The Autopsy Service: the (D

Chapter  Th e Autopsy Service Eugene J. Mark and Robert H. Young

he autopsy has a long and varied history. included systems of bells to be rung from the cof- TTh e word autopsy derives from the Greek fi n of the person buried alive to call attention to and means “to see for oneself,” and its fi rst docu- the fact or, as an alternative, lying-in rooms for mented use in the English language dates to 1651 the recently deceased under observation by atten- (1), in the quotation “when by an observation, we dants until putrefaction was apparent. get a certain knowledge of things.” Th e word nec- Th is chapter describes fi ve eras of the Autopsy ropsy, meaning specifi cally a postmortem exami- Service at Massachusetts General Hospital nation, dates from 1856 (1). Examination of the (MGH): before the founding of the department, deceased for various purposes occurred in antiq- in 1896; 1896–1926, under Drs. James Homer uity, and dissection of the human body as well as Wright and Oscar Richardson; 1926–1951, during dissection of animals for divination can be traced the tenure of Dr. Tracy Mallory as chief; 1952– to as early as 3500 b.c.e. in Babylon and Egypt. 1974, during the tenure of Dr. Benjamin Castle- Anatomic dissection for instruction in anatomy man as chief; and from 1975 to the present day. goes back at least to Galen in the second century Th e chapter concludes with discussions of par- c.e. Paracelsus (d. 1590), Giovanni Maria Lancisi ticular issues relating to the Autopsy Service: the (d. 1720), and Herman Boerhaave (d. 1738) had autopsy suite, the handling of bodies and tissues, interests in the autopsy, and Giovanni Battista autopsy services provided to other hospitals, and Morgagni (d. 1771) made systematic postmortem forensic pathology. observations for clinical correlations for 60 years. Carl von Rokitansky (d. 1878) and Rudolf Vir- Autopsy at MGH before : chow (d. 1902) were pathologists who pioneered The Jackson and Fitz Years the clinical utility of the autopsy in the nineteenth Autopsy at MGH can be traced to as early as 1835. century, and their names persist to identify the MGH was the only hospital of Harvard Medical two principal modes of dissection, the Rokitan- School (HMS) when the university Department sky dissection, in which organs are removed en of Pathology was offi cially established with the bloc, and the Virchow dissection whereby organs appointment of Dr. John Barnard Swett Jackson are removed individually. Manipulation of the in 1847 as Professor of Pathological Anatomy and deceased body by various mechanical means Curator of the Warren Anatomic Museum (chap- to prove death and prevent premature burial ter 1). Pathology at that time was in the hands of appeared as advertisements in the popular press clinicians, and the subject was not required for in the eighteenth and nineteenth centuries; these a medical degree until 1856. HMS was the fi rst

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North American medical school to teach pathol- for autopsy were debated over the years. Dr. N. J. ogy as a special course. Pathology in the mid- Bowditch noted, “It is highly important to the nineteenth century revolved around the autopsy, cause of science that such examination should and surgical pathology did not come of age until take place whenever it is practicable, but that the late nineteenth century, as evidenced by the they should never be performed contrary to the professorship endowed by George Cheyne Shat- known wishes or directions of the friends or fam- tuck that was entitled the Shattuck Professorship ily of a patient and should naturally be commu- of Morbid Anatomy in 1854; the title was not nicated to the superintendent of the hospital” (3). renamed the Shattuck Professorship of Patholog- On the other hand, the President and Directors ical Anatomy until 25 years later, in 1879. of the hospital had allowed postmortem examina- Dr. Jackson studied in Europe and practiced tion at times without consent or even knowledge general medicine for his entire career, but his of the family, and the benefi ts and challenges of chief interest was in pathological anatomy. His this circumstance were reported. On the positive fame rests in large part on his work as a curator side was the fact that the distressed family would for the Boston Society for Medical Improvement, not be troubled by a request to allow the autopsy. where he developed a museum that ultimately On the negative side was the family’s potential was given to HMS under the name of the Jack- discovery of an autopsy having been performed son Cabinet and placed in the Warren Anatomi- without their knowledge. Th e Coroner’s Offi ce cal Museum. Th is museum was housed for many had the authority to perform autopsies without decades in Building A of HMS; it now resides in permission from the next of kin, and this was the top fl oors of the Countway Library at HMS. said to factor into the development of MGH In 1847 Dr. Jackson published a descriptive cata- policies (4). logue of the Museum of the Society of Medical Th e role of the MGH superintendent in ob- Improvement and, in 1870, a similar catalogue of taining autopsies was described in a somewhat the Warren Museum. confl icted manner: From 1835 to 1850 much discussion at the Th e hardy cooperation of the superintendent— MGH about autopsies centered on who should he should be relieved of all responsibility—in perform them and when. As the records of the case of diffi culty—should be encouraged by the Medical Board of Massachusetts General Hospi- trustees to secure as many as possible—under tal relate, in 1835 a committee of MGH Trust- existing laws. He should be relieved, as far as ees appointed an offi cer whose duties included possible, from the necessity of asking for permis- admission of patients as well as obligations and sion from friends (of the deceased). Th ey usually duties assigned him by the hospital’s physicians object—are more likely to if approached with- and surgeons (2). One such duty was supervision out great tact, and often much time is required of examinations of the deceased. Dr. Jackson to explain the circumstances of the cases—even considered himself a “free agent,” authorized to with all willingness and enthusiasm on the part perform the examination in the manner and to of the superintendent he may be away when the the extent that he judged right. Nevertheless, the relatives come for the interview. (4) records state that he considered the wishes of the physicians regarding the time and circumstances At one point it was noted that the superinten- of the autopsy. He examined all the chief organs dent “was interested in procuring them—and by and stated that no autopsy would be complete this tact, and with zeal procured many—I am not without a thorough examination. aware that the hospital incurred any loss thereby.” Th e timing of the autopsy and the permission Th e superintendent was instructed to secure as

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many autopsies as possible. Furthermore, the Pathology and continued in this position until instruction was “to order an autopsy on all bod- 1892, when he was named Professor of the Th e- ies (with rare exceptions to take place 12 hours ory and Practice of Physick. Much of Dr. Fitz’s after death)—and refuse to deliver bodies, except seminal work in acute appendicitis and acute in rare instances . . . and should be relieved from pancreatitis was based on his autopsy experience asking permission—but should order the autopsy. at the MGH. In his classic work on perforating . . . Another suggestion was that there was no way infl ammation of the vermiform appendix (6), to obtain autopsies, except—were it expedient to Dr. Fitz described his experience on postmortem do so—to have as a regulation of the hospital examinations of appendicitis cases at the MGH, that all persons dying in the institution shall be including correlations of the pathological fi nd- submitted to postmortem examination” (4). Th e ings with the duration, location, and intensity of opposite feeling was also expressed: “No autopsy symptoms. He described 257 cases, although it shall be had within 12 hours after such notice is not clear that all these patients had autopsies. (of death) shall have been sent, unless with the He described the peritoneal pathology in patients expressed consent of the family or friends of such with peritonitis and contrasted the acute fatal deceased patient, and that no autopsy shall be cases with the chronic cases. had in any case where it shall have been expressly Dr. Fitz was succeeded as the Chair of HMS prohibited by the deceased patient or by his fam- Pathology by Dr. William T. Councilman, who ily or friends” (4). Over time the concerns about had received his M.D. degree at the University disclosure became increasingly apparent, and by of Maryland, had worked under Professors Hans the 1890s autopsies generally were not performed Chiari in Vienna, Julius Cohnheim and Carl Wei- without permission. By hospital directive and by gert in Leipzig, and Friedrich von Recklinghau- statute, that policy stands today. sen in Strasbourg, and had been on the faculty at From early times, the rate of autopsies at the Johns Hopkins University. Dr. Councilman felt MGH was of concern. Comparisons were made strongly that the MGH should acquire a building between the MGH and other academic institu- for pathology and engage a full-time pathologist, tions, including the University of Pennsylvania and he recommended Dr. James Homer Wright, in Philadelphia and Columbia University in New one of his trainees, for the position. York City. A letter on the matter at the time reads Additional evidence that autopsies constituted in part: “For several years previous to 1876 the an important part of the work of the department annual ratio of autopsies to death at the Massa- is provided in the 1904 third edition of Pathologi- chusetts General Hospital was between 48 and cal Technique by Dr. Wright and Dr. Frank Burr 56, in 1876 the ratio was 55, but since the per- Mallory (another of Dr. Councilman’s trainees) centage has rapidly fallen off , being 41 in 1877, (7). Th e book was divided into three parts, the 38 in 1878, 20 in 1879 and 21 in 1880.” Th e fi rst of which (52 pages of approximately 400 subject of more autopsies was vigorously debated total) was devoted specifi cally to the autopsy, in 1881 and again in 1886, but at neither time was including illustrations of instruments, lines of any real advance made (5). It was added that “the dissection of the heart and lungs, and recom- hospital records would be rendered incomplete mended contents for a travel bag for patholo- (without an autopsy), and the world at large gists performing autopsies in private homes. Th e would often lose the benefi ts to be derived from other two parts, on bacteriology and histology, the valuable observations of the hospital staff .” were also geared as much to autopsy pathology In 1879 Dr. R. H. Fitz (chapter 2), who had as to surgical pathology, as shown by the types of been trained by Virchow, became head of HMS specimens described.

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The Wright and Richardson the spleen and a caseous lymph gland were cul- Years, – tured into a guinea pig. Seventeen days later the guinea pig was “found gasping.” Th e autopsy of Th e fi rst MGH autopsy for which detailed records the guinea pig showed tubercle bacilli on smears still exist at MGH was performed in Octo- of necrotic lymphoid tissue. ber 1896, the month Dr. James Homer Wright Th e early bound volumes of autopsy reports became Chief of Pathology. Some excerpts of the have a title page identifying the pathologists report are noteworthy for showing the striking involved with the cases. Not all the cases are similarity of the earliest autopsy report to mod- signed individually. Th e fi rst bound volume ern reports. It begins with an external exami- (fi gure 15.1) comprises 50 cases, which were per- nation: the patient was an adult male of “good formed over an interval of three and one-half height, slender frame and slight musculature months. Th e autopsy reports are entirely in ink, development.” Th ere follows a gross description in fl owing script, for the fi rst four years. Begin- of the organs, concentrating on the lungs. Th is ning in June 1899, at autopsy number 400, typed is followed by the six anatomic diagnoses, three entries become interposed with handwritten of which are tuberculous (acute miliary tuber- ones. By the following year, script disappears and culosis, chronic tuberculosis of several lymph the reports are entirely typewritten. Each report nodes groups, chronic localized tuberculosis of runs between 10 and 20 pages. No clinical his- the lung) and three of which are probably due to tory was provided unless it could be deduced tuberculosis (ascites, pleuritis, and miliary abscess from the external examination. Th e postmortem of the kidneys). Sections from a necrotic area of 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) Figure 15.1 Th e fi rst volume of Records of Autopsies, 1–50, 1896 and 1897. appears in autopsy num- Spine (left), title page (center), inscribed with the names of James H. Wright and ber 110 (June 18, 1897), Oscar Richardson, and the fi rst page of the fi rst report (right) in a young woman with

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Figure 15.2 First photomicrograph in the autopsy records, 1897, showing inﬁ ltrating adenocarcinoma of the appendix

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 Figure 15.3 First hand drawing in the autopsy records, the liver with extension through the diaphragm 1897, showing four fractures of the atlas and a fracture of the odontoid process 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 4,200 autopsies. Other assistants participating on cause of death was fracture of the atlas: the atlas the Autopsy Service after this time included Drs. fracture sites are illustrated. A gross photograph William A. Hinton and George A. Buckley. Dr. with fi ne detail (fi gure 15.4) appears in autopsy Hinton went on to an illustrious career at HMS, number 903 (July 25, 1903), of a fracture of ver- developing the widely adopted Hinton test for tebrae C3 and C4 with compression of the spi- syphilis (chapter 3), and was the fi rst African nal cord after a diving accident in a 19-year-old American professor at HMS. patient. Autopsy reports throughout this era were At the conclusion of the fi rst 10 years of the replete with various forms of tuberculosis. Autopsy Service, 1,849 autopsies had been per- Among the 200 cases performed in 1906 and formed by Dr. Wright and his assistant, Dr. 1907 were 69 cases of tuberculosis, including 6 Oscar Richardson, who continued to be the two cases of miliary tuberculosis, 3 cases of tubercu- pathologists performing most of the autopsies losis of the spine, 5 cases of disseminated tuber- over the fi rst two decades of Dr. Wright’s tenure. culosis, and 2 cases of tuberculosis of the adrenal Demonstrations of dissection took place in an gland. Syphilitic aortitis with fatal aortic insuf- amphitheater in the Allen Street Building (fi g- fi ciency and congenital syphilis were well recog- ure 15.5). By April 1921 the pair had performed nized. In 1916 and 1917 alone, there were 9 cases

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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 Figure 15.4 Gross photograph in the autopsy records, Cabot (8; chapter 24), who had promoted the 1900, of a vertebral spine bisected with C3 and C4 notion of the modern hospital as a bedside labo- fracture and a spinal cord compression ratory and honed his skills in the laboratory to

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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

become one of the most respected clinicians in or three house offi cers at any one time. Th e ana- the hospital, issued a report that year that was tomic diagnoses appeared on the fi rst page of the based on approximately 1,000 autopsies per- report rather than toward the end, as had been formed at the MGH (9) (see fi gure 3.8). Th e the practice previously. A more detailed clinical report revealed conspicuous diagnostic inaccura- history became part of the report, as did the clini- cies on the part of clinicians and reinforced the cal diagnoses and the death report. Postoperative infl uential Flexner Report of 1910 (10), which cases accounted for a signifi cant number of the documented the need for greater scientifi c input cases, including orthopedic, gynecologic, and in medical education and a heightened role for neurologic, as well as breast surgery. Coronary universities in medicine. artery disease became more frequent than it had been in earlier decades, rheumatic heart disease The Mallory Years, –, and continued, glomerulonephritis was an occasional the Cocoanut Grove Fire of  cause of death, and cervical carcinoma was regu- During the tenure of Dr. Tracy B. Mallory from larly observed. When Dr. Charles Kubik became 1926 to 1951, the pathologists signing out autop- the fi rst neuropathologist on the Autopsy Ser- sies included, in addition to Dr. Mallory, Drs. vice, the number of neuropathological diagnoses Benjamin Castleman, Winfi eld S. Morgan, Ron- increased, particularly with regard to gliomas. ald Sniff en, and Edward A. Gall, as well as two An insight into the function of the Autopsy

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Service in those years is provided by the Cocoa- entire neck and face bloated, carbon monoxide nut Grove disaster (11; chapter 22). Th e fi re was 42 percent saturation. widely covered in the press, the MGH was gal- Autopsy 10617-C was performed by Benjamin vanized into unifi ed action for therapy of these Castleman. Diagnoses were third-degree burns patients, and new insights into the physiology of of both scapular and right thigh and extensive burns came from the Autopsy Service as well as second-degree and fi rst-degree burns as well. Dr. the Medical and Surgical Services. Th e Cocoanut Castleman commented that this was the only one Grove was a one-story nightclub with low ceilings of fi ve cases dying within seventy-two hours of and infl ammable hangings in the Bay Village sec- the catastrophe that showed defi nite broncho- tion of Boston, near Park Square. On the evening pneumonia. A note was made that the patient of November 28, 1942, the club was fi lled with an became unconscious while attempting to escape overcapacity Saturday night crowd of people. A from the Cocoanut Grove fi re, was received on fi re started in the lounge and resulted in panic. the operating fl oor at 2:00 a.m., where Vaseline Th ere was great loss of life, both immediate and strips were placed on face and hands and triple delayed. Between 10:30 p.m. and 12:45 a.m. 114 dye on the legs. Th e patient received antibiotics casualties were received in the MGH emergency and morphine but died at 5:35 p.m. room, of whom 75 were either dead on arrival or Autopsy 10618, performed by Drs. E. D. died shortly thereafter. Churchill and Shields Warren, was a 46-year-old Six autopsies were performed either at the white man with fi rst-, second-, and third-degree MGH or at the Northern Mortuary of Suff olk burns of the head, face, neck, and hands and County, which was part of the Medical Exam- membranous laryngitis and tracheitis and bron- iner’s Offi ce (see below) and adjacent to the hos- chitis. Th e patient was extremely hyperactive on pital. Th e six cases were examined personally by arrival at the hospital with respiratory embarrass- Tracy B. Mallory and the Chief Medical Exam- ment requiring intermittent oxygen, impend- iner, William J. Brickley. Th ree of the patients ing shock, and cherry-red color of denuded sur- were dead on arrival, and three died after varying faces, estimated total third-degree burn 80 per- but comparatively brief periods (40 to 62 hours) cent, with inhalation burns and corneal burns. of treatment. Standard autopsy protocol was He received fi ve units of plasma on day one; his followed. Notable in some cases was brilliant, blood pressure remained normal for a short time, cherry red discoloration of skin and muscles due but then he died. (Dr. Churchill was a senior sur- to carbon monoxide poisoning. Histologic fi nd- geon at MGH, and Dr. Shields Warren was later ings not specifi cally attributed to thermal burns to become Professor of Pathology and Chief of in the extant English literature included hem- Pathology at New England Deaconess Hospital, orrhagic tracheitis and bronchitis, pulmonary but it is unclear how he became involved with hemorrhage, and lakes of serum between the this single case.) epithelium and basement membrane of the skin Autopsy 10620, performed on December 1, with spontaneous detachment of the epithe- 1942, was a 29-year-old, powerfully built young lium. Th e clinical and pathological descriptions man with second- and third-degree burns of the of these autopsies are particularly vivid and serve face, scalp, hands, and ankles and laryngeal ste- as fi ne examples of descriptive medical writing. nosis. On arrival he was maniacal and uncontrol- Some examples are given here in paraphrased lable and vomiting with evidence of smoke inha- form. lation. He was treated with paraldehyde and died Autopsy 10617-B was described as a terribly early on the third day of hospitalization. burned young woman estimated to be about 25 Th e deaths from the Cocoanut Grove fi re were years of age, hair singed and burnt to stubble, 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 typically ran the conference seated at the head of that, any fatal complications that arose from the a circular metal table, with Dr. Walter Putschar confl agration were not specifi cally linked to the (chapter 12) to his immediate left and the staff fi re in the autopsy records. Still, these autopsies pathologist signing the cases out for that week were important in understanding the cutane- to Dr. Putschar’s left. Th e attending pathologists ous and pulmonary eff ects of thermal injury, as would rotate on a weekly basis and included the well as the indirect damage to other organs from majority of the staff pathologists, both surgical hypoxia and infection, and thus formed a base- and research, as well as chief residents or qualifi ed line for study by later physicians. senior residents who might have the privilege to sign out autopsies for the week. Upon Dr. Castle- The Castleman Years, – man’s departure from the conference at 9:15 or in When Benjamin Castleman became Chief of his absence, Dr. Putschar would move into Dr. Pathology in 1952, his strong interest in the Castleman’s chair and unhurriedly complete the autopsy was readily evident. Th e department conference. If other staff were called on to com- work would begin every weekday with his direct- plete the conference, they would generally remain ing the autopsy conference, sometimes referred to in the place in which they were already seated. as the “organ recital,” from 8:15 to 9:15 a.m. pre- Every case was presented by the prosector, and cisely. Woe to the resident who did not fi nish the X-rays were usually shown by a radiology resident presentation by 9:15, because at 9:15 Dr. Castle- on rotation. Dr. Castleman would make observa- man would rise from his chair without hesita- tions (fi gure 15.6) and only occasionally ask for tion and ascend the two fl ights to his offi ce. He 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. Staff pathologists with a special interest and Castleman had some favorite questions, such as expertise in autopsy pathology in the Castle- whether the parathyroid glands were enlarged, man era included Dr. Jónas Hallgrímmson, who whether the chordae tendinae were thickened, became Professor and Chief of Pathology at the and whether there was thrombus in the atrial University of Iceland; Dr. Kilmer McCully, who appendages. He might probe for a patent fora- became Chief of Pathology at the West Roxbury men ovale, while the prosector prayed that Dr. Veterans Administration Hospital, West Rox- Castleman did not discover one that the resident bury, Massachusetts; Dr. William Th urlbeck, had not found. who became Professor fi rst at McGill University Dr. Castleman described the conference as fol- in Montreal, then at the University of Winnipeg, lows: “Th e entire staff meets every morning at and then at the University of British Columbia, 8:15 and for up to one hour, I personally check Vancouver; Dr. Harold Dvorak, who became all the gross material of the autopsies of the day a Professor at HMS and Chair of Pathology at before. Th is is a very popular exercise and almost Beth Israel Hospital in Boston; Dr. John Blenner- every morning various members of the clinical hasset, who became a Professor and Chair of staff , both house and members of the visiting Pathology at Otago Medical School, Dunedin, staff , appear to take part when their case is com- New Zealand; Dr. Robert Fienberg, who was ing up” (12). In 1956, Dr. Castleman instituted Chief of Pathology at Beverly Hospital, Beverly, the post-sophomore fellowship, and during their Massachusetts, for approximately 40 years; Drs. year in the department, students from HMS Robert Harper, Lewis James, and James Gib- rotated on the Autopsy Service as an important son, a triumvirate who were the heart and soul part of their training. of Memorial Hospital in Worcester, Massachu- During the 1950s the rate of autopsies at the setts, for decades; and Drs. Alan L. Schiller and MGH declined from about 60 to 50 percent of Eugene J. Mark (see below). patients who had died at the hospital. Compa- During this period the bound volumes of rable teaching hospitals had autopsy rates that autopsy reports that had been used for the Case declined from about 20 to 10 percent. Dr. Castle- Records of the MGH (chapter 24) included the man commented on this trend: printed pages of the New England Journal of Med- icine for that case. By 1960 staff members were Explanations that had been off ered for this no longer listed on the fi rst page of the bound phenomenon include the removal of the require- volumes. In this era autopsy diagnoses were given ment by the hospital accrediting agencies for a a coding number for retrieval. Th e database for specifi ed percentage of consents for autopsies, retrieval of the diagnoses was a collection of index the belief that major advances in clinical diagnos- cards on a Rolodex, which resided in a sign-out tic techniques have rendered autopsies unneces- booth in the residents’ laboratory. sary, fear of information being uncovered that might be damaging in malpractice suits, and a The Recent Years,  decline in emphasis on the teaching of pathology to the Present Day in medical schools. Nevertheless, I believe autop- Th e tradition of the morning autopsy conference sies continue to provide important information as the fi rst item of business for the day changed in the quality of patient care, including fi ndings over the next decade, shifting to two afternoons a that are useful in the evaluation of eff ectiveness week, then to one afternoon a week, then to once and hazards of new forms of therapy. In addi- a week at noon. Th is refl ected both a decline tion, autopsies are necessary for the training of in the number of autopsies and less interest on pathology residents. (12)

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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 dis- Figure 15.7 Walter Putschar dissecting emphysematous secting room, even though he rarely was formally lungs at demonstration for new residents, ca. 1985 responsible for signing out cases. He took it upon himself to give a demonstration of an autopsy for conferences; attendees no longer sat around a the incoming house staff and took pride in show- table but stood and used a hand lens as the organs ing how an autopsy could be done in as clean a were passed around on small trays. He made the manner as possible (fi gure 15.7). autopsy conference more interactive by adopting When Dr. Castleman stepped down as chief, a Socratic method, asking for descriptions and the duties of directing the Autopsy Service were diff erential diagnoses of the gross pathology by taken by Dr. Alan L. Schiller (see fi gures 13.1 the resident, an approach that resembled the sur- and 13.2). Dr. Schiller’s primary interest in surgical pathology conference at that time. gical pathology was orthopedic pathology, and Dr. Schiller served a second term as head of the at that time he was already a renowned expert Autopsy Service from 1978 to 1984. He was then in this fi eld. He was also a superb general ana- succeeded by Dr. Frederick (“Fritz”) C. Koerner tomic pathologist and an exciting teacher, and he from 1984 to 1990. Dr. Koerner (see fi gures 13.2 wanted to spur the interests of the residents, cli- and 16.10), like Dr. Schiller, was renowned for his nicians, and medical students in the autopsy. He teaching ability. He particularly encouraged resi- ran the autopsy conference much as Dr. Castle- dents and staff to contribute their observations man had. at the conference. He would present cases as After several years Dr. Schiller wished to spend unknowns before providing any clinical history. more time on his work in bone and soft tissue, Dr. Koerner eventually wished to devote more and Dr. Eugene Mark, who was interested in time to surgical pathology, and he went on at pulmonary pathology, was appointed Director the MGH to become an internationally known of the Autopsy Service. Since much of pulmo- expert in breast pathology. nary disease at that time was heavily dependent Dr. James Southern was director from 1990 to on gross pathology, particularly chronic obstruc- 1996. Southern’s expertise was cardiac pathology, tive pulmonary diseases, the combination of pul- and his abilities to combine autopsy pathology monary pathology and autopsy pathology was and cardiac pathology proved fruitful. He was an practical. Dr. Mark changed the structure of the expert in the fi eld of congenital anomalies of the

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heart. Together with Dr. Th omas Aretz, another The Autopsy Suite: cardiac pathologist, and later Dr. Stuart Houser, The Physical Plant a cardiac surgeon who retired early to pursue a Th e Allen Street House, on Allen Street (now second career in pathology, he championed post- Blossom Street), was on the hospital side of Allen mortem injection studies of the coronary artery Street, just west of the western end of the Bul- system to correlate atherosclerotic lesions with fi nch Building. In 1920 building numbers 56, 57, myocardial infarcts and study the successes and 58, and 59 on Allen Street behind the hospital failures of coronary artery bypass surgery. were purchased, and these buildings were the site When Dr. Southern left in 1996, Dr. Eugene of the morgue and autopsy room as well as the Mark was invited to undertake a second tour of Histology Laboratory. Numbers 57 and 58, being duty as director. He declined the fi rst two invi- in poor condition, were torn down in 1937. Num- tations and fi nally accepted the third under the bers 56 and 59 were used for storage until being encouragement of Dr. Nancy Harris, who was torn down around 1952. Th e hearse entrance was at the time Director of Anatomic Pathology. Dr. attached to the Allen Street House. Th e name Mark promoted an interactive approach at the Allen Street persists today in the euphemism of autopsy conference; streamlined the autopsy “he went to Allen Street last night” (instead of protocol; stressed macroscopic analysis, using “he died last night”) and “Allen Street confer- visual, tactile (palpating the lung for consolida- ence” (instead of “mortality conference”). tion), olfactory (alcohol breakdown products), MGH Pathology moved into the newly con- and even auditory (sound of the knife scraping structed Warren building in 1956 (chapter 7). Th e the prostate in prostate cancer) senses to lead to autopsy suite occupied the majority of the base- a diagnosis; and initiated a consensus conference ment and included the dissecting room with two for autopsy pathology. He added an element of tables in the main room (fi gure 15.8) and a third drama to the autopsy conference with “CTD” table in a separate room for infectious cases. Th e (cross the table diagnosis), whereby residents morgue for holding bodies was down the hall from a distance of several feet might still be from the dissecting room. Th e diener’s offi ce was able to make the diagnosis. He stressed formal in the same area, as was the pathology photog- delivery of the clinical history, which was how raphy laboratory. Around the corner was a large surgery residents presented at Surgical Grand incinerator, which was used for incinerating both Rounds in the Bigelow Amphitheater. To aug- autopsy and surgical tissue, at that time a comment teaching, he had residents memorize short mon means of disposal of tissue. Across another stanzas from poetry that would be applicable to hallway was a formalin room, in which brains the case, to be delivered at an appropriate time and lungs were kept and tissue was stored. in the discussion (on secret signal!) to catch the Originally the autopsy conference room was audience unawares. He was a deputized Medi- across the hallway from the photography labora- cal Examiner for the Commonwealth of Massa- tory. Th e conference room had viewing boxes for chusetts and integrated forensic issues into the the radiologist on rotation and seats for approxi- autopsy conference. mately 20 individuals. Th e conference room was At the time of writing of this book, Dr. Mark converted to an expanded photography labora- has stepped down after his long second tenure as tory around 1980, and the conference room was Director. Th e new Director is Dr. James Stone, moved across the hallway. who has been head of cardiac pathology at MGH Th e autopsy dissecting room in the Warren for the past six years.

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Figure 15.8 Autopsy room, as it appeared from the 1950s through 2005 (photograph ca. 2000)

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. Figure 15.9 Formal opening of the renovated autopsy Access to the autopsy area now requires an elec- suite in 2008; Eugene Mark is holding volume 1 of the tronic pass. autopsy reports. In the background is Mindy Hull, a resident who went on to a career as a medical examiner in Boston.

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Figure 15.10 Th e new autopsy suite during renovations, 2006

direct access from the morgue to the hearse. In Handling of Bodies 2006 this route was closed because of new con- Since the Jackson era, interactions between struction, and now bodies are transported along funeral directors and the hospital have proven the basement corridor of the Warren Building variously cordial, neutral, or testy, and a few local through a private and inconspicuous door that funeral directors have come to be well known opens onto Charles Street. to the dieners. Th e delivery of bodies for many Under Dr. Mark’s direction, the department decades took place through a garage backing onto has just begun a collaborative study with the Radi- Allen Street. After the construction of the Warren ology Department to perform whole-body high- Building, the hearse entrance for undertakers was resolution CT scans. Th e results of the CT scans in that structure, in a garage below street level, will be available during or immediately after the oﬀ Blossom Street, with parking for two vehicles. dissection, so that further analysis of the tissues A tunnel connected the garage to the autopsy can be performed at that time to elucidate unex- suite and allowed transport of bodies from the plained lesions on the CT scan. Such CT scans, morgue to the hearse. (Dr. Castleman, and only which have been termed “virtopsies,” may in the Dr. Castleman, had permission to park his own future supplement some aspects of the autopsy. car in this garage!) With new hospital construc- Th e morgue has been virtually unchanged tion, the delivery of bodies switched to an area at since the Warren Building opened. But today’s the basement level of the Phillips Building (now Autopsy Service is involved in planning for mass Founders House). Th is provided convenient, disaster. Th e morgue can handle approximately

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10 stretchers, but provisions have recently been clinicopathological conferences in the 1920s, and made to store more bodies in a mass casualty a few specimens would be preserved for museum situation. Th ere are also arrangements for refrig- exhibition. Pediatric hearts would be kept as wax erated trucks to supplement the morgue in the models. Lungs would be cut into Gough sections event of mass casualties. and mounted between 8 x 11–inch pieces of plas- Th e number of autopsy technicians has varied tic. Some slides and blocks have remained from from fi ve to one. Th e hospital has been fortunate the early 1900s, but movement of specimens to have recruited exceptionally dedicated indi- among storage facilities and the expense and legal viduals to the position of Chief Autopsy Techni- issues of retaining specimens brought about less cian (“Chief Diener”). In this regard, it is notable storage and for shorter periods. that only fi ve Chief Autopsy Technicians have During the Castleman era, all specimens were essentially covered an era of more than 50 years available for presentation at the morning confer- (table 1). Th e duties of the autopsy technician ence, even if not shown. Both lungs were rou- have been melded to some degree with those of tinely infl ated with formalin. Most other speci- pathology assistants and technicians on the Sur- mens were kept in an unfi xed state for a limited gical Pathology Service. During the years of the time. Th ere were few concerns about universal Second World War, the work of a diener was per- precautions for infections other than for tuber- formed by conscientious objectors. culosis. Since the mid-1990s, almost all tissue in formalin is discarded after one year. Table 1. Chief Autopsy Technicians (“Chief Diener”) Th e numbers of blocks taken per case has var- Pre-1960s “Jake the Diener” ied widely. A standard for many years in the 1960s (name, unfortunately, unknown) and 1970s was a minimum of six blocks of tissue 1960s–1970s Walter Havey (heart, lung, liver, spleen, kidney, adrenal). Th is 1970s–1980s Joseph Stukas aspect of the service has changed over the years, 1990s Doris Dewing and in the 1990s and 2000s an average of 20 1990s–2010 James Taralli blocks of tissue has been examined histologically on each case. Additional preservation of tissue is accomplished through various research projects Handling of Specimens with the appropriate institutional approval. Gross photographs of the organs from the Th e Autopsy Service functioned seven days a autopsy had been taken in the pathology photog- week through the last half of the twentieth cen- raphy room, across the hallway from the autopsy tury. Almost no other hospitals perform autop- room, through the 1950s into the 1980s. In the sies on Sundays, and in 2006 the service stopped 1990s a photography station was put into place in that practice. Th ere has always been provision for the autopsy conference room so that organs need emergency autopsies at any time to obtain fresh not leave the autopsy suite. Th is was an improve- or frozen tissue vital for research studies and, ment logistically and for infection control. Film rarely, for clinical management of next of kin in for gross photographs was the standard until cases of infectious disease. approximately 2005, when digital photography Over the years, increasing interest by the gen- became the standard. eral public in the autopsy has generated concern Apart from the fact that tissues were fi xed in about permission for autopsies as well as pres- formalin and embedded in paraffi n, details of ervation and disposal of tissue. Although such preservation of specimens before the 1940s are concerns have been present at the MGH since not available. Specimens would be shown at the 1830s, a new era began in the 1980s, when

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retention of organs in Britain and to a lesser the time of the general autopsy. A primary con- extent in the United States prompted litiga- sultant for many years in eye pathology was Dr. tion about such retention when the next of kin Walter Putschar, who among other interests had were unaware of it. At the MGH the terms for a strong understanding of ophthalmic anatomy autopsy permission were changed; a family had and pathology from work he had performed in three choices: unrestricted autopsy; restrictions his student days in Germany. He stated that he dictated by the next of kin; organs to be returned had become interested in pathology of the eye to body with only tissue samples retained. Th e because no one else had been interested and it third choice has been increasingly frequent and appeared that the opportunities for original has prevented additional sampling when further investigation were great. questions arise in the days immediately after the Over the years the MGH has assisted both autopsy. community hospitals and government hospitals that have needed coverage for autopsies. Autopsies for Other Hospitals Dr. Castleman had colleagues in many hospitals Th e adjacent Massachusetts Eye and Ear Infi r- in the Boston area and reached out to provide mary (MEEI) is well known for surgery of the both autopsy and surgical pathology services. middle and inner ear, and this expertise is based Massachusetts hospitals that availed themselves in part on decades of clinicopathological correla- of MGH’s service included Emerson Hospital tion by Dr. Hale Trunic and his colleagues. Th e in Concord; Brockton Hospital in Brockton; collaboration benefi ted from the MGH Autopsy Chelsea Soldier’s Home in Chelsea; Dever State Service, since patients who had an examination School in Wrentham; Fernald State School in of the brain might also have the removal of the Waltham; and McLean Hospital in Belmont. Th e middle and inner ear using a customized circu- Dever, Fernald, and McLean sites were hospitals lar saw, and these specimens were handled by mostly for nervous system diseases, but in almost special decalcifi cation procedures at MEEI. Th e all cases a full general autopsy was performed. procurement, processing, and study of human Th ese prosections would usually be performed at temporal bones constitute a time-consuming the hospital by a resident without attendant staff and costly endeavor that lies outside the purview or diener. Th e general pathology resident and of most pathology departments and is therefore neuropathology resident would travel by taxi, performed in laboratories devoted to the study perform the autopsy in the morgue while the taxi of the temporal bone. Th e Otopathology Labo- waited, and return with the organs. Transporting ratory at MEEI was established by Dr. Harold the organs in large cases sometimes caused anxiety F. Schuknecht in 1961, when he was recruited as on the part of the taxi driver. Th e residents would Chairman of the Department of Otology and carry their large, square cases through the main Laryngology at HMS and Chief of Otolaryngol- lobby of the White Building, no doubt puzzling ogy at MEEI. Th e research in the laboratory has onlookers. (A vivid and entertaining story of a led to improvement in understanding cochlear winter taxi trip to Brockton Hospital to perform anatomy, biology of the spiral ligament, genetic an autopsy is provided by Dr. Fairfi eld Goodale deafness, developmental defects of the ear, and in his autobiography [13].)Th e organs would be the molecular basis of otosclerosis. presented to Dr. Castleman and his associates at Th e Autopsy Service has also interacted with the next morning conference. Slides and report the MEEI Eye Pathology Service. Deceased would be prepared in the normal manner and patients with ophthalmic diseases, particularly become an offi cial MGH case. tumors, have had eyes removed and examined at Th e residents going to these distant hospitals

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would receive a small honorarium, usually about system. Th e successful eff ort to replace coroners $25, for the extra work involved in travel and with medical examiners had been driven by the time away from the department. When the Massachusetts Bar Association and the Massa- senior author of this chapter returned from the chusetts Medical Society, both of which were in Fernald School and presented a case the follow- agreement that the physician looking into the ing morning in which the only fi nding was mod- cause of death must be removed from involve- est coronary artery disease, Dr. Castleman turned ment in possible criminal investigation and the to him and said, “Is that all you have to show?” lodging of charges. Th e Suff olk County Southern Dr. Mark replied, in a manner intended to be District Medical Examiner was initially based at humorous, “What do you expect for $25?” Dr. Boston City Hospital. In 1913 a second fl oor was Castleman was surprised and silent. He was not added to the original building, and the Medical a person to carry a grudge or even hard feelings, Examiner’s quarters remained there for many but Dr. Mark has always been sorry for that fl ip- years. Th at location was considered benefi cial in pant comment. part because of Dr. Frank Mallory and the coop- More recently, as morgues in community hos- erative and progressive nature of the Boston City pitals have closed, contracts have been established Hospital Pathology Department. After being in to perform autopsies for hospitals in eastern Mas- the Mallory Building at Boston City Hospital sachusetts. Th ese have included Newton-Welles- for two decades, the Medical Examiner’s Offi ce ley Hospital in Wellesley; North Shore Medi- was relocated in 1995 a few hundred yards north cal Center in Salem; Caritas Good Samaritan and east to 720 Albany Street, adjacent to Boston Hospital in Brockton; Lowell General Hospital Medical Center. An annex, the Suff olk County in Lowell; and Youville Hospital in Cambridge. Northern District Medical Examiner’s Offi ce, Th e Pathology group at Cambridge Hospital was for many years on Allen Street, adjacent to (Cambridge Health Alliance) is closely related to the MGH. MGH Pathology, and the Cambridge autopsies Th e Offi ce of the Chief Medical Examiner are done at MGH by pathologists whose primary (OCME) for the Commonwealth of Massachu- appointment is at Cambridge Hospital. setts was established by legislation in 1983. Th e Dr. Mark performed autopsies for the Depart- OCME and its forerunners have maintained a ment of the Army while on active duty in Germany relationship with MGH for many years, and Dr. in the early 1970s, then in the 1980s and 1990s at Oscar Richardson (chapter 3) served as Associ- the Cutler Army Hospital at Fort Devens, Massa- ate Medical Examiner for Suff olk County from chusetts, before Fort Devens closed. Th e depart- 1913 to 1921. Th e closest continuous relationship ment also occasionally performs private autopsies with the OCME was with Dr. Leonard Atkins for families and for other HMS hospitals upon (chapter 16). Dr. Atkins, who was a board-certi- request and consults on histopathologic fi ndings fi ed medical examiner and had an important role on autopsies performed elsewhere, such as those in autopsy pathology and cytogenetics at MGH, by the Offi ce of the Chief Medical Examiner for performed so-called views without dissection and the Commonwealth of Massachusetts. did some dissections in the department, particularly on weekends, when he took calls for the Forensic Autopsies and Relation OCME. At other times a body would be taken to to the Office of the the Medical Examiner’s Offi ce, where he would Chief Medical Examiner do the autopsy. Most forensic cases were not done Th e position of Medical Examiner was created with the resident. Over the years, consultants in in Massachusetts in 1877 to replace the coroner forensic pathology to the MGH Autopsy Service

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have included Drs. George Burgess Magrath molecular medicine. Important clinicopathologi- (1909–1912), William J. Brickley (1951–1959), cal correlations from the MGH Autopsy Service Michael A. Luongo (1952–1960s), Victor Rosen include appendicitis (6), the radiographic pre- (1950s–1980s), George Katsas (1980s–1990s), Eva sentations of pulmonary infarcts (14), and orga- Patalas (1990s), and Mindy Hull (late 2000s). nizing pneumonia (15). And, as documented Dr. Victor Rosen was a pleasant and mild- recently (16), the autopsy has served as a basis of mannered individual, who, some time after com- knowledge for the hundreds of residents in train- pleting his training at MGH, became interested ing who have passed through the department in forensic pathology. He studied under the since the 1930s. Over the space of approximately celebrated Los Angeles forensic pathologist Dr. 175 years and with more than 50,000 recorded Th omas T. Naguchi, who was a technical adviser autopsies, the MGH Autopsy Service has con- to the popular medical-detective television drama tributed to the advancement of knowledge both Quincy, M.E. Dr. Rosen wrote the plots for some for MGH patients and staff and for the medical episodes (personal communication, Dr. Robert community worldwide. E. Scully). Dr. George Katsas was another connection of References the department to the OCME. He gave a series of about six lectures per year in the 1980s and 1. Oxford English Dictionary, 2nd ed. Oxford: Oxford 1990s to the residents. Dr. Katsas was the Chief University Press, 1989. of Pathology at Waltham Hospital and also a 2. Records of the Medical Board of Massachusetts board-certifi ed medical examiner. He loved the General Hospital, vol. 1, Autopsies, June 30, 1848. analytic aspects of forensics and lectured at many 3. Letter of Nathaniel Bowditch, July 10, 1850, MGH conferences across New England and farther Archives. 4. MGH archives, unsigned documents. afi eld. In more recent years, Dr. Eva Patalas, who 5. Letter of R. H. Fitz, February 17, 1894, MGH is currently a pathologist at Cambridge Health Archives. Alliance, performed forensic autopsies and lec- 6. Fitz RH. Perforating infl ammation of the vermi- tured on forensic pathology at MGH. form appendix. With special reference to its early Th e OCME occasionally calls on specialists at diagnosis and treatment. Trans Assoc Am Phys MGH for expert autopsy opinions, particularly 1:107–144, 1886. in obstetrical cases and pneumonias. For the last 7. Mallory FB, Wright JH. Pathological Technique: A few years, Dr. E. Tessa Hedley-Whyte has done Practical Manual for Workers in Pathological Histol- brain-cutting sessions at the OCME. ogy. 3rd ed. Philadelphia: W. B. Saunders, 1904. 8. Dodds TA. Richard Cabot. Medical reformer dur- Conclusion ing the Progressive Era (1890–1920). Ann Intern Th e autopsy has a history longer than any other Med 119:417–422, 1993. facet of pathology. Th is history provides a valu- 9. Cabot RC. A study of mistaken diagnoses. Based on the analysis of 1,000 autopsies and a compari- able insight into the continuity of medical son with the clinical fi ndings. JAMA 55:1343–1350, knowledge and laboratory science and a beacon 1910. for future development in understanding human 10. Th e Flexner Report. Carnegie Foundation Bulle- disease—whether for quality assurance, clinico- tin No. 4, 1910. pathological correlation, development of new 11. Aub JC et al. Management of the Cocanut Grove surgical techniques or devices, instruction for all Burns at the Massachusetts General Hospital. Phila- levels of training and disciplines of medicine, and delphia: J. P. Lippincott, 1943.

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12. Castleman B, Crockett DC, Sutton SB, eds. Th e embolism and infarction. Am J Roentgenol Rad Massachusetts General Hospital, 1955–1980. Boston: Th er 43:305–325, 1940. Little, Brown, 1983. 15. Mallory TB, Brickley WJ. Pathology. With spe- 13. Goodale F. Th e Absolute Truth and Other Uncer- cial reference to the pulmonary lesions. Ann Surg tainties: A Remembrance. Lincoln, Neb.: iUniverse 117:865–884, 1943. Inc., 2005. 16. Hull MJ, Nazarian RM, Wheeler AE, Black- 14. Hampton AO, Castleman B. Correlation of post- Schaﬀ er WS, Mark EJ. Resident physician opin- mortem chest teleroent-genograms with autopsy ions on autopsy importance and procurement. ﬁ ndings. With special reference to pulmonary Hum Pathol 38:342–350, 2007.

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