Practical pathology

by Aldred Scott Warthin

When consent to an autopsy is withheld and the physician feels that such an examination is necessary, he should turn the case over to the Coroner or Board of Health, and act under such direction. Conflicting decisions, however, have been made in different States. The Supreme Court of Indiana (1909) held that a Coroner cannot order an autopsy unless there was a reasonable supposition that death had occurred from violence or casualty. A suit brought by an Indiana physician to recover fee for an autopsy held on the order and under the direction of a Coroner was set aside on the ground that there was not the slightest suspicion of death from casualty or violence. Such a decision is too narrow and not framed in accordance with the actual needs of the times in so far as the protection or enlightenment of the community is concerned. Under such a decision a Coroner or Board of Health could not in safety order an autopsy in the case of a death in which the diagnosis had not been established clinically, when no suspicion of violence or casualty exists, although the establishment of the diagnosis through an autopsy might be of the greatest importance to the family or community.

On the other hand the Court of Appeals in Kentucky (1906) affirmed judgment for the defendant in a suit for damages brought against a physician for performing an unauthorized autopsy to secure a burial permit, the court holding that, if the autopsy was made in good faith for the purpose of ascertaining the cause of death in order that a burial certificate might be granted, and if the autopsy was made decently with due regard to the sex of the deceased and without unnecessary incisions or mutilations, there could be no grounds for damages. This is a reasonable and just decision and laws framed upon it should be passed in all the States. Autopsies performed under such conditions, however, should always be conducted in the presence of several witnesses competent to testify as to the methods used.

In several States legal authority is given to the Board of Health to order an autopsy whenever the health interests of the people demand such an investigation. Autopsies performed under such orders against the desire of the relatives should always be carried out with extreme care and in the presence of proper witnesses.

State and charitable hospitals cannot be made liable for autopsy performed by Coroner or Board of Health, when the consent of the relatives is withheld. It is high time that all charitable institutions in this country should require an autopsy from all patients dying within their walls. The cards of admission should contain a clause to this effect, and such cards should be counter-signed by the nearest relatives.

Inasmuch as some life-insurance policies contain clauses requiring the presence of a representative of the company at the autopsy or a forfeiture of the claims, it is best to ascertain if such policies exist in any given case, and to notify the company. The Supreme Court of Missouri has decided that an autopsy made in ignorance of such an insurance clause is no bar to recovery if the company be notified in time for a re-examination of the body.

Supreme Court decisions also hold that consent for an autopsy implies removal of organs and tissues for microscopic study, when such is necessary to fulfill the object of the autopsy.

One of the great needs of this country is a uniform autopsy law and the establishment of a proper medicolegal autopsy code, as in Germany. As conditions exist at the present, crimes may be easily concealed, the safety of the community endangered by failures in diagnosis of communicable affections, and our morbidity and mortality statistics become a shame and reproach to the nation. The majority of our medicolegal autopsies are made by ignorant and imperfectly trained coroners and coroners’ physicians, mostly political appointees of inferior material. We need in our medical schools a greater amount of attention paid to the teaching of autopsy-technique and gross pathology. The community must also be educated to a realization of the value of autopsies. It is the duty of every physician and layman to work diligently for the improvement of existing conditions. Had the ideas of a former Governor of the State of Michigan been realized there would have been compulsory autopsies upon the bodies of every person dying within the State, and far-reaching results would have been attained. The economic importance of tuberculosis and the venereal diseases would have been made clear, the profession and laity alike educated, and the progress of preventive medicine tremendously aided.

4. PERMISSION FOR AUTOPSY. It is a desirable and certainly a wise precaution to obtain a written permit for the autopsy from the next of kin or from the legal representative of the body, in case the examination has not been ordered by law. Some of the legal decisions quoted above offer sufficient grounds for this precaution. The following form is in use in the University of Michigan Hospital.

No........ Ann Arbor, Michigan..................., 19..
Professor of Pathology........................
University of Michigan.

Permission has been given by........................., who bears the relationship of..................to........................, to hold a postmortem upon the remains of..........................., with the understanding that the object of such postmortem is to ascertain the cause of death, and that you are to use such means as you deem best to make a thorough examination for the proper attainment of the object desired, excepting that...............................................