The case for postmortem imaging

Abstract

In the late 1960s, as a medical student with a background in mathematics, I was given the opportunity to earn needed funds doing statistics for a pediatric pathologist, Dr. Richard L. Naeye [1, 2]. As generous mentors do, Dr. Naeye guided me to seek answers about things I noticed. This inquisitiveness led to one of the early papers on perinatal intraventricular hemorrhage (IVH) [3]. These three papers were based upon 1044 careful autopsies of perinatal deaths done at Babies Hospital in New York. I share this story in contrast to suggest that this research would not be possible today. The autopsy is all but gone from hospital routine, with autopsies performed in less than 5% of hospital deaths. Over the last 40 years, the steadily declining autopsy rate has been attributed to the unwillingness of families to accept the procedure, the reluctance of physicians (particularly house staff) to request permission, and failure of our health system to reimburse the cost of the procedure [4, 5]. Today, autopsies are performed routinely only for deaths that fall under jurisdiction of the medical examiner system (coroner). For those of us in pediatric radiology, child abuse and SIDS cases usually first come to mind. When I queried my pediatric pathologist colleague at Alfred I. duPont Hospital for Children, Dr. Katrina Conard, I learned that our hospital mirrors the national trend (Table 1). The United States military has always tracked both combat-related deaths and non-combat deaths (“DNBI” or disease and non-battle injury). After the Vietnam War, controversy arose concerning the effects of exposure to toxins such as Agent Orange [6]. In the aftermath of the first Gulf War in 1991, an ill-defined collection of symptoms in veterans led to the definition of Gulf War syndrome [7]. In retrospect, it was recognized that we could be better prepared to perform investigative study if there was access to autopsy material. Following September 11, 2001, when planning for the present conflict began, the Chief Armed Forces Medical Examiner (Capt. Craig Mallak, MC, USN) recommended that autopsy be performed for all deaths in the theater of war. This was seen as a way to provide both current data and the ability to address possible future questions. His suggestion became policy, and the Department of Defense Mortuary at Dover Air Force Base in Dover, Delaware, has autopsied all military deaths in Southwest Asia since the Gulf War began in 1991. Unfortunately, the number of cases has risen to more than 5000. Radiographs have been a part of forensic examinations since the discovery of the X-ray [8] and are part of every military autopsy. To enhance the information obtained with physical autopsy, the Department of Defense Advanced Research Projects Agency (DARPA) recognized the potential offered by multiplanar CT and funded the installation of multidetector computed tomography (MDCT) at Dover The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the view of the Departments of the Army, Navy, Air Force, or Defense.