served in this child's diseased arteries. Future studies of anfinoacidemias and fibromuscular dysplasia may yield convergent resuhs.

Acknowledgment We gratefidly acknowledge the assistance o f J o h n E. Coletta, M.D., who obtained the decedent's past and fanfil)' histories.

8. 9.

10. 11.

References 1. 1'atel, A. N., and Richardson, A. E.: Ruptured intracranial aneurysms in tim first two decades of life. J. Neurosurg., 35:571, 1971. 2. Spudis, E. V., Schar)j, M., Alexander, E., and Martin, J. F.: Dissecting arJeurysms in the neck and head. Neurology (Minneap.), 12:867, 1962. 3. Watson, A. J.: Dissecting aneurysms of arteries other than the aorta. J. I'ath. Bact., 72:-t39, 1956. 4. Wisoff, II. S., and Rothballer, A. B.: Cerebral arterial thrombosis in chiklren. Arch. Neurol., 4:258, 1961. 5. Dull'y, 1'. E., l'ormoy, B., Mauro, J., and Wehrle, P. F.: Acute infantile hentiplegia sccondary to spontaneous carotid thrombosis. Neurology (Minneap.), 7:664, 1937. 6. Bostrom, K., anti Lilieqtfist, B.: l'rimary dissecting anetlrysm t}f the extracranial part of the internal carotid and ~ertebral arteries. Neurology (Minneap.), 17:179, 1967. 7. Belber, C. J., and Iloffman, R. B.: The syndrome t)f

12. 13. 14.

15. 16. 17. 18.

November 1975

intracranial arleuryslll associated with fibromuscular hyperplasia of the renal arteries. J. Neurosurg., 28:556, 1968. Ilarrison, E. G., Jr., and McCormack, L J.: Pathologic classification of renal arterial disease in renovascular hypertension. Mayo Clin. Proc., 46:161, 197 I. Beuren, A. J., llort, w., Kalbfleisch, !1., Muller, H., and Stoermer, J.: D)'splasia of the systemic and pulmonary arterial system with tortuosity and lengthening of the arteries. Circulation, 39:109, 1969. Claiborne, T. S.: Fibromuscular hyperplasia. Report of a case with involvement of muhiple arteries. Am. J. Med., 49:103, 1970. Iosue, A., Kier, E. I., and Ostrow, D.: Fib~omuscular dysplasia involving the intracranial vessels. Case report. J. Neurosurg., 37:749, 1972. Price, R. A., and Va~vter, G. F.: Arterial fibromuscular dysplasia in infancy and childhood. Arch. i'athol., 93:419, 1972. l'atchefsky, A. S., and l'aplanus, S. 11.: Fibromuscular hyperplasia and dissecting aneurysm of the hepatic artery. Arch. I'athol., 83:1-1 I, 1967. Oxman, 1I. A., Sheps, S. (;., Bernatz, P. E., and I larrison, E. G., Jr.: An unusual cause of renal arteriovcnous fistula--fil~romttscular d)splasla of the renal arteries. Report of a case. Ma)o Clin. l'roc., 48:207, 1973. Ross, R., and Glomset, J. A.: Atherosclerosis and the arterial smooth muscle cell. Science, 180:1332, 1973. Aikawa, M., and Koletsky, S.: Arteriosclerosis of the meseuteric arteries of rats with renal hypertension. Am.J. l'athol., 61:293, 1970. McCully, K. S.: Vascular pathology of homocysteinemia; implications for the pathogenesis of arteriosclerosis. Am. J. Pathol., 56:111," 1969. McCully, K. S., and Ragsdale, B. D.: Production of arteriosclerosis by homocysteinemia..Am. J. Pathol., 61:1, 1970.



In the recent Open Forum, "A Debate on the Autopsy: Its Quality Control Ftmction in Mcdicine" [ l l u m . l'ath., 5:605-608, 1974], there is a faihn-e to come to grips with what is to many pathologists a reality: T h e quality control fltnction of the atttopsy is becoming meaningless, since so few o f them are being p e r f o r m e d . I)espite the expression b)' D r . J o h n D. l'orterfield, I)irector o f the Joint Comnfission on Accreditation o f I lospitals, that "there [has been] no indication o f an accelerated downward trend since 1971 when the new hospital accreditation standards were ptd)lishcd, [withottt a stated] required atttopsy rate," tny experience, in both large medical school associated hospitals and smaller community hospitals, is that the autopsy rate and the total n u m b e r o f autopsies p e r f o r m e d have decreased precipitously since 1971. ~ S u p p o r t for this observation comes fi-om the National Pituitar)" Agency, which is r e p o r t i n g a great reduc-

tion in pituitary glands received, 5000 fewer glands between May and S e p t e m b e r 1974, c o m p a r e d to tile same period in 1973. 2 This decrease is directl)" related to the removal o f the JCA t I guidelines. Even prim" to 1971 t h e J C A H standards inchtded no official atttopsy rate, but a guideline was provided in the Augnst 1957 bulletin o f tltc J C A H . a It served as a goad to the hospital inspector, hospital administrator, and practicing physician to maintain "rule o f thtnnb" autopsy rates of 20 per cent for contmttnity hospitals and 25 per cent for teaching hospitals. This guideline has not been applied since 1971. In 1975 our autopsy services have experienced the fill impact o f four years o f laissez-faire attitudes. S u c h p h e n o l l l e l l a as increased exposttre to malpractice liability, disimerested pathologists or clinicians, and financial strains on ral~itll)" increasing hospital budgets all may be contribttting to a lowering o f the autopsy rates. However, the salient factor responsible for the decrcase is that l)hysicians, freed o f the

CORRESI'ONDENCE stimulus o f the J C A H , are not asking that autopsies bc l~el-forxncd, clcsl)ite utopian dreams that "any professional stall" with scientific curiosity will not be satisfied with such a low level o f pcrfornmnce as 30 p e r cent." T h e reality is that even for ph)'sicians with tile desire and know-how, tile securing of an autops)' is often a hassle, which, avoided, spares the l~h)sician fiom confrontation and conflict with the next o f kin, potential work (since cases with postmortem examinations are more likely to be presented at rounds and conferences), and possible embarrassment if tile fi,adings are at variance with clinical impressions and therapeutic efforts. If the autopsy is to contribute to qualit) control in medicine as well as function as so lucidl) e n u m e r a t e d b)' l)r. B. F. Truml), methods must be implemented to encourage, prod, and even perhaps force requests for autopsies. This d e m a n d s that o u r elected and appointed leaders in p,'ithology function as "true believers" in the autopsy. T h e y must overcome physician inertia and public objection. T h e y must asst, me an activist role in bringing the autopsy back to its Icgitimate and needed role in primary and continuing education and quality control o f patient care. T h e i r task will not be eas)'. A generation o f medical students has been educated without positive emphasis on the role of the autopsy. Pathologists, with t h e i r "pure" research dominated activities in o u r medical schools and administrative and clinical pathology responsilfilities in o11r ]lOSpitals, must be retaught tile importance and application o f the autopsy. Busy clinicians and pathologists mllst re-establish the dialogues necessary to make tile postnlorlexn examination meaningfid, l'eer review a,atl mortality conferextces must be recognized as inadequate without atttopsy inforlnation. T o accomplish these goals, I offer the following suggestions for consicleration and action b)" tlnose whose voices are ]lean'el int thecouncils where tile future o f the autopsy is being determined. I. Tlle.loint Counmissicm on Accreditation of Hospitals should be encotnraged to establish and enforce ntinilnal standards of autopsy performance for all hospitals. T h e s e standards must state in specific mmtbers what constitutes a reasonable at,topsy rate for significant review o f the quality o f patient care. Obviously, propcrl)' selected cases for autopsy are better than an)' rate that is less than I{10 per cent, I)ut until such time that a method is developed to select tile " p r o p e r cases," a formal minimal rate should be established. Tlne rate need be no higher than it was in the past, since the simple existence o f a rate as a stimulus will probably

result ill the rate's being exceeded. A stimulus xnust be provided, a n d the J C A I I is a logical source for that stimnlus. 2. Specialty boards should establish minimal numbers o f autopsies for accreditation o f training programs, not only in pathology but in all clinical specialties. 3. I'hysicians' recognition awards and certificates recognizing continuing medical education should give credit for autopsies secured b)" attending physicians. T h e securing o f the autopsy implies a dialogue between the pathologist and the clinician. 9t. Governmental, insurance, and private funding agencies must be activel) convinced that the autops)" as a measure of tltlalit )" o f padent care, as an educational device, and as a research Iool is still in its golden age. T h e s e sources of funds, if the)' still have monies to gl'ant, must be e n c o u r a g e d to s u p p o r t the autopsy financially. With financial support, efforts must be m a d e to attract into our colleges of medicine pathologists interested and experienced in the use o f the autops)' as a teaching and research tool. On both tile undergraduate medical student and resident levels o f training, thc autopsy should be a p p r o a c h e d enthusiastically. I))'namic clinical correlation makes even the most "routine" cases exciting for the students. 5. Students should be taught not only why autopsies should be l)erformed but also how to request thenl. T h e students must be p r e p a r e d to dispel the misconceptions arising from uninformed, clich6 filled apathy and the myths and folk-lore that fill tile minds o f much o f the la)" public concerning atttopsies. 6. An active educational p r o g r a m about autopsies should be instituted for the lay public by organized medicine and particularly organizcd l)athology. If medicine does not want to assumc the initiative in sccttring atttopsies, perhaps the imblic can be convinced that autopsies help to guarantee the best of medical care. In this age o f dissemination through the la)" press o f intimate, dctailcd descriptions o f rape and m u r d e r , o f heart transplants and abortions, I am sure that tlne sensitivities o f the public would not bc insultcd b)" opcn discussions of tile subject o f ;mtopsy. MORIO.X J. RoBIxSOX, M.I). Mount Sinai Medical Center ,Miami Beach, Florida I. Ebent, R. V., et a].: O p e n fox'ttm. A debate on tile autopsy: its quality comrol function ill medicine. Ilum. Path., 5 : 6 0 5 - 6 1 8 , 197-1. 2. Raite, S.: Letter to tile editor. I'atho[oglst, 29:38, 1975. 3. I'erspectivcs on accreditation..Joint ('ommission on Accreditation o f Ilospitals, Nov.-I)ec. 1971.


Letter: Debate on the autopsy.

HUMAN PATIIOLOGY-VOLUME 6, NUMBER 6 served in this child's diseased arteries. Future studies of anfinoacidemias and fibromuscular dysplasia may yiel...
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