The first central nervous system autopsy in Southern Brazil

ABSTRACT Objective: The history of Anatomical Pathology in the state of Paraná, in southern Brazil, is closely linked with the foundation of the Universidade Federal do Paraná (UFPR). This study identified the first central nervous system (CNS) clinical autopsy performed by the Department of Anatomical Pathology of the UFPR. Methods: This study reviewed the autopsy report archives of the Hospital de Clínicas-UFPR from 1951 onward. The clinical anatomy interpretations of the autopsy report and possible etiologic agents were discussed. Result: The first adult clinical autopsy with CNS study was performed on April 23, 1952 on a 45-year-old man with lobar pneumonia with abscesses complicated by bacterial meningitis. Conclusion: This case was the first CNS clinical autopsy performed in the state of Paraná and, possibly, in southern Brazil. The death was due to an infectious disease, which was the main cause of death in Brazil in the 1950s.

Professor Tibiriçá moved to the Universidade Federal do Rio Grande do Sul, Porto Alegre in 1944 4 .
During these early years, autopsies were performed in the Santa Casa Hospital, where the UFPR medical students received training before the Hospital de Clínicas (HC-UFPR) was founded in 1961. The Department of Anatomical Pathology and Physiology moved to the HC-UFPR this same year 2, 3 .
The objective of the present study was to identify and report the first central nervous system (CNS) clinical autopsy performed by the Department of Anatomical Pathology and Physiology of the UFPR. This study will contribute to the register and historical analysis of the evolution of Neuropathology in Brazil and South America.

METHODS
The autopsy report archives of the Department of Anatomical Pathology of the HC-UFPR were reviewed from 1951 onward. Other possible clinical anatomy interpretations, different from the one at the time, are reviewed and discussed.

RESULTS
In the archives of the Department of Anatomical Pathology and Physiology, of the HC-UFPR, there are a total of 13,986 autopsy examinations, performed between 1951 and 2014. This period includes autopsies performed before the foundation of the HC-UFPR.
The first autopsy performed by the Department of Anatomical Pathology and Physiology of the School of Medicine of the UFPR was performed on November 18, 1951 on a 32-yearold white widowed woman. The cause of death was pulmonary tuberculosis (Figure 1). The first adult CNS autopsy was no. 70, performed on April 23, 1952. The case was a 45-year-old white man who was married and had worked as a bill collector. The cause of death was acute purulent meningitis (bacterial meningitis) associated with lobar pneumonia with abscesses ( Figure  2). Both autopsies were performed by Prof. Dr. Ruy Leal.

DISCUSSION
No records exist of autopsies performed in the UFPR during the early period . Autopsy services in other cities in Paraná state started in the 1960s and '70s 3 ; therefore, there is strong evidence that autopsy no. 70 was the first CNS clinical autopsy study performed in an anatomical pathology university laboratory in Paraná state, as well as in southern Brazil, as Professor Tibiriçá moved from the UFPR to the Universidade Federal do Rio Grande do Sul to organize the Anatomical Pathology service in the state of Rio Grande do Sul 4 .
According with the autopsy report, this case was considered at the time, by Dr. Ruy Leal, as lobar pneumonia complicated by lung abscesses followed by meningitis; however, the etiologic agent was not identified. The main causes of pulmonary abscesses are anaerobic bacteria (46%), comprising Peptostreptococcus sp (12%), Fusobacterium nucleatum (5%), and Prevotella sp. (1%); while 11% are aerobic, comprising Staphylococcus aureus (4%), Klebsiella pneumoniae (3%), Streptococcus pneumoniae serotype 3 (1%), Pseudomonas aeruginosa; and polymicrobians (43%) (aerobic and anaerobic) 5 . Most lung abscesses are caused by aspiration of oral secretions in patients with impaired consciousness. The meningitis was secondary to septicemic dissemination of bacteria to the brain. Lung abscesses constantly seed bacteria into the bloodstream, increasing the patient's risk of brain infection and meningitis 6 ( Figure 3A). Other possible interpretations are discussed in Figure 3B  Infectious diseases were the cause of death in both autopsies presented in this paper (Figures 1 and 2), consistent with the predominant causes of mortality in Brazil during this period. Mortality decreased significantly from the 1970s. While mortality from infectious and parasitic diseases has declined, mortality from chronic degenerative causes and injuries related to accidents and violence have increased 8 (Figure 4).
In conclusion, we report on the earliest adult CNS autopsy case in the records of the Department of Anatomical Pathology and Physiology of the HC-UFPR, this being the first CNS clinical autopsy performed in the state of Paraná, with strong evidence that it was also the first in southern Brazil. The death was due to an infectious disease that was the main cause of death in Brazil in the 1950s.