HUMAN PATHOLOGY-VOLUME 6, NUMBER 2
disease. His paper in the American journal of and cartilage resorption and angiogenesis (with
Pathology in 1959 described foci of thickening
and attenuation of the basement membranes,
with gaps or pores where endothelial and epi-
thelial cells were in intimate contact, in renal
biopsy specimens from patients with lipoid
nephrosis and subacute and chronic glomerulo-
nephritis. He suggested at that time that the
proteinuria was the result, at. least in part., of
the basement membrane defects. This work
evoked considerable criticism, and the ex-
istence of the gaps was questioned or con-
sidered preparative artifact, It took some 15
years and the development of tracer techniques
to verify the existence of such discontinuities
in the basement membrane. His original study
also provided a great impetus for further
definition of the permeability barriers in the
renal glomerulus in both normal and patho-
logic states,
A variety of other papers showed his broad
interests. He coauthored studies of osteoid
formation (with Dr. H. Robert Dudley),
metastatic calcification (with Dr. Giacomelli),
Correspondence
THE AUTOPSY
To THE EDITOR:
As one analyzes the discussion on the re-
lation of the autopsy to the quality of medical
care in the September 1974 issue of Human
Patholog), ["A Debate on the Autopsy"], the
conclusion seems to be an obvious one: There
should be both a qualitative as well as a quanti-
tatlve minimum standard requirement for all
autopsies and some proof of proper use of the
information obtained from such autopsies be-
fore appropriate accreditation of an institution
or hospital is given for purposes of training,
teaching, and adequate scientific medical care
of the patient.
Never has there been any adequate in-
spection of the nature and specific follow-up
studies of autopsies as they are performed at a
hospital, by the Accreditation Commission in
the evaluation of a hospital. Nor have any
autopsy protocols been inspected in a con-
certed manner, or even selected at random;
this could be a simple measure to test the
adequacy of the quality component of the
autopsy procedure. This inadequacy can be
corrected rather easily.
All participants contributed in an im-
260 portant manner to this important debate on
Murch 1975
Dr. Robert W. Schenk). Other work concerned
the ultrastructural features of demyelination
(with Dr. Henry de F. Webster), cell mediat.ed
reactions (with Dr. Wiener), and the first cor-
relative study relating cell coupling to junc-
tional morphology (with Dr. Werner R.
Loewenstein).
The legacy of results Dr. Spiro has left the
scientific community has had far reaching
effects in many areas of disease. The publica-
tions with which he was associated exhibit the
highest qualities in writing, techniques, and
reasoned discussion. His collaborators and the
many investigators from both the United States
and abroad who trained in his laboratory carry
on his tradition in the disciplines of health
related research. All pathologists concerned
with understanding human disease are in-
debted to David Spiro and his persistent efforts
in the application of electron microscopy to
pathology. The Editorial Board of Human
Pathology acknowledges his untimely passing
with great sorrow and regret.
the role of the autopsy as reported in the
September issue of Human Putholog»; there was
one exception, Alvan G. Foraker. One wonders
whether our critic does not actually dis-
like the autopsy as such. Does the absence of
all income from the autopsy condition the
attitude of some pathologists?
"Dr. Plodd" may find no interest in an
"obvious coronary" because he himself lacks
interest. Are all coronaries the same? Is there
nothing more to be learned, particularly now
when so many questions are being posed about
the relationship of coronary thrombosis, the
thrombus itself, its relation to the infarct (i.e.,
before or after), and the mechanism involved,
including the cause of death as such? Even a
macerated fetus may warrant. investigation on
occasion, as in the bony changes in syphilis.
Our critic too would probably find objection
to examining a decomposed body even though
we know that occasionally a bullet is found and
a crime detected or a lethal poisoning' exposed.
An examination of such corpses may not
be exhilarating or aesthetic, but they do
represent a disciplined approach to the
acquisition of truth when every bit. of truth is
needed in a particular case.
One might ask whether it is proper to have
a layman "smoking a big fat cigar" in the
autopsy room. Is this an appropriate and
dignified approach to the remains of a human?

In that very picture probably lies the essence
of our critic's attitude and the basis for his
negative attitude toward the autopsy.
It is our feeling that the autopsy, properly
performed, can serve a very useful purpose
in the evaluation of medical care, in teaching
and training, and in promoting general im-
provement of the scientific attitude of the staff
of an institution and their approach to the pa-
tient in any hospital. We hope, therefore, that
the Accreditation Commission will restore a
minimum percentage figure as a requirement
for approval, and reinforce this minimum
figure with some qualitative requirement, so
that the data can be equated between one
institution and another. Finally, we hope that
there will be included an added requirement,
or a recommendation at least, that the autopsy
findings be reviewed at departmental or other
conferences, so that appropriate lessons can
be learned and applied from the autopsy ex-
perience.
The fact is that the autopsy percentage
has been declining throughout the country,
and many think that the recent elimination of
any set percentage is accelerating this loss of
interest. Surely that fact is not promoting
better medical care; it can only do otherwise.
ALFRED A. ANGRIST, M.D.
Medical Society of the State of New York
Lake Success, New York
To THE EDITOR;
The Open Forum about autopsies formed
an interesting topic deserving of debate. In my
opinion, the arguments are temporal. Every
autopsy is unique. The percentage of autopsies
may well be meaningless. Nevertheless autop-
sies are beneficial and certainly the foundation
of the morphologic basis of pathology.
The reasons autopsies are performed
seem to fall into three overlapping categories:
to find the cause of death, to evaluate the ap-
propriateness of therapy, and to obtain a
scientific data base for inductive and deductive
reasoning (from which hypotheses may grow).
All three categories depend on proper investi-
gation of the circumstances with interaction of
the individuals involved. How often would it
have been essential to determine the vitreous
fluid glucose level? Did the dose of digitalis
have the primary role in the termination of
events? What parameters can be collected
effectively for posterity, if these are not used
immediately with a goal in mind, so that these
parameters will not end up being only of
historical interest?
GIVO* should stand for more than
the computer acronym. The only thing that
can be gotten out of autopsies is what is put
'"Garbage in, garbage out.
CORRESPONDENCE
into them. When the proper setting for the
postmortem examination is "quality con-
trolled," the autopsy and its percentage may
be considered of "quality control" merit. Until
then the benefits can only be appreciated by
those involved in each case.
GEORGE PETOE, M.D.
The Monterey Hospital, Ltd.
Monterey, California
To THE EDITOR:
By coincidence a letter of mine concerning
the "Importance of the Autopsy" was pub-
lished in the Archives (!/Patlwlog'y (Oct., Vol. 98,
p. 284, 1974) at virtually the same time that
Human Pathology published "A Debate on the
Autopsy." Readers of my letter will see that I
am on the affirmative side of the quest.ion.
Your debate stimulates additional comments
not expressed in my original letter to the
Archives and specifically directed toward your
debate.
First, many of the debaters appear to as-
sume that t.he "cause" of death in "routine"
cases is correctly identified prior to the autopsy,
and that this may reduce the necessity I'm-
autopsy in such cases. This position is stated in
its most extreme form by Dr. Foraker in his
humorous "Is This Trip Necessary?" Un-
fortunately it is necessary because the clinical
impression, no matter how "obviously" correct,
may in fact be incorrect. Before this point can
be debated further, it is necessary for those
with Dr. Foraker's point of view to specify
what percentage error they would allow physi-
cians in their judgment concerning the cause
of death, before they would decide that the
errors are sufficiently great to warrant an
autopsy in all cases, as an important means of
improving the practice of medicine. Wouldn't
even a 5 per cent error (one "routine" case in
20) be sufficiently large to warrant mandatory
autopsies as an educational tool for the use of
all practitioners?
Second, the autopsy is not merely the
means of identifying what the patient died of,
but it also identifies what he died with. Virt.ually
all your debaters overlooked or underempha-
sized the role of the autopsy as an opportunity
to identify the traces of multiple diseases
present during life but not playing a role in
the final illness. Thus the autopsy enables us
to check on the diagnostic skills and on the
therapeutic efficacy of all the physicians who
ever saw the patient, not merely of those seeing
him terminally. Moreover it gives us a vital
picture of disease that obviously should have
been brought to a physician's attention but may
not have been. Thus the autopsy provides a
key both to the distribution of medical care
provided by our society and to the level of care. 261