Clay A. Nichols

A decade of train-pedestrian fatalities: the Charleston experience

Although the cause of death is rarely in doubt in train-pedestrian fatalities, the manner of death is often unclear. The distinction between accident and suicide can only be made after careful evaluation of the history, scene investigation, autopsy findings, and toxicologic data. A retrospective analysis of 25 consecutive train-pedestrian fatalities investigated by our office between 1982 and 1992 is reported. The victims were predominantly healthy, young males. All but one person died at the scene. The cause of death was massive blunt trauma in 88% of the cases. In one case, the sole injury was decapitation. A tissue or blood ethanol level greater than 99 mg/dL was detected in 80% of the cases. A total of 60% of the cases involved persons likely to have been sitting or lying across the railroad tracks; all but one of these victims were intoxicated. The manner of death was determined to be accidental in 92% of our cases. Decapitation by a moving train is an injury highly suggestive of suicide. Massive blunt trauma, especially in the setting of ethanol intoxication, was highly associated with accidental death. Toxicologic analysis is essential in discriminating willful suicide from alcohol-induced incapacitation resulting in accidental death. Homicide, disguised as an accident or suicide, must be ruled out in all cases. Accurate determination of the manner of death is an important issue regarding civil litigation and dispersal of insurance benefits.

Multifactorial analysis of firearm wounds to the head with attention to anatomic location

Firearm wounds to the head are often fatal and are routinely encountered in the practice of forensic pathology in the United States. Often, the anatomic site of the entrance wound is used to support or refute the manner of death indicated by the scene investigation and/or circumstances of the case. The present retrospective study of 120 fatalities resulting from 140 firearm wounds to the head correlates the anatomic region of the entrance wound and range of fire with the manner of death. Other demographic data analyzed include age, race, and gender of the decedents, as well as evidence of drug and/or ethanol use. It is hoped that this study will provide concrete data to support the largely anecdotal associations between the specific site of entry of firearm injuries to the head and the manner of death.

Suicidal Ingestion of Barium-Sulfide-Containing Shaving Powder

Physicians, familiar with the common usage of barium medicinally as the contrast agent barium sulfate, may consider it an innocuous or at most a minimally harmful compound. The barium cation is extremely toxic and produces characteristic gastrointestinal symptoms, periorbital and extremity paresthesia, hypertension, and progressive flaccid muscular paralysis. Profound hypokalemia also may be induced. Overdose may be rapidly fatal unless the ingestion is recognized and appropriate treatment is instituted expediently.

Handling and Interpretation of Crossbow Injuries

The longbow and crossbow are infrequently encountered by the forensic pathologist. As these weapons become more popular for sport and hunting, more fatalities may be anticipated. Three crossbow deaths (two homicides and one suicide) are presented. Included is the first report of a multiple shot death. The design and physics of the crossbow are described. The proper preservation of evidence, as well as wound analysis and interpretation, in such deaths are detailed.

Suicide by environmental hypoxia (forced depletion of oxygen).

Suicidal suffocation by forced oxygen depletion (environmental hypoxia) with carbon dioxide (CO2) and with propane is discussed in two cases. No toxicologic proof was available with the former and circumstantial evidence weighed heavily. The latter case demonstrated inhaled propane by an on-scene transthoracic aspirate; all other toxicology specimens, including brain, liver, blood, kidney, fat, and vitreous, did not contain hydrocarbons. This second fatality was complicated by multi-agent overdose, including diphenhydramine, fluoxetine (Prozac), and nordiazepam. The designation of these deaths as due to oxygen depletion involved careful scrutiny of the autopsy, toxicologic, and scene findings. Complete analysis of all factors surrounding these rarely encountered suffocation deaths is stressed.

Recovery and evaluation by cytologic techniques of trace material retained on bullets

Fragments of tissue, intermediate targets, and debris related to firing are embedded in the fine striations and deforming edges of bullets. Because most of these fragments are too small to visualize and process as histologic sections, this material is usually washed away when the projectiles are cleaned following removal at autopsy. By preserving the rinsing material that results from routine cleaning of projectiles, it may be possible to evaluate adherent material from the bullet by cytologic techniques, including filter preparations, cell blocks, and smears of macroscopic tissue fragments. Bullet-wash cytology produced cellular elements, tissue fragments, and inert material from intermediate targets. Different tissue elements could be documented with a given projectile; this information could be utilized to document the path of a bullet through the body or intermediate target. This initial study suggests that low- and high-velocity projectiles produce different types of tissue debris, with much more fragmentation and scarcity of cellular components in the high-velocity rounds. Inert material, resulting from intermediate targets, such as clothing, as well as gunshot residue on the bullet or debris from the barrel could be distinguished on preparations. There was a difference in tissue representation of adherent material on the bullet; connective tissue, mesothelial coverings, and fragments from organs with higher elastic and cohesive properties were seen with much greater frequency on the filters than were loosely cohesive and friable organs such as liver and spleen. The cytologic preparations from projectile washings reflect both the path taken by the bullet and the ballistic damage to the organs. Thus, the cytologic evaluation of bullet washings may be useful in the incorporation of gunshot wound evaluation to support documentation of the trajectory of the projectile.

Massive hepatic necrosis and death following repeated isoflurane exposure: case report and review of the literature.

Multiple exposures to halothane have been shown to produce hepatic injury and subsequent hepatic failure often leading to death. Isoflurane, a related haloalkane, is considered a nonhepatotoxic alternative to halothane and its potential to cause injury has been greeted with skepticism. Described is a 30-year-old woman who developed hepatic failure and died after being exposed twice to isoflurane. Recent exposure to anesthetic agents must be considered when death is caused by massive hepatic necrosis.

A rock in a hard place. A brief case report.

Radiographs are often of assistance in locating foreign bodies, particularly bullets, at autopsy. It must be remembered, however, that all bullet-shaped radioopacities that appear to be within the skull are not necessarily projectiles. Described is a radiographic conundrum caused by a piece of gravel that pierced the scalp when the victim of a gunshot wound to the head fell to the ground. The stone, although bullet shaped, differed in radiodensity to metal and could have been recognized for what it was prior to much consternation on the part of the prosecutors. This case serves as a reminder of two pitfalls in the interpretation of gunshot wounds to the head. First, the radiodensity of a foreign body must be considered as important as its shape. Second, a foreign body outside of the convex surface of the skull may appear intracranial on both anteroposterior and lateral radiographs. Last, the prosecutor is encouraged to remain open minded and not to simply “see what he/she wants to see.”

Recovery and evaluation of trace material from wound edges in traumatic injury site

A small wound found on the ear of a homicide victim was inflicted by either a knife or a sharp fragment of ceramic. To test the potential usefulness of cytologic examination of wound edges for fragments of inert material from the assault weapon, the wound was rinsed and cytologic filters were prepared from the retained rinsing material. The particulate matter present on filters included microscopic fragments of crockery admixed with blood and other tissue components. This observation supported other physical evidence that the wound was caused by the sharp edge of a ceramic crock rather than by the knife. This case demonstrates the potential usefulness of cytologic examination of wound edges.

Death in Charleston, South Carolina. A retrospective

Over the past 324 years, Charleston, South Carolina, has triumphed over rampant infectious disease only to be overcome by more modern plagues: heart disease, neoplasia, homicide, and suicide. Examination of death records of the state of South Carolina, Charleston City, and Charleston County provides us with a glimpse of the medical challenges of our recent past; it also reminds us of the scourges that still ravage underdeveloped countries. The 18th- and 19th-century South Carolinians were besieged by tuberculosis, diarrhea, and a myriad of fevers. These diseases, though prevalent in other parts of the world, result in limited mortality in the 20th-century United States. A review of the historic trends in mortality in Charleston is presented; current significant causes of death, with emphasis on recent trends in homicide, are also discussed.