Looking Inside the Dead: The Rise of the Virtual Autopsy

We’ve all been so justifiably preoccupied with former Hurricane Sandy that you may have missed a story unfolding in England this past week. So, as a distraction from the trees, traffic and sludge:

Ronald Brown, an English veteran of World War II, would quietly complain from time to time about his bad leg, the reminder of a land mine that he stepped on in August 1944 in France. Army surgeons felt it was safer to leave the mine’s fragments in his flesh than to try and fish them out, and ever after, Brown’s knee set off airport scanners and ached too much for his grandchildren to sit on it.

When Brown died earlier this month, aged 94, he was cremated, and his daughter asked the crematorium if they could retrieve from his ashes the bullet that they believed caused his pain. She thought it would make a nice memento. What happened next, from The Telegraph:

His family … were stunned when staff handed them back a big bag of shrapnel.

The bag contained a whopping 6oz of bomb shrapnel that he had been carrying around for 60 years.

Daughter Jane Madden, 55, of Exeter, Devon said: … “I don’t think he ever realised all that was in his leg – it weighed about six ounces. He’d said there was a bullet in his leg but I was imagining one romantic piece of metal.”

This tangle, found in Ronald Brown’s ashes after he was cremated, may have been metal bits loaded into a World War II land mine — or coffin hardware. Original via ABC News.

The secret kept by the modest veteran, a tax inspector and widower who lived quietly in Exeter in the far southwest of England, captivated readers. They praised his uncomplaining sacrifice and marveled over the story of his injury; with his leg shredded, Brown reportedly dragged himself two miles to get medical care. Out of 900 people in his regiment, the East Yorkshire, he was one of only 29 to make it home.

And yet: If you look at the image at right, the contents of the bag of shrapnel, you’ll see some things — screws, for instance — that seem implausible for a 1940s version of an IED. World War II history buffs noticed the anomalies, and began asking questions. That led to a follow-up story:

The family of Ronald Brown, who died earlier this month aged 94, were led to believe the 6oz pile of metal had been retrieved from his body after he was cremated…

But today, after experts examined photographs of the metal pieces following newspaper reports, it appears the solution may be a little less macabre.

The “shrapnel” could instead be metal pieces from Mr Brown’s coffin, similar to those left over after any normal cremation…

His granddaughter Tasha Madden, 24, said the family were hoping to hear from the company which made the coffin with an explanation.

Why bring this up? Because there’s a modern practice that could have prevented the confusion, by identifying what was inside Brown’s body before he was cremated. As I explain in the current Scientific American, it is now routine for the bodies of US military members to be subjected to CT scan or X-ray before they are released for burial or cremation. The technique has been dubbed “virtual autopsy,” and while it is not yet widely used, it is gaining ground in civilian death-investigation and clinical pathology as well.

After about a decade of research, proponents concede that various difficulties—including high cost, competition for access to imaging machines and some inherent limitations of the technology—will likely prevent virtual autopsies from fully replacing the hands-on version. Nevertheless, the new techniques are answering cause-of-death questions that have frustrated traditional autopsies and are sidestepping religious objections. By enhancing medical education and suggesting improvements in emergency care, virtual postmortem examination is helping the living, too.

As that snippet suggests, “virtual autopsy” — or “postmortem imaging,” to be more precise — is better for some things than others. It is helpful for inquiring into cause of death without opening the body, making it a religiously acceptable option for observant Muslims and Orthodox Jews. It can look around breathing and chest tubes, which remain in at least some bodies (of service members, for instance) when they are delivered for postmortem. It can precisely locate fragments and projectiles, and it can identify trapped air and water, in blood vessels or lungs, that would be released if those structures were surgically opened. It has been especially useful in getting into places where surgical autopsy can be unacceptably destructive: fractures high up in the spinal column, and injuries to the face and skull.

It is not as good as traditional autopsy at identifying tumors, and it encounters difficulties locating cardiovascular problems — either clots or bleeds — because there is no circulation to move the contrast medium around. (To solve this, some hospitals are considering putting corpses on heart-lung machines. You may shiver now.) But the biggest obstacle, as with so much in American medicine, remains cost. Autopsy is already an unreimbursed procedure; that is one reason why it has been passing out of use. Virtual autopsy is even more so; outside of the military and a few civilian medical-examiner departments, almost everyone working on it is borrowing machines in off hours, and donating their time.

Virtual autopsy is worth pursuing, though, not just for illuminating the experiences of the dead, but for preserving the lives of more of the living. A pathologist within the Armed Forces Medical Examiner System told me that postmortem imaging of military casualties has uncovered equipment faults — inadequate coverage by body armor, too-short thoracentesis needles — that would never otherwise have been perceived.

What a pity it wasn’t available for Ronald Brown, so that his undoubted sacrifice wouldn’t have been sullied afterward by questions of how injured he “really” was. RIP.




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