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Context: A Treatise on Pathological Anatomy, published in 1829 by William E. Horner, is the first American textbook on pathology. Several articles have been written on Horner, but they do not evaluate the role that the knowledge he recorded played on the intellectual origin of the discipline of pathology in America. Only one article, published in 1930, deals in some detail with the content of the Treatise. Because of new historiographic standards, this is an opportunity to expand on, and update, that article. Furthermore, Horner's book is now available free online, and print-on-demand paperback copies can be ordered for a modest cost from online booksellers., Objective: To describe the organization and structure of the scientific knowledge found in the Treatise with the intent of demonstrating how this material created the intellectual basis for the origin of pathology as a discipline in America., Design: Using current historiographic standards, the knowledge included in the book is examined and contextualized within the social, professional, and educational conditions existing at the time of publication. The essay also includes biographic data on the author., Results: The Treatise contains important information on the principles, ideas, and practice of pathology in the nineteenth century and illustrates the influence of French literature on the author., Conclusion: The contribution of the Treatise as the first formal textbook on the subject in America is seminal and should be the basis for further historic studies on the organization and structure of scientific knowledge in pathology in America.

Context: -Sir William Osler, MD, and Howard Kelly, MD, were probably the preeminent practitioners of their respective specialties, internal medicine and gynecology, during the late 19th and early 20th centuries. Both were passionately interested in pathology. Although not widely known, during the 1880s, both allegedly pioneered "arm's length" methods to perform covert autopsies that involved removing abdominal and even thoracic organs via the anus, vagina, or a small perineal incision hidden behind the scrotum. These techniques were allegedly used, at least occasionally, to circumvent autopsy-consent regulations and to procure teaching specimens for medical museums., Objective: -To examine the historical evidence for these alleged events and to examine these behaviors within the context of (1) the need to obtain pathologic specimens for teaching gross pathology and clinical pathologic correlation to medical trainees, (2) the loose interpretation of autopsy-consent regulations at "charity hospitals" during the late 19th century, (3) the medical museum movement, and (4) the paternalistic approach to the practice of medicine typical of the times., Design: -To address these issues, standard historiographic methods were used to examine available primary and secondary historical sources., Results: -The evidence suggests that Kelly developed and published 3 arm's length methods for covert autopsies while a resident in Philadelphia, Pennsylvania, and that both Kelly and Osler pioneered the use of these methods in the 1880s. The brief history of these "minimally invasive" autopsy techniques is also examined by reviewing 19th and 20th century textbooks of autopsy technique., Conclusions: -Howard Kelly, MD, and William Osler, MD, pioneered arm's length methods for covert autopsies. In fact, this activity appears to have initiated the 2 doctors' long professional relationship.

Sir William Osler was the preeminent internist of his time, who also worked as a pathologist for a considerable period during his career. Between 1876 and 1889, he performed nearly 1000 autopsies in Montreal, Quebec, and Philadelphia, Pa. Many authors concluded that Osler stopped performing autopsies once he moved to Baltimore, Md, because the autopsy service was organized under William Welch, the professor of pathology. However, this assertion has been contradicted by a recent biography of Dr Osler. To reexamine this issue, the autopsy records of The Johns Hopkins Hospital and relevant publications were examined. The evidence suggests that Dr Osler was an enthusiastic, and sometimes engaged, observer of Hopkins autopsies but that he did not function as an autopsy prosector.

The downward trend in the rate of clinical autopsies has been extensively documented in the literature. This decline is of concern when the benefits of the clinical autopsy are considered. In contrast, the rate of medicolegal autopsies has not been studied in such detail. What little reference there is to medicolegal autopsy rates suggests an absence of the same downward trend. A retrospective review of autopsy data over a 13-year period from the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, and from the Office of the Chief Medical Examiner of Nova Scotia was conducted. This review showed a difference between the rates of clinical and medicolegal autopsies for the metro Halifax area. The clinical autopsy rate was consistently less than 30% and declined to 15% in 1999, while the medicolegal autopsy rate was consistently greater than 40% and rose to 62% in 1999. The literature proposes many reasons for the decline in the clinical autopsy rate, but none for this difference between rates. The explanation proposed here is the changing and currently uncertain purpose of the clinical autopsy versus the clear, and consistent over time, purpose of the medicolegal autopsy.

Between 1912 and 1980, many English language publications analyzed the correlation between clinicians' diagnoses and postmortem examinations. Surprisingly, the percentage of cases with undiagnosed principal underlying diseases or primary causes of death has not diminished during this period. The autopsy's unvarying percentage yield does not indicate a lack of progress, however, since bacterial pneumonia, hepatic cirrhosis, and common tumors were missed routinely in earlier eras but were rarely missed after 1970. Pulmonary embolism remains commonly missed, but the striking recent finding is the emergence of fungal and other systemic infections that were rarely noted in prior eras. Progress in diagnosis and treatment may allow patients to live longer and new or obscure diseases may develop that will often be missed clinically. An appropriately high autopsy rate will be required if medical progress is to continue.