Abstract
The editorial in the last issue (Horowitz RE. Autopsies: an exercise in futility? J R Coll Physicians Edinb 2009; 39:194-5) was provocative, valuable and of immediate concern. In addition it is worth recording the researches carried out in Edinburgh by HM Cameron, at that time a senior lecturer in the University Department of Pathology. He and his colleagues, McGoogan, Clarke, Wilson and Watson, provided an exhaustive and thorough enquiry on the role of the autopsy; an enquiry noteworthy for its close collaboration with consultants from four medical and two surgical units in Edinburgh.
In one of their series1 of l54 autopsies they found that 15% of main diagnoses were not confirmed and 42% of causes of death were not confirmed. These results were deemed by pathologists and clinicians to be clinically significant. Consequently they were not convinced that the clinician was always well placed to judge the potential value of an autopsy. In a prospective study2 of 1,152 hospital autopsies, there were many examples of overdiagnosis and underdiagnosis, all encountered in a routine hospital autopsy service. They also noted that death certificates were unreliable as a source of diagnostic data, the major diagnosis being wrong in about a quarter of cases.3
An editorial in the Journal of the Royal Society of Medicine questioned if we really can accept that modern clinical techniques are so definite as to be regarded as supporting the demise of the autopsy.4
Although there are many reasons for the decline of the autopsy, one factor is the sordid and depressing environment of many postmortem facilities. A significant rise of interest in Edinburgh occurred when the late Sir Alastair Currie improved accommodation, introducing air-conditioning, audio-visual aids and closed circuit television; specimens were dissected by junior staff and comments made by experienced consultants.
The idea of Dr Horowitz of a central or regional facility divorced from the hospital pathologist who then would be freed from the chore of the autopsy is indeed radical. It seems to me like the creation of a ghetto of the dead. The autopsy and the diagnostic biopsy are intrinsically linked, each supporting the other. The quality of both is improved by combination. After all, what is clinical medicine but pathology on the wing?
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