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- Herausgeber: Jonathan Ball
- Kategorie: Sachliteratur, Reportagen, Biografien
- Sprache: Englisch
Every contact leaves a trace: a single strand of hair or a tiny droplet of blood can be the silent witness at a crime scene. Locard's Exchange Principle underpins all forensic science and holds that the perpetrator of a crime will bring something to the crime scene and leave with something from it. Forensic experts use this principle daily to catch murderers and assailants. In Risking Life for Death, South African forensic pathologist Ryan Blumenthal offers a master class in this singular forensic technique based on real-life case studies. With more than twenty years' experience in the field, Blumenthal explains how to look for clues and traces, and how what he does not find at autopsy is often more important than what he does find. In other words, the absence of evidence can sometimes be of greater value than the presence of evidence. His account also highlights the dangers forensic pathologists are exposed to daily. As they try to unravel the puzzle of someone's death, forensic pathologists often face life-threatening infections, toxic gases and the hazards associated with high-profile cases – in effect, risking their life to solve someone else's death. An understanding of Locard's Exchange Principle can help you become a medical detective in your own life, can help you be a happier person and can even provide you with a better philosophy for growing older, Blumenthal argues.
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Veröffentlichungsjahr: 2023
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Risking Life
for Death
Lesson for the Living
from the Autopsy Table
RYAN BLUMENTHAL
Jonathan Ball Publishers
Johannesburg • Cape Town
To all those harmed, injured or killed as a result of
a crime, accident or other event or action.
Contents
Preface
Since the publication of my first book, Autopsy: Life in the Trenches with a Forensic Pathologist, people have sent me long messages about how the book affected them. There came a flood of Facebook friendship requests, I received countless selfies on Instagram of strangers holding my book – one of these from someone in a maximum-security prison whose picture had been taken while he was in full prison uniform, with his handcuffs on, holding my book. How he managed this is beyond me. Mothers wanting career advice for their kids began contacting me. Pensioners wanted to meet me for coffee. (The youngest person claiming to have read my book was seven years old, while the oldest was 96.)
People that I would never normally have access to were suddenly trying to connect with me. Apparently, I was the only one who could solve some or other specific forensic case. One Saturday at midnight, just as I was about to retire to bed, I got a phone call from Cape Town about a suspected food poisoning case: the person was worried about a salad they had eaten. Where could they submit the salad for forensic analysis? Of course, how could I assist, when Cape Town is not even my jurisdiction?
I had a stalker (you never get the stalker you want in life): It started with gifts from an unknown admirer who had read my book andescalated from there, as these things typically do – but, luckily, the entire debacle ended amicably. Then Autopsy went international, and my life really changed. At the time of writing, I had received countless questions and comments from as far afield as Marion Island – a very remote island in the subantarctic Indian Ocean. (Yes, a courier company delivers books to Marion Island.) I am thrilled that my book resonated with so many people and has travelled so far.
This book, my second, expands on the lessons for the living that can be gleaned from the autopsy table. I wrote it because I feel I have a moral obligation to serve my immediate community as well as the greater community of humankind. There remains so much injustice in this world, and forensic pathology is not some sideshow but rather, I believe, plays a central role. I also wrote it because I have been feeling somewhat dissatisfied of late, and unable to tolerate the situation. So, yes, my battle is also personal.
I hope that some of the ideas in this book may resonate with you and contribute to your well-being.
Beyond that, this book will teach you how to notice the smallest of details – how to really notice. For example, did you know that the strength of a handshake may tell you about someone’s health? Myotonic dystrophy is an inherited disorder that typically involves progressive muscle wasting and weakness. Clinical presentation of this disease is characterised by muscle weakness, cataracts, infertility (in males) and cardiac conduction defects. And so, when someone who has been diagnosed with myotonic dystrophy shakes hands, there may be a delay in relaxation of the thumb.1 Noticing how someone releases your hand within the first few moments after a handshake may tell you a great deal.
Forensic pathology is a field of tremendous scope and breadth. In this book, I share how forensic pathologists think and solve problems and apply basic principles. I explain the first principle that underpins forensic pathology: Locard’s Exchange Principle, or Contact Theory. This book seeks to be a master class in this one singular forensic technique.
Collecting all this data in a book has been like having had a thousand puzzle pieces in a box. Until you put the pieces together, you really have no idea what the final picture will look like. And now, at long last, after years of rearranging those puzzle pieces, they finally make sense, and it is my duty, and honour, to show you the importance of each puzzle piece and the view from overhead.
Please note that where the pronoun ‘he’ is used in the book, it is intended that the word ‘she’ is equally applicable – or ‘they’ – unless obviously inappropriate from the context. In writing this book, I have tried to be impartial and equally sympathetic to both sides (because there are always two sides).
Finally, on a completely different note, I always have plants in my office so that I can be surrounded by life, especially after spending my days surrounded by death.
Ryan Blumenthal
1
Solving puzzles
‘Is there a doctor on board?’ I was flying from Cape Town to Johannesburg.
The voice of the flight attendant sounded urgent. Immediately I shrank in my chair. I was sitting in a passenger seat at the front of the plane, with another 150 people on board. I am a forensic pathologist and had last seen a living patient in 2001. It was almost two decades since I’d last examined or treated a living human being, and so I was naturally hesitant to respond. At the time of the incident, I certainly didn’t look like a forensic pathologist: I was wearing my comfortable travel clothing and sipping a glass of white wine, with my mind focused on other things.
‘Is there a doctor on board?’ the voice of the flight attendant sounded increasingly frantic.
It would be illegal for me, as a forensic pathologist, to practise clinical medicine given that this is against the rules and regulations of the Health Professions Council of South Africa. And so I listened to the flight attendant calling out as I continued to sip my wine: ‘Please identify yourself if you have any medical training. We really have an emergency here.’ Eish, I thought to myself, no one is putting their hand up! Reluctantly, I raised my hand and at once the flight attendant came running towards me.
‘Please, doctor, we really need your help.’
‘I am a forensic pathologist, a doctor of the dead. I haven’t examined or treated a living patient in over twenty years. I do have some medical background knowledge, though, so if there really is no one else on board who can help, then I will see what I can do.’
‘Please doctor, there really is no one else who can help!’ she said pleadingly, her face flushed and deadly serious.
I got up from my seat and walked to the back of the plane. All the other passengers seemed to be watching and staring at my every move. I knew that I didn’t look the part. What was going through my mind at the time was: what happens if this is a heart attack or stroke patient? What if this is a drug mule? If I opened the aeroplane’s medical kit, then surely it would lead to much homework and many forms to complete. And what if the patient, tragically, were to die in my hands?
At the back of the plane, lying on the floor, was a 60-year-old female with a silver space blanket covering her body. She had an oxygen mask over her face. The woman looked diaphoretic (the medical term used to describe excessive, abnormal sweating in relation to environment or activity level).
I turned to the flight attendant. ‘Please bring her some sugar water or a glass of Coca-Cola, and then bring me her overhead carry-on bag. I want to see what’s inside it. I might find some pills or a clue, something that can alert me as to what’s wrong with her and help with my diagnosis.’
The 60-year-old woman managed a sip or two of the sugar water and I saw that she was slowly on the mend. Phew, I thought to myself. Lucky for her (and also lucky for me).
This was probably a hypoglycaemia attack – low blood sugar – or something like that. Right at that moment the flight attendant arrived with the patient’s hand luggage. I opened it . . . and guess what I found inside her bag. Drugs? No. Medicines? No. Strange devices? No.
Tucked in between her purse and her lipstick was the erotic romance novel Fifty Shades of Grey, by EL James. In summary, the novel follows the deepening relationship between college graduate Anastasia Steele and young business magnate Christian Grey, and is notable for its sexually explicit scenes featuring elements of sexual practices involving BDSM (standing for combinations of bondage and discipline, dominance and submission, and sadism and masochism). The bookmark was wedged between pages four and five.
‘Lady . . .’ I began. Her eyes were now fully open and alert as she sat upright, looking rather spritelier than minutes earlier, and decidedly less diaphoretic. ‘Perhaps you should only read one page per day.’
Both the recovering woman and the flight attendant burst into laughter at this. She made a complete recovery as I sat and monitored her for the duration of the flight back to Johannesburg, my hand resting on her wrist pulse. The situation could have been worse. Much worse.
I can tell a lot of what is happening in the world from noticing what is happening on my autopsy table. I can tell if a new gang has moved into the neighbourhood. I can tell if there is a new or emergent drug or disease, and I can even get a good sense of the health (physical, mental and psychological) of the nation without necessarily having to venture out of doors. Forensic pathologists may not be physically on the streets, yet we still have a relatively good idea of what is happening. I am fascinated to know what’s going on in the world by seeing it from the perspective of what’s happening in the mortuary.
When I examine a body, I can tell if a deceased person was a smoker, and whether they have been in the presence of smokers recently, thanks to the difficulty of removing the smell of second-hand smoke from clothing and hair. Also, chronic smokers generally have nicotine stains on their fingers, inelastic skin and wrinkles. Their facial skin loses its lustre and they often have lung pathology. Illicit drug users also tend to have signs of the pathology of chronic drug abuse on their bodies.
I can tell if a deceased person was near fried foods or a braai (barbecue): the smallest droplets of fried or barbecued food, or of aerosolised oils, can attach themselves to spectacles, clothing and hair, proving that they were in close proximity. I am able to deduce if someone was probably a tik addictor a cannabis abuser.
I notice these things every day – and, as with the diaphoretic woman on the plane, noticing the smallest details may help one better understand a situation, providing an advantage. Noticing requires excellent eyesight, but really noticing requires excellence in applying all one’s senses, so as to apprehend sounds, textures and odours too.
If you are reading this book, I assume you too want to notice the smallest of details, details to which the average onlooker may be oblivious. It is my desire to share one of the basic forensic principles with you, which will help you develop your forensic cognitive toolkit. You will have an extra weapon to help you critically assess and diagnose certain situations, or when you encounter information that requires critical review, like when you read something on Facebook, Instagram or WhatsApp: you will be able to interrogate it before simply forwarding it to all your friends and relatives.
It was a forensic pathologist who first determined that car power windows could be lethal when he reported the case of a 26-month-old girl who had been asphyxiated by just such a window. Gary Simmons, a forensic pathologist, was the first to highlight this previously unrecognised hazard. Now, most car power windows have a cut-out safety mechanism that stops the window closing if part of a body is stuck in it.1
This, indeed, is the ultimate purpose of science: based on systematic methodology, we observe, we learn and we understand the natural and social world we find ourselves in, so that this world can be made a better place for all of us.
Please note, I will not be making medical doctors or forensic pathologists of you. I will merely be sharing with you how forensic pathologists and medical detectives think. In a world where we are bombarded with information, it is my desire to help you navigate potential minefields.
First, a little more about me.
My grandmother Freda was one of the first female butchers in South Africa. One of my earliest recollections is of her carrying an animal carcass on her back. She was a tough old woman. Freda’s husband was Sam Blumenthal, an actuary and, apparently, quite a bright guy. Sadly, Sam passed away when I was 17 months old and so I never got to know him. No matter, their genes fused and melded and two generations later, I arrived. I have the genetic material of a butcher and that of an actuary. As a forensic pathologist, I am therefore a thinking man’s butcher!
Forensic medicine fascinated me from the start. I knew I wanted to be a forensic pathologist from my fourth year in medicine, when I was first exposed to the field. Forensic pathology is all about problem-solving. I love puzzles and my hobby has always been sleight-of-hand magic. In its purest form, forensic pathology is practical puzzle-solving. I was also drawn to the fact that forensic pathology is about the truth. I simply wanted to solve mysteries and, most of all, I wanted to catch bad guys.
I am grateful to have been trained by some of the discipline’s leading mentors. I have had several mentors in my life (and I believe that the sign of a good leader isn’t how many followers you have, but how many leaders you create). I am also extremely fortunate to have trained and spent my entire forensic pathology career, since I began my studies in this field, at a centre of excellence. I feel privileged to have nearly all the pathology disciplines housed in the same building, a practical disposition that greatly facilitates personal and professional interactions between the disciplines. Autopsies have consumed most of my adult life. I have spent more time in the autopsy suite than in almost any other pursuit.
Despite my constant exposure to death and dying, dealing with decomposing bodies, and earning a fraction of what my colleagues in clinical medicine earn, I have never been put off my profession, and I have always viewed these other factors as mere technicalities. And yet I confess that some days I do not feel like performing autopsies. It may be a decomposing body, a multiple shooting case, a mob assault case, a rape-homicide case, an abandoned foetus, or a complicated anaesthetic-procedure-related death. There are times when you are so fatigued that the only thing keeping you going is your disciplined training, your basic principles, your team, your systemic methodology and the reasons you went into this field in the first place. It is a dirty job that requires the ultimate in stamina and professionalism every day, no matter how you feel. Yet the feeling I get after completing an entire medico-legal examination – and discovering the ultimate truth – far outweighs all the negatives.
If you deal with death and tragedy every day, one of the greatest challenges is to maintain a positive and optimistic attitude to self and society. I have never turned down an opportunity to talk about forensic pathology. It is a wonderful chance to share forensic insights because I believe the dead have so much to teach the living. As forensic pathologists, we are independent: we do not serve any political party and everyone benefits from our service, irrespective of whether they be left-wing or right-wing, independent, conservative or liberal.
I believe that no one is more important than anyone else in society. Cashiers, garbage collectors and hamburger-flippers all play an important role in society and keep the world turning. Forensic pathologists are but a small cog in the large wheel that keeps the machine of the world moving. Forensic pathologists know that no one is literally ‘holier than thou’ because we have seen plenty of leaders and holy people die in depraved circumstances. In fact, we once found a religious leader dead in a house of ill repute. After amember of the police carelessly let slip this fact to the deceased’s wife, the woman was so incensed she furiously said: ‘He must now bury himself!’before she stormed off, leaving us with the unenviable task of managing the delicate matter of the religious man’s funeral.
Being a forensic pathologist demands humility. I have seen children die too soon and those suffering die too late. For some life is too short and for others, too long. So many these days are living longer than expected, and often there isn’t enough money to cover their medical treatment or their living expenses. (I have seen people who were financially secure for most of their working lives spend their final years as paupers.) Even if you have it all, you still have to maintain it all. I have learned that life is brutal, no matter who you are, and so working as a forensic pathologist requires a degree of introspection.
I often think about friends and colleagues who studied and worked with me. Some dropped out of medicine, some were faced with terrible tragedy, some were murdered. There were cases of substance abuse and mental health disorders, while others tragically took their own lives.
One of my dear friends, Dr Cival Mills, became a quadriplegic after a car accident. Mills wrote about his life in a book published in 2010, This Too Will Pass.2 Mills fell asleep at the wheel of his car after a long shift at the hospital where he was working as an intern, sustaining an unstable neck fracture. He was only 26 years old at the time and was confined to a wheelchair. Despite the accident and suffering a stroke years later, Mills refused to think of himself as being disabled, but rather saw himself as merely somewhat more challenged than other people. He took a ‘never feel sorry for yourself’ attitude. Dr Cival Mills died on Friday, 3 April 2015. His death was considered an unnatural death, and he ended up having a forensic autopsy at our medico-legal facility. It broke my heart.
Forensic pathologists must, as a matter of course, do a conceptual crash test of what we think we are going to find before beginning with an actual autopsy. We should predict what we believe we will encounter inside the body before cutting it open, and never just dive in, because we simply do not know what we might find. After all, there have been cases of live bombs packed inside a deceased’s body, or cocked and loaded weapons concealed somewhere about the person, or uncapped needles secreted in the pockets. Even deadly animals and insects have turned up during autopsies. Do read the story of the scuba diver who was found with a dead scorpionfish in his wetsuit in my first book, Autopsy.
That is why, at the outset, a scene examination must be performed and a meticulous case history made.
Please note that an autopsy and a post-mortem are not the same thing. A post-mortem is the examination of a dead body to determine the cause of death, which may entail external examination of the body after death, while an autopsy is a post-mortem examination to discover the cause of death or the extent of disease, which may entail dissection of the body after death. The difference between a post-mortem and an autopsy is therefore dissection. The term ‘post-mortem examination’ is a common alternative. Unfortunately, it suffers from a lack of precision about the extent of the examination, for in some countries many bodies are disposed of after external examination (termed a ‘viewing’) without dissection.3
The first autopsy I attended in my facility as a junior forensic pathologist was quite overwhelming. While some of the finer details of the case elude me right now, what I can clearly recall is that it was a sensory overload. The woman, who was a true beauty, had flown to Mauritius with her new husband and died suddenly and unexpectedly while having breakfast one morning. What makes this story even more remarkable is that there was a medical conference at the same hotel at that exact time. Almost all the guests having breakfast were qualified medical practitioners, yet none succeeded in resuscitating her. Her autopsy was performed in Mauritius and another was performed in South Africa. I attended the repeat autopsy.
The cause of death of the young bride was stated as saddle pulmonary embolism: a large blood clot had straddled the bifurcation of her pulmonary trunk. This condition is typically and immediately fatal.
I have seen many cases of pulmonary thromboembolism over the years. It typically looks like a little coiled black octopus straddling the pulmonary artery bifurcation. The blood clot has alternating black and grey areas within it. The black and grey areas (lines of Zahn) originate from enmeshed red blood cells, fibrin and platelets, which reflect the area of origin in the lumen of a vein in the pelvis or legs, typically an area of sluggish blood flow. Pulmonary thromboembolism is due to a blood clot (deep vein thrombosis) that travels to the lungs from the deep veins in the legs or from veins in other parts of the body, such as the pelvis.
Before her honeymoon, the young woman had started taking oral contraceptive pills, which had likely increased her risk of blood clotting. She sat still on an aeroplane for quite a few hours, which also increased her risk factors for deep venous thrombosis. (Immobilisation may lead to venous thrombosis in the lower extremities. Portions of this stasis thrombus may break away, travel through the venous circulation and lodge in the branches of the pulmonary artery.) The oral contraceptives and ‘economy class syndrome’ – which can also happen in first class, by the way – had a deadly impact on the young woman.
Pulmonary emboli may vary in size from large saddle emboli, which can obstruct the bifurcation of the pulmonary artery and produce sudden death, such as in this case, to less clinically significant smaller emboli, which can obstruct branches of the pulmonary artery and lead to pulmonary infarctions, which are wedge-shaped and located just beneath the pleura. People who are at risk for pulmonary embolism are typically those who have been inactive or immobile for long periods or people who have certain inherited conditions, such as blood clotting disorders.
Other risk factors include surgery and broken leg bones, while people who have cancer, smoke or are pregnant have also been associated with pulmonary embolism. Background cardiovascular diseases such as stroke, paralysis, chronic heart disease and high blood pressure have also been cited as increasing the risk for deep venous thrombosis and pulmonary embolism. A saddle pulmonary embolism is probably one of the quickest deaths. The cause of death is acute right-sided heart failure, a condition known as acute cor pulmonale. It is almost as if the right side of your heart were pumping against a brick wall.
These many years later, I wonder: if it were not for the woman’s beauty, or the fact that her death happened on her honeymoon – or perhaps the fact that it was my first autopsy, or that it happened in the middle of a medical conference – would I still remember this case? Having performed thousands of forensic autopsies, I often think: what if the pulmonary embolism had happened to someone else? Would it have affected me as much and would I still remember?
It is a fact that I simply cannot forget . . .
2
Locard’s Exchange Principle
A few years ago, a man was found dead on the floor of his kitchen in the east of my jurisdiction. We could see that there had been no breaking or entering. We knew that the man lived alone and that his family only discovered his inert body when they were unable to get hold of him. I was called in because this was considered a mysterious death, an unexplained death, or a SUDA – the sudden unexpected death of an adult.
I arrived on the scene in the evening and began by carefully observing the environment and noticing what often might seem irrelevant: at the scene there was an open jar of peanut butter (smooth, not crunchy) and there was a peanut-butter-stained spoon near the body. What was going through my mind at the time was the following: could this be an anaphylactic death (death resulting from an acute allergic reaction to an antigen, such as a bee-sting, to which the body has become hypersensitive)? Was he allergic to peanuts? And yet, at the same time, I was thinking: if he were allergic to peanuts, then surely he would have known about it? Why would he then be eating peanut butter?
The mystery could only be solved at autopsy, and it was at this point that I found what could only be described as a huge glob of peanut butterobstructing the upper pharynx, posterior palate and inner larynx of the deceased. It looked like complete upper airway obstruction due to peanut butter. There were no signs of anaphylaxis. No urticaria on the skin. Nothing else could explain or have contributed to his death. There were some signs suggestive of an asphyxia-type death at autopsy.
I never formally published this case, because over the years I have performed autopsies on a couple of people who have choked to death on other food material, such as steak, brown bread and sushi, for example. Choking refers to blockage of the internal airways, and death is typically the result of pure hypoxia – an absence of enough oxygen in the tissues to sustain bodily functions. This man apparently choked to death on smooth peanut butter, a fact that I still have some difficulty accepting. Who would have thought that this was even possible? Yet the evidence was undeniable.
What steps did I, as the forensic pathologist, take to arrive at a diagnosis on this case (and, indeed, all my cases)? What informs forensic pathologists even before we perform the actual autopsy? What is in the cognitive toolkit that we use?
The First Principle is the bedrock of modern forensics. Everyone’s favourite detective uses this principle, without naming it:. Sherlock Holmes, Hercule Poirot, Philip Marlowe, Miss Marple, Jessica Fletcher, Thomas Magnum, Nancy Drew, Columbo, Patrick Jane, Adrian Monk and even Tintin have all at one point or another used this singular forensic principle. It is called Locard’s Exchange Principle.
Dr Edmond Locard was a pioneer of forensic science. It was he who formulated the basic principle of forensic science: ‘With contact between two items, there will be an exchange,’ or, stated another way, ‘Every contact leaves a trace.’
Born in Saint-Chamond in France on 13 November 1877, Locard studied medicine in Lyon. He went on to publish more than 40 works, the most famous being his seven-volume series Traité de Criminalistique (Treatise on Criminalistics). Locard began his professional career by assisting Alexandre Lacassagne, a criminologist, physician and professor. In 1910 the Lyon Police Department granted Locard the opportunity to create, in a previously unused attic, the first crime investigation laboratory, where he could analyse evidence from crime scenes.
Locard worked as a medical examiner during World War I and managed to identify cause and location of death by analysing stains or dirt left on soldiers’ uniforms. He developed multiple methods of forensic analysis, and several police laboratories were created based on the work that he did.
Locard’s Exchange Principle holds, in essence, that the perpetrator of a crime will bring something into the crime scene and will leave with something from it, and that both of these can be used as forensic evidence.
It can be the smallest of things that ensures a criminal is caught. A classic example of Locard’s Exchange Principle is where fragmentary, or trace, evidence is left at, or taken from, a crime scene: where there is contact between two surfaces, such as shoes and the soil, or when fibres are left behind.
Let me give you a personal example. Many years ago, a medical colleague and friend gave me, as a gift, three rare quails. I carefully placed the quails in my small back garden and immediately set off to the pet store to buy a cage. When I returned, all three of my quails lay dead! And this, only a few hours after I had received them. Within moments of finding my murdered quails, I knocked at my neighbour’s door.
‘Your cat just killed my quails!’ I said, very upset.
‘I am sorry to hear about your quails,’ my neighbour replied, ‘but it is in the nature of cats to roam . . . and besides, how do you know it was my cat who killed yourquails?’
‘Lady,’ I responded, ‘I am a forensic pathologist. Please do not make me swab my quails!’
Should I have done a forensic investigation and swabbed my dead quails, I would most assuredly have found cat DNA, conclusively proving that my neighbour’s ginger cat (and not some other random cat) had killed my quails. Anyway, I had seen the ginger cat slinking off out of my backyard, and that is how I knew it was the culprit. I never did swab the quails; I simply walked away, my mood low.
