That was a fascinating special. It was these folks who when they got overly emotionally stimulated they would go into this paralysis. The British woman fell out during a funny movie and they showed a young teenage girl who would fall into the paralysis just sitting around laughing with her family. I know I have physical reactions to too much emotion (panic attacks or shivering) but nothing like that! Looking it up, it was TLC “I Woke Up in the Morgue” and the condition is cataplexy.
Yeah, re the Stephen King story: you’d think even if Richard Thomas’s character was paralyzed, he’d still be much warmer and less gray-looking than your average morgue population.
Excuse my ignorance, but aren’t gliding contusions an example of tearing due to an angular acceleration, while coup / contrecoup injuries are evidence of direct trauma at one site along with direct trauma at a site opposite as the brain sloshes against both sides of the scull? In other words, one is a shearing injury due to angular acceleration and the other is a direct impact injury due to linear acceleration, and I don’t get the relationship.
I understand both could be present, but I don’t understand why one would look for a contrecoup injury in response to a “fresh” gliding contusion. Further, falling and hitting your head would seem to be an example of linear acceleration and direct impact. If I were the examiner, and found both types of injuries, I might question whether they were evidence of a simple fall.
This is the same person as St. Teresa of Avila, right? The Wikipedia article doesn’t mention this interesting fact about her death; maybe you could add it.
So, if you’re delivered a body, the first thing you do is do an EEG/EKG? (I knew the King thing was fantastical, but talk about tapping into a base phobia!) Especially when you hear horror stories of anasthesia failing during surgery…
I’m a forensic pathologist in full-time practice in the United States; up to you if you want to call me an expert or not. I can’t write to the Dope from work, so I normally answer either late at night or early in the morning, whenever I have time. Sometimes when I do get on line, I answer several times in a row, which always feels slightly rude to me, but them’s the breaks. Sorry I didn’t have a chance to get back to the Dope for the last several days.
You and I are using common terms differently. Always a problem when one speaks layman’s language. I am using “gliding contusions” to mean “the superficial contusions developed across the undersurface of the brain when it passes over the roughened surfaces of the petrous ridges and the superficial orbital plates during acceleration from a fall onto the back of the head” (picture = http://neuropathology.neoucom.edu/test4/4testimages/4p25g-ccc.jpg). I suspect you only refer to those as “inferior frontotemporal contusions”, which accurately places them, but leaves out the mechanism (motion). You are probably using “gliding contusions” to mean the hemorrhages developed when shear injury from angular acceleration causes sudden stretching and tearing of the parasagittal veins (picture = http://neuropathology.neoucom.edu/test4/4testimages/4p23G-glidinghge.jpg). Here’s a typical cite Brain Contusion (Trauma) Imaging: Practice Essentials, Computed Tomography, Magnetic Resonance Imaging
I was taught to use the word “gliding contusions” in this sense by a neuropathologist who felt it was a reasonable use of the word, because it helped people to visualize the brain gliding forward across the rough injurious ridges of the base of the skull. If you only use it to mean angular shear acceleration injury, can we agree to disagree on the interpretation of “gliding”? If we can’t agree to disagree, which word would you use for the contrecoup contusions I am describing?
You surely don’t want me to go on to give a lecture on coup versus contrecoup, as you’re already entirely familiar with the concept, am I correct? So if we’ve straightened out the language difference, I won’t go on to your last paragraph, as it no longer applies.
Ivylass wrote:
So, if you’re delivered a body, the first thing you do is do an EEG/EKG? (I knew the King thing was fantastical, but talk about tapping into a base phobia!) especially when you hear horror stories of anasthesia failing during surgery…
No no no, Ivylass! Someone else does the EEG/EKG! I insist on the printed proof, is all.
As one of my dear colleagues once said when a nurse who’d screwed up phoned her to ask her to do her a favor and pronounce a body dead that was on its way to her for an autopsy: “No, you have to find someone to pronounce it dead. Because I do not have jurisdiction over people who are not dead. Until it’s dead, it ain’t my problem.”
Since this has degenerated a bit beyond the OP, can I ask another one.
After the dearly departed has been folded, spindled & mutilated on the table, do you stuff everything back in before you send him off to the funeral home or is it just incernerated and you send a shell off?
If you do stuff it in, do you attempt to get it back in the right places?
Folded spindled and mutilated! Hah! I like that! After all the care I take to get a proper body roll onto the table, back and front, propped up neatly on a chest and head block, given the neatest and nicest Y-shaped incision from the point of the shoulder down to the mons veneris, and you call that mutilated!
Why, who would agree with you - the Catholic Church for 1800 years or something???
Hmph.
We don’t just take the organs out, you know. We take them out, separate them from eachother, snip the vascular ins and outs, chop off any extraneous tubes, pull off the fat, and check their weights to the tenth of a gram. Then we dissect them. Extensively dissect them.
As I finish with each organ, having snagged samples small and large out of it for longterm preservation in formaldehyde and shortterm transformation into microscope slides, I drop them into a bag. The bag is held open by a large metal container with a handle that is called a kick bucket. (Because when your gloves are bloody, you can kick it over towards you without soiling its handle, and without tipping it over.) My non-pathologist husband thinks this name is wonderful, as it combines the words “kick” and “bucket” into one morgue-required appliance.
The bag is pulled out of the kick bucket at the end of the autopsy, tied off with morgue string (there is such a thing as morgue string, you know), and dropped back into the open body cavity through the Y-shaped incision. Did I mention the Y-shaped incision is large?
Of course the organs go back to be cremated or buried with the body, but there isn’t any question of trying to put them back where they came from, because they don’t look like organs any more. They look more like this or like this.
Image a shell of your former self stuffed with that and you’ve got it. You’d look like the Scarecrow’sbrains.
No need to apologize to me. This is still an at-will participation site.
I understand the literal gliding you are describing, but isn’t this an abrasion?
Yes, correct, but I don’t understand it to be specific only to the parasagittal veins. If you have a non-standard definition given to you by a mentor, I can accept that.
Now, would an acceleration of 9.8m/s/s (presuming he died on this planet!) be likely to cause such an abrasion? If so, I might have to rethink my next dive into a pool. There is, of course, a much more rapid deceleration, but that is when the more commonly defined contusion takes place.
Yes, I’m familiar with the concept, though I can’t say I am closer to understanding why one would look for a contrecoup injury in response to finding an abrasion on the underside of the brain. In the case of a fall, the thing I’d be most interesting in finding is the coup contusion. Contrecoup or either type of gliding contusion might be present in some circumstances, but it would be rare not to find a coup contusion. Or, I should say that’s the way it looks to me. I’m not an expert.
Did I just botch the autopsy? Is the buzzer going off and the nose glowing red?
Could it be, that you’re looking at the terms in general, while gabriela is referring to injury severe enough to cause death?
One might see non-fatal coup/contracoup injury, that doesn’t not cause basalar shearing. But, I could be wrong.
gabriela, I have seen one patient declared dead (by paramedics) and taken to the morgue, only to scare the beegesus out of a janitor a few hours later once she’d warmed up.
I was working in a burn unit, taking overflow from the other 6 ICUs. It was Hallow’een night. We got the call at 11:30pm from ER.
We didn’t get a bed ready, because we thought it was a last ditch effort at a Hallow’een joke. She showed up in our hallway an hour later.
The two medics who declared her after only touching her, are working in some other field now, I believe.
Well, I can’t say you botched the autopsy, but what you say above certainly isn’t in the mainstream of what’s been observed about head injury for the last six or eight decades. I can tell you what I’ve been taught and what I’ve observed at many, many posts. I can’t really tell you why it happens, because people much more expert than I are arguing over why it happens. But I can tell you what I’ve seen, and how we know from the autopsy without any need for witnesses when it’s coup and when it’s contrecoup.
OK, lecture on coup and contrecoup coming, with actual case studies.
Goes like this. Man is cleaning a slick and slippery metal grate over a chicken parts collection vat set into the floor at MmHmMm poultry processing plant. He is encased in plastic protective coverings over his work clothes. His plastic-coated boot slips on the ckicken-fat-coated grate. His feet go in the air, he falls with an acceleration of 32 feet per second per second (forgive me for English units - America clings so touchingly to the old ways). The back of his head hits the grate hard enough to split his scalp for 2 inches either direction. He falls unconscious into the vat. His unconscious body naturally makes breathing motions, and he asphyxiates on chicken fat.
(Yes, this was one heckuvan autopsy - I used infinite quantities of Simple Green and never got all the fat off him)
At autopsy, there is a spill of blood underneath the occiput of his scalp, associated unsurprisingly with the 2" laceration. There is no skull fracture in the occiput; it’s completely intact.
Open the skull, there is no blood over the brain at the occiput. Dry as a bone. Take the brain out, there is a thin film of subarachnoid blood across the inferior aspect of the frontal and temporal lobes, and there are fresh contusions across the same areas, deepest and worst in the areas that stick out the most and that hit the forwardmost – the frontal and temporal tips. There’s a ramifying hairline fracture through the right supraorbital plate - the thin plate of bone that overlies the right eyeball and keeps it separate from the brain. When I was lent a skull to study at the start of medical school, they warned us strongly about those bones and the ethmoids: they’re fragile! Don’t break 'em! They’ll crack!
So here we have a head with a serious injury to the back, and a brain with serious injury to the undersurface and the front. This is classic contrecoup injury. It is found in people who sustain a major fall, typically from standing. It is classic for the contusions to be found across the undersurface of the brain in front.
The simplified explanation for contrecoup injury is that the sudden deceleration of the head as it comes to a stop against the hard surface of the metal grate causes the brain to rebound away from the site of injury, and injure itself against the inside of the skull, on the opposite side. This makes sense to me. It certainly explains why the supraorbital plate cracked - from the impact of the brain hitting it. Why only on one side? The impact was slightly to the opposite side on the back of the head. Not exactly in the midline.
If you are wondering why, with a blow on the back of the head, the brain injury is seen only on the undersurface of the front of the brain, it’s because the brain is more tightly tethered to the skull on the undersurface, due to the brainstem and the cranial nerves; and has more room beneath the dura on the top. So it can slide past the bony arches of the inside of the top of the cranial vault, but bounces and jounces across the rough ridges beneath it.
The sine qua non of contrecoup injury is blood beneath the scalp (at the site of impact) on one side, injury to the brain on the other side. As I said, this idea of the brain bouncing to the opposite side of the cranial cavity because of sudden deceleration is the best explanation I’ve been offered; but I do understand that the arguing about the actual physics that explains this repeatedly observed finding is well beyond me.
Now. I don’t want to discuss any cases of fatal coup injury, since all the ones I have had are homicides. So I’m going to give you a hypothetical based on many autopsies. Imagine the same man, magically restored to health, standing looking nervously around him on a street corner. A member of a rival gang runs up to him and grabs his arm. He throws him off, but while their arms are going back and forth, another gang member rushes up with a two-by-four, and cracks him as hard as he can over the back of the head. The man collapses to the street. The two assailants run off. It takes a while for him to be discovered; when the ambulance comes, he cannot be resuscitated.
At autopsy, there may or may not be a laceration to the scalp across the occiput (probably would be, in the case described), but there will definitely be blood beneath the scalp at the site of injury. And there will be subarachnoid blood across the occipital lobes, and fresh occipital contusions. This is classic coup injury. Blood beneath the scalp is on the same side as blood across the brain and blood within the injured portions of the brain.
I have not seen contrecoup injury sustained in people who dive. This may be because the resistance of the water provides significant braking. Even though your acceleration through the air was at least 32 feet per second per second, and maybe more if you bounced up from a board to make a nice swan dive, you are likely decelerating through the water. The speed of vessels through air versus across land versus through water is considerably different, and there’s no reason why your body shouldn’t be slowed down far below 32 ft/sec/sec by the resistance of the water.
However, I have seen deaths in people who dove into shallow water. I remember one very tattooed fellow who was only three days out of jail. He was last seen performing tai chi like exercises on the waterfront near the hoity toity beach club. He was found floating in the water. At autopsy, a small abrasion on the undersurface of his chin; no other external sign of injury. Internally, a broken neck, with the direction of fracture showing it was hyperextension injury. That is, he landed on his chin, and bent his head back so far it broke his neck. Death was immediate, and was not related to any of his other conditions, such as his emphysema, his heart disease, or the fact that his blood toxicology was positive for both marijuana and cocaine.
I have chosen real cases (with identifying data I hope fully removed) so that you can feel this is a real observation. But I have to reiterate how often coup and contrecoup injury have been a repeated observation for many decades of forensic inquiry. That’s why we testify on them in court like that. Blood on one side of the head, brain injury and subarachnoid on the opposite side: contrecoup, or roughly “opposite to the blow” if you take liberties with the French. Blood and injury on the same side, coup, or blow. One implies fall with sudden deceleration of the whole head. One implies impact from a hard object with sudden deceleration of the object only, at a focal point on the head, likely with brief subsequent acceleration of the whole head.
I used only occipital as my example here, with inferior frontal and temporal contusions, because that is by far the commonest contrecoup injury seen. But I have also seen contrecoup injury where the bloody impact site was beneath the skin of the forehead, and the brain injury was in the occipital lobes; and where the site was left temporoparietal, or above the ear, and the brain injury was right temporoparietal. It can happen anywhere in the head.
I’m constantly fascinated that people have worked out a whole process for figuring out the way a person died. You look over every square inch, finding a scrape here, a bruise there, but the hands are undamaged and add it all up to determine that the poor sap was dead before they fell down the stairs, as opposed to falling and trying to break their fall or grab something. (Or the classic “pulled out of the lake, but there’s not much water in the lungs, so they were killed, then tossed in” scenarios.)
I don’t suppose you’re of any relation to TV’s Dr. G.
One thing that’s puzzled me somewhat is the term for the procedure has changed - when I was growing up, it was always an autopsy, but now, I’m hearing the term necropsy a lot more often. Why the apparent switch?
