How are autopsies performed to determine the cause of death. Is a post-mortem examination required?

Huge numbers of people die every day. Someone from old age and illness, and someone from an accident or incident. Anything can happen in life. The transfer of the body to the mortuary and the autopsy are preliminary procedures before the funeral. If there are traces of violent death or suspicion of it on the corpse, then an autopsy is mandatory (it is also called an autopsy, section). The pathologist carefully examines the body, performs an autopsy procedure and determines the cause of death.

Types of autopsies

There are three types of sections: pathological-anatomical, forensic and anatomical autopsy in the mortuary.

1. Pathological and anatomical autopsy is carried out in a medical institution where the patient died. It is done in order to determine the nature of the changes in the body caused by the disease, and to correctly establish why the person died. It is done by a pathologist at the city hospital in the pathological and anatomical department.
2. A forensic autopsy of the deceased is carried out by order of the courts in the event that there is a suspicion that the cause of death was a crime or murder.
3. Anatomical autopsy is performed at the Department of Anatomy. Pathological anatomy is studied by medical students in the 3rd year of medical school, since every doctor should be familiar with the work of a forensic scientist.

When did the concept of autopsy appear?

The history of autopsy goes hand in hand with the history of medical preparation. Historians are arguing about when the first sections were held in ancient Greece. Even Hippocrates looked at the sections as an unpleasant duty. The priests of Ancient Egypt, due to the mummification of the pharaohs, were well aware of the anatomy and secrets of embalming. Mummifications in ancient Egypt were subjected to the corpses of not only noble citizens, but also their animals.

Historians have sources that testify that the autopsy was carried out in ancient rome in the Middle Ages. Catholic priests denounced the autopsy. An exception was made by Pope Clement V for his attending physician. Then, at the height of the plague, Aesculapius asked permission to dissect the bodies in order to find out the cause of the disease. By the 16th century Catholic Church recognized the value of the autopsy.

Judaism tabooed dissection until the 18th century. It was allowed only in special cases.

Morgue autopsy procedure

The deceased is placed on a sectional table, to which the sink is adjacent. To study the medical history of the deceased is the first thing a pathologist should do. A doctor must be present at the section.

The pathologist starts the autopsy from the primary visual inspection body. First of all, the deceased is checked for hematomas, cuts, bruises, and swelling. After the superficial inspection has ended, the body is viewed inside.

First make the main sectional incision of the skin. An internal examination of the corpse is carried out. With the help of special tools, the abdomen is opened, the chest with adjacent ribs is revealed. The ribs are cut in that part, where they come into contact with bone tissue, then the pathologist opens the chest.

Some time after the end of the examination of the cavity, all the organs that were inside are pulled out and examined in a certain order. Usually the organs of the neck and chest are taken out separately, followed by the digestive organs and the genitourinary organs. The intestines are removed, and then a urine sample is taken for analysis from the cut bladder with a special scoop. In addition to urine, a blood sample and pieces of skin are taken for analysis for further laboratory testing.

The next step is to open the skull. First, an incision is made with a scalpel and the skin is shifted, then the skull cap is sawn with a special saw, which is made of soft grades of metal. The brains are removed from the skull and placed on a pallet with the remaining organs. And the eye sockets are also removed. Paranasal sinuses and middle ear cavity. Everything is carefully weighed and studied.

At the end of the whole event, the skull is darned, the scalp is pulled back and the skin is sutured. All the entrails that were extracted, fold back into abdominal cavity trying to avoid errors, sew up. The deceased is washed and, for a separate surcharge from relatives, they embalm and make up.

The cause of death is revealed. According to the law, a month is allotted for the conclusion of death, then a certificate of death is issued (it can be preliminary or final). The certificate indicates the immediate cause of death.

Epigraph:
I don't grumble
That God took the baby
And it hurts why they
Cursed over him?
Why, like black crows,
Part of the body is white
Tortured? .. Really
Neither God nor the king will intercede?

Vikenty Veresaev, "Doctor's Notes"

“Write any diagnosis - everything hurts in an old person!” - rightly notice the readers of "Peasant Woman" from the Dubovsky district. Is there a legal way to avoid surgical intervention after death?

This letter to the editor came from the village of Peskovatka.

“New laws have appeared in our region,” the author writes on behalf of all the villagers, however, he does not name names “for obvious reasons”. - The fact is that all the dead are forced to be taken to the morgue for an autopsy. I am 80 years old and when I die I don't want to be cut. And they all don't want it. This is some kind of mockery of the dead - why cut 70-80-90-year-olds. The end of life has come - and that's it. And without it, the funeral is very expensive. Many have to go into debt. Who is to blame for this - the law or local authorities?

Well, good questions. Let's figure it out!

Who came up with this?

The authorities of the Dubovsky district immediately disowned: "The initiative is not ours."

We do not have the authority to resolve such issues, - says Alexander Shrainer, deputy head of the administration. - As far as I know, this problem is typical for the whole region. I believe that if the death is criminal in nature, then an autopsy is definitely necessary. And the police have to pay for it. And if a person died, as they say, from old age, why? If relatives insist, then another matter. And one size fits all ... This is wrong!

The local government really has nothing to do with it. And regional too. All manipulations with the bodies of the dead are carried out in strict accordance with federal law. And this was not invented today: it turns out that the current order has been in effect for many years!

In what cases is an autopsy performed in without fail?

As the leading legal adviser of the regional State Bureau of State Bureau Zhanna Yevtushenko told Krestyanka, there are several documents regulating the entire process. Namely:

Law of November 21, 2011 No. 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation”;

Order of the Ministry of Health of Russia No. 354n “On the procedure for conducting post-mortem autopsies”;

Order of the Ministry of Health and Social Development
No. 346n "On Approval of the Procedure for Organization and Production of Forensic Medical Examinations in State Forensic Institutions of the Russian Federation".

An autopsy is an examination of the body of a deceased person, which is carried out to determine the nature of painful changes and establishing the cause of death, - Zhanna Yevtushenko explains. - In other words, they open the body in order to understand the cause of death. There are a number of cases where an autopsy must be performed. Including:

1. on suspicion that the death is of a violent nature;
2. if it is impossible to establish the final diagnosis of the disease that caused death;
3. in the event that the patient was admitted to the hospital before death and spent less than a day here;
4. if you suspect an overdose or intolerance medicines or diagnostic products;
5. if death is due to infectious disease, oncology (in the absence of histological verification of the tumor). Also, if death is associated with preventive, diagnostic, instrumental, anesthetic,
6. nimation, therapeutic measures, during or after the operation of blood transfusion and (or) its components;
7. in the event of the birth of a dead child;
8. if necessary, a forensic medical examination.

Is it possible to refuse?

The decision on the need for an autopsy is made by the hospital doctor or paramedic. If there is none of the above reasons, then the study is not necessary at all. But then why do people complain about the general direction in the anatomy? Most likely, there is no conspiracy here, just the majority of the dead in recent times just got on the to-do list.

Just in case, lawyers advise expressing one's will during one's lifetime: if the issue is controversial, then the doctor can meet halfway.

A wish can be expressed both orally, in the presence of witnesses, and in writing, - continues Zhanna Yevtushenko.

The application is written in free form, indicate the last name, first name, patronymic, address of residence. I, such and such, bequeath to bury myself without an autopsy (or refuse an autopsy). Date, signature, transcript of the signature. This letter remains with the family. Such a statement can also be written to the address of the organization that deals with the burial.

The law does not require mandatory certification of the paper by a notary, the expert clarifies. - In the absence of the will of the deceased, the spouse, close relatives (children, parents, adopted children, adoptive parents, siblings, grandchildren, grandfather, grandmother), other relatives or legal representative of the deceased, and in the absence of such, other persons who have assumed the obligation to carry out the burial of the deceased (this is prescribed in Article 5 of the Law of 03.04.2007
No. 1436-OD "On burial and funeral business in Volgograd region»).

Practice shows that each situation is very individual, - they comment in the office of the Commissioner for Human Rights in the Volgograd Region. - For example, a citizen prepared a notice about the unwillingness to open his body after death, but after it was completed, during the examination, representatives of law enforcement agencies had suggestions of possible violence. Then the doctors will reasonably conduct a post-mortem autopsy to establish the exact cause of death. At the same time, at the autopsy of the body of the deceased patient, who was long time on an outpatient basis, for example after acute violation cerebral circulation(stroke), with confirmed entries in the medical book, doctors will not insist.

Marina Zlobina. Photo Publishing House "Volgogradskaya Pravda"

There are moments when a loved one dies far from home and relatives cannot quickly come to see their relative on their last journey. In this case, there is a way out - embalming the deceased. And today we will find out what this term means, how the procedure is carried out in the morgue and at home.

Embalming the body in the morgue: what kind of event is it?

This is the process of impregnating the organs and tissues of a deceased person with substances that inhibit their decomposition. Special embalming solutions are injected under pressure into the corpse. And if the deceased was not opened, then the liquid is introduced through a cannula inserted in the right place.

It takes about 6-7 liters of solution to embalm the body. Regular composition the liquid used - formalin in its pure form or diluted with alcohol in equal proportions.

Embalming the body in the morgue is the determination in the tissue of the corpse of substances that inhibit the processes of decay. Such "conservation" of the deceased is carried out for educational, scientific, forensic purposes and, of course, for aesthetic and sanitary reasons.

In what situations is such a procedure necessary?

Body embalming is used under the following circumstances:

If it is not possible to hold a funeral immediately after the death of a person.

If it is necessary to wait for distant relatives who are obliged to say goodbye to the deceased.

To preserve the body for a long time in hot weather.

If a person died away from home and needs to be transported to his native land.

To improve the efficiency of diagnosis in necropsy ( postmortem and examination of the body, including internal organs).

For a funeral service in a church or temple.

Body preparation

How does the embalming procedure begin? Of course, with the preparation of the body of the deceased, which is carried out as follows:

1. It is necessary to put the deceased face up.

2. It is necessary to remove all clothes from the deceased. This is necessary in order for the specialist to follow the skin and control the entire process of embalming. The genitals must be covered with a sheet or towel.

3. Disinfection of eyes, mouth, ears, nose is carried out. This treatment helps to cleanse the body inside and out.

4. Shaving the deceased. Usually, facial hair is removed.

5. Removal of rigor mortis by massage. The main muscle groups are rubbed to relieve tension, and the joints are massaged to loosen them. If this is not done, then vascular pressure may increase, and this will definitely interfere with the embalming process.

6. It is necessary to close the eyes and mouth of the deceased. This must be done very carefully.

7. Do not forget to apply cream on the lips and eyelids - this will protect them from drying out, and also give them naturalness.

After completing all preparatory procedures the specialist proceeds directly to the embalming process, and after the end of this event, the deceased should still be placed in the coffin, and how this is done correctly will be described below.

Techniques to protect the body from decomposition

Embalming the body in the mortuary can be carried out in four ways:

1. Strip preservation of the tissues of the deceased.
2. Injection saving procedure.
3. Superficial "preservation" of the corpse.
4. Vascular embalming.

What procedure for embalming the deceased is suitable for a particular deceased, experts determine. And now we will briefly outline the differences and features of each of the techniques for protecting the body from decomposition.

Band embalming

Its essence lies in the processing of the internal organs of the corpse, because the fastest processes of decay begin to occur in the peritoneum and chest. This method is further divided into two subspecies:

Puncture;

Split.

In the first case, a puncture is made in the peritoneum and an antiseptic solution is poured through the hole (about one and a half to two liters). Embalming the body in the mortuary using the incision method is carried out as follows: a small section is performed with penetration into the anterior translucent serosa directly into the cavity. This method is used in such cases:

If you need a long-term transportation of a corpse, and putrefactive processes have already begun.

If the deceased is too obese.

injection embalming

This method is usually used in combination with puncture. The specialist impregnates with an antiseptic solution soft tissues exposed deceased - face, neck and hands. He injects a small amount of liquid and at the same time makes light massage. This is necessary so that the preservative is evenly distributed.

Superficial "preservation" of a dead person

This method is clear to many based on its name. The embalming procedure in this case is performed as follows: a special composition is applied to damaged skin (wounds, decomposition), as well as tanatogel. This method is the easiest and most affordable, since there is no need to pierce the body, make incisions and inject liquid into the body.

Vascular "preservation" of the body

This is very hard way which only an experienced pathologist can competently conduct. By the way, this method of saving the body is very rarely used. In this case, a special embalming solution is injected through the system blood arteries. With this method, the body of the deceased is preserved for a very long time.

Final stage

The last step is the placement of the dead in the tomb, and for this it is necessary to perform the following activities:

1. It is necessary to thoroughly wash the deceased: wash off the blood from the body and chemical elements remaining after embalming with the same disinfectant that was used before.

2. It is important to give the face natural look thanks to cosmetics. You also need to cut your nails and comb your hair.

3. Putting on clothes. Usually the family of the deceased chooses what their deceased relative will wear, so they bring the decoration in advance.

4. Determination of the body in the coffin. Calmly and carefully, the deceased should be transferred to the tomb. If relatives make some comments and express their suggestions about the appearance or position of the body, then you should use them and do as the relatives of the deceased want.

Where is the event taking place?

The procedure for embalming the deceased, the photo of which can be seen in this article, is carried out in the morgue if the person got there from the hospital, or at home. However, in last case Relatives must have a medical report on the death of a loved one in their hands.

The procedure itself lasts from 2 to 4 hours. It is advisable to perform it no later than 12 hours after the death is established.

Body embalming at home: why is it rare?

The preservation of the body of the deceased most often occurs in the morgue, and why exactly there, now we will figure it out.

1. Since the embalming procedure is a rather specific event, not every family will agree to it at home.
2. To date, there are few cases when the deceased can be left at home without sending him to the morgue for an autopsy.
3. In hot weather, the funeral can be held earlier than the third day, of course, if the relatives do not mind.

What will the specialist do outside the walls of the morgue?

Embalming at home is performed according to a simplified scheme - by the method of conventional abdominal fixation. Specifically, the specialist makes injections with a 10% formalin solution in a circle, starting from injecting from 50 to 150 ml of liquid, depending on the location. The expert does not touch the internal organs, except for the lungs. The specialist must be careful and careful not to damage the embalming

The person also performs the oropharynx. This is necessary so that physiological fluids do not flow. A special make-up or a mask is applied to the face of the deceased (it must be changed periodically until the moment of burial).

Pros and cons of embalming at home

Positive points:

The deceased is within the walls of his native home, as he wanted, and all this time the relatives will be near the deceased person.

The embalming procedure outside the mortuary is suitable for those segments of the population who, according to their religion, are forbidden to make incisions on the body of the deceased.

This method is suitable for the deceased, who previously suffered from liver diseases, while vascular “preservation” of the body (replacement of blood with formalin) often leads to strong changes in the face.

If relatives want to personally control the progress of the work of a specialist.

For an expert - the safety of working with HIV-infected bodies. Since there is no direct contact with blood, the risk of transmission of this disease is significantly reduced. With this method, scalpels and other cutting objects are not used, only a needle for introducing fluid into the cavity.

The procedure is cheaper than a similar one performed in the morgue.

Negative points:

The lifespan of the body reaches only 4-5 days.

Relatives will have to change the mask on their faces, which for many will seem like a real test, however, like the whole procedure.

What items should be brought to the morgue for the relatives of the deceased?

In order for the deceased to be brought to a “normal” appearance, relatives should be provided with the following things for men:

Clothing (panties, T-shirt, socks, shirt, shoes, tie, suit, handkerchief).

Towel.

Shaver.

Cologne.

And for the deceased women, the following items are needed:

Clothing (underwear, stockings, nightgown, head scarf, shoes; from outerwear - a dress, suit or robe).

Towel.

Cologne (toilet water).

Event cost

The embalming procedure is not very cheap, especially if it is done in a mortuary. On average, the price of carrying out the "canning" of the deceased at home ranges from 3500-5000 rubles. And such an event in the morgue costs 10,000-25,000 rubles, depending on the chosen method.

Now you know what embalming is, how this procedure is carried out in the mortuary, and what methods specialists use in order to preserve the body for a long time. We found out that such an event can be done at home, by the way, it will cost much less. But not every family is able to agree to embalming within the walls of their home. But be that as it may, wherever it is held, you still need to know: for the safety of the body, and also in case it is necessary to hold such an event.

Autopsy (synonym: section, autopsy) - examination of the body of the deceased in order to determine the nature of the existing changes and establish the cause of death. Distinguish pathoanatomical and forensic autopsy. Pathological anatomical autopsy - the study of the corpses of people who died from various diseases in hospitals.

Abrikosov method (A.I. Abrikosov, 1875 - 1955, Soviet pathologist) - a method of autopsy, in which organs are removed by complexes that make up the anatomical and physiological systems (a complex of organs of the neck and chest; liver, stomach and duodenum; kidneys and urinary tract and genitals; brain and spinal cord).

An incision according to Leshka is a collar incision with subsequent opening of the diaphragm. Used when you need to save face.

Fischer method - (B. Fischer-Wasels, 1877-1941, German pathologist) 1) a method of autopsy, in which, in order to preserve the integrity of the skin of the anterior surface of the neck, a sectional incision is made on the side of the mastoid processes obliquely to the handle of the sternum; 2) the method of opening the brain, which consists in dissecting it with parallel cuts in the frontal plane.

Shor's autopsy method - (G.V. Shor, 1872-1948, Soviet pathologist; syn. method of complete evisceration) a method of opening a corpse, in which the internal organs are removed as a single complex.

A forensic autopsy is performed according to a written order (relationship, direction, decision or determination) of the bodies of inquiry, investigation or court to establish the cause and time of death, determine the presence and nature of bodily injuries, lifetime, prescription and sequence of their formation, mechanism and method causing, identifying a causal relationship between the identified injuries and the onset of death, as well as to resolve other issues of a biomedical nature.

A forensic medical examination of a corpse is prescribed in all cases of violent death (murder, suicide, accident), regardless of the place and time of its occurrence, in case of death suspected of being violent, incl. and sudden (sudden) or from an unknown cause outside a medical institution, upon death of a patient during the first day of stay in a medical institution, if the diagnosis of the disease was not established, as well as upon death of a patient in a medical institution, if the investigating authorities accepted a complaint about an incorrect or illegal its treatment, in all cases of death of unknown persons and upon discovery of a dismembered corpse and its parts. Forensic autopsy of a corpse is carried out in compliance with the norms stipulated by the codes of criminal procedure union republics, special rules and "Instructions on the production of a forensic medical examination" (1978). It is carried out by doctors who have undergone special training in forensic medicine - forensic experts. In their absence, the autopsy of a corpse can be entrusted to any doctor (doctor-expert). As a rule, an autopsy is carried out in a forensic morgue or a dissecting room of a pathological and anatomical department. In some cases, for example, if it is impossible to deliver the corpse to the morgue, it can be carried out in temporarily adapted rooms, and in the summer even in the open air.

A forensic medical examination of a corpse includes a detailed examination of the clothes on it and the items delivered with it in order to identify damage, traces and overlays on them, an external examination (examination) of the corpse with a detailed description of post-mortem changes, and if damage is found, their nature, localization and features, the study of soft tissues and internal organs. In contrast to a pathoanatomical autopsy, it is forbidden to use water for washing organs during a forensic medical examination of a corpse, because. if poisoning is suspected, they should be sent for forensic chemical research. Examination of a corpse, as a rule, is supplemented by forensic chemical, histological, physical-technical, bacteriological studies, etc. Their choice, as well as the nature and number of organs and tissues sent for examination, are determined in each specific case by a forensic medical expert or medical expert taking into account the alleged cause of death and the questions posed to the examination.

When opening the corpses of unknown persons or when examining parts of a dismembered corpse, they pay attention to the features of clothing - its style, size, nature of the fabric, factory or other marks, catchy fittings, wear, traces of repair, describe in detail the contents of the pockets. In addition, they make up a verbal portrait, note special signs and other identifying features. The frozen corpse is thawed at room temperature before examination. No degree of putrefactive change of the corpse or its destruction can serve as a pretext for refusing an autopsy.

When examining the corpse of a child, it is necessary to establish whether he was a newborn, and if he was, then answer a number of additional questions: was he viable, live-born, full-term and mature, what was the duration of his intrauterine development, how long did he live after birth, was it needed assistance and whether proper care was provided. A newborn in forensic terms is an infant who lived after birth for no more than 1 day, viable - an infant with a body length of at least 38-40 cm, weighing at least 1500-1600 g, without malformations and diseases incompatible with life . Establishment of live birth is carried out with the help of so-called life tests. They are swimming (hydrostatic) tests: Galen-Schreyer lung test and Breslau gastrointestinal test (lungs and their fragments, stomach and intestines float in water), Dillon X-ray test (air is detected in the lungs and organs of the gastrointestinal tract during radiography) and some others. The term and maturity of the newborn is determined using generally accepted methods. The duration of intrauterine life is calculated mainly based on the length of the baby's body: if it is less than 25 cm, then the square root is taken from the set value (in cm), if more, then the set number is divided by 5; the result obtained corresponds to the number of lunar months. In addition, they are guided by the mass of the placenta (by the end of the 7th lunar month it is 375 g, by the end of the 8th - 450 g, by the end of the 9th - 460 g) and the length of the umbilical cord (respectively 42, 46, 47 cm) . The duration of extrauterine life of an infant is judged by changes in the umbilical cord and umbilical ring, the degree of resorption of the birth tumor, the passage of meconium, and the level of filling of the gastrointestinal tract with air.

The main documents that reflect the results of the autopsy are the “Conclusion of the forensic medical examination (expert opinion)” and the “Act of the forensic medical examination of the corpse”, including a record of the results of the autopsy, information about the organs and tissues sent for laboratory research and the results of these studies , diagnosis and conclusions (conclusion), containing answers to the questions posed to the forensic medical examination of the corpse.

Bibliography:

Avdeev M.I. Forensic medical examination of a corpse, M., 1976;

Petrov S.V. General Surgery: Textbook (2nd ed.). - St. Petersburg: Peter, 2003. - 768 p. - Series "National Medical Library").

Strukov A.I., Serov V.V. Pathological anatomy: Textbook. - 4th ed., stereotypical. - M.: Medicine, 1995. - 668 p., ill.

Shalevich M.A.; Buromsky I.V. Forensic medical examination of a corpse, M., 1983

Based on materials from the site http://www.labex.ru/page/sudmed_111.html

The general procedure and sequence for conducting a forensic medical examination of a corpse is determined by the rules for a forensic medical examination of a corpse.

The forensic medical expert, who is entrusted with the production of a forensic medical examination of a corpse, first of all gets acquainted with the materials (documents) provided to him. In the event that the expert needs additional information on this case, he has the right to file a petition for providing him with the missing materials.

Based on the issues raised for resolution of the examination and taking into account the information received from official documents, the forensic medical expert outlines a plan for the conduct of the examination. It determines the sequence of examination of areas, systems and organs of the corpse, the sectional techniques, techniques and samples necessary for this, outlines objects for taking and sending for laboratory research, etc. The plan is not a dogma, therefore, adjustments can be made to it during the examination process, it can be supplemented and changed.

The most expedient actions of an expert and their sequence during a forensic medical examination of a corpse are as follows:

1. Familiarization with the case materials: a decision on the appointment of an examination of the corpse; a protocol for examining the scene of an incident or a protocol for examining a corpse at the place of its discovery; medical documents; other materials of the case.

2. Drawing up a plan for a forensic medical examination of a corpse.

3. External examination of the corpse: examination of clothes, shoes, other items delivered with the corpse; examination of the outer integument of the body; sketching injuries on contour diagrams of parts of the human body, sketching injuries in full size on a transparent film or photographing them; taking for laboratory research smears, secretions, other objects identified during the external examination of the corpse and clothing.

4. Internal examination of the corpse: determination (selection) of the method of anatomical incision of the skin, separation of soft tissues and methods for isolating and examining internal organs; determination of the sequence and methods of examination of cavities and internal organs; opening of body cavities (skull, chest, abdomen, spinal canal, etc.); examination of cavities and internal organs on the spot; isolation of internal organs from cavities and their subsequent examination; examination of deep muscle layers (neck, back, buttocks, limbs); examination of bones and joints; taking objects for laboratory research.

5. Production of laboratory studies (chemical, histological, biological, etc.) and their evaluation.

6. Drawing up a pathoanatomical diagnosis based on a comprehensive assessment of the results of direct examination of the corpse and laboratory studies.

7. Drawing up and justification of the expert's conclusions.

8. Registration of the "Expert Conclusion" ("Act of the forensic medical examination of the corpse").

9. Registration of "Medical death certificate".

10. Drawing up a cover letter for the "Expert's opinion" and physical evidence for the person who ordered the forensic medical examination - the corpse.

The external examination of the corpse includes the examination of clothing, footwear and other items delivered with the corpse.

The study of clothing begins with a listing of its individual items and their position on the corpse at the time of examination. When describing clothes, the material from which it is made, color, degree of wear, safety of loops, buttons and fasteners are noted. On the clothes of the corpses of unknown persons, the presence of a characteristic pattern, marks, factory labels and other features is also noted. Describe the contents of the pockets, as well as other items delivered with the corpse.

If there are damages and dirt on the clothes, their location, shape, size, distance from the seams and other specific details of the clothing, direction, nature of the edges and ends, etc. are indicated. Damage and dirt on the clothes are compared with damage and marks on the corpse.

If damage is detected - tears, cuts, slip marks, tissue defects, abscission and other or characteristic deposits (lubricants, paints, soot, tread marks, etc.) or traces that look like blood, vomit or the action of caustic substances, as well as when identification of medicinal or other chemical substances, the expert must take measures to preserve them for subsequent referral to other experts for research or transfer to the investigator.

The temperature of the corpse is determined by touch with the back surface of the hand on the open parts of the body of the corpse and in areas covered by clothing or in contact with each other (armpits, inner thighs). At the same time, the degree of cooling of the corpse is noted, for example, "the corpse is cold to the touch in all departments" or "the corpse is warm to the touch." The accuracy of such a study is low, therefore, to measure the temperature of a corpse, it is better to use a thermometer, with which the temperature in the rectum, oral cavity, and armpit is determined. In the presence of special sensors, the temperature of a corpse can be measured in the chest cavity, in the liver.

The severity of rigor mortis is determined by the presence of mobility in various joints and by the magnitude of the effort required to shift or move different parts of the body relative to each other. For this purpose, flexion and extension of the neck, upper and lower limbs, and displacement of the lower jaw are performed. Rigor mortis is assessed as well expressed, moderately expressed, weakly expressed, or indicate that there is no rigor mortis. Since rigor mortis develops non-simultaneously, its severity in different muscles may be different, which must be indicated in the autopsy protocol.

When researching cadaveric spots first of all establish their existence. Next, they describe the localization of cadaveric spots, their nature (diffuse, abundant, island-shaped, weakly expressed),

color; pay attention to areas devoid of cadaveric spots (place of pressure on clothes, objects, etc.); note the reaction of cadaveric spots to pressure with a finger or a dynamometer (the spot disappears, turns pale, does not change color) and fixes the time required to restore the original color of the cadaveric spot (in seconds or minutes).

If there are late cadaveric phenomena(rotting, fat wax, mummification, peat tanning) describe their signs, severity and localization; note the presence of mold sites, their localization, size and color; deposits of fly larvae with an indication of their size, the presence of other insects.

Next, the skin is examined. They note its color and features, the degree of hair growth, the presence of traces of injections, scars, tattoos, birthmarks, anatomical and other individual features. The head, neck, chest, abdomen, back, upper and lower limbs, armpits, skin folds under the mammary glands, external genitalia, perineum and anus, and also feel the bones of the skeleton to establish pathological mobility or their deformities.

When examining the head, especially carefully examine hairy part and area for auricles. When examining the eyes, the color of the iris and the diameter of the pupils are determined, the condition of the protein and connective membranes is noted. Indicate the presence or absence of discharge from the openings of the nose, mouth and ears, the nature of the discharge, as well as the presence or absence of blood, food and vomit or other foreign objects in the mouth and nose, and in auditory canals- blood. They describe the state of the border and mucous membrane of the lips, the vestibule of the mouth, note whether the teeth are closed, whether there is an infringement of the tongue; the number of teeth, their color and features, the presence and number of crowns, including those made of yellow metal, list the missing teeth and the condition of the alveolar surface of the gums. Examine the condition of the eardrums using the frontal and ear mirrors.

When examining the neck area, carefully examine the places in the depths of the skin folds.

Examining the chest, indicate its shape, and in women, in addition, describe the mammary glands: the shape and size (two mutually perpendicular measurements through the nipple area) of the gland; the shape of the nipples, the color of the areola; when pressing on the gland, the presence and nature of discharge from the nipple is recorded.

When describing the abdomen, indicate its shape, the height of the anterior abdominal wall relative to the costal arches.

Inspection of the external genitalia in men determine the condition of the foreskin, the external opening of the urethra, scrotum; in women - perineum, labia, vaginal opening, hymen, vagina.

If there are injuries on the body of the corpse, the expert must establish and describe the following:

anatomical localization of damage (anatomical region and its surface);

orientation of damage relative to the longitudinal axis of the body (organ, bone);

the height of the damage from the level of the plantar surface of the feet (measurement is made to the lower edge of the damage);

type of damage (abrasion, hemorrhage, wound, fracture);

the shape of the damage (compared with geometric shapes); when the shape cannot be determined, indicate that the damage is of indeterminate shape;

damage dimensions (length, width, depth, height in centimeters);

the color of the damage itself and the color of the tissues around it (primary colors and shades);

relief of damage (with hemorrhages, dislocations, fractures - swelling and deformation of the tissues around them);

the nature of the edges, walls, ends, bottom of the damage;

the presence of overlays, dirt and foreign inclusions in the damage itself and in the tissues around it;

properties of tissues in the area of ​​damage (edema, hyperemia, inflammation, hemorrhage, indicating color, shape, intensity, size);

the presence or absence of bleeding from the injury;

the presence or absence of signs of healing of damage and its stages.

In addition to the above, the forensic medical expert must establish and describe the morphological features and signs that indicate the lifetime and prescription of the origin of the damage, as well as indicate the signs that allow the damage to determine the features of the trace-forming surface of the object (instrument of injury) and the mechanism of its action.

The study of damage is carried out first with the naked eye, and if necessary, with the help of a magnifying glass or a stereoscopic binocular or operating microscope.

The description of injuries in the autopsy report can be made sequentially, as certain areas of the body are described (for example, injuries on the head - when describing the head, etc.), or injuries can be described separately from the description of body regions, highlighting at the end of the section. "External examination" subheading "Injuries". The first option, in our opinion, is preferable.

It is advisable to sketch the detected damage on contour diagrams, and in some cases redraw it in full size. To do this, take a transparent polyethylene or washed x-ray film, impose it on the damage and transfer its outlines to the film with a ballpoint pen or marker. If possible, damage should be photographed, doing it according to the laws of scientific photography.

In accordance with the plan, at the end of the external examination, the forensic expert takes material (smears, secretions, blood, etc.) for laboratory studies, which is recorded in the research part of the "Expert's Conclusion".

An external examination of a corpse is only part of a forensic medical examination. Regardless of its results on an external study, one can never draw final conclusions about the causes and circumstances of death.

The internal examination of a corpse (autopsy, abduction, autopsy, section) is detailed in the Rules for the Forensic Medical Examination of a Corpse (1991).

The internal examination of the corpse should be as complete as possible. Without fail, the cranial cavity, chest and abdominal cavities are examined. The spine is subject to examination in the presence of injuries or diseases, as well as in case of traumatic brain injury, traffic accidents, falls from various heights, in other cases - if indicated.

The method of autopsy, the sequence and methods of examination of cavities and organs are determined by the expert, guided by the specific features of the case, the tasks set and the relevant methodological documents. It is advisable to adhere to a systematic order in the study and presentation of its results.

Anatomical incisions, separation of soft tissues, isolation and examination of internal organs are made by the expert himself. Sawing of the bones of the skull, spine and isolation of other bones of the skeleton can be carried out by a nurse under the guidance of an expert and always in his presence.

If pneumothorax or air (gas) embolism is suspected, an appropriate sample is pre-produced. Before the test, it is advisable to take x-rays.

When examining the corpses of women of childbearing age who died under unclear circumstances or with suspected abortion, an air embolism test is mandatory.

Test for air embolism should also be carried out in cases of suspected damage to the heart, lungs, large blood vessels, and in cases where death was preceded by medical intervention (surgery on these organs, puncture, cannula insertion, vascular catheterization, etc.).

Incisions of many tissues are made, if possible, without affecting external injuries, surgical wounds, fistulas, drains, catheters, cannulas, graduates, etc., as well as foreign objects remaining in the wounds. The color of the muscles, the greatest thickness of the subcutaneous fat layer, the presence (absence) of traumatic or pathological changes are noted.

Before removing the organs of the neck, chest and abdominal cavities, they are examined on the spot. Note the correct location of organs, malformations; degree of filling lungs pleural cavities, the height of the diaphragm; the presence of adhesions in the pleural and abdominal cavities; condition of the parietal pleura and peritoneum, mesentery, lymph nodes, areas of the solar plexus; swelling or collapse of the stomach and intestinal loops; the degree of blood filling of the superior and inferior vena cava. Indicate the presence or absence of foreign odor from cavities and organs. Where appropriate, to detect or rule out thromboembolism or foreign bodies in the respiratory tract, an autopsy and examination of the main trunk and main branches of the pulmonary artery or, respectively, the larynx and trachea are performed on the spot.

If poisoning is suspected, ligatures are applied to the esophagus, stomach and intestines.

If drowning is suspected, it is forbidden to wash tools, utensils, gloves and organs of the corpse with water before taking the material for examination for the presence of plankton.

For the removal of organs, the method of separate or complete evisceration is used, at the discretion of the expert and depending on the specific circumstances. It is important to provide good access to the organs, the possibility of their detailed study and, if necessary, maintain the topographic relationship between them and injuries.

All organs are measured and examined from the surface and in sections. They note their consistency, the severity of the anatomical structure, color, blood supply, specific smell, carefully examine and describe changes and damage; in hollow organs determine the nature and volume of the contents. Weigh the brain, heart, lungs (separately), liver, spleen, kidneys (separately). Weighing of the thyroid, goiter and pancreas, adrenal glands, pituitary gland, epiphysis and other organs is carried out in the presence of their pathology.

When examining the head, the state of the inner surface of the soft integuments is noted: color, moisture, consistency, blood filling, the absence or presence of hemorrhages, their color, shape, size (including thickness); examine from the surface and in the section of the temporal muscles.

Measure the thickness of the frontal, temporal, parietal and occipital bones on the cut, as well as the longitudinal and transverse dimensions of the skull (in case of traumatic brain injury). Examine the damage to the cranial vault, note the state of its sutures.

Describe the degree of tension and the color of the dura mater, its fusion with the bones, blood filling of the vessels and sinuses; transparency and blood filling of the soft meninges, the nature of the subarachnoid contents and cisterns. They note the symmetry of the hemispheres, the degree of severity of the relief of the furrows and convolutions, the absence or presence of bands from pressure by the edge of the falciform process, the cerebellar emargination, and the foramen magnum. On transverse or longitudinal (depending on the method chosen by the expert) sections of the brain, the severity of the general pattern of the structure of the brain tissue and its anatomical structures, especially in the stem region, as well as the degree of its moisture content and blood supply, are noted. Describe the contents of the ventricles, and also determine if they are dilated, the state of the ependyma and plexuses. The vessels of the base of the brain are examined, noting the presence of atherosclerotic changes, aneurysms, etc.

The pituitary gland is measured, the pattern and color of its tissue on the section are noted.

If intracranial hemorrhages, softening foci, tumors are detected, their exact localization within the lobe, size, weight, volume of epi- and subdural hemorrhages, appearance, shape from the surface and in sections, the state of the underlying substance of the brain are indicated.

After removal of the dura mater, the bones of the base of the skull are examined and their damage and features are noted; open paranasal sinuses, mark the absence or presence of content in them.

It is necessary to saw the bones of the cranial vault completely, avoiding the forcible separation of the vault and base of the skull during incomplete sawing of the bones.

When examining the spinal canal, attention is paid to the presence of fluid or blood in it, the condition and location spinal cord. The spinal cord with dura is removed. The type of membranes and the state of the brain tissue are described in successive (by segments) transverse sections.

Examine the vertebrae and intervertebral discs from the side of the spinal canal and note their features, damage, deformities, painful changes. Examine the area of ​​the atlanto-occipital joint to detect or exclude hemorrhages, torn ligaments, fractures.

Open the main arteries of the neck. The presence or absence of their pathological tortuosity, compression by osteophytes, tears of the inner lining of the vessels are noted, soft tissues and neurovascular bundles of the neck are examined to exclude hemorrhages.

Examine the tongue, tonsils, entrance to the larynx and esophagus, windpipe, thyroid and parathyroid glands, lymph nodes. Check the integrity of the hyoid bone and cartilage of the larynx; if damage is suspected, they are x-rayed.

Examination of the organs of the chest cavity includes examination of the anterior and posterior mediastinum, examination of the thymus gland, lungs, heart, aorta, esophagus and bronchi.

Examine the pulmonary pleura, note the presence of hemorrhages under it, their shape, size, multiplicity, localization.

They open the airways to small branches of the bronchi, indicate the absence or presence of contents in them, note the color and blood filling of the mucous membrane. Pay attention to the color of the lungs from the surface and on cuts, the degree of airiness and blood filling of the lung tissue, the nature of the fluid flowing from its surface when pressed, the presence and nature of focal changes. Describe the paratracheal and bronchial lymph nodes.

The method of opening the heart and aorta is chosen by the expert. The method should include the study of the coronary arteries throughout and the myocardium in all departments. They describe the state of the pericardium, the quantity and nature of its contents, the blood filling of the heart cavities and the nature of blood clots, the state of the epicardium, endocardium, myocardium, coronary arteries, valves, papillary muscles. Measure the thickness of the walls of the ventricles and septum. Determine the width of the aorta in the section (above the valves), examine the state of its inner shell throughout. In the presence of pulmonary pathology, separate weighing of the heart is performed.

The order of examination of the organs of the abdominal cavity and retroperitoneal space is determined by the expert.

The stomach is examined, its shape, quantity and type of contents (color, smell, texture, size and nature of food particles present), the condition of the mucous membrane (color, severity of folding, the presence of hemorrhages, ulcers, etc.) are established. They open the intestines throughout, describe the nature and amount of the contents of its various departments, color, condition of the mucous membrane and other features; note the location and appearance of the appendix. Special attention is paid to the nature and quantity of the contents of the stomach and various parts of the intestine if it is necessary to establish the prescription of the onset of death.

In the study of the pancreas, liver, spleen, adrenal glands, attention is paid to appearance organ (shape, color), tissue density to the touch, the severity of its anatomical structure, the degree of blood supply, the nature of the scraping from the spleen incisions. Organs are measured and weighed. They note the type and amount of contents of the gallbladder, the state of its mucous membrane, the patency of the ducts.

When examining the kidneys, their shape and size are determined, the color, density of the tissue, the nature of the surface after removing the capsule, the severity of the cortical, cerebral and intermediate (juxtamedullary) layers, the condition of the mucous membrane of the pelvis are indicated.

Determine the patency of the ureters and the state of their mucous membrane.

The order of examination of the pelvic organs is determined by the expert.

Record the amount of urine in bladder, its color, transparency, type and color of the mucous membrane, the presence of stones.

In women, the condition of the vagina and its vaults, the shape of the uterus, its cervix and external os are described, the size and consistency of the uterus are determined. Indicate the presence of a mucous plug, the opening of the cervix (with the designation of the degree of disclosure), note the discharge and damage. The state of the mucous and muscular layers of the uterus, as well as the tubes, ovaries, periuterine tissue with vessels are examined.

If there is an extraneous fluid in the uterus, it is sent for a forensic chemical study.

In men, the prostate gland is examined, the consistency and type of tissue are indicated, the degree of filling with the secretion of the seminal vesicles, the features of the testicular tissue are noted

During the examination of the corpse, material is taken for research in the departments of the forensic and forensic histological laboratories. The expert conducting the examination of the corpse determines the necessary types of research, based on the issues raised for resolution of the examination and the specifics of the case. The material is taken by an expert, and the packaging is carried out by a nurse under the guidance and control of an expert.

Mandatory referral for laboratory research is subject to:

blood and urine to determine the presence and quantitative content of ethyl alcohol - in case of violent death and suspicion of it (with the exception of deaths of adults who have been in the hospital for a long time and young children), as well as in the presence of the smell of alcohol from the organs and cavities of the corpse in case of nonviolent death;

blood to determine antigenic affiliation according to the ABO (H) system and other systems - in case of violent death, accompanied by external injuries or bleeding; murders or suspicion on them; sexual crimes or suspicion of them; examination of corpses of unknown persons;

pieces of internal organs and tissues for histological (histochemical) examination; after fixation and cutting, research is carried out if necessary, or the cut pieces are stored in the archive without research; the storage period of the archive is provided for by the relevant Rules;

organs and tissues of a corpse to determine the presence and quantitative content of toxic substances - if poisoning with chemicals, fungi, poisonous plants and food poisoning is suspected; list of seized organs and tissues required for forensic chemical analysis at toxic substances different groups, is given in the relevant annex to the Rules;

bile or urine to determine the category of excretion; subungual contents of the fingers - in case of murder or suspicion of it, sexual crimes;

tampons and smears of the contents of the vagina to detect sperm, study the morphological features of the vaginal epithelium, etc. - in case of sexual crimes or suspicion of them; in case of suspicion of sexual intercourse in a perverted form, tampons and swabs are taken from the mucous membrane of the mouth and rectum from corpses of both sexes;

hair from the head for a comparative study - in case of murder or suspicion of it; sexual crimes or suspicion of them; transport injuries; damage to the scalp; examination of corpses of unknown persons;

hair from the head, nails, large molar (6-7-8th teeth on upper jaw) without painful changes, muscle tissue for the determination of group-specific antigens in the study of putrefactive, mummified, dismembered and skeletonized corpses of unknown persons or, if necessary, identified corpses;

smears-prints from the respiratory tract (larynx, trachea, bronchi) and lungs for bacteriological and virological studies - in all cases of sudden (non-violent) death of children and, in appropriate cases, sudden death of adults;

blood, parts of internal organs, smears-imprints of organs for microbiological and virological studies - in case of suspected death from infectious diseases or bacterial food poisoning; if OOI is suspected, the material is taken in accordance with the procedure established by the Ministry of Health of the Russian Federation, with the participation of a bacteriologist of the sanitary and epidemiological station;

unopened kidney, fluid from the sinus of the main bone and 50.0-100.0 g bone marrow from the femur or humerus for research on diatom plankton - in the absence of a clear morphological picture of drowning; for control, a lung is removed from the same corpse; at the same time notify the person who ordered the examination of the corpse of the need to take 200-300 milliliters of water from the reservoir in which the corpse was found and send it for examination to the bureau;

pieces from various areas of the uterus, tubes, ovaries and vessels of periuterine tissue for histological examination, the contents of the cavity and part of the wall of the uterus for forensic chemical examination, swabs and swabs of vaginal and mammary gland secretions for cytological examination - if death is suspected as a result of community-acquired abortion ; in case of abortion complicated by sepsis, material is additionally withdrawn for bacteriological examination;

clothes, skin, parts of cartilage and bone with damage, parenchymal organs with a wound channel - for physical and technical examination in case of death from a gunshot injury, damage by sharp chopping, cutting, piercing and blunt objects;

bone remains of skeletal and unidentified charred corpses - to determine species, sex, age and height.

Objects intended to be sent to the forensic laboratory are seized, packed and sealed in accordance with the requirements of the appendix to the Rules. They fill out the appropriate form (forms) for referral to the laboratory, which also indicates who and when issued the decision to appoint a forensic medical examination of the corpse and questions from the decision to be resolved during the examination in the laboratory divisions.

The organization of the delivery of the seized material to the laboratory of the bureau of forensic medical examination is provided, depending on the specific circumstances, by the person who ordered the examination of the corpse, or the head of the city (district, interdistrict) department of forensic medical examination.

Upon receipt of the referral of the expert and the seized material, the head of the department of the forensic laboratory (forensic histology department) appoints an expert who is entrusted with the production of this examination. The investigator or, on his instructions, the head of the department explains to this expert his procedural rights and obligations and warns of criminal liability for refusing or evading to give an opinion or for giving a knowingly false opinion, about which his signature is taken away. This subscription is included in the introductory part of the "Expert's Conclusion" or is issued as a separate document. The expert of the laboratory performs the examination entrusted to him, guided by the relevant Rules and answering, within the limits of his competence, the questions put to him.

At the end of the study of the corpse, all organs under the control of an expert are placed in the corpse and sewn up. Additional incisions are also sutured. It is not allowed to place organs that do not belong to him or foreign objects in the cavity of a corpse.

It is not allowed to introduce preservative substances into the corpse until the examination of the corpse is completed and the material is taken for laboratory research. Upon completion of the examination of the corpse, conservation can be carried out only with the written permission of the person who ordered the examination.

If, during the examination of a corpse, a violent death from injuries, poisoning, complications of an out-of-hospital abortion, etc. was ascertained, which was not known to the person who ordered the examination, the expert must immediately notify this person by telephone of the established cause of death.

When an acutely contagious disease (rash, abdominal, relapsing fever, dysentery, etc.), the expert or the head of the department (department) immediately notifies the relevant sanitary and epidemiological station about this in writing. If signs of ASI are found, they are urgently reported to the local health department.

If gross defects in diagnosis and treatment are revealed during the examination of a corpse, the expert must notify the local health authority about this and take measures to discuss the case at the forensic clinical and anatomical conference only with the permission of the investigator in order to exclude disclosure of preliminary investigation data.

Bibliography:

1. Solokhin A.A. " Forensic Medicine”, M., 1998

2. Tomilin V.V. "Forensic medicine: Textbook for universities", M., 2001

3. Kryukov V.N. "SME of living persons", S-P., 1996

PATHOLOGICAL ANATOMY AND ITS PLACE AMONG MEDICAL AND BIOLOGICAL DISCIPLINES

Pathological anatomy is an integral part of pathology - a science that studies the patterns of occurrence and development of diseases, individual pathological processes and conditions.

In the history of development pathological anatomy four main periods are distinguished: anatomical (from antiquity to the beginning of the 19th century), microscopic (from the first third of the 19th century to the 50s of the 20th century), ultramicroscopic (after the 50s of the 19th century); the modern, fourth period of the development of pathological anatomy can be characterized as a period of pathological anatomy of a living person.

Modern medicine is characterized by a constant search for the most objective material criteria for diagnosing and understanding the essence of the disease. Among these criteria, morphological acquires exceptional significance as the most reliable. Modern pathological anatomy widely uses the achievements of other medical and biological disciplines, summarizing the actual data of biochemical, morphological, genetic, pathophysiological and other studies in order to establish patterns related to the work of a particular organ, system in various diseases. Due to the tasks that pathological anatomy is currently solving, it occupies a special place among medical disciplines. On the one hand, pathological anatomy is a theory of medicine, which, revealing the material substratum of the disease, directly serves clinical practice, on the other hand, it is a clinical morphology for diagnosis, which provides the material substrate for the theory of medicine - general and particular human pathology [Serov V.V., 1982].

General pathology is understood as the most common, i.e. characteristic of all diseases, patterns of their occurrence, development and outcomes. Rooted in particular manifestations of various diseases and based on these particularities, general pathology simultaneously synthesizes them, gives an idea of ​​the typical processes characteristic of a particular disease.

As a result of the progress of medical and biological disciplines (physiology, biochemistry, genetics, immunology) and the convergence of classical morphology with them, the existence of a single material substrate for manifestations of vital activity, including the entire range of levels of organization - from molecular to organismic, has become obvious, and no, even insignificant functional disorders can arise and disappear without being reflected in the corresponding structural changes at the molecular or ultrastructural level. Thus, further progress in general pathology cannot be made dependent on the development of any one discipline or group of disciplines, since general pathology today is a concentrated experience of all branches of medicine, evaluated from a broad biological standpoint.

Each of the modern medical and biomedical disciplines contributes to the construction of the theory of medicine. Biochemistry, endocrinology and pharmacology reveal the subtle mechanisms of life processes at the molecular level; in pathoanatomical studies, the laws of general pathology receive a morphological interpretation; pathological physiology gives their functional characteristics; microbiology and virology are the most important sources for the development of the etiological and immunological aspects of general pathology; genetics reveals the secrets of the individual reactions of the body and the principles of their intracellular regulation; clinical medicine completes the formulation of the laws of general human pathology on the basis of its own rich experience and the final assessment of the experimental data obtained from the point of view of psychological, social and other factors. So, general pathology implies such an approach to the assessment of observed phenomena, which is characterized by their broad biomedical analysis. For modern stage The development of medicine is characterized by the fact that disciplines that were previously predominantly or even exclusively experimental (genetics, immunology, biochemistry, endocrinology, pathological physiology, etc.) are becoming equally clinical.

Thus, modern general pathology includes:

Generalization of factual data obtained with the help of research methods used in various medical and biological disciplines;

Study of typical pathological processes;

Development of problems of etiology, pathogenesis, morphogenesis of human diseases;

Development of philosophical and methodological aspects of biology and medicine (problems of expediency, correlation of structure and function, part and whole, internal and external, social and biological, determinism, integrity of the organism, nervism, etc.) based on the understanding of the totality of facts obtained in various fields medicine;

Formation of the theory of medicine in general and the doctrine of the disease in particular.

The rapid development of clinical physiology, clinical morphology, clinical immunology, clinical biochemistry and pharmacology, medical genetics, fundamentally new methods of X-ray examination, endoscopy, echography and greatly enriched our knowledge of the actual details and general patterns development of human diseases. The increasing use of non-invasive research methods (computer tomography, ultrasound diagnostics, endoscopic methods, etc.) makes it possible to visually determine the localization, size, and even, to a certain extent, the nature of the pathological process, which essentially opens the way for the development of intravital pathological anatomy - clinical morphology, to which course of private pathological anatomy.

The scope of morphological analysis in the clinic is constantly expanding due to the ever-increasing surgical activity and advances in medical technology, as well as in connection with the improvement of the methodological capabilities of morphology. The improvement of medical instruments has led to the fact that there are practically no areas of the human body that would be inaccessible to the doctor. At the same time, endoscopy is of particular importance for improving clinical morphology, which allows the clinician to engage in morphological study of the disease at the macroscopic (organ) level. Endoscopic studies also serve the purposes of biopsy, with the help of which the pathologist receives material for morphological examination and becomes a full-fledged participant in resolving issues of diagnosis, therapeutic or surgical tactics, and prognosis of the disease. Using the biopsy material, the pathologist also solves many theoretical problems of pathology. Therefore, the biopsy becomes the main object of study in solving practical and theoretical issues of pathological anatomy.

The methodological possibilities of modern morphology satisfy the aspirations of the pathologist for an ever-increasing accuracy of the morphological analysis of disturbed vital processes and an increasingly complete and accurate functional assessment of structural changes. Modern methodological possibilities of morphology are enormous. They allow studying pathological processes and diseases at the level of an organism, system, organ, tissue, cell, cell organelle and macromolecule. These are macroscopic and light-optical (microscopic), electron microscopic, cyto- and histochemical, immunohistochemical and autoradiographic methods. There is a tendency to combine a number of traditional methods of morphological research, resulting in the emergence of electron microscopic histochemistry, electron microscopic immunocytochemistry, electron microscopic autoradiography, which significantly expanded the capabilities of the pathologist in diagnosing and understanding the essence of diseases.

Along with a qualitative assessment of the observed processes and phenomena, it became possible to quantify it using the latest methods of morphological analysis. Morphometry gave researchers the opportunity to use electronic technology and mathematics to judge the reliability of the results and the legitimacy of the interpretation of the identified patterns. With the help of modern research methods, a pathologist can detect not only morphological changes characteristic of a detailed picture of a particular disease, but also initial changes in diseases, the clinical manifestations of which are still absent due to the viability of compensatory-adaptive processes [Sarkisov D.S., 1988]. Consequently, the initial changes (the preclinical period of the disease) are ahead of their early clinical manifestations (the clinical period of the disease). Therefore, the main guideline in the diagnosis of the initial stages of the development of the disease are morphological changes in cells and tissues. Pathological anatomy, having modern technical and methodological capabilities, is designed to solve problems of both clinical diagnostic and research nature. The significance of the experimental direction is growing, when both the clinician and the pathologist are looking for answers to complex questions of the etiology and pathogenesis of diseases. The experiment is used primarily for modeling pathological processes and diseases, with its help new methods of treatment are developed and tested. However, morphological data obtained in an experimental model of the disease must be correlated with similar data in the same disease in humans.

Despite the fact that in last years in all countries the number of autopsies is steadily decreasing, post-mortem examination remains one of the main methods scientific knowledge illness. With its help, an examination of the correctness of the diagnosis and treatment is carried out, the causes of death are established. In this regard, the autopsy as the final stage of diagnosis is necessary not only for the clinician and pathologist, but also for the medical statistician and health care organizer. This method is the base scientific research, teaching fundamental and applied medical disciplines, by the school of a doctor of any specialty. Analysis of autopsy results plays an important role in solving a number of major scientific and practical problems, such as the problem of variability, or pathomorphosis, of diseases. The significance of this problem is constantly increasing, since more and more often the clinician and pathologist face the question: where does pathomorphosis end and where does the pathology of therapy begin?

GENERAL HUMAN PATHOLOGY, ITS MAIN PROVISIONS AND SIGNIFICANCE FOR PRACTICAL MEDICINE

In the context of the growing differentiation of biological and medical sciences, as well as the desire to uncover the molecular mechanisms of life disorders, especially importance acquires the integration of the most significant achievements of various branches of knowledge to create a holistic doctrine of the disease, reflecting the most general patterns of its occurrence, development and completion. This most important task is served by general pathology. Incorporating the main provisions of microbiology, biology, biochemistry, genetics, immunology, hygiene, pathophysiology and pathomorphology, as well as clinical disciplines, general pathology is essentially the scientific foundation of medicine. It uses both experimental and clinical facts, analyzes disorders and their manifestations at all levels - from molecular to systemic, and, most importantly, evaluates the significance of these disorders for the organism as a whole.

General pathology establishes universal laws, according to which all kinds of deviations from the norm occur in the animal organism; it thus creates a series of types of morbid processes, and is indeed a common part of the totality of pathology. Two things should be taken into account here.

First: general pathology is based on the study of typical forms of pathology and general pathological processes (dystrophy, hypoxia, tumors, etc., as well as thrombosis, inflammation, fever, etc.), taking into account certain patterns, adding up from them various diseases. In other words, it defines the common thing that unites all diseases and leads to an understanding of their essence.

Secondly, general pathology uses the patterns of occurrence, development and outcome of general pathological processes in those organs and systems where they were formed and found their target. In other words, depending on the function and structure of organs and systems, as well as their importance in maintaining homeostasis and the vital activity of the body. From particular organosystemic manifestations, general pathology raises pathological processes to the generalization of stereotypes, and at the same time it considers the role of organosystemic features in the development of general pathological processes and typical forms of pathology. For practical medicine, both the first and the second are important. The first provides a basis for understanding the essence of the disease in general, and the second - for understanding the nature of the formation of groups of diseases and their individual nosological forms.

General pathology is the most complex part of medicine, as it provides the highest medical generalization of knowledge based on recent achievements private disciplines, including clinical. General pathology is developing a theory of the disease, which is now of fundamental importance not only for medicine, but also for the life of our society, in which astrology, occult ideas about the disease are spreading, pseudo-therapeutic possibilities of individuals are being promoted, etc.

The methodological basis for the development of the theory of pathology is dialectical materialism; on its basis, general pathology has created a number of fundamental provisions that allow us to analyze the problem of illness and health in a new way. Among these fundamental provisions, the following should be mentioned: the relationship between structure and function, a systematic approach to considering the phenomena of pathology, the principle of recombination transformations, the role of regulation in the processes of damage and adaptation, a general biological approach to assessing processes in pathology and the significance of their individual variations, etc.

Structure and function in pathology, their relationship. In any pathological process or disease, functional and structural changes are detected. Although it is generally accepted that the two sides of all life processes - biological function and biological structure - are interconnected, interdependent and mutually condition each other, statements about the "primacy of functional and secondary structural disorders", the presence of purely functional stages of the disease, "functional" diseases, about "primacy of function" and "inertness of structure". Even when analyzing the mechanisms of the development of the disease, emphasizing the difference between functional and structural disorders, pathogenesis and morphogenesis are distinguished, respectively. These ideas were based on an attempt to use the categories "form and content" as a methodological basis for analyzing the relationship between the structure and function of the categories "form and content", although it is only correct to use the categories "matter and motion". Their connection and interdependence are reflected in the well-known expression of a prominent Russian therapist V. Kh. Vasilenko: "A function without a structure is unthinkable, and a structure without a function is meaningless."

A biological structure is a living material system or part of it organized in space in a certain way, which ensures the performance of a particular activity (molecule, subcellular organelle, cell, organ, system, organism). biological function is an activity, i.e. change in time of the state and / or properties of a living material system or its part, aimed at obtaining a result useful for it and self-preservation.

Any biological system is organized, structured in a certain way - from molecules various substances to the organism as a whole. Such structuredness, which ensures the expediency of the function, is the result of a long evolution of living beings in the process of their interaction with the environment, and it is this very structure that determines the performance of specialized forms of activity by the body. In complex organisms, various structures perform their specialized functions (secret secretion, contraction / relaxation, excitation transfer, and much more). At the same time, activity is not only a visible change in the state of the structure - shortening (contraction) of the muscle, for example; this and a change in its properties, in particular, for a muscle without visible shortening - isometric tension. The functions of the organism in evolution developed and improved in conjunction with the development and improvement of structures, also acquiring an expedient character.

The differentiation of structures ensured the "division of labor", i.e. function differentiation. This specialization of structures (functions) made them dependent on each other; the need for mutual assistance of structures determined the formation of various control systems, including the nervous system, which became an important mechanism for the unity, integrity of the body and its interaction with the environment. In evolution, ancient structures useful (expedient) for survival were preserved and their functions were preserved, as a result of which various structural and functional levels of vital activity have developed in complex organisms: molecular, subcellular, cellular, organ and systemic. At the same time, at all levels of life activity, there is an interconnection, conjugation of changes in structure and function as two inseparable sides of any life process. At all levels, the structure and function can conjugately change over a wide range, both in micro- and macro-time intervals. A change in the structure under the influence of some factor (for example, a membrane-embedded receptor) simultaneously affects its functional properties (receptor affinity for the mediator and intracellular signal transmission). The function of cells and their cooperations can weaken or even stop (reserve nephrons, alveoli, etc.) and their ultrastructures are restored in parallel. Structural-functional interaction on different levels and their subordination (subordination relations) are the basis for the regulation of lower-level processes by higher ones: this also makes a significant contribution to ensuring the integrity of the body and its interaction with environment. Unstructured biological systems do not exist; structure changes at any level are associated with a change in its state and properties, i.e. functions, and changes in the function are associated with a change in the organization of the system, i.e. structures. Conformational changes in a receptor, for example, built into the cell membrane, or even a single molecule, an enzyme in particular, are simultaneously a transformation of their properties, i.e. receptor affinity and enzyme activity, in other words, functions. In this case, we should speak rather not about the fusion of biochemistry with morphology and physiology, but about their interpenetration; morphology is becoming more and more functional, and biochemistry and physiology are becoming more structured (D.S. Sarkisov).

The fundamental position on the unity of function and structure removes the question of the possibility of the existence of "functional" diseases and the "functional stage" of diseases. The emergence of a nerve impulse is accompanied by a change in the organization of certain enzyme molecules, and in mental illness, a violation of the organization of synapses, the "stacking" of enzymes, neurotransmitters and vesicles is found. In a living organism, each of its functions can appear and change due to the action of physiological or pathogenic factors on the corresponding structures. None of the environmental factors can have a direct impact on one or another function, only indirectly, through the impact on the structures that form these functions.

A systematic approach to the assessment of normal and pathological phenomena. The desire of science to cognize the ever deeper, molecular and submolecular foundations of physiological and pathological life seems natural, logical and promising. However, any reaction of the body or process, both in the norm and in pathology at any level - from molecular to organismic, is multicomponent, i.e. seems to be systemic and has its own result. A system is a combination of connected and interacting elements that gives a result that cannot be due to any of these elements separately, and the biological significance of the result of any biological system can be objectively assessed only at the organismic level. Thus, it turns out that both symptoms and syndromes, as well as the pathological or adaptive processes underlying them, are systems with their own results. Accordingly, both health and disease are the state of the system, in this case the organism as a whole. Meanwhile, in medicine, a conceptual apparatus is constantly used that contradicts the systemic principle; although the concept of "disease" is applicable only to the organism as a whole, in many cases they write about diseases of molecules (hemoglobin, for example), lysosomes, mitochondria, cytoskeleton, etc. It should be limited to at least what has become generally accepted in accordance with the organosystemic principle in medicine (diseases of the heart, stomach, endocrine system, etc.). Outside the systemic principle - the only objective tool for analyzing the "whole" - the knowledge of the disease is impossible, since it is a form of the organism's vital activity, and not its parts.

Regulation of vital activity in normal and pathological conditions; antagonistic regulation. The use of the systemic principle in the analysis of the disease, in turn, is impossible without a correct understanding of the patterns of regulation of life, since the regulatory mechanisms determine the connection between the elements of the system and the relationships that develop between different systems. At the same time, an important role is played by the study of the molecular and structural foundations of the regulation of physiological processes, the significance of the degree and level of damage in the disruption of the control systems, the identification of special forms of life control that differ from the norm, etc. The basic principle of self-regulation - any deviation from the norm - is an incentive to return to the norm at certain stages of the development of pathology and at a certain, for example, higher, level of management may be lost. However, the mechanisms of self-regulation of life activity do not disappear completely as long as life is preserved; with an increase in the severity of disorders, the mechanisms of self-regulation of low levels of vital activity become leading up to the processes in metabolism. In extremely severe conditions that threaten death, the form of regulation may change and so-called extreme regulation may occur. Along with this, the correct use of a systematic approach and the definition of the role of regulatory mechanisms, regardless of their level and complexity, are fundamentally impossible without understanding the nature and significance of the basis of any form of management, which is the reciprocity of regulation. It is antagonistic regulation, i.e. ± influences - influences of the opposite sign, whether they underlie direct or reverse, intra- or intersystem relationships, determine the organization of any systems and their relationships in normal and pathological conditions (D.S. Sarkisov). From the point of view of D.S. Sarkisov, the opposite of regulatory influences creates unity, integrity of the entire management of the body's vital activity, and the basis of such management is the unity and opposite of anabolic and catabolic processes in the body.

Require comprehension from modern positions of the idea of ​​the place of nervous regulation among the whole variety of control systems, their relationship, as well as the features of work in conditions of pathology, primarily in the formation of adaptive processes. The correct understanding of the relations that develop between local and common processes in conditions of pathology, and, in addition, a correct understanding of the integrity of the body in general in the process of the development of the disease with its unfavorable course and in terminal states. What happens to integrative processes and adaptive reactions in such conditions of increasing severity of the disease and dying? Integrative connections may be less complex and diverse, but they exist and provide adaptive responses as long as life persists. Obviously, the goals of adaptation are not only the expansion of integrative connections with the increase of certain functions (P.K. Anokhin), but also the narrowing of these connections (isolation of cells, organs or systems) with the minimization of functions. Minimization of functions allows to reduce energy consumption and save energy supply for the biogenesis of structures - the material carriers of these functions. Indeed, in any specialized cell, the bulk of the energy of ATP goes to the performance of the function and the implementation of control signals; a much smaller part of the energy is spent on plastic processes and maintaining the structure. With a decrease in intracellular ATP regeneration, energy costs for the implementation of regulatory influences initially decrease, which leads to isolation (autonomization) of a cell or a set of cells, including because the formation of second messengers, such as cAMP and cGMP, is associated with the use of ATP. In the future, the function ceases, and in the pacemakers of the heart and respiratory neurons, the function is minimized to the limit compatible with life. Functional isolation and minimization of function allow for a certain time to maintain plastic processes and cell structure at a normal level. Damage to cell ultrastructures begins from the moment when the degree of drop in energy supply exceeds the level necessary to perform the function. This does not mean that in severe energy deficiency, changes in cell function occur without transformation of ultrastructures; on the contrary, ultrastructural and functional changes proceed conjugately, changes in the structure have an adaptive value. In addition to the above, the systemic response of the body and the role of antagonistic regulation can be correctly understood and used in solving the problem of the disease only on the basis of the principle of combination (recombination) of structures and functions, formulated by D.S. Sarkisov. In accordance with this principle, the adaptation of an organism in normal and pathological conditions or its improvement in phylogeny and ontogenesis is achieved not only through the inclusion or creation of new elements of biological systems, but also due to optimal combinations and recombinations of elements from among the existing ones. From these positions, the high speed and specificity of adaptive reactions to an unlimited number of pathogenic factors become understandable with a large saving in energy and plastic material costs in any biological system. There are also new aspects in understanding the emergence of various forms of pathology and the staging of their course. In particular, a relatively small number of general pathological processes due to their peculiar combination in each this moment and in the dynamics of the development of the disease, a large number of its nosological forms are determined with an almost infinite variation in the individual course of the disease. At the same time, the recombination principle of system formation cannot be realized without antagonistic regulation, since any rearrangement requires the inclusion of some structures (functions) while turning off others; violation of antagonistic regulation in pathology leads to a breakdown of systemic adaptive processes.

General biological approach to the evaluation of pathological phenomena. This approach to the world of pathology is most voluminously and reasonably applied by IV Davydovsky. The combinations developed and fixed in the genotype of organisms, which we observe in an individual in the form of one or another process and incorrectly call general pathological, are not pathological in essence, in their origin. In an individual, they can become damaging, and more often acquire a dual meaning (both positive and negative), often simultaneously due to either a violation of the genetic program or disorders in its implementation. From the point of view of the previously stated conceptual provisions and the general biological approach, it is necessary to completely revise the fundamental aspects of the theory of pathology: the doctrine of general pathological (typical pathological) processes, general etiology, pathogenesis, disease, etc.

The so-called typical pathological processes, their role in adaptation and life disorders. Among the various processes in the development of the disease, there is special group so-called typical (stereotypical, general pathological) processes, which occupy a special place in pathology, as they were developed in the process of evolution, fixed, developed and improved, ensuring the adaptation and survival of species. These usually include hyperplasia (regeneration), hypertrophy, thrombosis, inflammation, fever, immunity, infectious process, etc. These processes are characterized by the fact that they are caused by various pathogenic factors, have stereotypical manifestations and underlie many diseases or accompany them. In addition to such typical pathological processes, there are also typical forms of pathology - dystrophy, hypoxia, edema, tumor process, etc., which are present at all stages of evolutionary development, but arise due to the insufficiency of natural historical adaptation mechanisms that support metabolism (dystrophy), oxygen and energy regime (hypoxia), as well as constancy cellular composition organism (tumor). Some authors refer these phenomena to typical pathological processes.

Inflammation is a typical pathological process that has evolved as a protective and adaptive reaction of the body to local tissue damage, which provides localized fixation, destruction and elimination of the pathogenic agent and tissue decay products, as well as restoration of their integrity. If inflammation is not formed or its barrier role is reduced, there is a threat of generalization of the process and the development of sepsis. At the same time, the evolutionarily developed adaptive process of inflammation, like others (thrombosis, fever, infectious process), can lead individual organisms to death. Thus, the implementation of genetically determined (evolutionarily fixed) potentially useful response programs in individual individuals may be disturbed. Most often, the result of the implementation of such programs acquires a dual, useful and harmful value for the body, which requires medical correction. Violation of the implementation of these adaptive programs is associated with the characteristics of pathogenic factors, the localization of their action and the properties of the organism, its reactivity.

In the theory of pathology, a number of aspects can be distinguished that are of the most significant importance, without the disclosure of which it is impossible to form a doctrine of the disease. First of all, this is the problem of causality in pathology and the solution of key issues of the general etiology of human diseases. This section should define the role of external and internal factors in the occurrence of a disease, the so-called trigger value of a pathogenic stimulus, risk factors, etc. It is necessary to understand what should be invested in the concept of "pathogenic" (extreme, or painful) stimulus; what properties a pathogenic irritant and a specific organism have, as a result of which, when they interact, a disease occurs; what is the process of interaction between a pathogenic agent and an organism from the methodological and medical points of view? It is important to be aware that the same pathogenic stimulus can cause various diseases(for example, one allergen - various allergic diseases), and the same disease can occur under the influence of many pathogenic factors (hypertension). It is possible that with the development of medical science, this postulate may be subject to significant adjustments. Hypertension, for example, breaks down into various nosological forms. In each of these diseases will be found specific features associated with the properties of the pathogen(s) factor(s). At the same time, in a number of cases, disease-causing conditions (for example, dose, frequency, frequency and place of allergen administration) acquire a certain role in the occurrence of the disease; they can also determine the specific features of the disease.

The development of various issues of the pathogenesis of the disease currently remains relevant. In this direction, an essential role is played by the definition of the essence of damage, the allocation of its forms, levels and mechanisms, the definition of criteria for physiological and pathological damage, as well as the reversibility of the latter, and many other issues. In addition to rethinking from modern positions the mechanisms of changing cause-and-effect relationships, primarily neurogenic ones, the formation

vicious circles and self-deepening damage, requires close attention to the issue of methodological foundations disease development; illness is a "film", not a "photo". It constantly develops, sometimes fading, and then resuming. How to answer the question: what is the methodological basis for the development of the disease, its staging? From the point of view of the damage itself, the answer to this question is impossible to obtain. The inconsistency of the disease and the methodological basis of its development consist in the presence and counteraction of damage and adaptation (pathogenesis and sanogenesis). In the development of all aspects of pathogenesis, as well as sanogenesis, it is of fundamental importance the right decision problems of connection between structure and function in the modern understanding of these biological categories. Although it is obvious that this problem should be solved on the basis of the interdependence and conjugation of structural and functional changes, in violation of this provision, morphogenesis is often distinguished in the disease along with pathogenesis. If we follow the position on the inseparability of structure and function, then in pathogenesis (as well as sanogenesis) it is necessary to see not only morphogenesis, but also functional genesis (D.S. Sarkisov).

The most important direction in general pathology is the study of sanogenesis, the manifestations of which in the form of reactions immediately turn on under the action of pathogenic factors, and life disorders do not occur until the sanogenetic mechanisms function quite effectively. General pathology should answer not only the question of why the disease occurs, but also why the disease does not occur or why it occurs only in individuals under the action of pathogenic factors on many of them. Manifestations of sanogenesis are found in all periods of the disease and are based on the principles of self-regulation, as in the norm, however, during illness they can acquire qualitative features associated with damage. General pathology should reveal the essence and significance of these features of adaptive processes.

The development of the aspects discussed above is a prerequisite for the formulation of a clear and precise theory of the disease - the concept of the key patterns of its occurrence, the qualitative features that distinguish disease from health, its significance for the species and the individual, i.e. roles from a general biological and medical point of view. The existing definitions of the disease either focus on one of its manifestations (“deviation from the norm”, “violation of the balance of the body with the environment”, “damage to structures”, etc.), or are so cumbersome that they do not allow showing the main component the essence of the disease and cannot serve as a guide to action in practical medicine. Even in the clinic, there is now a tendency towards the dominance of symptomology and syndromology over nosology; the nosological principle should be the main thing in the doctor's thinking, determining his strategy and tactics in practice.

The question of the evolution of human diseases is important and complex; its solution is included in the sphere of strategic directions of modern theoretical and practical medicine. The development of previously uninhabited regions of the Earth, outer space, the emergence of new technologies and, in connection with all this, new pathogenic factors with which mankind has not come into contact, is fraught with the appearance of previously non-existent diseases. Widespread, especially when used improperly, sulfonamides and antibiotics leads to the emergence of diseases with an erased or unusual picture, resistant forms of infections, allergies, and the use of steroids - to the emergence of various kinds of endocrinopathies and immune deficiencies. The transformation of the properties of pathogenic factors and the emergence of their new species, the features of pathological processes in different periods of human development, as well as their therapy, are an obligatory area of ​​attention for a pathologist and doctor (evolutionary pathology, environmental pathology, drug pathology). From a practical point of view, issues related to the identification and essence of the stages of diseases, especially non-infectious ones, and deciphering the mechanisms of their regular change are of great importance. Here, a particularly important role for medical practice plays an analysis of preclinical forms of the disease and patterns of recovery of the body. The development of the main directions of the doctrine of the disease and the creation of its concept should become a new basis for the theory of constructing a diagnosis, i.e. determining its mandatory adequate structure. The study of the problem of causality in pathology and etiology, as well as the pathogenesis and sanogenesis of diseases with an in-depth analysis of the role of general pathological processes in their development creates the necessary prerequisites for the creation of modern principles of prevention and therapy.

RESEARCH METHODS IN PATHOLOGY

The goals facing any science can be achieved only if it has methods and techniques that are adequate to the tasks set. Therefore, pathology has developed and improved its methods over the centuries. It was the new opportunities that arose with the advent of new research methods that made it possible to make discoveries that radically changed views on pathology, to begin qualitatively new stages of its development.

Pathological anatomy uses three main methods of research - autopsy of the corpses of people who died from diseases (1); microscopic methods for studying tissues (2); an experiment that allows simulating pathological processes and diseases on animals (3). Each of these methods has a variety of techniques that together allow us to observe pathological processes not only at the level of the organism, but also at the cellular, subcellular and molecular levels. Thanks to these methods, the pathologist can observe the unity of structure and function both in physiological conditions and in pathological conditions, which qualitatively distinguishes modern pathology from pathological anatomy and pathological physiology even in the first half of the 20th century.

Autopsy

Autopsy of corpses (autopsy) is one of the oldest methods of morphological research. Since ancient times, autopsy (first of individual organs, and then of corpses) has been used to determine the causes of diseases and identify those changes in organs and tissues that occur during illness and lead the patient to death. It is the autopsy of the dead that allows us to say what the disease is, what morphological substrate corresponds to dysfunctions and clinical manifestations of the disease in its dynamics, during recovery, disability or death of the patient. According to the changes in organs and tissues found at autopsy, one can judge the effectiveness of certain therapeutic measures, the induced pathomorphosis of diseases, as well as medical errors and iatrogenies. Often, only at the autopsy, there are suspicions of a particular infectious disease, which makes it possible to conduct appropriate studies together with infectious disease specialists, epidemiologists, phthisiatricians and other specialists. Sometimes during the autopsy, errors in surgical intervention or in the manipulations performed, as well as criminal causes of death, are found. Finally, it is the results of the autopsy, a thorough study of all changes in the organs and systems of the deceased, that make it possible to form the most complete and objective picture of the disease that the patient suffered during his lifetime. Therefore, an autopsy necessarily involves the preparation of a pathoanatomical diagnosis, which is built on the same principles as clinical diagnosis. This makes it possible to compare clinical and pathoanatomical diagnoses, to state their coincidence or discrepancy, and in the latter case to evaluate the value medical error and look for its cause with clinicians. Thus, the autopsy of the dead serves the purpose of monitoring the diagnostic and treatment activities of a hospital or clinic and improving the skills of medical personnel. At the same time, the results of the autopsy, recorded in the autopsy protocol, make it possible to analyze the management of the patient in the clinic in cases where medical crimes may be involved, make it possible to conduct scientific research and develop statistical data. According to the results of pathoanatomical studies, medical statistics analyzes the causes and nature of mortality in the population. In connection with the above, autopsy does not lose its significance even with the widespread use of biopsy diagnostics of diseases. Only an autopsy allows you to see and evaluate the entire history of a person’s illness from beginning to end, analyze all stages of the patient’s treatment together with clinicians, summarize both positive and negative experience of doctors and discuss all aspects of treatment and errors at clinical and anatomical conferences of medical institutions. Pathological anatomical autopsies are performed by a dissecting physician in the pathoanatomical department of the hospital. Sometimes dissectors are called pathologists. There are no fundamental differences here, but officially the pathologists are teachers of the departments of pathological anatomy and employees of the relevant departments of research institutes. In the departments and committees of health care at the city level, as well as in the ministries of health at the regional, regional and republican levels, there is a pathoanatomical service and the post of chief pathologist. The results of an autopsy largely depend on the method of autopsy. There are several methods that the pathologist uses, depending on the specific situation and the conditions in which the autopsy is performed. One of the first to offer a special method of autopsy was Rudolf von Virchow, who removed the organs separately. In this case, however, the anatomical connections between the organs are violated, which in some cases can lead the dissector to an error. Later A.I. Abrikosov proposed to conduct an autopsy, following the topographic location of the organs, which are then divided into five systems and removed in five steps. The disadvantage of the method is that it leads to the division of anatomical and physiological systems into fragments. Sometimes it is necessary to dissect the tumor or operated organs. The most widespread in practice was the method of G. V. Shor, in which organs are isolated not one by one, but by a whole organocomplex. During evisceration, natural connections between organs are preserved, as well as changes in their topography resulting from the operation, the limits of tumor growth, etc. are determined. The use of the Shore opening method does not preclude the use special ways opening of individual body systems (for example, endocrine). Features of various methods of autopsy are described in special literature.

Biopsy - intravital taking of tissues, organs or cell suspension for microscopic examination for diagnostic purposes, as well as to study the dynamics of the pathological process and the effect of therapeutic measures on it. Depending on the method of taking the material, incisional, puncture, endoscopic and aspiration biopsies are distinguished.

incisional biopsy

In an incisional biopsy, a piece of tissue from an organ or the entire organ is surgically removed. The biopsy is fixed in a formalin solution or other fixative fluid, after which a histological examination is performed. Often, the nature of the pathological process (for example, the nature of the tumor) must be established during surgery. In these cases, an urgent biopsy is indicated. The tissue is fixed quickly, usually by freezing it in liquid nitrogen or carbon dioxide. Then, histological sections are prepared from the biopsy, stained and examined under a microscope for the purpose of urgent diagnosis. This is extremely important for determining the scope of surgical intervention.

Needle biopsy

With a puncture biopsy, a column of tissue from an organ is obtained using a special needle or trocar. A variety of puncture biopsy is trephine biopsy, in which bone or bone marrow tissue is obtained using a special tool - a trephine.

Endoscopic biopsy

Thanks to the development of endoscopic methods of research, endoscopic biopsy has appeared. Especially widespread is endoscopic biopsy of the stomach, intestines and bronchi. The volume of material obtained with the help of an endoscope is very small, therefore, a high degree of verification of the pathological process can be ensured only by examining 4-6 biopsies.

Aspiration biopsy

Aspiration biopsy is used to examine fluid contents hollow organs or aspirate obtained from body cavities using special instruments. For the same purpose, dialysis solution is studied from the bronchi, stomach, pleural or abdominal cavities, from the uterine cavity. The material obtained is subjected mainly to cytological examination.

Material preparation

Pieces of tissue obtained in one way or another for subsequent light microscopy (LM) are usually fixed in 10% neutral buffered formalin. To identify individual components of cells, special fixing fluids are used - Buena, Carnoy, etc. The fixed material is cut on a microtome, after which survey staining of the sections is used or various histochemical reactions are carried out. For electron microscopy (EM), there are special methods for preparing biopsy material, which is then cut on an ultratome, achieving a slice thickness of 30-50 nm.

A biopsy is also used in the clinic, where incisional biopsies of the cervix, skin, puncture biopsies of superficially located tumors, aspiration biopsies of the contents of the uterine cavity, maxillary (maxillary) sinuses and some other cavities are widely used.

Biopsy material can also be obtained for EM study. This method is most widely used in oncology. Sometimes only the study of the ultrastructure of tumor cells allows us to establish its histogenesis.

Microscopic research methods

Microscopic research methods - ways to study various objects using a microscope. In biology and medicine, these methods study the structure of microscopic objects, the dimensions of which lie beyond the resolution of the human eye. The basis of microscopic research methods are SM and EM. SM has several varieties, each of which uses different properties of light: phase-contrast, interference, luminescent, polarizing, stereoscopic, ultraviolet, infrared. In EM, the image of objects of study arises as a result of a directed electron flow.

Light microscopy

The SM is based on such determining factors as the resolution of the microscope, the directivity of the light beam, as well as the features of the object under study, which can be transparent and opaque. Depending on the properties of the object, the physical properties of light change - its color and brightness associated with the wavelength and amplitude, phase, plane and direction of wave propagation. For SM, biological objects are usually stained to reveal certain properties of them. In this case, the tissues must be fixed, since staining reveals certain structures of only dead cells. In a living cell, the dye is isolated in the cytoplasm in the form of a vacuole and does not stain the cellular structures. Nevertheless, living biological objects can also be studied in the SM (vital microscopy). In this case, a dark-field condenser is used.

Phase contrast microscopy is used to study living and unstained biological objects. It is based on the diffraction of a light beam depending on the characteristics of the object of study, on which the change in the length and phase of the light wave depends. In pathology, phase-contrast microscopy finds application in the study of protozoa, plant and animal cells, in the counting and differentiation of bone marrow and peripheral blood cells, in the study of tissue culture cells, etc.

Polarization microscopy makes it possible to study biological objects in light formed by two beams polarized in mutually perpendicular planes, i.e. in polarized light. This is achieved using film polaroids or Nicol prisms, which are placed in the microscope between the light source and the preparation. Polarization changes when light rays pass (or reflect) through different and optically dissimilar structures. In the so-called isotropic structures, the propagation velocity of polarized light does not depend on the polarization plane, while in anisotropic structures, its propagation velocity varies depending on the direction of the light along the longitudinal or transverse axis of the object. If the refractive index of light along the structure is greater than in the transverse direction, positive birefringence occurs, with reverse relationships - negative birefringence. Many biological objects have a strict molecular orientation, are anisotropic and have positive birefringence. Such properties are possessed by myofibrils, cilia of the ciliated epithelium, collagen fibers, etc. Comparison of the nature of the refraction of polarized light and the magnitude of the anisotropy of the object makes it possible to judge the molecular organization of its structure. Polarizing microscopy is one of the histological and cytological research methods, a method of microbiological diagnostics, etc. It is important that both stained and unstained and unfixed (native) tissue sections can be examined in polarized light.

Luminescence microscopy is based on the property of many substances to give luminescence - luminescence in UV rays or in the blue-violet part of the light spectrum. A number of biological substances, such as simple proteins, coenzymes, some vitamins, drugs (drugs) have their own (primary) luminescence. Other substances begin to glow when special dyes are added to them - fluorochromes (secondary luminescence). Fluorochromes can be distributed diffusely in the cell, but can selectively stain individual cellular structures or certain chemical compounds. This is the basis for the use of luminescent microscopy in cytological and histochemical studies. Immunofluorescence in a luminescent microscope makes it possible to detect various antigens and their concentration in cells, while it is possible to identify viruses, determine AT and immune complexes, hormones, various metabolic products, etc. Luminescent microscopy is used for diagnosis viral infections, with the help of secondary luminescence, malignant tumors are diagnosed in histological and cytological preparations, foci of ischemia of the heart muscle are determined in case of early dates myocardial infarction, detect amyloid in tissue biopsy specimens, etc.

Ultraviolet and infrared microscopy is based on the ability of absorption of UV and infrared rays of certain wavelengths by certain substances that are part of living cells, microorganisms or fixed, but not stained, tissues that are transparent in visible light. Macromolecular compounds, such as nucleic acids, proteins, aromatic amino acids (tyrosine, tryptophan, methylalanine), purine and pyrimidine bases, etc., have the ability to absorb UV rays. - their changes in the process of life. Infrared microscopy is used in medicine mainly in neuromorphology and ophthalmology.

For special purposes in pathology, other microscopic methods are also used - interference, stereoscopic microscopy, etc.

electron microscopy

EM is used to study the structure of cells, microorganisms and viruses at the subcellular and macromolecular levels. A significant resolution of the EM is provided by the flow of electrons passing in vacuum through electromagnetic fields created by electromagnetic lenses. With transmission EM, electrons pass through the structures of the object under study, and with scanning EM, they are reflected from these structures, deviating at different angles. As a result, an image appears on the luminescent screen of the microscope. With transmission (translucent) EM, a planar image of intracellular structures is obtained, while with scanning, a volumetric image is obtained. It is very useful to combine EM with other methods - autoradiography, histochemical, immunological methods. It becomes possible to observe the course of biochemical and immunological processes in the cell in combination with changes in intracellular structures. EM requires special chemical or physical tissue fixation. For research, they take mainly biopsy material. Sectional material can also be used, but as soon as possible after death, usually calculated in minutes. After fixation, the tissues are dehydrated, embedded in epoxy resins, cut with glass or diamond knives on ultratomes. In this case, ultrathin tissue sections with a thickness of 30-50 nm are obtained. They are contrasted, transferred to special metal grids and then studied in EM.

With ultratomy of the preparation, so-called semi-thin sections with a thickness of 1.5 μm can be obtained, which, after staining with methylene blue, are examined in the CM. This allows you to get an idea about the state of the tissue, the cells of which will then be studied in EM. The method can also have independent value.

In scanning (raster) EM, the surface of biological and non-biological objects is studied by spraying electron-dense substances on their surface in a vacuum chamber and studying these replicas that repeat the contours of the object of study.

staining methods

Microscopic methods are used in medicine in combination with histological methods for studying cells and tissues. To do this, as a rule, fixed tissue sections must be stained in order to reveal various cellular structures. The latter perceive dyes depending on their physicochemical properties. Therefore, dyes are divided into basic, acidic and neutral.

Basic, or basophilic, dyes are coloring bases or their salts (hematoxylin, methylene blue, toluidine blue, etc.). The colors of these dyes are dominated by shades of blue color. The color intensity (basophilia) depends on the number of acid groups in the cell structures that can interact with basic dyes. Acid, or acidophilic, dyes - coloring acids or their salts that stain cell structures in various shades red (eosin, erythrosin, Congo red, orange, etc.). Neutral dyes contain both basophilic and acidophilic substances (for example, the Romanovsky-Giemsa mixture). Such dyes may have the ability to dissolve in certain substances, coloring them (Sudan III, sharlakh, etc.). Often, methods based on the ability of these tissues to retain or restore salts are used to contrast cell or tissue structures. heavy metals(silver, gold, osmium, lead, etc.). These contrast techniques are called impregnation and are used in both SM and EM.

With the help of various dyes in everyday and scientific practice, survey stains are used to compile a general idea of ​​the state of the tissue under study (hematoxylin and eosin, azure fuchselin, etc.), as well as special stains to identify the features of the processes occurring in tissues and cells. Thus, Sudan III staining is used to detect fatty degeneration of cells, Congo red staining is used to determine amyloid deposits, silver impregnation is used to study nervous tissue, etc. Living and unstained objects are examined using special microscopic methods described above.

Histochemical methods

Histochemical and histoenzymatic methods make it possible to trace and evaluate the metabolism in tissues and cells in normal and pathological conditions; selectively assess the metabolism of proteins, lipids, carbohydrates and other metabolites, the localization and activity of enzymes and hormones, analyze the features of redox processes occurring in cells and tissues under pathological conditions, during adaptation and compensation. The range of application of histochemical methods in pathology is unusually wide. For histochemical studies, sections of freshly frozen tissues prepared in a cryostat are used, which makes it possible to preserve the intravital localization of a particular chemical compound. Histochemical methods are often combined with other SM and EM methods. To quantify the results of histochemical reactions, histophotometry, cytophotometry, microfluorometry, etc. are used.

Cytological examination of smears, scrapings and prints

The traditional methods used by pathologists to diagnose various diseases are the cytological examination of smears, scrapings and tissue prints from various organs and the morphological study of frozen or paraffin-embedded biopsy specimens of organs and tissues. Cytological studies make it possible to give a preliminary diagnosis within 20-30 minutes; they are widely used in outpatient and surgical practice. However, cytological studies disrupt the relationship between various cells and extracellular matrix. In addition, individual cell types may be absent from the cytological sample. Therefore, cytological data are often preliminary, and the final diagnosis is made after a morphological study of the biopsy after 4-5 days. The use of sections obtained from frozen tissue (cryostat sections) makes it possible to accelerate the processing of the material up to 1-2 hours, but at the expense of a deterioration in the morphological picture. In this regard, the study of biopsy material embedded in paraffin remains the main approach in pathoanatomical diagnostics. Very informative immunocytochemistry. Using specific AT and effective systems for their visualization, it is possible to obtain data that determine the choice of therapy for the disease and its prognosis. The use of these techniques is especially effective in the diagnosis of tumors, immune, autoimmune and inflammatory processes.

Autoradiography is close to gastochemical research methods, based on the detection in cells and in subcellular structures in the SM or EM of the localization of radioactive isotopes. The method allows you to visually assess the intensity of metabolism in cells and intracellular structures, as well as in the structures of various microbial and viral pathogens. Autoradiography makes it possible to observe the dynamics of metabolic processes, since α- and β-particles of the used isotopes, being localized and moving in certain structures, leave a mark on the photographic emulsion, which covers a histological or ultrathin tissue section.

MOLECULAR BIOLOGICAL METHODS

The rapid development and progress in the field of immunology, genetics, biotechnology, cellular and molecular biology have led to further improvement of the pathologist's methodological arsenal. In the field of cytology, cytological centrifuges (cytospins) have appeared, which make it possible to concentrate cells from various biological fluids and obtain a high-quality cell monolayer suitable for cytological and immunocytological studies in the shortest possible time.

Flow cytometry

An important advance in the field of cytology was the use of flow cytometry. Flow cytometer - a device that allows you to produce high-quality and quantitative analyzes physical and biological parameters of cells, phenotyping of leukocytes, DNA analysis. The device automatically measures the amount of light from the fluorochrome associated with specific ATs (CD3, CD4, CD8, CD19, etc.) or certain substances (for example, ethidium bromide - 4",6-diamidino-2-phenylindole) that stain DNA or RNA Using different fluorochromes, it is possible to obtain multi-parameter data from a single sample.The signal from each cell is collected within a few microseconds when the cell passes through the laser beam, processed by a computer and presented as quantitative data on the display.Samples containing suspension or small aggregates of cells, are prepared within 2-3 hours.The most widely flow cytometry began to be used in cytological practice after the development of ultrasound diagnostics and the use of fine-needle aspiration biopsy.Unlike conventional biopsy, fine-needle aspiration biopsy is less traumatic, does not require special preparation of the patient and sterile conditions.From received aspiration material la prepare a smear for cytological examination and a cell suspension for flow cytometry. The disadvantage of fine-needle aspiration biopsy is its lower information content and the impossibility of obtaining a cell suspension from solid tissues for flow cytometry.

Double or triple mark method

Improving visualization systems for fluorescent and enzyme labels made it possible to use several different labeled antibodies on one preparation in immunohistochemical studies. This is the double or triple label method.

This methodological approach is especially important in the study of tissue heterogeneous in composition and makes it possible to reveal the distribution of different cell populations during infiltrative growth of tumors, the development of a local immune response, etc. Under certain conditions, the same cell can express several antigens (co-expression), which are usually detected on different cells. In such cases, a fluorescent microscope is used, the image from which is transmitted to a computer.

The study of such preparations using confocal scanning laser microscopy is even more effective. A monochrome light source (laser) does not give optical distortions and allows scanning cells in a section or smear in the same plane at different depths. A special computer program makes it possible to combine images of the same regions containing cells with different fluorochromes and analyze the distribution of different labels on cells. When the labels coincide and overlap each other, a pseudo-colored yellow glow appears.

in situ hybridization

In the last decade, hybridization immunohistochemistry, or in situ hybridization, has been actively used in pathology. This technique, unlike those described above, is able to demonstrate the distribution of specific DNA or RNA sequences in individual cells on tissue sections, in smears, in cell culture, and chromosome preparations.

In situ hybridization is capable of detecting 20-50 copies of certain DNA or RNA sequences in a single cell. Thus, this method allows one to judge the biosynthetic activity of individual cells during their direct visualization and is widely used in the diagnosis of infectious diseases and neoplastic processes, including oncogenes, suppressor genes, growth factors, and factors that regulate the cell cycle. For example, this technique is used to identify RNA expression in endocrine tumors that are negative on immunohistochemical staining. In situ hybridization is also an important tool in gene therapy monitoring, as it allows detection of the location and distribution of therapeutic genes transfected with viral or plasmid vectors into cells or organs. The disadvantage of in situ hybridization is its relatively low sensitivity. This shortcoming is successfully compensated by the use of polymerase chain reaction.

polymerase chain reaction

Polymerase chain reaction (PCR) is a method based on the enzymatic accumulation of specific DNA sequences. In PCR, oligonucleotide primers (short DNA sequences) are used, which are located on the side of the DNA strand and thereby determine the region of interest in the DNA under study. The procedure includes repeated series of cycles, each of which consists of template denaturation, primer annealing, and primer extension with a thermostable DNA polymerase until an exponential accumulation of a specific DNA fragment is created, the end of which is determined by the 5'-end of the primer. After 20 cycles, the number of copies increases by 10 6 -10 8 times.For PCR, in addition to DNA, RNA can be used as a starting material.This procedure is known as reverse transcription PCR.With the help of reverse transcription, complementary DNA is built, which is determined by PCR.PCR is an extremely sensitive method, able to increase 1-2 copies of genes to a level that is easily determined by gel electrophoresis or blot hybridization according to E. Southern (the English name of the method is southern blotting).This increased sensitivity of PCR is often capable of giving false positive results when samples are contaminated.Modern laboratory equipment is maximally prevents such contamination. ion. The most important rule of PCR is the separate pre- and post-PCR steps. In addition, each PCR includes a negative PCR control

Currently, PCR has been further developed in the form of real-time PCR, capable of quantifying the studied nucleic acids. When conducting PCR, destruction of cells and tissues is required to isolate nucleic acids and transfer them to the liquid phase. Therefore, the results of PCR cannot be associated with a specific histological cell type, to determine the percentage of cells containing the studied sequence.

The molecular technique that combines the high sensitivity of PCR and the cellular localization of sequences detected by in situ hybridization is called in situ PCR. Often this technique is used to determine viral or proviral nucleic acid sequences. In addition, in situ PCR is used to study endogenous DNA sequences, including cellular gene rearrangement, chromosomal translocations, and mapping of genomic sequences with low copy numbers in metaphase chromosomes. However, this technique is not widely used due to the ease of obtaining a pseudo-positive result and the need for a large number of controls, the complexity of interpreting the results and their low reproducibility.

Microdissection

In connection with the foregoing, a microdissection method was proposed, which makes it possible to cut out individual identified cells or groups of cells with their subsequent analysis using conventional PCR. The first steps in this direction were made by cutting with a razor or scrapings of tissue of interest on a section under a microscope. Later, micromanipulators began to be used, which made it possible to precisely select individual clusters of cells. In both methods, the microdissection process is very long and depends largely on the skill of the operator. Currently, lasers are increasingly used for accurate and reproducible microdissection. A number of devices use the principle of laser microbeam microdissection, when cells or an area protected by a photopigment that prevents DNA damage in UV light is cut out with a precisely focused beam of an ultraviolet laser. Other devices use the principle of laser capture. This principle is based on the selective adhesion of selected cells or tissue fragments to a thermoplastic membrane activated by low-energy infrared laser pulses. The thermoplastic membrane used to transfer the selected cells has a diameter of about 6 mm and is located at the bottom of an optically transparent cap that closes a 0.5 ml microcentrifuge tube with DNA or RNA extraction solution. The morphology of the excised cells is well preserved and can be documented at all stages of the procedure. Since laser capture microdissection does not destroy surrounding tissues, 2-3 sites containing heterogeneous morphological structures (normal, borderline and tumor cells) can be taken for analysis from one preparation. Currently, microdissection with laser capture is widely used to analyze genetic changes in DNA, to determine the loss of heterozygosity in invasive tumors.

Thus, a modern pathologist has the ability to use a significant arsenal of methods, from routine to molecular biological, for the diagnosis of cytological and biopsy materials.

The choice of certain methods is determined by the type of material (smear, cryostat or paraffin section), the features of its fixation, the histoarchitectural features of the tissue, and the ultimate goals of the study.

Bashkir State Medical University

Abstract on the topic:

The theory of diagnosis as a doctrine

about the recognition of the disease"

Performed:

intern Astakhova E.O.