View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by VCU Scholars Compass The Modernization of the Autopsy: Application of Ultrastructural and Biochemical Methods to Human D.1sease * ** BENJAMIN F. TRUMP, M.D., JON M. VALIGORSKY, M.D., JANE H. DEES, B.A., WOLFGANG J. MERGNER, M.D., KOOK M. KIM, M.D., RAYMOND T. JONES, M.S., ROBERT E. PENDERGRASS, JOEL GA'RBUS, PH.D., JULIO H. GARCIA, M.D., JESUS E. VILORIA, M.D., JUNICHI TANAKA, M.D., HANNU KALIMO, M.D., YOSHINARI KAMIJYO, M.D., R. ADAMS COWLEY, M.D. From the Department of Pathology and the Maryland Institute for Emergency Medicine, University of Maryland School of Medicine, Baltimore The information gained through the autopsy because modern biological techniques have not been has played an important role in the evolution of employed in postmortem examinations. As a result, knowledge of human disease. At the time of Sem­ the clinical sciences have been cut loose from the melweiss, bedside symptoms and signs plus post­ conceptual base previously provided by information mortem examinations were the only investigative obtained at autopsy. tools available to study and understand the causes The autopsy has provided, and still provides, the and progression of disease, to assess the efficacy of stimulus for many attempts to reproduce disease in therapy and to monitor the quality of medical care. experimental animal models. This approach has be­ Feedback provided by postmortem examination was come increasingly difficult, however, in the case of highly instrumental in the development of physical human disease, principally shock. The study of diagnosis. The autopsy was virtually the sole means some pathological states in animal models requires of classifying disease. In the process, the autopsy testing in several species and final confirmation in spawned and furthered the development of almost man before this knowledge can be applied to living every contemporary technique for the diagnosis of patients. In our studies the application of cell biology disease of which radiology and electrocardiography techniques at autopsy has permitted the generation are notable examples. Once developed and refined, of new hypotheses which are more amenable to fur­ such clinical sciences have assumed a direction and ther exploration in experimental models and can be ideology aimed at the living patient and paradoxi­ more precisely related to human disease. cally, the contribution of the autopsy to patient care The chief limitation for the interpretation of has steadily diminished. Advances in the clinical sci­ observations made in the routine autopsy is caused ences have depended more on achievements made in by the delay in obtaining tissue following somatic biologic science and less on necropsy in large part death. The resultant autolytic changes invalidate most ultrastructural, biochemical and functional studies. * Presented by Dr. Trump at the 44th Annual Mc­ Investigations utilizing contemporary refined tech­ Guire Lecture Series, March 23 , 1973, at the Medical niques from the experimental laboratories of univer­ College of Virginia, Richmond. sity pathology departments are, however, the very ** Supported by the following grants from the Na­ tional Institutes of Health: GM-00431-12, AM-15440-02 a'nd ones needed to restore the postmortem examination GM-15700. to a primary role in patient care and in quality con- MCV QUARTERLY 9(4): 323-333, 1973 323 324 TRUMP, ET AL: MODERNIZATION OF THE AUTOPSY trol of health care. The use of biopsy obviates time The Immediate Autopsy Program at the Univer­ delay. While much valuable information can be and sity of Maryland is conducted by the Pathology De­ is obtained from biopsy, there are distinct limitations: partment in conjunction with the Maryland Institute a) The small size of biopsies restricts the number of for Emergency Medicine. The primary purpose of the analytical techniques that can be applied; b) Often, program is to document and clarify the pathological medical indications for biopsy do not outweigh the changes leading to organ failure in cases of shock risks involved for seriously ill patients; c) Finally, and trauma. This paper demonstrates that tissues the fact that complete organ sampling cannot be obtained at immediate autopsy yield valid observa­ performed make this contribution of limited value tions on the pathogenesis of cellular injury in shock. in the study of systemic disease. Methods have been discussed in detail elsewhere (5); A potential limitation in applying an immediate the autopsy procedure, however, will be briefly out­ autopsy technique is the selection of patients for any lined below. contemplated multidisciplinary approach. The volu­ Immediate autopsy is made possible by two minous data generated by intensive care units have legal instruments existing in the State of Maryland: made valuable contributions to medical knowledge a) the Medical Examiners' Law which charges the and patient care, yet little of these data has been Medical Examiner with the responsibility of deter­ related to phenomena at the tissue and cellular level. mining the cause of death and investigating medi­ It seems logical then to direct an intensive approach colegal and biological factors in deaths due to vio­ to this population of patients. Especially needed, we lence, traffic accidents and unexplained natural death; feel, are morphologic, biochemical and functional b) the Anatomical Gift Act, similar to laws enacted observations on tissues removed immediately after in many states and aimed at obtaining organs for death in order to correlate them with clinical data. transplantation, whereby the patient or his next of The initial objective of the immediate · autopsy kin can give permission for autopsy prior to death. is directed to the evaluation of cellular and subcellu­ All the individuals studied include cases of lar changes in major organ systems in cases of shock. "brain death" as determined by the Harvard cri­ Shock frequently accompanies trauma and consti­ teria ( 1). Once somatic death is determined by the tutes a significant determinant of the posttraumatic absence of heart beat, pulse and respiration, as well as morbidity and mortality, a major cause of death. an isoelectric EKG, the rapid sampling phase of the Antecedent diseases resulting in shock are legion and immediate autopsy is begun. The prosector, together shock is a component of the terminal phase of nu­ with the ten-member team, does a rapid sampling of merous illnesses of many causes. Morphologic tech­ several organs for study by light and electron micros­ niques used in the routine autopsy do not permit copy, immunofluorescence, enzyme histochemistry separation of the cellular effects of shock from the and studies of organelles after homogenization and effects of certain underlying diseases which cause differential centrifugation. Following the rapid sam­ shock. For example, in acute myocardial infarction ple phase, a routine autopsy dissection is performed. with cardiogenic shock it is often impossible to dis­ Simultaneously, the intracranial contents are tinguish the extent of primary myocardial injury from perfused in situ via polyethylene tubing inserted the damage secondary to shock. Although we know through the right common carotid and after ligation that there are common pathways of cellular reaction of the three other major cervicocranial arteries. The to a diversity of injurious agents, variations exist. fixative is composed primarily of aldehydes. Our studies have demonstrated that a distinction can Concepts of Cell Injury. Since Rudolph Vir­ be obtained between the effects of antecedent dis­ chow's famous papers of about one hundred years ease and the effects of shock when precise clinical ago, we think of disease in terms of cellular changes, data are correlated with ultrastructural, biochemical and define disease as the summation of the effects of and functional assays at immediate autopsy. This injury as well as the responses of cells to injury. In­ permits better understanding of the cellular shock, jury is defined as an event that alters cellular homeo­ which is of importance in the utilization of autopsy stasis. If the injury is lethal, such as complete ischemia technique to the study of other diseases. Without or anoxia, there will be a reversible phase prior to the knowledge of the changes resulting from shock, ade­ time of cell death. If the blood supply or oxygen are re­ quate evaluation of autopsy data in other diseases stored during this reversible stage the cell can re­ may be difficult or impossible. cover, return to the normal state of homeostasis and TRUMP, ET AL: MODERNIZATION OF THE AUTOPSY 325 continue functioning. At some point, however, damage approaches equilibrium with the environment. Thus becomes irreversible and the cell is said to die; even if there is a reversible and an irreversible phase the blood supply is restored recovery does not occur. following a lethal injury. Shown in figure 1 are some Instead, the cell undergoes necrosis and gradually of the key organelle changes which characterize these . .....>­ ...J CD .....4 "- 4 0 4 u ..... .....4 :g..., ~~~~~-+--+-~~~.... ~--.~ 2: 0 ...:I: 0..., <.!) z 4 a:: ' 0 ©~©. <7·~~.:,.~,,. , • 'Ii .. .J'). - u ''•(,/ TIME- Fig. I-Stages of cell injury. This diagram represents a conceptualization of the results of cell injury. Time is plotted along the abscissa and the range of homeostatic ability along the ordinate. An injury is applied at the arrow. This injury may be sublethal or acutely lethal. Lethal injury will be considered first. Curve C represents a homeostatic ability. Recovery can occur, however, if the injurious stimulus is removed prior to the point of cell death. Such recovery may proceed along the curve C' or C". Stages 2 and 3 represent progressive changes during this period. Stage 2 is characterized by dilatation of the endoplasmic reticulum and slight clumping of the nuclear chromatin. Some ribosomes may also be detached from the endoplasmic reticulum and the entire cell may be slightly swollen. Condensing of the mitochondria, additional swelling of the cell and the appearance of blebs along the cell membrane are charac­ teristic of stage 3.