Tiresias: Whither current pathology?

“Taceant colloquia. Effugiat risus. Hi locus is est ubi mors Gaudet succurrere vitae.”

(Let idle talk be silenced. Let laughter be banished. This is the place where death rejoices to teach those who live.)

Inscription at the entrance to autopsy rooms.

"They never look very big on the tables, the bodies"

Yann Martel

My friends,

It may seem that Tiresias is in a morbid frame of mind this week. Not at all. Tiresias is equanimous. The blind Tiresias, you see, sees all too clearly. Current histopathologists need reassuring that glass microscope slide, ex-vivo, post-mortem histopathology, which in principle hasn’t changed since Leeuwenhoek and Koch, will go the way of the autopsy. You see, my friends, Tiresias studied medicine when the autopsy was last test, the final arbiter. Tiresias as a student, and young and not so young doctor, at the end of each ward round, would head trepidantly to the autopsy room, for the final post-mortem examination of the patients that doctors had treated and who had died. It was a standard practice that, unless there were some extreme reasons not to, all patients who died in hospital were autopsied. The autopsy was the final and often salutary arbiter, and often a very painful one, which revealed the real diagnosis and real cause of death.

In the last 30- or 40- years autopsy, across the whole western world has gone the way of the dodo. In Australia, except for coroners’ cases, autopsies are rarely done. This is a result of a number of factors but the most crucially, to the relief of the doctors, is the increase sophistication of medical imaging which reveals some the diagnostic enigmas antemortem, which were only available post-mortem. This gives the false comfort to the doctors and the bereaved, so they can say the autopsy will have nothing to add. Quite apart from the medical advances, which provide a fig leaf for not doing autopsies, social changes have made autopsies socially unacceptable, so there is a confederacy of “Don’t ask, don’t tell.” Which suits everyone. Besides, autopsies are expensive.

Tiresias then wonders. Tiresias wonders if the current practice of glass-slide, analogue, impressionistic, very expensive histopathology will go the way of the autopsy. With Confocal Laser Endomicroscopy (CLE), which provides in-vivo, real-time digital, cost and time efficient, AI assisted histopathology, the need to biopsy, with its delayed complex process, requiring excision of tissue and associated sampling problems; the technically complex and expensive process of preservation, slicing, staining, placement on slides, then examination under microscope, give impressionistic diagnosis, which is often wrong, and always too late. Tiresias would like to think that some of the pathology companies realise this about this nice little earner, and might start to take some insurance through Optiscan, and avoid their Kodak moment.