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Editorial

Autopsy: The Undiscovered Country in Which We Already Reside

Wiles, Austin B. MD

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doi: 10.1097/PCR.0000000000000432
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The body might be considered the hardware of the complex technical device that is human thought.

—Jean-François Lyotard1

Every man should be capable of all ideas, and I believe that in the future he will be.

—Pierre Menard, author of Don Quixote2

This issue of the American Journal of Surgical Pathology: Reviews and Reports concerns the practice of autopsy. The primary focus is medical or hospital, rather than forensic, autopsy. But these boundaries are not firm. Much of the information discussed can be applied to either field.

The topics covered in this issue are diverse, and their scope is broad. This breadth is vital to accurately reflect the nature of contemporary medical autopsy. The practice of medical autopsy is not formally bounded or codified like other pathology subspecialties. There is no fellowship training or subspecialty board examination. The nature of the present pathology practice assumes that any pathologist with anatomic pathology training should have reasonable facility with medical autopsy performance. But the actual performance of medical autopsy may require any constitutive practice from the expanding corpus of diagnostic pathology techniques, from cytogenetic testing to pediatric pathology. With respect to technique, the practice of medical autopsy maps directly onto the territory of pathology at large itself. Arguably, medical autopsy is bigger than pathology.

There are no boundaries for the potential impact of the information medical autopsy generates. Grief is a universal human emotion. How autopsy data might comfort, enlighten, and contextualize life events informing the grief process for next of kin cannot be anticipated for any particular autopsy case. The results of medical autopsy may have import for any clinician. Autopsy is the criterion standard for establishing the cause of death in patients, thereby potentially impacting any end-point study within the practice of evidence-based medicine.3 The potential reach of autopsy expands as new clinical diagnostic techniques are invented, as these represent new opportunities for correlation. While the potential utility of contemporary autopsy is vast, its actual practice is small.

At present, the practice of medical autopsy is at its smallest. The rate of medical autopsy performance for decedents in the United States and worldwide has declined through the last century and is currently estimated to be less than 5%.4,5 In this respect, an issue of a journal articulating and elaborating the uses, utility, and practice of contemporary medical autopsy is untimely. It runs counter to our time and current trends. “History is made by only those who oppose history.”6 All true innovation is somewhat untimely. In accordance with this deeper spirit of innovation, I have the distinct pleasure of presenting the work and wisdom of an esteemed group of autopsy practitioners.

We begin the issue with Dr Alex K. Williamson's review of the scope of contemporary autopsy practice titled “Doing More With Fewer: Optimizing Value With Limited Numbers of Autopsies.” This review serves as a map to the territory for the practicing pathologist who needs to navigate the paradoxes of contemporary autopsy practice described above. In cartography, a cadastral survey is a special map that delineates ownership and value of particular territories. Dr Williamson provides an encyclopedic cadastral survey of the limitations of contemporary autopsy such that an autopsy practitioner might best demonstrate the value of the limited number of cases he/she is afforded.

Second, Dr Erin G. Brooks provides an unquestionably timely and vital article, “Pandemic Autopsy Biosafety Considerations.” In response to the pandemic, Dr Brooks has written a succinct and comprehensive review of biological safety precautions for autopsy staff. She delineates a cogent and clear compass for navigating a palimpsest of legal, scientific, and facilities frameworks to keep staff safe in autopsy from both well-characterized and emerging pathogens. This review should prove useful for both established autopsy laboratories and those that intend to build an autopsy service. While timely in its distilled wisdom from the COVID-19 pandemic, this text should prove timeless in its utility.

Next, Dr Jody Hooper provides the article, “Rapid Autopsy Programs and Research Support: The Pre– and Post–COVID-19 Environments.” This article functions as a recipe, a kind of map, for how to integrate an autopsy service with active research. The act of cooking is not merely the trivial combination of ingredients. Vital and satisfying nutrition comes from the mutual transformation of ingredient materials according to a plan, or recipe, which reflects an appreciation for the properties of those ingredients.7 Similarly, autopsy cannot simply be juxtaposed with research without some culinary skill. Dr Hooper is the master chef of autopsy and research.

Drs William Humphrey and Sharon Mount provide a comprehensive review, “Education in Autopsy: More Than the Y-Shaped Incision—Entrusting Trainees for the Future.” This insightful review articulates the foundational role that autopsy serves in the training of pathology. The text brilliantly combines the wisdom of an experienced autopsy practitioner with the openness and lack of preconception of a trainee. Such a perspective is referred to in Zen Buddhism as shoshin or “beginner's mind,” which is vital to being able to create and achieve new insights by discarding sclerotic and anachronistic preconceptions.8 Beautifully, this article simultaneously articulates such a perspective and demonstrates it. Drs Humphrey and Mount eloquently argue that the practice of autopsy forms the clear foundation for all the necessary skills of those who practice pathology, and therefore autopsy should be afforded a central place in training curricula.

Dr Hope Richard practices both autopsy pathology and neuropathology. As mentioned previously, the exact boundaries of autopsy are difficult to define. However, there should be no debate as to the clear and foundational interrelatedness of autopsy with neuropathology. Her review, “Multipolar Neuropathology: Survival Strategies for Professional Loneliness,” is a comprehensive and exhaustive syllabus for the practice of neuropathology. This article is intended to help those who may be tasked with doing neuropathology, including covering neuropathology intraoperative consultations, without fellowship training or many collegial resources. Readers should take note of her clarity, comprehensiveness, and strength of insight. This article is an embarrassment of riches for any practicing pathologist.

Penultimately, this issue includes 2 case reports from the above authors. Drs Ravi Singh, Geunyoung Jung, and Brooks present a case report of COVID-19 myocarditis from an autopsy case. Drs Nicole Johnson and Hope Richard present a case series of transcranial lesions. As with all excellent case reports, the story is best told in pictures. These cases have exceptionally instructive images including radiology, gross images, and photomicrography.

As a coda, the reader will encounter an article titled, “The End,” written by myself, Dr Austin Wiles. This is a review of the types of thinking that inform the practice of autopsy for medicine in general. Its text functions as a conceptual defense for the practice of autopsy in contemporary medicine. In it, the reader will encounter several concepts of death. Concepts of knowledge itself and the adventure of discovery have a foundational relationship to concepts of death. From Tom Stoppard's Arcadia, “It's the wanting to know that makes us matter.”9 But even in the lush, manicured garden of our greatest wisdom, there is something to haunt us as both physicians and people. Et in Arcadia ego.

I am humbled by the fantastic work of the contributors. I thank them so much for their incredible efforts during the COVID-19 pandemic. Thank you for reading.

REFERENCES

1. Lyotard J-F. Can thought go on without a body? In: Materialities of Communication. Stanford, CA: Stanford University Press; 1994:74–87.
2. Borges JL. Pierre Menard, author of Don Quixote. Ficciones. New York, NY: Everyman's Library; 1993.
3. Goldman L. Autopsy 2018: still necessary, even if occasionally not sufficient. Circulation 2018;137(25):2686–2688.
4. Shojania KG, Burton EC, McDonald KM, et al. Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. JAMA 2003;289(21):2849–2856.
5. Hoyert DL. The changing profile of autopsied deaths in the United States, 1972–2007. NCHS Data Brief 2011;67:1–8.
6. Deleuze G, Guattari Fl. A Thousand Plateaus: Capitalism and Schizophrenia. Minneapolis, MN: The University of Minnesota Press; 1987.
7. Wrangham R. Reason in the roasting of eggs. Collapse 2011;VII:331–344.
8. Suzuki S. Zen Mind, Beginner's Mind. Boston, MA: Shambhala Publications, Inc.; 2006.
9. Stoppard T. Arcadia. New York, NY: Farrar, Straus, and Giroux; 1993.
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