Forgoing search for medical truths

Autopsy: Postmortem examinations are the ultimate way to confirm diagnosis or to see the extent of disease. But fewer doctors are performing them.

January 25, 1999|By Diana K. Sugg | Diana K. Sugg,SUN STAFF

Katie Scully had endured the loss of a 3-month-old girl and suffered a miscarriage. Now, in the eighth month of her latest pregnancy, she hadn't felt the baby kick for hours. She almost held her breath as the doctors strapped the monitor around her stomach. There was nothing -- no movement, no heartbeat.

Scully and her husband, Steve, wondered if they were cursed. They wanted to know if they had passed on some genetic defect to their stillborn son. They asked for an autopsy.

"To suddenly not feel any life," said Katie Scully, 33, "it was like, what happened here?"

For two centuries, autopsies have been the ultimate way to answer that question. But fewer and fewer families and doctors are relying on them. Thirty years ago, about half of all U.S. hospital deaths were autopsied, compared to as few as 10 percent today in teaching hospitals and 1 percent in community hospitals.

Forgoing that final examination means families lose a piece of their medical histories. Society, too, is losing the truth. Without an autopsy, physicians get the cause of death wrong about 40 percent of the time, medical studies show. Incorrect death certificates skew vital statistics. Doctors miss new diseases. Murders are buried.

Dr. Hugo W. Moser, a researcher in neurodegenerative diseases at Baltimore's Kennedy Krieger Institute, laments the situation: "Autopsy is the only way to find some of the answers."

Dissections of human bodies have been done for thousands of years, mostly for religious reasons or to learn human anatomy. It wasn't until the early 1700s that doctors realized illness was directly related to observable changes inside the body. Eventually, autopsy was considered as important as diagnosis, and historians credit it with ushering in the modern era of medicine.

Dr. William Osler, the legendary chief physician at Johns Hopkins Hospital, championed autopsies when he arrived about 1900, making them routine and often performing them himself.

According to a published history, just before Osler died at age 70, he left detailed notes for his own postmortem. "I've been watching this case for two months," said Osler, "and I'm sorry I shall not see the postmortem."

The verdict: bronchopneumonia. Osler's diagnosis was correct.

Some physicians dispute Osler's view that the autopsy is the final word. They say a doctor who cares for a patient for a decade knows that person better than a pathologist who never met him. But experts say the value of autopsies cannot be denied.

Incorrect diagnoses

In a study published in October's Journal of the American Medical Association, researchers at Louisiana State University Medical Center compared a decade's worth of autopsy and death certificate data. They found that 44 percent of malignant cancers had been either misdiagnosed or undiagnosed.

"It was shocking," said Dr. Elizabeth C. Burton, a pathology resident and lead author on the study. "I just couldn't fathom how this could happen."

Around the country, pathologists say they see such errors all the time.

One woman's brain cancer turned out to be abscesses from the gum disease gingivitis, recalled Dr. Gregory J. Davis, Kentucky's state medical examiner. At Johns Hopkins Hospital, surgeons found that a patient believed to have lung cancer instead had tuberculosis throughout his body, said Dr. Barbara J. Crain, an associate professor of pathology and director of Hopkins' autopsy service. In another recent case, a patient believed to have heart failure turned out to have lymphomas.

"We continue to get surprising answers with autopsies where the diagnosis made during life turned out to be all wrong," said Moser. In about 10 percent of the cases where there is a discrepancy, studies have found the misdiagnosis affects quality of life or survival.

For certain conditions, an autopsy is the only way to confirm the diagnosis, or to see the extent of a disease. By revealing hereditary illnesses like early heart disease, postmortems serve as a warning to family members.

Looking for answers

As a nurse, Katie Scully knew the value of an autopsy. But when her red-haired, 3-month-old daughter, Carolyn Elizabeth, died suddenly in 1994, she and her husband feared an autopsy would mutilate the infant. They didn't want to let her go.

"I was numb. I couldn't even believe she was gone, and they were asking for an autopsy," said Katie Scully. "It was so fast and abrupt." The doctors, believing the case to be caused by sudden infant death syndrome, didn't push the matter.

But when the Northern Virginia couple lost their unborn son, Jack, two years later, they worried that the two deaths might be linked. Only the day before his death, Katie Scully had listened to his strong heartbeat at a routine pregnancy check-up.

"We just couldn't believe that we would have to bury two children," Steve Scully said. "There was no question. We knew almost immediately after the initial shock that we had to have the autopsy."

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