[Music]

[The U.S. Department of Health, Education, and Welfare, Public Health Service, presents T - 1898, V - 1898, MCMLXIX]

[A National Medical Audiovisual Center Production]

[Clinical Pathology Series, A Cooperative Project]

[Emory University School of Medicine and National Medical Audiovisual Center]

[Forensic Medicine Outlines, Narcotic Deaths]

[Part 2]

[Forensic Medicine Outlines, Milton Helpern, M.D., Chief Medical Examiner, The City of New York]

[Dr. Helpern:] I should like to continue the discussion of deaths associated with narcotism.

Before showing any more of the cases, I'd like to point out that the narcotic addict, 

despite the fact that he doesn't use sterile technique in giving himself injections, 

is able to inject the same vein hundreds of times, which is evident from the scarring above and around the injection sites, 

and this is rather interesting because in medical practice when intravenous injections are given, 

if more than five or six injections are given in the same area, 

the vein usually becomes thrombosed, and it's an amazing thing how these injections with the dirty equipment

does not result in the immediate closure of the vein from the repeated trauma that occurred, 

but that's just an interesting point in passing. 

I'd like to continue with some of these cases, and we can have the...

now, here's another example of what I just said. 

This person was found dead, and the tourniquet made from a stocking, you see, is still on the lower part of the arm, 

and here's the forearm with many recent injection sites,

and with fairly recent scarring and with some of this material oozing out

and having dried on the surface of the skin. 

Here's another demonstration of recent injection sites. 

By incising through the punctured area and through this; here's an old scar, you can see it. 

But these are sites of fairly recent injection, and notice how many there are. 

The addicts take many injections a day, and when you magnify that by the cost of the drug, 

you can see how much money an addict needs to keep himself in this habit, 

and in order to get that money, you can see what sort of criminal activities he has to indulge in. 

So you have this very complicated problem. 

Here's another case of an addict where we found no evident injections, 

no conspicuous injection site, but if you look over the dorsum of the hand, 

there's a little mark right there that looked a bit suspicious. 

In order to confirm it all one had to do was to incise the area, 

and there is the most recent injection site, 

and I think it shows up very well even though these are black and white recordings of the color films. 

This is another type of addict. 

This is the so-called skin popper. 

The subcutaneous addict who injects himself through his clothing and sometimes gets other people to inject him, 

because this man evidently has scars on his back. 

But these people develop abscesses, and when the abscesses drain, 

they leave these depressed oval-shaped scars, which are extremely numerous. 

And this is the addict who not infrequently develops a chronic sepsis, 

a cellulitis and phlegmon of the extremities, 

and is also apt to develop tetanus as a complication. 

Curiously, we see more tetanus among the cutaneous addicts in women than we do in men, 

and I think that may be associated with the fact that these addicts are,

the women are not inoculated with, immunized with toxoid. 

Most of the men are, as the result of their working in different industries and so on, 

in those who do work. 

But the fact is that there are fewer cases of tetanus in men than in women. 

This is a tetanus case, addiction leading to tetanus. 

You can see this skin's gone here. 

I made an incision down from the armpit, and here is a large fluctuant abscess 

in the deeper tissues from which the organisms can be cultured. 

Now you can see the armpit here and the skin of the chest wall, 

and here is this very large collection of pus. 

It's amazing how many of these abscesses these addicts have. 

Some of them develop a chronic edema of the extremities 

and they go on and take a long time in getting well,

or they go on and die of sepsis. 

Now, another complication that one sees in narcotic addicts, 

and one has to think of narcotic addiction as a possible primary cause for the lesion. 

This is a person, narcotic addict, who has a very severe rheumatic mitral valvulitis

with some mitral stenosis, and he also has a subacute vegetative endocarditis 

on the auricular surface of the mitral valve,

and eventually died from the infection, but this was associated with narcotic addiction. 

It goes along with the thrombophlebitis that one finds in the infected veins. 

Now, this is a narcotic addict who died of viral hepatitis. 

One would expect that with all the cross-use of these needles and syringes 

that the carrier of the virus would certainly transmit the virus to other persons 

through the common use of the syringe. 

This liver is very much shrunken in size, 

and I just photographed it to indicate that this is a complication. 

I'd say that most of the cases of viral hepatitis among addicts recover, 

and they form a reservoir for infection because some of these addicts do serve as blood donors. 

It's pretty hard sometimes to keep them out of the pool of donors, 

and blood from an addict can very easily result in viral hepatitis transmitted to a patient. 

The viral hepatitis, however, is not a common cause of death,

we see it from time to time...despite the fairly large incidence of hepatitis in the addict population. 

Here's another complication. 

This picture--you're looking at the head down this way, and this is the abdomen here. 

You'll notice a perforated duodenal ulcer with the escape of duodenal and gastric juice. 

We put some copper sulfate solution on the fat. There's fat necrosis in here.

You can see it colored blue with the [?] reaction. 

This is one of the complications. 

Addicts, when they're under the influence of their narcotic, 

are not as prone to suffer pain or the usual symptoms of a perforated viscous, 

and they can go unrecognized because first their symptoms are thought to be due to the fact that they're trying to--

these are symptoms of drug withdrawal, 

and secondly I think there is a deadening effect of the narcotic

on the whole pain mechanism in the individual. 

Another interesting complication that we've encountered in the last few years,

and which was reported by Dr. Sturner and Dr. Strassman and myself--

this appeared in a recent issue of the

Deutsche Zeitschrift fur die Gesamte Gerichtliche Medizin. 

It's this interesting bilateral but not symmetrical lesion in the globus pallidus

and in other parts of the basal ganglia which develop.

These are areas of cystic degeneration. 

We interpret them as resulting from the hypoxic states that occur during these acute incidents 

where the addict passes out and does not have enough oxygenation of blood 

and blood transfer to the brain. 

At any rate, we consider this a part of the hypoxic reaction

or state that may occur from time to time in the addicts. 

Now, these cases sometimes are active right up to the end. 

It's an incidental finding. 

There's no immediate disability beforehand, 

and we've seen cases where we haven't been able to determine anything at all

except that the person was a heavy user of narcotic

and had not necessarily suffered a period of unconsciousness that we knew about, 

but this is a very interesting lesion. 

Now we come to the lungs. 

The lungs of the narcotic addict are very suggestive. 

You see the diagnosis is really a composite diagnosis. 

We diagnose from circumstances, from needle punctures, from scars, 

from the general appearance of the organs, the tremendous congestion, 

and perhaps the lungs are the most striking organs of all. 

They become very heavy with edema fluid and with congestion. 

You can see the frothy edema fluid oozing from the bronchi. 

Sometimes this is mixed with coagulated milk that's been given to the addict 

in the attempt to resuscitate him, 

but really helps him pass out or makes any possibility of a recovery less likely. 

Now, these lungs in the very beginning show terrific congestion

and some hemorrhage and very marked edema. 

The lungs are stiff. 

They sometimes weigh over 1,000 grams apiece, 

and when you place them on the table they do not collapse, 

although there's a lot of variation to this. 

Microscopically, even with a very short period of survival, 

these patients or these subjects develop a very rapidly progressing pneumonia. 

There's pneumonitis with polymorphonuclear leukocytes and mononuclear leukocytes, 

and if one is not alert to the fact that this is a reaction to an acute, 

an acute reaction to an injection of the drug, 

one sometimes can misinterpret the findings and designate them as pneumonia;

that is, primary pneumonia, 

and I've seen cases of narcotic addiction dying in an acute reaction

where the pathological diagnosis and certification was influenzal bronchial pneumonia. 

Now, there is a pneumonia that develops very rapidly, 

but it's a secondary pneumonia and not a primary pneumonia, 

and this mistake must be guarded against. 

Other lesions have been described in addicts 

from the constant filtering out in the lungs of foreign material,

which is injected in the suspensions and so on, 

but our experience has been that these granuloma that you sometimes encounter

do not represent a very important part of the disease process. 

They are just further indicators of the intravenous addiction that these people undergo. 

But the pneumonia is something that one must understand because it can develop very rapidly, 

and within a few hours the lungs can be quite stiff

and very much like the pneumonias that you sometimes see

in cases of inhalation of smoke. 

Although, they're not like that at all, 

but they can develop in a very rapid way

and must not be misinterpreted as influenza. 

That completes the demonstration of the cases. 

We have in the population a rather abundant utilization

of the so-called street addict who buys this from the pusher

and the pusher who in turn gets it from somewhere else. 

Most of the preparations that we have contain heroin. 

Of course, other substances are used as substitutes, 

and we see a good many amphetamine cases, the so-called speed cases,

but they're of a different sort. 

The diagnosis of death from intravenous narcotism

must depend upon the combination of circumstances and pathological findings, 

and to disregard this combination and to try to find chemical corroboration in each case, 

this is an important thing to try to do, but the chemist doesn't always corroborate. 

And that type of case should not be excluded, 

because if you exclude the kind of case where the chemist can't corroborate,

then I would say that we are understating the problem. 

Now, at autopsy, material for chemical examination has to be taken, 

and portions of the liver are taken, portions of the brain are taken. 

The bile, the gallbladder and the bile provide a very good immediate location

or substance to test for, 

because in an intravenous narcotic addict who has been on heroin, 

the chemist usually recovers a morphine derivative in the bile. 

As you know, heroin is a substance which is manufactured from morphine. 

It's acetylated morphine, and when it gets into the body, it breaks down,

and the materials that are found represent

the morphine derivative from the acetylated mixture. 

Evidences of heroin or morphine can be found in the urine, 

and now urine-screening laboratories have been set up to assist in the control of narcotic addicts, 

and any control program has to have facilities for testing urine 

to see that the addict is clean, as they say. 

This is a rather important thing to do, 

and addicts have a great many ways of deluding those who are in charge,

and one has to be very careful when you are testing urine or screening urine 

that you are getting the urine from the addict. 

So that the collection of that urine sample is very important.

These addicts become very cute about getting people to go in and provide the wrong specimen, 

the substitution and so on, and this is something that must be guarded against. 

The other points I'd like to make out, to emphasize, 

is that microscopic examinations of the tissues should be carried out. 

What I didn't mention is the fact that there is 

almost a characteristic hyperplasia of the lymph nodes 

at the hilum of the liver. 

These hilar lymph nodes become very enlarged and succulent, 

as do lymph nodes elsewhere, but particularly in the region of the porta hepatis,

and this is a fairly characteristic finding. 

Then in a large group of addicts one finds varying degrees of involution of the thymus

or that is, there is lymphoid hypoplasia visible in the thymic tissue as well. 

There are some other interesting observations that I feel at this time 

I would not want to comment on. 

With regard to the organs in general, 

outside of the degenerative changes that occur in the brain, 

there's no evidence that narcotic addiction causes a deterioration in the organs. 

The liver sections do show a chronic type of inflammation in the porta hepatis--in the portal areas,

around the portal triads there's quite a bit of that, 

but otherwise not very much and certainly not very much 

in the kidneys and other tissues of the body. 

So, again, the diagnosis of a death from intravenous narcotism, 

heroin addiction, depends upon a knowledge of the circumstances and autopsy findings.

Some are more characteristic than others, 

and all of these cases really require a complete autopsy

and chemical examination for whatever it will provide. 

I think we'll stop at this point. 

Thank you.

[Music]

[Forensic Medicne Outlines, Milton Helpern, M.D., Chief Medical Examiner, The City of New York]

[Forensic Medicine Outlines, Narcotic Deaths]

[Clinical Pathology Series, A Cooperative Project]

[The End, T - 1898, V - 1898, MCMLXIX]