This Halloween, take a minute to notice amputated limbs littering haunted houses, scary stories about reanimated corpses that you tell by the fire while you’re camping, all that rubbernecking on the thruway when there’s a horrific accident, the endless tv shows, podcasts, and books dedicated to grisly murders… or even Instagram accounts like @Mrs_Angemi and @CrimeSceneCleanersInc boast hundreds of thousands of followers, all hoping to catch a glimpse of morbid pathology and the biohazardous remnants of foul play. This is obviously not a niche thing. We are just as much fascinated by violent death as we are scared by it. There is something about violence and death that is captivating to us. When violent death is combined with high-tech gadgets, police procedures, and super cool forensic testing, you get true crime, one of the most popular genres worldwide.
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Transcript for: Forensic Pathology and the History of Death Investigation
Researched and written by Marissa Rhodes
Produced by Marissa Rhodes and Averill Earls, PhD
Marissa: I’m a true crime junkie. But I’m also a social historian of medicine and the body, so today’s episode is a combination of my most favorite things. In the course of researching this episode, I realized that I was going to have to weave together three largely unrelated narratives: medical pathology has its own history; death investigation does too; and to make things more complicated, there’s a whole medico-legal infrastructure whose history we have to tell. First we’ll discuss death investigation and dissection before pathologists. Then we’ll cover the development of the field of pathology from 1500 to today. It’s important to realize that pathology has two components: a procedural component embodied in the autopsy, and an intellectual component, which contributes to the building of bodies of knowledge for diagnostic purposes. Clinical pathology brings these two facets together by way of dissection for diagnostic purposes, the autopsy. Forensic pathology uses the tools of the clinical pathologist, including the autopsy, for the purposes of criminal investigation and prosecution. Throughout the episode, I’ll also try to give you a basic history of medico-legal systems. Medico-legal systems have been used for centuries for punishment, in the case of post-execution dissection, and for investigation, in the case of early autopsies in suspected poisonings. As we work through this historical labyrinth, keep in mind that even though elements of forensic pathology have been around for centuries, modern medical examiners are a very recent phenomenon (As in.. 1980s recent). It’ll be sciencey but also creepy and cool, and super interesting.
I’m Marissa.
And I’m Averill.
And we are your historians for this episode of Dig.
Marissa: Before get started we wanted to give a shout out to Genevieve in Brooklyn. We got a fantastic email from her thanking us for the Caribbean slavery episode. She explained how the episode touched her personally because she just recently discovered her husband’s ancestors were slave-owning planters in St.-Croix and has been mulling over how to talk about their history with her kids. Getting your email made us so happy Genevieve because its proves to us that we really do history that matters. And it doesn’t just matter to us but also to our listeners who can make meaning in their lives when listening to our episodes. Much love from us.
Related Episodes:
- Photos of the Dead: Victorian Postmortem Photography and the Case of the Standing Corpse
- Employment Agencies in 18c London… and Boobs
- Tuberculean Chic: How the White Plague Shaped Beauty Standards in the 18th and 19th Centuries
Averill: Death investigations had been conducted for centuries and they very rarely involved medical experts. In fact, most people date the field of pathology back only as far as the medical community’s involvement in death investigation which began in the 18th century. Prior to that, searchers of the dead working for the local parish were responsible for investigating deaths in their districts. The most interesting thing about searchers of the dead is that they were all women. In fact most contemporaries called them “Women Searchers.” Most commonly they were also old and poor. In the Black Death context, this makes sense because who else would you have risking their lives in dens of contagion other than poor old hags, right? But searchers were licensed by the Bishop. They had penal authority, which was very uncommon in medieval and early modern England.
Marissa: Even after medical authorities began practicing diagnostic dissections, parish searchers more commonly handled death investigation. In October 1773, Lloyd’s Evening Post published the following short story:
On Monday a hearse and two coaches attended at a home near Walmouth, for the funeral of a widow Gentlewoman, who died on Saturday last; whilst the Coaches were waiting, a rumour was spread that the deceased had been poisoned , upon which a gentleman in the neighbourhood took the Parish Searchers with him to the house , and desired to see the body, which was refused; in consequence of the refusal a Constable was sent for, when admision [sic] being obtained, they found the deceased a miserable spectacle, her body swelled to an amazing size, and her tongue hanging out of her mouth. The woman of the house giving very unsatisfactory answers to the questions that were put to her, was taken before the Justice of the Peace, who committed her for further examination, and a Coroner’s Jury are summoned to enquire into the matter. 1
Anatomical theatre- Leiden
Based on this story, we know that searchers of the dead investigated suspicious death, they were sent by the parish, and that they had enough authority to summon a constable on their behalf. You may have heard of parish searchers before if you have read or listened to histories of the Black Death but few people realize that these searchers were permanent fixtures in English parishes. They weren’t just hired ad-hoc at times of epidemic. Searchers were appointed by parish authorities well into the 19th century.
Averill: When someone died, searchers would be called for by family or sometimes the town would ring a death bell. The searchers inspected the corpse and notified grave diggers that their services were needed. After inspecting the dead, searchers drew up a report of the death for the town’s death registers. These were called bills of mortality. The searchers were paid a fee for each corpse inspected and compelled to take an oath as to the accuracy of each bill of mortality. Only then could the parish clerk issue a certificate for interment.
Searchers’ primary goal was to identify deaths by infectious disease and to look for signs of violence on dead bodies. If infectious disease was the cause of death, municipal authorities were alerted so they could take steps to prevent an epidemic. If murder was suspected, the Constable would be notified and more investigation, such as a coroner’s inquest, would be performed. Searchers had no medical training; they were underpaid and it was not a pleasant job. Physician William Black calculated that in 1750, there were 23,757 deaths in London and the law required that each corpse was inspected by two searchers before interment. There were an estimated 147 teams of searchers that year so each searcher would have examined 161 bodies that year, a body every other day. (For more on searchers of the dead look to Kevin Siena, Deborah Harkness, Richelle Munkhoff and Wanda Henry).
Marissa: Searchers determined causes of death for the bills of mortality but they did not open the body. Even coroners rarely opened bodies. Coroners inquests more closely resembled a modern hearing or trial than it did the medical examinations performed by forensic pathologists today. Notable gentlemen presided over suspicious deaths, inspecting the corpse and hearing testimony from witnesses. They convened and passed a verdict on the cause of death after some discussion. However, as the eighteenth century wore on, magistrates became increasingly likely to order medical dissections for evidence in criminal investigations. This was especially common in the case of stillborn children, as women were often suspected of infanticide. For such cases, magistrates demanded that the cause of death be determined by a trained surgeon. This may, or may not, have included dissection.
Averill: Dissection in medical schools such as the University of Padua became common in the 1500s. In medieval Europe, surgeons were typically barber-surgeons, trained under apprenticeship, like any other tradesman. The use of dissection in medical education during the Renaissance was a game-changers. It combined the intellectual interests of physicians who typically dealt with medicine in a hands-off theoretical way, with the practice of surgeons who had the practical knowledge of body structures. In 1594, the University of Padua established the first known anatomical theater. Two years later, another one was built at Leiden, in the Netherlands. They resembled classical amphitheaters, with descending circular tiers leading down to an operating table where senior faculty would dissect a human corpse in front of student observers.
In Leiden, students and faculty had even begun to observe patients during their illnesses, at the time of their deaths, and then after death in the anatomical theater. This process naturally led them to speculate about the connection between their patients’ symptoms, how the disease caused their death, and then the signs they observed on the patient’s body as a result of the fatal disease. At this point in time, diseases were explained in terms of humoral theory. Humoral theory was developed by Galen of Pergamon, a Greek physician living in the Roman Empire in the 2nd century CE.
Marissa: Galen posited that the body contained four fluids or “humors”– blood, yellow bile, black bile, and phlegm. Healthy bodies contained a balance of these four humors, though everyone’s humoral make-up was slightly different. The humors had their own innate properties: blood was hot and wet, phlegm was cold and wet, yellow bile was hot and dry, and black bile was cold and dry. Imbalances humors could cause physical changes in the body as well as behavioral changes, such as irritability or depression. Disease was caused by either acute or chronic imbalance of humors.
“The Diseases and Casualties This Week,” 1665 | Wellcome Collection
Excess yellow bile, for example, made people choleric: symptoms could include anger, aggression, jaundice, fever, and heartburn. Physicians treated choleric patients with emetics- substances which would make patients vomit. The hope was that they might purge their excess yellow bile and bring the humors back into balance. Choleric patients were also sometimes treated with cold and wet foods. Physicians thought that if one’s body was too hot and dry (as was the case with cholertic patients) that cold and wet foods might also restore balance. There are many gendered aspects to Galenic medicine as well but we won’t have enough time to get into that here. Suffice it to say that Galen’s humors influence medical diagnosis well into the 19th century, even though trained experts began to dismantle his theories much earlier.
Averill: Humoral medicine was a limiting framework for their interpretations but still, physicians at Leiden were, as early as 1600, doing the work that would become the discipline of pathology two hundred years later. It took some time though, before anyone recognized the value of post-mortem autopsy to the field of diagnosis. There was no systematic process in place. Autopsies were few in number, and no one thought to record their observations for future diagnostic use. This changed after the Enlightenment, which popularized philosophies of materialism.
Over the course of the seventeen-hundreds, interest in human, animal, and plant anatomy exploded. Scientists were convinced that understanding the matter which made up the natural world was the key to explaining any question we might have. The Enlightenment reinvigorated empirical research and launched a collaborative effort to identify, record, and classify the entire natural world. Swede Carl Linnaeus, for example, devised binomial nomenclature, the system of classification still used by biologists today. He also created an animal taxonomy which placed humans in the category of primate. Materialist philosophy and the new preoccupation with documentation and classification triggered exponential growth in the number of anatomy theaters and the frequency of autopsy in medical educational programs.
Marissa: In 1761, Giovanni Morgagni published On the Sites and Causes of Disease, what many consider to be the first publication in the field of pathology. Morgagni was born in 1682 and attended the University of Bologna and became a professor at the University of Padua in 1711. (Side note: he and his wife, Paola, had twelve daughters and three sons– I can’t begin to imagine the labor she put into their family as he built his fantastic career shout out to Paola.) For fifty years, Morgagni practiced as a physician and medical professor, keeping careful notes. His colleagues called him “his Anatomical Majesty” because he was fascinated by human anatomy and never shied away from inspecting the bodies of his patients. Most of his colleagues developed diagnoses and courses of treatment through verbal interviews, but Morgagni actually touched his patients’ bodies. At the age of 78, Morgagni collected his notes from decades of practice; it included a total of 630 patients whom he followed during their illness, death, and autopsy.
Averill: He used this data to describe a new way of understanding the body- as a mechanical structure- whose functioning was interrupted by diseases that could be identified in post-mortem observations. He described how disease changed or damaged the structures of the body and how those structural changes caused symptoms, and sometimes death. For example, he differentiated between stomach cancer and stomach ulcers, identified heart-block syndrome (now called Adams-Stokes syndrome), and described the damage done to a human heart after a heart attack. When he passed away at the age of 89, his body was autopsied and it was found that his cause of death was a heart attack. Medical historian Roy Porter once wrote, “ It was Morgagni who… finally clinched the direct relevance of anatomy to clinical medicine.” In other words, Morgagni’s work, including all that careful documentation correlating symptoms to diseases to anatomical findings, tied the external pathologies noted by surgeons, with the internal pathology practiced by physicians. It also elevated surgery from a trade or vocation to a respectable, scientific profession.
Marissa: Initially, the field of medical pathology revolved around human tissue. Theories surrounding tissue pathology were developed for the most part in Britain in the 1760s and 1770s. Scottish surgeon John Hunter established an anatomy school in London around 1764. He earned his medical education at St. Bartholomew’s hospital in the 1750s and became the house surgeon at St. George’s Hospital in 1756.
The proliferation of hospitals in the eighteenth century gave pathologists a new forum for observation. Five general hospitals were established in London between 1700 and 1750. In 1719, two-thirds of the shires in England had no hospital or infirmary. By 1799, every shire had at least one hospital and most large cities had several. After 1750, the surgeons and physicians practicing in London’s hospitals, often called “the faculty” began lecturing and drawing enrollment of medical students from around the empire. They also supervised clinical rounds. This model of medical application was mostly new. The vast majority of surgeons had, to this point, performed trauma-related surgeries (without anesthesia by the way), short procedures like gallbladder removal, and they encountered corpses in the anatomy theater. They almost never treated patients experiencing symptoms or reviewed extensive medical records in relation to their procedures. (Morgagni was a bit of an outlier in this respect.) But Hunter’s generation, and those that followed, benefited from rounds of clinical observation in London’s many hospitals prior to surgeries and autopsies. This generation of surgeons were the first to not only contest humoral theory, but to establish a theory of pathology in its place, tissue pathology.
Averill: Tissue pathology regarded the body’s many systems as a complex array of layered tissues which had distinctive properties and performed distinctive functions. The brothers Hunter and their protegés articulated various pathologies as problems of the different tissues within the body. From 1760-1763, John Hunter served as an army surgeon in the Seven Years War. He was horrified by the state of trauma care, especially the process of wound dilation. In the 1760s, army surgeons typically dilated gunshot wounds using various tools so that they could reach the shot and gunpowder lodged in the patient’s tissues. Hunter suspected that the practice did more harm than good. In his later years, after decades of clinical observation and surgical intervention, Hunter published A Treatise on Blood, Inflammations, and Gun-Shot Wounds where he argued that inflammation was the body’s natural, healing response to trauma and not a pathology on its own.
Marissa: Before the invention of the microscope, tissues were the lowest common denominator– the smallest unit of observation available to the naked eye. This form of pathology was practiced and perfected in Paris by a cohort of teaching tissue pathologists– headed by Xavier Bichat. Parisian tissue pathologists had a large pool of subjects to study. Parisian hospitals were massive. The Hotel Dieu had as many as 3,000 beds in post-revolutionary and Napoleonic France. Parisian hospitals had a steady supply of the injured, sick, and dying, thanks to the chaos, violence, and starvation of the war-torn capital. Parisian physicians at the École de Santé systematized clinical rounds, death attendance, and post-mortem examinations. As one medical historian puts it, their findings were all “variations on the theme of ‘get this disease, die in this way, the morbid appearance of tissues thus displayed.’” Their value lay in the repetition of the same process time and again, to compile bodies of diagnostic knowledge whenever they encountered similar cases.
Averill: The Parisian faculty’s emphasis on tissues changed the way that medical students learned. Though dissection was a visual practice, anatomists still tended to teach their students primarily through verbal descriptions and lectures. Tissue pathology triggered a movement toward visual teaching aids, meaning pictures and diagrams. Prior to the rise of tissue pathology, the source of disease was located in specific organs. Students were easily able to understand organ functionality through lecture. Once the origins of disease were traced, instead, to types of tissues, such as lymphatic tissue, epithelial tissue, pericardial tissue, etc., visual aids became indispensable. In addition to diagrams, medical students consulted preserved specimens.
Marissa: Famed Scottish physician Matthew Baillie attributed his success in pathology to three things: his post as a resident physician in a large hospital, his teaching post at an anatomy school, and, most importantly, his access to prepared pathology specimens. There were several specimen collections in continental Europe and the use of preserved specimens in instruction was by many considered to be a particularly French medical practice. Still, the largest and most useful collection resided in London. John Hunter’s older brother William Hunter, was also a surgeon, pathologist, and avid collector. William Hunter gave his students access to the vast collection of medical specimens which he had assembled over the course of his career. He was known for a spectacular business acumen which allowed him to build elaborate networks around London to procure cadavers for dissection or specimen preparation. In the rest of Britain, cadavers were in short supply. William Hunter drew medical students from all over Britain because he used his cadavers and specimens to teach medicine in “the French style.” When he passed away in 1783, William Hunter’s collection contained 15,000 preserved specimens.
Most of them consisted of preserved cross-sections of tissues- both wet and dry preparations which presented with various morbid pathologies. For example, specimen 21.45 showed the dentate nucleus of the cerebellum of a man who suffered from chronic madness; interestingly, the cerebellum appeared normal. The suprarenal gland of Queen Charlotte’s elephant, which was dissected in 1776, is preserved in this section of the collection. Dental students found the preserved dentitions particularly useful; there are many jaws of children which show the various developmental stages of tooth eruption and loss. There are also 260 different specimens which show various stages of fetal development, placental problems, and uterine or ovarian disease. The fetal specimens include one set of identical triplets.
Averill: In recent years, William Hunter’s anatomy collection has ignited debates over the ethical implications of exhibiting human and animal specimens. In 2010, an amateur historian managed to get an article published in in the Journal of the Royal Society of Medicine wherein he accused the Hunter brothers and their colleague, William Smellie, of murdering 35-40 pregnant women and their fetuses. The author argued that he had documentation that the three physicians were responsible for the burking deaths of vulnerable women who sought their professional expertise. This, he argues, is why William Hunter was so skilled at procuring cadavers; he was killing them himself. Of course, the press ran with this. His interpretation of his evidence has been largely debunked by several medical historians. Still, several historians have confirmed that gestating and postpartum women and fetal remains were the most desired specimens.
A prosecutor performing an investigative dissection | Wellcome Collection
The collecting impulses of tissue pathologists were, in hindsight, problematic but still they made several important discoveries. Xavier Bichat classified 21 types of tissues that made up the human body, launching the field of histology. Edward Jenner, a student of Hunter’s, developed the world’s first vaccine in 1789. René Laënnec invented the stethoscope for listening to activity within the patient’s chest. Prior to this invention, physicians placed their ears against the patient’s body to listen to heart and lung sounds. Leopold Auenbrugger von Auenbrugg devised the diagnostic technique of percussion, tapping the body with an instrument to detect structural problems. William Cullen developed a disease classification scheme– called nosology– and Samuel Hahnemann invented homeopathy. Note that scientists were focusing on ways that autopsy might advance medical theory and not on how autopsy might help investigate criminal cases. Searchers and non-invasive coroners inquests were still being used as the primary tools for criminal investigations.
Marissa: By the 1830s, Parisian physician Auguste Chomel and his colleagues were conducting methodical observations of patients in large numbers. This allowed for the compilation of large data sets that could be statistically analyzed. This allowed pathologists to not only determine causes of illness and death, but to determine comorbidities and offer patients prognoses. In other words, they could recognize diseases that often occur together and predict with some degree of accuracy how long a patient might live, or how they might fare after contracting a particular disease. These promising developments did not, however, insulate medical pathology from criticism.
Averill: People were beginning to resent pathologists’ funding of criminal gangs of body snatchers, sometimes also called resurrectionist men. One cannot discuss 19th-century medical pathology and exclude body snatchers from the conversation so let’s take a quick detour from the narrative of the discipline to answer the question of where surgeons were getting all these bodies from. (We have an old episode on Frankenstein which covers body snatching in a literary context so check that out. It’s an old one and we have dreams of redoing it but it hasn’t happened yet.)
Traditionally, medical schools secured cadavers from the gallows. England has a long history of post-mortem harm. The Murder Act of 1752 ordered that criminals convicted of homicide were to be hanged and then sent for post-mortem dissection. Though the criminal was already dead, the opening of their bodies, usually in public venues by penal surgeons, was regarded as a humiliating punishment worse than death. (This is how Elizabeth Brownrigg was punished- yes ANOTHER episode connection). There was also a practical aspect to criminal dissection; penal surgeons were also making sure that the criminal was actually deceased. Occasionally, hanged criminals were revived after their bodies were cut from the scaffold, especially in cold weather. The primary purpose of this choreographed performance, however, was to deter violent crime; but surgeons and medical students benefited from the state’s criminal code. In London, there was an anatomy theater built specifically for criminal dissections but in almost all cases, the hanging was done in the public square. In April 1813, the hanging of Edith Morrey reportedly drew a crowd of 10,000 in the small town of Chester. Morrey’s body was opened on site to confirm death before being delivered to the local infirmary to undergo full dissection.
Marissa: Surgeons also used the bodies of the poor who died in infirmaries or hospitals and could not afford burial. Still, demand outpaced the supply of cadavers. Body snatchers took advantage of this problem, stealing bodies from poor houses, asylums, cemeteries, and even directly from their own homes. A black market quickly developed to supply medical schools with stolen cadavers. Undertakers filled coffins with sawdust, procurers bribed nurses and gravediggers to covertly traffic fresh corpses. Some body snatchers were even found to have killed vulnerable people only to turn around and sell their cadavers. Eventually, the desperation for corpses was felt by respectable, well-to-do families. In January 1832, The Observer (London) reported that a “gang of body snatchers” had stolen the corpse of Mr. Wilson, “a man of property” from his deathbed. 2
That same year, the Anatomy Act was passed in parliament. The 1832 act was meant to damage the network of illegal cadaver trafficking by giving legal authorization to alternative supply streams. But, as the fabulous historian of death Elizabeth Hurren has noted, the primary purpose of the Anatomy Act was to protect respectable families from grave robbery and body theft. Hurren found that poor relief authorities and asylum personnel sold cadavers of the poor to medical establishments to recoup the costs of having cared for the person while alive. This attempt to address body snatching might have improved the problem for the wealthy but the poor were exploited more than ever before, even in death. In the 1870s, there was an anti-welfare movement in Britain and Hurren has found that the supply of pauper cadavers doubled during the campaign. So she makes the point that the economic agendas of poor relief authorities were aligned with the research and training needs of medical establishments. One thing to keep in mind is that cadaver supply is a problem even today. (But with 3D printing technology, we have the ability to print artificial but anatomically accurate specimens- super interesting).
Averill: Over the course of the 1830s and 1840s, microscopists continued to improve their instruments. Scientists all over Europe began to observe the tiny structures that composed human tissues, cells. Matthias Schleiden and Theodor Schwann were the first to describe the cell and its basic functioning. They argued that cells were the building blocks of life for plants and animals. They coined the term “metabolic” for the chemical exchanges that took place within and between cells. Scientists debated the merits of cell theory for decades. Still, the idea of a pathology based on cells rather than tissues remained theoretical until German pathologist Rudolf Virchow published the (creatively named) article Cellular Pathology in 1858. He argued that disease occured when cells malfunctioned or produced defective copies of themselves. As one medical historian put it, to Virchow, “cells were the units not only of life but also of death.” 3
Virchow’s article served as the foundation of the new pathology, based on cellular rather than tissue biology. This new paradigm changed the ways that pathologists diagnosed disease and determined cause of death. And it couldn’t have come at a better time. Nineteenth-century cities were crowded and unsanitary. Nutritional deficiencies, infectious disease, and traumatic injury interfered with most people’s quality of life. In Manchester, UK, for instance, death rates in the city were triple the rates in the immediate countryside. In New York City, rates of infant mortality doubled between 1810 and 1870. In German cities, 94.7 out of every 10,000 people died from gastrointestinal disease, and another 67.3 out of every 10,000 people died from respiratory infection. This means that about 15,000 people died each year in each large Germany city from diarrhea and tuberculosis alone. These numbers are huge; for the sake of comparison I found that in 2017, there were 100 tuberculosis deaths in all of Germany.
Marissa: Municipal officials in nineteenth century cities (in Europe and America) were intent on slowing the spread of disease and improving the health of the working class. Public health officials recognized autopsy as a means of identifying outbreaks of infectious disease, accidental deaths due to hazardous conditions, and instances of homicide. Slowly, autopsies were incorporated into normal procedure in death investigation. As they became more common, pathologists such as Sir William Oslow, developed autopsy protocols. These protocols called for the opening of the chest cavity and inspection of the organs. This systematic approach improved the accuracy of forensic and diagnostic conclusions. Medical and legal officials were convinced of the importance of autopsy to medical knowledge and public health, but the public still needed convincing.
Doctors were often unable to obtain consent for autopsies because the general public regarded dissection as a form of mutilation. At this point, in both Europe and the United States, the medieval inquest system had all but disappeared. Coroners had been vested with the power to compel physicians to order autopsies and their primary goal became the identification and investigation of suspicious death. Their power within the medico-legal system continued to increase for the next 100 years.
Averill: In the 1890s, American gynecologist Howard Kelly suggested a new, less invasive autopsy technique. Kelly argued that pathologists could access and remove internal organs for examination with incisions only in the vagina, perineum and rectum. The legs of the cadaver would be elevated in stirrups for the procedure and pathologists would reach into the chest cavity from between the legs. This type of autopsy left the visible parts of the body intact and unscarred. (I have to say this procedure seems even more invasive than a regular Y-incision. Yikes.) Perhaps this is why it didn’t gain traction in the field. But it shows that people were trying to make autopsy more palatable for the general public.
What followed was an explosion of new disciplines, especially once scientists used microscopes to watch cells split. They were able to better understand the science behind cellular generation which has all kinds of implications for the study of cancer, genetics, skin grafting, etc. Immunology also benefited from the efforts of cellular pathologists. Cellular pathology had potential to improve people’s lives. Virchow’s understanding of cells influenced the way that he practiced his craft. Virchow wrote several articles about tumor pathology. With a new understanding of cellular function, Virchow stressed the importance of inspecting excised tumors under the microscope to ensure that it had histologically (cell-based) “clean margins.” This meant that the surgeon had excised enough tissue to assure that no cancerous cells were left behind.This principle is still followed today.
Pathology drawings from the 19th century | Wellcome Collection
Marissa: Julius Cohnheim used the new cellular principles to study inflammation. In decades past, inflammation was thought to be a problem occuring at the tissue level. But Cohnheim suspected that inflammation started at the cellular level. His hypothesis was proven by vivisection (check out our old vivisection episode) which is basically dissection of living animals. He showed that not all cells had inflammatory capabilities. Cohnheim used vivisection to demonstrate how trauma and infection prompted local cells to solicit the aid of inflammatory cells from elsewhere in the body. Cellular biology also launched the field of bacteriology. Medical scientists knew more than they ever had before about the growth and behavior of bacteria cells.
Averill: Even though cellular pathology led to tremendous scientific advancement, it may have had a negative impact on medical students’ understanding of the body. Scientists engineered precision machinery that could slice paper-thin specimens, dyes to make structures more visible, and chemicals that could preserve and not destroy such delicate tissues. Medical education revolved around microscopic specimens and therefore, practicing pathologists had a more localized understanding of disease. They focused on culturing samples from abscesses and identifying the pathogens extracted from the body with very little insight into how the body functioned as a whole. Comparative anatomist Ernst Haeckel worried that the new generation of medical students “will only know cross sections and colored tissues, but neither the entire animal nor its mode of life!” Medical historians call this crisis a “hunger for wholeness” 4 and it peaked in the beginning of the 20th century. Pathologists felt like they had zoomed so far into the structures of the body that they had lost sight of how the system was working as a whole. Scientists launched a movement to integrate cellular pathology with the body as a whole. Russian and German scientists began calling for a return to the clinical approach that had arisen in the 18th century, when pathologists performed clinical rounds in Europe’s hospitals.
Marissa: Ironically, it was the rapid diversification of medical specialties that allowed for a more holistic approach to pathology. Firstly, there was chemical pathology. There had been a few forays into chemical diagnostics in the early 19th century. In the 1830s, Richard Bright used chemical analysis of the urine of patients with dropsy (edema/heart failure) to prove that it contained a certain protein and indicated malfunctioning of the kidneys. From that point forward, dropsy was diagnosable through this technique of chemical analysis. But for almost two centuries, chemical tests on specimens for the purpose of diagnosis were rare. It wasn’t until the 21st century that chemical analysis became a routine part of post-mortem examination. This was before the time of rapid chemical assays, and the inclusion of diagnostic laboratories in most hospitals. Still, the field of chemical pathology bridged that gap between bedside and morgue that had opened during the cellular pathology phase. This is because patients were undergoing chemical analyses when they presented with symptoms, while they were being treated, and again after they died.
Averill: Something similar happened with surgical pathology too, which also came into being in the early 20th century. Surgical pathologists would excise a tumor from someone’s breast, examine the tumor, and then create a report of the diagnosis. They didn’t usually examine cadavers of the patients they’d operated on but their reports gave medical examiners a pathological trajectory that had not been standard in the past. Now, during autopsy, pathologists could consult vast bodies of medical records, prepared by pathology specialists throughout a patient’s lifetime. This marked a return to clinical pathology for the rest of the 20th century.
Pathologists were satisfied with the direction of the field but strangely, starting in 1960, autopsies
Instruments used to treat gunshot wounds | Wellcome Collection
declined and pathologists’ contribution to medical innovation all but disappeared. There have been several studies performed about this odd decline and all of them have found that it was not the deceased’s family member who were declining autopsy, it was clinicians who were becoming less and less likely to request them. They argued that diagnostic medicine had advanced so far that they typically knew what a patient had died from based on tests they had performed while the patient was still alive. In the case of foul play, clinicians argued that investigative techniques were so effective that they rarely needed an autopsy to discover the cause of death. This all makes sense. Trained pathologists found that opportunities for autopsy became rare and pathologists lost their place as leaders in medical innovation and diagnosis. Pathology went on to play important roles in clinical chemistry and more recently, genomics, but I get the impression that pathologists are now the red-headed step-children within the medical community.
Marissa: It was at this point, in the time when hospital autopsy was rare, that pathologists became more intimately involved with criminal investigation. Forensic pathology, which has the goal of finding the cause and manner of suspicious deaths, quickly became the most visible branch of the field. This required a drastic reorganization of medicolegal systems in Europe and America. New York City was the first to institute a medical examiner system in 1915 after they had received repeated criticism for the failures of their coroner system. Forensic investigation, which was becoming increasingly popular, put professional pathologists in the middle of criminal investigations. While English coroners were increasingly medically trained and employed by municipalities, American coroners still tended to be political appointees and most had no medical training. In America, most cities opted to establish a medical examiner system; they used taxpayer money to hire a trained pathologist who conducted post-mortem autopsies at the behest of legal authorities. Medical examiners perform autopsies in the case of suspected murder, accidental death, suicide, and other sudden deaths. Once medical examiner systems became more prevalent, autopsies outside of the criminal scope continued to be performed in hospitals by medical pathologists seeking knowledge about a patient’s disease trajectory.
Averill: In England, the coroner system remained in place but the coroner morphed into a figure that bore little resemblance to his/her medieval counterpart. Even today, English coroners are medically trained and act as independent investigators of death. They perform more post-mortem examinations than most medical examiners and have the ability to summon witnesses or examine evidence related to any death. In continental Europe, where the coroner system was never established, a third system emerged. This system used independent pathologists rather than medical examiners on municipal payrolls. Even today in continental Europe, police have the power to order medical examinations by trained pathologists. Legal authorities develop special relationships with medico-legal organizations, often non-profits or research institutes. Unnatural deaths are then referred to prosecutors.
In the United States, many towns, usually rural ones, have maintained their coroner system even though the medical examiner system is the preferred norm. Most studies show that the coroner system yields higher autopsy rates. In the UK, autopsy rates are as high as 99% in big cities. They tend to pay closer attention to seemingly natural deaths and each death gets more attention. But the medical examiner system results in much more effective death investigations, better aiding the prosecution, when criminality is involved. They do, however, yield lower autopsy rates on the whole.
Marissa: In many ways, forensic pathology was an unlikely discipline. It required an end to parish searchers and coroner’s inquests, and in some states, the elimination of coroners altogether. It requires advanced medical training but doesn’t pay as well as other medical disciplines because they are so often civil servants rather than physicians in private practice. It also required a recognition that medical pathologists were best-suited to investigating death. It seems obvious to us now but it took hundreds of years for us to reach that conclusion and to put practical steps in place to install trained pathologists in medical examiners offices. And to be honest, I fear for the future of forensic pathology only because their success depends on tax revenue and federal grants.
Averill: In 2000, the CSI franchise launched its first show and ignited a television empire of crime shows centered on forensic pathology. (Crossing Jordan is another one and I’ve watched every episode several times.) These shows portrayed forensic pathologists as glamorous and their work as instrumental to solving the world’s most gripping murder mysteries. There is some evidence that this enthusiasm for forensic medicine led to a mismatch in the job market. In the early 2000s, trained pathologists exceeded the number of medical examiner positions by more than 30%. There were few of them, but they were suddenly expected to do a lot. Medical examiners generally assess the crime scene, extract samples and interpret toxicology and radiology reports, conduct autopsies and related tests, and testify in criminal trials.
The American medico-legal system has undergone harsh criticism in recent years. They are often unable to keep up with the latest investigative technology; morgues are staffed predominantly by people without training in forensic pathology (casualization of labor). A study of 1600 American counties with coroners found that many of them had nothing more than a high school education and some were working part-time in addition to working a full-time job in an unrelated career. These shortcomings have occasionally led to undetected murders, or even innocent people going to prison for crimes they did not commit.
Marissa: Adding insult to injury, the CSI Effect has undermined the value of traditional police work in criminal trials. Modern juries expect forensic evidence and are shocked to discover that most criminal cases go forward with only circumstantial evidence compiled by detectives. Jurors are disappointed by the gap between the high-tech world of CSI and the harsh reality of medical examiners’ resources. Still, some forensic pathologists, such as Jan Garavaglia and Nicole Angemi, have developed cult followings on true crime tv networks or using social media. I’m thinking that there has to be some way for forensic pathologists to capitalize on people’s true crime obsessions to get the things they need.
There are some non profits working on this such as END THE BACKLOG, a project designed to fund the processing of hundreds of thousands of rape kits which sit untested because of a lack of resources.
SOURCES:
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