Lesson 2
The features of leadthrough of pathoanatomical research are in the case of death from illnesses of infectious pathology.
Features of section dying from surgical or obstetric-gynaecological pathology.
Features of section of dying child. Features of clinic-pathoanatomical analysis and organization of sections in pediatric practice
PATHOLOGOANATOMIC BUREAU PURPOSES AND METHODS AUTOPSY LEGISLATIVE REGULATION IN UKRAINE
Pathologoanatomic service is designed to improve the processes of diagnosing and therapy.
It also represents the function of theoretic control by comparing clinical and anatomic diagnosis and analysing clinical and morphologic data. It also participates in the diagnosing process especially in the field of oncology. Pahologoanatomic service is a link of the epidemiologic net. It can reveal the cases of infectious diseases and prevent their spreading. Pathologoanatomy also delas with scientific researches on human pathology.
The pathologoanatomic service is represented by the pathologoanatomic bureaus, pathologanatomic departments of medica institutes nad specialised pathologoanatomic institutes and laboratories.
The pathologoanatomic service is headed by the State Chief pathologoanatomist. Regional departments are managed by the department chiefs.
The usual methodology of the local pathologoanatomic bureaus includes the following points :
· Autopsy and the following examination (necropsy), biopsy samples analysis
· Supplemental analysis (experiments, microbiologic, X-ray, biochemical, cytological, etc)
· Researches on ethiology, pathogenesis and tanathogenesis of the examined cases
· Comparison of clinical and pathologoanatomic diagnosis
· Clinico-pathologoanatomic councils
· Pathologoanatomic conferences.
The regional pathologoanatomic bureaus are headed by the regional most skilled pathologist. He’s subordinate to the State Chief pathologist. He regulates the activities of the local pathologoanatomic service branch and organizes the pathologists councils.
The State Chief pathologist and the regional Chiefs report to the Helath Ministry of their activities.
The regional Chiefs have the subordinate Pathology comission chosen by the Pathology scientific council.
The pathologoanaotmic bureau is a structural unit of the pathology service. It performs macroscopic and microscopic analysis and is capable of conductingother examinations (bacteriologic, chemical, etc). It performs histologic analysis of operation, biopsy and experimental samples.
It may involvethe diagnosing services of the local hospital if needed.
The pathologoanatomic bureaus are founded in the hospitals with at least 100-150 places, in lunatic asylums counting over300 places, in oncologic hospitalswith at least 100 places.
In countricide the pathology service is conducted by the regional departmetns of city pathology bureaus. The pathologist of the regional departments examine the materilas both from their local hospital and the region they are responsible for. If the case demands arriving to the spot they use the transport of their local hospital.
Biopsy and section samples from regional hospitals arc sent to the regional pathologoantomic bureaus.
The purposes of the pathologoanatomic bureau are as follows :
· Determination of tanathogenesis, pathology character and etiology
· Revealing of acute infectious disease cases by autopsy
· Analysis of operation and biopsy samples -Improvement of the clinicists theoretic knowledge on pathology by instructing them
· Control of the clinical and diagnosing process by comparing clinical and pathologoanatomic diagnosis
· Researches on the activities of the pathologoanatomic bureau.
If the medical staff of the hospital includes one pathologist only, he automatically becomes the chief of the hospitals pathologoanatomic bureau. The bureau chief can be changed by the regional Chief pathologist.
The hospital pathologoanatomic bureau chief participates in the yearly hospital report by filling in the pathology report.
He also s in charge of the histologist and laboratory staff training.
Pathologist conducts autopsy, protocols it and analyses the biopsy and operation samples. He also fills in the pasthologoanatomic diagnosis and the clinico-pathologic epicrisis (a special document where he points his opinion on the cases pathogenesis).
Pathologists never do night-watches or daily duty.
The laboratory staff subordinate to the pathologists process the operation and biopsy samples for histological analysis and protocol the examination itself.
The pathologoanatomic bureau should be equipped with all instruments and apparatus needed to conduct the mentioned researsch. The autopsy rooms should be adequate to the hygienic standards.
The daily schedule of the pathologoanatomic bureau is planned by the chief physician.
The duties of the regional pathologoanatomic bureaus are
· Autopsy , biopsy and operation samples analysis (material from local hospital and the controlled area)
· Comparison of clinical and pathologoanatomic diagnosis
· Clinical-anatomic council.
Regional service pathologists visit the local hospitals for autopsy. All small local hospitals should have an autopsy room with minimum equipment. The regional service pathologists use the transport of the local hospital.
Receiving, Holding and Giving away the Corpses
The corpses arrive to the pathologoanatomic bureau with special notes posted to them. Those notes have the name, age, gender, case history number, ward number and the clinical diagnosis on them. The corpses are taken to the bureau at least 2 hours after death. Pathologoanatomic death signs help to determine the exact time.
The death registry note arrives to the local governmental office at the day of the autopsy, signed by thepathologist. If the autopsy had been cancelled, it is signed by the ward physician.
Unidentified corpses are the subject of the forensic medicine eaxmination. They are photographed, their photographs are kept together with case histories.
Usually corpses stay at the bureau for 3 days. They are given to the relatives (on arriving of the death registry) or other persons in charge of the burial procedure.
As the three days go and no one takes the coarse away, the hospital arranges the burial or sends it for training of students unless the corpse demands special burial.
The corpses of persons dead through acute infectious diseases (typhus, scarlet fever, dysenteric) are given away for burial in the isolated coffin onle or for cremating, no usual procedures of valedictions are allowed. The corpses are put into coffins according to the sanitary standards.
The burial is registered. All documents present in the case are registered too.
Autopsy Regulations
All persons dead in hospitals undergo autopsy.
Autopsy can be cancelled in so cases, although. The chief physician presents a written proposal on autopsy cancel to the chief pathologist. That proposal explains the motivation of this cancel. It is kept along with the case history. Its copy goes to the yearly hospital report.
Obligate cases of autopsy :
· Death within 24 hours after arrival. Cases of supposed homicide are examined by forensic medicine pathologist
· Cases of forensic medicine examination
· Cases of infectious disease and supposed cases
· Cases of obligate scientific investigation
· All cases of obscure diagnosis.
Corpses undemanded by relatives are sent to the anatomy departments of medical institutes for experiments.
Unidentified corpse are sent for forensic investigation.
All case histories of the deceased persons are sent to the pathologoanatomic bureaus before
All these case histories should be completely filled and signed by the ward physician (main pathology, its complications, intercurrent pathology, operations, epicrisis completed by the final diagnosis).
Each autopsy is protocolled. The protocol consists of the following data :
· Name, gender, age
· Profession
· Date of arrival, date of death, date of autopsy
· Clinical diagnosis, operations (dates)
· Main clinical sympthoms, data of X-ray and laboratory analysis, therapy mode.
The pathologoanatomic diagnosis includes the following points
· Main pathology
· Main pathology complications
· Intercurrent pathology
· Bacteriologic, histologic, other types of analysis (filled on data arrival)
· Pathologoanatomic epicrisis (analysis of tanathogenesis and pathogenesis based on the examination data)
· Pathologoanatomic diagnosis.
The protocol is signed by the pathologist.
If the autopsy reveals some facts demanding thorough forensic investigation, the process is stopped. It should be protocoled, the reasons for forensic examination should be listed.
Autopsy of Newborns and Still-Born Babies
All dead newborns and still-born babies over
Still-born babies under 1000 gr weight and
Newborns dead at labours are taken to the pathologoanatomic bureau with placenta.
The protocol of dissection is usual.
If autopsy reveals the facts pointing to homicide, forensic experts are informed
Autopsy of Children
All children aged 7th days – 14 years that died at hospitals undergo obligate autopsy.
All 100 % of children autopsy are followed by histological samples examination.
Cases of unexpected death (unless children were undergoing constant dyspanserisation) are investigated by forensic medics. Ordinary pathologist can be invited for consultations. Cases of death among dyspanseric children are investigated by ordinary pathologist.
If infectious disease is suspected, obligate microbiologic (virusological, immunofluorescent) sample examination is conducted.
Perinatal lethality is death within 7 days on birth. Still-borns lack respiration on birth. Perinatal lethality is calculated by dividing the number of still-born cases and cases of death within 7 days to all births number.
Perinatal lethality is subdivided into the following subclasses :
· Antenatal (before birth)
· Intranatal (during birth)
· Postnatal or neonatal.
STRUCTURE AND LOGIC OF THE PATHOLOGOANATOMIC DIAGNOSTICS.
COMPAIRING OF THE CLINICAL AND PATHOLOGOANATOMIC DIAGNOSIS.
CLINICO-ANATOMIC EPICRISIS
Principles of the diagnosis’ formulation.
Clinical and pathologoanatomic diagnosis are formulated on the pathogenetic base — they reflect the development of disease, explain the mutual connection and successive order of the changes. The main disease, its complications and accompanying diseases should be differentiated in these diagnoses. Evaluation and classification of the clinical or pathologoanatomic changes by the importance and their role in development of the disease and death of a patient is the premise for such approach.
The main disease — is the disease, that itself or throught its complications caused death of a patient, combinated main disease. Often there are two or more diseases that develop independently from one another. They may be competing or combined. One of them may be the back-ground (accompanying). Competing disease are two or more nosologic forms, where each of them itself or through its complications may lead to death.
Accompanying disease is the one that played important role in pathogenesis of the main disease or stipulated its extremely severeness.
Background disease — is one that is not etiologically connected with the main one, but plays the main role in pathogenesis and worsening of the main disease’s course.
For statistic examination of the materials, only one disease may be put on the first place in case of combined main disease. Corresponding explanations should be presented in the clinico-anatomic epicrisis.
To the complications of the disease belong those pathologic processes which pathogenetically or directly connected with main disease, though in some case they may have another etiology (for example, purulent meningitis) in purulent otitis; peritonitis in perforational ulcer of the stomach.
It is possible that death took piace because of performed therapeutic (including operative) or even diagnostics procedures. For such cases there are special heading in the ICD (International Classification of Diseases): N 930-936; N 960-979 and N 997-999. If medical procedure was promoted according to the wrong diagnosis, such procedure is put on the place of the main disease in the diagnosis, in some case it may be put on the place of complication.
Often, the notions, expressing clinical complexes of symptoms — cardio -vascular insufficiency, uremia, etc. are to be used in the anatomic diagnosis, but always with the list of characteristic for them morphologic changes or with the not “according to the clinical data”. Sometimes importance of the clinical data (including the history) is so considerable that they become the base for pathologoanatomic diagnosis (surgical diseases after extirpation of the organ, death of a new-born because of maternal pathology, psychiatric diseases).
Comparing of the clinical and pathologoanatomic diagnoses.
When comparing of the diagnoses, there are following categories of the grades:
1) Coincidence of the diagnoses.
2) Different diagnoses. The diagnoses may be different by:
· Nosologic principle (tuberculosis of the lungs instead of the cancer).
· By etiology (tuberculosis meningitis instead of the meningococcal).
· By the localization of the affected organ or a system (cancer of the stomach instead of the cancer of the pancreatic gland).
In combined main disease, absence or wrong diagnosis of one of the diseases is called the difference of the clinical and pathologoanatomic diagnoses.
3) Difference of the diagnoses by complications, that considerably changed the course of the main disease or have the character of the death cause.
4) Difference of the diagnoses by the main accompanying diseases.
Questions of different diagnoses are solved by the chairman of the pathologoanatomic department, the chairman of the clinical department and in argumentive cases — on the pathologoanatomic conferences.
Reasons of different diagnoses:
· short-time of in-patient period (less than 24 hours);
· objective difficulties of the diagnostics;
· incomplete examination of a patient;
· insufficient study of the history of the disease and laboratory and x-ray data;
· wrong interpretation of the diagnoses put by the consultants;
· wrong formulation of the diagnoses.
Different diagnoses are met in 5-10 %.
Clinico-anatomic epicrisis.
Clinico-anatomic is the final conclusion. Its content depends on concrete case. Necessary components of the epicrisis:
a) comparing the clinical and pathologoanatomic diagnosis;
b) conclusion about the cause of the death;
c) defects in the diagnostics and treatment.
Prosector in epicrisis may (sometimes have to) give the supplementary data about mutual connection and the order of the changes, about clinical and morphologic peculiarities of the case. Supplementary data is needed in case of combined main disease. If the diagnoses are different, the cause of difference should be pointed out with analysis of the documents from the point of possibility of the right diagnosis formulation and present its opinion of the wrong diagnosis role in the lethal outcome.
PECULIARITIES OF THE DIAGNOSIS CONSTRUCTION
IN THE PERINATAL PATHOLOGY
Pathology of the perinatal period has the considerable part in the pediatric practice. Perinatal period starts from the 22 week of the intrauterine development to the end of the 7th day of the extrauterine. Death of the fetus or new-born that took place in this period called perinatal.
Asphyxia, labor trauma, hemolytic disease of the new-born, hemorrhagic diseases, developmental defects, infections diseases belong to the main group of pathologic processes causing perinatal death of the fetus. Asphyxia of the fetus and new-born depending on the clinical situation may be the main disease or complication of the other disease (congenital pneumonia, bronchopulmonary dysplasia, developmental defects, etc.).
Diseases of the fetus along with the diseases and states of a mother (placenta), that stipulated the first ones, is recommended to name the perinatal diagnosis. It has 3 parts:
· 1st part: diseases of the fetus (new-born) according to the general principle.
· 2nd part: pathology of the placenta (on the first place — the main pathology, that have stipulated the cause of the death), then the pathology that promoted the first one and the last one — the other pathology.
· 3rd part: pathology of the maternal organism: the main disease or state of the mother is the one that caused the disease and death of the fetus (new-born).
So, in spite of that there are many pathologies met in perinatal practice, and peculiarities of its course, general principles of the diagnosis’ formulation are the same as for adults. Nosologic principle in formulation of the main disease, composing by ICD – 10, grounding of the formulation and composition of the disease (data of the morphologic, bacteriologic and other examinations), registration of the iatrogenic pathologic.
Comparing of the clinical and pathologoanatomic diagnoses.
One of the main problems of pathologoanatomist is the “scientific control over the diagnostics and treatment by means of comparing of the clinical and pathologoanatomic diagnoses”.
This comparing is promoted by means of autopsy with following examination with generalization of the sectional materials (usually ones in 3 monthes), during analysing of the results of the biopsy and operational materials’ examination.
Clinico-anatomic comparing includes not only the comparing but solving of the problems, connected with examination of the patient, opportune diagnostics, grounding and timeliness of the therapeutic procedures, exploration of the cause and mechanism of the death.
Comparing of the clinical and pathologoanatomic diagnoses is made by nosologic principle, by three items: by the main disease, its main complication, and by the most important accompanying diseases.
Comparing of the diagnoses, performed by the pathologoanatomist is the most important factor is improving of doctors’ qualification, and promotes revealing of the most weak spots in the health care system..
Different diagnoses are the clinical and pathologoanatomic diagnoses of one patient that don’t coincide. Pathologoanatomist have to point out the categories of difference by the following statements.
1. Disease wasn’t revealed on the previous stage and in connection with the severe state of a patient, progredient course or in connection with quick death (short in-patient period), so it was impossible to state the right diagnosis in this hospital. To this group belong: patients with malignant tumors in inoperable states, with cardiogenic, bacterial shock, etc.
2. Disease wasn’t revealed in the given medical department because of insufficient examination of the patient, absence of the necessary and available tests.
3. Wrong diagnostics lead the wrong medical tactics that played the main role in the lethal outcome. To this group belong: all urgent cases requiring immediate surgery (acute appendicitis, obstruction of the intestine, acute cholecystitis, etc.). In the perinatal period the comparing of the diagnoses is made only by the diseases of the fetus (new-born) using following statements:
· The main disease was revealed right and its cause from the side of the placenta (mother).
· Main disease was revealed right, but mothers’ and placenta’s diseases, that have caused the main disease of the fetus (new-born) that lead to its death weren’t revealed.
· Main diseases wasn’t revealed.
· Lethal complication wasn’t diagnosed.
· Important accompayining disease wasn’t diagnosed.
Comparing clinical and pathologoanatomic diagnoses the following categories of the grades are set:
· Coincidence of the main clinical and anatomic diagnoses.
· Difference of the main clinical and anatomical diagnoses.
· Difference of the diagnoses by the important complications, that have considerable influence into the course of the main disease and become the main
· death cause.
· Difference of the diagnoses by the main accompanying diseases.
At evaluation of the clinical diagnostics quality in perinatal practice the procent of placentas’ that weren’t sended to pathologoanatomist in relation to the general amount of autopsy of the newborn is to be taken into account.
PATHOLOGOANATOMIC EPICRASIS AND TANATOGENESIS
Etiology pathogenesis of the disease dynamics of the diagnostic process in clinic, differential diagnostics should be reflected in the epicrisis. Timeliness of the diagnosis, ground the direct cause of the death and its mechanisms should be stated.
Following moments should be reflected in the pathologoanatomic epicrisis.
1. Crounding of the diagnosis of the main disease, i. e. the explanation why among all pathology of a patient, the given pathology is the main.
2. Composition of the clinical and pathologoanatomic diagnoses by all headings (main, backgrounds, competing, combined diseases, their complications, accompanying) with statement of their coincidence or difference.
3. In case of difference of the clinical and pathologoanatomic diagnoses the reason of their difference wrong explanation of the found in clinics pathologic changes of the organs should be given.
4. Covering of the importance of the combined, background and competing disease development mechanism if there were such.
5. Promotion of the differential diagnostics between the diseases.
6. Reflection of the timeliness of the stated in the clinics final diagnosis and evaluation of importance of this fact onto the treatment and outcome of the disease.
7. Revealing of the main (direct) cause of the death, i. e. the process laying in the base of tanatogenic mechanisms.
8. Analysing of the processes, that where stipulated by treatment-diagnostic procedures, and influence of the last ones onto morphologic expressions of the disease.
9. Defects of the medical care (late or wrong diagnostics, hospitalization, untimely provision of the medical care, etc.) with evaluation of these factors influence onto the treatment and outcome of the disease.
10. Examination of tanatogenesis.
11. Examination of the natural and treatment pathomorphois.
AUTOPSY. AUTOPSY CLINICO-ANATOMIC ANALYSIS
Autopsy (dissection, obduction) is the corpse examination designed to reveal its structural changes and determine the pathogenesis mechanism. The autopsy gives information on the diagnosis and therapy quality and helps to figure out the lethal pathology.
Death is a complete irreversible termination of life functions and the systems regulating them (biologic death). There are three ways of death- natural, homicidal and pathologic.
Forensic Medicine Subject
Homicide produced by any aggressive external factor is the subject of forensic medicine. All cases of obscure diagnosis, suspicions of homicide, DOA cases and cases of relatives complaints become the subjects of forensic analysis. Unexpected death which strikes an obviously healthy person is also the subject of forensic investigation. Unexpected death occurs within 6 hours in obviously healthy persons. It takes 24 hours for quick death at the same conditions. Both quick and unexpected death are typical for latent pathology.
Severe failures of medical aid are also examined by forensic analysis. Such are failures of blood transfusion, overdose, failures of operation and narcosis.
Pathologoanatomic Autopsy Subject
Cases of death in hospitals arestudied by pathologoanatomic autopsy. Cases of death after diagnosing and therapeutic manipulations also become the point of examination. Examples-damage of atrial wall during catheterisation , esophagus wall rupture during esophaguscopy – the cases, when the tanathogenic accident had nothing to do with the main pathology.
The doctor in charge should be present at the autopsy and informed of all his mistakes so that he could avoid them in future.
The obligate autopsy had been originated in 1919. It can be performed at any time after the official death constatation. It is performed in the autopsy room of the pathologoanatomic bureau. It is performed at least 2 hours after the clinical death certification. Scientific research may demand earlier autopsy, then two doctors should certify the death.
Autopsy can be cancelled by the Chief Physician in special cases (religious ones). Autopsy cancel should be protocolled in the case history. No cancle is available in cases of early death, death after diagnosing or therapeutic manipulations and in cases of infectious diseases.
Methods of Autopsy (Wirchov’s Heller-Zenker, Kiari, Letulle, Abrikosov , Shore , and combined methods)
Abrikosovs method is the separate extractions of organs from body cavities. The complex of mouth cavity, neck, respiratory and circulatory organs is extracted, then aorta and esophagus are cut near the diaphragm and the abdominal cavity complex goes. The uro-genital organs go the last.
Shores method is the complete evisceration. All organs of neck, thorax, abdomen and pelvis are extracted as a single complex.
Autopsy is begun as the case history and the autopsy indication arrive. The pathologist studies the case history to figure out the clinical features of the case, the former medical manipulations (operation, transfusions, reanimation). Pay special attention to the clinical diary, laboratory data, clinical epicrisis, final diagnosis and the date of its definition. If some points turn to be obscure, the physician in charge explains them.
Corpse identification is followed by the external examination. Pay special attention to death signs-low temperature, dim keratus, no popular photoreaction, corpse stiffness, imbibition. External examination reveals gender, proportions, skin and nails structure (color, rash, haemorrhages, edema, operation wounds, medical manipulations signs-if any). Visible mucous coats (mouth, nose, eyes) can be examined too.
Some important data can be obtained during the external examination. Severe corpse stiffness usually follows exicosis (cholera, tetanus, etc.), poor stifness is the symptom of sepsis. Yellow color of skin and scleres is the symptom of icterus. Lemon-yellow color is typical for the hemolytic icterus, while deep yellow is the sign of parenchymal icterus, greenish-yellow color is found in case of obturatory icterus. Dark skin with hypergpigmentation is a symptom of
Then goes the examination of body cavities and organs. Their position is studied first. Look for deformations or comissures. Then examine the cavities (thoracal and peritoneal) check or liquid, comissures and alien bodies. Check peritoneum for deposits or dim areas,, check the operation sutures if any. Then evisceration goes. It may be either complete (by Shore) or particial (by Abrikosov). The eviscerated organs shape, size, structure, surface, cuts and scrubs are checked. Any pathologic processes should be characterised anatomically.
Hollow organs are cut to reveal their contents and mucous coat. To check the bone marrow, sternum, vertebral bodies and some tubular bones (usually femur) are cut. Normal bone marrow of flat bone is red, while the one of tubular bone is yellow. The sternum and femur is cut longitudinally, the vertebral bodies are cut frontally or sagitally.
Blood vessels and joints claim thorough examination.
Cranial dissection is done after the soft tissues are removed. The cut os soft tissues goes behind the ears and up to vertex. The bone cover is removed with a circular cut. Dura mater is incised and the brain is extracted. Its hemispheres are cut. Orbits, sinuses and ear cavities can be opened if needed. To remove the spine cut the vertebral arches.
The autopsy protocol contains some information from the case history – name, clinical diagnosis, clinical examination and laboratory analysis data and the main features of therapy. The autopsy results are protocolled. The document is completed by the anatomic diagnosis and pathologoanatomic epicrisis. Epicrisis concerns tanathogenesis and the dynamics of the pathologic processes. Pathologoanatomic diagnosis and epicrisis are copied to the case history.
Still-Born Babies and Newborns Autopsy
Body weight and head parametres should be measured. Point the prematurity signs- if any soft ears, hair on shoulders and back, low umbilical ring, short nails, opened vagina (female), kriptorchism (male) or over-maturity (dense cranial bones, solid suture). Check the umbilical cord (length, structure, color, contents). Pay attention to the skin color. Pale skin is typical for acute anemia and white asphyxia, cyanosis is found in blue asphyxia. Rash is typical for syphilis and lysteriosis.
Check the head shape, fontaniculi, neck flexibility, hemorrhages, laryngeal cartilages and other points of possible birth trauma. Check thorax parametres, skin and bone defections, throx deformations, etc. Check clavicles and extremities for possible fractures (birth trauma). See tentorium cerebella and the falciform process – they are often damaged at labours.
Each autopsy is followed by histologic samples analysis. Other samples may vary depending on the pathology type. The samples are put into the 10-12 % formaldehyde and processed. Cytological, microbiologic, virusologic and biochemical analysis are performed if needed.
Autopsy in Case of Infectious Disease
This type of autopsy should be performed in the special autopsy room equipped with disinfecting liquids (5-8 % lisole, 5-10 % formaldehyde) and disinfecting apparatus to process the corpse, clothing and instruments. Pay special attention to preventative measures designed to stop the infection from spreading. Disinfect the autopsy table, the pathologists overall, etc.
The special garment for the case consists of the long overall, a water-resistant apron, gum gloves a cap and gum boots.
It’s better to make the Abrikosov’s eviscreation in this case- it prevents the biologic liquids from leaking. Histological, bacteriologic, mycological, virusologic and serologic analysis are obligate.
Autopsy in Case of Biohazard Disease
If the biohazard case is suspected, normal autopsy is stopped immediately. All staff and guests but the pathologist himself present in the autopsy room are evacuated and isolated. The local sewer system is blocked, the sewing waters are collected into the disinfecting compartments.
The epidemiologic bureau and the Chief therapeutic are informed immediately. The autopsy is continued by the biohazard team.
Special attention is played to personal prophylaxis and safety. All possible preventative measures are taken to stop the infection. Avoid Shore’s evisceration, better use the in situ method which avoids organs extraction so that biologic liquids stay within the body cavities and none leak. All sewing waters are disinfected with chlore.
The final diagnosis is certified by the bacteriologic analysis. The samples shouldn’t be processed by the desinfectiong liquids. The blood is taken from heart chambers and the cubital vein. Pneumonial exudation is taken for bacteriologic and virologic analysis. The stomack and intestine contents are put into separate jars and sent for analysis is poisoning is supposed. Gall bladder is opened after the examination only.
The autopsy results are protocoled.
Autopsy Protocol
The protocol consists of three parts :
1. Anamnesis data part consists of name, profession, hospitalisation date, clinical diagnosis.
2. The second part consists of the anatomic description of all changes found at autopsy and the results of histological analysis.
3. The third part contains pathologoanatomic diagnosis and the analysis of clinical period.
Pathologoanatomic analysis should be certified by the histologic analysis of tissue samples.
Morphologic changes revealed by autopsy are compared to the clinical data, the essence of pathology and its morphologic expressions are analyzed by the pathologist and the physician. Then the pathologist writes his diagnosisnad the clinico-anatomic epicrisis and compares clinical and pathologoanatomic diagnosis.
The pathologoanatomic diagnosis should determine the relations between morphologic changes and clinical symptoms, medical manipulations and the pathology itself. Also mind the impairments of the organisms resistance properties.
Pathologoanatomic diagnosis is the final part of the complicated diagnosing process which had begun at the hospital and is finished in the autopsy room.
After the autopsy pathologist compares clinical and pathologoanatomic diagnosis and figures out the main pathology,, its complications and background pathology. If clinical and pathologoanatomic diagnosis vary, the essense of this point is explained.
The clinical-anatomic epicrisis includes the personal opinion of the pathologist based on all the data (clinical, morphologic, laboratory, etc). There’s no rigid scheme of the epicrisis- it varies depending on the case according to its pathogenesis. The epicrisis may concern the following problems :
· Main pathology diagnosis analysis. Its dynamics and its complications pathogenesis
· Tanathogenesis mechanisms
· Analysis of factors which break the homeostasis (genetic, immune, ecologic, labour, etc)
· Analysis of medical manipulations, their efficiency and time terms
· Possibilities of early diagnosing
· Possible diagnosing mode
· Hospitalisation and the diagnosing process analysis
· Indications to operation. Characteristics of operation
· Characteristics of drug therapy
· Characteristics of reanimation
Physicians staff can be envolved into the epicrisis composition. The comparison of clinical and pathologoanatomic diagnosis means the analysis of the physicians mind and checking of the failure points and the reasons of mistakes.
Autopsy Importance
· Autopsy proves the material essense of human structure and functions and the material essense of pathology
· Autopsy provides the data on organ, system, tissue, cellular and subcellular levels of pathology
· It enables the comparison of clinical and pathologoanatomic diagnosis thus improving diagnosing and therapeutic process
· It can reveal the failures of diagnosing and therapy and analyse them (diagnosing , manipulating, strategic, etc)
· It provides scientific control as it helps to accumulate the statistic data
· It helps the education process
· It helps planning the medical activity (statistic data)
· It can revea/ some infectious pathology and thus prevent epidemy
· It helps to study the morphogenesis and pathomorphology at any stage of the disease
· It reveals unique and rare types of pathology, new forms of nosology, natural and medical pathomorphosis
· It provides the progress of medical science, as any serious research needs morphologic approval
· It studies the problems of tanathogenesis and tanathology
Autopsy is the basic method that reveals the material substrate of death.
PATHOLOGOANATOMIC DOCUMENTS.
DISSECTION PROTOCOL AND
THE CLINICO-PATHOLOGOANATOMIC EPICRISIS
Pathologoanatomic Documents. Dissection protocol and the Clinico-Anatomic Epicrisis
The results of the clinico-anatomic section examination are presented by the pathologoanatomic diagnosis and the clinico-anatomic epicrisis (Greek ері – after, krisis – resolution). The success of the clinico-anatomic analysis depends on the thoroughness of the macro-and microscopic examinations involving the data of clinical, laboratory and bacteriologic tests and the final comparison of the clinical and the dissection data.
The epicrisis should contain the disease ethiology, pathogenesis, clinical dynamics, and the differential diagnosis. The time of the diagnosis determination and the tanathogenesis mechanism and premises should be included also.
The pathologoanatomic analyzing becomes more and more complicated. The modern therapeutic methods (radiotherapy, chemotherapy, immunotherapy), manipulations (reanimation, haemodialysis) and the modern operations (cardial surgery, tissue transplantation), secondary diseases, which appear as the result of some operations might change the pathogenesis, pathomorphology and the tanathogenesis of some diseases.
Pathologoanatomic epicrisis composition is the most complicated part of the dissection procedure. It explains and supplements the pathologanatomic diagnosis.
The pathologoanatomic explains the difference between clinical and pathologoanatomic diagnosis, if any exists.
So, the pathologoanatomic epicrisis should include the following points :
1. Certification of the diagnosis- explaining which of the found pathologies had been main and why
2. Comparison of clinical and pathologoanatomic diagnosis in all types (backround pathology, concuring pathology, combined pathologies, intercurrent pathology), and checking if they are similar
3. If clinical and pathologoanatomic diagnoses are different, the essence of the dysconcordation is explained. The reasons of the clinical mistakes should be analysed
4. Analysis of background and concuring pathologies and their role in tanathogenesis
5. Differential diagnosis
6. Analysis of the clinical diagnosis determination terms and whether it influeced the treatment mode and the result
7. Determination of the death cause (the tanathogenesis basis)
8. Analysis of the processes, caused by the therapeutic and diagnostic processes and how they influenced the pathogenesis
9. Figure out the drawbacks of medical care (late hospitalisation, poor diagnosing, inadequate treatment) and analyse their role in the tanathogenesis
10. Determination of the diagnosis
11. Determination of natural and medical pathomorphosis
In case of perinatal pathology (delivery traume, asphyxia, acute newborn anaemia) figure out the reasons. Example- delivery trauma –possible reasons – first delivery, prematurity, rapid delivery, delivery incompatabilty, early amniotic liquid excretion, low volume of amniotic liquid, fetus position anomaly, obstetric operations, etc.
Asphyxia – possible reasons – mother has diseases accompanied with anoxia, mothers infections and intoxications, early placental loosening, pathologic placental position, development anomalies, umbilical pathology, hematomas, etc.
Hemolytic disease of newborns claims its causes to be determined (Rh-conflict, ABO conflict, antibodies in mothers plasma). In case of congenital pathology all previous pregnancies , pathologic genealogy and possible terathogenic influences (infections, fever, radiation, pressure changes) should be listed.
Tanathologic review completes the clinico-anatomic analysis. The problem of the tanathologic review had been studied thoroughly by G.V. Shore, who stated that the pathologoanatomic analysis should reconstruct the former structure of the functional systems and the chronologic outline of the disease using the morphologic data.
Tanathology is the theory of death. It is a part of general biology which studies the process death, as the termination of life concerning the whole organism. Tanathogenesis studies the processes that caused death.
Tanathogenesis analysis explains the causes and the mechanisms of death, enables pathologoanatomic diagnosis and post-mortem epicrisis composition, tanathogenic factors classification and possible influence on some of them.
The pathologoanatomist has to chose the most important morphologic changes among the multiple structural abnormalities, caused by the pathologic process. The analysis of the tanathogenesis depends on this choice.
The problem is that the clinical diagnosis would always explain the tanathogenesis. To understand it you should analyze all the data you had received during the dissection, taking into consideration the constitutional features of the examined organism and other factors. The purpose is the determination of reasons, which made further biologic existence impossible. The analysis of these factors written as a clinico-anatomic epicrisis is the tanathologic review itself.
Usually death is followed by the characteristic anatomic changes –the morphologic expression of the patoautokinesis outcome. It helps to understand the mechanisms of the tanathogenesis. But still there are cases when obvious tanathogenic structural changes are absent. Examples – various comas without any characteristic morphologic changes and points of differentiation.
Mechanisms of tanathogenesis are of extreme importance. In some cases early influence on the tanathogenic mechanisms prevents death ( examples- cases of traumas and operations). Tanathogenic mechanisms can be activated by the inadequate usage of medicines, medical manipulations, idiosyncratic reactions. All these factors make the tanathologic review even more complicated.
Mind, there are many obscure and unclear problems in the tanathogenesis theory. Further researches on the case are of extreme importance. They concern terminal states, problems of clinical and biologic death, etc.
Complex analysis of the tanathogenesis in various cases improves the clinical skills and benefits the researches on the problems of diagnosing and treatment.
The dissection protocol is an important scientific document, moreover, it can become a reason of the court investigation. That’s why all the pathomorphology changes found at the dissection should be described there. It’s better towrite it right after the dissection itself without any detentions.
No abbreviations, empty paragraphs, vulgar slang, et are alowed to be put into the protocol. All the corrections should be explained and listed. The explanations are also needed if any organs weren’t dissected. The protocol sould be written briefly and clearly. All the questions should be answered briefly and completely. Pay special attention to the anamnesis and the disease clinics. Add the data of laboratory analysis if any. Also add the data of X-ray, fluorography, ECG, tomography etc if any.
Mind, that pathologoanatomic protocols are often used for scientific research and the clinico-pathologoanatomic conferences so they should contain brief, but complete information on the case
The description part includes the information on the organs It should complete only the objective data, not your supposals about the possible diagnosis. No “gastric cancer found” but “a node 6/4 cm found on the gastric mucous coat in the pyloric region. The node rises
Description of organs includes their size and weight. The color of organs depends on its perfusion rate (anemic organs are grayish) and various colored substances – lipofuscine, bile pigments, carbon, iron, etc.
The dissection protocol is followed by the раthologoanatomic diagnosis and epicrisis.
Usualy all these documents are completed before the histological analysis data arrive. If the latter tend to changes the situation, the pathologoanatomic diagnosis might be corrected according to the reason. The doctor in charge should be informed about the changes of the pathologoanatomic diagnosis.
Protocol of Pathologoanatomical Examination
Address ________________________
Republic _______________________
Сity ________________________ Hospital ________________________
Department __________________ Case History _____________________
1. Name ________________________
2. Gender M / F
3. Age ________________________
4. Address ________________________
5. Profession ______________________
6. Arrival _______________________ after the disease had started
7. Spent ________________________ days in hospital
8. Death date _______________________
9. Dissection date ___________________
10. Doctor in charge __________________
11. Dissection attended by _______________
12. Previous diagnosis __________________
13. Diagnosis on arrival _________________
14. Clinical diagnosis, date _______________
15. Final diagnosis (main pathology, complications, intercurrent pathology) __________________
16. Laboratory analysis data __________________
17. Pathologoanatomic diagnosis (main pathology, complications, intercurrent pathology ) __________________
18. Clinical diagnosis failures
Wrong main pathology _________________
Wrong complications __________________
Wrong intercurrent pathology ____________
Late dіagnosіng _______________________
Wrong tanathogenic factor indicated __________________
Reasons of wrong diagnosing
Objective difficulties of diagnosing __________________
Short period of presence in hospital __________________
Poor examination __________________
Examination data overestimation __________________
Rare pathology __________________
Wrong formulation __________________
19. Death cause
Codes
______I a
______ b
______ c
______ d
______II
20. Clinico-pathologoanatomic epicrisis
Protocol, pages ______ supplied
Pathologoanatomist ______ (name)
Department Chief________________(name)
3 copies must be made (first- protocol, second goes to case history, third is a dissection file)
21. Results of the pathologoanatomic examination
Height ______
Body weight ______
Organs weight ______
brain ______
heart ______
lungs______
liver ______
spleen______
kidneys
right ______
left ______
Samples taken for pathohistologic examination (number) ______
Blocks prepared ______
Samples taken for other examinations ______
External examination. Habitus. Height. Weight. Complexion. Pigmentation, rash, scars, skin diseases, wounds, raws (size, color, edges type, bottom type), necroses. Corpse stiffness. Bones and muscles. Thickness of the subcutaneous fat on thorax and abdomen.
Cranial cavity. Head skin. Bones- thickness, lamina vitrea state, defections -if any (trepanation, traumas, tumors, metastases), dura mater, its position to lamina vitrea and pia mater, its color and tension. Sinuses and their contents. Pia mater- color, comissures, undulations, tubercular and nodular structures- if any. Basal cranial vessels- state of walls and intima.
Brain. Cortex of hemispheres, truncus and cerebellum – surface, surfacial symmetry, structure, saturation. Cuts. Color of cortex, subcortical nodes and white substance. Distinctly colored limits of substances- if present. Tubercular substances and neoplasms. Areas of degeneration and hemorrhages, cysts (shape, size, topography, color, structure, contents). Ventricles – shape, contents, ependima state. Spine. Dura and pia mater, their configuration and structure. Transversal cut picture.
Abdominal cavity. Organs. Peritoneum state. Comissures and liquid-if any. Omentum and mesenteriums.
Thoracic cavity. Diaphragm cupolas height (on medioclavicular lines). Anterior mediastinum state, pleural cavities state (comissures and liquid – if any). Pericardial cavity (comissures and liquid).
Cardio-vascular system. Heart. Shape, size, weight. Epicardium state. Venous openings maximum width. Chambers and auriculi contents (liquid blood, blood clots, thrombus, other). Parietal endocardium state, tendineal strings, valvulae, pectineal muscles. Right and left ventricle walls thickness. Myocardium (color, structure). Blood vessels, venous valves state. Pulmonary artery, aorta, coronary vessels, subclavial and carotic arteries, etc.
Respiratory system. Larynx, pharynx, bronchial mucous coats. Lungs: size, structure, surface color, cut color. Pneumonia regions, cavernas, bronchoectasions, tubercli, pneumosclerosis, neoplasma, emphysema- if any. Pleura state (comissures, exsudation, fistules)
Alimentary tract. Mucous coats (color, surface, haemorrhages, defections, neoplasms, lymphatic nodes). Liver: weight, size, structure, color of cuts. Bile ducts (mucous coats, contents). Pancreas- weight, size, color of cuts.
Uro-genital organs. Kidneys – size, structure, cuts (distinct limits of layers, color of layers, capsules/surface ratio). Mucous coats of calyxes, urethers and bladder. Gonads- size, structure, cuts. Genitals state.
Haemopetic organs. Spleen – weight, size, surface color, cuts color, cuts scrub. Lymphatic nodes (topography, size, position to surrounding tissues, structure, cuts color). Bone marrow – color, structure.
Secretion organs. Thyroid gland, suprarenal glands, thymus, hypophysis, epiphysis. Shape, size, cuts.
Data of bacteriology, bacterioscopy, etc.
THE AIM AND THE TASKS OF PATHOANATOMIC SERVICE, IT’S PLACE IN THE SYSTEM OF PUBLIC HEALTH
Pathoanatomy is the basis of clinical medicine. It’s tasks include not only the describtion of material substrate of diseases but also the interpretation of dynamic interactions, which are fixed in order of structure changes considered as clinical. Prosector, clinical pathologist, is the direct observer and interpretator of changes happened in organism of diedman in their anatomic expression and sectional hall is the place, where importance of many clinical parametres, including the norm, can be estimated with enough definition.
«Death helps life» – that help is done by pathoanatomy to every abstract patient in result of continious consultative help to clinician, of taking part in perfection of his knowledge in a way of elucidation of intravital diagnostic mistakes and lowering of their probability after demonstration autopsies and also promotes best understanding of pathogenesis and different (evolutional, age, therapeutic and other) pathomorphysis of diseases, that’s impossible without deep works of prosector in sectional hall. Since the end of XIX century developing pathologic histology gave powerful push to the development of modern pathology, became the safe assistant of pathoanatomist. Researching operational and biopsical material, it helps clinician in his diagnostic and medical work. Today every third-fourth patient in hospital is subjected to biopsy, which is not only diagnostic but sometimes prognosing means and eVen the way of control for effectivity of treatment. So, pathoanatomist’s activity is according to the human tasks of medicine – to the struggle for health and life of concrete patient.
Pathoanatomic service appeared from necessity of searches of criteries of right diagnostics and treatment of patients. In public health it exists in a kind of system of measures directed to emprovement of medical-diagnostical work. It is conducted by diagnostic control for treating and diagnostic activity with the help of one of the basic methods of pathoanatomy – autopsy and all-sided investigation of organs of corpses of people died from different diseases in medical institutions. In it’s tasks and maintenance pathoanatomic service is closely connected with clinic. Prosector studies diseases during autopsy, consequently, he is also clinician but he uses anatomic way of investigation.
Prosector, basing on the facts found during autopsy, helps clinicians to distinguish diseases and to use the arcenal of therapeutic means for their treatment. Facts, accumulated during autopsies and their clinical – pathoanatomic comparements are summed up, systematized and then they promote improvement of diagnostics of diseases and their treatment.
Consequently, prosector is not only practical physician, but he is also an investigator who analyses and compares information of pathoanatomic autopsies. People, who aren’t enough informed in pathoanatomic work, consider that it has only describing character and pathoanatomists – only simple registrator of postmortal finds. Such opinion, as L.E. Snesarev marked (1950), «- is deeply mistaken, because it doesn’t consider that the aim of pathoanatomist is checking of intravital diagnosis on dead material. Really, he deals with dead, fixed anatomic structures, but with the help of microtom, elective methods of painting and microscop he elucidates thin details of structure elements». Comparing anatomic and histologic information with clinical and other, prosector reproduces the process of disease of dead man. Consequently, pathoanatomist deals not only with structure forms, but also with processes developing in time.
Autopsy of the courpses obligatory added by histologic and sometimes histochemical investigation of internal organs. Bacteriologic, serologic and virusologic researches are also conducted iecessery cases. All that helps to establish the disease’s diagnosis, mechanism of it’s development, origin, directly cause of death of the patient in comparing with clinical information.
Right and timely diagnostics of disease, knowledge of etiology and pathogenesis are important to treating doctor for choice of purposeful methods of treatment and prophylactics. Every process of investigation must be necessary controled, that is carried out in diagnostical and treating physician’s activity by comparement of clinical and pathoanatomic diagnostics that is conducted by prosector together with clinician.
Short essay of development of prosectoring service in our country. Prosectoring service in our country began develop more early then in foreign countries. During life of Peter I and his heirs according instructions and decrees regulating prosectors activity were issued. One of institutions, issued by govering Sinod in 1754 and adressed to hospitals, contains: «the patients, who were treated by you and died must be dissected by you to find the cause of disease, unsuccessful treatment and death found things must be recorded in details, you must do it in presence of doctors and students who want to present». This instruction also contains the following: «Because anatomy of dead bodies helps medicine in understanding of the causes of diseases, unsuccessful treatment and death and it promotes your following great successes».
One of the founders of native pathoanatomy I. Kostomarov formulated the tasks of pathoanatomy in following way (1820):
1. to investigate anatomicaly the organ, which is changed in structure and other parts which are connected with that organ (pathomorphology);
2. to try to understand physiologicaly or pathophysiologicaly the mechanism of formation of that disease (pathogenesis);
3. to define the relations between organic diseases and life phenomenons (clinical – pathoanatomic comparements).
So, from the very begining native pathoanatomy had the aims to help clinic. Becoming the holder of the chair of pathoanatomy of medical department of Moscow University in 1843 prof. A.I. Polunin said: «1 will continiously pay attention on the connection of anatomic changes with fits noticed during life», that means so conduct clinical-pathoanatomic comparements. A.L Polunin (1820-1888), the creator of
A.I. Polunin was the physician – materialist and considered that pathoanatomy gave the possibility to estimate right the disease’s phenomenons and find connection between them. He wasn’t only beautiful specialist but also the considerable public figure, the dean of medical department and then the rector of university, editor of medical magazine. With his taking part one of the first prosector was organized in Moscow near educational house. Well-known in the world surgeon N.I. Pirogov (1810-1881) took a great part in development of the native pathoanatomy. He informed one of his correspondent that the mono-graphy «Pathologic anatomy of Asiatic cholera with the atlas … in Russian and French …» «is based on results of 800 autopsies of deadmen died from cholera». Moving in
The founder of the school of pathoanatomists of Petersburg is one of the greatest representatives of this science prof. M.M. Rudnev (1837-1878). He was the holder of the chair of pathoanatomy of Medical-surgical academy from 1867 till 1878. His doctor’s dissertation was called «About formations in a kind of hillocks on serous coats» (1867). The main scientific investigations of M.M. Rudnev were dedicated to amyloidosis, cerebrospinal meningitis, visceral syphilis, cholera, histogenesis of cancer and so on. He also composed guidance in general pathology (1873), published the magazine «Journal for normal pathologic histology and clinical medicine». M.M. Rudnev was the first who put into operation the practical lessons on microscopic pathoanatomy.
The founder of the large school of pathoanatomists was also M.N. Nikiforov (1858-1915), who was the holder of the chair of pathoanatomy of Moscow University from 1897 till 1915. During his leadership considerable improvement of teaching and scientific activity took place. His works about granulation tissue, chorion epithelium, name of which he suggested, were wide popular. In 1885 he composed first in Russia textbook «Microscopic technics», which was reissued eight times: in 1895 he published the atlas on pathologic histology; in 1898 he composed the first native textbook «The basis of pathoanatomy», reissued four times and then reissued by A.I. Abrikosov. Doctors dissertation of M.N. Nikiforov was dedicated to the changes of lien during typhus. His works about inflammation also had a great importance. He created macroscopic museum.
Academician N.F. Melnicov-Razvedenkov (1866-1937) was one of the greatest pathoanatomists in Ukraine, the holder of the chair in Kharkov Medical Institute from 1901 till 1919. He took an active part from
Clinical-anatomic direction of native pathoanatomy is explained by that the greatest Russian therapeutists and surgeons of XIX century simultaneously worked as prosectors till pathoanatomy standed out in undependent subject in 1849.
Inspite of considerable achievements of pathoanatomy prosectoring activity wasn’t wide spread in our country at the beginning of our century; it didn’t exist as united state organization. There weren’t places for autopsies in many hospitals, staff of pathoanatomists wasn’t prepared. Till 1917 there were only 12 medical departments which couldn’t provide our country not only with pathoanatomists, but even with medical staff; except this, autopsies were not obligative in that time. Fame of pathoanatomy was created by such scientists as G.V. Shor, A.I. Abri-kosov, N.N. Anichkov, I.V. Davydovsky, M.A. Skvortsov, A.A. Vasilev, M.F. Glazunov and others.
Prof. G.V. Shor (1872-1948) was the holder of the chair of pathoanatomy of Female Medical Institute in Petersburg. I Leningrad Medical Institute, now named in honour of LP. Pavlov, was organized on it’s basis.
G.V. Shor was outstanding pathoanatomist. His doctors dissertation was called «Primary cancer of bronchus, lungs and pleuras». He suggested new way of pathoanatomic autopsy with the help of total evisceration of organs, which now has become wide spread and called the methods of Shor. G.V. Shor suggested the method of prolonged conservation of organs for creation of museum preparations. Big scientific interest belongs to his monography, become bibliographical rarity, «About death of man (introduction in thanatology)». Questions about death causes, formulated in it, are still very actual. His investigation, dedicated to experimental reproduction of cancer in animals, to pathoanatomy of military poison substances, to organization of prosectoring service, are also interesting.
Academician prof. A.I. Abrikosov (1875-1955) took outstanding place iative science, he was the holder of the chair of pathoanatomy of I Moscow Medical Institute from 1920 till 1953. His doctors dissertation «About first anatomic changes in lungs at the beginning of lung tuberculosis» had large theoretical and practical importance. He was first who described original tumour myoblastome, also called in literature as Abrikosov tumour. His works «About olegranuloms» (1927), «About lipoid pneumonias» (1943) are very interesting. Text-book on pathoanatomy for medical students, repablished several times, created by him, has got a wide spreading. A.I. Abrikosov also wrote three volumes of guidance on pathoanatomy for doctors (one of them together with acad. N.N. Anichkov); created textbook on pathoanatomy of oral cavity and teeth for stomatologists. He is the author of the book «The technics of pathoanato-mic autopsy of corpses», republished several times.
The activity of academician prof. LV. Davydovsky (1887-1968) has got general acknowledgement. He is well-known scientist and philosopher far from the borders of our country. Being outstanding pathoanatomist, he was the holder of the chair of pathoanatomy of II Moscow Medical Institute. His special desert is the rebuilding of pathoanatomic education according to nosologic principle (1925), that has got general approval. Wide fame belongs to his monography about epidemic typhus fever (1921-1922). He created «Guidance on pathoanatomy and pathogenesis of human diseases», republished three times, and also line of works on pathoanatomy of infectio-nal diseases, pathology of military wound, on wound exhaustion on questions of general pathology/prosectoring service and so on.
His special desert is that he first organized clinical-anatomic conferences, which promote improvement of diagnostics and treatment of patients, he also unified pathoanatomic diagnostics.
Prof. N.N. Anichkov (1885-1966) was also an outstanding pathoanatomist. He was the holder of the chair of pathophysiology from 1920 till 1938 and from 1939 till 1946 – of the chair of pathoanatomy of S.M. Kirov Military – Medical Academy. His doctors dissertation was dedicated to inflammation changes of myocard and was named «To the teaching of experimental myocarditis» (1912). He described special cells in myocard called myocytes of Anichkov. N.N. Anichkov together with prof. V.V. Khalatov created infiltration theory of atherosclerosis that was acknowledged and developed in the works of his pupils and followers.
N.N. Anichkov and his staff created many models of infectio-nal diseases. His works about reticuloendothelial system have got wide acknowledgement.
Academician MA. Skvortsov (1878-1958) was outstanding specialist on pathoanatomy of children’s age. He created serious guidance «Pathoanatomy of the main diseases of children’s age», republished three times. His works dedicated to rheumatism, allergy, lymphogranulomatosis and questions of pathology also are very interesting.
Prof. A. A. Vasilev (1901-1943) had got a wide fame as an organizator and first leader of pathoanatomic service of military forces. A. A. Vasilev was lost near Stalingrad in 1943. According to his initiative and with his taking part in army pathoanatomic laboratories and central pathoanatomic laboratory belonged to Military – Sanitary administration were organized. Principles of organization of pathoanatomic service in army, created by him, exist still present time.
The famous pathoanatomist of our country was academician prof. M.F. Glazunov (18^7-1967), who was as the head of pathoanatomic service of military forces after the death of A.A. Vasilev. After war M.F. Glazunov was some time the head of the chair of pathoanatomy of Leningrad State Institute of Doctor Perfection, and then during many years he directed the morphologic laboratory of prof. N.N. Petrov Onkologic Institute. His monographies «About scurvy», «Tumours of ovaries» are well-known and have been a big contribution in medical science.
Big contribution in development of pathoanatomy in Ukraine belongs to prof. E.I. Gaina, the holder of the chair of pathoanatomy of Kiev Medical University, prof. M.I. Dal, the holder of the chair of pathoanatomy of Kiev Institute of Doctor Perfection, prof. Derman the holder of the chair of pathoanatomy of Kharkov Medical University. Their numerour followers are at the head of majority faculties of pathoanatomy in Ukraine at present time.
STRUCTURE OF PATHOANATOMIC DIAGNOSIS.
THE MAIN PRINCIPLES OF THE CONSTRUCTION OF PATHOANATOMIC DIAGNOSIS, EPICRISIS, THANOTOGENESIS, CONCLUSION OF DEATH’S CAUSE, COMPARING OF DIAGNOSIS.
DOCTORS’ MISTAKES, THEIR CAUSES AND SOURCES.
During autopsy pathoanatomist doesn’t mark only morphological changes, but also compares them between each other and with information of disease’s history. But final conclusion about essence of marked pathologic processes, their clinical «equiwalents» about dynamics of disease, it’s nosologic belonging and about cause of death is made by pathoanatomist, often with clinician, on finishing of autopsy. The composes pathoanatomic diagnosis and clinical-anatomic epicrisis and then compares clinical and pathoanatomic diagnosis. Often final conclusion about character of disease is made after several additional (histological, bacteriological, virusological, biochemical and other) inverstigations of materials taken from corpse.
Making pathoanatomical diagnosis pathoanatomist uses the laws of formal and dialectical logic trying not only to define the character of the disease with all it’s consequences that caused lethal result, but also defining, asit possible, the etiology of disease, dynamics of development of morphological changes in their order of appearing and in connection with intravital manifesnations and conducted medical procedures and with that pathological background which also lies in the basis of un favourable development of disease causing the violation of homeostasis, resistance and reaction of patient’s organism.
It’s specially important to elucidate the influence of treating-diagnostical measures because modern vedical interferences and numerous diagnostical methods in their totality can change natural flow of disease, that is marked with the termin «medical pathomorphosis», and they can be not only useful for concrete patient, but also cause negative effect on some stage of disease or even death. So creating ofpathoanatomical diagnosis includes all steps and links of scientific process.
Consequently, creation and wording of pathoanatomic diagnosis are not a formal act, but they are the conclusion in exact terminological form of results of clinical-anatomical analysis of disease’s manifestations in their dynamics, interaction and dependence. Diagnosis is being formed in the result of difficult comprehention of discovered facts which were marked by clinician during disease and morphological changes noticed during autopsy in their comparing. So, pathoanatomic diagnosis is the final step of diagnostic process that started from first patient’s visit to doctor and finished near sectional table.
Pathoanatomic diagnosis always starts from wording of the main disease-nosological unite. Fill this time this principle in firm. In a kind of exception the basis of diagnosis may be syndrome. It can be in situations when syndrome, being the basic cause of death, hasn’t yet got a nosological «design», that means that it isn’t included in any nosological form (for example, syndrome of Marphan, Peijts-Djgers and so on).
Next to the main disease it’s complications are enumerated (in pathogenetic order). In the end of diagnosis the list of attendant diseases and other (for example, residual) pathological processes is given.
That order of composing of diagnosis, anatomical and clinical, hasn’t been changed till last time. It is comfortuble for the physicians of all specialities, for the aims of medical, statistics and for administrative organs of public health.
But last decades it was needed to make some changes in discribed scheme of pathoanatomic diagnosis and to define more precisely the notion of the main disease, to mark it’s varients. It was needed because the amount of numerous disease of one and the same individual considerably rised. These diseases are in difficult interactions between lach other and have different influence on clinical manifestation of very appeared disease. They also have different pathoanatomical and thonatogenetical meaning and often they ask for application of different diagnostical and medical measures. The causes of increasing of number of numerous diseases are a lot of factors of the modern human existence – changed ecological conditions of life; prolongation of humen life; consequences of the disease that have bech untreated before, but now it’s possible to treat them, but they leave consequences which are ground for new diseases; unfavourable consequences of medical diagnostical measures and so on. Today, according to some information, only in 1 % of cases people who are older go have one disease. Supposition that line of diseases combines on the basis of general constitutional peculiarities of organism (coordinated diseases) is advanced. Also it’s supposes that one disease «opens road «to another one lowering the resistance and reactivety of organism (subordineted disease) and that some disease combine with each other occasionally.
The necessity of some changes of pathoanatomical diagnosis scheme is demanded by such processes that haven’t been put in diagnosis before. These are, for example, unfavourable results of medical measures especially made according to wrong diagnosis and caused lethal result (for example, apblasia of the bone marrow after rays therapy because of wrong definition of the character of tumor as a malignant; operative intervention that ended with lethal result with absence of supposed disease; medical measure that had been wrongly carried out and caused death, for example some hemotransfusional complications; application of the strong phormacologic remedies and biologicaly active substances; lethal allergic reactions after application of some reonedies; death in the process of premedication before operative or diagnostic intervention; death in the result of diagnostic measures, profilactic inoculation and so on.
The wording of pathoanatomic diagnosis with availability of pathologic processes connected with medical interventions demands from prosector not only medical, but also ethical and juridical appraisal (with the help of legal – medical expert), especially if consequences of medical intervention are supposed to be put in the basis of diagnosis.
According to the regulations of LDC (IX reconsideration) all such cases can be devided into groups depending on the character of intervention and it’s importance for disease development and in thanatogenesis.
1). Lethal result as a consequences of surgical trauma because of technical errors of operation. In such situation surgical trauma is equal to any other and must be considered as equivalent of the main disease that is especially clear in cases of operations made with prophylacticain, with cosmetic aims or with not enough ground for operation. This group of lethal results is especially difficult for definition of the role of operative trauma in thanatogenesis. It’s not homogeneous and can be devided into two subgroups:
a) death after operation connected with defects of intervention or with wrong diagnostics of the disease that caused unjustified or to big in valic operation. In such cases surgical trauma must be considered as main disease;
b) death after operation which was expedient according to the character of disease. Such lethal results usually happen with difficult to cure patients. They depend on the lack of ability of organism to go through the operation because of difficulty of disease or neglecting of it or infective complications prophylactic of which on that step of disease can’t be perfect. In such cases operative trauma and it’s consequences must be put in diagnosis like complications of the main disease.
2). Death from narcosis, which can be consequence of different causes: individual lack of ability to go throw preparation, it’s overdose, asphyxia, late intuation, larly extubation, bronchospasm, aspiration of food mass. That kind of death can happen even in the period of premedication. It can be considered that all marked kinds of «narcosis» death must take first place in diagnosis and the disease, which was the cause of operation, vust be included of heading of the background disease.
3). Lethal results of patients with tumors, connected with consequence of treatment with chemical preparations because of wrong definition of tumor as malignant one, must be considered as main disease.
4). Lethal results, connected with hemotransfusional complications. Such complications always must «be at the heat»of anatomic diagnosis.
Describet deviding of lethal results in connected with medical, especially surgical, interventions and supposed appraisal of them asamain cause of disease is still discussed. But rules of composing of pathoanatomical diagnosis that exist now in such group of lethal results they don’t reflect real importance of medical interventions in lethal results, low attention to them from the side of public health organs and treating doctors and, they don’t promote to improvement of treating process and they give wrong indexes of sick rates and mortality that distort real situation.
Marked reculiarities of modern step of complication of the notion of main disease, that means also the main cause of death, cause that former synonymous of the main disease is unaceptable in many causes that demands the reconsideration of that definition. In result of discussion that took place on the pages of magazine «Архив патологии» and touched these questions, several new diagnostic definitions were suggested.
Let’s start from the termin «combination main disease». The cases with two or more diseases being in different, often difficult interactions are included in that notion. That demans the marking between combinated main diseases following their varieties:
1). «Competing diseases» – that termin means two or more diseases of patient, every of them can be cause of death, that’s why it’s very hard to distingaish the main disease even after detain $ clinical-anatomical and thanatogenetical analysis.
2). «Combined diseases» – two and more diseases every of which can’t cause death itstelf: in combination they cause lethal result.
3). It was considered worth while to include in the scheme of pathoanatomical diagnosis additional heading – «background disease». That termin means disease that, preceding the main one or combining with it, makes the flow it more difficult or plays impotent role in it’s dynamics or appearing of complications. Background diseases often are chronic, they violate homeostasis in some degree. The typical example of background disease in diabetes melitus if it causes hard flow of infectional, heart-vessels and many other diseases. Hypertonia, atherosclerosis, sometimes malignant tumors belong to background diseases. Background and main diseases can make up combined main disease. The group of background diseases can include some unfavourable consequences of medical measures that makes flow of main disease more hard or causes the appearence of hard complications.
Including in diagnostic scheme the heading «Background diseases» has agreat importance for elucidation of the role of processes being included in the group of accompanying diseases. The former scheme of pathoanatomic diagnosis contained the diseases that made the flow of main disease more hard and also the pathological processes that didn’t play such role, for example, consequence ofearlier disease that had left only morphologic tracks (paunches, connection of serous leafs), bening tumors and other. As it is shown by experience and results of discussions, the heading «background disease «can have great importance in analysis of many cases of perinatal death of fetuses and newborns, in elucidation of taking part in pathological process and in lethal result of the complex mother – placenta – fetus (child).
Shown addition to the scheme of pathoanatomic diagnosis promote to more objective and exact appraisal of role and importance of very discovered numerous diseases and also permit to make clear medical pathomorphosis and to promote to definition of importance of conducted medical measures for flow, morphologic changes and result of disease.
Composing pathoanatomic diagnosis in cases of numerous diseases physician must umember that atatisticist will into consideration that disease as main one, which will be put in first place in diagnosis. Such way of registation of numerous diseases causes line of conventions and simplibyiags which narrow scientific value of received materials.
Clinical-anatomical epicrisis differing from pathoanatomical diagnosis includes the opinion of pathoanatomist about pecualiarities of that case, basing on all received information (clinical, laboratorical, morphological and so on),and also explanation of diagnosis thesises, if it’s necessary. There is no clear scheme of epicrisis composing and it’s not needed because in every case they have to reflect different sides of processes basing on peculiarities of disease’s flow, thonatogenesis and many other things. That’s why in some cases ipepicrisis they have to pay attention to some questions and miss other which can be principal in other cases.
It’s passible to show the maintenance of epicrisis only in general form in a king of list of questions and problems, which can form it’s basis: ground of diagnosis of the main disease, picture of dynamics of it’s development, pathogenesis of it’s complications; elucidation of thanatogenesis; elucidation of factors which can cause the violation of homeostasis (genetical, immunological, life conditional, ecological, productional and so on) before disease’s development and during it’s flow: important role of epicrisis belongs so analysis of conducted medical-measures their expedientness, timeliness; possibility of larly prehospital aand hospital diagnostic; using of necessary diagnostical methods; timeliness of hospitalization, dynamics of diagnostical process; corectiress of readings to operative intervention, characteristics of that intervention; characteristics of drug therapy; characteristics of reanimational measures.
Epicrisis in it’s first and, especially, in it’s second part, which is dedicated to the quality of medical help, must be composed basing not only on history of disease, but also on active taking part of treating doctors, often only after detail discussion of case on conference of the medical – control commision or on clinical –anatomical conference. In essence, all marked questions, reflected in clinic – anatomic epicrisis, must be discussed on these conferences. Answer on the se questions lets to characterize all steps of medical – diagnostic process, it’s mistakes, mistakes of medical thinking and organization of medical – prophilactic work in concrete examples in the that medical institute, activity of «paraclinical» departments, administration, economy services and, of course, it reflected the qualification of treating doctors and role of consultants.
Comparing of clinical and pathoanatomical diagnosis is one of the important part of clinical – anatomical analysis of autopsy’s information. Results of this analysis are included in final part of clinical – anatomical epicrisis and are subjected in obligative order to discussion on clinical – anatomical conference. As it’s clear, comparing of diagnosises is one of the important part of clinical – anatomical comparing generally, that means it’s important for wild circle of questions of examination, taking care, treatment, documentation, etc.
Comparing of diagnosises often is understood as simple comparison of final clinical and pathoanatomical diagnosises. That’s wrong. During comparing of diagnosises it’s needed to analyse the dynamics of clinician’s thinking on every stage of diseases flow according to fact information that permited to define first diagnosis and think about following diagnostical measures, their expedienty, timeliness and corectness of confirmation or change of first and then final diagnosis. The last one is the result of observation of the patients during it’s being in hospital and of polyclinical information, anamnesis of disease and life. In cases of wrong clinical diagnosis in time of such detail analysis of diagnostic process it’s often possible to establich on what stage and why the thought of clinical has gone in a wrong way.
In our country the comparing of clinical and anatomical diagnosises is declared like obligative measure according to the scheme suggested by I.V. Davydovskiij and retified by leading pathoanatomists of the country. Inthe bases of diagnosis comparing thyput nosological principle. Comparing is being corned out in three headings: in main disease. In it’s main complications and in main attendant diseases. Possible causes of noncoincidence of diagnosises can be objective difficulties, brevity of observing, over – estimation or underestimation of consultants corclusion, laboratory information, other investigation and so on. That pronciples of diagnosis comparing have been using more then 40 years, generally, they justified them self. Diagnosis comparing is the main factor in rise of qualification of treating doctors and promeses to elucidation of the week places in organization of medical help to population. But during time some lacks of principals of diagnosis comparing were elucidated. So, the attempts to value the quality of work of medical institute or medical departments inside it basing only on the percent of divergence of diagnosises are mode. Doing they don’t take into consideration the profile of institute, it’s charge, diagnostic possibilities, contingent of patients, possibilities of hospitalization. Found defects of clinical diagnostics are mechanicaly fixed for the medical institutes in which patient died, but considerable part of them belongs to the previos stages of treatment – on district, in polyclinics, in other hospital.
Such wrong understanding of the results of diagnosis comparing is dagnerous because treating will try to establish the exact diagnosis at any price, using difficult and even dangerous diagnostic measures, won’t take into consideration the condition of patient. The analyses of made mistake mustn’s become uninterest for doctors: they don’t need only solution of the question of final diagnosis coincided or it didn’t. If diagnosises «didn’t coincide» then detail analysis couldn’t be changed by searches of justifications. Together with in some pathoanatomists sometimes change clinical – anatomical analysis by «prosecutor’s» approach to the problem, accusing physicians in made mistake and don’t explain it. Opposite cases, when pahtoanatomist under pressure of administration and treating doctors lowers antificiently the amount of divergences of diagnosises, aren’t permited. Such practics can cause the lowering of clinicians’ interest to analysis of sectional materials, make these analyses formal and have negative influence on quality of clinical – anatomical conferences. From that point of view the report of pathoanatomical department musn’t be formal, in opposite case the organs of public health will be deprived of one of the important sources of information about what defects are in the system of organization of medical –diagnostical work. Pathoanatomist’s information can’t be changed by other sources because pathoanatomical materials more often elucidate the lacks of organisation of medical – diagnostical work, basing on these materials it’s possible to elucidate with complete objectiveness where, on what stage and why these lacks appeared. It should be marked that the reports of LV. Davydovskiij and S.S.Vaijl still have their importance, they contain valuable information about causes of death and quality of medical –diagnostical work, these reports are based on materials given by pahtoanatomic departments of hospital. That makes clear the preat importance of these reports in our time, taking into concoderation all changes happened in medical – diagnostical process and in organization of medical service in a whole.
Lacks of comparing of pathoanatomical and clinical diagnosises in majority cases are following:
1). The question about what disease is the main can be the subject of discussion. For example, in it possible consider the atherosclerosis as main disease in case of death from infarct of myocard, if the last one hadn’t beeoticed intravital? The stamp of «noticed» main disease, certainly, is bad because it lowers the atatention of clinician to such hard, in that case lethal processes which are the independent nosologic unite with many varieties.
2). Can malignant tumor, sharp infection disease be in diagnosis in a kind of accompanging or background disease ? So, the patient with cancer of stomach, of sharp infection disease can die, for example, from infarct of myocard. It’s clear, that including of sach disease iumber of accompanging disease isn’t excused because shey plaged some role in thanatogenesis and that’s why they must be considered as background diseases ?
3). The intermetation of cases of trauma of old people causes big problems, because these traumas cause lethal heart insufficiency, as it happens, for example, after braking of neck of hip. In such cases heart insufficiency is the result of violation of compensation of life functions which is unsteady in old age and trauma is the push for such decompensation playing role of ethiologic factor and must be considered as main disease.
4). About difficulties, happening in cases of death, connected with mistakes of medical – diagnostical measures. It had been told before.
5). Lethal results, happened with patients who had been less one dag in hospital for inpatiens, demand special analysis, such cases are connected often with urgent conditions and are in special position according to diagnostics. In that case it’s more important to establish the causes of hard condation of the patient (coma, bleeding, sharp stomach, shart heart insufficiency, poisoning and so on) for conductiong of urgent measures for it’s liquidation, but elucidation of nosologic belonging of disease is still important as for other diseases.
Analysing clinical diagnosis in cases of it’s divergence with anatomical, it’s should be taken in consideration where the wrong diagnosis was established – on previous stage of treatment or in hospital where death came. First happened of patient entered hospital in condition that didn’t permit to carry out the full investigation and establishment of diagnosis had no influence on tragic result. If wrong diagnosis was established in previous medical institute shen it should be elucidated in what degree it had influenced in result of disease.
These considerations let devide all cases of diagnosis divergenses into three categories:
Category 1. The disease hadn’t been recognozed on previous stage of treatment and in hospital, where patient died, it was impossible to establish the right diagnosis because of hard condition of the patient, neglected stage of because of quickly coming of death. Usually in such cases wrong diagnostics had no consequences for patient. This category includes the patients with malignant tumors in unoperationable condition or in period of wide spreading of metastasises, with more difficult for diagnosticsliseases in final stage of process (for example, collagenosis, nephrosclerosis). Criterion of difficulty of disease that daesn’t let to carry out the necessary diagnostical measures is the main for including of such observations in first category.
Category 2. The disease isn’t recordnized in the hospital, where patient died althound there were possibilities for establishment of right diagnosis, as in terms of being, also as in condition of the patient.
But wrong diagnostics didn’t have essential negative influence on result of disease because of incurability or because of impossibility of radical help in that stage of disease (neglected malignent tumors, patients with several hard diseases, patients in final stage of chronic heart, kidneys or liver insufficiency).
Category 3. Right diagnosis isn’t established in hospital and that makes the main influence on the flow of disease, treatment and lethal result. This category includes urgent cases demanding immedieate radical help: destructive appendicitis, pancreonecrosis, perforating bleding ulcuf of stomach, pinched hernia, cardiogenic ‘ shock conneted with infarct of myocard, brain unsult, acute lobar pneumonia, other sharp infection diseases.
Coinudenu of diagnosises of main disease mast be considered as formal if right diagnosis was late and didn’t cause the conducning of right expedient medical measures. Today this important hart of history of disease canit be carried out in full value because it doesnit permit to elucidate when the diagnosis, shat was put on titlepage of disease’s history, has been established. That important moment is seldom fixed in diary of disease’s history too. Sometime it’s passible to sappase approxionate same of diagnosis establishment bnfsing only on records of consultants or on remarks of the holder of deportment or on prescribing of medicines. Absena of marked information causes that it’s hard to elucidate the development of «diagnostig thought «of physician, and final clinical diagnosis often becomes unexpeited. It ispit based on diary’s records or additional investigations and it doesn’t seem based at all.
As it was mentioned, the structure of sick – rate and mortality of population has sharply chander last decades. Physician often meets combination of several hard diseases, diagnostics of which and definition of rale of everg of them in condition of the patient become more difficult. Moyu disease become «forgotten» because modern physician doesnit meet them. These are some acute infectional diseases, lepra, syphilis, in some degree tuberculasis and other. That’s very mentioned and some other diseases often are not distinguish intravital and it’s hard to distinguish shem for pathoanatomist too. The character of medical – diagnostic measures has changed too. That influences on the fluw of many diseases, caures the recovering of many of them that before were considered as lethal as absolute lethal life of patients becomes more long that causes strong or ween patomorphosis. The same is canses by reanimation that lets to return to life the patients after their clinical death, to support the existence in special artifical condition.
Praseding to their oun lares. That’s why the new chapter of pathology – «pathology – sherapy» appeared. This charter contains sickly conditions caused by medical measures. So, clinical picture and pathoanatomy of many wole – knoun diseases have sharply changed being influenced by modern therapy. Mentioned canges in medical practics cause that big problems of defmision of pathogenesis of many pathological processes, dependence of them oatural development of disease or on conducted medical measures, appeare during analysis. These problems are oven more considerable during elusidation of thanatogenesis taking into consideration of clinical information and also their uncritical perception, over – estimation of pathoanatomic information anol wish to «adapt» shem to clinical diagnosis.
The subjective causes are:
a) scanty qualification of procector in the questions of his speciality and adjacent subjects and over – estimation of his own knowledge;
b) hurry, unsufficient attention and unsystematic way in earring out of autopsy; c) absence of consultations about sectional anservations with more experienced pathoanatomists when such possibility exists.
Medical mistakes are devided into tactical and technical. Medical – tactical mistakes in surgery consist 20 – 25 % of all doctor mistakes. That group contains: inoportune hospitalization of reading and contrareadings to operation, in choice of time and valume of surgical intervention, overdose of medicines, wrong prescription of them, absence of application of medicine, using of contaminated or infected blood and other liguids in transfusions.
Medical – technical mistakes are met during instrumental, diagnostical and medical manipulations: leaving of alien bodies in wounds and cavities, perforation of uterus wall during ambrasio, damage of urinary bladder’s wall during different operative interventions.
Organizational mistakes are met more often. Their character and importance strongly variat and are difficult subjected to exact appraisal and calculation. Examples of it are failures of the work of service of «quick help «and also of medical institutes. These mistakes are absence of connection between hospital and polyclinics, lacks in dispansery’s watehing, wrong arragment of the staff; bad cjntrjl after staffs duties, delag of patients «examenation and immediate help, defects in providing of medicines, blood and so on. Certainly, materil part of organizational measures depends on real possibilities and concrete situation; but considerable part of organizational mistakes can be removed by the forces and possibilities we have.
Mistakes in missing of medical documentation. Usually, the medical card of hospital’s patient, records of autopsies, ambulant cards of olcafmen are subjected to analysis.
The mistakes in missing of medical cards of hospital’s patient are following:
a) wrong design of clinical diagnosis (M.K. Dal, 1949):
· -careiess of it’s writing (records with different inks, unclear hand writing, arbitary shortening of words),
· -bad order of position of diagnosis parts,
· -absence of the date of establishment of one or another
component of diagnosis,
· -absence of deviding into main disease, complications and accomdanying diseases,
· -desing of diagnosis according not to nosologic forms of sease,
· -substitution of main disease in pathogenetic mening by the main dinical displays of the disease which often are the complication of it,
b) violations in reflection of dynamics of disease development, in particular, information of daily rounds, consultations, consiliums, not full reflection of disease’s proceeding in transfered stages of epicrisis;
c) insufficient reflection of conducted laboratory and special investigations (X-ray investigation, endoscopy and other);
d) in postlethal clinical epicrisis – unsufficient elucidation of essence sides of beginning, proceeding of the disease, unconorete conclusion about mechanisms and direst canse of death.
In dering of autopri’s record following mistakes can be admited:
1. Careless in writing of autopsy’s record.
2. . Absence of information about mass and volume readings of organs.
3. Absence of detail descriptions of morphologic changes that impedes clinical – anatomic comparing.
4. In card of section and in clin ical – anatomic diagnosis the causes of divergence, their importance in lethal result of disease are not shown.
5. Mistakes of behavior of medical staff in medical institutes often connect with violation of deontology’s principles. Pathoanatomis necessary needs strong self- control and delicacy in formulation of death’s causes which should convince relatives shat mistake in medical – diagnostic help was justified by definite objective causes and difficulties. He should not give occasion that actions of treating doctors could be estimated by viatives of dead man as a fault or medical crime. Freating doctor answers the questions connected with life of patient till she moment of his death, but only pathoanatomist can talk about causes of death.
6. Mistakes, connected with prophylactic measures, get more importance from year to year because of great scales of inoculations, vaccination, biologically active substances.
To the aims of lowering of specific weight of doctors’ mistakes in our country their analysis on clinical – anatomic conferences and on meeting of medical – control commissions is wide practiced. That measures promote the formation of medical thinking, increasing of physician’s qualification, elucidation of «wear places» in organization of medical – diagnostic and prophylactic work in concrete hospital, region, city and so on.
GENERAL INFORMATION ABOUT NOSOLOGY. INTERNATIONAL CLASSIFICATION OF DISEASES. MACROSCOPIC OF PATHOLOGICAL PROCESSES.
The unification of principles of this processes, states and nosological forms, reflecting in a diagnosis, registration have importance in a creation of fundamental scientific principles of verification of various pathologoanatomical human processes, statistical registration of morbidity and lethality.
Diagnosis (Greek, diagnosis – recognition) represent the medical conclusion about state of health of patient, about diseases which he have or about cause of death, expressing in terms, which stipulated by accepted classifications and nomenclature of diseases. The establishment of diagnosis is concern to final part of diagnostic, processes or definite stage of course of diseases,
Diagnostic (Greek, diagnostical – capable to recognize) is part of clinical medicine, which study the content, methods and consecutive steps of diseases recognition process or particular physiological states. The process of diseases recognition and estimation of individual biological and social peculiarities of fellow is called by diagnostic in the narrow sense. This process include the purposeful medical inspection , interpretation of receiving results.
Diagnostic can be various depending on purpose, nature of examining object and using diagnostic methods. The clinical, pathologoanatomical, epidemiological and forensicly – medical diagnosises are discern in connection with mentioned.
The particular physiological states of organism (pregnancy, climacteric, barillicarrierity ect.) can be by content of a diagnosis, and also the conclusion about epidemiological nidus is can be by content too. Diagnosis is substantiation to choice of treatment methods of patient and prophylactic measures.
Diagnosis can reflect not only designation of diseases, but the nature, aetiology, pathogenesis, its basic manifestations, complications, structural base of disease, character and degree of breach of physiological systems. In connection with this the diagnosis must contain the etiological, pathogenetic, morphological and functional components.
Methodological bases of diagnostic have the set of specific traits, connecting with complication of structure and function of human organism and must rest upon principles of determinism, dialectical unity of organism and environment. There are three intercomplementarying approaches, to generalization of symptoms in a diagnostic tactics: nosological, syndromic and construction of a diagnostic algorithm.
The methods of a diagnostic inspection include the proficiency of medical interrogation of patient, observation and inspection of patient, elaboration and application of special methods of studying of morphological, biochemical and functional changes, which stipulated by disease or particular physiological state.
The diagnosis in human’s lifetime of morphological changes in organs is settled with the help of physical methods, rengenologic inspection, radioisotopic scanning, endoscopy, cytological research or with the help of biopsy.
Every disease is accompanied by determine structural dynamic improvements in organs and tissues. Their essence and localization to find its reflection in a morphological component of a diagnosis, which must be constitutive part both of lifetime diagnosis, and of posthumous.
The nosological principle is leading in a construction of diagnosis. There are about 130 definitions of “nosological unit” notion in a literature. The leading pathologoanatomists of our country considering the nosological unit like a pathological process, which have the general aetiology, pathogenesis, morphology, organopathology, clinical manifestations and definite prognosis (A.V. Smoljannikov, A.I. Strucov, V.V. Serov), and not all indicated components of nosology are clear. For example, such diseases, like infections, professional are characterized by established aetiological factor, well known pathogenesis, morphological substrat and its dynamic, organopathology and clear-cut clinical manifestations.
However, the much diseases are characterized by obscure to end aetiology (hypertensive disease, atherosclerosis, stomach ulcer disease, many tumors, or unclear pathogenesis, that raise multitude theories.
There are also nosological forms, having the definite aetiology, pathogenesis, organopathology, clinic, but not established substrat of this disease yet (for example, spasmophilia). There are also diseases, which have only definite clinic, while the cause, mechanism of development, pathological anatomy of them not elucidated quite yet (for example, some psychical diseases).
Thus, the difficulty of definition of nosological forms connected with heterogeneity of aetiology, pathogenesis, clinic, morphology, prognosis and social importance and with insufficient studing of diseases.
The grouping of nosological units by different indices, which pursue the various purposes, represent the classification of diseases. The latter is serve as a guiding principle for all scientific generalizations and, consequently, have the essential importance in a statistic methodology. The homogeneity of definitions and principles of construction of classification is necessary precondition of progress of science.
There are clinical, pathologoanatomical, based on aetiological, organic signs and others classifications. The statistic classification, which determine the methods of organization and work of all medical institutions occupy the upper grade in hierarchy of all classifications.
There are many particular classifications, which created for definite medical disciplines (for example, diseases of mouth cavity and teeth, diseases of stomach, tumors of various localizations ect.). All classifications are revised with a progress of medical science. Some syndromes include in a part of nosological forms and vice versa.
At the some time all diseases can be united by following parameters:
1. By etiology (infectious and different non-infectious diseases).
2. By principle of community of socially mediated action on human organism of natural and artificial factors (professional diseases, military pathology ect.).
3. By anatomo-topografic sign of localization of basic seat of lesion (disease of lungs, heart, LOR-diseases and others).
4. By belonging to determine sex, age (woman’s, child’s diseases, diseases of old age).
5. By sign of community of forms of its development and course (acute, subacute, chronic).
6. By likeness of pathogenetical mechanisms (allergic diseases, rheumatic diseases, neuro-dystrofical processes).
The 29 World Assembly of the health protection assume the 9-th revision of International classification of diseases for receiving of comparable facts about the morbidity and mortality of population in different countries and studying of effectiveness of medical arrangements. This classification reflect the basic notions in modern medicine and drew up with regard of aetiological, pathogenetical, morphological, topical, functional signs and with regard of different levels of organization of medical service in a various regions of the world. All diseases divides on 17 classes:
I. Infectious and parasitic diseases.
II. Neoplasm’s.
III. Diseases of endocrine system, disorders of nourishment, branches of metabolism and immunity.
IV. Diseases of the blood and hemopoietic organs.
V. Mental disorders.
VI. Diseases of the nervous system and sense organs.
VII. Diseases of the blood circulation system.
VIII. Diseases of the respiratory organs.
IX. Diseases of the digestion.
X. Diseases of the urogenital system.
XI. Complications of pregnancy, child birth, post-natal period.
XII. Diseases of the skin and hypodermic tissue.
XIII. Diseases of the skin-muscular system and connective tissue.
XIV. Inborn anomalies (vices of development).
XV. Separate states, appearanced in perinatal period.
XVI. Symptoms, signs and inexactly designated states.
XVII. Traumas and poisonings.
The 8-th revision, besides the diseases, include the considerable number of states: old age (797), indomitable vomiting of pregnants (643), endured pregnancy (645), massive aspiration syndrome (770.1), anorexia (783.0), polygaphia (783.6), disuria (788,1), enuresis (788.3), sudden infant death syndrome (death in a cradle – 798.0).
Not all principles, regulations, wordings and dividing accordings to subject headings of ICD are applicable in a daily work in our country, because the ICD calculate upon all countries with different level of medicine development, with representatives of different medical schools and generations.
PERINATAL MORTALITY
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Classification and external resources |
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Infant, neonatal, and postneonatal mortality rates: United States, 1940-2005 |
Perinatal mortality (PNM), also perinatal death, refers to the death of a fetus or neonate and is the basis to calculate the perinatal mortality rate. Variations in the precise definition of the perinatal mortality exist specifically concerning the issue of inclusion or exclusion of early fetal and late neonatal fatalities. The World Health Organization defines perinatal mortality as the “number of stillbirths and deaths in the first week of life per 1,000 live births, after 24 weeks gestation”, but other definitions have been used. The UK national figure is about 8 per 1,000 and varies markedly by social class with the highest rates seen in Asian women.
Preterm birth is the most common cause of perinatal mortality, causing almost 30 percent of neonatal deaths. Infant respiratory distress syndrome, in turn, is the leading cause of death in preterm infants, affecting about 1% of newborn infants. Birth defects cause about 21 percent of neonatal death.
Fetal mortality refers to stillbirths or fetal death. It encompasses any death of a fetus after 20 weeks of gestation or 500 gm. In some definitions of the PNM early fetal mortality(week 20-27 gestation) is not included, and the PNM may only include late fetal death and neonatal death. Fetal death can also be divided into death prior to labor, antenatal (antepartum) death, and death during labor, intranatal (intrapartum) death.
Early neonatal mortality refers to a death of a live-born baby within the first seven days of life, while late neonatal mortality covers the time after 7 days until before 28 days. The sum of these two represents the neonatal mortality. Some definitions of the PNM include only the early neonatal mortality. Neonatal mortality is affected by the quality of in-hospital care for the neonate. Neonatal mortality and postneonatal mortality (covering the remaining 11 months of the first year of life) are reflected in the Infant Mortality Rate.
Perinatal Mortality Rate. The PNMR refers to the number of perinatal deaths per 1,000 total births. It is usually reported on an annual basis. It is a major marker to assess the quality of health care delivery. Comparisons between different rates may be hampered by varying definitions, registration bias, and differences in the underlying risks of the populations.
PNMRs vary widely and may be below 10 for certain developed countries and more than 10 times higher in developing countries . The WHO has not published contemporary data.
INFANT MORTALITY
Infant mortality is the death of a child less than one year of age. Childhood mortality is the death of a child before the child’s fifth birthday. National statistics tend to group these two mortality rates together. Globally, ten million infants and children die each year before their fifth birthday; 99% of these deaths occur in developing nations. Infant mortality takes away society’s potential physical, social, and human capital.
Generally the most common cause worldwide has been dehydration from diarrhea, a preventable disease; however, a variety of programs combating this problem have decreased the rate of children dying from dehydration. Many factors contribute to infant mortality such as the mother’s level of education, environmental conditions, and political and medical infrastructure. Improving sanitation, access to clean drinking water, immunizationagainst infectious diseases, and other public health measures could help reduce high rates of infant mortality. The U.S. National Institute of Child Health & Human Development (NICHD) has made great strides in lowering U.S. infant mortality rates. Since the institute was created the U.S. infant mortality rate has dropped 70%, in part due to their research.
Infant mortality rate (IMR) is the number of deaths of children less than one year of age per 1000 live births. The rate for a given region is the number of children dying under one year of age, divided by the number of live births during the year, multiplied by 1,000.
Forms of infant mortality:
- Neonatal mortality is newborn death occurring within 28 days postpartum. Neonatal death is often attributed to inadequate access to basic medical care, during pregnancy and after delivery. This accounts for 40–60% of infant mortality in developing countries.
- Postneonatal mortality is the death of children aged 29 days to one year. The major contributors to postneonatal death are malnutrition, infectious disease, and problems with the home environment.
- Perinatal mortality is late fetal death (22 weeks gestation to birth), or death of a newborn up to one week postpartum.
Some causes of congenital infant mortality are malformations, sudden infant death syndrome, maternal complications during pregnancy, and accidents and unintentional injuries. Environmental and social barriers prevent access to basic medical resources and thus contribute to an increasing infant mortality rate; 99% of infant deaths occur in developing countries, and 86% of these deaths are due to infections, premature births, complications during delivery, and perinatal asphyxia and birth injuries. Greatest percentage reduction of infant mortality occurs in countries that already have low rates of infant mortality. Common causes are preventable with low-cost measures. In the United States a primary determinant of infant mortality risk is infant birth weight with lower birth weights increasing the risk of infant mortality. The determinants of low birth weight include socio-economic, psychological, behaviorial and environmental factors.
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