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 åð³ – 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 ðàthologoanatomic
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
_______________________
Ñity ________________________ 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
d³agnos³ng
_______________________
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 in necessery 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 in native 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
«Àðõèâ ïàòîëîãèè» 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 been noticed
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 in number 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 on natural 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
|
Classification and external
resources |
|
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.
VIDEOS:
·
Thromboembolic
of pulmonary artery in pregnant woman