The autopsy

Correspondence THE AUTOPSY T o TIlE EDITOR;

T h e comedy o f tile debate about autopsies proceeds witli an air o f Gilbert a n d Sullivan intplausibility. In a letter to the Editor, a pafllologist castigates other pathologists for actively discouraging autopsies; I in a separate letter anotller patllologist, anxious for referrals, finds tllat tile fault is with primary physicians wllose fear o f ntalpractice claints inhibits referrals, and he looses a broadside at die J C A H for not regulating the medical practice of pathologists;"- a self-styled "eklerly" patltologist criticizes a young pathologist in residency for writing about tile autopsy without reading the r e p o r t o f a s y m p o s i u n t S - a synlposiuna tlmt slle in fact a t t e n d e d and stmmmrized in her article! 4 At tile sante tinte, to insure tlmt everyone is covered, d e p a r t m e n t clmirnten are faintly d a m n e d , and the Editor is taken to task for publislling the work o f a young person! All three letters, and ntucl~ o f tile widespread debate, betray an eagerness to distribute some sort o f blame a r o u n d on everyone else, and it's not really clear wllat everyone else is being blamed for. Dialogue, suggestions, plans, and stlaring o f ideas are surely important, but it seenls to me tllat tllis a b u n d a n c e o f sackcloth, ashes, and recriminations, coupled with dazed rellections on wllat ntight have been, is unlikely to lead anywllere. Surely a course more likely to akl the resurgence of tile autopsy would be for eacll of us to search carefiflly (and honestly, like Dr. Robinson's physicians 2) for wlmt is best in o u r own situation, develop o u r objectives, our plan, and go to it in a way that is helpfid, usefnl, attd appreciated. I f a surgeon Dotes tlmt lie is being r e f e r r e d progressively fewer patients for surgery, he is unlikely to reverse the trcnd by blante-fixing o r calling for governmental regulation: Tile surgeon had best look to Iris own practices! In my na'/vet6, I really can't see why we should expect priumry physicians to go repeatedly to tile considerable trouble o f sendI n g n s patients for autopsies for o u r "interest." First it has to be useful, helpful, interesting, or profitable for the referring ph)'sician. It is desirable tllat it also be profitable and interest-

ing to us, but if it does not appeal to them, we will not get the referrals. I look forward happily to the day, not too far off, when a professional fee will be allowed tl~roughout the country for the autopsy pathologist. I have moments o f real hand-rubbing glee, however, when I retlect that, like professional fees for surgery or any other medical practice, tile fee will be allowed only if rite pathologist personally p e r f o r m s rite autopsy o r is personally present and supervisiilg d u r ing its entire performance. Such scurrying a r o u n d tllere will be! Pathologists vying witlt each other for posts! Referral patterns assiduously cuhivated! Even a few filrtive kickbacks to referring physicians! Oh, dear! Dr. Kaplan doesn't know how lucky she Ires been, doing those autopsies with responsibility a n d autonomy. 4 Tontorrow's resident, elbowed aside in the scdnctiox] o f tile dollar, while holding the suction o r o p e n i n g the gut, will bi~ wondering what h a p p e n e d to all the autopsies fornler residents used to have responsibility for! A fitting bit o f slapstick in ~'{his long low conlcdy, on which rite c u r t a i n ~ l ! o u l d be descending rigllt now. I say hooray for rite patl~ologists, tile referring pllysicians, tile J C A H , the clmirmen (I blusll), tile Editor, a n d the letter writers. A n d I say a special hooray for Dr. Kaplan's good i m m o r e d look at tile present, and lter hot)eful, creative look at the fllture. T h e decline of the autopsy is over if such as she are rising in our ranks; it is time for pathologists to catch up with its resurgence. ROLLA B. HILL, M.D. S U N Y - t ' p s t a t e ,Medical Center Syracuse, New York

1. 2. 3. 4.

Lener. ttum. Path., 9:609, 1978. l.etter, ttum. l'ath., 9:610, 1978. l.ener, lhmL l'ath., 9:611, 1978. Kaplan, R. A.: "File autopsy--to be or not to be. thtm. l'ath., 9:127-129, 1978.

T o TIlE EDITOR:

Haruspical is a naughty word. "Haruspical" relates to tile formulation o f predications based on inspection o f the entrails o f sacrificial atdmals. It was a practice o f ancient

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" H U M A N I ' A T H O L O G Y - - V O L U M E 10, NUMBER 2 Rome. It is also not unlike a practice o f the present day, done unwittingly, o f course, and unintentionally as well. N o r is it obvious. Nevertheless, predictions are m a d e from observations on llnman tissues, the predictions are seldoni correct, and "haruspical" bids fair to describe the process. It is not tlie word tllat is "naughty"; it is the practice that is grievous. How could modern inan possibly be engaged in such a desultory business? Autopsy examinations are p e r f o r m e d and nmcli use is m a d e o f tlie observations tlierefrom. It is a necessary and important p r o c e d u r e for niedicine; students learn and experienced physicians refi'esh tlieir recollections o f patliologic processes. It is all well and good so long as tlie observations are correct and verifiable. Tliis is almost always the case. W e r e a prediction to be m a d e from suclI an examiImtion, liowever, it wonld liave tlie llavor of a haruspical practice. Moreover, tlie tlavor would be especially strong if the prediction were neither verifiable n o r correct. T h e diagnosis o f "carcinoma in situ" fits tiffs category; it is evidently not verifiable, it is often not even correct, and the meaning o f the term is ambiguous as well.~ T h e diagnosis is also objectionable on two other grounds. O n e is that it frequently occasions tiie amptttation o f tissue such as the breast or uterus, and it provokes the idea o f cancer in the mind o f tile patient. Tliat idea is both worrisome and ineradicable. T h e second is the willingness o f patllologists to declare not wliat is seen and is verifiable, but wlmt is predicted and is not. T h a t is a haruspical difference. Observations reveal that carcinonIa in situ spontaneously regresses in sonle cases, remains static in others, and becomes invasive in perImps only a third o f tlie cases over a period o f a decade or more3 T h a t does not snlack o f reliability. T o call soniething cancer tlIat nia)' o r nlay not become cancer is siniply unsotmd. It is not that die diagnosis is rare or applies to only one tissue; it is extremel)' common and tile list o f tissues implicated by tiIe term is inipressively long. T h e patiiologist must, o f course, be reliable. What lie says has to be cotmted on. T h e pllysician bases lIis treatment on tlie word o f the patlmlogist, and the patient is vulnerable to botll. T o allow a practice o f uncertain reliability is thus unworthy o f tlie specialty. A n d to predict tiie future from an exanlination o f the present is a doubtflfl enterprise. TIIe duty o f tlie pathologist is to stick to tlie facts. T h e y are verifiable and uncllanging, l'redictions are, o f course, all right if they are labeled as sucii. TlIey can't be proved and tliey may be wrong. T h a t is altogether acceptable if the prediction is registered as onl)" an opinion. It is when

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prediction is recorded as fact that difficuhy arises, l'redictive diagnoses such as carcinoina in sitn tlIat overlook the fact (epithelial atypia) and predict the flltnre (cancer) are bad business. Registering wliat the tissue shows rather than predicting wliat it will become is a lesson well wortli learning. CIIANDLER S.XnTH, M.D. TrnnIan Medical Cenler Kansas City, Missouri 1. Smith, J. C.: Carcinoma in situ. ttum. l'ath., 9:373-37-t, 1978. '2. Firminger, H. A.: A pathologist looks at spontaneous regression of cancer. Nat. Cancer Inst. Monogr., 44:15-18, 1976.

MAST CELLS IN APLASTIC ANEMIA T o TIlE EDITOR:

Tile recent publication of" Naeim et al) from tile UCLA Bone Marrow: T r a n s p l a n t T e a m r e p o r t e d a possible correlfition between the n n m b e r o f marrow mast cells a n d tile likelihood o f suct:essfld #jlgraftnlent in patients witll aplastic anenlia~,;'~ review o f five patients with aplastic aneffil,x, transplanted at the Cleveland Clinic during die past two )'ears confirms their experience. O u r five patients, all adolescents, received HLA identical, mixed lymplmcyte c u h u r e - n o n r e a c t i v e bone marrow after conditioning with cyclopliosplminide. Mast cells were e n u m e r a t e d in p r e t r a n s p l a n t toluidine blue stained bone marrow aspirate specinlens. T h e average n u m b e r o f nmst cells in eacll o f 20 o r niore oil fields taken from the p e r i p h e r y o f tlie nIarrow particles was counted. Specimens from 10 nornIal cliildren and adnhs contained an average o f 0.28 mast cell p e r oil fiekl (range = 0.15 to 0.55). One patient had a mast cell count o f 3.7 p e r oil field and e n g r a f t i n g failed. After m o r e yigorous conditioning with c)'clopliospllamide, antitliymocyte globulin, and procarbazine, a second transplant was attempted. Bone nlarrow specimens obtained 23 days after tile second transplant contained cells o f tlie d o n o r karyotype; llowever, tlie patient died two days later later o f infections conlplications. Engrafting also failed in a sccond patient witli 2.0 mast cells per oil field. T h e three r e m a i n i n g patients have experienced successful nmrrow engrafting. Two, with mast cell counts o f 0.9 and 1.2 p e r oil field, are hematologically nor-