in a solution of formaldehyde at 10%, is sectioned at least 3-4 weeks after the autopsy with further classical histological procedure [3] the rest of the brain is then never deposed in the body, but cremated with other anatomical wastes.
Thus the question is: is-it legitimate to bury a corpse without the brain – this symbolic organ – in order to satisfy the physician´s curiosity and/or the scientific necessity (mainly to get neuropathological diagnostic and/or conserve it for further researches in the fields of degenerative disorders or infectious diseases) [4-9]?
Indeed, brain is an organ with a strong symbolic signification. This is also the case for the heart,9 which is also sometimes removed for comparable scientific reasons. Previous studies have shown that most of the families are very reluctant to whole brain removal: for example, in England, on a total of 111 families consulted in a context of a forensic autopsy, if 96% authorized research use of tissue samples, only 17% agreed to whole brain donation [5].
In order to estimate the accuracy of post-mortem neuropathological examination of the whole brain, we carried out a brief survey. Between January 2009 and April 2011, 32 brains (=13.4%) have been removed on a total of 238 autopsies of adult individuals (in a good state of preservation, without exteriorization of the intra-cranial structures) performed by one of us (PC) in the Department of Pathology and Forensic Medicine of the R. Poincaré University Hospital (West Paris, France), and get full analysis by a neuropathologist. This sample was composed of 19 males and 13 females (sex ratio of 1.46). The average age was 55.6 years-old (extreme ages from 14 to 85 years-old). Manners of death included 21 natural deaths (including 4 of encephalic origin), 6 suicides, 2 homicides and 2 accidental deaths. On this total of 32 cases, 23 were forensic autopsies (72%), and 9 were purely hospital/scientific ones.
For all cases, the neuropathological examination of the whole brain never changed the final diagnostic of the cause of death given at the end of the autopsy (Tables 1 and 2). However, circumstances of death (i.e. the subsequent patho-physiological status of the individual) has been modified and/or completed in almost 62,5% of the cases (n=20).
| Case | Age | Sex | Circumstances of death | Cause of death at the end of the autopsy | Brain lesions related to the death mechanism | Associated brain lesions |
|---|---|---|---|---|---|---|
| 1 | 41 | M | Interpersonal violence in a context of chronic alcohol and cannabis intoxication | Bilateral pneumopathy complicating a sub-dural hematoma | Uncal herniation with subdural hydroma + important and diffuse axonal ruptures in the white matter + diffuse vascular congestion | Old lacunar infarct |
| 2 | 41 | M | Suicide at home with massive drug and alcohol intoxication | Asphyxia following Mendelsohn syndrome after massive drug and alcohol intoxication | Diffuse vascular congestion | Old traumatic lesions (temporal and frontal) |
| 3 | 45 | M | Found dead on the ground in winter in a context of HIV+ and depression | Hypothermia | Slight diffuse vascular congestion and ischaemic neuronal lesions | VIH encephalitis |
| 4 | 56 | F | Found dead in the water of her bath-tub in a context of progressive dementia and muscle weakness | Sudden death following arrhythmogenic right ventricular cardiomyopathy | - | Old and recent demyelinizing plaques |
| 5 | 61 | M | Found dead at his table in a context of chronic alcohol intoxication | Asphyxia following Mendelsohn syndrome after acute heart arrhythmia on ancient myocardial infarction | Severe diffuse vascular congestion and ischaemic neuronal lesions | Encephalopathy related to liver insufficiency and PP vitamin deprive + deterged old traumatic lesions |
| 6 | 61 | F | Found at home, seated, in a context of chronic alcohol intoxication and familial violence | Asphyxia following Mendelsohn syndrome after massive alcohol intoxication + old lesions of cerebral and cerebellum + pyometritis | Intense diffuse vascular congestion | Old traumatic lesions (temporal and frontal) |
| 7 | 65 | M | Fire in his apartment in a context of chronic tobacco intoxication | Acute CO intoxication | - | Deterged old traumatic lesions + senile degenerative alterations + atrophy of mammillary bodies possibly of alcoholic origin |
| 8 | 67 | M | Traffic accident, death after one month of hospitalization | Pulmonary embolism following prolonged confinement | Cranio-cerebral trauma (left hemisphere lesion with sub-arachnoidal hemorrhage) | Old traumatic lesion (right side) + Alzheimer type II glia + diffuse vascular lesions |
| 9 | 71 | M | Found dead at home in a context of Parkinson disease, diabetes mellitus, kidney insufficiency, hypertension, and chronic alcohol intoxication | No evident cause of death + diffuse atheromatosis lesions (including coronary arteries) | - | Senile neurofibrillar degenerescence |
| 10 | 73 | M | Sudden collapse when going to the toilets in a context of chronic lymphoid leukemia | Intra-cranial hemorrhage + left ventricular hypertrophic cardiomyopathy + old myocardial infarction + right ventricular dilated cardiomyopathy | Extensive cerebral contusions + sub-arachnoidal hemorrhage + left temporal horn inundation + brain oedema + intracranial hypertension + uncal herniation | Lesions related to chronic lymphoid leukemia |
| 11 | 74 | F | Found dead at home in a context of Alzheimer disease and heart surgery | Acute myocardial infarction | - | Degenerative and diffuse vascular lesions related to senile dementia |
| 12 | 77 | F | Murder by chlorhydric acid absorption followed by strangulation attempt and knife wounds | Diffuse physical burns on upper respiratory and digestive tracts | Ischemic lesions related to agony | Hypertensive arteriopathy lesions + moderate senile degenerative lesions |
| 13 | 79 | F | Found dead at home in a context of diabetes mellitus, arterial hypertension, hyper-cholesterolemia, epilepsy, and slight dementia | Acute myocardial infarction | Vascular congestion | Diffuse characteristic Alzheimer lesions + diffuse vascular alterations |
| 14 | 84 | F | Suicide by precipitation in the Seine river in a context of Alzheimer disease | Drowning | - | Characteristic diffuse Alzheimer lesions + senile degenerative lesions |
| 15 | 85 | F | Suicide by precipitation from a height in a context of depression | Bone and visceral polytrauma | - | Degenerative alterations and vascular lesions related to senile dementia |
Table 1: List of all forensic autopsies for which the conclusions have been modified and/or completed by the neuropathological examination of the whole brain (n=15).
| Case | Age | Sex | Circumstances of death | Cause of death at the end of the autopsy | Brain lesions related to the death mechanism | Associated brain lesions |
|---|---|---|---|---|---|---|
| 1 | 26 | M | Hospitalization for agitation and fever, seizures, and Gayet-Wernicke syndrome | Septic chock on pulmonary abscess | - | Gayet Wernicke encephalopathy + slight liver insufficiency related encephalopathy |
| 2 | 27 | F | Hospitalization for ineffective therapeutic in a context of drug consummation and VIH+ | VIH encephalitis | Multi-centric lymphoma | NeuroAIDS |
| 3 | 80 | M | Hospitalization for sudden liver insufficiency | Multivisceral insufficiency (especially liver) + acute necrosing pancreatitis | Intense liver insufficiency related encephalopathy | Minor senile degenerative lesions |
| 4 | 80 | F | Hospitalization for confusion and agitation, then sudden collapse | Pulmonary embolism | Severe vascular congestion | Characteristic aspects of Alzheimer disease |
| 5 | 82 | M | Hospitalization for endocarditis, then sudden collapse | Acute myocardial infarction | - | Multiples embolic infarction, some hemorrhagic, of various ages + liver insufficiency related encephalopathy + diffuse arteriolar hyalinosis + slight senile degenerative lesions |
Table 2: List of all hospital/scientific autopsies for which the conclusions have been modified and/or completed by the neuropathological examination of the whole brain (n=5).
Results
Our study confirms that post-mortem examination of the whole brain is scientifically legitimate: even if it does not modify the initial diagnosis given by the forensic pathologist, it allows a complete evaluation of all data relative to the health status of the individual. So, the research of the truth (from a forensic point of view) and the necessity of giving answers to families (from an humanistic point of view) imply a pursuit of such whole brain sampling and further analyses, especially when an anomaly is known for the patient, or macroscopically seen at the time of the autopsy.
Is it however possible to ameliorate this practice? How not to deprive a human dead body from some of its symbolic organs? Several practical solutions may be proposed:
1. To delay temporarily the restitution of the cadaver to the family during the time necessary for the brain tissues fixation and microscopic sampling (around one month).
2. To perform a post-mortem head MRI [10] in order to select cases requiring further neuropathological studies with a whole removing of the brain.
3. The presence of a neuropathologist during the autopsy, in order to perform his examination on the fresh brain, with immediate focal sampling and reintegration of the rest of the brain within the body (especially for cases of intracranial haemorrhage).
Behind this case of full brain sampling is the problem of the introduction of emotions and cultural visions that we have about internal organs. The brain (and the heart as well) indeed represents a symbolic entity; reasonably, one may hypothesize that less individuals would carry about complete sampling of the spleen or the appendix. Further questions follow this point of view: are our scientific approach modulates according to cultural background? Do we perform autopsies (scientific and forensic ones) for the cadaver itself (i.e. his memory, his personal cause of death, in an individual way) or for the others (i.e. the society, in a collective way) [11]?
There is clearly a notion of temporality and finality of the autopsy: is the goal a complete and global knowledge, or the full respect of the cadaver´s integrity?