FEATURE

Autopsy: Coaxing Secrets From the Dead Every drug is a poison; every poison, a drug.

When Mrs. Rose, an outwardly healthy woman of 58, died suddenly of unknown causes, her husband and family were understandably distraught. Mr. Rose, who himself was suffering with a slowly progressive and terminal cancer, was driven to solve the mystery of his wife’s death and agreed readily when their physician suggested performing an autopsy. Several weeks later, the physician told Mr. Rose that the autopsy revealed that his wife had died of an overdose of propoxyphene, a drug prescribed not for Mrs. Rose but for Mr. Rose. How did this happen? Months earlier, she made the fatal mistake of borrowing some of her husband’s propoxyphene to treat a severe headache. Soon, she was furtively taking several tablets daily for imaginary ills. To maintain her supply, she told her husband’s physicians that he was using 2 tablets every 4 hours, when he actually only took 1 or 2 at bedtime. Mrs. Rose had become addicted to the drug, and, driven by shame, had concealed her addiction from everyone as she carried out a complicated strategy of juggling prescriptions among pharmacies. She had vowed to carry her secret to the grave. She did. But an ancient tool of science revealed her secret when she was powerless to conceal it any longer. The word “autopsy” was derived from the Greek autopsia, meaning “to see with one’s eyes.” Throughout most of history, autopsy findings were limited to what could be deduced from the evidence available to the naked eye.1 Today, x-ray and medical technology augment the pathologist’s eyes, allowing more than just visual examination of bodies. Autopsy is the gold standard for ascertaining cause of death in American medicine, serving to confirm pathology, clinical diagnoses, and the appropriateness of predeath treatments. Autopsy findings wind their way to practicing pharmacists via circuitous routes. Researchers and toxicologists use autopsy findings to monitor how drugs really work over the short and long terms. Regulators and legislators connect autopsy findings with police reports, medication error reports, and case reports to develop new labeling or implement stricter laws. Medical chemists use the same findings to seek new and better drugs.

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Journal of the American Pharmaceutical Association

JEAN WALLIN. GENTLE SILENCE. 2000. 21" X 18". ACRYLIC ON CANVAS. USED BY PERMISSION OF THE ARTIST.

Jeannette Y. Wick and Guido R. Zanni

Today, pathologists perform three types of autopsies. The hospital (or clinical or academic) autopsy is requested or performed by hospital staff to learn more about a patient’s illness and treatment. Securing family consent for this quality improvement and teaching tool is obligatory.2 The forensic autopsy addresses legal and judicial concerns regarding the circumstances surrounding a person’s death,

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clarifying both the cause (e.g., acute respiratory failure) and manner (e.g., suicide from self-administered drug overdose) of death. Legal entities such as the coroner (an elected official) or state medical examiner (an appointed official) perform these autopsies, and no consent is needed from the next of kin or other representative.2 The rapid autopsy is used to harvest tissues, including stem cells, and organs from adults who die. Collecting stem cells in this way may remove the need to use tissues from aborted fetuses.2 Scientists have found that astrocytes, microglia, and neurons harvested from even the very old are in excellent condition at the time of death.3

A Brief History of Autopsy The practice of human dissection dates back thousands of years and has been perceived as everything from desecration to punishment of the dead to noble volunteerism.4 The ancient Egyptians dissected loved ones’ bodies before mummification, which took about 70 days. They removed all of the organs except the heart because they decompose so quickly; these were mummified separately in canopic jars. Later, they stored the canopic jars in the tomb.5 By 1300 the Babylonians accepted and advanced autopsy and applied their newfound knowledge to surgical techniques, which became the most advanced in the world. Among the Greeks and Romans, human dissections were performed to study the processes of disease.2 During the Middle Ages, Europeans considered dissection desecration of the dead. They believed that since human beings were made in God’s image, autopsy was taboo, except in one instance: postmortem punishment. Based partly on biblical accounts of people rising from the dead or having life breathed into them after death and partly on superstition, people believed they would need their bodies in the afterlife. Heinous criminals were both executed and dissected to extend punishment beyond death or prevent eternal life.6 Perhaps today, when families refuse to grant consent for autopsy believing that their loved ones “have suffered enough,” remnants of these historic views persist.7 Fortunately, science prospered during the Renaissance, and interest in anatomy was revived.8 Renaissance artists, including Leonardo da Vinci, dissected many human corpses with society’s approval to understand body mechanics and improve their art. By then, soul and body were considered separate entities. By the 17th century, human dissection was respected as a true science, particularly in Italy. During this century, physicians formed alliances with the legal system to investigate suspicious deaths.2 In the 19th century, European and American medical educators recognized dissection’s role in teaching, and cadaver dissection became part of standard laboratory training. Many cadavers were those of criminals, obtained after judges ordered dissection following capital punishment. The First Federal Congress of the United States gave judges the right to sentence criminals to death

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Questions Families Frequently Ask About Autopsy 1. What can autopsy identify? An autopsy can help families understand how a relative died, if a medical error was made, if hereditary illness was involved, or if the deceased’s problem was contagious.12 2. After the autopsy, is the whole body returned? Practices vary. Some institutions bag the organs and return them to the body cavity; others incinerate removed organs. Some tissues may be saved for use in research or teaching. The best way to know what will be returned after autopsy is to read the autopsy consent carefully.13 (In an extreme and infamous case, Albert Einstein’s brain was removed during his 1955 autopsy and sequestered for the next 40 years. Thomas Harvey, the autopsy pathologist, preserved the brain in a Tupperware container.14) 3. Do the major religions forbid autopsy? All major religions demand respectful treatment of corpses and forbid desecration of the grave. Christianity, Judaism, and Islam do not absolutely prohibit autopsy, and Hinduism permits the procedure.7 Various popes have allowed human dissection. Leonardo da Vinci received approval to perform more than 30 dissections, and, in the 15th century, Pope Sixtus IV allowed the dissection of bodies in Bologna and Padua. While Islam forbids the “disfigurement of the dead,” the injunction is not interpreted literally, and, in 1952 the Islamic School of Jurisprudence’s leader sanctioned autopsies for the purpose of investigating unnatural deaths. Reform Judaism permits autopsies to increase medical understanding.7 4. When is the corpse embalmed? Embalming is usually done after autopsy. If the deceased was known to have an infectious illness, embalming may be done before autopsy. 5. When is the body sent to the funeral home, and can the service be open-casket? Generally, the body is released within hours of autopsy. This depends on the morgue’s hours, which are usually Monday through Friday. The incisions on the cadaver are not visible when the body is presented for viewing. and dissection. By cultural consensus, people linked the soul’s fate somehow to the treatment of the body after death, and Congress hoped that the threat of dissection would serve as an extreme deterrent to crime.9 Still, cadavers were scarce. Demand stimulated supply, and morbid entrepreneurs resorted to grave robbing. In the world’s anatomical research capital, Edinburgh, some body snatchers killed loners and sold their bodies. Public outcry throughout Western cultures eventually led to uniform legislation in the 20th century limiting cadavers used for science and education to those donated.4,10

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FEATURE

Autopsy

The belief that scientists could examine cadavers and deduce or infer valuable medical knowledge was one of a set of strong convictions that drove the development of 20th century’s medical model of disease progression, diagnosis, and treatment. The etiologies and progression of Legionnaire’s disease and AIDS, as well as the cause of “the café coronary” (choking deaths), were all elucidated, in part, by autopsy.11 Body and organ donation are now esteemed as noble, altruistic acts. Also, a heightened awareness that autopsy could unravel the causes of suspicious and unnatural deaths gave birth to forensic pathology and increased legal and medical reliance on clinical autopsy.

Autopsy Procedures Autopsies are either limited or complete. A limited autopsy involves examination of a single body part (e.g., the lungs) or specific region (e.g., the chest). Sometimes, families may limit an autopsy, excluding certain organs from the procedure (e.g., the brain), or the medical examiner or pathologist may believe that only one area of the body requires investigation. Some argue, however, that limited autopsies lead to limited answers.15 During a complete autopsy, the brain and all organs of the neck, thorax, abdomen, and pelvis are removed and examined. A complete autopsy affords the best clues about possible drug involvement, as discussed further below. A complete autopsy takes between 2 and 3 hours, and a final report is generally completed within 30 days.13 Complete autopsies usually require only two incisions. One extends from ear to ear across the top of the pate. The pathologist peels away the scalp, removes the skull cap by sawing circumferentially, and removes the intact brain. A second, Y-shaped incision extends from the anterior shoulder regions toward the midline over the sternum and downward to the pubis. The pathologist removes the chest wall, then removes, examines, weighs, and sections the organs. Some pathologists remove all of the organs from tongue to anus in one large block. Others remove organs individually. Microscopic samples of major viscera and other tissues are prepared, and laboratory and toxicology tests are ordered. Absent a clinical or forensic need, the eyes and spinal cord are not routinely removed.13 Hospital autopsies are usually confined to the autopsy room; forensic autopsies frequently begin at the crime scene. Along with a detailed body examination, trace evidence that may implicate others, such as fibers and hairs, is collected. The major components of a forensic autopsy are listed in the sidebar on this page.

Trends in Autopsy Rates Autopsy rates have steadily declined from approximately 50% in the 1940s to between 10% and 15% in 1985.16 From 1986 through 1995, annual inpatient death rates remained constant, but

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Components of a Forensic Autopsy At the crime scene Collecting and testing trace evidence obtained with adhesive tape pressed repeatedly on clothing and objects Identifying and tagging the body Photographing the body clothed Examining and describing all external marks and wounds Examining evidence that might suggest the body was moved or dragged In the morgue Measuring and weighing the body Photographing the body nude and examining it for marks Conducting a complete autopsy Preparing body fluids and organs for toxicology testing Testing all evidence for the presence of bodily fluids from others (e.g., blood, semen) Source: References 2, 16.

autopsy rates declined further to 7%.17 For years, the National Center for Health Statistics collected national autopsy data, but the organization stopped doing so in 1995. Independent researchers continued to watch, however, and one study documents a continued decline from 1995 through 1997.18 A recent survey found that half of 244 hospitals autopsied at rates below 9%,17 and some hospitals have not conducted autopsies in years.20 Even with internal medicine residency accreditation requiring a 15% autopsy rate, some teaching hospitals report rates of 2% to 3%.19,20 Fewer autopsies are performed on the elderly than on the young.16And, although the hospital autopsy rate has fallen, autopsy rates for unnatural deaths have remained relatively stable.18 Negative public attitudes may be eliminated as the cause of this decline: 68% of the public have no personal objections to autopsy.21 The numerous factors that have contributed to the decline in autopsy rates include:8,16,18,22 Lack of reimbursement for the procedure by insurers and Medicare. Belief (or misperception) that advanced technologic and diagnostic procedures provide more accurate information and can replace autopsy as a tool. Fear that discovering diagnostic errors and faulty treatment decisions may result in litigation. Practitioners’ reluctance to seek consent because doing so can be time-consuming. The shift in medical schools away from anatomical dissection to sophisticated computerized learning aids. The increasingly cumbersome nature of autopsy procedures as a result of increased awareness of the risk of infectious diseases. The Joint Commission on Accreditation of Healthcare Organizations eliminated its minimum mandatory autopsy rates as an accreditation requirement in 1971.

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Payment Issues The average autopsy costs between $500 and $3,500, depending on type and requested histologic and toxicologic tests.21 The jurisdiction where the death occurred pays for forensic autopsies. Generally, when a hospital orders an autopsy, the hospital absorbs all costs. Medicare and most private insurers, including managed care companies, do not reimburse for autopsy because it is not a therapeutic intervention. Medicare does, however, allow a hospital to include autopsy overhead costs in its cost report, which is used to set reimbursement rates. Families often request an autopsy when they question the antemortem diagnosis or the quality of care their loved one received before death. Some hospitals charge families to recover the costs, and others simply refuse to perform the autopsy, sometimes as a legal maneuver.13 Since hospitals are not legally obligated to conduct autopsies, many families and attorneys turn to private companies and independent pathologists. For a specified fee, credentialed pathologists perform the autopsy, arrange for the necessary tests, and report the findings to the family. Often, independent pathologists lease a hospital’s morgue and lab facilities.23,24

Determining Drug Use or Abuse Postmortem To determine manner of death, the medical examiner coordinates toxicology test results, the deceased’s medical history, autopsy findings, and the circumstances leading to death.23 Classified in five ways (natural, suicide, accidental, homicide, and undetermined), manner of death often involves drugs.2 Alcohol, morphine, and cocaine have been known throughout human history as the “three curses” and continue to be implicated in many drugrelated deaths.23 With rare exceptions, modern toxicologic assays can identify almost any drug remaining in body tissues,23 although as recently as 1979 pharmacy students were taught that four drugs were undetectable (keep reading) and, hence, were instruments of the perfect crime. That is no longer the case. Today, fewer than 1% of autopsies lead to a finding of “undetermined.”23 When the pathologist suspects drugs may have played a role in a person’s death, he or she has numerous ways of proceeding. He may collect blood, urine, and vitreous humor if a complete autopsy is not authorized. Or, during autopsy, he may collect blood from the femoral vein, subclavian vein, root of the aorta, superior vena cava, and/or heart. Blood samples are always placed in glass so that plastics do not leach into the sample. In addition, the pathologist collects all of the vitreous humor and 20 cc of urine and bile. In some cases, he will take 50 gram samples of liver, kidney, and muscle tissue. The stomach contents and vomitus are also important.23 Each of these components has specific value. Only circulating drug affects organ function, so determining blood levels is particularly important. When there is no blood because the body has

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been embalmed or traumatized, vitreous fluid reflects levels of drug found in the blood 1 or 2 hours before death. Urine and bile will only reveal the presence or absence of drug, not quantity. Hair and fingernails partition some drugs, the most notorious being cocaine and arsenic. Toxicology screening can be performed on any of the samples listed above. Specific tests reveal the presence of ethanol, acidic and neutral drugs, basic compounds, narcotics, volatiles, and cannabis.2,23 When bodies in various states of decomposition challenge the pathologist, insects appearing in predictable cycles come to the rescue. A universal death scent attracts insects, and, within 10 minutes of death, green flies appear, eat, and lay eggs. Twelve hours later, the eggs hatch into maggots that feast for the next 12 to 24 hours. They leave, only to be replaced by beetles hungry for drying skin. Next, spiders, mites, and millipedes join the parade. When insects satisfy their hunger, they eat not only the body, but whatever was in the body (like drugs), allowing pathologists to analyze the insects for indications of what was in the deceased person’s system at the time of death. Insects collected from the body reveal time of death with surprising accuracy, and predeath intoxication, too. Many drugs, including barbiturates, benzodiazepines, opiates, and cocaine, can be detected by examining insects in the lab.2,23 Pathologists who examine the dead must interpret results cautiously. If the deceased lived for several days after ingesting a fatal drug dose, all of the drug might have been metabolized. This is not always the case, and, especially if the deceased was hospitalized or had lab work done recently, antemortem samples may still be available for comparison. Some drugs redistribute throughout the body after death, and their levels may mislead the pathologist. And some individuals can tolerate drug levels that would be fatal to most others, again misleading the pathologist.23 Throughout the process, the pathologist repeats two questions: What was the cause, and how did this person die? Was this a natural death, or was foul play involved?

Accidental D eath Consider that all drugs are poisons and all poisons are drugs,25 and rule Mrs. Rose an accidental death. Her death, like most from propoxyphene, occurred when she took too many tablets over a short period of time. A mere 680 mg to 780 mg can be lethal. The pathologist uncovered her secret when a toxicology screen returned with a norpropoxyphene level three times her propoxyphene level—an indication of chronic use. Mrs. Rose died of cardiac toxicity.23 Other medications, as well as illicit drugs and alcohol, are often implicated in accidental death. Half of all motor vehicle accidents involve alcohol. Autopsy pathologists look for blood levels of ethanol, and also use vitreous ethanol levels, which are 1.2 times blood levels. They also look at the pancreas and liver for signs of chronic use.23,25 Sometimes, it is a home remedy that results in tragedy. Over the

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FEATURE

Autopsy

JEAN WALLIN. SKINNY GIRL IN RED. 2002. 37" X 31". ACRYLIC ON CANVAS. USED BY PERMISSION OF THE ARTIST.

last 20 years, pathologists have periodically seen clusters of unexplained deaths from lead poisoning and determined that various home remedies, such as the traditional Mexican remedy for empacho (intestinal illness) and Asian remedies for intestinal discomfort or cramps, are almost 100% lead. Telltale signs of acute lead poisoning found only on autopsy include kidney damage, cerebral hemorrhage, and swollen, pale brains.23,26–28 Unexplained deaths in children always require autopsy, and confirmation of lead poisoning by autopsy is part of the case definition when patterns of lead poisoning emerge. Public health officials continue to campaign against azarcon, greta, and koo sar use by immigrant populations.27,28 Chronic lead poisoning, like that seen when children eat paint chips, produces broad bands at the ends of the bones, identifiable on x-ray.23

Suicide Drugs are second only to guns as tools of suicide. Tricyclic antidepressants are used most often, but other drugs are also commonly used. Some pathologists believe that tricyclics redistribute after death, so vitreous levels, stomach contents, and peripheral evidence such as empty vials and prescription records become important. Any drug with a narrow therapeutic index can cause death quickly, but even those that are fairly safe can contribute to demise when taken in combination with other drugs. One of the most perilous combinations is alcohol and benzodiazepines.23,26 Hom icide Homicide using drugs does occur, but this variant of the perfect crime has become less practicable than ever. The four drugs that used to be undetectable—insulin, succinyl choline, digoxin, and potassium—can no longer hide from the scrutiny of modern technology. The first are detectable via gas chromatography–mass spectrometry or chemiluminescent radioimmunoassay, even after embalming.23 Potassium poisoning is difficult to detect, but the case may be made by investigation, confession, and finding of paraphernalia. Detection of high concentrations in soft tissue around a needle mark are also helpful. A control sample on the other side of the body would be needed to establish baseline concentrations of potassium in body tissue.29 When foul play is suspected, the pathologist will augment what she can see (e.g., needle marks, skin discoloration) with autopsy toxicology findings and other evidence to determine cause of death. N atural Death Even if drugs are not implicated in a death, pathologists find evidence indicating that people used over-the-counter, prescription, or illicit drugs during their lives. For example, the elderly woman who had a penchant for cascara laxative will acquire melanosis coli pigment, a brownish black colon discoloration.26 The man who took minocycline for arthritis might have a normal,

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but diffusely black, thyroid gland. Or the pathologist may determine that an elderly patient who seemed to have succumbed to pneumonia either was treated with an ineffective antibiotic or actually died of pulmonary embolism. Whether death is natural, suicide, homicide, or accidental, access to the deceased’s complete medical history explains pathologic changes that are unusual, even if they did not contribute directly to death.

Autopsy versus Technology In 1912 Cabot30 reviewed 3,000 autopsies at Massachusetts General Hospital and found that common diseases were incorrectly diagnosed in more than 50% of the cases. His study remains a classic. Today, diagnostic techniques are more sophisticated (e.g., imaging techniques, molecular biological assays and biopsy techniques), and clinicians believe they provide accurate information.18 Research findings, however, demonstrate that confidence in technology is often misplaced; studies still highlight significant discrepancies between antemortem diagnoses and autopsy findings. One study examining 100 intensive care unit deaths found a 20% discrepancy between clinical and postmortem diagnoses, and, of those, 45% of patients should have received different treatment.16 Roosen and colleagues22 found that autopsy confirmed

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only 81% of antemortem diagnoses, and a therapy change would had been indicated in 16% of the cases had the correct diagnoses been known. Another study suggests 11% of patients at a university hospital, and 12% at a community hospital, would have survived had the correct diagnosis, as confirmed by autopsy, been made.20

Conclusion Although not performed as often as in the past, autopsies continue to have a vital role in medicine. Autopsy can be used to ascertain the quality of care a terminal patient received, to confirm the accuracy of a diagnosis, to discover new diseases, and to provide unusual opportunities for teaching and research.18 Those who fear that autopsy findings may fuel litigation should consider the reverse: Autopsy actually puts litigation to rest in many cases,31 as more than half of all suspicious deaths are revealed through the procedure to have been due to natural causes.10 Autopsy is one of the few tools that validates the accuracy of medical technology. Until concordance between antemortem and postmortem data is near perfect, the autopsy will continue to be the gold standard for ascertaining cause of death. A popular sign in many autopsy rooms states, “Hic locus est ubi mors gaudet succure vitae”—this is the place where death delights to serve the living.32 Keywords: Autopsy, toxicology, cadaver, overdose, pathology, medical history, poisoning. Jeannette Y. Wick, RPh, MBA, is senior clinical research pharmacist, National Cancer Institute, National Institutes of Health, Bethesda, Md. She is also the author of Supervision: A Pharmacy Perspective, published by APhA, with release expected in early 2003. Guido R. Zanni, PhD, is a health systems consultant based in Alexandria, Va. The paintings of Jean Wallin were used by permission of the artist. Wallin’s paintings can be viewed online at www.carlislefa.com. The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, stock holdings, gifts, or honoraria. The views expressed in this article are the authors’ and not those of any government agency.

References 1. Webster’s Third New International Dictionary of the English Language. Springfield, Mass: Merriam-Webster Inc; 1993. 2. Newman J, McLemore J. Forensic medicine: matters of life and death. Radiol Technol. 1999;71:169–85. 3. Zeman J. Alternatives may be possible for fetal tissue research. Daily Nebraskan. January 8, 2001. 4. Tward AD, Patterson HA. MSJAMA. From grave robbing to gifting: cadaver supply in the United States. JAMA. 2002;277:1183. 5. Mummification. Egypt Exhibit. Carnegie Museum of Natural History Web site. Available at: www.carnegiemuseums.org/cmnh/exhibits/ egypt/mummification.html. Accessed July 26, 2002.

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6. Prestieu S. Leonardo da Vinci’s anatomical studies: an unique biomechanical approach. Available at: www.stanford.edu/~mgorman/essays/ Sarah/sarah.html. Accessed July 26, 2002. 7. Davis GJ, Peterson BR. Dilemmas and solutions for the pathologist and clinician encountering religious views of the autopsy. South Med J. 1996;89:1041–4. 8. Gregory SR, Cole TR. MSJAMA. The changing role of dissection in medical education. JAMA. 2002;277:1180–1. 9. Punishment of Crime Act. Birth of the Nation: First Federal Congress Project Web site. Available at: www.gwu.edu/~ffcp/exhibit/p6/ p6_7.html. Accessed July 26, 2002. 10. McDowell J. The corpus and the hare: demand for bodies led to murder in 19th century Edinburgh. Modern Drug Discovery. October 2000:77–80. Available at: http://pubs.acs.org/subscribe/journals/ mdd/v03/i08/html/10time.html. Accessed June 3, 2002. 11. Brody JE. A price to pay as autopsies lose favor. New York Times. January 9, 2001:F8. 12. Oppewal F, Meyboom de Jong B. Family members’ experience of autopsy. Fam Pract. 2001;18:304–8. 13. Hanzlick R, Mosunjac MI. The rest of the story. Arch Intern Med. 1999;159:1173–6. 14. Paterniti M. Driving Mr. Albert: A Trip Across America With Einstein’s Brain. New York, NY: Dial Press; 2000. 15. Davis GJ, Hanzlick R. A tale of the unexpected: finding a zebra. Arch Intern Med. 1997;157:2296. 16. Dessmon HY, El-Bilbeisi H, Tewari S, et al. A study of consecutive autopsies in the ICU: a comparison of clinical cause of death and autopsy diagnosis. Chest. 2001;119:530–6. 17. Hanzlick R, Baker P. Institutional autopsy rates. Arch Intern Med. 1998;158:1171–2 18. Burton EC, Nemetz PN. Medical error and outcomes measures: where have all the autopsies gone? Medscape General Medicine [journal online]. 2000;2(2). Available at: www.medscape.com/viewpublication/ 122_index. Accessed July 29, 2002. 19. The importance of an autopsy. About.com: Death and Dying Web site Available at: http://dying.about.com/library/weekly/aa061399.htm. Accessed July 29, 2002. 20. Landefeld CS, Chren MM, Myers A, et. al. Diagnosis yield of the autopsy in a university hospital and a community hospital. N Engl J Med. 1988; 318:1249–54. 21. Burton EC, Nemetz PN. Institutional and economic influences on autopsy performance—in reply. Medscape General Medicine [journal online]. 2000;2(3).Available at: www.medscape.com/viewpublication/ 122_index. Accessed July 29, 2002. 22. Roosen HJ, Frans E, Wilmer A, et al. Comparison of premortem clinical diagnoses in critically ill patients and subsequent autopsy findings. Mayo Clin Proc. 2000;75:562–7. 23. DiMaio VJ, DiMaio D. Forensic Pathology. 2nd ed. Boca Raton, Fla: CRC Press; 2001. 24. Reynolds A. The need to know: Denton business fills niche for families seeking answers in the deaths of loved ones. Dallas Morning News. November 11, 1999:1H. 25. Tebbett IR. Forensic science and the role of the pharmacist. Drug Topics. 1990;134:92–100. 26. Friedlander E. Ed’s Pathology Meltdown. Available at: www.pathguy.com. Accessed July 2, 2002. 27. Lead poisoning associated with use of traditional ethnic remedies— California, 1991–1992. MMWR Morb Mortal Wkly Rep. 1993;42:521–4. 28. Adult lead poisoning from an Asian remedy for menstrual cramps— Connecticut, 1997. MMWR Morb Mortal Wkly Rep. 1999;48:27–9. 29. Fierro M, Virginia Department of Health. E-mail correspondence with J. Y. Wick. July 2, 2002. 30. Cabbot RC. Diagnostic pitfalls identified during a study of three thousand autopsies. JAMA. 1912;59:2295–8. 31. Webster JR Jr., Derman D, Kopin J, et al. Obtaining permission for an autopsy: its importance for patients and physicians. Am J Med. 1989;86:325–6. 32. Collins KA, Bennett AT, Hanzlick R. The autopsy and the living. Arch Intern Med. 1999;159:2391–2.

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Autopsy: Coaxing Secrets From the Dead: Every drug is a poison; every poison, a drug.

FEATURE Autopsy: Coaxing Secrets From the Dead Every drug is a poison; every poison, a drug. When Mrs. Rose, an outwardly healthy woman of 58, died...
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