Am J Forensic Med Pathol • Volume 36, Number 2, June 2015
Letters to the Editor
prevention measures may significantly decrease or eliminate this serious event. Also, the catheter inserted a long time ago may cause air embolism complication because of fibrous tunnel formation, so the catheters need more attention during removal. We hope these comments add to the value of the article by Nagai et al.1
AUTHOR DISCLOSURE INFORMATION The authors report no conflicts of interest. Kadir Ceviker Department of Cardiovascular Surgery Suleyman Demirel University Medical Faculty Isparta, Turkey [email protected]
Rasih Yazkan Department of Thoracic Surgery Suleyman Demirel University Medical Faculty Isparta, Turkey
Hakan Demirtas Department of Radiology Suleyman Demirel University Medical Faculty Isparta, Turkey
REFERENCES 1. Nagai H, Maeda H, Kuroda R, et al. Lethal pulmonary air embolism caused by the removal of a double-lumen hemodialysis catheter. Am J Forensic Med Pathol. 2014;35(4):237–238. 2. Feil M. Reducing risk of air embolism associated with central venous access devices for air embolism surgical procedure intravascular procedure. Pa Patient Saf Advis. 2012;9(2):58–64. 3. Mirski MA, Lele AV, Fitzsimmons L, et al. Diagnosis and treatment of vascular air embolism. Anesthesiology. 2007;106(1):164–177.
Regarding a Peculiar Case of Suicide Enacted Through the Ancient Japanese Ritual of Jigai To the Editor: e have read the paper published by Maiese et al1 concerning the case of suicide in which the victim inflicted wound in the neck, with a replica of the so-called tanto knife. The authors described the victim as a devotee of Japanese culture and weapons, therefore concluding this case as a form of Japanese ritual suicide called jigai. We have also read the Letter to the Editor by Pierre,2 in which he challenged the arguments of Maiese et al concerning the term jigai in describing this case. There is another possible controversy in this particular case and it concerns the cause of death. It was concluded that death
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was “caused by critical hemorrhagic shock in a subject with reduced coronary reserve.” However, there is another possible (at least) contributing cause of death, which might have been overlooked. When the stab or cut wounds are located on the neck, another potential cause of death has to be considered—air embolism.3 Air embolism consists of an interruption of the circulatory system by bubbles of air that gain access to the circulation, usually through the venous side. Every autopsy in a death case involving an open wound in the neck area should begin with a check for air embolism. In these cases, due to negative pressure in these structures, air is sucked inside the venous system, and could be the cause of death.3–5 In neck injuries, another condition for air embolism to occur is that the omohyoid muscle of the neck is preserved. Omohyoid muscle tenses the lower part of the deep cervical fascia in prolonged inspiratory efforts, reducing the tendency for soft parts to be sucked inward.6 It means that one of the effects of this muscle is tightening of the cervical fascia, therefore preventing the collapsing of internal jugular vein. In other words, for air embolism to occur when the internal jugular vein is injured, the omohyoid muscle must be intact, or otherwise the vein would collapse, preventing air to enter the circulation. Approximately 70 to 150 mL of air is sufficient to cause fatal air embolism.3 In the case presented, the inflicted wound was described as a 4-cm-long slash on the right lateral cervical side of the neck. The wound affected skin and soft tissue below, ultimately causing only a partial severing of the internal jugular vein, whereas other structures were preserved. Thus, there were conditions for air embolism to occur in the victim. Therefore, some additional autopsy or postmortem radiology techniques were required for either proving or denying air embolism.3,5 It seems that none of these examinations were performed. The position of the deceased—leaned to a later side of the bathtub, allows the possibility that all the blood flew out postmortally through the wound on the neck, and most of the blood could have originated from the head. Also, no other macroscopic signs of exsanguination were present (such as subendocardial suffusions, etc). Besides all that, the vein was partially slashed—and not through the entire circumference—which again raises the possibility of air embolism as a possible cause of death. Even the ritual of jigai anticipates the death with as little blood as possible, since only the veins, and not arteries or other structures should be affected. Therefore,
the technique, as well as cultural implications of this ritual suicide, also favors causes of death other than exsanguination, with air embolism being the most probable. Also, if the deceased chose this ritual way to die, we must assume that he knew what he was aiming at the neck.
AUTHOR DISCLOSURE INFORMATION The authors declare no conflict of interest. Vladimir Živković, MD, PhD Institute of Forensic Medicine University of Belgrade School of Medicine Belgrade, Serbia
Slobodan Nikolić, MD, PhD Institute of Forensic Medicine University of Belgrade School of Medicine Belgrade, Serbia [email protected] [email protected]
This study was supported by the Ministry of Science of Republic of Serbia, Grant No. 45005. REFERENCES 1. Maiese A, Gitto L, dell'Aquila M, et al. A peculiar case of suicide enacted through the ancient Japanese ritual of Jigai. Am J Forensic Med Pathol. 2014;35(1):8–10. 2. Pierre JM. Suicide, swords, and cultural sanctioning. Am J Forensic Med Pathol. 2014;35(4):284. 3. Dettmeyer R, Verhoff M, Schuetz H. Forensic Pathology—Fundamentals and Perspectives. Heidelberg: Springer; 2014. 4. Živković V, Nikolić S. Pneumopericardium as a consequence of air embolism. Forensic Sci Med Pathol. 2015;11:122–123. 5. Shkrum M, Ramsay D. Forensic Pathology of Trauma—Common Problems for the Pathologist. Totowa, NJ: Humana Press; 2007. 6. Standring S, ed. Gray's Anatomy—The Anatomical Basis of Clinical Practice. 39th ed. Edinburgh: Elsevier-Churchill Livingstone; 2005.
Brain The Best Matrix for Volatile Testing? To the Editor: e wanted to share with your readers a couple of interesting results we recently obtained in inhalant intoxication deaths. For background, at the Bexar County Medical Examiner's Office (BCMEO) in
W
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Letters to the Editor
prevention measures may significantly decrease or eliminate this serious event. Also, the catheter inserted a long time ago may cause air embolism complication because of fibrous tunnel formation, so the catheters need more attention during removal. We hope these comments add to the value of the article by Nagai et al.1
AUTHOR DISCLOSURE INFORMATION The authors report no conflicts of interest. Kadir Ceviker Department of Cardiovascular Surgery Suleyman Demirel University Medical Faculty Isparta, Turkey [email protected]
Rasih Yazkan Department of Thoracic Surgery Suleyman Demirel University Medical Faculty Isparta, Turkey
Hakan Demirtas Department of Radiology Suleyman Demirel University Medical Faculty Isparta, Turkey
REFERENCES 1. Nagai H, Maeda H, Kuroda R, et al. Lethal pulmonary air embolism caused by the removal of a double-lumen hemodialysis catheter. Am J Forensic Med Pathol. 2014;35(4):237–238. 2. Feil M. Reducing risk of air embolism associated with central venous access devices for air embolism surgical procedure intravascular procedure. Pa Patient Saf Advis. 2012;9(2):58–64. 3. Mirski MA, Lele AV, Fitzsimmons L, et al. Diagnosis and treatment of vascular air embolism. Anesthesiology. 2007;106(1):164–177.
Regarding a Peculiar Case of Suicide Enacted Through the Ancient Japanese Ritual of Jigai To the Editor: e have read the paper published by Maiese et al1 concerning the case of suicide in which the victim inflicted wound in the neck, with a replica of the so-called tanto knife. The authors described the victim as a devotee of Japanese culture and weapons, therefore concluding this case as a form of Japanese ritual suicide called jigai. We have also read the Letter to the Editor by Pierre,2 in which he challenged the arguments of Maiese et al concerning the term jigai in describing this case. There is another possible controversy in this particular case and it concerns the cause of death. It was concluded that death
W
122
www.amjforensicmedicine.com
was “caused by critical hemorrhagic shock in a subject with reduced coronary reserve.” However, there is another possible (at least) contributing cause of death, which might have been overlooked. When the stab or cut wounds are located on the neck, another potential cause of death has to be considered—air embolism.3 Air embolism consists of an interruption of the circulatory system by bubbles of air that gain access to the circulation, usually through the venous side. Every autopsy in a death case involving an open wound in the neck area should begin with a check for air embolism. In these cases, due to negative pressure in these structures, air is sucked inside the venous system, and could be the cause of death.3–5 In neck injuries, another condition for air embolism to occur is that the omohyoid muscle of the neck is preserved. Omohyoid muscle tenses the lower part of the deep cervical fascia in prolonged inspiratory efforts, reducing the tendency for soft parts to be sucked inward.6 It means that one of the effects of this muscle is tightening of the cervical fascia, therefore preventing the collapsing of internal jugular vein. In other words, for air embolism to occur when the internal jugular vein is injured, the omohyoid muscle must be intact, or otherwise the vein would collapse, preventing air to enter the circulation. Approximately 70 to 150 mL of air is sufficient to cause fatal air embolism.3 In the case presented, the inflicted wound was described as a 4-cm-long slash on the right lateral cervical side of the neck. The wound affected skin and soft tissue below, ultimately causing only a partial severing of the internal jugular vein, whereas other structures were preserved. Thus, there were conditions for air embolism to occur in the victim. Therefore, some additional autopsy or postmortem radiology techniques were required for either proving or denying air embolism.3,5 It seems that none of these examinations were performed. The position of the deceased—leaned to a later side of the bathtub, allows the possibility that all the blood flew out postmortally through the wound on the neck, and most of the blood could have originated from the head. Also, no other macroscopic signs of exsanguination were present (such as subendocardial suffusions, etc). Besides all that, the vein was partially slashed—and not through the entire circumference—which again raises the possibility of air embolism as a possible cause of death. Even the ritual of jigai anticipates the death with as little blood as possible, since only the veins, and not arteries or other structures should be affected. Therefore,
the technique, as well as cultural implications of this ritual suicide, also favors causes of death other than exsanguination, with air embolism being the most probable. Also, if the deceased chose this ritual way to die, we must assume that he knew what he was aiming at the neck.
AUTHOR DISCLOSURE INFORMATION The authors declare no conflict of interest. Vladimir Živković, MD, PhD Institute of Forensic Medicine University of Belgrade School of Medicine Belgrade, Serbia
Slobodan Nikolić, MD, PhD Institute of Forensic Medicine University of Belgrade School of Medicine Belgrade, Serbia [email protected] [email protected]
This study was supported by the Ministry of Science of Republic of Serbia, Grant No. 45005. REFERENCES 1. Maiese A, Gitto L, dell'Aquila M, et al. A peculiar case of suicide enacted through the ancient Japanese ritual of Jigai. Am J Forensic Med Pathol. 2014;35(1):8–10. 2. Pierre JM. Suicide, swords, and cultural sanctioning. Am J Forensic Med Pathol. 2014;35(4):284. 3. Dettmeyer R, Verhoff M, Schuetz H. Forensic Pathology—Fundamentals and Perspectives. Heidelberg: Springer; 2014. 4. Živković V, Nikolić S. Pneumopericardium as a consequence of air embolism. Forensic Sci Med Pathol. 2015;11:122–123. 5. Shkrum M, Ramsay D. Forensic Pathology of Trauma—Common Problems for the Pathologist. Totowa, NJ: Humana Press; 2007. 6. Standring S, ed. Gray's Anatomy—The Anatomical Basis of Clinical Practice. 39th ed. Edinburgh: Elsevier-Churchill Livingstone; 2005.
Brain The Best Matrix for Volatile Testing? To the Editor: e wanted to share with your readers a couple of interesting results we recently obtained in inhalant intoxication deaths. For background, at the Bexar County Medical Examiner's Office (BCMEO) in
W
© 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
