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Criminal Mischief: The Art and Science of Crime Fiction: Episode #34: Toxicology Part 3

Criminal Mischief: Episode #34: Toxicology Part 3

 

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From HOWDUNNIT: FORENSICS

COMMON DRUGS, POISONS, AND TOXINS 

In the remote past, most poisoners favored botanical products such as hemlock, oleander, deadly nightshade, foxglove, hellebore, monkshood, opium, and many others. These were easily available and untraceable. More recently, various chemicals have been added to this long list of plant-based poisons, which has made the work of the toxicologist that much more difficult. 

I said earlier that when the forensic toxicologist is faced with determining whether an individual’s death or abnormal behavior is related to toxin exposure, he will use all evidence, including the results of toxicology testing, the autopsy examination, and statements from investigating officers and witnesses. To effectively use this information, he must be familiar with many aspects of drugs and poisons: He must know the chemical makeup and physiological actions of drugs and their breakdown products; understand how drugs are metabolized in the body and what the potential toxic properties of these metabolites are; know how these chemicals affect a normal person, as well as those with various illnesses and addictions; and be aware of the symptoms and signs produced by these chemicals. In addition, a working knowledge of street and recreational drugs is essential, since these are often involved in injury and death. 

Obviously, a discussion of every known chemical, drug, and poison is far beyond the scope of this book. We will, however, look at many of those that crop up in real-life cases as well as in works of fiction. 

We will examine the things that the ME and the toxicologist consider in assessing the effects of any of them in death, injury, or legal matters. For example, some drugs cause severe depression or addiction and may lead the user to take his own life. Others may distort perceptions to the point that the user accidentally causes self-harm through some foolish act. Trying to fly from a building would fit this description. Other drugs may cause anger, aggression, or an actual psychotic episode, and the user may commit assaults or homicides while under the chemical’s influence. Some drugs are so addictive that the user will commit all types of illegal acts (robbery, assault, or murder) to obtain money to purchase them. Other substances are just downright deadly. 

ALCOHOL

Alcohol is derived from the fermentation of sugars and comes in a variety of types, with ethanol (ethyl, or drinking alcohol), methanol (methyl, or wood or denatured alcohol), and isopropanol (isopropyl, or rubbing alcohol) being the ones most commonly encountered. All alcohols are central nervous system (CNS) depressants. Central nervous system basically means the brain. These alcohols cause sleepiness, poor coordination, slowed movements and reactions, and distorted perceptions. In short, all the symptoms and signs you recognize in someone who is drunk. In larger amounts, they can lead to coma, cessation of breathing, and death from asphyxia. 

Ethanol 

Ethanol is by far the most commonly abused drug. Not only are its toxic effects potentially lethal, but the loss of coordination and poor judgment that is associated with its use can lead to violent and negligent acts. There is potential for physical addiction with alcohol and withdrawal can be an arduous and dangerous process. Without proper medical treatment, death rates from alcohol withdrawal syndromes, such as delirium tremens (DTs), can be 20 percent or more. 

Alcohol in the body follows a fairly simple pathway. Once ingested, it is absorbed into the bloodstream and disseminated throughout the body, where 95 percent of it is metabolized (broken down) by the liver into water and carbon dioxide. The remaining 5 percent is excreted unchanged through the kidneys and lungs, a fact that is critical to sobriety testing. 

Alcohol Metabolism 

The body eliminates most toxins in what is called a dose-dependent fashion; that is, the higher the dose taken, the more rapidly the toxin is metabolized. A small amount activates only some of the enzymes that break down the toxin, whereas a larger amount activates more enzymes in order to handle the increased load of toxin. 

Alcohol is metabolized in a linear fashion in that any amount of alcohol intake activates all the enzyme systems that destroy it. This means that from the first drink, the system operates at almost maximum efficiency and there is little or no ability to increase it. The average rate of ethanol destruction in the body is roughly equivalent to one drink per hour. 

Why is this important? With rapid intake of alcohol, as is seen in binge drinking that is so common among college students, the body has no method for increasing the removal of the alcohol. The system is already running at top speed and excessive intake overruns the body’s ability to deal with it. The result is that the concentration of alcohol in the blood will rise rapidly and this can lead to coma and death. 

Methanol 

All alcohols are potentially toxic, but methanol is particularly so. Methanol is the denatured alcohol used in Bunsen burners in high school science or chemistry classes. Unlike ethanol, the liver converts methanol to formic acid and formaldehyde, the same stuff the coroner uses to preserve the tissues he removes from corpses. 

Methanol ingestion causes nausea, vomiting, pancreatic and other organ damage, confusion, loss of coordination, and brain damage that can lead to blindness, seizures, coma, and ultimately death from asphyxia. 

Isopropanol 

Isopropanol is also an intoxicant and a CNS depressant whose effects usually appear within ten to thirty minutes after ingestion, depending upon the amount consumed and whether food or other beverages are taken as well. Fifteen to 20 percent of ingested isopropanol is converted to acetone, which produces acidosis (excess acid in the body). This greatly complicates things. The victim appears drowsy and off balance, and possesses a staggering gait, slurred speech, and poor coordination. Nausea, vomiting (sometimes bloody), abdominal pain, sweating, stupor, coma, and death from respiratory depression may follow. Hemorrhage into the bronchial tubes (breathing tubes or airways) and chest cavity may occur. 

Isopropanol also absorbs through the lungs and the skin. Not infrequently, infants experience isopropanol toxicity from alcohol-and-water sponge baths used to treat childhood fevers. 

OTHER CNS DEPRESSANTS

Opiates, barbiturates, and other tranquilizers are CNS depressants. They make a person sleepy and lethargic and are called downers. 

Opiates 

Opiates are in the alkaloid family of chemicals and are derived from the sap of the poppy. The opiates are divided into natural, semisynthetic, and synthetic, depending upon their source and method of manufacture. They are narcotic sedatives (sleep producing) and analgesics (pain relieving) that produce euphoria, lethargy, and, in larger doses, coma and death from respiratory depression and asphyxia. This is more common when an opiate is mixed with alcohol, which is also a brain depressant. Most opiates are taken either by mouth or injection, and all have great potential for abuse and physical addiction. 

Natural opiates come directly from the poppy with morphine, a powerful narcotic much like heroin, and codeine being the basic ones. Codeine is found in many cough suppressants, has a low potential for abuse, and, unless used with alcohol, rarely causes death. Combining morphine with acetic anhydride or acetyl chloride produces heroin (diacetylmorphine), which is by far the most commonly abused opiate. 

After injection, heroin is almost immediately broken down into monoacetylmorphine and then to morphine. In the living user, testing typically only reveals morphine since this two-step conversion process occurs fairly quickly. This means that the testing cannot determine if the person used heroin or morphine, since in either case only morphine would be found. 

The autopsy findings in individuals who die from a heroin overdose are fairly consistent. The ME usually, but not always, finds evidence of pulmonary edema, which is water in the lungs. The lungs often show evidence of talc crystals and cotton fibers, as these are used to cut and filter the heroin, respectively. When the drug is given intravenously, these crystals and fibers are carried through the right side of the heart and are filtered from the blood and trapped by the lungs. 

Semisynthetic opiates are created by molecular alterations of morphine and codeine. Many medical analgesics are of this type. Hydrocodone, oxymorphone, and oxycodone (OxyContin) are examples. 

Synthetic opiates are constructed in a laboratory and are not derived from either morphine or codeine. Methadone is the best known of this class because of its use in treating heroin addiction. Other synthetic opiates include meperidine (Demerol) and fentanyl drugs.

Barbiturates 

Barbiturates are derived from barbituric acid. Known as hypnotics (sleeping pills), they include pentobarbital, amobarbital, secobarbital, butabarbital, and phenobarbital. Only phenobarbital, an excellent anticonvulsive (prevents seizures) medication, is widely used today. When mixed with alcohol, barbiturates can readily lead to coma and death from asphyxia. 

CNS STIMULANTS 

Stimulants or “uppers” are a commonly abused class of drugs that rev up the nervous system and pump up the blood pressure and heart rate. The ones most commonly used are amphetamines and cocaine. These drugs increase alertness, lessen fatigue, and suppress appetite. However, with continued use, they cause irritability, anxiousness, aggressive behavior, paranoia, fatigue, depression, and death. 

Chronic users tend to develop tachyphylaxis. This means that the body “gets used to” them and their effects are lessened. The user must take ever-increasing amounts to get the same “kick” because the body produces more of the enzymes that metabolize these drugs so that they are destroyed and eliminated at a faster rate. 

Amphetamines 

Amphetamines belong to the phenethylamine class of chemicals and are what we term sympathomimetics, in that they mimic, or act like, the sympathetic side of the autonomic nervous system. This is the fight or flight response. Amphetamines rev up the body for emergency action. To do this, they increase blood pressure, heart rate, and respiration, and produce euphoria and a sense of high energy. 

Cocaine 

Cocaine is a CNS stimulant that increases alertness, elevates blood pressure and heart rate, and raises body temperature. In higher amounts, it can lead to seizures, strokes, heart attacks, and death.

Typically, cocaine is snorted, or inhaled through the nose. When introduced this way, it rapidly absorbs through the membranes that line the nose and enters the bloodstream. Its effects are felt in just a few minutes. As with amphetamines, cocaine has the problem of tachyphylaxis so the “high” tends to diminish with repeated use. So, abusers have found even faster ways of reaching the “high” they seek. 

Cocaine can be mixed with baking soda and water, and heated until all the liquid is evaporated; the solid material remaining is crack cocaine. This form has a much lower boiling point (becomes a gas at a lower temperature), which allows it to be smoked. When inhaled, this gaseous form is very rapidly absorbed through the lungs and into the bloodstream.

HALLUCINOGENIC DRUGS 

Hallucinogens alter perceptions and mood, lead to delusional thinking, and cause hallucinations. 

Delusions are beliefs that have little or no basis in reality. The person might believe that he is being watched or monitored or that his neighbor, boss, or spouse is trying to harm him. 

Hallucinations are sensory experiences that are not real. That is, they are not an abnormal sensing of some sensory input; rather, the entire sensory experience is created within the person’s mind. These creations may involve any or all of the senses. They may be visual, auditory, olfactory, taste, or tactile. Sometimes these sensations are so real that the person can’t separate the hallucination from reality, or worse, the hallucination becomes the reality. 

Hallucinations are part of severe schizophrenia and other mental disorders and can occur in victims of strokes or senile dementia. They are often seen with use and withdrawal from alcohol and other drugs. Hallucinogenic drugs are specifically designed to produce hallucinations. 

The most frequently encountered hallucinogens come from the plant world (marijuana, peyote, and mushrooms) or the chemistry laboratory (LSD, STP, and PCP). Their identification depends upon both physical and chemical analyses.

Cannabinoids 

By far the most commonly used hallucinogen, and one of the mildest, is marijuana. It goes by many street names including Mary Jane, weed, and pot. It is a cannabinoid, which means it is derived from the Cannabis sativa plant. The active ingredient tetrahydrocannabinol (THC) is found in marijuana at a concentration of 2 to 6 percent. Hashish is the oily extract of the plant and contains approximately 12 percent THC. 

Though marijuana can be added to food and eaten, the most common method of introduction is through smoking. It is rapidly absorbed through the lungs, reaches peak blood levels in fifteen to twenty minutes, and usually lasts about two hours. It produces euphoria, sedation, loss of memory, reduced coordination, and also stimulates appetite. 

The body breaks down THC into a series of compounds, the most important being 9-carboxy-tetrahydrocannabinol (9-carboxy-THC), which is the major urinary metabolite. Urine drug testing looks for this compound, which can be found up to ten months after last use. One problem is that even passive exposure can lead to a positive urine test. For example, if a person is in the area where someone is smoking marijuana, his urine may reveal low levels of 9-carboxy-THC. 

Cacti and Mushrooms 

Peyote is a small Mexican cactus that has enjoyed a ceremonial use by many native tribes for centuries. The active chemical in the plant is mescaline, which is a hallucinogen in the alkaloid family. Either TLC or GC can confirm the presence of the alkaloids. Further testing to identify mescaline is not necessary since the possession of plant material itself is illegal. 

Mushrooms present a different problem. With marijuana and peyote the mere possession of the plant is illegal, while the possession of mushrooms is not. This means that the toxicology lab must identify the psychoactive components (psilcin and psilocybin) of the mushroom before they can be deemed illegal. 

LSD AND OTHER HALLUCINOGENIC CHEMICALS 

There are a wide variety of chemically produced hallucinogens, with the most common ones being lysergic acid diethylamide (LSD) and phencyclidine (PCP or angel dust). 

LSD is very potent and as little as 25 micrograms can produce an “acid trip” that lasts for twelve hours. Though LSD is not directly fatal, the hallucinations it produces are typically vivid and there have been many instances of users harming themselves because of these altered perceptions. The primary screening test for LSD is the Van Urk color test. 

PCP is an extremely powerful drug with unpredictable effects. It comes as a powder or in a capsule or pill. It can be swallowed or smoked. PCP can cause depression, irritability, feelings of isolation, and is notorious for producing psychosis, paranoia, and violent behavior. An acute schizophrenic episode may suddenly occur many days after use. In a large enough dose, it can cause seizures and death. 

Immunoassay of urine is used for PCP screening and may remain positive for a week after last use. GC/MS provide confirmation. 

Other chemical hallucinogens include dimethoxymethylamphetamine (STP), dimethyltryptamine (DMT), and methylenedioxymethamphetamine (MDMA), also known as ecstasy. 

DATE RAPE DRUGS 

The date rape drugs are a collection of chemicals of various types that share the ability to make the user relaxed, disoriented, and compliant. Some are pharmaceutically manufactured, while others are cooked up by someone with marginal experience and a chemistry book. The major members of this group are Rohypnol (flunitrazepam), ecstasy, GHB (gamma-hydroxybutyrate), and ketamine hydrochloride. 

Rohypnol, GHB, and ketamine are commonly used in date or acquaintance rapes, which is where the moniker comes from. They cause sedation, a degree of compliance, poor judgment, and amnesia for events that occur while under their influence. These properties make them effective in date rape situations. 

A small amount of GHB or Rohypnol can be slipped into the victim’s drink or a bottle of innocuous-appearing water. She may appear and act normally, or might seem happy, excited, pleasantly sedated, or mildly intoxicated. Neither the victim nor her friends recognize how impaired she actually is. She might leave with her would-be assailant because her judgment is impaired and euphoria enhanced. Only later will she realize that something happened, but her memory of events will be spotty or absent. This is exactly what happened with Andrew Luster’s victims.

The reactions to these drugs are unpredictable and vary from person to person.

Rohypnol (Street Names: Roofies, Roaches, Rope, Mexican Valium) is a benzodiazepine sedative in the same family as Valium and was developed to treat insomnia. Currently, it is neither manufactured nor approved for use in the United States, but is available in Mexico and many other countries. It is manufactured as white tablets of either one or two milligrams that can be crushed and dissolved in any liquid. It takes action twenty to thirty minutes after ingestion, peaks in about two hours, and its effects may persist for eight to twelve hours. 

Rohypnol typically causes sedation, confusion, euphoria, loss of identity, dizziness, blurred vision, slowed psychomotor performance, and amnesia. The victim has poor judgment, a feeling of sedated euphoria, and vague or no memory of what has happened. 

Ecstasy (Street Names: E, X, XTC, MDMA, Love, Adam) was first manufactured in 1912 and originally patented in 1914 as an appetite suppressant but was never marketed. It disappeared until the 1960s when it was rediscovered and became a drug of abuse. Currently, it is made in underground labs and distributed in pill or capsule form. It has amphetamine (speed-like) as well as hallucinogenic effects. The user has enhanced sensations and feelings of empathy, increased energy, and occasionally profound spiritual experiences or irrational fear reactions. It may cause increased blood pressure, teeth grinding (bruxia), sweating, nausea, anxiety, or panic attacks. 

GHB comes as a white powder that easily dissolves in water, alcohol, and other liquids. Currently, it is often found as “Liquid E,” a colorless, odorless liquid that is sold in small vials and bottles. 

The effects of GHB appear five to twenty minutes after ingestion and typically last for two to three hours. It causes loss of inhibitions, euphoria, drowsiness, and, when combined with other drugs, increases the effects of these drugs. Users might also experience amnesia, enhanced sensuality, hallucinations, and amnesia.

Ketamine is a rapidly acting intravenous or intramuscular anesthetic agent that causes sedation and amnesia. It comes as a liquid, which is often heated and evaporated to a white powder residue. The powder can be added to a liquid such as a bottle of water, compacted into pills, or, most commonly, snorted. Whether swallowed or snorted, it takes effect almost immediately and is fairly short in its duration of action, typically forty-five minutes to two hours. 

Many of its effects are similar to ecstasy, but it also possesses dissociative effects, which means the person “dissociates” from reality in some fashion. Often the user experiences hallucinations, loss of time sense, and loss of self-identity. One common form is a depersonalization syndrome, where the person is part of the activities while at the same time is off to the side or hovering overhead watching the activity, including his own actions. As mentioned earlier, this reaction is also common with PCP. Users call these effects “going into a K Hole.” 

Since ketamine is a sedative and general anesthetic, its potential for serious and lethal effects is real. If too much is taken, the victim may lose consciousness, stop breathing, and suffer brain damage or die. 

MISCELLANEOUS TOXINS 

Cyanide is one of the most lethal chemicals known and can enter the body by inhalation, ingestion, or directly through the skin. The most common forms are the white powders sodium cyanide (NaCN) and potassium cyanide (KCN) and the gaseous hydrogen cyanide (HCN). Most poisonings are accidental, but suicidal and homicidal cyanide poisonings do occur. HCN is used in gas chamber executions. Cyanide is a metabolic poison, which means it damages the internal workings of the cells. 

Strychnine is a neuromuscular toxin that causes powerful convulsive contractions of all the body’s muscles. The body adopts a posture known as opisthotonos, which means the back is arched so that only the back of the head and the heels of the feet touch the floor. Death results from asphyxia, since breathing is impossible during such violent muscular contractions. At death, rigor mortis often occurs very quickly because the muscles are depleted of ATP during these contractions (see Chapter Five: Time of Death, “Rigor Mortis”). Strychnine is rarely used for homicide since its extremely bitter taste makes it difficult to disguise in food. It is occasionally used for suicide, but since it has the deserved reputation for being very painful, this is also rare. 

Mushrooms were discussed earlier (see “Hallucinogenic Drugs”). But those of the psilocybin variety are not nearly as sinister as are the mushrooms of the Amanita family, such as the death cap and death angel mushrooms. These poisonous mushrooms have been implicated in accidental, suicidal, and homicidal deaths. 

The death cap is so toxic that a single mushroom can kill. The two main toxins are amanitin, which causes a drop in blood sugar (hypoglycemia), and phalloidin, which damages the kidneys, liver, and heart. The real treachery of these mushrooms lies in that fact that the symptoms—nausea, vomiting, diarrhea, and abdominal pain—are slow to onset, typically beginning six to fifteen hours after ingestion, but can be delayed as much as forty-eight hours. In general, the later the onset of symptoms, the worse the chances for survival. This is because the toxins go to work on the liver and other organs almost immediately, but since symptoms are delayed for many hours, the victim doesn’t know to seek medical help until it is very late. At autopsy, the ME finds severe damage to the liver and the toxicologist might find a low level of sugar in the blood, as well as the amantin and phalloidin toxins. 

Ethylene glycol is the major ingredient in many antifreeze solutions. In the body, ethylene glycol breaks down into several compounds, the most important being oxalic acid. When oxalic acid is absorbed into the bloodstream, it reacts with calcium in the blood to form calcium oxalate. This reaction consumes the blood’s calcium, and low levels can cause a cardiac arrest and death. The calcium oxalate is filtered through the kidneys where it can clog up the microscopic tubules and severely damage the kidneys. At autopsy, the ME finds the crystals in the tubules of the kidney. Oxalic acid is also found in raw (not properly cooked) rhubarb, which can lead to accidental poisonings. It is rarely if ever used for suicide or homicide. Ingestion of this plant can irritate the gastrointestinal tract and cause mouth, throat, and esophageal pain and possibly bleeding. In those who die from this plant, the autopsy reveals a burned and irritated mouth, esophagus, and stomach, low blood calcium levels, and calcium oxalate sludge in the kidneys. 

Heavy metals are dangerous metallic elements such as arsenic, mercury, lead, bismuth, antimony, and thallium. Arsenic was the major homicidal poison for hundreds of years but is not frequently used now. One reason is that it works slowly. Even a large dose will take hours to kill someone. And since the death is very painful, the victim will often seek medical help before death and sur- vive. It is occasionally used as a chronic poison. 

The most common arsenical compound used in homicidal poisonings is arsenic trioxide, which is a white powder. A dose of 200 to 300 milligrams is usually lethal. Symptoms begin about thirty minutes after ingestion and include nausea, vomiting, abdominal pain, bloody diarrhea, a metallic taste in the mouth, and a slight garlicky odor to the breath. Arsenic severely damages the lining of the stomach and intestines and the ME will easily see this at autopsy in those who die. He will also find fatty deposits in the liver, kidneys, and heart. 

Lead poisoning is uncommon and usually occurs in an industrial setting. Occasionally children will peel away and eat wall paint that contains lead. Even though lead has not been a component of interior paints for decades, many older buildings still have layers of old lead-based paint. Lead poisoning can cause anemia, nausea, vomiting, abdominal pain, weakness, numbness, and seizures.

Insulin is a naturally occurring hormone that is essential for life. It is also synthetically manufactured and is a life-saving treatment for many diabetics. On occasion, diabetics die from an accidental overdose of insulin, but it has also been used for suicide and homicide. In fact, for many years it was considered to be an almost perfect murder weapon. The injection of a large dose dramatically drops the level of sugar in the blood, and since the brain needs a continuous supply of nutrition, death occurs very quickly. And since insulin is normally found in all of us, how could its presence raise suspicion? Now, insulin levels can be determined by radioimmunoassay and if the level at autopsy is found to be very high, the ME searches for a rare insulin-secreting tumor in the pancreas. If he finds no tumor, it is logical to suspect that insulin has been administered by someone else and the ME launches a search for hidden injection sites on the corpse. 

Succinyl choline is an injectable drug that paralyzes every muscle of the body and prevents all movement, even breathing. Death is from asphyxia. It has also been considered a nearly perfect murder weapon. 

After injection, it is very quickly metabolized by the body and leaves behind little evidence of its presence. However, since the 1980s the gas chromatography and mass spectrometry (GC/MS) combination has allowed for detection of the drug’s metabolites. If the ME suspects that this drug has been used, he takes blood samples as well as excises the tissues around any suspected injection sites and sends these materials to the toxicologist. Toxicological testing using GC/MS is directed toward finding metabolites of the drug, which, when found, proves that the drug was at one time present in the victim. This sophisticated testing was a direct result of the Carl Coppolino case. 

To dig deeper into this subject grab a copy of either 

FORENSICS FOR DUMMIES: http://www.dplylemd.com/book-details/forensics-for-dummies.html

HOWDUNNIT: FORENSICS: http://www.dplylemd.com/book-details/howdunnit-forensics.html

 

Dry Ice Can Kill You

OK, we all know that dry ice will keep things cool in your cooler, and even freeze things rock hard. You can also make that cool smoke coming out of a glass of water or maybe a centerpiece for a banquet or some such. Guess what? It can also kill you. 

It seems that at a birthday party in Moscow, they wanted to cool the pool down to take a nice bracing dip. So, they dumped some dry ice in. It cooled the water but also created a cloud over the top. Bet it looked really, well, cool.

The problem is that dry ice is the solid form of carbon dioxide (CO2). That’s the gas your body exhales through the lungs in order to get rid of it. High CO2 levels in the body are deadly. Normal ambient air is about 21% oxygen but contains only 0.04% CO2. So when the cloud of CO2 gas collected over the pool that obviously increased the level of CO2 while decreasing the level of oxygen (O2) by simple replacement. That is, each liter of air above the pool now contained a reduced amount of O2 and a greatly increased level of CO2. As the people breathed this mixture they became weak and dizzy and ultimately lost consciousness simply because they were not getting enough oxygen through their lungs to the bloodstream and ultimately to the brain. Apparently three of them died and many others were close. The take-home message is: don’t do this.

https://www.newser.com/story/287606/dumping-dry-ice-into-pool-kills-3-people-at-moscow-party.html

Lake Nyos

In 1986, a similar thing happened on a much larger scale at Lake Nyos in Cameroon. Some sort of geological event—-there is still controversy over exactly what happened—-created a CO2 cloud that spread across the area, killing over 1700 people. CO2 is heavier than air, so tends to hug the ground and settle in valleys and low areas. That’s what happened here. And at that Russian swimming pool.

https://en.wikipedia.org/wiki/Lake_Nyos_disaster

 

When Your Antagonist Goes Viral

When Your Antagonist Goes Viral
by DP Lyle

Imagine this: Your protagonist is faced with a deadly enemy that can’t be seen, felt, smelled, tasted. Undetectable until it’s way too late. Imagine victims dropping all around him, many with horrible and frightening symptoms and signs. Things like blotchy purple skin rashes, raspy, wheezy breathing, bloody vomiting and diarrhea, confusion or psychotic and aggressive behaviors. Yet the cause of all this mayhem is unseen, and unknown.

 

 

How do you identify such an enemy, or defend yourself from it?

Infectious diseases have terrorized the world for centuries. The Black Death was just one, the worst, of the plagues that swept through Medieval Europe. It killed one third, maybe one half, of Europe’s population. With many of the above symptoms. The meager state of medical care—-or understanding—in 1350 could do little. The church was equally impotent. 

Imagine the terror that gripped the entirety of Europe. What caused these horrible things to happen? Was it bad air, some miasma? Was it spread by one group or another? Was it punishment for your sins?

Where could you go to avoid the plague? What could you do to protect yourself and your family? Who could you turn to? What would you do if an infected stranger appeared at your door? Would you trust your local officials or pray to a God that let this happen? 

There were no heroes available at that time.

But there have been, and are, other plagues that are more modern and equally as deadly. The 1918 flu claimed millions of lives around the world. Now we have such pleasant afflictions as HIV, Ebola, and the Marburg virus. Besides, isn’t the coming Zombie Apocalypse due to an errant virus?

Scary stuff.

 

Plague Doctor

 

The Plague was caused by a bacterium that today is easily treated with antibiotics. Drugs that weren’t available in the 14th century. Okay, great, The Black Death can’t happen today. Not so fast. What about viruses? Things like Ebola and Marburg. We have little effective testament for these guys. So, a new Black Death is always possible. And as the world turns, new creatures are evolving. A series of simple mutations could easily produce the next pandemic and yet again kill off half the population. In fact, it probably will someday. History repeats itself.

And such an unseen enemy can make for a nearly perfect fictional antagonist. I mean, you can flash a mirror, or cross, at Dracula, or fire a silver bullet into the Wolfman, or simply run from Frankenstein—he wasn’t very fleet of foot. Godzilla stomping your city to rubble creates different, but not insurmountable, problems. 

But where do you hide from a virus? 

I’ve practiced medicine for over forty years and I can say without doubt that the greatest stress placed on any human is when they face death, disease, or injury. There are so many unknowns and the feeling of helplessness is universal. The same is true if the sufferer is a parent, child, or loved one. It produces anxiety on a very basic and visceral level.

This innate fear of death and disease is part of the human experience. And excellent fodder for thriller writing. Sure Frankenstein and Godzilla are scary, but what about an unseen, unavoidable, untreatable enemy? One that has no boundaries, permeating the air you breath, the water you drink, the loved one you hug. There is nowhere to hide since the miasma can creep beneath your door.

It doesn’t bite, or maul, or stomp, or any of those physical things, but rather attacks from within. By the time the victim realizes something is wrong, it’s often too late to fix. Or worse, there is no fix.

Infectious processes have been the subject of many thrillers, both written and cinematic. Michael Crichton’s Andromeda Strain (1971) was an early example. An organism comes from outer space and kills quickly. Earthlings have no defense. Just as Europeans had no defense when the Black Death appeared. Others include The Cassandra Crossing (1976), 28 Days Later (2002), and Outbreak (1995).

Thrillers need a resilient, believable, relentless, deadly, seemingly-unstoppable antagonist. An unseen infectious creature that attacks from within fits the bill.

The Black Death: http://www.historytoday.com/ole-j-benedictow/black-death-greatest-catastrophe-ever

1918 Flu: https://www.smithsonianmag.com/history/journal-plague-year-180965222/

Originally posted on the Horror Tree Blog: https://horrortree.com/when-your-antagonist-goes-viral/

 
 

Franken-Mosquitoes Are Coming

 

Do you know what the most dangerous creature in the world is? The one that has been responsible for more human deaths and illnesses than any other?

The mosquito. And it’s not even close.

They’ve brought us such pleasant surprises as malaria, yellow fever, the Zika virus, Dengue Fever, Sleeping Sickness, Chagas Disease, West Nile virus, and a bunch of other diseases you’ve probably never heard of. The number of illnesses and deaths ascribed to these various diseases is nothing short of staggering.

And now scientists have genetically altered the mosquito in the hopes that they would help lower the mosquito population. You see, these new “:Franken-mosquitoes” were supposed to die quickly. Didn’t happen, and even worse, these genetic changes just might make them harder to kill. Which means that the lowly, annoying mosquito could be an even more powerful disease transmitter. File this under unintended consequences.

Bugged Out: https://www.thesun.co.uk/tech/9947305/deadly-super-mosquitoes-accidentally-created/

WHO Executive Summary on Insect-borne Diseases: https://www.who.int/whr/1996/media_centre/executive_summary1/en/index9.html

 

 
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Posted by on September 19, 2019 in Medical Issues

 

Criminal Mischief: Episode #27: ABO Blood Typing

Criminal Mischief: Episode #27: ABO Blood Typing

 

LISTEN: https://soundcloud.com/authorsontheair/27-abo-blood-typing

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ABO Blood Type System

From FORENSICS FOR DUMMIES

By simply typing the blood at a crime scene, investigators narrow their suspect list and completely exonerate some suspects by using the population distribution information for the four ABO blood types. 

Population Distribution of ABO Blood Types

O: 43%

A: 42%

B: 12%

AB: 3%

Besides determining the ABO type, serologists are able to further individualize blood samples. RBCs contain more proteins, enzymes, and antigens than those used in the ABO classification system. These include antigens with such catchy names as Duffy, Kell, and Kidd and intracellular enzymes such as adenylate kinase, erythrocyte acid phosphatase, and the very useful phosphoglucomutase (PGM).

PGM is an enzyme that appears in many different forms, or isoenzymes, and at least ten of them are fairly common. Regardless of ABO type, a particular individual can have any combination of the isoenzymes of PGM. The ME and the serologist use that fact to further narrow the list of suspects for further DNA analyses and confirmation that they were capable of leaving a particular bloodstain.

For example, say that a stain is Type AB and has PGM 2. The ME knows the AB blood type is found in only 3 percent (see Table 14‐1) of the population, and PGM 2 is found in only 6 percent of people. Because these two factors are inherited independently, the probability of a particular individual being Type AB, PGM 2 is only 0.18 percent or less than 2 per 1,000. 

If the police find blood at the scene that matches the blood of a suspect who has Type AB, PGM 2 blood, the probability that that suspect is not the perpetrator is 2 in 1,000. Although not perfect, those odds still are much better than a coin toss. 

Testing for Paternity 

You inherit your blood type from your parents. For that reason, a serologist can assess paternity in many cases. The crime lab is often involved in paternity testing because paternity may be a critical component in determining child support, custody, and visitation. It also may play an important role in crimes and civil proceedings that involve kidnappings, insurance fraud, and inheritance conflicts. 

Inheriting your blood type 

ABO blood types, or phenotypes, come in only four varieties: A, B, AB, and O. But, for some blood types two genotypes, or gene pairings, are possible. A phenotype is what something looks like (in this case the ABO blood type), while the genotype is the underlying genetic pattern. We receive our ABO genes from our parents, one from Dad and one from Mom. 

The important thing to know in this system is that A and B genes are co-dominant (equally dominant), while the O gene is recessive. So someone who receives an A gene from one parent and an O gene from the other has Type A blood, but not Type O, because the A gene is dominant. 

Determining Possible Genotypes from Phenotypes 

Type A: AA or AO

Type B: BB or BO

Type AB: AB

Type O: OO

People with Type O blood must have an OO genotype. They can have neither an A nor a B gene because having one or the other dominates the O gene and produces either Type A or Type B blood. 

A person with Type A blood can either receive an A gene from each parent and thus have an AA genotype or an A gene from one parent and an O gene from the other for an AO genotype. Remember, A is dominant, so when it is paired with the recessive O gene, the A gene determines blood type. People with the AA and AO genotypes both have Type A blood, but genetically speaking, they’re different. 

Type A parents who have AA genotypes can provide only A genes to their offspring, because all their eggs or sperm have an A gene. But Type A parents who have AO genotypes can provide either an A gene or an O gene to their offspring, because half their eggs or sperm have an A gene, and the other half have an O gene. When both parents are Type A, several possibilities exist for the genotype their offspring will have.

In each of the scenarios presented in Figure 14‐1, the child’s blood type is Type A, except when both parents donate an O gene. In the latter case, the child’s genotype and blood type (phenotype) respectively are OO and Type O. These parents can’t have any offspring who have Type B phenotype or BB, BO, or AB genotypes, because neither parent has a B gene to donate. 

Determining Fatherhood

Blood typing can exclude paternity but cannot absolutely verify it. For example, a man with Type AB blood can’t father a child with Type O blood. So if a child has Type O blood, all men with the Type AB are ruled out as the child’s father. A man with Type A (genotypes AA or AO) blood can be the father, but only if he has an AO genotype. Men who have AA genotypes also are excluded. Men with the AO genotype, however, can’t be ruled out at this point. 

To dig deeper into this complex system grab a copy of either:

FORENSICS FOR DUMMIES: http://www.dplylemd.com/book-details/forensics-for-dummies.html

 

HOWDUNNIT: FORENSICS: http://www.dplylemd.com/book-details/howdunnit-forensics.html

 

Criminal Mischief: Episode #22: Common Medical Errors in Fiction

Criminal Mischief: Episode #22: Common Medical Errors in Fiction

LISTEN: https://soundcloud.com/authorsontheair/criminal-mischief-episode-22-common-medical-errors-in-fiction

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SHOW NOTES: http://www.dplylemd.com/criminal-mischief-notes/22-comon-medical-errors-in.html

Too often, fiction writers commit medical malpractice in their stories. Unfortunately, these mistakes can sink an otherwise well-written story. The ones I repetitively see include:

Bang, Bang, You’re Dead: Not so fast. No one dies instantly. Well, almost no one. Instant death can occur with heart attacks, strokes, extremely abnormal heart rhythms, cyanide, and a few other “metabolic” poisons. But trauma, such as gunshot wounds (GSWs) and blows to the head, rarely cause sudden death. Yet, how often has a single shot felled a villain? Bang, dead. For that to occur, the bullet would have to severely damage the brain, the heart, or the cervical (neck) portion of the spinal cord. A shot to the chest or abdomen leads to a lot of screaming and moaning, but death comes from bleeding and that takes time. Sometimes, a long time.

Ask any emergency physician or nurse. GSW victims reach the ER with multiple holes in their bodies and survive all the time. This is particularly true if it’s Friday night (we called it the Friday Night Knife and Gun Club), during a full moon (yes, it’s true, a full moon changes everything), or if the victim is drunk. You can’t kill a drunk. That’s a medical fact. They survive everything from car wrecks to gunshots to falling off tall buildings. The family van they hit head-on will have no survivors, but the drunk will walk away with minor scratches, if that.

Sleeping Beauty: I call this the “Hollywood Death.” Calm, peaceful, and not a hair out of place. As if simply asleep. Blood? Almost never. Trauma? None in sight. The deceased is nicely dressed, stretched out on a wrinkle-free bed, make-up perfect, and with a slight flutter of the eyelids if you look closely. Real dead folks are not so attractive. I don’t care what they looked like during life, in death, they are pale, waxy, and gray. Their eyes do not flutter and they do not look relaxed and peaceful. They look dead. And feel cold. It’s amazing how quickly after death the body becomes cold to the touch. It has to do with the loss of blood flow to the skin after the heart stops. No warm blood, no warmth to the touch.

Sleeping Beauty also doesn’t bleed. You know this one. The hero detective arrives at a murder scene a half hour after the deed to see blood oozing from the corpse’s mouth or from the GSW to the chest. Tilt! Dead folks don’t bleed. You see, when you die, your heart stops and the blood no longer circulates. It clots. Stagnant or clotted blood does not move. It does not gush or ooze or gurgle or flow or trickle from the body. 

Trauma? What Trauma?: You’ve seen and read this a million times. The hero socks the bad guy’s henchmen in the jaw. He goes down and is apparently written out of the script since we never hear from him again. It’s always the henchmen, because the antagonist, like most people, requires a few solid blows to go down. Think about a boxing match. Two guys that are trained to inflict damage and even they have trouble knocking each other out. And when they do, the one on his back is up in a couple of minutes, claiming the other guy caught him with a lucky punch. Listen to me: Only James Bond can knock someone out with a single blow. And maybe Jack Reacher or Mike Tyson. A car-salesman-turned-amateur-sleuth cannot.

And what of back eyes? If a character gets whacked in the eye in Chapter 3, he will have a black eye for two weeks, which will likely take you through the end of the book. He will not be “normal” in two days. A black eye is a contusion (bruise) and results from blood leaking into the tissues from tiny blood vessels, which are injured by the blow. It takes the body about two weeks to clear all that out. It will darken over two days, fade over four or five, turn greenish, brownish, and a sickly yellow before it disappears. On a good note, by about day seven, a female character might be able to hide it with make-up.

Similarly, what of the character who falls down the stairs and injures his back? He will not be able to run from or chase the bad guy or make love to his new lover the next day. He will need a few days (or maybe weeks) to heal. And he will limp, whine, and complain in the interim. And if he breaks something, like an arm or leg, he’ll need several weeks to recover.

I Can Run, and Jump, and Fight Like an Olympian: The typical fictional PI (maybe real ones, too) drinks too much, smokes too much, and eats donuts on a regular basis. He is not training for the Olympics. He will not be able to chase the villain for ten blocks. Two on a good day. And hills or stairs will reduce that to a very short distance. Yet chase montages in movies and books often seem to cover marathon distances. And then a fight breaks out. 

Of course, some characters can do all this. Not the PI mentioned above but maybe Dustin Hoffman can. Remember “Babe” Levy (Dustin Hoffman) in Marathon Man? He had to run for his life as Dr. Christian Szell (Sir Laurence Olivier) and his Nazi bad guys chased him endlessly. But early in the film, we learn that he runs around the reservoir in Central Park every day. He constantly tries to increase his distance, improve his time. He could run for his life.

Hopefully, when you run across medical malpractice in your reading you’ll be forgiving and enjoy the story anyway. But maybe not.

 

Criminal Mischief: Episode #18: Gunshot To The Chest

XRay Chest Bullet

 

Criminal Mischief: Episode #18: Gunshot To The Chest

LISTEN: https://soundcloud.com/authorsontheair/gswtochest

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Gunshot wounds (GSWs) come in many flavors and those to the chest can be particularly dicey. Yet, a chest GSW can be a minor flesh wound, a major traumatic event with significant damage, or deadly. If you have a character who suffers such an injury, this podcast is for you.

Here are a few interesting questions about chest GSWs:

Could a Person Survive a Gunshot to the Chest in the 1880s?

Q: My scenario is set in 1880. A man in his early 20s is shot in the back by a rifle. He loses a lot of blood and is found a couple of hours later unconscious. Could he survive and if so how long would it take him it recuperate? Also, would it be possible to bring him to consciousness long enough for another man to get him into a buggy. Is any part of this scenario possible?

A: Everything about your scenario works. A gunshot wound (GSW) to the chest can kill in minutes, hours, days, or not at all. The victim would be in pain and may cough and sputter and may even cough up some blood. He could probably walk or crawl and maybe even fight and run if necessary. Painful, but possible. He would likely be consciousness so could even help get himself into the wagon.

If all goes well, he should be better and gingerly up and around in a week or two. He would be fully recovered in 6 to 8 weeks.

After surviving the initial GSW, the greatest risk to his life would a secondary wound infection. Since no antibiotics were available at that time, the death rate was very high—40 to 80 percent—for wound infections. But, if he did not develop an infection, he would heal up completely.

How Is A Gunshot To The Chest Treated?

Q: I have a few questions regarding a gunshot wound that my poor character will be sustaining later on in my story. Supposing it’s a fairly small caliber bullet (typical handgun fare, not buckshot or anything) and it hits near the heart without puncturing anything important, how long might his recovery time be? He’s a strong, kinda-healthy guy in his thirties, although he drinks a fair amount and used to smoke. He’ll be rushed to a high-quality hospital immediately and receive the best care throughout recovery…what’s his outlook? When will he be allowed to go home, if all goes well? How long before he’s healed to normal?  When will it be safe for him to walk around, drive, have sex, etc.?

A: In your story, what happens to your shooting victim depends upon what injuries he received. A gunshot wound (GSW to docs and cops) can be a minor flesh wound or can be immediately deadly or anywhere in between. It all depends on the caliber and speed of the bullet and the exact structures it hits. A shot to the heart may kill instantly or not. The victim could die in a few minutes or survive for days or could recover completely with proper medical care and surgery. It’s highly variable but ask any surgeon or ER doctor and they will tell you that it’s hard to kill someone with a gun. Even with a shot or two to the chest.

A small caliber and slow speed bullet—such as those fired by .22 and .25 caliber weapons—are less likely to kill than are heavier loads and higher velocity bullets such as .38, .357, or .45 caliber bullets, particularly if they are propelled by a magnum load—such as a .357 magnum or a .44 magnum. Also, the type of bullet makes a difference. Jacketed or coated bullets penetrate more while hollow point or soft lead bullets penetrate less but do more wide-spread damage as the bullet deforms on impact.

All that is nice but the bottom line is that whatever happens, happens. That is, a small, slow bullet may kill and a large, fast one may not. Any bullet may simply embed in the chest wall or strike a rib and never enter the chest. Or it could enter the heart and kill quickly. Or it could puncture a lung. The victim here would cough some blood, be very short of breath, and could die from bleeding into the lungs—basically drowning in their own blood. Or the lung could collapse and again cause pain and shortness of breath. But we have two lungs and unless the GSWs are to both lungs and both lungs collapse the person would be able to breathe, speak, even run away, call for help, or fight off the attacker. Whatever happens, happens.

This is good for fiction writers. It means you can craft your scene any way you want and it will work. He could suffer a simple flesh wound and have pain, shortness or breathe, and be very angry. He could have a lung injury and have the above symptoms plus be very short of breathe and cough blood.  If the bleeding was severe or if both lungs were injured he could become very weak, dizzy, and slip into shock. Here his blood pressure would be very low and with the injury to his lungs the oxygen content of his blood would dip to very low levels and he would lose consciousness as you want. This could happen in a very few minutes or an hour later, depending upon the rapidity of blood loss and the degree of injury to the lungs.

Once rescued, the paramedics would probably place an endotracheal (ET) tube into his lungs to help with breathing, start an IV to giver IV fluids, and transport him to the hospital immediately. He would then be seen by a trauma surgeon or chest surgeon and immediately undergo surgery to remove the bullets (if possible) and to repair the damaged lung or whatever else was injured. He could recover quickly without complications and go home in a week, rest there for a couple of weeks, return to part-time work for a few weeks and be full speed by 3 to 4 months. Or he could have one of any number of complications and die. Or be permanently disabled, etc. It all depends upon the nature of Injuries, the treatment, and luck.

What Does a Close-range Gun Shot to the Chest Look Like?

Q: I have a question regarding gunshot wounds. In my latest mystery, a man and a woman, my heroine, struggle for a gun. It goes off, hitting the man in the chest. I want the man to live, but be temporarily incapacitated and need hospital care, so if the chest isn’t the best location, other suggestions are welcome. What would the gunshot wound likely look like before and after the man’s shirt was removed? Would there be a lot of bleeding where my heroine would take his shirt off and stuff it over the wound?

A: A gunshot wound (GSW) to the chest would work well. For it to be quickly fatal, the bullet would have to damage the heart or the aorta or another major blood vessel, such as the main pulmonary (lung) arteries. Under these circumstances, bleeding into the chest, the lungs,  and around the heart would likely be extensive and death could be almost instantaneous or in a very few minutes. He could survive even these injuries, but this would require quick and aggressive treatment, including emergent surgery, and a pile of luck.

If the bullet entered the lung, the victim could die from severe bleeding into the lung and basically drowning in his own blood. Or not. He could survive such an injury and would then require surgery to remove the bullet, control the bleeding within the lung, and repair the lung itself. This would require a couple of hours of surgery, a week in the hospital, and a couple of months to recover fully.

The bullet could simply embed in the chest wall and never enter the chest cavity. It could bounce off the sternum (breast bone) or a rib and deflect out of the chest, into the soft tissues of the chest wall, or downward into the abdomen. Once a bullet strikes bone, it can be deflected in almost any direction. Sometimes full-body X-rays are required to find the bullet. If the bullet simply embedded beneath his skin or against a rib or the sternum, he would require a minor surgical procedure to remove the bullet and debride (clean-up) the wound. He would be hospitalized for only 2 to 3 days and would go home on antibiotics and basic wound care.

Close-range, but not direct muzzle contact, wounds typically have a small central entry wound, a black halo called an abrasion collar, and often an area of charring around the wound. The charring comes from the hot gases that exit the barrel with the bullet. In addition, there is often tattooing, which is a speckled pattern around the entry wound. This is from the soot and unburned powder that follows the bullet out of the muzzle and embeds (tattoos) into the skin. The spread of this pattern depends upon how close the muzzle is to the entry point, If it over about 3 feet, then no tattooing or charring will occur.

In your scenario, the victim’s shirt would likely collect the soot and heat so that it would be charred and “tattooed,” rather than the victim’s skin. So, the shirt would show an entry hole, charring, and blood. Once the victim’s shirt was removed, the entry wound likely be a simple hole without any charring or tattooing, since the shirt would have collected this material and absorbed most of the heat. The wound could bleed a lot, a little, or almost none. It depends upon how many of the blood vessels that course through the skin and muscles are damaged.

Yes, her initial efforts should be the application of pressure over the wound to control bleeding until the paramedics arrive.

For more fun questions check out my Q&A books:

F&F200X302

FORENSICS and FICTION: http://www.dplylemd.com/book-details/forensics–fiction.html

MF&F 200X320

MORE FORENSICS and FICTION: http://www.dplylemd.com/book-details/more-forensics-and-fiction.html

M&M 200X300

MURDER AND MAYHEM: http://www.dplylemd.com/book-details/murder-and-mayhem.html

 

Criminal Mischief: Episode #16: Arsenic: An Historical and Modern Poison

Arsenic

Criminal Mischief: Episode #16: Arsenic: An Historical and Modern Poison

LISTEN: https://soundcloud.com/authorsontheair/criminal-mischief-episode-15-arsenic-an-historical-and-modern-poison

SHOW NOTES: http://www.dplylemd.com/criminal-mischief-notes/16-arsenic-an-historical.html

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Howdunnit200X267

From HOWDUNNIT:FORENSICS

Toxicology is a relatively new science that stands on the shoulders of its predecessors: anatomy, physiology, chemistry, and medicine. Our knowledge in these sciences had to reach a certain level of sophistication before toxicology could become a reality. It slowly evolved over more than two hundred years of testing, starting with tests for arsenic. 

Arsenic had been a common poison for centuries, but there was no way to prove that arsenic was the culprit in a suspicious death. Scientist had to isolate and then identify arsenic trioxide—the most common toxic form of arsenic— in the human body before arsenic poisoning became a provable cause of death. The steps that led to a reliable test for arsenic are indicative of how many toxicological procedures developed. 

1775: Swedish chemist Carl Wilhelm Scheele (1742–1786) showed that chlorine water would convert arsenic into arsenic acid. He then added metallic zinc and heated the mixture to release arsine gas. When this gas contacted a cold vessel, arsenic would collect on the vessel’s surface. 

1787: Johann Metzger (1739–1805) showed that if arsenic were heated with charcoal, a shiny, black “arsenic mirror” would form on the charcoal’s surface. 

1806: Valentine Rose discovered that arsenic could be uncovered in the human body. If the stomach contents of victims of arsenic poisoning are treated with potassium carbonate, calcium oxide, and nitric acid, arsenic trioxide results. This could then be tested and confirmed by Metzger’s test. 

1813: French chemist Mathieu Joseph Bonaventure Orfila (1787–1853) developed a method for isolating arsenic from dog tissues. He also published the first toxicological text, Traité des poisons (Treatise on Poison), which helped establish toxicology as a true science. 

1821: Sevillas used similar techniques to find arsenic in the stomach and urine of individuals who had been poisoned. This is marked as the beginning of the field of forensic toxicology. 

1836: Dr. Alfred Swaine Taylor (1806–1880) developed the first test for arsenic in human tissue. He taught chemistry at Grey’s Medical School in England and is credited with establishing the field of forensic toxicology as a medical specialty. 

1836: James Marsh (1794–1846) developed an easier and more sensitive version of Metzger’s original test, in which the “arsenic mirror” was collected on a plate of glass or porcelain. The Marsh test became the standard, and its principles were the basis of the more modern method known as the Reinsch test, which we will look at later in this chapter. 

As you can see, each step in developing a useful testing procedure for arsenic stands on what discoveries came before. That’s the way science works. Step by step, investigators use what others have discovered to discover even more. 

Acute vs. Chronic Poisoning 

At times the toxicologist is asked to determine whether a poisoning is acute or chronic. A good example is arsenic, which can kill if given in a single large dose or if given in repeated smaller doses over weeks or months. In either case, the blood level could be high. But the determination of whether the poisoning was acute or chronic may be extremely important. If acute, the suspect list may be long. If chronic, the suspect list would include only those who had long-term contact with the victim, such as a family member, a caretaker, or a family cook. 

So, how does the toxicologist make this determination? 

In acute arsenic poisoning, the ME would expect to find high levels of arsenic in the stomach and the blood, as well as evidence of corrosion and bleeding in the stomach and intestines, as these are commonly seen in acute arsenic ingestion. If he found little or no arsenic in the stomach and no evidence of acute injury in the gastrointestinal (GI) tract, but high arsenic levels in the blood and tissues, he might suspect that the poisoning was chronic in nature. Here, an analysis of the victim’s hair can be invaluable. 

Hair analysis for arsenic (and several other toxins) can reveal exposure to arsenic and also give a timeline of the exposure. The reason this is possible is that arsenic is deposited in the cells of the hair follicles in proportion to the blood level of the arsenic at the time the cell was produced. 

In hair growth, the cells of the hair’s follicle undergo change, lose their nuclei, and are incorporated into the growing hair shaft. New follicular cells are produced to replace them and this cycle continues throughout life. Follicular cells produced while the blood levels of arsenic are high contain the poison, and as they are incorporated into the hair shaft the arsenic is, too. On the other hand, any follicular cells that appeared while the arsenic levels were low contain little or no arsenic. 

In general, hair grows about a half inch per month. This means that the toxicologist can cut the hair into short segments, measure the arsenic level in each, and reveal a timeline for arsenic exposure in the victim. 

Let’s suppose that a wife, who prepares all the family meals, slowly poisoned her husband with arsenic. She began by adding small amounts of the poison to his food in February and continued until his death in July. In May he was hospitalized with gastrointestinal complaints such as nausea, vomiting, and weight loss (all symptoms of arsenic poisoning). No diagnosis was made, but since he was doing better after ten days in the hospital, he was sent home. Such a circumstance is not unusual since these types of gastrointestinal symptoms are common and arsenic poisoning is rare. Physicians rarely think of it and test for it. After returning home, the unfortunate husband once again fell ill and finally died. 

As part of the autopsy procedure, the toxicologist might test the victim’s hair for toxins, and if he did, he would find the arsenic. He could then section and test the hair to determine the arsenic level essentially month by month. If the victim’s hair was three inches long, the half inch closest to the scalp would represent July, the next half inch June, the next May, and so on until the last half inch would reflect his exposure to arsenic in February, the month his poisoning began. Arsenic levels are expressed in parts per million (ppm).

An analysis might reveal a pattern like that seen in Figure 11-1. 

IMAGE in HOWDUNNIT: FORENSICS

 The toxicologist would look at this timeline of exposure and likely determine that the exposure occurred in the victim’s home. The police would then have a few questions for the wife and would likely obtain a search warrant to look for arsenic within the home. 

LINKS: 

Arsenic Poisoning (2007): CA Poison Control: https://calpoison.org/news/arsenic-poisoning-2007

Arsenic Poisoning Cases Wikipedia: https://en.wikipedia.org/wiki/Arsenic_poisoning_cases

Arsenic” a Murderous History: https://www.dartmouth.edu/~toxmetal/arsenic/history.html

Facts About Arsenic: LiveScience: https://www.livescience.com/29522-arsenic.html

Poison: Who Killed Napolean?: https://www.amnh.org/explore/news-blogs/on-exhibit-posts/poison-what-killed-napoleon

Victorian Poisoners: https://www.historic-uk.com/HistoryUK/HistoryofEngland/Victorian-Poisoners/

12 Female Poisoners Who Killed With Arsenic: http://mentalfloss.com/article/72351/12-female-poisoners-who-killed-arsenic

 

 

Criminal Mischief: Episode #13: Alice in Wonderland Syndrome

Criminal Mischief: Episode #13: Alice in Wonderland Syndrome

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LISTEN: https://soundcloud.com/authorsontheair/criminal-mischief-episode-13-alice-in-wonderland-syndrome

SHOW NOTES: http://www.dplylemd.com/criminal-mischief-notes/13-alice-in-wonderland.html

PAST SHOWS: http://www.dplylemd.com/criminal-mischief.html

One pill makes you larger, and one pill makes you small

And the ones that mother gives you, don’t do anything at all

Go ask Alice, when she’s ten feet tall

White Rabbit, The Jefferson Airplane

Alice2

And then there was this excellent question from my friend and wonderful writer Frankie Bailey that was published in SUSPENSE MAGAZINE as part of my recurring Forensic Files column:

What Drugs Might Cause Side Effects in My Character With Alice in Wonderland Syndrome?

Q: I have a question about Alice in Wonderland Syndrome (AIWS) My character is in his mid-30s. From what I’ve gathered from reading about this syndrome, it is fairly common with children and with migraine sufferers and it is controllable. However, I want my character to have side-effects. In other words, even though the AIWS and his migraines are under control, he is increasingly erratic. Insomnia, impotence, and irritability would all be a bonus. Could he be dosing himself with some type of herb that he doesn’t realize would have these side-effects when combined with the medication prescribed for AIWS. Or is there a medication for AIWS that might cause these kind of side-effects but be subtle enough in the beginning that the person becomes mentally unstable before he realizes something is wrong?

FY Bailey

A: Alice in Wonderland Syndrome is also known as Todd’s Syndrome. It is a neurologic condition that leads to disorientation and visual and size perception disturbances (micropsia and macropsia). This means that their perception of size and distance is distorted. Much like Alice after she descended into the rabbit hole and consumed the food and drink she was offered.

AIWS is associated with migraines, tumors, and some psychoactive drugs. It is treated in a similar fashion to standard migraines with various combinations of anticonvulsants, antidepressants, beta blockers, and calcium channel blockers. Both anticonvulsants (Dilantin, the benzodiazepines such as Valium and Xanax, and others) and antidepressants (the SSRIs like Lexpro and Prozac, the MAOIs like Marplan and Nardil,, and the tricyclic antidepressants like Elavil and Tofranil, and others) have significant psychological side effects. Side effects such as insomnia, irritability, impotence, confusion, disorientation, delusions, hallucinations, and bizarre behaviors of all types–some aggressive and others depressive. Beta blockers can cause fatigue, sleepiness, and impotence. The calcium channel blockers in general have fewer side effects at least on a psychiatric level.

As for herbs almost anything that would cause psychiatric affects could have detrimental outcomes in your character. Cannabis, mushrooms, LSD, ecstasy, and other hallucinogens could easily make his symptoms worse and his behavior unpredictable.

Your sufferer could easily be placed on one of the anticonvulsants, one of the antidepressants, or a combination of two of these drugs and develop almost any of the above side effects, in any degree, and in any combination that you want. This should give you a great deal to work with.

What is Alice in Wonderland (AIWS) Syndrome?

A neuropsychiatric syndrome—also know as Todd’s Syndrome after Dr. John Todd, the physician who first described it in 1955—in which perceptions are distorted and visual hallucinations can occur. Often objects take an odd size and spatial characteristics—-just as Alice experienced. They can appear unusually small (micropsia), large (macropsia, close (pelopsia, or far (teleopsia).

It can be caused by many things including hallucinogenic drugs, seizures, migraines, strokes, brain injuries, fevers, infections, psychiatric medications, and tumors.

Migraines are often preceded by auras—visual, auditory, olfactory.

Lewis Carroll was known to suffer from migraines. His own diary revealed he had visited William Bowman, an ophthalmologist, about the visual manifestations he regularly had when his migraines flared. So it just might be that he himself experienced AIWS and took his experiences to create Alice.

AIWS Wikipedia: https://en.wikipedia.org/wiki/Alice_in_Wonderland_syndrome

AIWS Healthline: https://www.healthline.com/health/alice-in-wonderland-syndrome#outlook

AIWS NIH Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4909520/

AIWS and Tumor: https://www.livescience.com/64520-alice-in-wonderland-brain-tumor.html

AIWS and Visual Migraines: https://www.webmd.com/migraines-headaches/alice-wonderland-syndrome#1

 

What’s the Deal with Typhus?

Ever heard of Typhus? Probably in history class, or something similar. It reared its head many times during the Middle Ages and helped take down Napolean’s Grand Army in 1812. Many believe that as much as one-third of his army succumbed to the disease. It pops up here and there from time to time. Like now. Seems LA has a Typhus problem and it’s centered around City Hall.

Typhus is what we call a Rickettsial disease since it is caused by a bacterium known as Rickettsia typhi—-at least the form that comes from fleas is. A Rickettsial disease you’ve likely heard of is Rocky Mountain Spotted Fever (RMSF). There are several types of Typhus, each caused by a different bacterium and spread by a different vector. Scrub Typhus is carried by mites, Endemic Typhus by lice, and the one that’s affecting LA is Murine Typhus, which is carried to humans by fleas from infected rats.

Flea

When an infected vector bites a human, the bacterium enters the body and spreads. A week or two later the victim will develop fever, chills, and headaches. Sometimes GI symptoms such as nausea, vomiting, and abdominal pain occur. Not unlike a bad flu. Then, a few days later, the rash appears. 

Typhus-murine

If untreated, the disease can cause severe damage to the kidneys, liver, lungs, heart, brain, and can lead to death. But once diagnosed, the treatment is rather easy. The antibiotic doxycycline, sometimes ciprofloxacin, kills the rickettsial bacterium quickly and efficiently.

Right now, LA is treating the infected and trying to figure the best way to clear the rodents and fleas from City Hall. It’ll be a big job.

Typhus Wikipedia: https://en.wikipedia.org/wiki/Typhus

Typhus in LA: http://www.newser.com/story/271086/city-hall-faces-medieval-illness.html

Napolean and Typhus: https://qcurtius.com/2017/07/16/the-victory-of-general-typhus-napoleons-catastrophic-invasion-of-russia/

Typhus WebMD: https://www.webmd.com/a-to-z-guides/what-is-typhus#1

Murine Typhus CDC: https://www.cdc.gov/typhus/murine/index.html

 
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Posted by on February 11, 2019 in Medical History, Medical Issues

 
 
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