Autopsy Photography and Radiology

Autopsy Photography

The benefits of autopsy photographs have increased greatly with digital photography, and gross photographs can be important parts of autopsy reports, clinical conferences, consultation, teaching, and research. Digital cameras are quite easy to use and, with a moderate amount of attention to sample preparation, composition, and camera settings, produce excellent gross photographs. Additionally, digital photographs are easy to share and display, but with this there comes the need for additional safeguards against improper access or sharing of such photographs. Photographic systems must be engineered to prevent improper distribution of autopsy photographs, particularly ones that display external features of bodies or protected health information. In most cases, only a carefully chosen subset of digital photographs are appropriate for release into the general medical record. Of course, photography in the autopsy room should be restricted only to approved personnel using data-secure digital cameras and information systems.

Pathologists generally use photographs to demonstrate morbid anatomy, but they may be equally important to document normal anatomy. In either case, to be successful, autopsy photography must demonstrate the subject accurately, enhance written or verbal descriptions, and be performed easily and economically. These are important skills to learn during pathology training and should be a part of all training programs. The photograph also reflects departmental quality in general. A dramatic, resplendent photograph presented at a conference or in consultation goes a long way toward enhancing the pathology department's reputation. It is our hope that the material presented briefly herein will help the reader become a more capable medical photographer. For those desiring a more detailed discussion of photographic principles and specialized techniques, we recommend a number of excellent textbooks.

Photographic Equipment and Supplies

Camera

There are many different cameras or photography systems that would be appropriate for autopsy photography. Most digital cameras take excellent photographs with proper settings, but a major consideration is how to import photographs securely to the correct case in the laboratory information system (LIS) used for autopsies. Commercial photographic systems are available that include cameras, photographic stand, computer, and software that can both control the camera and transfer images to the LIS, but these can be quite expensive. Some information systems also have camera communication protocols, both wired and secure wireless, that interface directly with digital cameras. These allow direct uploading, and homemade systems based on these have been described. Finally, storage on secure encrypted media may be used that are then taken to a workstation for uploading. No matter which camera system is chosen, much attention should be given to linking the photographs to the correct case and keeping the photographs secure. Often an indicator of case number is included in the corner of the field of view to embed case information in the photograph itself, but it should be remembered that the case number is interpreted in some institutions as protected health information when sharing the image. The LIS should have clear designation of which personnel may view or download photographs.

Many autopsy services will find it necessary to have both a handheld digital camera and photographic stand–mounted camera. In both cases, either a digital SLR or high-quality compact “point-and-shoot” camera should suffice. Features that are important include (1) macro capability for close range, (2) capability for both automatic and manual modes for exposure settings, (3) ability to manually set f -stop high enough for good depth of field, (4) good white balance adjustments, (5) fill-in flash with capability for turning it off, and (6) live preview capability on an easily viewable screen. Zoom can be quite handy for easy composition of photographs and can be useful to maintain adequate distance for good depth of field and optimal illumination. It is best that cameras be capable of at least 5 megapixels/image, particularly because many images will be cropped significantly if used in presentation or publication. It also is helpful to have the ability to review new photographs with enough detail to gauge whether they are sufficient before proceeding. No matter which camera is used, it is critical to spend time learning its various settings, and having a spare identical camera is prudent. It is not good practice to allow photographs to be taken with cameras other than those that are part of the engineered secure system.

Photographic Stand and Specimen Box

Photographic stands from a number of manufacturers are available through suppliers of professional photographic equipment. For specimen photography, one requires a stand with a vertical column. These may be freestanding (copy stands) or mounted on a wall. In either case, they should be sturdy and placed in areas free from vibrations. In addition to vertical movement, a good photographic stand often allows camera movement toward and away from the front of the column and rotation on this axis. Specimen boxes can be purchased or handmade according to the specifications supplied by Vetter. For autopsy photography, specimen boxes should provide even background illumination and have a surface area that accepts large specimens. The ideal specimen box has a removable top plate that is easily changed and cleaned. It is helpful if the box can also be configured to provide white transillumination for digitization of plain x-ray films for entry into the LIS.

With a photographic stand, a flat black camera is desirable because it reduces the possibility of reflection in the background; gaffer's tape can be used to mask reflective surfaces as needed. It is helpful to have a live preview image, either through swivel viewfinder or accessory screen that can be viewed easily while adjusting the specimen. A cable or remote shutter release is mandatory because it reduces camera motion and eliminates reflections on the background from the operator's hand. Photographic stands usually have provisions for accessory lighting angled from above on each side, and the best sets allow the angle of the incident light to be changed. Given the live preview of digital photography, it is now easier to check that automatic white balance on the camera is properly gauged for the chosen lighting setup. Fluorescent lights have the advantage of emitting less heat, but there are many options for lighting.

Background

The ideal background isolates the subject, is not distracting, and is free from clutter. Backgrounds in use for specimen photography include white, black, gray, and colored. There is considerable disagreement among specimen photographers about the ideal background choice. Each has its advantages and disadvantages, and ultimately one's choice is based on personal preference. However, regardless of which color background is chosen, make sure that it is easily cleaned. This condition is achieved when the top plate or surface in contact with the specimen is easily removable and washable. Glass or Plexiglas plates fulfill this requirement.

White backgrounds do not compete with the color of the specimen, although specimens may appear lighter. They are effective in isolating the specimen but achieve a better definition of contour and outline for dark specimens than they do for light specimens. One of the advantages of white backgrounds is that they convert well to black-and-white publication prints. The major disadvantages include distracting shadows and glare that may be difficult to eliminate. Typically, white backgrounds are obtained through the use of a transilluminated light box, a relatively easy system to assemble and maintain.

Black backgrounds provide a dramatic impact. When projected in a dark room, specimens photographed against a dark background have the appearance of floating, providing a three-dimensional effect. Like white backgrounds, black backgrounds do not compete with the color of the specimen. However, they provide better isolation of lighter specimens than dark specimens. Black backgrounds may place too much emphasis on the outline of the subject, particularly if it is light colored. This has the effect of distracting the viewer from important internal details. Some find it difficult to obtain consistent black backgrounds except with deep-nap velvet, which has the disadvantage of requiring frequent washing. Vetter relies on a glass-topped black box made by placing clear glass over a wooden box with its insides painted flat black and its bottom lined with black velvet. The distance separating top plate and background adds to the three-dimensional effect. Others spray the back of the glass with flat black paint and then place the specimen on the other side.

Most who use colored backgrounds for specimen photography prefer blue or blue-green because these colors complement the pink to red colors of most tissues. Colored backgrounds provide vividness and clarity to the subject. They also increase the visibility of important white, black, or gray areas present in the specimens that tend to be lost against white, black, or gray backgrounds. When projected on a screen, the reflected light from the background adds brightness and helps maintain viewers' interest. However, colored backgrounds cause viewer color adaptation, which influences true color perception. For this reason, many deem colored backgrounds undesirable. Colored backgrounds are easily obtained with transillumination and colored glass or Plexiglas sheets or with colored mat board placed in a specimen box.

Gray backgrounds avoid many of the pitfalls mentioned for black and colored backgrounds in that they do not concentrate undue attention on the specimen border or produce false color perception. However, like white backgrounds, gray backgrounds produce visible shadows that are difficult to eliminate. Furthermore, uniform gray backgrounds are difficult to repeat from photograph to photograph because of color cast and reflectivity of specimens.

Photographic Technique

Unlike photography in surgical pathology, a handheld camera is frequently necessary in autopsy pathology. The photographer should be familiar with basic functions of the camera, including switching between record and display, adjustment of exposure settings, flash settings, and viewing images for adequacy. New users should be coached about when to use flash and how to brace the camera to avoid movement when pressing the shutter button. When handheld, the camera base should rest on the supinated left palm, while gripping the right side with the right hand, all while bracing elbows against either an immovable object or the photographer's flanks.

When using a photographic stand, one can establish a standardized set of photographic conditions that can yield excellent results, even for the novice photographer. The object is steadied on the photographic stand, brought into focus, and the white balance is checked for adequacy. For most modern digital cameras, the autofocus works very well, but the photographer should be aware that autofocus programs usually only ensure that the central portion of the photographic field is in focus. Illumination should be changed to demonstrate the gross findings, usually by changing the orientation of the object and angle of the lights, until the preview image looks optimal. Contoured objects often need to be rotated to optimize illumination of important features from side lighting. Deeper recesses may be illuminated by turning on the fill-in flash, and it is usually best to compare images taken with and without flash. An important aspect that is not obvious to most novice photographers is that the depth of field must be considered. The depth of field is the range of distances from the camera that are in acceptable focus; this is increased by setting the f -stop to maximum and by increasing the distance of the camera from the object along with zoom-in. For most photodocumentation it is best to maximize the depth of field.

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