Friedrich Zenker (1825—1898). On the occasion of the 200th anniversary of his birth

Posttraumatic fat embolism follows the injury. The fat emboli in circulation could cause death in three ways: isolated lung fat embolism, systemic fat embolism and fat embolism syndrome (FES). In forensic pathology, only two trauma scores, based on disintegration of anatomic structures, could be used for objectivization, comparison and establishment of severity of injuries. One of them is Injury Severity Score--ISS, based on Abbreviated Injury Scale--AIS. The second one is Hannover Polytrauma Score--HPTS, based on the total sum of all injuries and age of the injured person. The objectives of this paper were to establish the correlation between outliving period and trauma severity (based on ISS and HPTS values), in persons died from posttraumatic fat embolism and/or its complications, and to establish which of these score systems could be better for prediction of development of the posttraumatic fat embolism. The retrospective autopsy study was performed and it included the material of the Institute of Forensic Medicine in Belgrade for period 1988-2001. The autopsy reports and clinical medical data were analyzed, for persons died from posttraumatic fat embolism and/or its complications. In all cases, the fat embolism was the single cause of death, verified by autopsy. In each case, ISS and HPTS values were obtained. The sample was statistically prepared (chi2 test, correlation coefficient, regression line). The sample included 50 persons: 41 males and 9 females. The proportion of men was statistically significant (chi2 = 20.480; p < 0.001). Average age of male was 55.26 years (SD = 21.39) and of female was 55.78 (SD = 17.45). There was no statistically significant disproportion among the age distribution of the sample (chi2 = 6.4; p > 0.05). The outliving period varied from 1-14 days: the average was 5.92 (SD = 3.39; Med. 5.50; Mod. 2). The average value of 1SS was 19 (SD = 7.70; Med. 19; Mod. 14), and for HPTS average value was 28.16 (SD = 12.87; Med. 26.50; Mod. 12). In literature, there have been data about critical ISS value: 12-20. HPTS value of 20 to 35 was lethal in 25%. Each injured of our sample had, at least, one long bone or pelvic fracture. There was negligible negative correlation between outliving period and 1SS and HPTS values in our sample: coefficient of linear correlation r = -0.117, t = 0.83 and r = -0.088, t = 0.59. Our sample was representative (t = 8.37). These data pointed out that the outliving period of the observed patients, died from post-traumatic fat embolism, was not in relation to general severity of injuries but to fat embolism per se and its consequences. There was low positive correlation between ISS and HPTS values: r = 0.296, t = 2.147, coefficient of determination r2 = 0.0876 and linear regression HPTS = 18.7588+0.4948 ISS. These data indicated that direct correlation between scores was only about 9% and the rest of correlation i.e. 91% depended on other factors. There was negative negligible correlation between outliving period and severity of injury based on ISS and HPTS, in patients died from posttraumatic fat embolism. So, these score systems are useless for prediction of duration of the outliving period in the injured died from fat embolism as well as for prediction of posttraumatic fat embolism as cause of death.

Notes on Contributors

The manner of death, i.e. if death is moros or violent, is the most important fact for the court and therefore, the most important part of the finding of autopsy reports [1]. To recognize the manner of death in cases with long outliving period after injury could be difficult for forensic pathologists. In such cases, the dissector should be able to point out the direct relationship between initial injury and death by using his (her) own experience and medical knowledge. Could the deaths provoked by low injuries be prevented? These injuries have score of 3 by Abbreviated Injury Scale (AIS) i.e. 12-20 by injury Severity Score (ISS) [3-5]. The purpose of this paper is to suggest the measures for improvement of postmortem autopsy diagnosis of causes of death in cases with long outliving period (more than 15 days) after initial traffic injury. A retrospective autopsy study was performed. It included the material of the Institute of Forensic Medicine in Belgrade for 1998. The autopsy report and accessible clinical medical data were analyzed for persons fatally injured in traffic accidents who outlived trauma more than 15 days. The sample was statistically prepared (chi 2 test, correlation coefficient). The sample included 31 persons injured in traffic accidents with outliving period longer than 15 days: 21 males and 10 females (chi 2 = 0.047; p > 0.1). Average age was 49.90 years (SD = 18.28). All persons in our sample were over the age of 19. The most commonly injured persons were pedestrians (16). The mean outliving period was 41.19 days (SD = 12.60). There was a weak positive correlation between outliving period and age in our sample (coefficient of linear correlation r = 0.35). The authors combined the autopsy and available clinical data in order to get the ISS value for each case. The mean ISS value was 36.18 (SD = 8.70). There was no correlation between outliving period and severity of trauma (coefficient of linear correlation r < 0.14). All deaths in our sample were violent according to autopsy reports. In autopsy reports, dissectors always noted only one injured body region: head and neck injuries in 21 cases, chest injuries in 3, trauma of locomotor system in 5 and in 2 cases abdominal injuries. However, by analyzing these reports, the authors emphasized that in 22 cases one body region was severely injured, in 7 cases two body regions and three regions in 2 cases. According to the authors severe injury has score 3 or more by 3. In four cases the dissectors pointed no complication of initial injuries as a competitive cause of death. In 15 cases they mentioned it as general, and in the rest of cases as decided (e.g. pneumonia, sepsis, thromboembolism, etc.). In five cases, the complications of initial injury were the precipitated and immediate cause of death (the initial injury in all these cases was less than 16 by ISS i.e. severe but not critical). The seven cases were treated microscopically. These microscopical findings only proved the already established microscopical autopsy findings and were not crucial for case solution. It was alarming, that one third of cases in our sample were completed without considering the clinical medical data. This is forensic vitium artis. Nowadays, there are a few syndromes which could be the cause of death i.e. fat embolism syndrome [7], multiple organ failure) [8, 9] and systemic inflammatory response syndrome [9, 10]. The diagnosis of these syndromes is possible only clinically: the autopsy and histological findings are not specific. As long as a direct chain of events can be traced from the injury to the death, then the initial injury must be considered to be the basic cause of death, and this fact may have profound legal implications for both civil compensation and criminal responsibility. Some of the most difficult problems in forensic pathology concern deaths from which posttraumatic complications are disputed as being fatal causative factors. The agony and dying are irreversible dynamic pathophysiological processes. By autopsy only the morphological consequences of these processes could be noted by dissector. The dynamics of dying, direct correlation between initial injury and death, as well as appearance and development of complications provoked by trauma could be established only by clinical medical data. Therefore, medical clinical data are crucial for forensic pathologists and for solving the problems about the mode and manner of death in cases with long outliving period. Microscopical findings have only academic and scientific importance and are less useful in daily practice. The authors suggest that all complications of injury must be generally involved in autopsy reports, and all severe injuries should separately be registered both in medical data and autopsy reports. The finding of cause of death must include all observed severe injuries and not only one of the most severe injuries and its complications.

Women played substantial roles as healers in Renaissance and Reformation Europe, as well as experiencing ill health and serving as a focus of medical inquiry. The history of pre-modern women and medicine received its first modern treatment in a 1930s overview by a feminist physician, but the topic only began to receive sustained attention from the 1970s, when women’s history emerged as an academic discipline and the history of medicine became oriented to social history. Prior to this period, the history of medicine had emphasized the scientific developments that led to breakthroughs and the men who had made them and was often written by physicians. The ordinary everyday practice of medicine, let alone the kinds of domestic or marginal healing often performed by women, were simply not part of the agenda of the discipline. Feminist scholarship of the 1970s, combined with a new social history of medicine, broadened the remit of historians of medicine. Initially, historians offered stories of how male doctors elbowed female midwives out of the birthing room: a kind of feminist morality tale, a rejoinder to late 19th and early 20th century obstetricians’ portrayals of midwives as ignorant, superstitious, and dangerous. Such portrayals, of course, tell us more about the politics of obstetrics at the turn of the 20th century than they do about early modern midwives. Scholarship on women, health, and healing has expanded considerably since the 1970s, and such studies often complicate or nuance our more general understanding of early modern health and healing. First, scholarship on practitioners has broadened beyond midwives. While midwives were significant health-care providers (often the only medical occupation to be clearly designated in many historical records) we can now situate them in a much larger array of female healers. Healers ranged from the many women who prepared sophisticated medicines in their homes and treated family, friends, and neighbors, to the more specialized health-care workers such as searchers (who examined bodies to determine cause of death) and the variety of women who provided forms of nursing care in their own and others’ homes and in hospitals. Research into women and women’s experiences has also extended into other areas of medical history. Scholars have developed the history of the patient by examining the role of gender in shaping how women (and men) experienced illness and made meaning of their sufferings. Historians have also explored how ideas and practices about gender and body intersect with the history of medicine in multiple ways, from studies of popular ideas about reproduction to a new interpretation of the rise of anatomy that takes gender as a central category of analysis.

The history of medicine in non-European countries has often been characterized by the study of their native traditional medicine, such as (Galenico-)Islamic medicine, and Ayurvedic or Chinese medicine. Modern medicine in these countries, on the other hand, has usually been viewed as a Western corpus of knowledge and institution, juxtaposing or replacing the native medicine but without any organic relation with the local context. By discarding categories like Islamic, Indian, or Chinese medicine as the myths invented by modern (Western) historiography in the aftermath of the colonial and post colonial periods, the book proposes to bridge the gap between Western and 'non-Western' medicines, opening a new perspective in medical historiography in which 'modern medicine' becomes an integral part of the history of medicine in non-European countries. Through essays and case studies of medical modernization, this volume particularly calls into question the categorization of ‘Western’ and ‘non-Western’ medicine and challenges the idea that modern medicine could only be developed in its Western birthplace and then imported to and practised as such to the rest of the world. Against the concept of a ‘project’ of modernization at the heart of the history of modern medicine in non-Western countries, the chapters of this book describe ‘processes’ of medical development by highlighting the active involvement of local elements. The book’s emphasis is thus on the ‘modernization’ or ‘construction’ of modern medicine rather that on the diffusion of ‘modern medicine’ as an ontological entity beyond the West

Management of post-traumatic fat embolism in the emergency department

Notes on Contributors

Each fracture of long or pelvic bones as well as large contusions of subcutaneous fat tissue cause releasing of fat globules that rapidly penetrate into circulation through the ruptured veins of the injured tissue, and reach the lung circulation [1,2]. During the first phase, fat emboli block the functional lung circulation by their mechanical effect in capillaries producing so called isolated post-traumatic lung fat embolism [3]. The surface layer of a fat embolus, which is practically in liquid state, behaves as a membrane of very high density, i.e., as it is under high pressure which obstruct the blood stream [4] that is finally stopped at the level of lung blood vessels with diameter of approximately 20 mu [5]. This pathophysiological mechanism produces cor pulmonale acutum, with poor pathological findings [8]. Nowadays, the post-mortem diagnosis of lung fat embolism is based on microscopical examination of tissue specimens, usually prepared with special histological staining (Sudan III) [9]. The grading of fat embolism according to Sevitt's criteria is generally accepted [10]. Taking of slices from apicoventral areas of the lungs has been recommended [11]. With longer outliving period, the total number of fat emboli in the lung circulation gradually decreases, due to their disintegration and resorption. It has been stated that fat globules completely disappear about 4-6 weeks after injury, and that they should not be searched for microscopically in this post-traumatic phase [11]. The aim of our work was to determine whether the age of injured, their gender, total severity of trauma, outliving period, and hypovolemic shock that develops after injuring, may induce development of more severe forms of post-traumatic lung fat embolism. A prospective histological study was performed on the autopsy material of the Institute of Forensic Medicine in Belgrade. The analyzed sample consisted of individuals with injuries that might be a source of fat emboli (fractures of long bones, large contusions of subcutaneous fat tissue). The lung slices were systematically taken and stained with special fat staining (Sudan III). In each particular case, the grade of lung fat embolism was counted on the basis of microscopical appearance, according to Sevitt's criteria. The total severity of trauma was estimated by calculation of the Injury Severity Score (ISS) [13, 14]. In no cases from the analyzed sample, the fat embolism was mentioned as either singular or plural cause of death. The obtained results were analyzed by means of appropriates statistical methods (ANOVA, LSD-test, chi 2 test. Man-Whitney test, Fischer's test of correct probability). The analyzed sample included 58 fatally injured individuals, 39 males and 19 females. The average age was 54.10 years (SD = 16.56), the average value of ISS was 34.69 (SD = 5.88), and the average outliving period was 3.74 days (SD = 5.88). However, all these data look differently when the analyzed sample has been stratified and analyzed according to the estimated grade of lung fat embolism. It was not showed that severity of lung fat embolism depends on sex of the injured (chi 2 = 0.842; p > 0.05). The groups with the slightest and the most severe grade of lung fat embolism are statistically significantly different in relation to age of individuals (ANOVA, p = 0.017). By means of LSD test, it has been showed that the group with the most severe grade of lung fat embolism (grade III) is statistically significantly different comparing to other two groups (with grade I and II) in relation to the age of injured (the values are p = 0.16 and p = 0.19 respectively, and the both groups are less than p = 0.05). In the group with the most severe grade of lung fat embolism, the older individuals are statistically significantly represented comparing to other two groups. The analysis of our sample showed that the most severe grade of post-traumatic lung fat embolism (microscopical grade III according to Sevitt's criteria) was determined in older individuals, more severely injured, and with shorter outliving period. The severity of fat embolism depends neither on sex of the injured, nor on development of post-traumatic hypovolemic shock. The obtained results related to the influence of hypovolemic shock on severity of fat embolism should be accepted with a caution. Namely, sometimes there is an intention to simplify a procedure of creating of autopsy conclusion about the cause of death, so that loss of blood is not mentioned at all, in spite of fact that it could have been a concurrent cause of death, while in other cases exsanguination is designated as a sole cause of death, forgetting the possibility that fat embolism could have really been the immediate cause of death.

Fat and Bone Marrow Embolization in a Donor as the Cause of Death in a Lung Recipient

Background: Fat embolism frequently occurs as a result of trauma, such as long bone fractures and orthopedic surgeries, as well as in certain non-traumatic conditions. The formation can be attributed to mechanical or biochemical processes. According to Hullman's biochemical hypothesis, elevated C-reactive protein levels facilitate the precipitation of very-low-density lipoproteins and chylomicrons, forming fat globules that may result in fat embolism. Based on the abovementioned hypothesis, this study aims to detect fat embolism in autopsy patients (postmortem) suffering from bronchopneumonia and determine its possible role as a cause of death. Methods: A group of autopsies of deceased individuals with bacterial purulent bronchopneumonia with confirmed or presumed elevated C-reactive protein levels was rigorously selected, excluding those with other potential causes of fat embolism such as cardiopulmonary resuscitation, hypothermia, and diabetes mellitus. Multiple organs were sampled for frozen section analysis using Oil Red O fat staining and assessed for the presence and extent of fat embolism. The Falzi score, as modified by Janssen, was employed for the lung tissue. Results: In 73% of the cases, predominantly sporadic, Grade 0 or Grade I fat embolism was observed; however, in none of the cases was fat embolism identified as the cause of death or as a significant contributing factor. Furthermore, neither fat embolism syndrome nor multiorgan fat embolism were detected. Conclusions: Although an elevated C-reactive protein level facilitates the formation of fat globules and fat embolism, its role as a direct cause of mortality remains uncertain. It may predispose individuals to such conditions and potentially interact with other factors, such as minor soft tissue trauma, to exacerbate the severity of fat embolism or its clinical manifestations. These findings underscore the necessity for further comprehensive investigations within the contexts of infection/inflammation, fat embolism, and dyslipidemia.

Causes of Death From Avalanche

Fat embolism in pediatric patients: An autopsy evaluation of incidence and Etiology

Reviewed by: The Making of Modern Chinese Medicine, 1850–1960 by Bridie Andrews Xiaoping Fang Bridie Andrews. The Making of Modern Chinese Medicine, 1850–1960. Contemporary Chinese Studies Series. Vancouver: University of British Columbia Press, 2014. 294 pp. $99.00 (cloth). Repr. Honolulu: University of Hawai'i Press, 2015. 294 pp. $30.00 (paper). Western modernity as the single normative modernity has been the paradigm and criterion used to analyze and measure the rise of Chinese medicine in changing sociopolitical contexts. Within this narrative, the binary dichotomy between "Western" and "Chinese" medicine has been problematic. Bridie Andrews's The Making of Modern Chinese Medicine aims to break this dichotomy by examining the motives driving the active assimilation of Western medicine and the reasons for the rise of a new Chinese medicine. By analyzing the history of modern Chinese medicine, Andrews intends to shed light on the history of Western influences in non-Western societies and on the ways that science is perceived and performed as a marker of modernity. The book investigates the significant issues in modern Chinese medicine in chronological order. Chapters 2 and 3 mainly focus on medical practices up to the early twentieth century. The diverse spectrum of medical practice shows the coexistence of "modern" and "traditional" approaches to medicine and highlights the role of medical pluralism in the modernization process. From chapter 4 to chapter 8, the book analyzes how sociopolitical changes impacted Chinese medicine, facilitated responses to shifts in medical culture by early Chinese medical communities, the state, reformers, and medical professions, and contributed to the rise of modern Chinese medicine. The Japanese medical reform made a great impact on China's medical community and motivated the modern Chinese state to assume responsibility for public health care. Modern social and medical reformers integrated medicine into their struggles for sociopolitical change and the strengthening of Chinese medicine as an indigenous medicine. The rise of professional associations and the establishment of the National Quarantine Service became key events in the institutionalization of Western medicine in China, while the Chinese medical community underwent more significant institutionalization and professionalization. Western medicine also had a significant impact on modern Chinese medicine through the adoption of Western-style case histories and the relocation of acupuncture points in the new acupuncture. This book makes significant contributions to theoretical understandings of the history of Chinese medicine in modern China. Rather than upholding the dichotomy between Chinese and Western medicine, Andrews argues that the process was one of dynamic interactions and mutual impacts. She proposes a set of concepts to describe these effects: "translation" (or "appropriation") and "syncretism." The former involved "appropriat[ing] or translat[ing] elements of culture differently" and included missionary, European, and Japanese medical models for Chinese medicine. The latter implied a two-way exchange affecting both Western and Chinese medical practices, such as the West's curiosity regarding Chinese materia medica and Chinese practitioners' growing interest in Western medical practices and institutions [End Page E-17] (214). Andrews further suggests that "Chinese and Western medicines are two mirrors facing each other at a short distance. Each mirror holds the image not only of the other but also of the other's view of itself (216)." The book also greatly advances empirical understandings of three key issues in the history of medicine in China. First, it vividly reveals aspects of Western medical practice prior to its triumph and aggressiveness in the twentieth century that have been neglected up to this point. As the book shows, there were significant similarities between these and Chinese medicine, notably in the drug combinations used by both. Meanwhile, Western medical missionaries applied the strategy of "accommodation" to downplay the difference between their approach and that of Chinese medicine, such as looking for local substitutes for herbal medicines, comparing market prices, and adopting indigenous architectural styles for hospitals. Second, Andrews profoundly analyzes an important question about the rise of medical professionals with different training backgrounds and political inclinations and the emergence of different professional societies and associations. There were three medical associations by the establishment of the Nanjing Nationalist government in 1928: the China Medical Missionary Association (CMMA; also known as the China Medical Association...

Fulminant pulmonary fat embolism - undetected silent killer.

Book Reviews The Growth of Medical Thought. By Lester S. King. (Chicago: University of Chicago Press, 1963. Pp. ix + 254. $5.50.) The author of this book is "a pathologist with a background in history and philosophy," to quote from the jacket. This combination of interests is reflected in the Preface itself, where it is stated, "The history of medicine is part of the history of ideas." However, the text itself, unfortunately, is too episodic in treatment and too homiletic in tone to do justice to the explicit goal the author sets for himself at the very outset, which is "to indicate the growth of medical science and the patterns of medical doctrine," by a consideration of a few key figures in the history of Western medicine who represent certain distinct trends in medical theory. In his previous book, The Medical World of the 18th Century (1958), the author likened the historian to the photographer, but he forgot to bring out that a good historian needs (to exploit his own analogy) a movie camera in order to exhibit adequately the growth of things. An ordinary camera will not do for historiography. The volume opens with ancient Greek medicine and ends with the pioneers in molecular pathology. In the present reviewer's opinion, the most effective chapters of the book are the ones dealing with two of the most controversial figures in the whole history of medicine, namely, Galen and Paracelsus. For there more than anywhere else in the book, we learn the sobering lesson that just because, say, Galen's "doctrine of faculties" in Roman medicine is "wrong" (that is, false in fact), from the standpoint of modern science, is no reason for calling it "foolish" (that is, false in theory) --Moli~re to the contrary notwithstanding (p. 77). While Galen's Aristotelian "modes of thought may seem somewhat strange to us," Dr. King insists, "we must preserve a judicious historical attitude" (p. 49) towards them just the same, if our objective is to understand their raison d'etre in the first place. He uses the same criterion with respect to Paracelsus, even though he spoils his case a bit by contradicting himself concerning that bombastic figure of Renaissance medicine, describing him on one page as "essentially a poet and not a scientist or philosopher" (p. 125), and then declaring on another that he "was at heart a philosopher" (p. 137). Now, no matter whether we agree with the author's interpretation of Paracelsus as a "Neo-Platonist" in medicine, he deserves credit for discussing [2s7] 238 HISTORY OF PHILOSOPHY that enigmatic Swiss iatrochemist sympathetically. In any event, Dr. King's sympathetic approach to Paracelsus manages to throw considerable light on the Paracelsian advice to all future physicians: Don't read books! Read the stars, but read them "in Neo-Platonic fashion" (p. 114)! While the author is "judicious" about Galen and Paracelsus in particular, he is far from being so when it comes to Friedrich Hoffmann, a medical materialist and "systematist" from Halle in the eighteenth century. Paradoxically enough, Dr. King has a marked antipathy for the doctor of "sympathy " himself (p. 173). Incidentally, the only other physician in the book who is not liked--apparently for his being polemical (p. 215)--is a famous fellow-pathologist of the last century, Rudolf Virchow. Still, it is only fair to add that the author acknowledges fully Virchow's important contributions to the field of cellular pathology. Finally, Dr. King not only has his likes and dislikes as to the medical men he actually selects from modern medicine to represent changes in theory of disease, but he seems also to have a definite bias in another and more serious sense. With the exception of the Epilogue and Chapter IV, which includes Vesalius and Harvey as well as Hoffmann, all the episodes of modern medicine deemed worthy of study derive from the Germanic world. Curiously enough, although there is no discussion of the germ theory of disease as such in the book, there is mention of Koch, but not of Pasteur. And French physiologist Claude Bernard, the great medical philosopher who tried to do in the nineteenth century for scientific medicine what...