Th e Autopsy Service

pathology_chap15.indd185
Chapter
Th e Autopsy Service Eugene J. Mark and Robert H. Young
The autopsy has a long and varied history. Th e word autopsy derives from the Greek
and means “to see for oneself,” and its fi rst documented use in the English language dates to 1651 (1), in the quotation “when by an observation, we get a certain knowledge of things.” Th e word nec- ropsy, meaning specifi cally a postmortem examination, dates from 1856 (1). Examination of the deceased for various purposes occurred in antiq- uity, and dissection of the human body as well as dissection of animals for divination can be traced to as early as 3500 b.c.e. in Babylon and Egypt. Anatomic dissection for instruction in anatomy goes back at least to Galen in the second century c.e. Paracelsus (d. 1590), Giovanni Maria Lancisi (d. 1720), and Herman Boerhaave (d. 1738) had interests in the autopsy, and Giovanni Battista Morgagni (d. 1771) made systematic postmortem observations for clinical correlations for 60 years. Carl von Rokitansky (d. 1878) and Rudolf Vir- chow (d. 1902) were pathologists who pioneered the clinical utility of the autopsy in the nineteenth century, and their names persist to identify the two principal modes of dissection, the Rokitan- sky dissection, in which organs are removed en bloc, and the Virchow dissection whereby organs are removed individually. Manipulation of the deceased body by various mechanical means to prove death and prevent premature burial appeared as advertisements in the popular press in the eighteenth and nineteenth centuries; these
included systems of bells to be rung from the cof- fi n of the person buried alive to call attention to the fact or, as an alternative, lying-in rooms for the recently deceased under observation by atten- dants until putrefaction was apparent.
Th is chapter describes fi ve eras of the Autopsy Service at Massachusetts General Hospital (MGH): before the founding of the department, in 1896; 1896–1926, under Drs. James Homer Wright and Oscar Richardson; 1926–1951, during the tenure of Dr. Tracy Mallory as chief; 1952– 1974, during the tenure of Dr. Benjamin Castle- man as chief; and from 1975 to the present day. Th e chapter concludes with discussions of par- ticular issues relating to the Autopsy Service: the autopsy suite, the handling of bodies and tissues, autopsy services provided to other hospitals, and forensic pathology.
Autopsy at MGH before : The Jackson and Fitz Years
Autopsy at MGH can be traced to as early as 1835. MGH was the only hospital of Harvard Medical School (HMS) when the university Department of Pathology was offi cially established with the appointment of Dr. John Barnard Swett Jackson in 1847 as Professor of Pathological Anatomy and Curator of the Warren Anatomic Museum (chapter 1). Pathology at that time was in the hands of clinicians, and the subject was not required for a medical degree until 1856. HMS was the fi rst
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Keen Minds to Explore the Dark Continents of Disease
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North American medical school to teach pathology as a special course. Pathology in the mid- nineteenth century revolved around the autopsy, and surgical pathology did not come of age until the late nineteenth century, as evidenced by the professorship endowed by George Cheyne Shat- tuck that was entitled the Shattuck Professorship of Morbid Anatomy in 1854; the title was not renamed the Shattuck Professorship of Patholog- ical Anatomy until 25 years later, in 1879.
Dr. Jackson studied in Europe and practiced general medicine for his entire career, but his chief interest was in pathological anatomy. His fame rests in large part on his work as a curator for the Boston Society for Medical Improvement, where he developed a museum that ultimately was given to HMS under the name of the Jack- son Cabinet and placed in the Warren Anatomi- cal Museum. Th is museum was housed for many decades in Building A of HMS; it now resides in the top fl oors of the Countway Library at HMS. In 1847 Dr. Jackson published a descriptive catalogue of the Museum of the Society of Medical Improvement and, in 1870, a similar catalogue of the Warren Museum.
From 1835 to 1850 much discussion at the MGH about autopsies centered on who should perform them and when. As the records of the Medical Board of Massachusetts General Hospi- tal relate, in 1835 a committee of MGH Trust- ees appointed an offi cer whose duties included admission of patients as well as obligations and duties assigned him by the hospital’s physicians and surgeons (2). One such duty was supervision of examinations of the deceased. Dr. Jackson considered himself a “free agent,” authorized to perform the examination in the manner and to the extent that he judged right. Nevertheless, the records state that he considered the wishes of the physicians regarding the time and circumstances of the autopsy. He examined all the chief organs and stated that no autopsy would be complete without a thorough examination.
Th e timing of the autopsy and the permission
for autopsy were debated over the years. Dr. N. J. Bowditch noted, “It is highly important to the cause of science that such examination should take place whenever it is practicable, but that they should never be performed contrary to the known wishes or directions of the friends or family of a patient and should naturally be commu- nicated to the superintendent of the hospital” (3). On the other hand, the President and Directors of the hospital had allowed postmortem examination at times without consent or even knowledge of the family, and the benefi ts and challenges of this circumstance were reported. On the positive side was the fact that the distressed family would not be troubled by a request to allow the autopsy. On the negative side was the family’s potential discovery of an autopsy having been performed without their knowledge. Th e Coroner’s Offi ce had the authority to perform autopsies without permission from the next of kin, and this was said to factor into the development of MGH policies (4).
Th e role of the MGH superintendent in ob- taining autopsies was described in a somewhat confl icted manner:
Th e hardy cooperation of the superintendent—
he should be relieved of all responsibility—in
case of diffi culty—should be encouraged by the
trustees to secure as many as possible—under
existing laws. He should be relieved, as far as
possible, from the necessity of asking for permis-
sion from friends (of the deceased). Th ey usually
object—are more likely to if approached with-
out great tact, and often much time is required
to explain the circumstances of the cases—even
with all willingness and enthusiasm on the part
of the superintendent he may be away when the
relatives come for the interview. (4)
At one point it was noted that the superintendent “was interested in procuring them—and by this tact, and with zeal procured many—I am not aware that the hospital incurred any loss thereby.” Th e superintendent was instructed to secure as
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many autopsies as possible. Furthermore, the instruction was “to order an autopsy on all bodies (with rare exceptions to take place 12 hours after death)—and refuse to deliver bodies, except in rare instances . . . and should be relieved from asking permission—but should order the autopsy. . . . Another suggestion was that there was no way to obtain autopsies, except—were it expedient to do so—to have as a regulation of the hospital that all persons dying in the institution shall be submitted to postmortem examination” (4). Th e opposite feeling was also expressed: “No autopsy shall be had within 12 hours after such notice (of death) shall have been sent, unless with the expressed consent of the family or friends of such deceased patient, and that no autopsy shall be had in any case where it shall have been expressly prohibited by the deceased patient or by his family or friends” (4). Over time the concerns about disclosure became increasingly apparent, and by the 1890s autopsies generally were not performed without permission. By hospital directive and by statute, that policy stands today.
From early times, the rate of autopsies at the MGH was of concern. Comparisons were made between the MGH and other academic institu- tions, including the University of Pennsylvania in Philadelphia and Columbia University in New York City. A letter on the matter at the time reads in part: “For several years previous to 1876 the annual ratio of autopsies to death at the Massa- chusetts General Hospital was between 48 and 56, in 1876 the ratio was 55, but since the percentage has rapidly fallen off , being 41 in 1877, 38 in 1878, 20 in 1879 and 21 in 1880.” Th e subject of more autopsies was vigorously debated in 1881 and again in 1886, but at neither time was any real advance made (5). It was added that “the hospital records would be rendered incomplete (without an autopsy), and the world at large would often lose the benefi ts to be derived from the valuable observations of the hospital staff .”
In 1879 Dr. R. H. Fitz (chapter 2), who had been trained by Virchow, became head of HMS
Pathology and continued in this position until 1892, when he was named Professor of the Th e- ory and Practice of Physick. Much of Dr. Fitz’s seminal work in acute appendicitis and acute pancreatitis was based on his autopsy experience at the MGH. In his classic work on perforating infl ammation of the vermiform appendix (6), Dr. Fitz described his experience on postmortem examinations of appendicitis cases at the MGH, including correlations of the pathological fi ndings with the duration, location, and intensity of symptoms. He described 257 cases, although it is not clear that all these patients had autopsies. He described the peritoneal pathology in patients with peritonitis and contrasted the acute fatal cases with the chronic cases.
Dr. Fitz was succeeded as the Chair of HMS Pathology by Dr. William T. Councilman, who had received his M.D. degree at the University of Maryland, had worked under Professors Hans Chiari in Vienna, Julius Cohnheim and Carl Wei- gert in Leipzig, and Friedrich von Recklinghau- sen in Strasbourg, and had been on the faculty at Johns Hopkins University. Dr. Councilman felt strongly that the MGH should acquire a building for pathology and engage a full-time pathologist, and he recommended Dr. James Homer Wright, one of his trainees, for the position.
Additional evidence that autopsies constituted an important part of the work of the department is provided in the 1904 third edition of Pathologi- cal Technique by Dr. Wright and Dr. Frank Burr Mallory (another of Dr. Councilman’s trainees) (7). Th e book was divided into three parts, the fi rst of which (52 pages of approximately 400 total) was devoted specifi cally to the autopsy, including illustrations of instruments, lines of dissection of the heart and lungs, and recommended contents for a travel bag for pathologists performing autopsies in private homes. Th e other two parts, on bacteriology and histology, were also geared as much to autopsy pathology as to surgical pathology, as shown by the types of specimens described.
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The Wright and Richardson Years, –
Th e fi rst MGH autopsy for which detailed records still exist at MGH was performed in Octo- ber 1896, the month Dr. James Homer Wright became Chief of Pathology. Some excerpts of the report are noteworthy for showing the striking similarity of the earliest autopsy report to modern reports. It begins with an external examination: the patient was an adult male of “good height, slender frame and slight musculature development.” Th ere follows a gross description of the organs, concentrating on the lungs. Th is is followed by the six anatomic diagnoses, three of which are tuberculous (acute miliary tuberculosis, chronic tuberculosis of several lymph nodes groups, chronic localized tuberculosis of the lung) and three of which are probably due to tuberculosis (ascites, pleuritis, and miliary abscess of the kidneys). Sections from a necrotic area of
the spleen and a caseous lymph gland were cul- tured into a guinea pig. Seventeen days later the guinea pig was “found gasping.” Th e autopsy of the guinea pig showed tubercle bacilli on smears of necrotic lymphoid tissue.
Th e early bound volumes of autopsy reports have a title page identifying the pathologists involved with the cases. Not all the cases are signed individually. Th e fi rst bound volume (fi gure 15.1) comprises 50 cases, which were performed over an interval of three and one-half months. Th e autopsy reports are entirely in ink, in fl owing script, for the fi rst four years. Begin- ning in June 1899, at autopsy number 400, typed entries become interposed with handwritten ones. By the following year, script disappears and the reports are entirely typewritten. Each report runs between 10 and 20 pages. No clinical history was provided unless it could be deduced from the external examination. Th e postmortem interval was recorded. Each volume has an index
coded by diagnosis and also by organ. Micro- scopic descriptions of selected slides, usually about 10 slides per case, are included. A written bacteriology report is present for most cases.
Th e fi rst gross photograph appears in autopsy number 59 (March 9, 1897) and shows ulcer- ative endocarditis of the mitral valve with rup- ture of the valve asso- ciated with multiple embolic infarcts in the heart, spleen, and kidneys. Th e fi rst photomicrograph (fi gure 15.2) appears in autopsy number 110 (June 18, 1897), in a young woman with
Figure 15.1 Th e fi rst volume of Records of Autopsies, 1–50, 1896 and 1897. Spine (left), title page (center), inscribed with the names of James H. Wright and
Oscar Richardson, and the fi rst page of the fi rst report (right)
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acute purulent peritonitis resulting from a per- forated adenocarcinoma of the appendix. Th e fi rst photomicrograph of infectious organisms appears in autopsy number 136 (August 13, 1887), of a young emaciated man with actinomycosis in the liver with extension through the diaphragm into the lung. Th e fi rst hand drawing (fi gure 15.3) appeared in autopsy 141 (September 5, 1897), of a 74-year-old man with a shrunken brain whose cause of death was fracture of the atlas: the atlas fracture sites are illustrated. A gross photograph with fi ne detail (fi gure 15.4) appears in autopsy number 903 (July 25, 1903), of a fracture of ver- tebrae C3 and C4 with compression of the spinal cord after a diving accident in a 19-year-old patient.
At the conclusion of the fi rst 10 years of the Autopsy Service, 1,849 autopsies had been performed by Dr. Wright and his assistant, Dr. Oscar Richardson, who continued to be the two pathologists performing most of the autopsies over the fi rst two decades of Dr. Wright’s tenure. Demonstrations of dissection took place in an amphitheater in the Allen Street Building (fi g- ure 15.5). By April 1921 the pair had performed
4,200 autopsies. Other assistants participating on the Autopsy Service after this time included Drs. William A. Hinton and George A. Buckley. Dr. Hinton went on to an illustrious career at HMS, developing the widely adopted Hinton test for syphilis (chapter 3), and was the fi rst African American professor at HMS.
Autopsy reports throughout this era were replete with various forms of tuberculosis. Among the 200 cases performed in 1906 and 1907 were 69 cases of tuberculosis, including 6 cases of miliary tuberculosis, 3 cases of tuberculosis of the spine, 5 cases of disseminated tuberculosis, and 2 cases of tuberculosis of the adrenal gland. Syphilitic aortitis with fatal aortic insuf- fi ciency and congenital syphilis were well recog- nized. In 1916 and 1917 alone, there were 9 cases
Figure 15.2 First photomicrograph in the autopsy records, 1897, showing infi ltrating adenocarcinoma of
the appendix
Figure 15.3 First hand drawing in the autopsy records, 1897, showing four fractures of the atlas and a fracture
of the odontoid process
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of syphilitic aortitis. Many other infections were documented, including pneumonia, meningitis, malaria, osteomyelitis, diphtheria, endometritis, typhoid fever, and streptococcal diseases.
Observations uncommon today included cra- nial trepanations, Addison’s disease, and acute rheumatic heart disease. Endocarditis of varying forms markedly outnumbered cases of coronary artery disease or myocardial infarct. A variety of cancers, ruptured duodenal ulcers, gangrene of the lung, amyloid, and pericarditis were recorded. Th e distribution of carcinomas among the various organs overall was similar to that encoun- tered today, but lung carcinomas were rare (see chapter 7).
From September 24 to October 24, 1918, during the global pandemic sometimes termed the Spanish fl u, 22 autopsies were performed on patients who had either a clinical diagnosis of infl uenza or a pathological diagnosis of pneu- monic infl uenza. Th e autopsy protocol of these cases was shortened from six to eight pages (already shorter than the 10–20 pages in the earliest autopsy reports) to an average of one and a half pages. Th e lung in infl uenza was described histologically as extensive hemorrhagic fi brin for- mation and a relatively sparse infi ltrate of infl am- matory cells. Infl uenza was identifi ed as histologically distinct, its appearance not that of the usual organizing pneumonia.
During the latter part of the Wright and Rich- ardson era, the clinical history usually included only one sentence, describing the state of nutri- tion of the patient, history of recent surgery, age, sex, and race. Th e cases came from the East Med- ical Service and the West Medical Service, which were the entirety of the Medicine department at the time, and there were virtually no surgical cases coming to autopsy.
An important development to publicize the value of the autopsy came in 1910. Dr. Richard Cabot (8; chapter 24), who had promoted the notion of the modern hospital as a bedside laboratory and honed his skills in the laboratory to
Figure 15.4 Gross photograph in the autopsy records, 1900, of a vertebral spine bisected with C3 and C4
fracture and a spinal cord compression
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or three house offi cers at any one time. Th e anatomic diagnoses appeared on the fi rst page of the report rather than toward the end, as had been the practice previously. A more detailed clinical history became part of the report, as did the clinical diagnoses and the death report. Postoperative cases accounted for a signifi cant number of the cases, including orthopedic, gynecologic, and neurologic, as well as breast surgery. Coronary artery disease became more frequent than it had been in earlier decades, rheumatic heart disease continued, glomerulonephritis was an occasional cause of death, and cervical carcinoma was regu- larly observed. When Dr. Charles Kubik became the fi rst neuropathologist on the Autopsy Ser- vice, the number of neuropathological diagnoses increased, particularly with regard to gliomas.
An insight into the function of the Autopsy
become one of the most respected clinicians in the hospital, issued a report that year that was based on approximately 1,000 autopsies performed at the MGH (9) (see fi gure 3.8). Th e report revealed conspicuous diagnostic inaccura- cies on the part of clinicians and reinforced the infl uential Flexner Report of 1910 (10), which documented the need for greater scientifi c input in medical education and a heightened role for universities in medicine.
The Mallory Years, –, and the Cocoanut Grove Fire of
During the tenure of Dr. Tracy B. Mallory from 1926 to 1951, the pathologists signing out autopsies included, in addition to Dr. Mallory, Drs. Benjamin Castleman, Winfi eld S. Morgan, Ron- ald Sniff en, and Edward A. Gall, as well as two
Figure 15.5 Demonstration of an autopsy at Allen Street by Oscar Richardson (in white gown), watched by David Edsall (in suit and tie), Chief of Medicine at MGH, ca. 1912–15
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Service in those years is provided by the Cocoa- nut Grove disaster (11; chapter 22). Th e fi re was widely covered in the press, the MGH was gal- vanized into unifi ed action for therapy of these patients, and new insights into the physiology of burns came from the Autopsy Service as well as the Medical and Surgical Services. Th e Cocoanut Grove was a one-story nightclub with low ceilings and infl ammable hangings in the Bay Village sec- tion of Boston, near Park Square. On the evening of November 28, 1942, the club was fi lled with an overcapacity Saturday night crowd of people. A fi re started in the lounge and resulted in panic. Th ere was great loss of life, both immediate and delayed. Between 10:30 p.m. and 12:45 a.m. 114 casualties were received in the MGH emergency room, of whom 75 were either dead on arrival or died shortly thereafter.
Six autopsies were performed either at the MGH or at the Northern Mortuary of Suff olk County, which was part of the Medical Exam- iner’s Offi ce (see below) and adjacent to the hospital. Th e six cases were examined personally by Tracy B. Mallory and the Chief Medical Exam- iner, William J. Brickley. Th ree of the patients were dead on arrival, and three died after varying but comparatively brief periods (40 to 62 hours) of treatment. Standard autopsy protocol was followed. Notable in some cases was brilliant, cherry red discoloration of skin and muscles due to carbon monoxide poisoning. Histologic fi ndings not specifi cally attributed to thermal burns in the extant English literature included hemorrhagic tracheitis and bronchitis, pulmonary hemorrhage, and lakes of serum between the epithelium and basement membrane of the skin with spontaneous detachment of the epithelium. Th e clinical and pathological descriptions of these autopsies are particularly vivid and serve as fi ne examples of descriptive medical writing. Some examples are given here in paraphrased form.
Autopsy 10617-B was described as a terribly burned young woman estimated to be about 25 years of age, hair singed and burnt to stubble,
entire neck and face bloated, carbon monoxide 42 percent saturation.
Autopsy 10617-C was performed by Benjamin Castleman. Diagnoses were third-degree burns of both scapular and right thigh and extensive second-degree and fi rst-degree burns as well. Dr. Castleman commented that this was the only one of fi ve cases dying within seventy-two hours of the catastrophe that showed defi nite broncho- pneumonia. A note was made that the patient became unconscious while attempting to escape from the Cocoanut Grove fi re, was received on the operating fl oor at 2:00 a.m., where Vaseline strips were placed on face and hands and triple dye on the legs. Th e patient received antibiotics and morphine but died at 5:35 p.m.
Autopsy 10618, performed by Drs. E. D. Churchill and Shields Warren, was a 46-year-old white man with fi rst-, second-, and third-degree burns of the head, face, neck, and hands and membranous laryngitis and tracheitis and bronchitis. Th e patient was extremely hyperactive on arrival at the hospital with respiratory embarrass- ment requiring intermittent oxygen, impend- ing shock, and cherry-red color of denuded sur- faces, estimated total third-degree burn 80 percent, with inhalation burns and corneal burns. He received fi ve units of plasma on day one; his blood pressure remained normal for a short time, but then he died. (Dr. Churchill was a senior surgeon at MGH, and Dr. Shields Warren was later to become Professor of Pathology and Chief of Pathology at New England Deaconess Hospital, but it is unclear how he became involved with this single case.)
Autopsy 10620, performed on December 1, 1942, was a 29-year-old, powerfully built young man with second- and third-degree burns of the face, scalp, hands, and ankles and laryngeal ste- nosis. On arrival he was maniacal and uncontrol- lable and vomiting with evidence of smoke inhalation. He was treated with paraldehyde and died early on the third day of hospitalization.
Th e deaths from the Cocoanut Grove fi re were identifi ed in the autopsies as specifi cally due to
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the fi re for only one month after the event. After that, any fatal complications that arose from the confl agration were not specifi cally linked to the fi re in the autopsy records. Still, these autopsies were important in understanding the cutane- ous and pulmonary eff ects of thermal injury, as well as the indirect damage to other organs from hypoxia and infection, and thus formed a base- line for study by later physicians.
The Castleman Years, –
When Benjamin Castleman became Chief of Pathology in 1952, his strong interest in the autopsy was readily evident. Th e department work would begin every weekday with his directing the autopsy conference, sometimes referred to as the “organ recital,” from 8:15 to 9:15 a.m. pre- cisely. Woe to the resident who did not fi nish the presentation by 9:15, because at 9:15 Dr. Castle- man would rise from his chair without hesita- tion and ascend the two fl ights to his offi ce. He
typically ran the conference seated at the head of a circular metal table, with Dr. Walter Putschar (chapter 12) to his immediate left and the staff pathologist signing the cases out for that week to Dr. Putschar’s left. Th e attending pathologists would rotate on a weekly basis and included the majority of the staff pathologists, both surgical and research, as well as chief residents or qualifi ed senior residents who might have the privilege to sign out autopsies for the week. Upon Dr. Castle- man’s departure from the conference at 9:15 or in his absence, Dr. Putschar would move into Dr. Castleman’s chair and unhurriedly complete the conference. If other staff were called on to complete the conference, they would generally remain in the place in which they were already seated.
Every case was presented by the prosector, and X-rays were usually shown by a radiology resident on rotation. Dr. Castleman would make observations (fi gure 15.6) and only occasionally ask for input from the attending staff , but he would quiz
Figure 15.6 Autopsy conference, probably 1962–1963, with Benjamin Castleman, Karoly Balogh, and Walter Putschar (seated, left to right). Also identifi ed, standing, left to right, are Sheldon Baddock (hand on face, behind the person leaning over the table at the left), Jónas Hallgrímsson (standing behind Dr. Castleman), John Barlow (standing behind Drs. Balogh
and Putschar), James Gibson (standing in the right foreground).
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the resident on what he or she had found. Dr. Castleman had some favorite questions, such as whether the parathyroid glands were enlarged, whether the chordae tendinae were thickened, and whether there was thrombus in the atrial appendages. He might probe for a patent fora- men ovale, while the prosector prayed that Dr. Castleman did not discover one that the resident had not found.
Dr. Castleman described the conference as follows: “Th e entire staff meets every morning at 8:15 and for up to one hour, I personally check all the gross material of the autopsies of the day before. Th is is a very popular exercise and almost every morning various members of the clinical staff , both house and members of the visiting staff , appear to take part when their case is coming up” (12). In 1956, Dr. Castleman instituted the post-sophomore fellowship, and during their year in the department, students from HMS rotated on the Autopsy Service as an important part of their training.
During the 1950s the rate of autopsies at the MGH declined from about 60 to 50 percent of patients who had died at the hospital. Compa- rable teaching hospitals had autopsy rates that declined from about 20 to 10 percent. Dr. Castle- man commented on this trend:
Explanations that had been off ered for this
phenomenon include the removal of the require-
ment by the hospital accrediting agencies for a
specifi ed percentage of consents for autopsies,
the belief that major advances in clinical diagnos-
tic techniques have rendered autopsies unneces-
sary, fear of information being uncovered that
might be damaging in malpractice suits, and a
decline in emphasis on the teaching of pathology
in medical schools. Nevertheless, I believe autop-
sies continue to provide important information
in the quality of patient care, including fi ndings
that are useful in the evaluation of eff ectiveness
and hazards of new forms of therapy. In addi-
tion, autopsies are necessary for the training of
pathology residents. (12)
Staff pathologists with a special interest and expertise in autopsy pathology in the Castle- man era included Dr. Jónas Hallgrímmson, who became Professor and Chief of Pathology at the University of Iceland; Dr. Kilmer McCully, who became Chief of Pathology at the West Roxbury Veterans Administration Hospital, West Rox- bury, Massachusetts; Dr. William Th urlbeck, who became Professor fi rst at McGill University in Montreal, then at the University of Winnipeg, and then at the University of British Columbia, Vancouver; Dr. Harold Dvorak, who became a Professor at HMS and Chair of Pathology at Beth Israel Hospital in Boston; Dr. John Blenner- hasset, who became a Professor and Chair of Pathology at Otago Medical School, Dunedin, New Zealand; Dr. Robert Fienberg, who was Chief of Pathology at Beverly Hospital, Beverly, Massachusetts, for approximately 40 years; Drs. Robert Harper, Lewis James, and James Gib- son, a triumvirate who were the heart and soul of Memorial Hospital in Worcester, Massachu- setts, for decades; and Drs. Alan L. Schiller and Eugene J. Mark (see below).
During this period the bound volumes of autopsy reports that had been used for the Case Records of the MGH (chapter 24) included the printed pages of the New England Journal of Med- icine for that case. By 1960 staff members were no longer listed on the fi rst page of the bound volumes. In this era autopsy diagnoses were given a coding number for retrieval. Th e database for retrieval of the diagnoses was a collection of index cards on a Rolodex, which resided in a sign-out booth in the residents’ laboratory.
The Recent Years, to the Present Day
Th e tradition of the morning autopsy conference as the fi rst item of business for the day changed over the next decade, shifting to two afternoons a week, then to one afternoon a week, then to once a week at noon. Th is refl ected both a decline in the number of autopsies and less interest on
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the part of the clinical services and the Pathol- ogy faculty. Th e recent era also brought forward new types of challenging cases. Th ese included autopsies for patients with AIDS; pathology of transplantation from the active transplant services (pulmonary, cardiac, liver, kidney, and pan- creas); newly appreciated viral infections, including SARS and H1N1 infl uenza; complex cardio- vascular surgery; endovascular grafts; and the pathology of graft-versus-host disease in patients undergoing bone marrow transplantation and stem cell therapy. Beginning in the 1980s autopsy reports were computerized, and soon the reports were available in electronic form only.
During the 1960s and into the 1980s, Dr. Wal- ter Putschar would routinely stroll into the dissecting room, even though he rarely was formally responsible for signing out cases. He took it upon himself to give a demonstration of an autopsy for the incoming house staff and took pride in showing how an autopsy could be done in as clean a manner as possible (fi gure 15.7).
When Dr. Castleman stepped down as chief, the duties of directing the Autopsy Service were taken by Dr. Alan L. Schiller (see fi gures 13.1 and 13.2). Dr. Schiller’s primary interest in surgical pathology was orthopedic pathology, and at that time he was already a renowned expert in this fi eld. He was also a superb general anatomic pathologist and an exciting teacher, and he wanted to spur the interests of the residents, clinicians, and medical students in the autopsy. He ran the autopsy conference much as Dr. Castle- man had.
After several years Dr. Schiller wished to spend more time on his work in bone and soft tissue, and Dr. Eugene Mark, who was interested in pulmonary pathology, was appointed Director of the Autopsy Service. Since much of pulmonary disease at that time was heavily dependent on gross pathology, particularly chronic obstruc- tive pulmonary diseases, the combination of pulmonary pathology and autopsy pathology was practical. Dr. Mark changed the structure of the
conferences; attendees no longer sat around a table but stood and used a hand lens as the organs were passed around on small trays. He made the autopsy conference more interactive by adopting a Socratic method, asking for descriptions and diff erential diagnoses of the gross pathology by the resident, an approach that resembled the surgical pathology conference at that time.
Dr. Schiller served a second term as head of the Autopsy Service from 1978 to 1984. He was then succeeded by Dr. Frederick (“Fritz”) C. Koerner from 1984 to 1990. Dr. Koerner (see fi gures 13.2 and 16.10), like Dr. Schiller, was renowned for his teaching ability. He particularly encouraged residents and staff to contribute their observations at the conference. He would present cases as unknowns before providing any clinical history. Dr. Koerner eventually wished to devote more time to surgical pathology, and he went on at the MGH to become an internationally known expert in breast pathology.
Dr. James Southern was director from 1990 to 1996. Southern’s expertise was cardiac pathology, and his abilities to combine autopsy pathology and cardiac pathology proved fruitful. He was an expert in the fi eld of congenital anomalies of the
Figure 15.7 Walter Putschar dissecting emphysematous lungs at demonstration for new residents, ca. 1985
196
heart. Together with Dr. Th omas Aretz, another cardiac pathologist, and later Dr. Stuart Houser, a cardiac surgeon who retired early to pursue a second career in pathology, he championed postmortem injection studies of the coronary artery system to correlate atherosclerotic lesions with myocardial infarcts and study the successes and failures of coronary artery bypass surgery.
When Dr. Southern left in 1996, Dr. Eugene Mark was invited to undertake a second tour of duty as director. He declined the fi rst two invi- tations and fi nally accepted the third under the encouragement of Dr. Nancy Harris, who was at the time Director of Anatomic Pathology. Dr. Mark promoted an interactive approach at the autopsy conference; streamlined the autopsy protocol; stressed macroscopic analysis, using visual, tactile (palpating the lung for consolida- tion), olfactory (alcohol breakdown products), and even auditory (sound of the knife scraping the prostate in prostate cancer) senses to lead to a diagnosis; and initiated a consensus conference for autopsy pathology. He added an element of drama to the autopsy conference with “CTD” (cross the table diagnosis), whereby residents from a distance of several feet might still be able to make the diagnosis. He stressed formal delivery of the clinical history, which was how surgery residents presented at Surgical Grand Rounds in the Bigelow Amphitheater. To aug- ment teaching, he had residents memorize short stanzas from poetry that would be applicable to the case, to be delivered at an appropriate time in the discussion (on secret signal!) to catch the audience unawares. He was a deputized Medi- cal Examiner for the Commonwealth of Massa- chusetts and integrated forensic issues into the autopsy conference.
At the time of writing of this book, Dr. Mark has stepped down after his long second tenure as Director. Th e new Director is Dr. James Stone, who has been head of cardiac pathology at MGH for the past six years.
The Autopsy Suite: The Physical Plant
Th e Allen Street House, on Allen Street (now Blossom Street), was on the hospital side of Allen Street, just west of the western end of the Bul- fi nch Building. In 1920 building numbers 56, 57, 58, and 59 on Allen Street behind the hospital were purchased, and these buildings were the site of the morgue and autopsy room as well as the Histology Laboratory. Numbers 57 and 58, being in poor condition, were torn down in 1937. Num- bers 56 and 59 were used for storage until being torn down around 1952. Th e hearse entrance was attached to the Allen Street House. Th e name Allen Street persists today in the euphemism of “he went to Allen Street last night” (instead of “he died last night”) and “Allen Street conference” (instead of “mortality conference”).
MGH Pathology moved into the newly con- structed Warren building in 1956 (chapter 7). Th e autopsy suite occupied the majority of the basement and included the dissecting room with two tables in the main room (fi gure 15.8) and a third table in a separate room for infectious cases. Th e morgue for holding bodies was down the hall from the dissecting room. Th e diener’s offi ce was in the same area, as was the pathology photography laboratory. Around the corner was a large incinerator, which was used for incinerating both autopsy and surgical tissue, at that time a com- mon means of disposal of tissue. Across another hallway was a formalin room, in which brains and lungs were kept and tissue was stored.
Originally the autopsy conference room was across the hallway from the photography laboratory. Th e conference room had viewing boxes for the radiologist on rotation and seats for approximately 20 individuals. Th e conference room was converted to an expanded photography laboratory around 1980, and the conference room was moved across the hallway.
Th e autopsy dissecting room in the Warren
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Building was relatively unchanged from 1956 to 2005, at which time an extensive renovation was accomplished (fi gure 15.9). Th e main dissecting room now has two L-shaped dissecting tables and operating room lights (fi gure 15.10). Th e southern one-third of the dissecting room (toward Cam- bridge Street) was walled off and used to create a new conference room. Th is conference room uses the same trapezoidal metal tables that were used for decades in the earlier conference rooms. A large, curtained window separates the new conference room from the dissecting room to permit observation of autopsies without the necessity of dressing for universal precaution. Th ere is a bath- room with shower on the corridor leading from the main hospital corner to the dissecting room. Access to the autopsy area now requires an electronic pass.
Figure 15.8 Autopsy room, as it appeared from the 1950s through 2005 (photograph ca. 2000)
Figure 15.9 Formal opening of the renovated autopsy suite in 2008; Eugene Mark is holding volume 1 of the
autopsy reports. In the background is Mindy Hull, a resident who went on to a career as a medical
examiner in Boston.
198
Handling of Bodies
Since the Jackson era, interactions between funeral directors and the hospital have proven variously cordial, neutral, or testy, and a few local funeral directors have come to be well known to the dieners. Th e delivery of bodies for many decades took place through a garage backing onto Allen Street. After the construction of the Warren Building, the hearse entrance for undertakers was in that structure, in a garage below street level, off Blossom Street, with parking for two vehicles. A tunnel connected the garage to the autopsy suite and allowed transport of bodies from the morgue to the hearse. (Dr. Castleman, and only Dr. Castleman, had permission to park his own car in this garage!) With new hospital construction, the delivery of bodies switched to an area at the basement level of the Phillips Building (now Founders House). Th is provided convenient,
direct access from the morgue to the hearse. In 2006 this route was closed because of new construction, and now bodies are transported along the basement corridor of the Warren Building through a private and inconspicuous door that opens onto Charles Street.
Under Dr. Mark’s direction, the department has just begun a collaborative study with the Radi- ology Department to perform whole-body high- resolution CT scans. Th e results of the CT scans will be available during or immediately after the dissection, so that further analysis of the tissues can be performed at that time to elucidate unex- plained lesions on the CT scan. Such CT scans, which have been termed “virtopsies,” may in the future supplement some aspects of the autopsy.
Th e morgue has been virtually unchanged since the Warren Building opened. But today’s Autopsy Service is involved in planning for mass disaster. Th e morgue can handle approximately
Figure 15.10 Th e new autopsy suite during renovations, 2006
The Autopsy Service
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10 stretchers, but provisions have recently been made to store more bodies in a mass casualty situation. Th ere are also arrangements for refrig- erated trucks to supplement the morgue in the event of mass casualties.
Th e number of autopsy technicians has varied from fi ve to one. Th e hospital has been fortunate to have recruited exceptionally dedicated individuals to the position of Chief Autopsy Techni- cian (“Chief Diener”). In this regard, it is notable that only fi ve Chief Autopsy Technicians have essentially covered an era of more than 50 years (table 1). Th e duties of the autopsy technician have been melded to some degree with those of pathology assistants and technicians on the Sur- gical Pathology Service. During the years of the Second World War, the work of a diener was performed by conscientious objectors.
Table 1. Chief Autopsy Technicians (“Chief Diener”)
Pre-1960s “Jake the Diener” (name, unfortunately, unknown)
1960s–1970s Walter Havey
1970s–1980s Joseph Stukas
Handling of Specimens
Gross photographs of the organs from the autopsy had been taken in the pathology photography room, across the hallway from the autopsy room, through the 1950s into the 1980s. In the 1990s a photography station was put into place in the autopsy conference room so that organs need not leave the autopsy suite. Th is was an improvement logistically and for infection control. Film for gross photographs was the standard until approximately 2005, when digital photography became the standard.
Apart from the fact that tissues were fi xed in formalin and embedded in paraffi n, details of preservation of specimens before the 1940s are not available. Specimens would be shown at
clinicopathological conferences in the 1920s, and a few specimens would be preserved for museum exhibition. Pediatric hearts would be kept as wax models. Lungs would be cut into Gough sections and mounted between 8 x 11–inch pieces of plas- tic. Some slides and blocks have remained from the early 1900s, but movement of specimens among storage facilities and the expense and legal issues of retaining specimens brought about less storage and for shorter periods.
During the Castleman era, all specimens were available for presentation at the morning conference, even if not shown. Both lungs were routinely infl ated with formalin. Most other specimens were kept in an unfi xed state for a limited time. Th ere were few concerns about universal precautions for infections other than for tuberculosis. Since the mid-1990s, almost all tissue in formalin is discarded after one year.
Th e numbers of blocks taken per case has varied widely. A standard for many years in the 1960s and 1970s was a minimum of six blocks of tissue (heart, lung, liver, spleen, kidney, adrenal). Th is aspect of the service has changed over the years, and in the 1990s and 2000s an average of 20 blocks of tissue has been examined histologically on each case. Additional preservation of tissue is accomplished through various research projects with the appropriate institutional approval.
Th e Autopsy Service functioned seven days a week through the last half of the twentieth century. Almost no other hospitals perform autopsies on Sundays, and in 2006 the service stopped that practice. Th ere has always been provision for emergency autopsies at any time to obtain fresh or frozen tissue vital for research studies and, rarely, for clinical management of next of kin in cases of infectious disease.
Over the years, increasing interest by the general public in the autopsy has generated concern about permission for autopsies as well as preservation and disposal of tissue. Although such concerns have been present at the MGH since the 1830s, a new era began in the 1980s, when
200
retention of organs in Britain and to a lesser extent in the United States prompted litiga- tion about such retention when the next of kin were unaware of it. At the MGH the terms for autopsy permission were changed; a family had three choices: unrestricted autopsy; restrictions dictated by the next of kin; organs to be returned to body with only tissue samples retained. Th e third choice has been increasingly frequent and has prevented additional sampling when further questions arise in the days immediately after the autopsy.
Autopsies for Other Hospitals
Th e adjacent Massachusetts Eye and Ear Infi r- mary (MEEI) is well known for surgery of the middle and inner ear, and this expertise is based in part on decades of clinicopathological correlation by Dr. Hale Trunic and his colleagues. Th e collaboration benefi ted from the MGH Autopsy Service, since patients who had an examination of the brain might also have the removal of the middle and inner ear using a customized circular saw, and these specimens were handled by special decalcifi cation procedures at MEEI. Th e procurement, processing, and study of human temporal bones constitute a time-consuming and costly endeavor that lies outside the purview of most pathology departments and is therefore performed in laboratories devoted to the study of the temporal bone. Th e Otopathology Labo- ratory at MEEI was established by Dr. Harold F. Schuknecht in 1961, when he was recruited as Chairman of the Department of Otology and Laryngology at HMS and Chief of Otolaryngol- ogy at MEEI. Th e research in the laboratory has led to improvement in understanding cochlear anatomy, biology of the spiral ligament, genetic deafness, developmental defects of the ear, and the molecular basis of otosclerosis.
Th e Autopsy Service has also interacted with the MEEI Eye Pathology Service. Deceased patients with ophthalmic diseases, particularly tumors, have had eyes removed and examined at
the time of the general autopsy. A primary con- sultant for many years in eye pathology was Dr. Walter Putschar, who among other interests had a strong understanding of ophthalmic anatomy and pathology from work he had performed in his student days in Germany. He stated that he had become interested in pathology of the eye because no one else had been interested and it appeared that the opportunities for original investigation were great.
Over the years the MGH has assisted both community hospitals and government hospitals that have needed coverage for autopsies. Dr. Castleman had colleagues in many hospitals in the Boston area and reached out to provide both autopsy and surgical pathology services. Massachusetts hospitals that availed themselves of MGH’s service included Emerson Hospital in Concord; Brockton Hospital in Brockton; Chelsea Soldier’s Home in Chelsea; Dever State School in Wrentham; Fernald State School in Waltham; and McLean Hospital in Belmont. Th e Dever, Fernald, and McLean sites were hospitals mostly for nervous system diseases, but in almost all cases a full general autopsy was performed. Th ese prosections would usually be performed at the hospital by a resident without attendant staff or diener. Th e general pathology resident and neuropathology resident would travel by taxi, perform the autopsy in the morgue while the taxi waited, and return with the organs. Transporting the organs in large cases sometimes caused anxiety on the part of the taxi driver. Th e residents would carry their large, square cases through the main lobby of the White Building, no doubt puzzling onlookers. (A vivid and entertaining story of a winter taxi trip to Brockton Hospital to perform an autopsy is provided by Dr. Fairfi eld Goodale in his autobiography [13].)Th e organs would be presented to Dr. Castleman and his associates at the next morning conference. Slides and report would be prepared in the normal manner and become an offi cial MGH case.
Th e residents going to these distant hospitals
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would receive a small honorarium, usually about $25, for the extra work involved in travel and time away from the department. When the senior author of this chapter returned from the Fernald School and presented a case the following morning in which the only fi nding was mod- est coronary artery disease, Dr. Castleman turned to him and said, “Is that all you have to show?” Dr. Mark replied, in a manner intended to be humorous, “What do you expect for $25?” Dr. Castleman was surprised and silent. He was not a person to carry a grudge or even hard feelings, but Dr. Mark has always been sorry for that fl ip- pant comment.
More recently, as morgues in community hospitals have closed, contracts have been established to perform autopsies for hospitals in eastern Mas- sachusetts. Th ese have included Newton-Welles- ley Hospital in Wellesley; North Shore Medi- cal Center in Salem; Caritas Good Samaritan Hospital in Brockton; Lowell General Hospital in Lowell; and Youville Hospital in Cambridge. Th e Pathology group at Cambridge Hospital (Cambridge Health Alliance) is closely related to MGH Pathology, and the Cambridge autopsies are done at MGH by pathologists whose primary appointment is at Cambridge Hospital.
Dr. Mark performed autopsies for the Depart- ment of the Army while on active duty in Germany in the early 1970s, then in the 1980s and 1990s at the Cutler Army Hospital at Fort Devens, Massa- chusetts, before Fort Devens closed. Th e department also occasionally performs private autopsies for families and for other HMS hospitals upon request and consults on histopathologic fi ndings on autopsies performed elsewhere, such as those by the Offi ce of the Chief Medical Examiner for the Commonwealth of Massachusetts.
Forensic Autopsies and Relation to the Office of the
Chief Medical Examiner
Th e position of Medical Examiner was created in Massachusetts in 1877 to replace the coroner
system. Th e successful eff ort to replace coroners with medical examiners had been driven by the Massachusetts Bar Association and the Massa- chusetts Medical Society, both of which were in agreement that the physician looking into the cause of death must be removed from involve- ment in possible criminal investigation and the lodging of charges. Th e Suff olk County Southern District Medical Examiner was initially based at Boston City Hospital. In 1913 a second fl oor was added to the original building, and the Medical Examiner’s quarters remained there for many years. Th at location was considered benefi cial in part because of Dr. Frank Mallory and the coop- erative and progressive nature of the Boston City Hospital Pathology Department. After being in the Mallory Building at Boston City Hospital for two decades, the Medical Examiner’s Offi ce was relocated in 1995 a few hundred yards north and east to 720 Albany Street, adjacent to Boston Medical Center. An annex, the Suff olk County Northern District Medical Examiner’s Offi ce, was for many years on Allen Street, adjacent to the MGH.
Th e Offi ce of the Chief Medical Examiner (OCME) for the Commonwealth of Massachu- setts was established by legislation in 1983. Th e OCME and its forerunners have maintained a relationship with MGH for many years, and Dr. Oscar Richardson (chapter 3) served as Associ- ate Medical Examiner for Suff olk County from 1913 to 1921. Th e closest continuous relationship with the OCME was with Dr. Leonard Atkins (chapter 16). Dr. Atkins, who was a board-certifi ed medical examiner and had an important role in autopsy pathology and cytogenetics at MGH, performed so-called views without dissection and did some dissections in the department, particularly on weekends, when he took calls for the OCME. At other times a body would be taken to the Medical Examiner’s Offi ce, where he would do the autopsy. Most forensic cases were not done with the resident. Over the years, consultants in forensic pathology to the MGH Autopsy Service
202
have included Drs. George Burgess Magrath (1909–1912), William J. Brickley (1951–1959), Michael A. Luongo (1952–1960s), Victor Rosen (1950s–1980s), George Katsas (1980s–1990s), Eva Patalas (1990s), and Mindy Hull (late 2000s).
Dr. Victor Rosen was a pleasant and mild- mannered individual, who, some time after com- pleting his training at MGH, became interested in forensic pathology. He studied under the celebrated Los Angeles forensic pathologist Dr. Th omas T. Naguchi, who was a technical adviser to the popular medical-detective television drama Quincy, M.E. Dr. Rosen wrote the plots for some episodes (personal communication, Dr. Robert E. Scully).
Dr. George Katsas was another connection of the department to the OCME. He gave a series of about six lectures per year in the 1980s and 1990s to the residents. Dr. Katsas was the Chief of Pathology at Waltham Hospital and also a board-certifi ed medical examiner. He loved the analytic aspects of forensics and lectured at many conferences across New England and farther afi eld. In more recent years, Dr. Eva Patalas, who is currently a pathologist at Cambridge Health Alliance, performed forensic autopsies and lectured on forensic pathology at MGH.
Th e OCME occasionally calls on specialists at MGH for expert autopsy opinions, particularly in obstetrical cases and pneumonias. For the last few years, Dr. E. Tessa Hedley-Whyte has done brain-cutting sessions at the OCME.
Conclusion
Th e autopsy has a history longer than any other facet of pathology. Th is history provides a valuable insight into the continuity of medical knowledge and laboratory science and a beacon for future development in understanding human disease—whether for quality assurance, clinicopathological correlation, development of new surgical techniques or devices, instruction for all levels of training and disciplines of medicine, and
molecular medicine. Important clinicopathological correlations from the MGH Autopsy Service include appendicitis (6), the radiographic pre- sentations of pulmonary infarcts (14), and organizing pneumonia (15). And, as documented recently (16), the autopsy has served as a basis of knowledge for the hundreds of residents in training who have passed through the department since the 1930s. Over the space of approximately 175 years and with more than 50,000 recorded autopsies, the MGH Autopsy Service has con- tributed to the advancement of knowledge both for MGH patients and staff and for the medical community worldwide.
References
1. Oxford English Dictionary, 2nd ed. Oxford: Oxford University Press, 1989.
2. Records of the Medical Board of Massachusetts General Hospital, vol. 1, Autopsies, June 30, 1848.
3. Letter of Nathaniel Bowditch, July 10, 1850, MGH Archives.
4. MGH archives, unsigned documents. 5. Letter of R. H. Fitz, February 17, 1894, MGH
Archives. 6. Fitz RH. Perforating infl ammation of the vermi-
form appendix. With special reference to its early diagnosis and treatment. Trans Assoc Am Phys 1:107–144, 1886.
7. Mallory FB, Wright JH. Pathological Technique: A Practical Manual for Workers in Pathological Histol- ogy. 3rd ed. Philadelphia: W. B. Saunders, 1904.
8. Dodds TA. Richard Cabot. Medical reformer during the Progressive Era (1890–1920). Ann Intern Med 119:417–422, 1993.
9. Cabot RC. A study of mistaken diagnoses. Based on the analysis of 1,000 autopsies and a compari- son with the clinical fi ndings. JAMA 55:1343–1350, 1910.
10. Th e Flexner Report. Carnegie Foundation Bulle- tin No. 4, 1910.
11. Aub JC et al. Management of the Cocanut Grove Burns at the Massachusetts General Hospital. Phila- delphia: J. P. Lippincott, 1943.
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12. Castleman B, Crockett DC, Sutton SB, eds. Th e Massachusetts General Hospital, 1955–1980. Boston: Little, Brown, 1983.
13. Goodale F. Th e Absolute Truth and Other Uncer- tainties: A Remembrance. Lincoln, Neb.: iUniverse Inc., 2005.
14. Hampton AO, Castleman B. Correlation of postmortem chest teleroent-genograms with autopsy fi ndings. With special reference to pulmonary
embolism and infarction. Am J Roentgenol Rad Th er 43:305–325, 1940.
15. Mallory TB, Brickley WJ. Pathology. With special reference to the pulmonary lesions. Ann Surg 117:865–884, 1943.
16. Hull MJ, Nazarian RM, Wheeler AE, Black- Schaff er WS, Mark EJ. Resident physician opinions on autopsy importance and procurement. Hum Pathol 38:342–350, 2007.
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/ENU (Use these settings to create Adobe PDF documents that are to be checked or must conform to PDF/X-1a:2001, an ISO standard for graphic content exchange. For more information on creating PDF/X-1a compliant PDF documents, please refer to the Acrobat User Guide. Created PDF documents can be opened with Acrobat and Adobe Reader 4.0 and later.) /ESP 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/ITA (Utilizzare queste impostazioni per creare documenti Adobe PDF che devono essere conformi o verificati in base a PDF/X-1a:2001, uno standard ISO per lo scambio di contenuto grafico. Per ulteriori informazioni sulla creazione di documenti PDF compatibili con PDF/X-1a, consultare la Guida dell'utente di Acrobat. 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