Autopsy training programs. To right a wrong.

Autopsy rates have decreased from a peak of 41.1% in 1964 to less than 5% in many hospitals today. This disaster has stimulated many symposia and articles on the values of the autopsy, the reasons for its fall, and possible remedies. The many benefits of the autopsy include quality assessment of clinical diagnoses; added knowledge about new diseases, environmental hazards, and genetic disorders; and evaluation of new technologies. The autopsy is also a powerful educational tool. The main reasons for its decline include fear of medical litigation and professional discreditation due to unexpected findings, the unsubstantiated notion that technologic advances have rendered the autopsy obsolete, cost-cutting pressures, and inadequate compensation for pathologists. This essay addresses a remedy for another major contributing problem: clinicians' frustration at poorly performed autopsies due to defective training of autopsy pathologists. Requirements for excellent autopsy training programs include an intensive review of anatomy applied to dissection methods, including sequences of dissection; direct supervision of early cases by a competent and responsible senior pathologist at the autopsy table, with full responsibility assigned to the trainee only after completion of this apprenticeship; review of all cases with clinical staff at regularly scheduled gross organ conferences; and a sustained commitment by department heads to make necessary programmatic changes to meet these standards. Pathologists must demonstrate pursuit of excellence in performance of the autopsy before other ambitious elements are sought for its revival.

Physical examination of the aged patient.

The aged patient presents challenges to the examining physician. Some of these relate to inefficient historical information transfer, reduced mobility, increased disease burden, cognitive and sensory alterations, and confusing background changes in the prevalence and interpretation of physical signs that would be unequivocally abnormal in the younger adult. This review suggests techniques to overcome these difficulties. Descriptions of methods of improving evaluation and interpretation are grouped into the following categories: general appearance and vital signs; skin; head and neck; respiratory and cardiovascular systems; abdomen, rectum and genitalia; musculoskeletal system; hands and fett; and neurologic and mental status evaluations. Several newly recognized signs are also described. The extra time, effort and ingenuity required for examination of the aged patient are richly repaid by enhanced diagnosis.

Amyloid heart disease manifested by systemic arterial thromboemboli.

Amyloid heart disease characteristically produces a stiff heart syndrome whereby diastolic filling is impaired yet systolic function is well preserved. We report two patients with this pattern of amyloid heart disease, both of whom developed cardiogenic thromboemboli. The rarity of this complication is striking given the pathophysiologic bases of amyloid heart disease. Investigation of contributing causes revealed that the phenomena appeared to represent the cumulative effects of disorders producing stasis, endothelial disturbance, and probable abnormalities in blood coagulability, the classic Virchow's triad revisited. Understanding of the pathophysiologic basis of this event leads to specific suggestions for workup and management in this patient population.