Postmortem explanations
Most autopsies done to find causes of natural deaths -- not slayings
By DAVID RUMBACH
South Bend Tribune (IN)
January 24, 2007
SOUTH BEND -- When a young father collapsed and died at a restaurant in Texas, the shocked family looked to the age-old practice of autopsy for answers. As in most cases of surprise death, the investigation did not turn up evidence of foul play, Dr. Joseph Prahlow of South Bend recalls.
Instead, it took an unexpected turn by revealing a rare disease and providing vital medical information for the man's family.
Prahlow was an assistant examiner with the Dallas County Medical Examiners Office in the late 1990s when the case fell to him.
Now he performs about 90 percent of the autopsies in St. Joseph and Elkhart counties, as well as a substantial portion of the autopsies in Marshall, LaPorte and Porter.The initial clues in the Texas case came to light even before he opened the man's abdomen with a scalpel and found more than a half-gallon of blood pooled in the cavity.
Pathologists start autopsies by scrutinizing the outside of the body, and it was in this external exam that he discovered a curious fact: The man's joints were so flexible, he could bend the fingers backward with ease.
More often than not, sudden deaths turn out to be garden-variety cases of heart disease, often with an enlarged heart the main culprit.
But the loose joints and pooled blood, which came from a ruptured aorta, sent Prahlow down a more exotic line of reasoning.
He suspected a rare connective tissue disease called Ehlers-Danlos syndrome that not only makes joints floppy, it also weakens blood vessels.To test the hypothesis, cells called fibroblasts were collected from muscle tissue and coaxed to grow in a lab dish. The culture was shipped to a world expert in Seattle, who confirmed Prahlow's hunch.
Because Ehlers-Danlos can be passed on to children, the discovery did more than simply help soothe anguish with an explanation.
"The man's children are now aware of the disease and can be tested for it,'' Prahlow says.
They can take precautions and be monitored by their doctors. An operation on the dead combined with some keen medical sleuthing had raised the odds of survival for the living.Unexpected deaths
In a lot of autopsies, the morgue becomes an extension of the crime scene -- literally.
With the cause of death -- gunshot wounds, for example -- fairly obvious, the focus is on meticulous collection of hair and other minute evidence.
The police are there, usually two officers who stand by the table and watch the autopsy before taking official custody of the forensic evidence. Everyone is aware that their every move must stand up to intense scrutiny in court.
But most aren't like that. State law gives the coroner authority over a wide array of deaths, not just the ones involving apparent foul play.Those include the many deaths when seemingly healthy people drop over, Dr. Michael O'Connell, the St. Joseph County coroner, says.
"If the death can't be explained or the person didn't have a physician, we have to come up with a cause of death and sign the certificate,'' O'Connell, a longtime family doctor in South Bend, says. The coroner also determines the manner of death, with the death certificate allowing for one of five possibilities: homicide, suicide, accident, natural or undetermined.
Autopsies aren't always necessary to solve an unexplained death, O'Connell says
In 2005, his office took jurisdiction over 238 deaths, about 10 percent of the county's total number of deaths, according to a Tribune review of public coroner's reports for that year.
Of the 115 autopsies done for coroner's cases, nearly six times as many were for unexpected natural deaths as for homicides, 61 vs. 11.The rest were divided among accidents (31) and suicides (7). In five cases, no cause could be found.
The telltale heart
Heart disease in its various forms is the No. 1 killer of men and women in the United States.
Some forms, such as congestive heart failure, cause years of misery before they kill.
By contrast, sudden cardiac arrest kills in an instant and sometimes strikes relatively young people who seem just fine.So it's not surprising that heart disease shows up most frequently as the cause of mysterious deaths.
In almost half of the natural deaths investigated by the coroner in 2005, the person was found to have atherosclerosis -- a buildup of fatty plaque in the arteries.
For their living patients, doctors might do an angiogram -- injecting a special dye into the bloodstream and taking an X-ray -- to figure out how bad the blockage is.
The beauty of autopsy is that Prahlow can take a direct approach: He simply removes the heart, slices open the arteries that supply the heart muscle and looks into them.
Someone whose coronary arteries are blocked by 75 percent or more is at elevated risk of cardiac arrest.This kind of arrest, the sudden sputtering of the heart's electrical system, can occur without a heart attack.
"That's all I need to make the ruling (of cardiac arrest due to atherosclerosis),'' he says.
An even simpler way to gauge heart health in the dead is to put the heart on a grocer's scale.
Hearts heavier than about 14 ounces in men or about 12 ounces in women are considered to be enlarged, Prahlow says, which raises the risk of cardiac arrest.
And like having blockages, having an enlarged heart is a risk factor for sudden cardiac arrest in people who seem fairly healthy.The precise defect with the electrical circuitry -- pathways of specialized nerve fibers -- usually can't be seen, even by someone holding the heart in his or her hand.
Instead, the ruling is made on the basis of seeing the risk factors and ruling out other explanations.
Yearning to know 'Why?'
Family members shocked by a sudden death yearn to know why. Never more so than when the lost loved one was a child.
Indiana law gives special consideration to the deaths of infants and young children.With few exceptions, it requires autopsies be conducted in deaths of any person between the ages of 1 week and 36 months.
"It's very unusual that we don't do an autopsy on a pediatric (death),'' O'Connell says.
In 2005, 10 autopsies were conducted on children younger than 2 years old, including eight by Prahlow.
Four of the cases were possible SIDS deaths (sudden infant death syndrome), a ruling that is tricky to make.
Based on Prahlow's autopsy and other evidence, one of the cases was determined to be an accidental overlay; someone sleeping with a 4-month-old had rolled on top of the baby, smothering it.While that ruling was a hard truth for the family to take, it was nonetheless important, Prahlow says.
"Overlay is preventable,'' he says.
Another autopsy revealed that babies had died of tuberculosis, heart dysrhythmia, seizures stemming from prematurity, and brain injuries inflicted in a homicide.
Despite his expertise, Prahlow said he can't always provide answers and then the cause of death goes down as undetermined. It keeps him humble.
"I'm very experienced at saying, 'I don't know,' '' he says.And even in cases where a cause is found, the answer is sometimes unsatisfying.
It's known that enlarged hearts and blocked arteries lead to sudden cardiac death in some people.
But why is it that many other people with the same degree of enlargement or blockage don't drop over?
It's a haunting question for families that Prahlow simply can't answer.
"I can tell them why they died, but I can't tell them why they died (and not others with similar risks),'' he says.Like few other jobs, being an autopsy pathologist forces a person to confront death.
Practitioners of this age-old form of medicine see death in all its guises: bodies crushed by trains, burned in fires and punctured by gunshots and stabbings. They see vigorous-looking teens felled by cardiac arrest.
Prahlow said he's amazed by the ability of the human body to survive disease and trauma.
"But the opposite is also true,'' he says. "My job forces me to be aware of the fact that life is extremely fragile. It makes me a paranoid dad, but it also strengthens my faith in God.''
How autopsies are done
Autopsies begin with a review of the person's medical history, including not only recent illnesses but diseases and treatments they've been given throughout life.
Before the cutting begins, the autopsy pathologist conducts a very thorough external examination. Clothing, jewelry, tattoos, body piercings are all documented, along with external wounds, rashes, scars and other external markings. Some straightforward external findings help solve cases, said autopsy specialist Dr. Joseph Prahlow. Pinpoint hemorrhages in the eye called petichiae may indicate strangling, he said.
Next, the pathologist and his or her assistant, traditionally called a "diener,'' open the body and examine the internal organs, using a variety of scalpels, long knives, saws and scissors. Organs are viewed, cut open and weighed to look for disease, Prahlow said. This is called the "gross'' part of the autopsy, not because it's yuckie, but because it involves abnormalities large enough to be directly observed.
A complete autopsy looks at virtually all organs, including the brain. Sometimes families give permission for limited dissection, Prahlow said, of just the brain or even a single gland.
The final part of an autopsy in done later in laboratories and usually takes two to six weeks to complete, county coroner Dr. Michael O'Connell said. During the surgical part of the autopsy, the pathologist takes slices of tissue from each organ and samples of various bodily fluids, including, of course, blood and sometimes even the vitreous inside the eyeball. In the lab, the pathologist will look at the tissue under a microscope and send the fluid samples off for tests to find drugs, poisons and pathogens. Remarkably, bodies dissected in autopsy can be put back to together well enough to be shown at a funeral home.