Autopsy (cont.)
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.
Next: Should the autopsy be revived? »
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