AAOS Bulletin - February, 2006

Tales from the Crypt

Stanford orthopaedists, others unravel mystery of 2,000-year-old child mummy

By Carolyn Rogers

Photos courtesy of Stanford University and Brown & Herbranson Imaging

Profile of the child mummy within the cartonnage/mask.

Clad in a pharaoh’s headdress, gold-beaded wig, white tunic and a cobra bracelet, Cleopatra (otherwise known as Amy L. Ladd, MD) made a dramatic entrance to Grand Rounds at Stanford University Medical School this past October.

Inspired by her recent encounter with a mysterious 2,000-year-old Egyptian mummy, Dr. Ladd donned the Cleopatra costume and persona to give her presentation, “Tales from the Crypt: Orthopaedic Lessons from a 2,000-Year-Old Mummy.”

“It was over-the-top—something I’ve never done before,” says Dr. Ladd, professor of orthopaedic surgery at Stanford. “It was a lot of fun.”

Unraveling the mystery

Dr. Ladd’s adventures in Egyptology began the past spring, when curators at the Rosicrucian Egyptian Museum in San Jose, Calif., reached out to Stanford, which houses one of the world’s most advanced scanners, and Silicon Graphics, Inc. (SGI), for help in unraveling the mystery of a rare child mummy who’d been stored at the museum for nearly 75 years. Unlike other mummies in their collection, the curators knew almost nothing about the mummy they’d named Sherit—ancient Egyptian for “little one.” Unlike the days of Howard Carter—who discovered, and some say desecrated, the tomb of King Tut—unwrapping mummies for curiosity’s sake is considered unethical by today’s standards. Therefore, the story of Sherit’s life and death had remained a mystery.

Radiographs taken in the 1950s provided few answers, revealing just the outline of the bone; the child itself was completely invisible. The curators couldn’t tell whether or not the child was disabled or disfigured, nor did they learn the cause of death. The X-rays did show that the hips were displaced, leading researchers at the time to believe the child had died as the result of an accident.

Thanks to modern science, however—and the collaboration between the museum, SGI and Stanford—the child mummy who’d lost its identity some 2,000 years ago now has some of its life story back.

Cleopatra at Grand Rounds

Throughout her Grand Rounds lecture, Dr. Ladd remained “in character” as Cleopatra, asking her questions in a regal, domineering manner.

“I told the doctors, with particular attention to the junior orthopaedic residents, that I—Cleopatra—needed their help in deciphering who this mummy child was, and what the child represented in my lifetime,” Dr. Ladd explains. “I used the mummy as a piece of forensic medicine, trying to discern clues as to how the child might have lived, the sex of the child and the cause of death.”

She reviewed a range of diseases, infections and musculoskeletal disorders common at the time and still common in most developing nations, and then referred to images of the skeleton. She asked, “Does this child have poliomyelitis? Malaria? Or spina bifida, like one of the babies found in King Tut’s tomb?”

The mummy child hadn’t actually suffered from any of these conditions, but it was a great excuse to review pediatric orthopaedic pathology, essential for every resident’s education, she says.

The residents and faculty in attendance reportedly loved Cleopatra, as well as her entertaining and educational talk. “I got a bit of ribbing,” Dr. Ladd says. “Residents and colleagues are asking how I’m going to be able to top it.”

In fact, she is slated to present “Jeopardy: The Upper Extremity Fractures Edition,” by the time this issue goes to print.

Who was Sherit?

The quest to solve the mystery of Sherit began in earnest on May 6, 2005, when museum officials carefully transported the mummy from the museum to Stanford University Hospital.

Once at Stanford, Rebecca Fahrig, PhD, associate professor of radiology, and her colleagues took some 60,000 images of the mummy using a high-end Siemens AXIOM computed tomography (CT) scanner—all without disturbing the child’s fragile remnants. The scanner has an arm that rotates around the patient, thus enabling radiologists to view an individual from many angles without moving the patient at all.

Stanford was the first medical center in the world to acquire the scanner—one of only five in the world capable of producing such high-resolution images.

Both scanner technology and SGI visualization solutions are improving at a dramatic rate, so the results are the most detailed images of any mummy to date. The images are 10 to 100 times more detailed than those used to create the popular 3-D images of King Tut, whose remains were scanned in Egypt in January 2005.

The “mummy team”

It took mere hours to capture more than 82 gigabytes (GBs) of data, but it would take months to process and analyze it all.

The “mummy team” that would carry out the work was assembled by Dr. Ladd’s friend, Paul Brown, DDS—a retired dentist, now a researcher at the Stanford-NASA National Biocomputation Center. The team was made up of plastic surgeons, orthopaedic surgeons, dentists, computer scientists, anthropologists and bioengineers. (Dr. Ladd callsDr. Brown the “Mummy Daddy.”)

Photo courtesy of Stanford Radiology

The mummy is placed on Siemen’s C-Arm AXIOM scanner at Stanford.

“Fifteen to 20 people were involved on the Stanford side, in addition to the radiology technicians and staff who imaged the mummy,” Dr. Ladd says. “SGI had a host of computer scientists working on the project, too.”

The team also included a chemist who analyzed some of the resins to identify the musky perfume poured on the child’s body, a world-renown alchemist to re-create the perfume and a medical modeler who created a plastic 3-D replica of the mummy’s skull. A plastic surgeon and sculptor together created a lifelike, painted clay bust.

Altogether, about 50 people donated their time and expertise to help solve the mystery of Sherit.

“Anthropology, forensics and detective work”

Once the images had been captured, it took the team several weeks to process and manipulate the images into a visually accessible, workable form.

Dr. Ladd worked with Dr. Brown throughout the project. Her specific role was to determine the mummy’s age and skeletal health and to corroborate the dental information, if appropriate. Her Stanford colleague James Gamble, MD, a pediatric orthopaedist, played a central role in educating the team about pediatric illnesses, both chronic and acute, which could afflict the skeleton. An Egyptologist helped them with questions about diet, Egyptian culture and the mummification process.

“It was really a combination of medical anthropology, forensics and detective work,” says Dr. Ladd. “As doctors, a lot of what we do is detective work. This is the same idea, except the patient couldn’t tell us what was wrong.”

Once the scans had been properly prepared, key team members gathered for a series of visits. “A total of five to 10 members from SGI, the Museum and Stanford met each time,” Dr. Ladd says. “We all crowded around the computers, putting our ‘two cents’ in and arguing it out.”

After conducting detailed analyses of several areas—including the hands, teeth, feet, skull, groin, spine and chest plate—the team was able to provide answers to decades-old questions, including: How old was the child? Was it a boy or a girl? Was the child disabled? Why was the head cocked at such an odd angle? What was the cause of death?

A mystery revealed

The images tell the story of a young Egyptian child whose body was draped in linen and adorned with round earrings, an amulet and a Roman-period necklace before being wrapped in gilded cartonnage (plastered layers of fiber or papyrus)—all suggesting a life of wealth and privilege. Amazingly, the researchers were also able to see a drawing of a sphinx on one layer of the child’s bandages.

The mummy’s perfume—the remains of which appear as a kind of black tar around the face and neck—was identified as a mixture of frankincense and myrrh, bathed in moringa oil. “The mummy lived around the year 0 C.E., so the combination of frankincense and myrrh should not be surprising to those who remember the biblical story of the gifts of the Magi,” Dr. Ladd says. Pouring this mixture onto the mask was likely the last contact the parents had with their little girl.

Yes, the child was definitely female.

“She had short, resin-coated black curls. She also had buckteeth, a small, receding chin and an angular face, very reminiscent of the skeletal features of King Tut,” says Dr. Ladd.

The hair was the first clue that the mummy was a girl.

“Boys’ heads would have been shaved at that time,” she explains. Orthopaedists were able to confirm her gender based on scans of the pelvis.

How old was the child?

Sherit was judged to be 4 to 5 years old, based on a number of indicators.

Dr. Ladd and her colleagues determined the age by comparing images of the mummy’s wrist bones to images contained in Gruelich and Pyle’s Radiographic Atlas of Skeletal Age, which was cataloged and published at Stanford more than 50 years ago.

Photo courtesy of Amy L. Ladd, MD

Dr. Ladd’s 5-year-old daughter, Katy, lies in front of the child mummy, who died at about 4 to 5 years of age

Dentists confirmed the age by viewing the startlingly detailed images of her teeth. The mummy’s embedded adult teeth had not yet pushed through the gums, and her six-year molars were not ready to erupt—indicating that she was significantly younger than 6 years old.

Cause of death

The little girl wasn’t murdered nor did she suffer a tragic accident. In fact, she probably walked until near the time of her death, which appears to have come suddenly.

“The scans show a girl with a healthy skeleton and no signs of trauma, lengthy chronic illness or dietary deficiency,” Dr. Ladd says. “We saw artifact fractures, but they were clearly a result of the mummification process, not trauma.”

As it turned out, the reason the child’s head was turned down at an odd angle was because the cartonnage was made too small, and the mummy had to be crammed into the space.

The bones themselves are exquisitely preserved, Dr. Ladd notes. “You can see the minerals, the growth plate, the meniscus … It’s astounding to see.”

“These scans could be mistaken for one of my kids in clinic, the images are so good and the skeleton so well preserved,” says Dr. Gamble.

The only clues to Sherit’s demise are the thinned areas of her skull—indicating increased cranial pressure over a fairly acute time. The team believes she most likely died from a viral or bacterial disease—probably viral meningitis or encephalitis.

Bringing Sherit to life

With the mystery “solved,” it was time to reveal their findings to the world. On Aug. 3, 2005, the team unveiled the images at a press conference held at SGI’s Reality Center Theater in Mountain View, Calif.

Sitting in the darkened theater, the assembled media and researchers watched as the mummy was “virtually unwrapped.” The 3-D visual journey took audience members on a virtual tour through the skull, into the chest cavity, down to the mildly misaligned pelvis, to the short leg bones and finally to the feet. Layer by layer, frame by frame, the mummified child came to life, looming in front of them on a 25-foot screen.

“When we presented the story, suddenly this wasn’t just some dried-up, 2,000-year-old mummy,” Dr. Ladd recalls. “It was the story of the life of a child.”

Many people told Dr. Ladd the experience made them sad, thinking of this young girl and her family’s sorrow.

“It was amazing how it became more than just a scientific exercise, but the true story of a living person,” Dr. Ladd says. “It was pretty cool to see the transformation.”

Evolving imaging technology will change medicine

This project attracted a lot of publicity, Dr. Ladd says. “But what’s most exciting is the really amazing high-resolution imaging that we used in this project, and how we think it’s going to change medicine.”

It was fun to see the technology put to use on a project of widespread interest, she admits. “Still, the mummy project is just one representation of how medicine is going to change as computer imaging becomes more accessible and more real-time.”

Evolving imaging technology will improve many aspects of medicine, including exponentially more accurate clinical diagnosis, surgical training through virtual reality simulation with haptic feedback (computer-generated touch and feel) and surgical planning. She also thinks one of its greatest powers lies in patient education.

“One day we’ll be able to use real imagery to show patients exactly what their injury or condition looks like,” she says. “We’ll be able to say ‘I’m going to cut this, and repair that,’ and demonstrate the procedure with animations using the patient’s own data.

“This gives an entirely new meaning to informed consent,” Dr. Ladd says. “Being able to show patients all of this using real 3-D imaging, instead of black-and-white text with an occasional line drawing or picture, will make it so much more powerful for surgeon and patient alike.”

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