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 185 pathology_chap15.indd 185 8/16/11 10:20 AM Keen Minds to Explore the Dark Continents of Disease 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 186 pathology_chap15.indd 186 8/16/11 10:20 AM The Autopsy Service 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.