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Hypothermia. Clinical, Pathomorphological and Forensic Features. Research in Legal Medicine

2004; Elsevier BV; Volume: 94; Issue: 1 Linguagem: Inglês

10.1093/bja/aei507

1471-6771

Nigel R. Webster,

Restraint-Related Deaths

I am not sure what the basis of the series is, but this is volume number 31 in the series Research in Legal Medicine. Apparently, from the preface to this volume, it represents a series of talks delivered at an interdisciplinary workshop on hypothermia held in December 2002. All contributors to the volume are from Germany, Switzerland or Austria. The text is in English with a summary at the beginning of each chapter in both English and German. The English leaves a little to be desired; however, it does produce some interesting translational errors, some of which I highlight below. If you are into hypothermia then this is the book for you. Except that there is very little in it about the various ways of treating patients with hypothermia—in fact only three and a half pages followed by 4 case reports. There are apparently no randomized controlled trials of the various methods, such as external warming vs extracorporeal circuit warming, and therefore no recommendations have been offered. However, it has everything else and much more. For example, the book starts with a chapter on the hypothermia experiments conducted in the Dachau concentration camp in 1942 and 1943. These experiments were carried out under the direct orders of SS Reichsfuhrer Heinrich Himmler in order to further study the effects of cold, so that it would enable the design of suitable practical clothing to survive ditching in the North Sea. The description of these experiments taken from contemporaneous reports is quite graphic and certainly horrifying. Although it does not say it in this chapter, some of the subjects although profoundly hypothermic, may have been dissected while still not actually dead. We are told later on in the book that the diagnosis of death in hypothermic subjects is very difficult and often impossible. However, we are saved from some of the detail as the author states ‘I will not go deeper into the subject at this point’. Later on, there is an account from two of the very few survivors of the Estonia ferry accident in 1994. In one of the first chapters, where the forensic aspects of hypothermia are mentioned, the difficulty of diagnosis of death in the hypothermic individual is again raised. ‘When the forensic pathologist appears he is confronted with a cold body. Whether the victim is really dead is sometimes hard to determine. Some people are dead when they are cold and dead. Some people are apparently only cold but not dead for instance after three hours of asystole and many hours after initial apnoea but can successfully be resuscitated. Successful attempts of resuscitations have been reported when core temperatures were below 20°C. Therefore mountain doctors differentiate between death (hypothermia V) and apparent death (hypothermia IV).’ The chapter goes on to detail the different types of hypothermia—acute (immersion) as experienced after sudden immersion in cold water like ‘diverse [sic] breathing oxyhelium’—subacute (exhaustion) as in climbers exposed to a combination of moderate cold with wind and rain—and urban hypothermia where predisposing factors such as age, drug use, loneliness and alcohol use play a role. The chapter on tissue damage caused by freezing I found interesting and it is obvious from this chapter that cryopreservation of single cells is certainly possible but we are a long way off yet being able to cryopreserve either organs or whole bodies. The concept of ice crystals within the cells forming and actually piercing the cell membrane has apparently now been disproved and has now given way to an osmotic gradient disruption theory. The author concludes that ‘cryopreservation of whole organisms—except those that are physiologically adapted to such conditions (e.g. Nematods or Tardigrades [sic]), as they are microscopically small and survive even the loss of most of their body water—appears to be entirely impossible. Cryopreservation of human bodies is not more than desecration of bodies, as these will never return into life again’. The other interesting aspect of forensic hypothermia is what happens during the cooling process—the phenomena of paradoxical undressing and the hide and die syndrome. Apparently in around 50% of deaths attributable to hypothermia, the body is found either partially or fully undressed. This often results in the erroneous assumption that the deaths are associated with some sexual attack. This is particularly a problem because it is normally the clothes from the lower half of the body that are removed. The reason for this undressing is not known, but one theory is that the vasomotor centre becomes paralysed giving rise to the sensation that the body temperature is higher than it actually is. The other strange, but perhaps more understandable phenomenon is the hide and die syndrome. This occurs in about 20% of hypothermia deaths. Bodies are then found ‘hidden’ in some strange places—under a bed or bench, on a shelf or behind a wardrobe. There are also details of the epidemiology of hypothermia that are interesting. Those working on intensive care have often wondered whether hypothermic patients having been under the influence of too much alcohol are more resistant to the cold. The answer is here—there is ‘a longer survival period in an intoxicated condition’. I am not sure why the book was sent to an anaesthetic journal for review—and I certainly would not have bought it myself. But as you may see from my review I enjoyed reading it and learnt many interesting facts from it.