An autopsy: A historical vignette

HISTORY OF PATHOLOGY

An Autopsy: A Historical Vignette William H. Hartmann, MD This paper recounts a case report from 1853 that describes the circumstances surrounding the death of a young woman, the request for and granting of permission for an autopsy, and exposition of how the autopsy findings were used from the point of view of education, quality control of practice, and vital statistics. There is, in addition, a description of the evolution of the use of the word autopsy.

Ann Diagn Pathol 3:192-194, 1999. Copyright © 1999 by W.B. Saunders Company Index Words: Autopsy, history, pathology, medicine ~ M e E following article from the Nashville Journal of dicine and Surgery presents the case study of a y o u n g slave w o m a n a n d the circumstances u n d e r which a n autopsy was performed. ART. II. Death From Exterior Uterine Hemorrhage, byJ.O. Sharber, MD, Versailles, TN. I was called, in company with Dr. Hall, to see Grace, a colored girl, who was about 35 years of age, whom we found laboring under great prostration, very restless, with respiration hurried and laborious, and with cold and pulseless extremities. It was about 7, [sic] P.M., when we first saw the patient; learned that she was attacked early in the morning with very severe pain in her lumbar hypogastric regions, followed soon with retching and vomiting, with a disposition occasionally to syncope, which symptoms followed her until she expired, which was about two hours after our a r r i v a l . The patient and her friends supposed herself to be enceinte about three months, and the pains an effort at miscarriage, though she had no external show. She had the symptoms of a patient who was sinking under extreme hemorrhage, though with not as great a disposition to syncope. TREATMENT. The indications to fulfill in the treatment were, to bring about reaction, restore the nervous energy, and equalize the circulation, which indications our most potent stimulants, conjoined with hot bricks and sinapisms to extremities, failed to fulfill, and the patient gradually sunk down into the profound

From theAmericanBoardofPathology, Tampa,FL. Presented in part at the A.B. PearsonMemorial Lecture, Wellington, New Zealand, May 24,1985. Address reprint requests to William H. Hartmann, MD, American Board of Patholo~, PO Box 25915, Tampa,FL 33622-5915. Copyright © 1999 by W.B. Saunders Company 1092-9134/99/0303-0007510.00/0 ]92

sleep of death, and we were left to conjecture as to what might have been the true cause of her death. This being the case, we asked permission of the master to make an autopsy, which request, in the first place, he failed to comply with, in consequence of the same aversion that generally exists in the South and South-West to such inspections. But soon after interment (in consequence of a rumor which got afloat, which said the probability was that the girl was brought to her death by having received poison) we were requested to make the autopsy, which resulted in revealing the true cause of the patient's death which was not in consequence of having received a poisonous draught, but caused by internal hemorrhage. In laying open the abdomen, it was found to be filled with coagulated blood and serum. This hemorrhage had originated from an ulcer on the right margin of the fundus of the uterus. By its ulcerating and eroding influence it had destroyed the texture of a uterine vessel of some magnitude, and thus gave rise to the great affusion [sic] of blood into the abdominal cavity, and was sufficient cause for the great prostration and sudden death of the patient. I regard the ulcer as being one of a carcinomatous character, and as having been of several years [sic] standing. It occupied about the space of a square inch in extent. It had pretty nearly destroyed the texture of the walls of the uterus within the bound [sic] of its circumference. The uterus appeared to be in a normal condition, with the exception of the portion occupied by the ulcer. It was in a non-gravid state; and the girl was not pregnant, as she supposed, though her menses had ceased to appear, and her mamma: had began [sic] to enlarge. The internal organs all appeared to be in a healthy condition, with the exception of the uterus. There were no external marks of disease, with the exception of a small ulcer under the left mamm~e, though not of a serious character. I learned it had been of some few years [sic] standing. Previous history of the patient.--Gave birth

Annals of Diagnostic Pathology, Vol 3, No 3 (June), 1999: pp 192-194

An Autopsy: A Historical Vignette

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to a child about seven years since [sic]. Patient stated that she had been regular in her periods for the last six or seven years, but had not become pregnant until within the last few months. I learned that she had been, during the last four or five years, the frequent subject of great lumbar pain, which would disqualify her for labor for a time. Those pains were thought to have originated from an affection of the kidneys; but the kidneys were found to be normal. The ulcer of the uterus I conceive to have been the true source of those distressing lumbar pains complained of by the patient. The cervix and os uteri are very obnoxious to cancerous affections; but I do not know that I ever knew the fundus uteri to be the seat of carcinoma before this instance.January, t853)

year, which details the autopsy findings in a young man, refers to the procedure as autopsia cadaverica.2 The first use of the term autopsy to mean postmortem examination remains shrouded in history, but it was used as early as 1678 as referenced in The True Intellectual Systems of the Universe.~ The author states:

This article is of interest for several reasons, not the least of which is the plight of the unfortunate young woman. The poignancy of her situation reminds us of some of the reasons we decided to practice medicine in the first place: to relieve suffering, fight disease, and promote health. As more recent experience has proven, these goals of medicine are often achieved on the basis of wisdom acquired through postmortem examination. This case study illustrates the educational and scientific benefits to be found in the performance and interpretation of autopsies and sharing of the findings. Because of an "aversion . . . to such inspections, ''l which evidently existed at that time, permission for the autopsy was not given until there were circumstances of sufficient concern to the reputation of the master and the community to warrant it. Yet, the autopsy, once performed, not only led to establishing the cause of death and cleared the air in the community, but also contributed to the education of Dr Sharber and the readers of the journal. It also resolved a potential public health issue by ruling out poisoning as the cause of death. In addition, the findings would have been valuable as vital statistics of the time, if such were kept. Perhaps its greatest value was in establishing the fact that the patient died of intra-abdominal hemorrhage from a cancer of the uterus. These points make up a fairly complete exposition of the value of an autopsy. It is interesting that the conclusions drawn from the autopsy findings were accomplished without benefit of microscopic examination. One wonders what other findings would have been revealed if histologic preparations of the uterus and the "small ulcer under the left mamma= I had been possible. The article is also of interest because it documents the scholarly use of the term autopsy for a postmortem examination, perhaps for the first time in the central South. An article in the same journal from the previous

It seems, therefore, that the use of the word autopsy to signify the dissection of a dead body and use of the findings is much earlier than generally accepted. In 1756, Albrecht von Haller published, in German, a medical dictionary 4 that defines autopsy as: "Autopsia, der eigene Augenschein, das Selbstsehen, wenn man wirklich etwas selbst sieht, und den Augenschein davon einnehmt; also sagt man autopsia anatomica, wenn man einen in der Zergleiderung auf den Augenschein yon etwas fuhren kan." One translation of "Autopsia, der eigene Augenschein, das Selbstsehen, wenn man wirklich etwas selbst sieht, und den Augenschein davon einnehmt," refers to autopsy as "Seeing for oneself; an observation that one makes by oneself and the understanding and interpretation of the observation." That part of the definition does not relate specifically to the current use of the term to mean postmortem examination. The second part of the definition, "also sagt man autopsia anatomica, wenn man einen in der Zergleiderung a u f d e n Augenschein von etwas fuhren kan," does, however, relate to the current use of the term to mean postmortem examination, based on the following translation: ';When one can lead others to see for themselves at dissection; by dissection one can lead someone else to observe and understand the observation. ''4"7However von Haller's definition is translated, it seems reasonable that he accepted the use of the word for examination or dissection of bodies (der Zergleiderung) and contemplation of the findings. According to Skinner, 8 the word autopsy was first used to indicate an examination of the body after death in 1829. The patient was the Empress Maria Feodorvna of Russia, who probably died of a cerebrovascular accident. The word autopsie (German spelling) is used many times in the case report and it also appears in the title. 9 The autopsy was performed 30 hours after death by Professor Bugarsky and his associates and is treated in a

And Lastly, the Cartesian attempts to salve the Motion of the Heart Mechanically seem to be abundantly confuted, by Autopsy and Experiment, evincing the systole of the Heart to be a muscular constriction, caused by some Vital Principle, to make which, nothing but a Pulsifick Corporeal Quality in the Substance of the Heart itself, is very Unphilosophical and Absurd.

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matter-of-fact way in the report. The paper contains the sentence "Professor Bugarsky was certain he had never seen a brain of such weight, ''7 which suggests that postmortem examinations were not an unusual procedure. The use of the term autopsy for postmortem examination evidently remained controversial as late as 1874. A dictionary of medical sciences 1° defines the word in its original Greek form, Autopsia, as "Inspection; examination by one's self Esic]; self-inspection," but then goes on to add "Often improperly used for the following: Autopsia Cadaverica, attentive examination after death, practiced for the purpose of investigating the causes and seat of an affection of which a person may have died." The term autopsy is then defined as "Wounds" and is referenced to "Dissecting wound," which is "a wound received in the dissection of dead bodies." That definition of the term does seem to relate to the current meaning, in spite of the editorial "often improperly used." In The Oxford English Dictiona~7n there are two definitions of autopsy. The second definition listed is more or less the one we use today, including "dissection of a dead body." According to Stedman's Medical Dictiona~7,I2 the modern use of the term autopsy to mean postmortem examination is listed first: Autopsy 1. An examination of the organs of a dead body to determine the cause of death or to study the pathologic changes present, syn necropsy, thanatopsy. 2. In the terminology of the ancient Greek school of empirics, the intentional reproduction of an effect, event, or circumstance that occurred in the course of a disease and observation of its influence in ameliorating or aggravating the patient's symptoms, syn postmortem examination. (G. autopsia, seeing with one's own eyes). This current definition of autopsy has its roots in the same quest for knowledge that was evident in the autopsy of the slave woman, Grace. The article based on the events surrounding her death is of historical value in its documentation of an example of diagnosis, treatment, and the value of performing an autopsy when the science of medicine was in its infancy.

The Autopsy If there were a place where each cared For his fellow man, If there were a time when each worked to help The other, If that could be, then each death Would not only be mourned, but studied. If that could be done, who is to know what Might be?

William H. Hartmann, MD February 1, 1985

Acknowledgement The author expresses appreciation to Cathy Anderson.

References 1. SharberJO: Death from exterior uterine hemorrhage. Nashville J ivied Surg 1853;6:259-261 2. Russworm FA: A case of fungus cerebri. Nashville J Med Surg 1852;3:130-132 3. Cudworth R: The True Intellectual Systems of the Universe, London, 1678, Faksimile-Neudruck. Stuttgart-Bad Cannstatt, Germany, Friedrich Frommann Verlag (Gunther Holzboog), 1964 4. von Hailer A: Medicinisches Lexicon. Germany, Franfurt & Leipzig, 1756, p 107 5. Hrett MW: Personal communication, 1984 6. McCaw HC: Personal communication, 1984 7. Parl F: Personal communication, 1984 8. Skinner HS: The Origin of Medical Terms. New York, NY, Harper PuNishing, 1970 9. von Rub J, Creighton W, Bluhm D: Krankheit und Autopsie der verstorbenen verwittweten Kaiserinn yon Russland, Maria Feodorvna. Salzb Medchir Ztg 1829;1:107-I 12 10. Dunglison R: Dunglison's Medical Dictionary (revised ed). Philadelphia, PA, Henry C. Lea, 1874 11. MurrayJAH, Bradley H, Craigie WA, et al (eds): The Oxford English Dictionary, Vol 1. Oxford, UK, Oxford 12. Spraycar M (ed): Stedman's Medical Dictionary (ed 26). Baltimore, 1rID,Williams & Wilkins, 1995