Notes from an emergency room doctor: One incision is made Y-shaped, from the armpits to the center of the chest and straight down to the lower abdomen. Another is made in the back of the head, from ear to ear. The body cavities and brain are exposed and everything is examined by sight, by feel, by smell. This is not the start of any great surgical cure. This is rather how an autopsy begins – the medical examination of a dead human body usually performed at the request of legal authorities, physicians, or next of kin to determine the cause of death.
Nowadays, however, it seems that the only time the public hears about an autopsy is in conjunction with some violent death. Either the police want one to pursue a murder investigation or a coroner is trying to identify the victims of some horrendous accident. But autopsy used to be and is much more than a graphic scene for some television “who-done-it.”
Autopsy used to be the definitive manner in which medicine assessed the quality of a society’s health care. About 50% of those who died in U.S. hospitals were autopsied throughout this century, peaking to 52% in 1966. But the autopsy rate has since then steadily declined to less than 15% today. One might speculate that physicians now have a greater understanding of disease and more sophisticated methods of diagnosis and that therefore there is less need for autopsy. But researchers at Brigham and Women’s Hospital in Boston studied autopsies from the 1960’s, 1970’s, and 1980’s and found that, in each decade, about 22% of autopsies revealed a major clinical diagnosis that had been missed. And, 10% of the time fore-knowledge of that information would have altered therapy and probably prolonged patient survival.
Autopsy obviously has an important place in promoting medical knowledge and improving the quality of care. Unfortunately, fewer autopsies are performed today because doctors and hospitals fear that besides providing useful information on improving therapies and care, the autopsy will also provide fodder for malpractice attorneys. And often, in the most complicated cases where the most could be learned, families decline autopsies feeling that their loved ones have already suffered enough in the hands of medical science.
In the Middle Ages, the Catholic church forbade dissection of the human body. It wasn’t until the Renaissance that that policy changed and physicians were permitted to dissect the human body to discover its workings and disease processes. Though perhaps gruesome in description, autopsy is the one medical procedure that changed medicine from an extension of ancient wizardry into a true science.
Today, the public benefit that could come from performing more autopsies has been lost because of our foul medicolegal climate and our human frailty in handling grief. And I expect it will take a lot of old fashioned wizardry to change all that.