CAFFEINE

The most popular of all drugs. A mild CNS stimulant, which works as an antagonist at the adenosine A₁ and A_2A receptors. Use sparingly (if at all). Your enhanced efficiency is bought at the price of greater fatigue and problems resting after the effect wears off. Ask a pharmacologist about the cyclic-AMP connection.

The drug also increases adrenergic tone (which accounts for its ability to enhance cardiac rhythm problems and the perception of hypoglycemia). When a patient says they are having palpitations (i.e., they're aware of their heartbeat, which may be slow-regular, fast-regular, or irregular), ask about caffeine use (Lancet 341: 1254, 1993); however, even in the setting of an acute myocardial infarct, these rhythm problems are very unlikely to be dangerous (Heart & Lung 21: 365, 1992).

*Fun to know! Tea in China goes back at least to 2700 BC. "The English drink tea" because it was considered patriotic after they displaced the Dutch as chief imperialists in China. As the American Revolution was beginning, tea became a symbolic issue, and ever since, Americans have preferred coffee. Coffee itself was supposedly discovered by an Arab goatherd, who noted the goats became frisky after eating the berries. Its use became popular among Benedictine monks, who needed something to stay awake during marathon prayer sessions. Of course it was considered a drug menace when it became popular in Europe in the late 17th century; England's Charles II tried to ban it without success, and Bach's Coffee Cantata describes a 1730's father's effort to rescue his daughter from coffee-drinking. Chocolate was a gift from the First Americans, while the kola nut came from Africa.

In spite of what you've heard, caffeine simply does not produce measurable sustained hypertension (Am. J. Card. 73: 780, 1994). Nobody's been able to show any convincing risk for atherosclerosis, heart attack (Arch. Int. Med. 152: 1767, 1992), stroke, or sudden death.

*There's a current flap over caffeinated coffee drinking (two or more cups per day) and osteoporosis in women. However, the effect vanishes if the woman also drinks a glass of milk each day, and this finding makes me think that some other variable, not coffee drinking, is the cause. See JAMA 271: 280, 1994.

*There's another flap over caffeine use and fetal loss. This might be real, but it isn't a huge effect See JAMA 270: 2940, 1993 and Am. J. Pub. Health. 82: 85, 1992 (makes the claim), JAMA 269: 593, 1993 (refutes the claim, and also denies that babies are more likely to be growth-retarded). Baby does experience the same enhanced wakefulness and diminished sleep that Mom does if she takes coffee: Am. J. Ob. Gyn. 168: 1105, 1993. Caffeine use isn't a risk factor for prematurity: Am. J. Pub. Health. 82: 87, 1992).

The alleged link with bladder cancer just doesn't hold up (Lancet 341: 1432, 1993). I'm very skeptical about the supposed link to pancreatic cancer, since it's inconstant and tobacco is likely to be a confounding factor. The alleged link with mouth and tongue cancer is anything but impressive (Cancer 70: 2227, 1992).

The medical community has finally documented what most adults already know: caffeine enhances the jitteriness of falling and low blood glucose (Ann. Int. Med. 119: 799, 1993).

*Generalized anxiety disorder patients shouldn't take coffee (Arch. Gen. Psych. 49: 867, 1992), but it's okay for panic-disorder patients (ditto).

We'll talk about the headache of caffeine withdrawal (probably the most common headache) under CNS (Mayo Clin. Proc. 68: 842, 1993). All about caffeine withdrawal, for those not acquainted with this: NEJM 327: 1109, 1992. Yeah, there's a mild physical addiction, which we've ignored because of our silly attitudes about "addiction" in the first place ("I won't give my cancer patient morphine because she will die addicted").

*Internists will love West. J. Med. 157: 544, 1992, a compendium and critique of epidemiological studies.

ALCOHOL (ethanol, ethyl alcohol, "grain alcohol", etc.)

When I put my arms around you and kiss you on your mouth,
Then I am happy even without beer!

--Ancient Egyptian love song

Man, being reasonable, must get drunk.
The best of life is but intoxication.

--Lord Byron

I remember a mass of things, but nothing distinctly; a quarrel, but nothing wherefore. O God, that men should put an enemy in their mouths to steal away their brains! That we should, with joy, pleasure, revel, and applause transform ourselves into beasts!

--Shakespeare's Cassio

*Noah needed a drink when the flood waters receded, and made an "ass" of himself, becoming the "butt" of his son's joke (Genesis 9:20). And so sin "reared" up once again. See also Matthew 11:18-19 (drink or abstain, people will criticize you).

{37891} wino crossing

It would be difficult to overstate the contribution of excessive alcohol drinking to ill-health, the patient load of a general hospital, or the business of a Medical Examiner's office. The behavioral changes in acute and chronic alcoholism require no description here.

In your lecturer's opinion, the harm done by alcohol exceeds by an order of magnitude the harm done by actual ingestion of the equally-available illegal drugs. Yet most people who drink alcohol sensibly appear to take no harm and perhaps even derive some healthy pleasure.

Your lecturer hopes no one takes strong offense from the word "drunkard" for a person who is very drunk. "Alcoholic" implies loss of self-control over the long-term. A non-alcoholic may be very drunk on a particular occasion. Your lecturer remembers; that's why he quit doing it after a few bad experiences! So did most of you. By contrast, a real-life alcoholic won't learn even from a string of bad experiences, which is what makes them different.

* Your taxes paid for an expensive government anti-alcohol program specifically targeted at fraternity and sorority members. Most of the older Greeks refused even to sit through the eight-hour indoctrination session. Those that did mostly refused to give the answers that the government wanted to prove their program worked. The authors were truthful enough about the fiasco, and this simply confirmed my old Al-Anon wisdom, "You cannot control another person's drinking." See J. Stud. Alcohol 60: 521, 1999.

"Proof" (whiskey, other hard liquor) is double the percentage of ethanol in the bottle. Eighty proof whiskey is 40% alcohol.

*We don't know how ethanol produces its buzz; currently there's lots of talk about GABA receptor channels (Proc. Nat. Acad. Sci. 92: 3633, 1995). Older ideas, which still might be right, focused on solubilization of ethanol in the brain lipid and the corresponding physical changes.

The liver metabolizes alcohol first to acetaldehyde (via alcohol dehydrogenase), then to acetic acid, and ultimately to carbon dioxide and water. (* Microsomes and peroxidase-catalase systems also help handle some alcohol.)

There is no question any more that heavy alcohol use by itself can and does permanently damage the brain. The problem's not so much that brain cells are destroyed (that's largely bunk) but that they are damaged ("loss of dendritic spines"). Check out Alc. & Alc. 25: 467, 1990; Exp. Neurol. 106: 156, 1989.

Alcohol causes the majority of auto fatalities. Thankfully, today it's considered correct and even smart to choose one partygoer as designated driver. This participant remains cold-sober. (Try it. You'll probably enjoy it.)

It takes about 5 beers or 5 shots of 80 proof liquor in rapid succession for the typical 70 kg man to reach the "legal" level of intoxication (100 mg/dL), but impairment of judgment and coordination occur at much lower levels. Watch for a lowering of acceptable driver's blood alcohol levels to 50 mg/dL or even lower.

"The books" cite blood alcohol levels of 350-500 mg/dL as "fatal", but there's lots of variability. It's commonplace for a driver to be arrested with a blood alcohol of 300 md/dL or more. A chronic alcoholic may also die with a low blood alcohol "from cardiac rhythm disturbance brought about by alcoholism."

Most people metabolize alcohol at a rate of 15 mg/dL/hr, using basically zero-order kinetics. That means you burn off about the equivalent of 1 beer or 1 shot of the hard stuff in 1 hour. Habitual drinkers handle the stuff much more rapidly, and there's much variability among people (for example J. For. Sci. 38: 104, 1993).

* Future pathologists: Post-mortem ethanol levels are a subject of much interest. Worth knowing:
Blood levels are a bit lower than serum levels because serum has more water, and of course ethanol is distributed through the aqueous phase.

If the blood alcohol level is higher than the vitreous level, probably death occurred before equilibrium was achieved, i.e., the dead person had not been drunk for long.

In a putrefied body, the blood alcohol level can be as high as 150 mg/dL. For the first day, there will only be alcohol production if bacteria / candida are already flourishing in the bloodstream, i.e., death was due to sepsis / hyperthermia / bowel perforation. Refrigeration slows the process down greatly. Urine will not support the growth of bacteria post-mortem unless there is glycosuria.

Alcohol passes rapidly through the gastric mucosa, so if there's even 5 g/dL of alcohol in the stomach, the dead person had a drink within an hour prior to death.

Alcohol in the stomach is prone to diffuse into the nearby heart and great vessels; moving the body may also cause some to be aspirated into the lungs with the same effect. Your best blood to sample for alcohol comes from the femoral vein. Take a sample from the vitreous also.

The ratio of urine alcohol to blood alcohol can help you guess whether the person was actively drinking prior to death. If the ratio is under 1.2, the blood alcohol was probably rising at the time of death. If it is over 1.3, the person was probably drinking over a longer period of time.

Some drinkers (it's probably partly hereditary) eventually reach a point in which they cannot stop drinking once they have started. This is a sure sign that it time to stop drinking, now, altogether, for the rest of your life. You will also need some assistance doing this. This is available. Despite the existence of many profitable-trendy "counselling centers", etc., etc., the best help is probably still "Alcoholics Anonymous" ("Rational Recovery"/"Secular Sobriety" is the alternative for those who don't want AA-mysticism, or some AA members understand the "G--" word to mean "Good Orderly Direction").

*The long-term results are not salutary for either partner, but every adult knows that alcohol is an extremely effective short-term anesthetic against nagging and verbal abuse. This is a very common step that leads to the chronic domestic violence syndrome. You might be able to teach both parties a few new ways of coping, Doc.

*One major concern of a drinker and/or druggie considering sobriety is the loss of friendships. Don't worry. Drinking "friends" will be replaced by higher-quality friends in the sobriety movement. This is well-known by now, and makes me wonder whether people drink (do drugs, join stupid political and ideological movements, etc.) because they are really seeking friendship. One thing your lecturer likes about skydiving is that nobody's drunk or on drugs -- and a group of substance-free chums is hard to find among today's grown-ups.

*Subclassification of alcoholism, simplified:

Type I: Crybabies ("At least I'm not a criminal")

Type II: Criminals ("At least I'm not a crybaby")

Type I is memorialized in "The Little Prince": "I drink to forget... to forget that I am ashamed... ashamed of drinking!") Type II tends to run in families and announce itself early.

* Naltrexone and alcamprosate to reduce the craving: JAMA 281: 1318, 1999.

Anyone overcoming alcohol dependence, regardless of kind or type, deserves our heartiest admiration and congratulations.

* A post-Joe-Camel group thinks doctors need to know that in today's kiddie cartoons, "good characters use tobacco and alcohol as frequently as bad characters" and have "story plots without clear verbal messages of any negative long-term health effects associated with use of either substance" (JAMA 271: 1131, 1999).

For alcohol assays on the living or the dead, send us blood in a gray-top (sodium fluoride anti-bacterial, anti-enzyme) tube. Keep your sample frozen or in the refrigerator.

Future pathologists: You'll use both (1) alcohol dehydrogenase methods and (2) gas chromatography for alcohol assays. The former detects methanol and isopropanol also; the second does too, but distinguishes them from ethanol. Remember that a putrefying body can produce alcohol levels up to 50 mg/dL.

"Alco-Screen" dipstick to measure the alcohol in spit: Ann. Emerg. Med. 18: 1001, 1989.

Here's a partial listing of the bad health consequences of prolonged heavy drinking:

• alcoholic hepatitis and hepatic cirrhosis
• brain damage (loss of dendritic spines, Wernicke, Korsakoff, cerebellar atrophy)
• pancreatitis (acute and -- ouch! -- chronic)
• cancer of esophagus, throat, and larynx
• GI bleeding from ulcers, varices, gastritis
• fetal alcohol syndrome (ask a pediatrician; you cannot rehabilitate these kids very well Lancet 341: 907, 1993)
The classic kid with fetal alcohol syndrome has a long upper lip, epicanthic folds, a small head, and is mildly mentally handicapped. There's a lot of variability. Alcohol causes apoptosis of fetal neurons: Science 287: 1056, 2000.
• neuropathy (at AA's, many people complain years later about numb fingers)
• cardiomyopathy (this isn't common)
• rhabdomyolysis (seldom dramatic, but probably contributes to long-term wasting)
• hangover, tremulousness, seizures, delirium tremens on withdrawal ("pink elephants on parade", etc.)
• losing job, family, friends
• oh, and by the way, it probably has a slight favorable effect on HDL and coronary atherosclerosis. Gee whiz.

We're only now figuring out how alcohol affects the brain at the molecular level.

Post-mortem alcohol levels are fraught with interpretive problems. Alcohol diffuses post-mortem from stomach to heart's blood. Bacteria from the gut reach the bloodstream by 6 hr, or faster if the gut is injured, and ferment glucose, especially if it's warm and/or there's a high blood glucose. This won't exceed 50 mg/dL the first day, and is usuaully much less, but can get to 200 or more if there are several days for decomposition. Be sure you also get a post-mortem vitreous sample (always possible) and a post-mortem urine sample (usually possible), and draw your blood from the femoral vein rather than the heart.

* Thanks to the savvy pathologist testing the vitreous, we knew that Henri Paul, who was driving Princess Diana, really DID have a blood alcohol level of around 175 mg/dL when he crashed (Br. Med. J. 316: 87, 1998).

I've been asked if I ever get the DT's. I don't know. It's hard to tell where Hollywood ends and the DT's begin.

--W.C. Fields

Methanol ("meth", "wood alcohol", "blind, vomiting, and drunk") is metabolized to formaldehyde (yeah, you know that's gotta be bad for you) and thence to formic acid (which gives the famous high anion gap acidosis). The retina toxicity is infamous ("like stepping into a snowstorm") and can be persistent. Part of the treatment involves saturating alcohol dehydrogenase with ethanol.

Isopropanol ("rubbing alcohol", users are "rubby-dubs", etc.) is about twice as potent an intoxicant as ethanol, but really nasty to the gastric mucosa. Metabolized to acetone via alcohol dehydrogenase, and produces an modest anion gap acidosis.

Ethylene glycol (anti-freeze) is metabolized to glycolaldehyde, glyoxylic acid, and oxalic acid. This stuff produces both a striking anion gap acidosis, and little crystals that carve up renal tubules, meninges, etc. Not a nice way to die.

By federal law, all US ethylene glycol has added fluorescein, so the urine of an antifreeze-drinker fluoresces under your Wood's lamp. Handy in the emergency room.

* A locally-produced cough syrup, laced with ethylene glycol, killed around 100 Haitians (JAMA 279: 1175, 1998).

{07016} ethylene glycol fatality; note crystals in the renal tubules

Ethylene glycol poisoning Kidney crystals KU Collection

* No surprise: More underclass people die unnatural deaths in the days after the end-of-the-month check comes than in the days before the end-of-the-month check comes. The difference is explained by drugs and alcohol (NEJM 341: 93, 1999).

WOUNDS FROM GUNS

An armed society is a polite society. -- Robert Heinlein

Firearms WebPath Tutorial

Abrasion ring: Roughing up of the skin as the bullet pulls it inward; when the skin recoils, it will appear as an abraded ring around any entry wound.

{07252} how an abrasion ring forms

Caliber: In the English-speaking countries, diameter of the bore of rifled small arms, in hundredths or thousandths of a inch, i.e., .357 is 357/1000ths of an inch across. Continental Europe uses a different system.

Firing pin: The part of the gun that strikes the cartridge when the trigger is pulled

*Gauge: Venerable term to describe the diameter of a shotgun bore. It's the number of lead balls of the diameter of the shotgun bore that together weigh a pound. Exception: The 0.410 gauge shotgun has a 0.410 inch bore.

Handgun: A low velocity (650-1400 feet/second) rifled hand-held weapon.

* Lands: Ridges ("rifling") on the inside of the barrel, imparting to the bullet a gyroscopic rotation around its long axis which stabilizes its flight

* Magnum: Means nothing any more. Glamour term.

Primer: Explosive struck by the firing pin, which in turn ignites the gunpowder.

Secondary missiles: Fragments of bone or whatever struck free by a bullet, which then pass through, and damage, tissue as bullets do

Shotgun: A smooth-bore shoulder-arm weapon that fires a bunch of pellets plus plastic wadding.

Around 2/3 of the homicides in the U.S. result from gunshot wounds ("GSW"'s), and the gun is the U.S. male's preferred means of successfully committing suicide.

Power grows out of the barrel of a gun. --Mao Zedong Right or wrong, genocide occurs only when the victims are unable to shoot back. European kings got much nicer when peasants were able to pierce armor using crossbows. Paul Revere's ride was prompted by a move by the British redcoats to seize the private arms of the Boston militia. And like it or not, private ownership of firearms remains a part of life in the US. Heavily-armed societies may have high homicide rates (Brazil, inner-city Los Angeles, South Africa) or remarkably low homicide rates (rural Alaska, Switzerland). Of course, if children or mentally-scrambled people have access to a homeowner's gun, everybody is in extra danger.

* Currently, the "politically correct" stance for physicians seems to be to urge their patients to give up gun ownership. People even talk about such "firearm counseling" as a duty of the primary care physician. Before you decide this is your duty, please read South. Med. J. 94: 88, 2001 about your possible liability issues should you use your position as a physician to pursue an anti-gun agenda.

If you, as a clinician, understand gunshot wounds, your documenting them may be great help in eventually preventing a miscarriage of justice. It's a topic that's important but gets missed in undergraduate medical education (AJFMP 24: 273, 2003).

What really comes from the barrel of a gun? Flaming gas, soot, unburned gunpowder, and a bullet. These can tell you how far the gun may have been from the victim.

1. The flaming gas travels for a few inches and will produce a burn.

2. The soot travels for a few more inches (6-7 with most handguns) and will produce a soot mark ("smudge") which you can wipe off. Future pathologists: Look for soot on the hand that fired the suicidal bullet. If it's not there, probably this is a "clever" homicide instead.

3. The unburned powder travels for up to a few feet (3 feet is usual for a handgun), and produces the "powder stippling" or "powder tattoo" (not "powder burns", please; these are typically embedded in the skin so you cannot wipe them off).

{07249} powder tattoo around an entry wound

4. The bullet will enter (or graze) the body. If it enters, it will scratch the surrounding skin, producing the abrasion ring.

In order to get a reliable estimate of the range, the particular gun and type of ammunition must be test-fired. Future medical examiners: In looking for powder and soot, remember to check the clothing, too. Future pathologists: Silencers absorb much of the smoke and powder.

Tight contact cutaneous entrance wounds: The muzzle is held against skin or clothing so tight that the gas, soot, and powder pass right through the broken skin.

If the blast enters a confined space (i.e., a tight-contact gunshot wound against the calvarium or zygomatic arch), you'll see a star-shaped ("stellate") entry wound, as the skin is turned backwards and lacerated. There may be a muzzle imprint from recoil of the weapon.

Loose contact cutaneous entrance wounds: The muzzle is held at the skin, but not pressed hard against it.

You'll see a small amount of soot at the edges, but there's no room for the powder to spread out for a dispersed tattoo. Again, there may be a muzzle imprint. Stellate bursting is less likely, but can occur.

Intermediate cutaneous entrance wounds (6"-3' or so)

If the bullet wound isn't a tight contact wound, and there's no soot, the shot probably came from several inches away. If there's powder stippling, you're probably within a range of three feet or less. The more dispersed the powder, the greater the distance. Test-fire the weapon and ammunition again. The soot and/or powder tattoo may tell you the direction of the shot.

Distant range cutaneous entrance wounds: No powder, soot, or stellate blow-out. (Of course, if the victim was shot through clothing, check to see if there's powder or soot on the clothes.)

Exit wounds may be produced by primary or secondary missiles.

Note that you won't see an abrasion ring here (unless the victim was leaning up against a hard surface or the bullet hits an unyielding piece of clothing, i.e., a belt!) The wound may be stellate. If there's still any doubt about entry vs. exit wound, look at the clothing and check for residue.

Internal injuries

As the bullet passes through the body, its energy is received by the tissues and dispersed in radial fashion. A temporary cavity is created with a diameter many times that of the bullet. Within 5-10 thousandths of a second, the cavity collapses, but the damage has been done. The faster the bullet, the worse the damage. In injuries from rifles (except the lower-velocity .22 caliber type), most of the damage is due to the temporary cavity.

If the bullet exits the body, it will carry some of its energy with it, sparing the tissues. If the bullet yaws (i.e., tilts) as it enters the body, more energy will be dispersed over a shorter area. The configuration of the bullet, the length of the track, and the nature of the tissue struck all determine the seriousness of a bullet wound.

Bullets may fracture bones. Skull fractures are typically beveled outward in the direction in which the bullet passed (physics, with variations, J. For. Sci. 38: 339, 1993). Fractures of the skull often radiate from the bullet hole, and/or the supraorbital plates shatter like eggshells.

Note that real-life people who get shot seldom simply fall over, like they do in the movies. Leave medicolegal stuff (direction of fire, range of fire, number and sequence of shots fired, time and degree of disability) to us.

As a matter of fact, if you spend time on the medical examiner's service, you'll be impressed how hard it is, generally, to kill a healthy young adult. Your lecturer once autopsied a gentleman who was stabbed through the heart, severing both descending coronary arteries and piercing the septum, and the descending aorta; the gentleman ran four city blocks before he fell down. Supposedly the brain can remain conscious for maybe 15 seconds after blood flow stops (ask Louis XVI).

"Suicide by cop": J. For. Sci. 45: 384, 2000; Ann. Emerg. Med. 32: 665, 1998.

Shotgun injuries (you can't just call these "gunshot wounds")

A close-range shotgun injury is the most destructive of civilian gunshot wounds. Why? (1) The weight of the pellets, and the energy in the gas, is very great. (2) The pellets almost never leave the body, so their entire energy is used damaging tissue. Close-range shotgun wounds to the head almost always cause it to burst.

At greater distances, the shotgun pellets fan out, so fewer hit the target. This makes range the key to the severity of the shotgun wound.

{07079} abrasion ring {07080} abrasion ring {07630} muzzle imprint {07083} bullet fractured skull, note bevel {07235} bullet fractured skull, note bevel {07325} supra-orbital plate shattered {07089} powder stippling ("tattooing") {07033} powder stippling {07090} bullet graze {07091} shotgun wound, close-up {07173} shotgun wound {07229} shotgun wound {07093} suicide, gun in mouth {07095} powder residue on hand {07132} gunshot wound and beating {07102} through and through {07111} stellate wound {07231} stellate wound {07034} exit wound {07035} bullet through brain {07171} histology of entry wound, with char {48999} shot in the heart

Beveled skull wound WebPath Photo

President Garfield's spine injury (gunshot assassination) AFIP

Recovered bullet WebPath Photo

Bullets Grooves from firing WebPath Photo

Contact wound WebPath Photo

Tight contact wound Abrasion ring and muzzle imprint WebPath Photo

Tight contact wound Abrasion ring and great muzzle imprint WebPath Photo

Loose contact wound Smoke fouling WebPath Photo

Gunshot wounds Sketch WebPath Photo

Gunshot wound Powder residue WebPath Photo

Midrange wound Powder tattooing WebPath Photo

Midrange wound Powder tattooing WebPath Photo

Entry and exit wounds WebPath Photo

Exit wound WebPath Photo

Shotgun suicide Tom Demark's Site

Gunshot residue X-ray microanalysis WebPath Photo

Handgun and rifle rounds WebPath Photo

Exit wound KU Collection

Multi-gunshot wound suicides (could have fooled somebody): AJFMP 10(4): 275, 1989. Suicide by gunshot while driving (the author notes that many auto "accidents" are probably suicides; AJFMP 10(4): 285, 1989).

* The Kennedy Assassination:

I've examined various writings from various sides, and have decided there's nothing too puzzling about it, at least from the standpoint of the pathology. "Oswald acted alone" probably isn't provable one way or the other, but the pathology is interesting.

Lee Harvey Oswald, sharpshooter and left-wing kook, fired three shots from the Book Depository.

The first bullet missed, struck the pavement, and sent a bit of concrete flying, cutting a spectator's face.

The second bullet passed into the back of President Kennedy's right shoulder, produced a stress fracture of T1, came out the front of his neck just below the larynx (perforating his shirt collar), then went through the right side of Governor Connally's chest, and ended up in the governor's thigh. If you say a single bullet isn't likely to do this kind of thing, you don't know what you're talking about.

The president's upper body lurched and his arms flexed in reaction to the spinal injury, creating the impression that his head was being forced backwards by a shot from the front.

The bullet was rolling when it struck the governor, which is why the entry wound was large.

The third bullet struck the president in the back of the head, sending blood and 70% of the right cerebral hemisphere splattering. The entry wound in the back of the head was small, and the exit wound in the right parietal bone was six inches across. The head was first pushed forward, then the seizure and jet effect of blood and brains forced the head back, again creating the false impression of a shot from the front.

Nobody looked at the president's back at Parkland, and they didn't notice the head wound until his heart had just about stopped completely. The guy who intubated him saw blood in the trachea, so a Dr. Perry did a tracheostomy. In doing so, he obliterated the neck wound, which he also unwisely speculated to be an entry wound.

The autopsy was performed at Bethesda amid much excitement. It was a tough job, and it is clear from the report that the pathologists were not really allowed to do their job. Partly because of pressure from Bobby and Jackie, the pathologists did not shave the scalp around the head wound (!), did not examine the spine or describe the kidneys or adrenals (!!) or the clothes (!!!) or the neck organs (!!!!), and failed to note whether there was an abrasion ring around the entry wound from the second bullet. They claimed they could not establish the trajectory of the bullet that caused the back wound, and later speculated that something fell out on the way to Parkland.

Bits of the parietal bone were later found on Dealey plaza, beveled out, confirming it was an exit wound.

Back in the early Vietnam era (1963), the federal executive branch was secretive. The Feds impounded the x-rays and autopsy photos, and the pathologists had to rely on their own (faulty) memories for the positions of the head wounds. Some important evidence got shredded early-on. Things are better now with this aspect of government behavior, thanks mostly to the social changes of the later 1960's and early 1970's.

The conspiracy theorists focus on reporting rumors, claims by cranks, idle speculators, and even obvious crazies, and failing to report other key facts. The single pathologist (Dr. Cyril Wecht) who dissents from the Warren Commission's report was already a longtime conspiracy buff.

"Unexplained deaths of people connected with the assassination" mostly aren't unexplained. They are the unnatural deaths of crooked or nutty people, or the natural deaths of other people. The conspiracy buffs listed the people who died during the next few years and calculated the odds against all these people dying around the same time. This is a classic misinformation-artist's fallacy: Flip a coin 100 times, select only the times it came up "heads", then figure the odds against a coin coming up heads each of 50-or-so times. Anyway, many of the "unexplained deaths" were of people friendly to the Warren Commission and/or only peripherally involved. And after 30 years, no one has come forward to confess, nobody has been caught murdering witnesses (which according to the some of the conspiracy theorists has continued over the decades), and Oliver Stone produced his farrago of lies ("JFK") without being molested.

People who know guns tell me that they don't believe that a lone assassin could have gotten off three shots so quickly. For more on the Kennedy assassination, see J. Am. Coll. Surg. 178: 517, 1994 (the governor's coat; the exit bulge was too small to have been produced had the bullet not passed through the president first); JAMA 267: 2791, 1992; JAMA 268: 1736, 1992; JAMA 269: 1540 & 1544, 1993. The neurosurgeons re-examine the case: Neurosurg. 54: 1298, 2004; and examine a new account Neurosurg. 53: 1019, 2003.

BLUNT TRAUMA {00155} coup contusion of brain; note cone shape {07051} child abuse {07036} car wreck

Hemopericardium Car wreck WebPath Photo

Skull fracture Car wreck WebPath Photo

Ileal perforation Blunt trauma Virtual Hospital

Tearing, shearing, and crushing. The amount of damage delivered by a blow from a blunt object varies directly with: the force used in delivering the blow the surface area that takes the blow (i.e., blows to the head do more mechanical damage than blows to the back; blows from a rounded pipe or a knob on a club do more damage than the side of a board) Remember Ek=(1/2)*mv2? The capacity to hurt someone is directly proportional to the mass of the object, and to the square of its velocity.

Abrasions result from friction removing the epidermis, with little or no damage to the dermis. They heal with no scar. The pathologist will usually see a remnant of the epidermis at one edge.

Caning Corporal punishment Singapore

Caning Corporal punishment Singapore

Ante-mortem abrasions are reddish from inflammation and perhaps minor bleeding.

Post-mortem abrasions are yellow, with a fibrin coating resembling parchment. A good rule is that if a wound has a yellow edge, it is post-mortem (why?)

An abrasion may be the only external sign of blunt force injury, which may have done serious internal damage.

"Pressure abrasions", from vertical force, are common over the zygoma and the side of the nose and orbits when someone falls. "Patterned abrasions" may tell the nature of the object causing the injury (i.e., tire tracks, pipes, rings on a fist), or merely the clothing. "Nail scratches" need no description; "claw marks" are deeper, U-shaped lesions that have penetrated the upper dermis.

*Future pathologists: Here's a system for dating abrasions under the microscope:

• 4-6 hr... polys around vessels


• 8 hr... polys under the scab


• 12 hr... polys in the scab


• 12-24 hr... polys finally fill the scab


• 30-72 hr... epithelial regeneration begins


• 5-8 days... good granulation tissue


• 9-12 days... best epithelial reparative hyperplasia


• 12 days... good collagen, vascularity of granulation tissue is regressing

* And for hard-core pathologists dating skin wounds... (AJFMP 16: 203, 1995)

• Fibronectin strings: First few minutes. Proved person was alive when it happened.


• Fibroblasts positive for laminin or heparan sulfate: 36 hours minimum.


• Tenascin, type III collagen: 2 days minimum.


• Type V or VI collagen: 3 days minimum.


• Type I collagen spots, fibroblasts positive for type IV collagen, basement membrane fragments positive for their typical stuff: 4 days minimum.


• Type I collagen strings, fibroblasts stain for alpha-smooth-muscle actin: 5 days minimum.


• Return of the basement membrane: 8 days minimum.


• Smooth staining of the basal layer of the epidermis for cytokeratin: 13 days minimum.

Always present:

• 13 days: Basement membrane fragments


• 22 days: Good solid basement membrane.


• 24 days: Smooth staining of the basal layer of the epidermis for cytokeratin.





Contusions are areas of hemorrhage in soft tissue, due to ruptured blood vessels, due to blunt trauma. Same as a "bruise". Usually, we reserve "contusion" / "bruise" for cases in which the overlying skin is not broken. If it's palpable, it's a "hematoma".

The blood in most skin bruises is mostly in the subcutaneous tissue. Bruises become more prominent with time, because the blood cells and their liberated hemoglobin spread into the overlying dermis.

Like abrasions, contusions may or may not be patterned. A patterned contusion, unlike most others, has most of its red cells in the dermis from the beginning, because the dermis was forced between protuberances on the impacting surface.

Some purists say that a bruise is a contusion visible through the skin.

It's easier to bruise loose tissue (your orbit) than tightly-woven tissue (your palm).

{07065} kid beaten with electric cord

Don't mistake the "mongolian spot" or other pigmentation for a contusion. Remember that bruises show up better on light-skinned people, and that scalp bruises are often hard to see. If in doubt, incise the lesion.

Colors of a bruise: Blue/purple --> violet --> green --> yellow --> vanishes. Sadly, the rate of color change is tremendously variable, and you can't use it to estimate the time of a bruise. One recent study (For. Sci. Int. 50(2): 227, 1991) found the only reliable rule is that yellow always means >18 hours. Uh, one of my skydiving bruises showed yellow at 16 1/2 hours.

Pretty reliable: If the color has clearly not begun to change, it is less than 48 hours. If the color has obviously changed and become variegated, it is more than 48 hours.

Unless there is a hematoma which will organize, histology will usually only show the presence or absence of hemosiderin in the bleed. (Complement isn't going to be fixed, so neutrophils won't be coming in). Hemosiderin, usually not present until 72 hours, may sometimes be present by 24 hours.

Even heavy trauma may not produce a bruise. Conversely, bruises can be much larger than the object that produced them, due to stretching and avulsion of nearby vessels.

A good rule is that a child who isn't walking shouldn't have a bruise. ("No cruise, no bruise.") After that, a kid living a full, happy life will often have several bruises.

Factors making a bruise more severe:

• Lax tissue (around eyelids; older people; those genetic connective-tissue syndromes)
• Delicate tissues (children, older people)
• Scanty muscle mass / obesity
• Bleeding tendency (amyloidosis, alcoholism, hemophilia, aspirin-takers, patients receiving anticoagulants)

NOTE: Yes, you can produce a bruise on a newly-dead body, though with no blood pressure, it won't be as impressive as one produced by the same force in life. And post-mortem extravasation of blood can simulate bruising: AMFJP 19: 46, 1998.

* Future pathologists: How to skin a body in search of contusions -- something you'll need to do if the person has died in police or prison custody AJFMP 17: 316, 1996.

Advanced decomposition and livor mortis can produce lesions indistinguishable from contusions.

Lacerations: Splits and tears of skin and/or soft tissue, due to stretching-shearing or crushing, on the body surface or deep inside.

{07070} blunt-thing wound {07072} blunt-thing wound {07591} blunt-thing wound

Laceration Tom Demark's Site

Tongue laceration Patient fell EMBBS

Don't mistakenly call an incised wound, produced with something sharp, a "laceration".

To produce a good laceration, there must be something hard (usually bone) close beneath the point of impact. It's easy to lacerate your scalp or shin, hard to lacerate your abdominal wall.

You can spot lacerations by their irregular, crushed, abraded, undermined, bruised edges, and the presence of elastic and connective-tissue bridges in their depths. It's usually (not always) easy to tell these from incised wounds; lesions produced by very dull knives or the edges of boards may produce difficulties.

No, the shape of a wound doesn't tell the exact shape of the instrument which produced it. The classic example is the Y-shaped lesion produced by a metal rod.

An "avulsion" is a laceration in which a portion of soft tissue has been ripped off the underlying fascia or bone, or an organ ripped off its attachments. The overlying skin may be ripped, or sometimes only a pocket of blood is created deep in the tissues.

* Dog bites: J. For. Sci. 38: 726, 1993. The English lady who slept in the hospital with her pet rat which bit her and gave her abscesses: Br. Med. J. 309: 1694, 1994.

Blunt trauma to the chest

{07040} motor vehicle accident

Open fracture Not wearing a seat belt WebPath Case of the Week

Run over Intestines out through anus EMBBS

Transected pulmonary artery
Car wreck
Pittsburgh Pathology Cases

The costal arches provide more protection to older adults, in whom they have usually calcified. Younger people may have organ damage with little external evidence of injury.

Ribs fracture because of (1) direct blows over one or more ribs; (2) indirect trauma from front-to-back chest compression (falls from a great height, getting run over, CPR); (3) pathologic fractures (metastatic cancer, primary bone disease); (4) child abuse (especially by today's savvy abuser who knows he/she can "blame the injuries on CPR" -- Am. J. For. Med. Path. 21: 5, 2000).

Problems caused by fractured ribs:

• flail chest (i.e., breathing is made very inefficient because of paradoxical movement of a group of broken ribs)
• lacerated intercostal vessels and hemothorax
• lacerated lung and pneumothorax / hemopneumothorax (NOTE: A simple fracture of a rib is unlikely to damage the lung. However, at the time of injury, the rib can be displaced and do damage, then return to its normal location. Don't be fooled.)
• penetration of the heart, great vessels (ribs 1-3), or diaphragm-liver-spleen (ribs 10-12).

Fracture of the sternum usually results from steering wheel injury, people jumping on the chest, getting run over, or CPR injury.

Seat belt injuries: J. For. Sci. 38: 972, 1993. You're still better off with it on than with it off; * even politicians realize that seat belts save lives, and (even better) money.

Blunt trauma to the heart and pericardium

Like indirect rib and sternal fractures, this most often results from steering wheel/dashboard injuries, falls from heights, people jumping on the chest, or getting run over. Blunt trauma to the heart is more common than incised wounds.

A bruise to the heart may undergo necrosis, produce rhythm and EKG disturbances, and develop an aneurysm just like an acute MI.

* The new police weapon, a beanbag to stun and knock over perpetrators: Ann. Emerg. Med. 38: 383, 2001.

A laceration of the heart may produce rupture (free wall, septal, papillary muscle, chorda). The left coronary artery or its plaques may be damaged, or a dissecting hematoma may be produced in the aorta or coronary system.

Forcing the heart downward may rip the ascending aorta transversely. This usually happens in steering wheel injuries. Or the sudden compression of the heart may burst the ascending aorta. Or a sudden deceleration injury can lacerate the descending aorta just beyond the origin of the left subclavian artery. (How do you think that might happen?) If the vertebral column is fractured and dislocated, the aorta may be ripped. Tiny rips in the aorta may bleed late, or develop into post-traumatic "pseudo-aneurysms", with their walls composed only of collagen.

{03224} "steering wheel" aortic transection

Ripped aorta
Car wreck
WebPath Photo

Diaphragm and lungs

In addition to the familiar iatrogenic pneumothorax (positive-pressure respirators, needles in the chest), blunt trauma to the chest can rip the tracheo-bronchial tree or the pleura beneath a rib.

If the lung is compressed while the glottis is closed, there may be several bursting ruptures of the lungs.

Tension pneumothorax results when a bronchus or portion of pleura is ruptured and the airway communicates with the pleura. During inspiration, air is forced into the pleural cavity. During expiration, the flap closes, and air remains in the pleural cavity. Eventually, the mediastinal structures will be shifted away from the tension pneumothorax, compromising venous return to the heart.

Rupture of the diaphragm from strong compressive force at or below its level is fairly common, particularly on the left, where the liver affords less protection.

Future pathologists: In suspected child abuse, one favorite defense is "the child simply stopped breathing / choked and the injuries resulted from CPR". Each case must be considered individually. In-hospital CPR in kids without bleeding problems doesn't seem to cause retinal hemorrhages, and if they occur at all they're tiny (Pediatrics 99: E3, 1997). Old claims about CPR causing serious liver lacerations (NEJM 207: 500, 1962) reflect the era's ignorance about child abuse. CPR occasionally ruptures the stomach of a child, but beyond this, the injuries it causes children seem minor (Am. J. For. Med. Path. 21: 307, 2000; Am. J. For. Med. Path. 21: 5, 2000).

Abdomen

Even when there is no external evidence of trauma to the abdomen, the liver, spleen, or distended stomach or intestine can be lacerated. (The abdominal muscles are much more pliable; empty hollow organs move easily and are very difficult to injure by blunt trauma.)

The liver is very commonly lacerated, by virtue of its consistency and placement. Any surfaces may be shattered, depending on the direction of the force. If there's fatty change, it's even easier to lacerate. Blunt-force injuries to the gallbladder and bile ducts are uncommon except in conjunction with liver injury.

Lacerated liver Car wreck WebPath Photo

Most trauma to the pancreas is due to steering-wheel injuries. The result is typically acute autodigestion, and pseudocyst formation and so forth may occur.

The spleen is hard to rupture unless it is enlarged and/or the capsule is fragile (i.e., infection mono, malaria). In these cases, even mild trauma can rupture it.

The kidneys may be bruised, but rupture is uncommon, and won't occur in isolation. A full bladder is easy to rupture.

Blows to the pregnant uterus (auto accidents, battery, falls) may separate the placenta from the wall, killing the unborn child. Or the fetus may be injured; little is known of the anatomic pathology in this situation.

* Future pathologists: Most "rupture of the distal esophagus / stomach" seen at autopsy occurs early-postmortem as part of putrefaction ("esophagogastromalacia"). Histology shows no vital reaction. Don't be fooled.

* Future pathologists: Trauma to the liver is commonplace as a result of CPR ("oops, a little bit low....") in adults, but in kids this is very uncommon (Am. J. For. Med. Path. 21: 307, 2000).

Injuries to the extremities

These most often result from motor vehicle accidents, falls, and battery. Several things are worth remembering.

Fracture of a long bone can produce a fat embolus.

{07145} fat embolus (oil red O, glomerulus)
{07148} fat embolus (brain capillary)
{07149} fat embolus (bone marrow in lung artery)

Cannonball injury
General Sickles
AFIP

Legs amputated by a train
Drug dealer punished by
another dealer -- EMBBS

Crush injuries can result in myoglobinuria and temporary renal shutdown.

Other special types of blunt wounds

"Defense wounds" on a attack victim are likely to occur on the backs of the hands, wrists, and arms.

You'll learn the various types of bony fractures on your orthopedics rotation.

*More about brain trauma when we do CNS. Yes, diffuse axonal injury can result from being hit on the head by a perpetrator (J. Clin. Path. 45(9): 840, 1992).

*The 90-year-old lady who was pecked almost to death by chickens: For. Sci. Int. 52: 25, 1991.

WOUNDS FROM SHARP THINGS

{07068} sharp-thing wound

Instead of producing lacerations, pointed and sharp things produce:

• stab wounds (i.e., the track is deeper than the width of the skin wound); murder or freak accidents; big review For. Sci. Int. 52: 107, 1991
• Incised wounds (cuts, i.e., the track is less deep than the width of the skin wound); fights, suicide attempts, falls onto or through glass
• chop wounds (incised wounds plus an underlying bone fracture or groove, made by heavy instruments);
• iatrogenic wounds. Future pathologists: Don't be fooled. Leave the tubing in prior to autopsy.
• Dicing injuries from windshield glass or gravel (borderzone between abrasions and sharp wounds)

No, 'tis not so deep as a well, nor so wide as a church door; but 'tis enough, 'twill serve: ask for me tomorrow, and you shall find me a grave man.

-- Shakespeare's Mercutio

{07043} stab wound of head {07066} stab wound {07071} stab wound {07131} stab wound {07031} stab wounds {07160} stab wound, knife guard went in {38252} stab wound of chest {38256} stab wound of chest

Ronald Goldman's Autopsy
Text only
Not for young or sensitive viewers

Most fatal stab wounds are knife homicides. You can distinguish wounds by sharp instruments from lacerations by:

• clean, sharp margins;
• absence of bruising at the edges;
• absence of bridging deep in the tissues;

The sharper the knife, the easier it is to penetrate the skin. Once the skin is penetrated, it's very easy to go deeper until bone is hit.

Note that a dull knife will give abraded, bruised margins, and a very dull knife will give jagged, contused margins.

If tremendous force is used, you may see the pattern of the knife guard. If both ends of a stab wound are blunt, the ricasso (i.e., the area near the guard where both edges are dull) or the guard itself actually went in.

Knowledgeable perpetrators twist the knife, once inserted, to allow lungs to collapse and vessels to be opened. This is likely to turn the skin wound into a "V", "L", or "Y".

In the real world, it's impossible to determine the size or shape of a knife from the wounds produced.

If the blade is not completely inserted, the track will be shorter than the blade. If great force is used, the track will be longer than the blade. (Remember that the chest wall can be deformed easily.)

If the blade is not completely inserted, the skin wound may be narrower than the blade. If the knife is not moved straight in and out, the skin wound may be wider than the blade.

The elasticity of the skin may also make the width of the wound a few millimeters wider or narrower than the blade (how?)

The shape of any knife wound will be determined mostly by Langer's lines (remember those?). If the wound is perpendicular to the lines, it will gape. If it is parallel, it will remain slit-like.

Here's a thought question. What are the ways that scissors stab wounds might look?

If the knife has a sharp and a dull edge (most U.S. knives do), one end of the entry wound may be more pointed than the other. In reality, both ends are usually sharp, since the knife usually enters obliquely and cuts as it goes, and in any case, both sides of the actual knife tip are often sharp.

If there are multiple stab wounds, it's easier to make an educated guess about how thick and how long the weapon was.

Future pathologists: Don't probe knife wounds much. You'll make them deeper and learn nothing useful.

You can produce a fatal stab wound with anything sharper than a table fork.

Scissors (open or closed), barbecue forks, Phillips screwdrivers, broken bottles, and arrows (target or hunting) all produce fairly distinctive wound patterns. Arrow wounds in North Dakota: J. For. Sci. 34: 579, 1989; in Georgia J. For. Sci. 34: 691, 1989. Nail gun suicides: AJFMP 11: 282, 1990.

Stab wound to the heart
Surgical photo
EMBBS

Shark bite From one of Uncle Sam's cautionary websites

Nail gun mishap Through orbit, no sequelae Patient x-ray from NEJM

Some clever perpetrators deliver a single icepick blow into the auditory meatus, hoping the pathologist will miss the entry wound and also decide, "Must be sudden coronary death, we don't need do to the head."

Much less common are fatal stab wounds that are self-inflicted (even macho-men Mark Antony and Yukio Mishima botched their attempts) or accidental (falls onto pitchforks, fences, or knives in dishwasher racks).

Stab wounds kill by involving an important organ.

When the heart is involved, death usually results from hemopericardium and tamponade.

When the great vessels are involved, death usually results from hemothorax or hemoperitoneum.

When the lungs are involved, death usually results from hemothorax, less often from pneumothorax.

When the gut is perforated, death usually results from peritonitis.

Neck wounds (stab or incised) kill by producing air embolization, asphyxiation, or exsanguination. Death may also be due to compression of neck structures by a large hematoma.

In stab wounds of the brain, the patient often does not lose consciousness, at least immediately.

Fatal hemorrhage from a stab wound of the extremity is rare unless the femoral artery is severed.

{53702} guy with "behavioral disorder"
{53703} knife swallowed by guy in {53702}

Swallowed a safety pin
Crazy person
EMBBS

Incised wounds

Injury from something sharp (like a stab wound), broader than it is deep (in contrast to a stab wound). A "slash".

{07388} incised wounds {07391} incised wounds

Stab wound Single edged blade WebPath Photo

Knife wound Hilt mark WebPath Photo

A person may commit suicide by severing an artery, broken glass may cut the neck, or a neck wound inflicted by a perpetrator may be fatal. (In neck wounds, death is likely to result from air embolism.) A drunkard or druggie may die after punching out a pane of glass. Other incised wounds are very rarely fatal.

Future medical examiners: (1) "Hesitation marks" are very superficial cuts made by the wound-be suicide, prior to making the fatal deep cut. They are generally present if it's a suicide. However, perpetrators may also hesitate. (2) Would-be suicides seldom shoot, cut or stab themselves through clothing. (3) Perpetrators and would-be suicides will use their dominant hand and locate their cuts accordingly. (4) You'll see "defense wounds" on the palms (grabbed the knife), the backs and ulnar aspects of the arms, and sometimes the legs. (5) Homicidal incisions of the neck are usually long and deep if inflicted from the rear, short if inflicted from the front.

{07398} throat was cut
{07399} hesitation wounds

Incised wound Tom Demark's Site

Defense wounds Simulated WebPath Photo

Defense wound Real WebPath Photo

Defense wounds Real WebPath Photo

Most incised wounds have very shallow ends. A "wrinkle wound" is several discontinuous incised wounds, caused when a knife wrinkles the skin, cutting only the crests.

{07383} wrinkle wound

The dimensions of an incised wound tell you nothing about the weapon with which it was made. Again, Langer's lines determine whether the wound will gap. (NOTE: "Gap" is a real verb, cognate to "gape".)

Chop wounds are categorized separately because they combine features of incised wounds and lacerations, or may appear intermediate.

Machete, meat-cleaver, and propeller wounds belong in this category.

Typically, a chop wound will produce an obvious defect in the underlying bone. Depending on how sharp the instrument is, the overlying wound may appear to be an incision or a laceration.

*How the pathologists approached one of the Jeffrey Dahmer murders: J. For. Sci. 38: 985, 1993.

LACK OF AIR:

{07045} suffocation

Entrapment and environmental suffocation

Suffocation, strictly defined, means death from lack of oxygen in the environment. A looser definition, which also includes smothering as a form of suffocation, is failure of oxygen to reach the uppermost airway.

Suffocation is usually accidental, from entering or being trapped where there's too little oxygen (i.e., in a high, un-pressurized airplane, in a fire, in a long-closed rusted-out tank, or deep in a mine with saprophytes and methane) or insufficient air flow (i.e., as oxygen is depleted by the victim, death results; typical case is a kid in an abandoned refrigerator).

Citations of "fatally low percentages of oxygen in the air" recall the hemoglobin-oxygen dissociation curve. Below around 60 torr, the hemoglobin thinks it's supposed to give up oxygen, not take it on board.

At autopsy, you'll find nothing specific.

* Africa's Lake Nyos and other volcanic killer lakes emit carbon dioxide episodically, with mass deaths: J. Forensic Sci. 33: 899, 1988, Br. Med. J.298: 1437, 1989; Sci. Am. 283: 92, July 2001, Nature 409: 554, 2001.

* Relatively common today, thanks to some books promoting it, is suicide by helium or some other inert gas, used to flush oxygen from a plastic bag over the head. Am. J. For. Med. Path. 24: 306, 2003.

Smothering

Death from occlusion of the mouth and nose by something pressing on the face.

Smothered homicide victims are the very old, the very young, the very sick, or the very intoxicated. The preferred instrument is the pillow or wet washcloth, or the face may be pushed into the bedding. Or the nose and mouth may be occluded using the hands. For the very debilitated, a wet washcloth is sufficient. The most you will see at autopsy are petechiae (sclerae, conjunctivae), nail marks, and bruising of the lips. Even these will probably be absent.

Positional asphyxia simply due to bedrails is well-known (Lancet 363: 343, 2004). Having the bedrails up might help against lawsuits, but also means that patients who climb over them (to go to the bathroom or for whatever reason) are much more likely to fall and to fall farther. (I'm a sleeping-bag man myself....)

{12354} smothered?

Mechanical asphyxia
Conjunctival petechiae
WebPath Photo

Less often, homicidal smothering results from inept use of gags by perpetrators. Usually, the victims are elderly robbery victims.

Suicides favor the types of plastic bags from the dry cleaner's. "Hemlock Society" suicides favor oral overdosage on a Mexican benzodiazepine followed by placing a plastic bag over the face.

As you would expect, where there is no struggle for breath, there will be no petechiae (AJFMP 17: 308, 1996).

In children, death due to smothering by a plastic bag is a common accident. If a mattress is too small for the crib, the child can smother in the gap between them.

*Your lecturer claimed for many years, contrary to classic teaching, that a child or passed-out drunkard or druggie can smother on bedclothes or a mattress. We now know that this is one of the major causes of "SIDS". More later.

Whether the death is homicidal, suicidal, or accidental, autopsy findings will usually be entirely negative.

Choking

Obstruction within the air passages. When "natural", the cause is epiglottitis. Your lecturer has seen accidental deaths due to a roll of sliced ham ("just popped it in..."), a section of canned peach, a swollen tongue chewed during DT's, and a set of dentures.

Homicidal choking usually results either from (1) stuffing a baby's mouth with toilet paper to stop its crying, or (2) using a rag in the mouth in conjunction with a gag.

Most deaths from choking are accidents. Common objects in kids include peanuts, un-popped popcorn kernels, little balls and screws, and the caps of ball-point pens. In grown-ups, the "café coronary" usually results from a drunkard swallowing poorly-chewed beef "down the wrong throat". Less often, pills can end up in the airway, or falling into deep sawdust, grain elevators, etc., can cause death.

{07213} candy corn occluding airway

Fatal acute aspiration Bryan Lee

Tracheo-carotid fistula Bryan Lee

Drunkards, druggies, and the very debilitated can and do die of aspirating chewed food or vomit. Be careful making this diagnosis, since agonally, perhaps 25% of people get food on the airway, and there can be reflux when the dead body is moved.

Don't accept "laryngospasm" as a cause of death. The larynx would relax when hypoxia becomes severe.

However, classic textbooks of forensic pathology give little play to airway obstruction in unconscious or very debilitated patients due to the tongue. Ask any anesthesiologist; this is important, and probably is the final pathway out of life for many people.

Mechanical asphyxia

Pressure outside the body can also cause asphyxia. Familiar causes include large snakes (J. For. Sci. 34: 239, 1989), riot crush, falling into grain (kills a few dozen agricultural workers each year), garage doors (kids playing with the automatic opener: Ped. 98: 770, 1996), human piles, and cars falling off the jack onto your chest. Each time you breathe out, your chest is further constricted. When you try to breathe back in, you cannot.

At autopsy, you'll see bruises, petechiae all over the conjunctiva and sclera, and impressive congestion of the head. (* Future medical examiners: Lots of things can give you petechiae on the eyes by producing strong pressure waves. See, for example, J. For. Sci. 38: 203, 1993).

An important variation is positional asphyxia. In this situation, someone slips into a confined space, and each exhalation causes the person to slip deeper.

STRANGULATION: Occlusion of the blood flow and/or air passages in the neck by external compression.

In any strangulation, death is due to lack of oxygen to the brain. While the carotids are easy to compress, it takes severe twisting of the neck to occlude the vertebral arteries. Nothing you can do will occlude Batson's plexus, which is an important part of the venous drainage of the brain.

In hangings, the pressure is often great enough to prevent most arterial flow to the head, and therefore, you will not see petechiae. In fatal ligature and manual strangulation (and often but not always in smotherings), there will always be petechiae on the conjunctivae. The finding is by no means specific; you can see petechiae here in death from right-sided heart failure, after vomiting, or even from lying face-down after death.

*Shakespeare's Desdemona is strangled / smothered by her husband and left for dead. Emilia comes in. Desdemona revives briefly, speaks, then dies. Either this is Shakespeare's poetic license (seems most likely) or she was rendered unconscious by occlusion of the mouth-and-nose, trachea, and/or carotids, then revived, succumbing moments later to increasing edema of the tongue-throat or larynx from injury during the struggle. Alternatively, the director can have Othello stab Desdemona to death in front of Emilia. This has been done with much impact.

{07056} petechiae in strangulation {07074} manual strangulation

It's difficult to occlude the airway by compressing the neck. If this is done, it's done by pushing up on the larynx and hyoid to occlude the back of the throat.

* The Whitechapel serial killer ("Jack the Ripper") was neither the first nor the last serial killer of prostitutes, but was the first to gain a great deal of media attention. When the woman lifted her skirts and thus had both hands occupied, the killer strangled her, probably pushing the larynx up or compressing it from both sides in order to prevent a loud cry. He then laid the body down gently on the ground, turned the head to the left, stood on the right side, and cut the left side of the throat to prevent blood from squirting onto himself. Like others of his kind, he took anatomic souvenirs. He did not have sex with, or masturbate over, the bodies. Probably we will never find out who "Jack the Ripper" actually was.

"Jack the Ripper"
Autopsy Reports


Mary Jane Kelly
Scene photo
One of Jack's victims

*Sphincter incontinence is common in strangulation, but by no means inevitable. Erection and ejaculation during judicial hanging are probably legends.

Hanging: Compression of neck structures is secondary to a noose tightened by body weight. Review of the anatomy: Forens. Sci. Int. 56: 65, 1992.

Most of these are suicides. The weight of the head (12 lb) slightly exceeds the weight required to compress the carotids. The victim may be fully suspended, upright with legs on the floor, kneeling, sitting, or lying down. It takes 33 lb of pressure to compress an adult's trachea, so this usually doesn't happen in a hanging. Sometimes, death is due to the tongue being forced upward to occlude the airway.

You'll usually find the noose above the larynx. Look for marks, unless the ligature is soft and the body was taken down soon after death.

After most hangings, you'll see a protruding tongue. Don't expect always to see deep injuries in the neck, or petechiae around the eyes (why not?)

Tardieu spots are small hemorrhages resulting from the weight of a column of blood rupturing blood vessels after death. These can be impressive in the lower extremities of a hanged body.

{07046} hanging

In judicial hanging, the "client's" upper cervical vertebrae (C2, C3, and/or C4) are supposed to be broken and/or dislocated by a carefully-planned drop (* actually, doing this right is the exception: For. Sci. Int. 54: 81, 1992). Suicides won't be able to do this unless they have cancer, Down's (maybe), rheumatoid arthritis, or osteoporosis weakening the vertebral column.

Death by Hanging Dino Laporte's PathosWeb

Suicidal hanging Source unknown Not for young or sensitive visitors.

Suicidal hanging Source unknown Not for young or sensitive visitors.

Jonbenet's Autopsy Report Boulder County Coroner Text only

Hanging of Jewish civilians
Romania under Nazi occupation
WWII era

Sexual (autoerotic) asphyxia: A curious, fairly common accident in which a man hangs himself while acting out his personal, private, kind-of-unusual sexual fantasies.

You are likely to find (1) a towel or cloth between the rope and the neck, to avoid producing a hard-to-explain mark afterwards; (2) dirty books and pictures, women's clothing, a mirror, and/or maybe even a camera; (3) some kind of evidence that this isn't the first time (i.e., check that closet top for rope marks); (4) something to prevent his semen from splattering; (5) the deceased could have tied himself up that way. Review AJFMP 16: 232, 1995.

Your lecturer doesn't believe these men do this stuff "because hypoxia heightens orgasm". If this were true, more men would ask their wives and girlfriends to squeeze their necks during romantic interludes. Being tied up is a well-known turn-on for lots of men, alone or with their special partners. Danger may also be a thrill (I wouldn't know, skydiving is very safe). Guys: if you do this stuff, just don't tie the rope around your neck when you're alone.

*Different things are turn-ons for different men, and some men inhale icky things rather than tying themselves up. Your lecturer autopsied one 15-year-old who suffocated on "Pam" pan spray while masturbating. These are all accidents, not suicides. Two different guys and their accidentally-fatal romantic relationships with their hydraulic tractor shovels: J. For. Sci. 38: 359, 1993. Also Psych. Clin. N.A. 15: 703, 1992 ("the dangerous paraphilias", enough to make it obvious enough that it's the link with physical danger that's a turn-on).

*Once considered a "men-only" phenomenon, we now know that a few women do this stuff, too. The difference is that women almost never use props, toys, or funny clothes (For. Sci. Int. 48: 113, 1990).

Autoerotic asphyxia
Source unknown
Not for young or sensitive visitors.


Homicidal hanging is rare, but a very clever perpetrator who is alone with the victim in a private place can render the victim unconscious by a blow to the head and then hang him. The subgaleal hematoma will be the giveaway. Authentic-looking noose marks can be made on a body if it is hanged two hours or less after being murdered by some other means. When in doubt, a complete autopsy is worthwhile.

*Grammarians: People are "hanged", inanimate things are "hung". The only exception is when a man is bragging (or, less likely, getting a compliment) about his equipment.

Many a good hanging prevents a bad marriage.


-- Shakespeare, Twelfth Night

Ligature strangulation: Compression of neck structures is secondary to a noose tightened by something other than body weight

These are usually homicides, and the victims are usually women. An occasional enterprising suicide may use a tourniquet method, and lie on the stick to hold it in place. Accidental ligature strangulations occur (for example, Isadora Duncan's scarf, some skydiving mishaps).

The appearance of the mark can be highly variable. If a towel is used, there may be none. Future pathologists: Don't mistake ordinary crease marks of newborns, folks with jowls, or decomposed people for ligature marks.

Again, there will always be conjunctival petechiae.

{07189} ligature strangulation {10415} ligature strangulation (belt)

Manual strangulation: Compression of neck structures by someone else's body part.

This is always homicidal. (Possible exception: Someone bumps his own carotid sinus and has a rhythm disturbance. I think this is very unlikely unless the person is already very sick. Anyway, this hardly counts as "manual strangulation".)

There will always be conjunctival petechiae. Usually, the force used is sufficient to produce hemorrhage. Older people tend to have more extensively calcified (and therefore breakable) thyroid cartilage horns, hyoid bones, and tracheas. Ante-mortem fractures of the hyoid bone are pathognomonic of manual strangulation. As usual, there must be hemorrhage, or you can't call a fracture ante-mortem. All about hyoid bones and strangulation: J. For. Sci. 37: 1216, 1992.

Again, look for nail marks ("claw marks", "scratch marks"), little bruises, and so forth. "Clever" perpetrators strangle drunkards and children using the palm, without producing finger marks or damaging the deep structures of the neck. In this case, there may be no marks.

*Medical historians! Burke and Hare, old-time Scottish medical school anatomy department provisioners, decided that robbing new graves was too much work. They started obtaining the corpses of poor folks by "burking", i.e., sitting on the chest and occluding nose and mouth with their palms.

{07047} strangled by hand
{07137} strangled by hand

Strangled by hand
Ed Lulo's Pathology Gallery

* Future pathologists: If you suspect strangulation, open the head before you dissect the neck. This will prevent overdistended veins, especially between esophagus and spine, from rupturing and confusing the picture.

Future criminal-justice types: Choke holds (really, "bar arm holds") may produce death by (1) fracturing the airway, (2) hypoxia sensitizing the heart to rhythm disturbances induced by catecholamines during the continuing struggle, or (3) atheroembolization. Carotid sleeper holds compress the carotids only, but as the recipient struggles, the neck can be damaged.

Future medical examiners: Blood behind the esophagus, or next to the cervical spine, or petechiae on the laryngeal and epiglottis mucosa mean nothing. Don't send somebody to jail for a non-strangling.

CHEMICAL ASPHYXIA

Hydrogen cyanide, carbon monoxide, and hydrogen sulfide (oil refineries, manure pits, geothermal plants) are poison gases.

Cyanide (JFMP 18: 185, 1997; Am. J. For. Med. Path. 23: 315, 2002): Blocks the cytochrome system.

Cyanide sodium and potassium salts are used in electroplating, as fumigants, and as insecticides. There is marked dyspnea before death, and criminals in the gas chamber have signalled that death from cyanide gas is, indeed, painful.

* Burning plastics produces cyanide, and often people who die in household fires have lethal levels of cyanide in their blood.

Unlike in the spy movies, it always takes a few minutes to die of cyanide poisoning, even when it is in gas form, and victims remain conscious for a while. (This happened in the Nazi death camps, and in the gas chambers used for capital punishment.) You need around a fifth of a gram of either the salt or the gas; when the salt is ingested, stomach acid (if present) turns it into the lethal gas. (* NOTE: Rasputin probably had achlorhydria; why?)

At autopsy, look for (1) bright red blood (i.e., cyanide prevents utilization of oxygen) (2) the "bitter almonds" smell (around 1 person in 3 cannot smell it); (3) thiocyanate in the blood (normal folks, especially smokers, will have some of this on board already.)

We know of no cumulative harmful effect from cyanide.

* Politics and junk science.... The FDA banned Chilean grapes in the early 1990's. Someone analyzed exactly two grapes (really!) and discovered traces of cyanide in both. What the media didn't tell you, and the FDA apparently didn't know or care, is that there's a small amount of cyanide (as nitrile) in all grapes, and that there was no more cyanide in the grapes in question than in any other grapes. I am not making this up. The result was a major public scare, and an economic disaster for the poor people of Chile. See Nature 369: 27, 1994.



Carbon monoxide (AJFMP 18: 406, 1997).

The colorless, odorless, slightly-lighter-than-air gas that results from burning carbon in relatively low amounts of oxygen. Before the era of the catalytic converter, automobile exhaust contained about 5% carbon monoxide. There's plenty in cigaret smoke.

Carbon monoxide acts by tying up hemoglobin. Its affinity for hemoglobin is 200 times that of oxygen. Smokers are likely to have 10% saturation of hemoglobin. Saturation from 20-30% will make you sick (it's at this point that cherry-red lividity may appear). Saturation of 60% or more will probably kill you (less if you've got angina, emphysema, etc.)

In acute toxicity, there is headache, drowsiness, and ultimately confusion and coma.

The pathologist will find cherry-red livor-mortis, but this isn't specific. You can see it in hypothermia or cyanide poisoning as well. Fortunately, there are instruments to measure the amount of carbon monoxide in the blood.

After an episode of acute poisoning, there may be residual difficulty with memory, speech, and/or coordination. If the patient survives for four or more days, necrosis of the globus pallidus is common. Occasionally, the damage to the globus pallidus is not apparent, and the patient seems to recover, but then goes on to develop progressive destruction of the globus over months, by some unknown mechanism.

* Now that cars produce very little carbon monoxide, successful garage suicides are much less common, and usually result from oxygen depletion and carbon dioxide overload rather than carbon monoxide, though some will be produced when the oxygen in the air is relatively depleted (Am. J. For. Med. Path. 23: 123, 2002).

{07013} carbon monoxide, acute; note the cherry-red livor mortis
{07116} carbon monoxide after-effects on globus pallidus

Carbon monoxide
Cherry red
WebPath Photo

In chronic toxicity (i.e., that home heater is defective), the family complains of headache and malaise. Since carbon monoxide accumulates over time, symptoms do not vanish simply from leaving the house. It takes a clever physician to make the diagnosis, and ultimately save the family from brain damage and even death.

INJURY DUE TO FIRE

{24922} burn
{46535} burn
{46536} burn

Surface burns

First-degree: The outer epidermis is damaged. The dermal vessels probably dilate, but there are no blisters.

Second-degree: Living cells are killed in the epidermis. There will be a blister.

Third-degree: No more epidermis.

Fourth-degree: Charred through.

Today, it's more meaningful to talk about partial thickness and full thickness burns. In the latter, all the skin adnexal structures (hair follicles, sweat glands) are gone from the region of the burn, meaning you will need a skin graft to re-epithelialize it.

Fatal burns, "necklacing"
African political punishment
Burning tire is placed around neck


You'll learn the "rule of 9's" for estimating surface area burned. Complications of burns include:

• hyperkalemia, from disruption of red cells and other cells by the heat;

• shock and hemoconcentration, from the tremendous amount of fluid lost in the inflammatory exudate (this is the most serious problem in the emergency department);
• acute renal tubular necrosis;
• disseminated intravascular coagulation, due to damaged vessel walls and bad stuff getting into the bloodstream (distant endothelium really is damaged; for the molecular biology, see Surgery 106(2): 310, 1989);
• Curling's ulcers of the gastric mucosa, with GI bleeding.
• infection of the burn (pseudomonas, candida); this is the most serious problem in today's burn unit.

{07186} thermal injuries
7103} second-degree burn histology
{07184} could be Curling's ulcers

Internal thermal injuries

House fire temperature is usually around 1200F, and this isn't nearly hot enough to ash a body. Typically, people dying in house fires are found more or less blackened, and often in the "pugilistic attitude" (i.e., like a boxer) with the strongest muscles flexed.

People caught in a burning building inhale smoke, fumes, and heat. Often (and mercifully), the immediate cause of death is hypoxia and/or inhalation of carbon monoxide and/or hydrogen cyanide.

Damaged lung will develop ARDS, pneumonia, and so forth. Histopathology of lung lesions following household fires: Hum. Path. 21(12): 1212, 1990 (there are few surprises).

Persons dying in fires typically have soot in the airways, and will always have elevated carboxyhemoglobin levels. (Arson is a time-honored means of trying to conceal homicide. A murder victim whose trailer is then burned by the perpetrator will not have soot in the airway or much carboxyhemoglobin on board.)

The medical examiner can usually make an identification of the body by means of dental records or fingerprints.

*In a flash fire, there may be instantaneous edema of the oropharynx and glottis, preventing entry of soot into the trachea or carbon monoxide into the blood (AJFMP 17: 24, 1996). My own worst mistake in pathology resulted from my not knowing this.

* Spontaneous human combustion probably doesn't occur. In the best-documented cases, the deceased is an overweight alcoholic who has passed out while smoking in a big cottony chair. The ashes fall, the chair smolders, the victim is overcome by carbon monoxide, the fat melts, and the "candle effect" reduces the cigaret, chair and victim to ashes without burning down the house.

NOTE: Please don't smoke in bed, even if you are drunk.

DROWNING

Probably more material of a speculative nature has been written about drowning ("fresh water vs. salt water"; "electrolytes in the different cardiac chambers"; "finding diatoms", etc.) than about any other subject in pathology. The reason, of course, is the problems with determining whether a dead body was alive or dead when it entered the water. Don't worry about this stuff.

In drowning, death is due to asphyxia. If water enters the lung (occasionally, laryngospasm prevents this but it is VERY rare -- AJFMP 25: 291, 2004), expect to see foam in the mouth. A pathologist's essay on handling bodies from the water: J. Clin. Path. 45(8): 654, 1992.

When a child "drowns in the bathtub", look for other evidence of child abuse (Arch. Ped. Adol. Med. 150: 298, 1996; Ann. Emerg. Med. 25: 344, 1995; Arch. Dis. Child. 70: 435, 1994) -- holding a child under the bathwater is a fairly common form of child abuse, and when fatal, it may be unusually difficult to prove.

* You remember that people with mutant KCNQ1 or RyR2 are prone to drown unexpectedly (Mayo Clin. Proc. 80: 596, 2005 for the molecular autopsy).

Near-drowning, of course, is a serious cause of brain damage (Emerg. Med. Clin. N.A. 10: 339, 1992; there is a self-help group for friends of these unfortunates in Kansas City).

{07139} drowned; the foam is a mix of pond water and lung surfactant
{07147} drowned
{07027} decomposition speeded by warm water

Drowning Petrous bone hemorrhages WebPath Photo

Drowning Plant material in airway WebPath Photo

PRESSURE CHANGES

Blast injuries

Air blasts are actually high-amplitude sound waves emanating from explosions. The blast can enter and blow out the lungs and their vessels, or compress the chest, or rupture hollow organs in the abdomen. The physics is easy to understand: Body parts with different densities will be displaced relative to one another, causing them to be torn.

In immersion blast, the same physics applies. Under these circumstances, it's best to be floating prone or supine on the water surface. Guess where the water blast goes if you're treading water....

Bomb and land mine injuries combine projectiles and blast force. As long as the US, Russia, and China are all still manufacturing land mines, the prospects for their elimination seem poor (Lancet 357: 731, 2001).

Decompression injuries ("caisson disease", "the bends")

When the pressure of a person's surroundings decreases greatly, dissolved gas in the blood and tissues will turn into bubbles, wrecking havoc (bubble emboli, vapor lock of vessels, in science-fiction it includes bursting-apart of the body though this did not happen to the Russians whose space capsule decompressed). This happens in real life when divers surface too rapidly, or in futuristic fiction, when spacemen remove their spacesuits at the wrong time.

ELECTRICAL INJURIES High-voltage alternating current (i.e., 7680 volts, from the generator plant) kills by generating heat. Low-voltage alternating current (i.e., 110 volt household current) kills by inducing ventricular fibrillation; or if the amperage is high, the heart simply cannot re-polarize. C=V/R, where: C is current in amperes V is voltage in volts R is resistance in ohms

Effect of current:



• 1 milliamp... tingle, "let-go" current


• 10 milliamps... "can't-let-go" current


• 30 milliamps... respiratory paralysis


• 75-250 milliamps... ventricular fibrillation is likely


• 4 amps... asystole

Electrical burns are generally small, gray, charred marks with a grayish-white rim (blood was driven out, then vessels were seared closed). And in the large majority of electrocutions on household appliances, there is NO lesion found on autopsy. Death does not occur instantaneously after the shock, and the victim's last act may be to turn off the defective tool or remove the contact, making it much harder to recognize that this is an electrocution. Late complications of a "minor" electrical injury, which may be fatal, result from endothelial damage and thrombosis (Lancet 363: 2136, 2004).

Lightning is direct current, and thus produces a different kind of injury (review J. For. Sci. 38: 353, 1993). The typical lightning stroke produces arborescent (fern-shaped "* Lichtenberg figures") burns; my physics isn't good enough for me to understand how it happens, but they are distinctive (review AJFMP 17: 99, 1996). If the lightning passes through heart or brainstem, the victim is likely to die. Otherwise, survival is usual, and injuries will probably be minimal. Around half of people struck by lightning die. All about being struck by lightning: AMFJP 17: 89, 1996.

Struck by lightning
Lichtenberg figures
Patient photo from NEJM


If you're outside in a storm and your hair starts to stand up and you feel tingly, lightning is about to strike. If you can't get in a car, get to the lowest ground that you can and crouch ("catcher's position". This is the new advice from the National Weather Service, which is concerned about your heart being close to the ground, which carries current for a few hundred feet, should you lie flat. No controlled studies, and since so far as I can tell a taser cannot cause a cardiac rhythm problem, this sounds hokey to me. Any physicists out there?)

*{07519} ...and that one word were "Lightning!", I would speak.... -- Lord Byron

{07190} lightning wound
{07513} lightning wound
{07037} electrical injury and burn
{07107} electrical trauma
{07109} lightning death
{07504} lightning death
{07183} electrocuted
{07187} electrical injuries
{07480} electrical injuries
{07486} electrical injuries
{07495} electrical injury, where current exited
{11127} electrical injury, where current exited
{07537} lamp-in-the-bathtub homicide

*A judicial execution uses 31 cents worth of electricity (1990 figure). In reading up on the history of judicial electrocution in the U.S., I learned that it's easy to bungle, but probably nobody has suffered since Thomas Edison's foolish attempt to electrocute a criminal by running a current from one arm to the other (!).

Under given circumstances that surfaced, the results were far less than aesthetically attractive. But with rare serene exceptions, after forty-odd years of experience, it is held that most deaths are without aesthetic attractiveness, regardless of causation.

-- Frank Kilgo, M.D.;

Medical Director, Florida State Prison, after a condemned man accidentally caught on fire in the electric chair

HEAT EXHAUSTION AND HEAT STROKE ("hyperthermia")

These result from over-production of heat, or the inability of the body to radiate heat. Babies, the elderly, and those taking anticholinergic agents and phenothiazine drugs are especially vulnerable to these problems.

In heat exhaustion, a person over-exerts in a hot environment. As a result, fluid and electrolyte imbalances and lactic acidosis may render a person sick or even dead. In addition, the over-exertion can result in rhabdomyolysis and myoglobinuria.

In heat stroke, the body temperature rises, by whatever means, to a point at which the brain no longer properly controls body temperature (around 41C or 106F). The result is rapid, generalized vasodilatation, coma, and death.

Classic textbooks make a big distinction between "heat exhaustion" and "heat stroke", but in practice, it's likely to blur. Scenarios range from forced exercise on a hot day, to forced labor in hot quarters, to cocaine abuse, to extreme fever.

* My friend Barry Lifschultz MD, medical examiner in Chicago, was one of the authors of the epidemiologist's criteria for a heat-related death (Am. J. For. Med. Path. 18: 11, 1997). At the time of collapse, the core temperature should be 105 degrees F or higher; if cooling has been attempted prior to taking the temperature, mental status changes at the time when the temperature was highest and elevated muscle and liver enzymes are to be expected. Of course there is no pathognomonic sign at autopsy.

Hyperthermia
Southern Utah
WebPath Photo

HYPOTHERMIA

Below 31C / 86F, our enzymes don't work well. As a person dies of hypothermia, the skin blanches (vasoconstriction, why?), then reddens (loss of vasomotor control, with resultant rapid loss of heat.) The latter effect probably explains why many people who are freezing to death remove their clothes. Death probably results from brain and/or heart dysfunction.

* Dr. Overman, past medical examiner of Jackson County, shared the following anecdote: The danger of hypothermia is greatest when the victim is immersed in cold water. This was most strikingly demonstrated when the Titanic struck an iceberg in the North Atlantic. One hour and fifty minutes of the sinking, another ship appeared and picked up the survivors. There were enough life jackets on board for all 2,207 people. 705 people in lifeboats were rescued. All others who were in the water died. Virtually all of them died of hypothermia rather than drowning. At the time of the sinking, the water temperature was approximately 32 degrees F. The Coast Guard estimates that with the water temperature of less than 35 degrees F, the expected survival time immersed in water is less than 45 minutes.

Cold water

WebPath Photo

Local hypothermia damages tissue by freezing of water, resulting displacement of ions, and vasoconstriction and loss of vasomotor control. Everyone is familiar with frostbite (which can progress to gangrene), and lesser degrees of cold injury. Note that fingers may be frostbitten but not appear red until they are re-perfused. In this type of injury (and many others), damage to the nerves can produce the troublesome, longstanding causalgia pain syndrome.

Gangrene
From frostbite
WebPath Photo

Chilblains is a curious inflammatory purpura (the histology shows a microvasculitis) which appears as sore purple spots on parts of certain people's bodies after cold exposure. Mysterious but not dangerous. I suspect microthrombi are the actual cause.

* Nobody understands the coagulopathy of hypothermia. Thrombin gets activated, DIC occurs, platelets get activated -- lots of things happen. See J. Trauma 44: 846, 1998.

Future pathologists: Was the body alive or dead when it went into the snow? Easy call! Frostbitten skin is purple (why?), and under the microscope you'll see vacuolated epithelial cells, edematous dermis, and engorged capillaries (AJFMP 31(1): 18, 1992).

{07557} hypothermia

TORTURE

Inflicting severe pain as a means of coercion.

We'd all prefer not to hear or talk about this (most med schools never mention it: JAMA 276: 1676, 1996), but it's part of our world. The fact that these practices go on today is testimony to human evil and human (usually governmental) ability to find justification for wicked practices. Alleged to be government policy, typically used by one-party states for discouraging dissent, in >80 countries in the past ten years. What "counts" nowadays as torture is itself highly politicized -- read today's headlines.

The accuracy of information obtained using torture has been discussed some in the medical literature since the September 11 terrorist attacks. The idea is that under torture, the bad guy tells the truth because of an animal instinct to survive and/or because his cognition is impaired. One could only wish that a barbiturate infusion ("truth serum") worked better. Obviously we can't do good controlled studies, and life's taught me to be mistrustful of people's "impressions" especially when it comes to behavior. If torture does become legal and/or is widely practiced, they'll want a physician in attedance. Would you do it?

* Democracies generally limit the use of torture to anti-terrorism: Dan. Med. Bull. 37: 556, 1990, abstract 91160373; Br. Med. J. 308: 61, 1994; Am. J. Forens. Med. Path. 18: 321, 1997 -- Israeli security produces first known "shaken adult" fatality), or conditions in which there is a low-level race war (Lancet 344: 350, 1994); US forces, including health-care workers, in the rough interrogation of terrorists in Iraq and Afghanistan: Lancet 364: 725, 2004; Br. Med. J. 313: 1265, 1996; you'll need to decide whether this is morally acceptable and/or wise.

* I would distinguish this (though you might not) from the rough-but-not-horribly-cruel, extra-legal police "street justice" that helps maintain public safety in communities where the official law doesn't work (as in high-crime areas of US cities). Ask me about this if you like; today's policeman is "damned if he does, damned if he doesn't", the winners are too-often the crybaby criminals and their lawyers, and the losers are decent people.

* The term "third degree" for harsh police questioning refers to medieval and early-modern protocols for torture on the rack (1st degree: shoulders, victim probably recovered; 2nd degree: elbows and knees, victim was crippled; 3rd degree: vertebral column, victim was paralyzed and died in hours or days).

* Some countries use corporal punishment for criminal offenders. Delaware used whipping as an alternative to incarceration into the 1960's; the skin was almost never broken, and the purpose was to embarrass the perp and make it clear that punishment was being delivered without requiring time behind bars. Thankfully, we now sentence non-dangerous offenders to "community service" instead.

Of course, in our "enlightened" times, governments wish to avoid detection. Therefore, they prefer mental cruelty, sexual stuff (Lancet 336: 289, 1990; the methods are those that will not leave marks), near-asphyxiation, near-drowning, electricity from a magneto or charged object (field telephones and "stun weapons" are popular, delivering an agonizing but safe voltage), and application of electricity over a relatively large surface area (i.e., saline-soaked gauze pads between the skin and the jumper cables / magneto telephone; this is the world's most popular means of inflicting severe physical pain; review Am. J. For. Med. Path. 5: 333, 1984).

Low tech torture often involves beating with sandbags, which can rupture the guts without bruising the skin. When this leads to an agonizing death from peritonitis in a few days, there will be no external signs of torture, and the police will claim "heart attack". Chronic painful neuropathies are usual after other low-tech procedures ("Palestinian hanging", i.e., by the arms from behind in internal rotation, "falanga", i.e., whipping the soles of the feet), and beating and kicking the head is likely to begin chronic headache problems (For. Sci. Int. 108: 155, 2000).

* For a current list of practices in Turkey, and relative frequencies, see Am. J. Psych. 76: 76, 1994. Sikh radicals: Lancet 345: 225, 1995. Iraq: Br. J. Psych. 172: 90, 1998. Tibet J. Nerv. Ment. Dis. 186: 24, 1998. Burma: Am. J. Pub. Health 86: 1561, 1996, Br. Med. J. 312: 293, 1997. Bhutan: JAMA 280: 443, 1998. The press has ignored a Maoist insurgency in Nepal which has taken over much of the country and is torturing extensively: Lancet 358: 752, 2001. Problems for doctors investigating claims of torture in Mexico: JAMA 289: 2135, 2003 ("I'm sorry, we don't have a camera"). The Taliban was torture-happy: JAMA 280: 449, 1998. Persecution of physicians by the Taliban: Lancet 355: 50, 2000. Sierra Leone Lancet 353: 1365, 1999. Children and torture: Lancet 356: 2093, 2000. Iran: J. Nerv. Ment. Dis. 185: 74, 1997. Guatemala: J. Fam. Pract. 44: 209, 1997. Mobutu's Zaire: Br. Med. J. 312: 293, 1996. Zimbabwe's Mugabe tortures opposition politicians: Br. Med. J. 324: 317, 2002. Brain damage is common after some forms of torture, and it is now being quantitated using visual evoked potentials: Int. J. Leg. Med. 109: 114, 1996. Compared with government torture, the Italian Mafia is surprisingly humane, even when executing its traitors: Am. J. For. Med. Path. 19: 87, 1998. The choice of suicide method after torture typically mimics the torture method used (drowning, blunt force, or stabbing): J. Tr. Stress 11: 113, 1998.

People who have been genuinely tortured usually have post-traumatic stress disorder (intrusive memories, "increased arousal", i.e., jumpiness) and particularly sleep disturbances. These seem to be fairly predictable in survivors (J. Nerv. Ment. Dis. 177: 147, 1989), and in fact having been tortured is the strongest predictor of future post-traumatic stress disorder (Br. J. Psych. 162: 55, 1993). Treating survivors: J. Nerv. Ment. Dis. 179: 4, 1991; JAMA 272: 357, 400, & 600, 1994; Br. J. Psych. 166: 705, 1995. Commitment to a cause, a strong social support, and prior knowledge and preparedness seem to be helpful in preventing the most severe post-traumatic stress disorder, but the after-effects are still serious and long-term (Am. J. Psych. 15: 76, 1994).

Physicians have demonstrated real heroism in resisting these practices, and trying to control them. Other physicians have cooperated (Saddam's doctors: JAMA 291: 1480, 2004). As with the other problems of the poor nations, the outlook is "guarded" or worse. Encouraging news (from the Danes) include (1)* no claimants since the mid-1990's from Latin America, and (2)* no reports of physician complicity. Further reading for humanitarians: West. J. Med. 157: 301, 1992; JAMA 268: 584, 1992; JAMA 270: 606 & 616, 1993; J. Nerv. Ment. Dis. 179: 4, 1991; JAMA 264: 2097, 1990 (the old South Africa); J. Nerv. Ment. Dis. 185: 74, 1997; West. J. Med. 165: 112, 1996; Ann. Int. Med. 122: 607, 1995; JAMA 276: 396 & 416, 1996.

Because of attempts to avoid detection, it may be difficult to determine whether a person seeking political asylum is simply making up a story. Presently, there are attempts being made to make this scientific, but it's still a real challenge. See For. Sci. Int. 76: 69 & 77, 1995; update from Denmark Am. J. For. Med. Path. 26: 125, 2005. For now, if you are asked to assist with such a determination, I recommend:

• A full history and meticulous physical examination, with a focus on determining whether claimed sensory deficits and paresthesias can be explained anatomically and/or are consistent with causalgia
• Bone scan (Lancet 337: 846, 1991; this is likely to pick up injuries to the periosteum and previous electrical torture, up to two years later)
• Imaging studies when in doubt, especially to document deep sort tissue injuries (the Danish study cited above was reluctant, even when it was clear they were dealing with some liars)

East Timor Human Rights Council Photos
Includes some of the now-famous photos taken by soldiers
and sold (!) to human-rights activists
Not for young or sensitive viewers

IONIZING RADIATION

Terms:

cosmic rays: Matter at relativistic velocities, from supernovas in distant galaxies, etc., etc. The particles they produce on colliding with our atmosphere are (along with terrestrial isotopes) the source of the natural background radiation.

curie: A unit of isotope that undergoes 3.7 x 10¹⁰ disintegrations per second.

gamma ray: A high-energy photon, capable of ionizing atoms and mutating your genes

half-life: How long it generally takes for half of the atoms in a sample of isotope to disintegrate

LET: "Linear energy transfer". A measure of the penetrating power of a form of radiation.

rad: A dose of energy resulting in absorption of 100 ergs per gram of target tissue. Abbreviated "r".

REM: "Roentgen equivalent for a man". A measure of the power to damage cells. Same as "RBE -- Relative biological effectiveness."

roentgen: How much radiation results in emission of one electrostatic unit of charge in 1 cc of air

x-ray: A human-made gamma ray.

* Target theory: Mathematical modelling for the statistical aspects of radiation injury and chemical carcinogenesis. "Single target theory" would have no minimum threshold for harm from radiation. This makes no sense biologically and doesn't fit with the empirical data, i.e., anybody offering this idea today is a crook.

"Big Robbins" describes the effects of ionizing radiation in much detail. You're already familiar with the generation of free radicals, which (whatever the details) is how gamma rays do their harm to living tissue. Here's what's worth learning now:

The most radiosensitive normal tissues are lymphoid organs, bone marrow, and germ cells. Not surprisingly, the most radiosensitive tumors are lymphomas, leukemias, and seminoma/dysgerminoma.

Cells that normally divide a lot (i.e., epidermis and its adnexa, GI mucosa, bronchi) are more vulnerable to radiation than most other organs. Germ cells and lymphocytes also carry the instruction: "If you're hurt, then die, don't divide." (Why might that be?) Bone, muscle, cartilage, and nerve are highly radioresistant. Except as noted above, the susceptibility of a cancer to radiation has little to do with the susceptibility of its parent cell.

Under the microscope, pathologists recognize two features of radiated tissue.

1. The vessels exhibit exaggerated hyaline sclerosis; much like the arterioles in diabetes and hypertension, but more extensive and worse. This narrowing of vessels continues to get worse for the rest of the patient's life. (In the acute phase, look also for obvious injury to the endothelium; at high doses, look for fibrinoid necrosis of vessels.) Review J. Laryngol. Otol. 111: 988, 1997.

2. Scattered cells often exhibit large, hyperchromatic nuclei which one could mistake for cancer cells. Probably what's happening is that the radiated cells can duplicate their DNA in preparation for division, but cannot divide.

Radiation sickness While it is commonplace to dose a part of the body with 4000-5000 rads to kills cancer cells, a total-body dose of radiation will have the following untoward effects.

200- 500 rads

Hemopoietic syndrome. Early nausea and vomiting on the first day. Afterwards, blood cells disappear from the body (lymphocytes first, since they are the most vulnerable; afterwards, short-lived neutrophils and platelets; ultimately, survivors become anemic.) Victims receiving 200 rads will probably survive; those receiving 500 rads will probably die.

500-1000 rads

Gastrointestinal syndrome. Severe nausea and vomiting occur within a few hours, and are only the most prominent symptom in a body in which many cells have died in many places. Most victims will die in a few days.

>5000 rads

Cerebral syndrome. Brain necrosis and edema will produce drowsiness, coma, and death in an hour or two.

In survivors of Hiroshima and Nagasaki, the following additional health effects were noted:

• a greatly increased (10-20x) incidence of acute myelogenous leukemia, chronic myelogenous leukemia, and acute lymphocytic leukemia (Sr⁹⁰ deposited in bone gets the blame)
• an increase in the rate of thyroid cancer (radioactive iodine was blamed; not all of these cancers were troublesome, and we don't know how much the true rate was increased over baseline)
• modest increases in the rates of breast and salivary gland cancer (also reportedly lymphoma, plasma cell myeloma, and a few other solid tumors)
• radiation cataracts;
• brain damage in the unborn (the fetal brain is highly radiosensitive).

In survivors of Chernobyl, the following additional health effects were noted:

• about 100-fold increase in thyroid cancers, especially aggressive papillary carcinomas, especially in kids, from the I-131 exposure (still holding up, with the expected highest incidences in those exposed when very young and those exposed heavily: Cancer 86: 149, 1999; Cancer 88: 1470, 2000);
• possibly some increase in the amount of hypothyroidism, same reason;
• some increase in the prevalence of birth defects to unborn children who were exposed;
• remarkably little else. Particularly, no increase in leukemias. See Br. Med. J. 132: 1119, 1996. Update Arch. Env. Health 55: 181, 2000.

• All across Europe, there were claims of increased numbers of birth defects in babies conceived immediately after the fallout. This seems to be mostly reporting bias, since certain birth defects are known to result from injuries at particular times during embryonic life, and the dates simply didn't add up. See Arch. Env. Health 56: 478, 2001.

American service personnel exposed during the atomic tests after WWII do not seem to have any increased total cancer risk or total mortality (Occ. Env. Med. 60: 165, 2003).

*One often-discussed idea for a petty tyrant's nuclear weapon ("dirty bomb") is a conventional bomb packed with radioactive waste from a nuclear power plant.

*Goiania is a town in Brazil where some lowlifes stole Cs137 from an abandoned radiation therapy unit (!); the glowing particles ended up being distributed as "carnival glitter" (!!). The result was a lot of radiation sickness and some deaths (Mut. Res. 373: 207, 1997).

You'll learn in the clinic about the deleterious effects of therapeutic radiation. Pulmonary fibrosis has long been well-known. Many people still do not appreciate that radiation to the brain, while it may help control cancer, will often produce appalling brain damage (Cancer 63: 1962, 1989).

{25532} x-ray burn

* * * 

Lead me from death to life, from falsehood to truth.
Lead me from despair to hope, from fear to trust.
Lead me from hate to love, from war to peace.
Let peace fill our heart, our world, our universe.

-- Brihadaranyaka Upanishad (Hindu scripture)

The biggest problem in the world is that nobody helps each other.

--Anakin Skywalker

Do you love your Creator? Love your fellow-beings first.

-- Mohammed

Lord, make me an instrument of your peace.
Where there is hatred, let me sow love,
where there is injury, pardon,
where there is discord, union,
where there is despair, hope,
where there is doubt, faith,
where there is darkness, light,
where there is sadness, joy.
O divine master, grant that I may not seek so much
to be consoled as to console,
to be understood as to understand,
to be loved as to love.
For it is in giving that we receive,
it is in pardoning that we are pardoned,
and it is in dying that we are born to eternal life.

-- Attributed to "Francis of Assisi" (John Bernardone) c. 1230

I am an absolute pacifist. It is an instinctive feeling. It is a feeling that possesses me, because the murder of men is disgusting. -- Albert Einstein (Christian Century, 8/28/1929)

The ballot is stronger than the bullet.

--Abraham Lincoln 5/19/1855

I am proud of the fact that I never invented weapons to kill.

--Thomas A. Edison, NYT 6/8/1915

I think that people want peace so much that one of these days governments had better get out of the way and let them have it. -- Dwight D. Eisenhower, 8/31/1959

* * * 

On not becoming a victim of homicide

Violence usually begins with invasion of someone's personal space, respect, or dignity. Everyone feels entitled to these things, whether or not everyone else agrees.

Despite the attention given to random violence, especially in our slums, in recent decades, most homicides are still committed by someone the victim knows. The larger story of any homicide or suicide seldom shows the finer side of humankind. Your lecturer is no expert on security or crime prevention, but he's had considerable reading and professional experience relating to homicides.

The following suggestions will not make you immune to becoming a homicide victim, but will greatly reduce your risk of dying at the hand of someone you know:

1. Don't bully anyone, physically or verbally.

2. Don't ridicule anyone. (This is a really important survival tip.)

3. Don't try to take another person's wife or girlfriend.

4. Don't crowd or speak rudely to a person who is obviously upset, even if he or she is threatening you or someone else.

5. When a relationship breaks up, be tactful and kind to the person to whom you were important.

6. Don't deal drugs.

7. Don't do sexual things for money or drugs.

8. Men: Don't carry a weapon. (This applies in the vast majority of circumstances. There are exceptions.)

9. Women: Don't be a sexual tease.

10. Gay men: Don't do sexual things with men you don't know well, or with jealous (i.e., nutty, insecure) men. Don't ask out men you don't know well. (Homicides: AJFMP 17: 350, 1997).

11. Children and teens: If the adults you must live with are abusive, pretend you love them anyway.

Sociobiology in action: Living with a step-parent is the most powerful risk factor for child abuse yet identified. See Science 261: 987, 1993. A child in Canada is sixty times more likely to be murdered by a step-parent than by a parent: Sci. Am. 273(4): 174, Oct. 1995. Readers will not be surprised that in the US, infanticide is far more common if Mom is less than 17: NEJM 339: 1211, 1998.

*Child-kills-parent: rare. Usually Dad is murdered, usually for being a control freak.

* In the townships of "the new South Africa", a child is almost as likely to be killed in cold blood (often shot to death, something which almost never happens in the U.S.) as he/she is to die in an accident (Am. J. For. Med. Path. 24: 141, 2003).

NOTE: Alcohol is a factor in a majority of homicides. Certain men, under the influence of alcohol, are prone to fire their handguns at other people for no reason. Even when there is some motive, a majority of murderers have alcohol on board at the time of the crime, and a majority of victims have alcohol on board.

NOTE: When there is a motive for murder, other than disputes among drug-culture types, sex is almost always involved, and usually somebody has insulted the murderer's pride in this particular area. The most classic of all non-underworld, non-underclass homicides is the man who kills the woman who left him.

* NOTE: There are 20,000 violent murders yearly in the US (J. For. Sci. 42: 279, 1997). "If a man kills one person, he's a criminal. If a man kills 100,000 people, he's a hero." Whether the violence is individual or institutionalized, violent people will surprise you by their selective delicacy of conscience. They may be crusaders for good causes and pillars of the local place of worship, exhibit extreme tenderness toward children, the sick, the elderly, and so forth. Hitler and Ted Bundy embraced vegetarianism, because they professed to abhor harming innocent creatures. Hitler was opposed to using animals for medical research.

* NOTE: Criminality has no easy explanation. The classic parents of a criminal (an alcoholic bully father, a hysterical pill-popping mother) are folks whom you'll meet soon enough, but many criminals come from "nice homes", and most brothers of hardened career criminals have no criminal records themselves. For decades, the social psychologists have insisted that "violent criminals suffer from low self-esteem", and based treatments on this ideology. A review team found that there was never been any empirical evidence that this is true. Having known a few, I concur strongly with the team that they are mostly big-ego types who have decided they are special, above the law (Sci. Am. 284(4): 96, 2001). Other "enlightened" explanations for criminality just don't fit the facts either: Poverty isn't the explanation, since self-reports of misbehavior correlate very little with class. Most poor folk are decent, law-abiding people who hate the criminals among whom they must live. Despite much effort, nobody's been able to demonstrate that police and courts treat blacks and whites differently if they've done the same bad things. Injustice isn't the explanation, since police, victims, and criminals all agree about what's right and wrong and what should be done with wrongdoers. A few traits of career criminals are well-known: (1) they socialized poorly as kids; (2) they were poorly supervised by their parents; (3) they are sensation-seekers and continually seek new excitement; (4) by any reasonable definition, they are racists; (5) they drink alcohol; (6) they have never been seriously interested in serious religion; (7) they suffer less from a bad conscience than do the rest of us. I would have added (8) they are demanding of everyone except themselves; career criminals are the worst crybabies. Most criminals learn early to cite past wrongs (personal, ancestral) to gain sympathy and special privileges. There's a review in Nature 368, 111, 1994. There's a adoption study that concluded that childhood misbehavior was mostly caused by the environment, but found that your number of adult convictions correlated better with convictions of your biological parents rather than your adoptive parents (!!; Lancet 345: 466, 1995; has a list of candidate genes).

* Easy, wrong answers: If "violence in the movies and on TV" is a major factor in our epidermic of violence (as suggested in JAMA 267: 3059, 1994), why is the murder rate 10 x lower in Canada, where they watch the same shoot-'em-ups? See Psychiatry 56: 3, 1993. And if handguns are the problem, why is the murder rate similar in non-inner-city Canada (where murderers use knives and bludgeons) and non-inner-city areas our own states that adjoin Canada (where gun ownership is much higher, and the murderers use guns; see Am. J. Epidem. 134: 1245, 1991)? More on international comparisons: JAMA 263: 3292, 1990. In some US elementary and high schools, most of the students are armed with guns simply for self-protection, yet there are surprisingly few shootings, and the kids are far safer in school then outside. Although there is much less legal gun ownership in Sweden, there are still plenty of mass-shootings: AJFMP 19: 34, 1998. Murder rates per 100000 people per year worldwide: South Africa 75.3 (Am. J. For. Med. Path. 24: 141, 2003), Philippines 38, Lesotho 36, Jamaica 18, US 8, France 4, Britain 1.3, Ireland 0.5. Obviously there's something more than "guns cause murders". More easy explanations that aren't true... The familiar right-wing claim that more people have died violently since the 1859 publication of "The Origin of Species", and the familiar left-wing claim that "science leads to a devaluing of human life", both ignore the fact that the world is more densely populated today thanks to science (public health, fertilizer); nevertheless, Tamurlane probably killed as many people as Hitler did in his own era. The familiar right-wing claim that child abuse is a new phenomenon caused in particular by the decline in "family values" ignores the fact that physicians simply denied, ignored, or covered it up during the "good old days" before the 1960's. Reading about how we "discovered" why some babies have multiple fractures of different ages is chilling. Society calls for radical changes in the wake of shooting sprees (by loonie day-traders whose neighbors knew something was badly wrong, by high-school kids who were teased and ridiculed for years by their "well-adjusted" peers, and so forth). But at the same time, society goes gah-gah when honest scientists try to look at the impact of genes or brain chemistry on bad behavior, or when people talk about putting obviously dangerous, mentally-ill people in long-term institutional care. Again, there are no easy answers.

* To compound the mystery... During the early 1990's, the rates for murder, assault, robbery, and burglary all dropped precipitously in the US. The causes remain obscure (Sci. Am. 290(2): 82, Feb. 2004). The epidemic of murder among black and hispanic men ages 14-24 peaked around 1991 (5x above the usual norms, 1 in 20 ended up being murdered by a peer in some communities) and is dropping, perhaps because crack use is being replaced by marijuana use, and marijuana dealers are a non-violent bunch (uh...?) Booming economy (timing's off)? Roe v. Wade causing fewer unwanted neglected children (timing's off)? More cops (NYC experience)? Concealed-carry (maybe)? More prisons with the bad people off the streets (uh, this isn't the "politically correct" answer, but it's the one I find easiest to believe)? Crime prevention as a public health measure is reviewed in Britain's Lancet 358: 1717, 2001; it holds America's ugliest statistics up for examination, and points what has worked and what hasn't; its explanation for the drop in our murder rate is the policy by the police to focus their attention ("by the book" or not) on the really bad people and the really bad places. The statistics (a 1% increase in prison population reduces murder by 1% and violent crime by about 2%) seem to confirm the common-sense idea that keeping bad people off the streets is also helpful. Simply increasing the numbers of officers is supposedly less helpful, and the "zero-tolerance" nonsense (i.e., busting kids for having nailclippers or an aspirin) does no good.

* You heard it here first. Today's polygraph testing is a parlor trick, mere salesmanship-and-subscience (NEJM 327: 122, 1992, Lancet 360: 1261, 2002, and the fact that a bunch of Castro's people all beat the polygraph to go to work for the CIA some years back, settled it for me). Not that it really matters, but the inventor of the polygraph was not a physiologist but a cartoonist who went on to create "Wonder Woman". The Japanese are experimenting with brain wave patterns which indicate whether a suspect recognizes, or does not recognize, a crime scene. Sounds interesting. For. Sci. Int. 51: 95, 1991. More generally, your lecturer has fair confidence in the criminal justice system's ability to discriminate guilt from innocence, usually, with the unique exception of men falsely accused of sex crimes. This is what the inmates themselves told me in the 1980's, and my own experiences and reading bear this out. In today's political climate, an innocent man must often plea-bargain and even serve prison time (Science 256: 301, 1992; KC Star March 13, 1993; remember also Potiphar's wife Genesis 39:7-20). This has now become a public scandal, as has recently happened (1994) with the "false memories" fiasco of the early 1990's and the ultra-bizarre, no-physical-evidence child-molestation witch-hunts ("Believe the children!") of the past 30 years. In the meantime, men, you must "love defensively", and you shouldn't even talk much to a woman unless you know she isn't nuts. Of course, women have always known not to talk to a man until she knows he isn't nuts, because there is still plenty of real violence and abuse.

A man always finds it hard to realize that he may have finally lost a woman's love, however badly he may have treated her.

"Sherlock Holmes", The Musgrave Ritual

* Punch-and-Judy have been considered funny, but domestic violence isn't. Wife-beating (and girlfriend-beating, and of course child abuse) continues epidemic despite the fact that it's receiving much more attention lately (as it should). About 1.5 million women in the US experience "intimate partner violence" each year (JAMA 288: 589, 2002; this is still too many though it may be fewer than you've been told). Around 10% of emergency room visits by adult women result from their getting beaten in an ongoing man-beating-woman situation (JAMA 1995; discusses the error in Am. J. Psych. 151: 630, 1994 by militant feminists who claimed the number was 35%). He is often an alcoholic bully or junkie with scrambled brains, but the stereotype doesn't always hold. Psychiatrists talk about insecurity as the basis for the habitual wife-bearer's part (gee whiz), and so forth. A small minority are sociopaths, i.e., charming, personable men who are incapable of acting from moral principles. In turn, she is often a nagger ("...you Just Don't LISTEN!!!!") who constantly belittles him. While they were dating, she liked his aggressive, assertive style. Now she's sorry, but where would she go? Plus, she likes it when he apologizes and makes up each time (even after she has him arrested). When a man kills a woman, it's likely that this stuff has been going on beforehand. Both partners usually have lousy overall living skills, though sometimes the woman is well-educated and/or hard-working and just has poor people-skills. Because of politics, if she beats him, or both beat each other, or if he even grabs her arms to keep her from hitting or scratching him, the system still focuses on him as the problem. With the new focus on "keeping the family together to keep Mom off welfare", the problem will get worse. Some of these people may be educable, for their sake and for the kids'. In the meantime, your first concern as a physician is the physical safety of the woman and children. Exactly what to do to help in the long-term is much tougher to know; getting women to shelters and to advocacy seems to help, nobody really seems to have anything that helps the men be better husbands / boyfriends, and there are risks of causing reprisals (JAMA 289: 589 & 601, 2003).

Whether it's abuse of a child or a romantic partner, the behaviors of the abuser are pretty much stereotyped, and you will come to recognize the constellation.

• They are emotionally hypersentive;


• They are control-freaks, and allow the victim too little freedom (abusers are very common in the anti-everything cults);


• They make the victim responsible for their own happiness or lack thereof, and blame the victim for their own emotional problems


• They have unrealistic expectations of the victim;


• They threaten violence and may commit it; when this happens, it escalates;


• They deny the significance of the violence they commit ("It was just a love tap");


• They blame others for their own mistakes;


• They keep the victim isolated physically and emotionally;


• They wake the victim up at night for verbal abuse.

The common denominator, of course, is that the abuser feels entitled to love, and has such poor living skills that he or she cannot get it any other way. Public discussions usually ignore this obvious fact, but understanding it may help you, the physician, help people make sense out of the vicious cycle. The crew at Galveston has finally gotten up evidence to show that, yes, beating a pregnant woman can give her preterm labor and chorioamnionitis (Am. J. Ob. Gyn. 170: 1760, 1994).

On not becoming a suicide:

Here's a list of principal reasons people take their own lives. This pathologist's impression is that this is approximately the sequence from most-common toward least-common. It is not exclusive, but covers the large majority of cases. This list is among the greatest of all monuments to human stupidity and cruelty, typically by those surrounding the ultimate victim (there are exceptions).

1. Failed relationship... (any age, either sex) 2. Organic mood disorders... (young and middle-aged adults) 3. Financial disaster... (adult men) 4. Chronic poor health... (teens and adults, either sex; suicide in older folks is very often triggered by impending nursing home placement) 5. Abuse (physical or verbal) by a parent... (older children, teens) 6. Fear of being a homosexual... (teens and up, mostly men; see Am. J. Pub. Health 92: 1338, 2002) 7. Bad body image... (teens, younger adults) 8. Schizophrenia... (teens and adults, either sex)

School failure is probably less common than any of these causes of suicide. Athletic failure is also less common.

NOTE: Alcohol is a contributing factor to the crisis that precipitates the suicide in at least 1/3 of cases, probably more.

NOTE: Illegal drug use will exacerbate any of the above problems.

Reactive depression usually results from being dumped or being trapped; both are more depressing than the death of a loved one (Arch. Gen. Psych. 60: 789, 2003). In "conservative traditional societies", it is commonplace for a teenaged girl to commit suicide after being forcibly "married" to a man she hates (Am. J. For. Med. Path. 24: 214, 2003.)

You can find something better than death everywhere. -- "The Bremen Town Musicians"

* Shakespeare's Hamlet in the soliloquy is asking "Is life worth living?" He calls death "the undiscovered country" from which "no traveler returns" despite (according to Shakespeare's sources) having recently talked with a ghost. This is probably intentional. Despite the trappings of supernaturalist religion, Hamlet could be any post-Age-of-Faith person considering suicide.

NOTE: Among physically-healthy young people who attempted suicide, failed, and got appropriate follow-up care, 99% are pleased, one year later, that they failed. For a more recent, pretty-much equally optimistic study from Vanderbilt, see J. Traum. 33: 457, 1992; in addition to the familiar truisms, intervening in crazy family situations seems to be critical.

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