THE EFFECTS OF GUNS, KNIVES, EXPLOSIVES, AND OTHER WEAPONS OF DEATH

Can a Stun Gun Serve as a Murder Weapon?

Q: I'm working on a story that requires one man to kill another while both are in a crowd of people. My thought is that the killer uses a stun gun. While these devices are not supposed to be fatal, is it possible that death could result from the application of a longer-than-usual dose of electricity if the victim has a heart condition or pacemaker?

A: Interesting question.

You are correct in your assumption that stun guns are nonlethal and would result in the death of a normal, healthy adult only in the rarest of cases.

Stun guns and TAZERs deliver a high-voltage, low-amperage shock;—usually around 50,000 volts, but some deliver up to 300,000 volts. This causes violent contractions of the muscles and is very painful. Most people collapse to the ground and writhe in pain. Some people are tough and can yank out the TAZER electrodes or knock the handheld stun gun from the attacker's hand. Individuals who are larger, angrier, or on certain drugs such as PCP or methamphetamine would be more likely to overcome the effects of the electric current.

A pacemaker consists of a pulse generator (the device itself) and leads (wires) that connect the pacer to the heart (Figure 11). Pacers are typically placed just beneath the clavicle (collarbone) and are visible as a watch-dial-sized lump on the chest wall. The pacing leads are passed through the subclavian vein, which lies just beneath the clavicle, and advanced through the superior vena cava into the right side of the heart, where they are wedged into the lower tip of the right ventricle. The leads are then attached to the pulse generator.

The electrical current from a stun device would permanently damage the pacemaker only if it was applied directly over the pulse generator unit itself. This could fry its electronics. A stun gun would have to be held against the chest or the TAZER wires would have to penetrate the skin directly over the pacer for this to occur. If the charge was applied anywhere else on the body, it would be unlikely to harm the pacer itself.

That said, the current could interfere with the sensing function of the pacer in such a way that the pacer would think the heart was beating when it wasn't. A pacer is a demand device, which means it reads the electrical current of the heart and fires only when the heart doesn't. If the heart beats normally, it simply sits and watches. An electrical current could be sensed by the pacer as cardiac activity, and thus the pacer would do nothing.

However, most people with pacers are not what we call "pacer dependent." Pacer dependent means that the native heart rhythm is absent or very slow, and without the pacer, the person's heart rate drops to very low levels—thirty beats per minute or less—and death could ensue. Most people have pacers as a safety net for intermittent slowing of the heart rate. In this case, interfering with the pacer's sensing function would not be lethal since these patients have a sufficient native rhythm to survive.

A stun device could kill someone with a pacer, but it's unlikely.

As for someone with heart disease, if the person had coronary artery disease or some form of dangerous cardiac rhythm for which he was taking medication, the pain and shock of the attack could precipitate a heart attack or a fatal arrhythmia. Pain, shock, fear, and anger cause the release of adrenaline from the adrenal glands into the bloodstream. This causes an acute increase in heart rate and blood pressure, which could lead to a heart attack or could precipitate fatal changes in heart rhythm.

If your killer knew that your victim had a cardiac history or a "bad heart"—maybe he has daily angina attacks or uses nitroglycerin frequently during physical or emotionally stressful situations—

he could reasonably expect that a TAZER or similar attack might cause the death of the victim. If you set up this background, your method of murder is completely plausible.

What Happens to the Victim of a Stun Gun Attack?

Q: In my current book a character gets hit by a stun gun. What will happen? Will she be unconscious? When will she be able to get up? Will she remember being hurt?

A: Stun guns are handheld contact devices that require the user to place the business end against the attacker's or victim's skin, while TAZERs are handheld projectile devices that fire a pair of darts attached to the hand device by wires. The darts penetrate the skin, even through some clothing. The length of the wire in most commercially available devices is about fifteen feet.

Either will deliver a high-voltage, low-amperage charge that paralyzes the victim by contracting all his muscles. The voltage varies from type to type over the range of 50,000 to 300,000 volts. In some TAZER devices the initial charge will last five to ten seconds and be followed by a series of shorter charges up to about thirty seconds in total duration. This varies by device and manufacturer.

The victim isn't permanently harmed but may require several minutes to recover from the jolt.

The victim will typically drop to the ground, and as the muscles contract, her back will arch and her limbs will convulse as in a seizure. We call these tonic-clonic motions. She may cry out or moan but will not likely be able to make any purposeful movements such as standing, running, or crawling. After several minutes she would be normal once again—perhaps a little more wary but able to perform all physical movements and activities. There should be no residual impairment.

The victim is not unconscious and would probably remember everything, perhaps in great and painful detail.

Will a Stun Gun Shock Others Who Are in Contact with the Victim?

Q: have a scene where a character who feels no pain is down on the ground being beaten by guards who have nightsticks and stun guns. During the fray one of the guards hits him with his stun gun. If the guard using the stun gun is touching the man, would he be shocked by the electrical charge as well? And would the other guards who are also touching him be shocked, too?

A: The answer is yes to both.

Anyone in contact with the person who is receiving the current will also get the shock. That is why during cardiopulmonary resuscitation (CPR) we yell "clear" before we push the button that releases the current. You have seen this on ER, I'm sure. Otherwise, the person doing the chest compressions, taking a blood pressure, or touching the patient for any reason would also be shocked by the defibrillator current.

Today, many patients have implantable defibrillators (basically a paramedic in a box): this is a device placed beneath the skin of the chest and attached to the heart by electrode wires. These devices monitor the patient's heart rhythm, and when a potentially lethal abnormal rhythm occurs, they deliver a shock to the heart internally, which hopefully restores the rhythm to normal. People touching the patient at the time of discharge will feel a mild shock—nothing harmful or painful but noticeable.

What Would a "Bang Stick" Wound Look Like?

Q: If someone used a "bang stick," like those used against sharks, as a murder weapon, what would the wound look like? Where is the most lethal place to aim it?

A: A bang stick is basically a stick with an explosive charge at its end. The charge is typically a shotgun shell. These devices are used as a defense against sharks and for alligator hunting. The business end is pressed against the target and fired. In some, the shot (lead pellets) are left in the shell so that it acts like a shotgun, while in others the shot is removed and the killing force is the concussive force of the exploding gunpowder.

The wound would be of the contact variety (see the later question, What Does the Wound from a Close-Range Gunshot Look Like? in "The Police and the Crime Scene" section). If the pellets are present, the wound would be as if a shotgun was placed in contact with the skin and fired. The wound would be a combination of the expanding gases, which would rip the skin in a stellate (starlike) pattern, and the shot, which would penetrate into the tissues and cause widespread destruction.

If no pellets are present, the wound would be from the expanding gases alone. The resulting configuration would depend on where the contact was made. If it was over a bone, such as the skull, the explosive gases would expand laterally and rip the tissues into the classic stellate wound. If it was over softer tissues, such as the abdomen, the wound might still appear stellate but would tend to be deeper and less widespread.

The best location to assure the death of the intended victim would likely be against his temple or his neck, where his carotid artery or jugular vein could be injured.

Is a Blow to the Head More Deadly in a Heart Patient?

Q: In my story an elderly man gets hit over the head with a cane. He falls and dies, either from the blow to the head or from his bad heart. Is it feasible that one good blow would kill a man with a bad heart? Would there be a lot of blood around? I'm hoping not, since I would prefer a fairly neat scene.

A: It is indeed possible to die from a single blow to the head with a cane or any other object, especially if the victim is elderly. Older people are especially prone to skull fractures from falls or blows to the head since their bones are more brittle. But even without a fracture, an intracranial bleed (bleeding in or around the brain) can cause death.

Death from an intracranial bleed could occur almost immediately or at a slower rate, depending on the force of the blow, the area of the brain injured, and the swiftness and volume of the bleed. You could almost guarantee death if the victim was not found for several hours and the intracranial bleed was extensive.

An assault of any kind on a person with significant heart disease could precipitate a heart attack or sudden death from a cardiac arrhythmia, which would be caused by the outpouring of adrenaline from the fear and pain that would accompany such an attack. You don't really need that here since the blow alone could do the victim in.

Blows to the head often lacerate (cut or tear) the scalp, which typically bleeds profusely. However, many result in only a bruise or abrasion of the scalp with little if any external bleeding. Either way, an extensive intracranial bleed can occur and lead to death, so it is reasonable for you to have a "fairly neat scene."

Will Ground Glass in Food Kill a Person?

Q: I'm writing a story about an abused wife who decides to kill her husband by feeding him ground glass from a saltshaker. How much would it take to do that? Would it have to go on over time? What would his symptoms be? Would it speed things up if the husband had an ulcer?

A: First the bad news. This is unlikely to work.

The glass would have to be very finely ground, or the victim would notice it as he ate. As we chew, we sense even tiny pieces of gravel, sand, glass, gristle, and so forth. Salt dissolves but glass doesn't, so the food would seem gritty unless the glass was ground into a powder. But very fine glass is unlikely to cause any lethal damage to the GI tract. It would be more of an irritation, with minor bleeding if any at all. If you could get the victim to eat coarser glass, such as crushed instead of ground, the glass shards would damage the stomach and intestine and could cause bleeding.

This works with dogs because they don't really chew their food, and they are accustomed to biting through bones and gristle, and they wouldn't know what the glass was anyway. They simply swallow the larger pieces of glass that do the damage, then go off somewhere and slowly bleed to death. A person would know something was wrong with the food, and if not, he would go to a doctor about the bleeding.

Even with coarser glass, the bleeding would probably not be massive or life-threatening but slow and lead to anemia and fatigue. The stools would become black from the blood, and the victim would see a doctor. Yes, an ulcer would make this worse since he would have two points for potential bleeding, but only the ulcer

would have the potential to cause severe life-threatening bleeding. I doubt the ground glass would damage the underlying ulcer enough to cause a severe bleed.

Now, the good news.

If your victim had a serious heart condition such as coronary artery disease (CAD) and had had several heart attacks (myocardial infarctions, or MIs) in the past and now has ongoing angina (chest pain from the heart due to poor blood supply, usually felt as a tightness or squeezing sensation), then the anemia from the slow bleed might lead to a heart attack that could kill him.

In CAD the arteries that supply blood to the heart are narrowed from atherosclerosis. This means that the blood that reaches the heart muscle is reduced by these blockages. Anemia is a condition characterized by reduced red blood cells (RBCs) in the blood. It is the RBCs that carry oxygen, and so in anemia the blood carries less oxygen.

If these two entities occur together, not only does the heart muscle have less blood flowing to it from the obstructed arteries but also the blood it does get has less oxygen—a dangerous combination. We see this a lot. A patient with CAD and mild angina may become very unstable and even suffer a heart attack or die if he develops anemia from a bleeding ulcer or from some other cause.

As the anemia progresses, his angina would get worse, and since he's an abusive jerk, he might not go to his doctor. He would develop progressive and frequent angina attacks, any one of which could blossom into a full MI and kill him.

His M.D. might sign the death certificate since the wife would say her husband had had worsening of his angina, wouldn't go to the doctor, and finally clutched his chest and fell over dead. This way no autopsy would be done, his anemia and his irritated glass-filled GI tract would never be seen by the M.E., and her life would go on.

So the ground glass could work in your story, just not directly.

How Long Does It Take to Smother Someone with a Pillow?

Q: My victim is killed by suffocation—a pillow over the face. How long would this take? She is an elderly woman and not especially strong. She is in a nursing home because of two broken legs suffered in a car accident. I've written this with the assumption that it would be a quick means of killing her. Then I saw somewhere that it can take as long as ten minutes to kill someone this way. So what's the story? Do I have to start over?

A: No, you don't have to start over. An elderly lady would die in two to five minutes and probably toward the lower end of this range. A younger, stronger victim might be able to put up a good fight so that the suffocation would be intermittent; that is, he or she might knock or push the pillow away several times and be able to grab a gulp of air. He would be able to continue this until the oxygen level in his blood dropped sufficiently and he became weak, lost consciousness, and died. Your elderly lady would struggle but probably wouldn't be strong enough to dislodge the pillow, even for a gasp of air. This is particularly true since she has two broken legs and thus would not be able to get much leverage.

Her struggles, as well as the fact that she would be extremely frightened, would lead to rapid consumption of the oxygen in her bloodstream so that death would occur more quickly. Also, an elderly victim such as yours would likely have at least some degree of heart and lung disease, and these would make her tolerance for lack of oxygen even less. Two to three minutes would probably be it.

She would die from cardiopulmonary arrest (the heart stops). If she showed no signs of external injury, her death could be judged to have been natural by her family M.D., since elderly persons frequently die in their sleep—especially in nursing homes after auto

accidents. Her private M.D. might assume she had a fatal heart attack or a pulmonary embolism (PE). A PE is a blood clot that travels from the legs or pelvis to the lungs. This is a common cause of death in bedridden patients and in those who have suffered injuries to their lower extremities. Your elderly lady would have both of these risk factors for PE. Her M.D. might sign the death certificate, and that would be the end of it.

But if the M.E. performed an autopsy, he would likely see the characteristic petechial hemorrhages (red dots and small splotches from broken microscopic capillary vessels) in the conjunctivae of the eyes (the pink part). These are found in smotherings and in both manual and ligature strangulations. If he did, a homicide would be suspected.

How Does an Ice Pick to the Back of the Neck Kill?

Q: In my story, a killer shoves an ice pick into the back of a guy's neck, right under the skull, and kills him instantly. Does this work? How?

A: Since life depends on an intact communication between the brain and the body, any injury to the spinal cord in the cervical area is potentially lethal. If an ice pick or knife blade is forced between two of the neck bones (cervical vertebrae) and slices or macerates (chews up) the spinal cord, death is fairly well assured. The cervical portion of the spinal cord is divided into eight levels, which correspond to the eight cervical vertebrae. They are designated C1 through C8.

Though damage to any level of the cervical cord could do the trick, the higher the better. Why? The levels between C3 and C5 control respiration, so any injury at or above this level would shut down breathing and lead to death.

Your killer could best accomplish his deed by insinuating his

weapon between the second and third cervical vertebrae (Figure 12). The entry point would correspond with the small hollow depression in the back of the neck that is just below where the skull joins the neck. A cut here would anatomically and functionally separate the brain from the spinal cord and, thus, the body. Think of it as a localized guillotine, a cutting of the spinal cord without completely removing the head. The effect is the same.

With a transection (cutting) of the spinal cord, all the body's muscles would immediately become flaccid (limp), and the victim would drop to the floor. He would be unable to speak or breathe because the nerves to the diaphragm, which arise from C3 through C5, would be interrupted. Also, with the loss of enervation to the

body, the blood vessels would rapidly dilate (open up), causing the blood pressure to drop, and shock, unconsciousness, and death would follow.

Would the victim be conscious for a few seconds? Possibly, but he would be as flaccid as a scarecrow, unable to move, speak, breathe, or cry for help. Death would be as immediate as it could be.

What Are the Most Lethal Wounds That Can Be Made with a Knife?

Q: In my story, a right-handed murderer with a very sharp six-inch blade kills a man with one "slice." I know that it's possible for the victim to go into shock and die right away. What I don't know is what the knife has to cut in order to get that result. What would the coroner's report say was the cause of death?

A: I assume from your question that you want the victim to die fairly quickly. There are several possibilities.

A professional assassin can maneuver a blade between the cervical vertebrae (neck bones) and slice the spinal cord in one movement. Usually the attack comes from behind. The assassin slaps a hand over the victim's mouth and thrusts the blade into the back of the neck, slipping it between the bones. The victim goes limp, falls, and dies almost instantly.

From a similar position the killer can draw the blade across the victim's neck, cutting through the carotid arteries and the trachea (Figure 13). Since the carotid arteries supply blood to the brain, the victim dies quickly, and the cutting of the trachea below the vocal cords prevents the victim from crying out. This is what happened to Nicole Brown Simpson.

A thrusting stab wound to the heart is lethal most of the time and fairly quick. The same can be said for the lungs if a major

artery is severed. But people often survive stab wounds to the chest and even the heart, and would, of course, be able to call for help.

A slashing or stabbing wound to the abdomen might work if the aorta or vena cava was sliced. The problem is that both lie along the back of the abdomen, and a six-inch blade might not reach them. It could, though, if the attacker was strong, thrust the knife deeply, and then made a sweeping motion with the blade. Death would take several minutes since it would require the victim to bleed to death.

The cervical spinal cord cut, the throat slashing, or the stab to the heart are the most effective ways and have the highest likelihood of killing the victim.

The coroner or M.E. would be able to determine the cause of

death without difficulty. The cervical cut would be called "transection of the spinal cord at the cervical level." The throat slashing would be termed "transection of the carotid arteries." The stab to the heart would lead to blood filling the pericardium (the sac around the heart), which would compress the heart and interfere with its function. This would be called "death due to pericardial tamponade secondary to a penetrating knife wound." The abdominal stab would result in "death due to exsanguination secondary to a penetrating abdominal knife wound with perforation of the aorta" or vena cava or both.

Gruesome, huh?

What Stractures Must Be Injured to Make a Stab Wound to the Back Lethal?

Q: The scenario is for the sleuth to go into the office and find her boss dying with a letter opener lodged in his back.

Is there an artery in or near the lungs? If a victim is stabbed in the back and this artery is hit, would he then literally drown in his own blood? Would the victim be able to speak and give the sleuth the inevitable cryptic clue? If no artery is hit, would the stab wound in one lung be enough to kill him?

A: Let's review a little anatomy and physiology first. Our lungs are designed for gas exchange. This is simply the loading of oxygen into the blood and the removing of carbon dioxide and other toxins from the blood. To do this, the blood and the air must come into close contact with each another. The lungs allow this to happen by having billions of microscopic air sacs and billions of tiny blood vessels that surround these sacs.

The basic circulation system of the body is divided into the systemic and the pulmonary circuits (Figure 14). The systemic circuit is the left ventricle pumping blood out the aorta and into the various arteries of the body, ultimately reaching every organ and nook and cranny, and then the blood's return via the veins to the right side of the heart. The pulmonary circuit is the right ventricle pumping this blood into the pulmonary arteries, which continually divide into smaller and smaller vessels and spread to all parts of the lungs like a fan. After the blood collects oxygen, it flows through the pulmonary veins into the left side of the heart and the left ventricle.

This points out two facts important to your question: First, the entire volume of blood in the body flows through the pulmonary circuit continuously. This is necessary since the lungs are the only means available to load vital oxygen into the blood. Second, the lungs, like every other organ in the body, receive a portion of the systemic blood flow. This is the oxygenated arterial blood that keeps the lung tissue itself alive. Thus, the organs known as lungs are extremely vascular (loaded with blood vessels—arteries, veins, and capillaries) and bleed profusely when injured (Figure 15).

Now back to your question. A penetrating wound to the lung as occurs in stabbings and gunshots would result in bleeding into the lung and then out the mouth and nose. The blood coming from these orifices would be bright red and frothy since it is mixed with the air flowing in and out of the lungs as the victim struggles for breath. As the lungs fill with blood, the victim would literally drown in his own blood. The injured lung may or may not collapse, which would only add to the victim's struggle to breathe.

The victim would be able to speak as long as he could move air in and out of his lungs, so he would be able to give the sleuth the telltale clue. If the sleuth was savvy, he might roll the victim onto the side of the injury, using gravity as an ally.

For example, if the victim was stabbed in the left lung and lay on his right side, the blood from the injured left lung would follow the dictates of gravity and flow from the left bronchus (the main airway off the trachea to the left lung) into the right bronchus and then into the right lung. Thus, the "good" lung would fill with blood, and the victim would now have both lungs in trouble and would die more quickly. If your sleuth rolled him onto his left side, gravity would tend to keep the blood in the already injured left lung, and the uninjured right lung would not fill with blood and would continue to function normally. This maneuver might

save the victim's life or at least prolong his life so that the needed clue could be obtained.

What Noises Are Made by Victims of Stabbings or Gunshots to the Neck?

Q: My character needs to walk by a room with an open door and be drawn in by a hissing or gurgling noise to find a corpse. Would this type of noise occur if the vic-

tim was shot in the neck? How long might the noises continue after shooting?

A; The short answer is yes.

A gunshot wound (GSW) or any other type of penetrating wound (knife, arrow, ax, machete, and so forth) could produce these sounds if and only if the wound was in the lung itself or one of its airways. The sounds you describe require air moving through a liquid such as blood. Think of a bellows being pumped into a thick liquid, which is exactly what is occurring.

Drowning victims and persons suffering pulmonary edema (literally, lungs filled with water) from heart failure or toxic exposure (such as chlorine or another irritative gas) or certain other processes sound the same way. Again, the sound is that of air bubbling through a liquid regardless of the underlying cause.

A GSW or stab wound to the throat or through the chest into the lung could produce this. Blood would flood the airways (trachea and bronchial tubes), and the movement of air in and out as the victim attempted to breathe would produce a bubbling or gurgling sound. Obviously, these sounds would require that the victim still be alive and trying to breathe when the person walked by the room. He might hear the victim's last breaths and then would find a corpse.

The time lapse from wound to death is extremely variable and depends on the nature, location, and depth of the wound plus the age, fitness, and health of the victim, with the former factors being more important than the latter. This gives you free rein to have the victim die in minutes or hours after the injury.

Can Someone Who Has Been Stabbed in the Neck Speak?

Q: Is it possible for someone shot or stabbed in the neck to utter a few intelligible words before expiring?

A: Yes, unless the larynx (voice box) or vocal cords are damaged or the trachea is severed below the larynx or vocal cords. The larynx is the Adam's apple, and the vocal cords stretch across the airway inside the larynx. Sound requires that air move between the cords in sufficient volume and velocity to vibrate them and thus produce sound. If the cords are severely damaged, this may not be possible.

Also, if the trachea is severed below the vocal cords, air exhaled from the lungs exits through the wound, and not enough would reach the cords to produce vibrations and thus sound (Figure 16). People who have had trauma to the larynx or have severe lung disease that requires a permanent tracheotomy (hole cut into the tra-

chea just below the larynx) have to plug the tracheotomy hole in order to speak. Otherwise the air escapes through the hole and never passes through the vocal cords. This is a similar situation to the wound described above.

If the vocal cords and the trachea remain intact, noises and speech would be possible—bubbly, wet, raspy, but still speech.

Where Would an Intoxicated Person Have to Be Shot to Put Him in a Coma for Two Days?

Q: My evil villain is going to shoot someone who is blotto drunk and passed out. Not being a professional killer, he shoots the guy and, thinking he must be dead, leaves the scene.

The questions are these: If he was not found for several hours, could he still be alive and yet remain unconscious for a day or two? If so, in what part of his body would he have to be shot?

A: The scenario you lay out could happen. The two-day period of unconsciousness could not be from the alcohol since it is rapidly metabolized (broken down) by the body, and the victim would wake up after a few hours. If he took in enough alcohol to put him out for two days, he would die in short order from the depressive effects of that much ethanol intake.

Gunshot wounds (GSWs) to most of the body would not lead to a two-day coma. A GSW to the head could. The bullet could enter the skull and damage the brain (which would lead to surgery, a long convalescence, and so forth), or it could simply penetrate the scalp and cause a concussion with or without a fracture of the skull bone (cranium). The concussion could cause a period of unconsciousness, disorientation, confusion, and amnesia, or any combination of these as fits your story.

This type of concussive injury could lead to two days of coma or, more likely, a few hours of coma, and then over the next two days the victim could pass from somnolence (sleepiness and difficulty in arousing) to confusion and disorientation, to periods of wakefulness and progressive lucidity, to being fully awake with intact memory, absolutely no memory of the events, or spotty memory. His amnesia could even be retrograde, which means he would have no memory of events prior to his GSW. This retrograde amnesia could extend back for only a few minutes, a few hours, or, in extreme cases, forever.

I think this type of GSW makes the most sense for your scenario and is entirely plausible. Have the bullet either burrow beneath the scalp—in which case the surgeon could remove it under local anesthesia—or bounce off the skull and exit the scalp entirely. When he is found unconscious, he would be taken to the hospital emergency department, where an ER physician and a surgeon would care for him.

X rays would easily determine if the skull was fractured or not, if the bullet entered the brain cavity or not, or if any bullet fragments were left behind within the scalp after the bullet exited. If the bullet did not enter the brain cavity or fracture the skull, the surgeon would remove the bullet and any bullet fragments, clean and dress the wound, and likely place a surgical drain (a short piece of soft rubber tubing) into the wound to allow drainage of body fluids from the injured area. This lessens the incidence of infection. Closing such "dirty wounds" with sutures would allow collection of these bodily fluids within the wound. These fluids make a good culture medium and would promote the growth of infectious bacteria.

The victim would remain in the hospital for several days and receive intravenous antibiotics. At least twice a day the wound would be examined for signs of infection (redness, swelling, pain, pus formation), cleaned, and a fresh dressing applied. After several days the drain would be removed. The concussion would resolve, and the victim would be essentially normal again.

How Did David Kill Goliath?

Q: I have an interesting question for you. It regards the combat between David and Goliath. Other than the Old Testament, there are no historical accounts of which I am aware. I hope you can help me get the medical details of the combat exactly right. Apparently the rock that David slung did not kill Goliath but only stunned him enough to drop him to the ground, allowing the boy time to separate his head from his neck. The tantalizing single detail is that the rock sunk into his forehead (not his temple). The reference is 1 Samuel 17:48—51. What specifically happened to Goliath from just before the stone landed until just after the neck was severed?

A: Great question.

From the description of the brief combat in 1 Samuel, the rock was embedded in Goliath's forehead, and he "fell upon his face to the Earth." A rock to the head can be merely painful or it can kill. Somewhere in between these results, it can cause a concussion, which like a left hook in boxing can stun the recipient or render him unconscious.

Typically, an object such as a rock would cause "blunt force trauma" and not "penetrating trauma," as with a bullet. A blunt force injury to the head may or may not fracture the skull; may or may not cause unconsciousness; may or may not cause bleeding within the brain; and may or may not kill.

A penetrating head wound, by definition, means that the object breached, or penetrated, the skull. This is a more serious injury since the brain itself is traumatized directly by the object. Such penetrating wounds fracture the skull, but they may or may not

cause unconsciousness; may or may not cause bleeding into the brain; and may or may not kill.

The rule here is that whatever happens, happens. I once saw a man injured in an industrial accident where a metal disk flew out of a grinding machine and struck him in the forehead. He was knocked out, but only briefly. When he reached the hospital, the disk protruded from his forehead as if some miniature flying saucer had attacked him. On further exam I found that the disk's leading edge had penetrated his skull and embedded in his brain. He was awake, alert, and neurologically normal. A neurosurgeon removed the disk and he did well, with no residual problems. Could he have died instantly? Yes. Could he have bled into his brain and required more extensive surgery or died from this complication? Yes. Could he have suffered permanent brain damage? Yes. The point is that none of these happened. Whatever happens, happens.

Now back to David and Goliath. In 1 Samuel 17: 4 it states that Goliath possessed a height of "six cubits and a span." Many experts feel that a cubit was roughly 17 inches, while a span was approximately 9 inches, which means Goliath was over 9 feet tall. If this story is true and not merely a parable, Goliath most likely suffered from both gigantism and acromegaly. These conditions are typically caused by tumors of the pituitary gland, which secrete excess amounts of growth hormone (GH). GH causes lengthening and thickening of bones and muscles. Before puberty and the closing of the epiphyses (growth plates) in the bones, persons so affected grow very tall and have long arms and legs. After the epiphyses close, bones no longer can grow lengthwise, but under the continued influence of excess GH, they grow thick. This is particularly true of the hands, feet, jaw, and forehead. Acromegalics have thick hands and fingers, square, shovel-like jaws, and thick, protruding foreheads that seem to cantilever over their eyes. Remember Andre the Giant, the professional wrestler? He is a perfect example. Like Andre, Goliath must have developed a GH-producing pituitary tumor at an early age, and grown very tall, and then in his teens and twenties the continued excess of GH made him muscular and thick-boned.

If Goliath did suffer from acromegaly, it is likely that David's stone embedded in the flesh of the giant's forehead but did not penetrate the skull. In other words, a blunt force injury. Goliath was stunned or rendered unconscious by the concussive blow, and death came when David severed his spinal cord with his sword. In France this type of death was served up by the guillotine.

Of course, if David hurled the stone with enough velocity (with or without the aid of a divine hand), the missile could have penetrated the skull, resulting in a penetrating head wound. Death could have come from this or from the later beheading.

The passages that cover the battle are somewhat confusing. Verse 50 says, "David prevailed over the Philistine with a sling and with a stone, and smote the Philistine, and slew him." Verse 51 says, "David ran and stood upon the Philistine, and took his sword, and drew it out of the sheath thereof, and slew him." Did he slay him with the stone or the sword? Did he merely "prevail" over Goliath with the stone and then slay him with the sword?

I would suspect that David knocked Goliath unconscious, or nearly so, with a blunt force injury from the stone, which embedded in the flesh of Goliath's forehead but did not penetrate his skull, and then David finished him with the beheading. But I could be wrong.

POISONS AND DRUGS

Is There a Drug or Poison That Mimics Death but Allows the Victim to Survive?

Q: Is there a drug that truly mimics death to the point that a not-so-careful physician might pronounce death and then leave, after which the victim recovers? If so, how would the drug be administered, how long would the effects last, and is there an antidote?

A: You're going to love this. Zombie Powder. Yes, Zombie Powder.

It is the toxin of the puffer fish, also called the blowfish. The toxin is called tetraodontoxin or tetradotoxin (I've seen it written as either and also abbreviated as TTX), and it is found in the ovaries of the blowfish. The toxin is not destroyed by cooking, but if the entrails are removed before preparation, the fish itself is harmless.

In Japan the dish is prepared in a manner that leaves a little of the toxin behind. It is called fugu and is a delicacy. The residual toxin, in small doses, gives the diner a flushed and tingly feeling. The fish must be prepared to perfection, or it can be deadly—kind of like gastronomic Russian roulette. The chefs who do this are specially trained and licensed, and even these guys screw up from time to time. Recently, maybe a year or two ago, I read about several deaths in Japan from this.

In Haiti the toxin is used in certain voodoo religious rituals, and it is used in the "zombification" of field-workers and others. It can be sprinkled on the skin of the victim or added to his food, and it takes effect in a few minutes or up to four hours or so. It absorbs through the skin or the gastrointestinal tract.

It is basically a neurotoxin (affects the neurologic system) and causes paralysis, speech difficulty, slow, shallow respirations, and a decreased heart rate, with a weak and thready pulse. The victim may appear dead and is indeed fairly close. The skin of the victim is cool and pale, his breathing slow and shallow, and with an almost unpalpable pulse, one could easily assume the victim was dead.

If he survived the first twenty-four hours, without treatment he would gradually come around over the next two or three days. Proper treatment is directed toward preventing brain damage (see below) and would consist of hospitalization and giving oxygen and drugs to support the blood pressure while the toxin's effects wore off.

How to make a zombie? you ask. Simple. Sprinkle some of the powder in the victim's food or in his shoes. He will become dizzy, short of breath, and weak, and collapse. Then lay him in a shallow ditch, cover him with leaves, and come back in about twelve hours. He will be calm, controllable, and a good field-worker.

What causes this is an anoxic encephalopathy, which means the brain is damaged due to the lack of an adequate oxygen supply. This is the same type of brain injury that occurs in victims of drowning, cardiac arrest, carbon monoxide poisoning, and asphyxiation from any cause. In the case of tetraodontoxin poisoning, the low heart rate and blood pressure and slowed breathing causes the concentration of oxygen in the blood to fall to very low levels, which damages the brain—sort of a metabolic "frontal lobotomy." The surgical version of this happened to Jack Nicholson in One Flew over the Cookoo's Nest.

In the 1980s this happened to one of my patients. According to Joe (not his real name, of course), he owned a factory in Haiti, and Jean Claude Duvalier, a.k.a. "Baby Doc," wanted it, but Joe refused to sell. So Baby Doc had some of his Tonton Macoutes goons "zombie-ize" Joe and took his factory. They slipped into his house at night and powdered his shoes. The next thing Joe remembered was waking up three days later, in a three-hundred-year-old prison with rats gnawing on his toes. It took the U.S. State Department a month to get him out of Haiti.

Where would you get this stuff? Haiti, for sure, or perhaps in the Algiers area of New Orleans, where voodoo is still heavily practiced.

What Poison That Can Be Secreted in a Glass Will Kill Instantly When Swallowed?

Q: In my story a poison is placed in a glass. The victim then pours water into the glass and drinks it, dying immediately. At first glance it looks as though he has had a heart attack. However, my sleuth suspects he was

poisoned. What poison would fit this scenario, and what clues would tip off my sleuth that the victim was indeed poisoned?

A: There are several possibilities for your scenario, but one excellent choice: cyanide. It is quick, nasty, and effective. Even if someone attempted to save the victim, it is nearly impossible because treatment must begin immediately if any chance of survival is to be realized. Why? Cyanide is a "metabolic poison" in that it basically shuts down the ability of the body's cells to use oxygen. The red blood cells cannot carry oxygen to the tissues, and the tissues of the body can't use the oxygen anyway. It is as if all the oxygen is removed from the body instantly. This process is immediate and profound, and leads to death in one to ten minutes depending on the dosage. So even if CPR is begun immediately, the body cells still can't use the oxygen supplied by this process.

Symptoms are rapid breathing, shortness of breath, dizziness, flushing, nausea, vomiting, loss of consciousness, maybe seizure activity, and then death. These are also common symptoms of a heart attack. This sequence of symptoms happens very quickly, in a matter of seconds or minutes. The victim develops sudden, severe shortness of breath and a flushed face; he may clutch at his chest, collapse to the floor, and die, with or without having a seizure in the process. Also, his skin appears very pink, and if the victim hits his head or scrapes an elbow and bleeds, the blood is a noticeably bright cherry red. This is also true in carbon monoxide poisoning.

Your sleuth could suspect cyanide poisoning from the sudden onset of breathing difficulty followed by a sudden collapse. The pinkish skin color and the bright red color of the victim's blood would be additional clues.

Hydrogen cyanide is a gas and would not fit your situation. It is primarily used in fumigation and can be lethal if inhaled or absorbed through the skin. It is the gas used in gas chamber executions.

Potassium cyanide (KCN) and sodium cyanide (NaCN) are your best bets. They are white powders with a faint bitter almond smell, which most people do not notice. Either could easily be sprinkled into a glass, especially if the glass was opaque, colored, or etched. Both are very powerful and only a small amount would be needed. They readily dissolve in water, alcohol, or a mixed drink.

One caveat: Your killer must be careful when handling KCN or NaCN. They are both easily absorbed through the skin and could do in your killer. Rubber gloves and a complete avoidance of direct contact with the powder would be wise.

KCN and NaCN are used commercially in metal recovery such as extracting gold or silver from their ores and in electroplating such metals as gold, silver, copper, and platinum. They could be pilfered from a jewelry or metal plating company. They are also sold by several chemical supply firms.

In your story a small amount of the powder could be put in the glass and swirled to coat the inside. When the water is added and consumed, the victim would collapse and die very quickly.

Can Ingested Cocaine Kill?

Q: In my story the victim is killed by ingesting cocaine placed in his drink, a Manhattan. The vermouth would probably hide any possible taste. I have read a book on poisons and thought this was feasible. Is it possible? Cyanide would be easier and faster, but for my murderer cocaine was readily available.

A: The short answer is yes, cocaine would work and could work very quickly if the dose is large enough.

Cocaine revs up the brain and can cause seizures, and these can be lethal, especially if they trigger a condition known as status epilepticus. Typically, seizures are self-limited, running their course in a couple of minutes and then ceasing. But in status (for short) they continue sometimes for hours or even days. IV medications such as Dilantin, phenobarbital, or one of the other anticonvulsant (antiseizure) drugs sometimes won't break them. Occasionally, we have to paralyze these types of patients with Anectine (a curare-like drug that paralyzes all muscles—not just the seizing ones but also those needed for respiration) and place them on a ventilator until things settle down. This prevents them from dying from lack of ventilation or aspiration of stomach contents. Breaking these types of seizures can take several days in severe situations.

Even without status a seizure can be lethal since it interferes with respiration or can lead to vomiting and aspiration. More likely, however, the cocaine would cause some cardiac event such as the following:

1. Lethal cardiac arrhythmias (irregularity in the heart's normal rhythm): Ventricular tachycardia or ventricular fibrillation may occur as a result of the direct effect of cocaine's stimulating properties. Most people who die suddenly after cocaine use do so from this type of change in the cardiac rhythm. It may occur after ingestion, snorting, intravenous (IV) injection, or freebasing, which is the smoking of cocaine. With freebasing the cocaine is absorbed through the lungs almost as fast as if given by IV.

2. Coronary arterial spasm (narrowing from the contraction of the muscles in the walls of the arteries): The coronary arteries are the ones that supply blood to the heart muscle. When they spasm, the flow of blood can be severely and even completely restricted, and the area of the heart supplied by that artery may die (heart attack, myocardial infarction, or MI) or a lethal arrhythmia, as described above, may result secondary to poor blood flow to the heart muscle. This is not uncommon, and I have seen several patients over the years with this occurrence.

Crack cocaine, because of its greater concentration and delivery through the lungs, is particularly dangerous.

In your scenario the ingestion of cocaine from a spiked drink could cause all the above. A seizure, a heart attack, or a sudden death from an arrhythmia or any combination could happen. The victim may clutch his chest and complain of shortness of breath, become pale, and sweat profusely—exactly like a heart attack. He may fall to the floor in a grand mal seizure. His back would arch, his eyes roll back, and powerful jerking motions of his arms and legs would occur. He might bite his tongue, causing it to bleed, or he might vomit and aspirate. In the case of the arrhythmia, the victim would simply collapse and die. Fade to black, cut, print, roll the credits.

One more thought: Cocaine is bitter and is a local anesthetic that numbs the victim's mouth. However, the taste can be masked, especially if it is the victim's third or fourth drink. And since the absorption rate of cocaine by the GI tract is fairly rapid by the time the victim senses the numbing effect or otherwise figures out that something is amiss, he might be on the floor with no pulse. Additionally, if the victim is not a user, his tolerance for an acute dose of cocaine is greatly reduced so that a smaller dose can prove lethal.

What Happens in Carbon Monoxide Poisoning?

Q: I am working on a story in which one of the characters is murdered by piping the exhaust from a gasoline engine into the room where she is sleeping. What actually happens in this circumstance? What causes death? I read that people who die in this manner have bright red skin. True? Why? How long after she lost consciousness would she still have a chance to survive if found?

A: The culprit in exposure to exhaust from a gas-powered engine is carbon monoxide (CO). It can also come from a faulty gas heater or a fireplace where the gas or the wood are incompletely burned. Complete combustion of gas or wood forms carbon dioxide (C0₂), the same gas we exhale with each breath. Though high levels of CO₂ can be harmful and even deadly (this is what happens when people suffocate in car trunks, abandoned refrigerators, vaults, and so forth), CO₂ is not nearly as toxic as CO.

Our red blood cells (RBCs) contain hemoglobin, which is an iron-containing molecule that binds oxygen and carries it to our tissues, where it is released. The tissue cells then use the oxygen for all their vital processes. Inhaled CO is rapidly absorbed through the lungs and into the bloodstream, where it binds with hemoglobin with an affinity 210 times that of oxygen. This means that if air is inhaled that contains CO, the hemoglobin prefers to take on the CO and not the oxygen. The cells can't use CO, so the net effect is that they are suffocated.

The combining of CO with hemoglobin produces carboxyhemo-globin, which gives the blood a bright cherry red color. It is true that people dying from CO poisoning can have a bright red color to their skin and the mucous membranes inside the mouth, but not always. Cyanosis causes the skin to have a blue-gray color and it occurs due to lack of oxygen; this duskiness may mask the red hue from the carboxyhemoglobin.

Most fatal cases are found to have carboxyhemoglobin levels in their blood of 50 percent or more, though the old, young, and chronically ill may succumb to levels as low as 25 to 30 percent. This is particularly true of people with chronic heart or lung disease.

At autopsy the M.E. would suspect CO poisoning from the history (the victim being found in a garage with a car engine running), the reddish color of the internal tissues, and the cherry red hue of the blood. This cherry red color of the blood usually requires a concentration of carboxyhemoglobin greater than 30 percent. The skin in dependent areas, where the blood settles after death, are most likely to show the characteristic red color, but this may be masked by the purplish blue color of the dependent lividity. Even in these situations, however, the margins of the lividity may show the red color. The M.E. would then test the blood for carboxyhemoglobin in order to determine if it was the cause of death.

By the time she absorbed enough CO to lose consciousness, she would be very near the point where she would suffer permanent brain damage and death.

As to how long your victim could survive after losing consciousness, there is no exact answer since too many variables are involved. Her age, weight, and general health status; the concentration of the CO; how airtight the room was; and what drugs or alcohol, if any, she consumed prior to exposure are just a few of the things to consider. A ballpark would be half an hour at the outside; fifteen minutes would be better. If you need to make it an hour or so, provide some sort of ventilation into the garage—something the killer didn't notice that would supply just enough fresh air to extend the time of death a little. It might be an open window, or perhaps the family dog comes to investigate after the bad guys leave and pushes open the door that leads from the house to the garage, thus allowing some fresh air to enter.

What Duration of Exposure to Natural Gas Would Be Required to Kill a Person?

Q: I'm setting up an attempted murder. A character goes home, gets roaring drunk, and passes out. Then somebody sneaks into his house, turns on the gas stove, and blows out the pilot light. Any idea on how long it would take the guy to die or, in this case, how long he can be in there without dying? I want him to get sick but survive with no ill effects.

A: This is a difficult if not impossible question to answer, which is a good thing for story crafting. There are lots of options.

The effect of the gas on the person depends on three things in general: the concentration of the gas inhaled, the duration of exposure, and the condition of the victim prior to the event.

The concentration would depend on the flow from the gas jet, the size of the room or house, and the amount and character of ventilation in the room. A small studio apartment would fill with gas more quickly than a 5,000-square-foot house. Also, the victim would likely be closer to the point of origin of the gas. A studio would have the kitchen area and the sleeping area in the same room, as opposed to the bedroom being down the hall or upstairs from the kitchen in a house. Open windows, ceiling fans, or the air-conditioning system would supply some degree of ventilation and prolong the intended victim's survival. Of course, the electrical circuits of the fan or air conditioning could trigger an explosion once the gas concentration reached a certain level, but that doesn't fit your scenario.

The exposure time is self-explanatory. The longer the exposure at any given gas concentration, the more likely death would occur.

The condition of the victim plays a role because people with heart or lung disease, diabetes, liver or kidney problems, and certain other medical conditions would be more susceptible than the average person. Also, alcohol or other sedative drugs would interfere with the cough reflex and impair the victim's ability to recognize the symptoms of exposure (cough, shortness of breath, headache, an unpleasant taste in the mouth, blurred vision, and so forth), thus lessening the likelihood that he would realize what was happening until it was too late.

Why is this confusion good? Because you have great leeway in how you handle the plot. Whether it's an hour or several hours and whether your victim survives or not is up to you. I wouldn't leave him in the room overnight or all day, particularly if his home is a small apartment. Most people would die from even moderate levels of exposure for that amount of time. Otherwise, make it fit what you want.

What Substance Could Be Added to Water to Hasten Death in Someone Stranded in a Desert?

Q: In my story a young man is released deep in the desert with only a bottle of water. Is there a substance that could be added to the water that would hasten dehydration and death?

A: Two very simple ones: alcohol and diuretics.

Alcohol acts like a diuretic, as anyone who has had a couple of beers knows. Remember, you don't buy beer, you merely rent it. Alcohol depresses the posterior lobe of the pituitary gland, which makes a hormone called antidiuretic hormone (ADH). This hormone causes the kidneys to hold on to water. The depressing effect

of alcohol decreases the amount of ADH released and thus what reaches the kidneys. The result is that the kidneys "open up," and urine volume increases dramatically. Thus, alcohol is a diuretic.

Diuretics are a class of drugs that, by several different mechanisms, force the kidneys to filter more water from the bloodstream and produce more urine. Common ones are hydrochlorothiazide (HCTZ), Dyazide, and Lasix (furosemide). HCTZ and Dyazide are mild, while Lasix is powerful. In fact, a single dose of Lasix may bring about the loss of several quarts of water. That is why this particular medication is useful and at times lifesaving for the treatment of individuals with heart failure and pulmonary edema, a condition in which the body is severely fluid overloaded and the lungs are filled with water.

In your situation you could dissolve a 40-milligram Lasix tablet in the water. It has little taste, but to make sure no funny taste is detected, Gatorade or fruit juice could be used. In this case the killer would give the victim a liquid that the victim believes is lifesaving, while in reality the concoction will only make things much worse. Depending on the temperature, the terrain the victim must cross, the dryness of the air, and the size, age, and health of the victim, it may take a couple of days for him to reach a life-threatening level of dehydration. The addition of Lasix to his water supply may cut this to a few hours.

Is There a Drug That Not Only Subdues a Victim but Also Erases Her Memory?

Q: Situation: A woman pulls into her garage, opens her car door, and is attacked by someone who wants her temporarily unconscious. Can he give her a rap in that magical spot under the jaw or thereabouts and momentarily knock her out? Would that blot out her immedi- ately previous memory? Or could he give her a jab in

the arm with some quick-acting drug that would work for a while, so that she comes to in a hour or so and is not permanently damaged?

A: Yes, you can knock someone out with a blow to the head, jaw, temple, and even the neck. It requires the blow to be delivered with enough force to disrupt brain function and thus cause a loss of consciousness. This is a "concussion" in medical terms. Usually the victim wakes up in a minute or two, but she could be out longer. Fifteen minutes or a half hour—either is possible.

In the movies the hero knocks someone out with one punch, but in real life it is not always that easy and may require several blows. The hero then forgets about the unconscious henchman, as if he were suddenly written out of the script, and continues to pursue the main villain. How many times have you seen that? The truth is that the henchman is likely to awaken in a couple of minutes, get himself together, and surprise the hero, who was sure he would never be a problem again. At least that is the way the script reads. Another case of art not imitating life.

In your situation, if the villain needs her out for only a few minutes to a half hour, a single blow to the back of the head is realistic. If he needs her unconscious for an hour or more, the blow to the head isn't enough.

The problem with memory loss is that it is unpredictable. Sometimes it occurs, sometimes it doesn't. What you are proposing is "retrograde amnesia," which is a backward loss of memory—that is, the loss of memory for events that occurred prior to the injury. This is even less likely but certainly does happen. Victims of major auto accidents who are knocked out may not remember leaving home in the car or where they were going.

Your victim could be surprised and never really see the attacker. Then memory is not part of the equation. Or you could have her see the attacker and suffer retrograde amnesia. In the latter case the

memory may return later. This is a good plot twist and something for the assailant to worry about.

Drugs are a more difficult problem since few drugs act instantly. Some act in a few seconds, but to do so they must be given intravenously. A drug such as sodium pentothal would fit this situation.

Your victim could be overpowered and an IV injection given, but this would probably require two attackers since it's hard to hold someone down and find a vein with a needle at the same time. Another route that is almost as fast as an IV is an injection under, in, or around the tongue. The tongue is so highly vascular that it's almost like giving the drug intravenously. That's why nitroglycerin is taken under the tongue by patients with angina and why many drug addicts use this area when their veins are scarred beyond use.

Another possible scenario for you might be for the attacker to approach from behind and knock out or stun the victim with a blow to the back of the head. He then can give a drug that makes her compliant and blocks her memory. Maybe he needs her help to find whatever he is after in her house or something like that.

The perfect drug for this would be Versed (midazolam), manufactured by Roche Pharmaceuticals. It can be given intravenously in a dose of 2 to 4 milligrams (mg) or intramuscularly in a dose of 5 to 10 mg. It works within a minute and has a sedative effect. More important, it causes almost complete amnesia for its duration of action, which is two to five hours. The victim would be very pliable, would follow commands, could walk and talk, and may appear normal or slightly sedated but would have absolutely no memory of what happens. Your attacker could knock out your victim with a blow to the head and then inject about 5 mg of Versed in her arm or hip, and when the victim wakes up from the blow a few minutes later she would be under the influence of the drug and remember nothing of what happens over the following several hours. This might work well for you.

Is There a Toxic Pesticide That Can Be Disseminated by Fire or an Explosion?

Q: In my novel a ship loaded with a pesticide banned by the Food and Drug Administration for its toxic effects docks in a harbor. The ship is sabotaged with incendiary devices and catches fire. The pesticide tanks rupture, producing a toxic gas that sickens and kills people in the harbor. Is this possible? If so, what pesticide could be on board?

A: There are several that fit your scenario.

Sarin and parathion are anticholinesterase neurotoxins. They block the cholinesterase enzymes that are necessary for proper functioning of the muscles and nerves. It is complicated physiology that would take literally thousands of words to explain. Fortunately, you don't really need to know the details to write a credible scene.

Parathion is a yellowish brown liquid that is used as an insecticide and to kill ascaria worms. It also comes as a gas that is quickly absorbed through the skin or lungs. The victim dies a horrible death. Symptoms begin in thirty to sixty minutes and include constricted (small) pupils, muscle spasms and weakness, involuntary twitching, nausea, vomiting, diarrhea, cardiac arrhythmias, a burning sensation in the skin, and pulmonary edema (lungs filled with water). Respiratory failure and death soon follow.

Sarin is even more toxic. A single drop on the skin can be deadly. It doesn't damage the skin but quickly penetrates it and enters the bloodstream. It is particularly dangerous if heated or if mixed with water or steam because it releases extremely toxic fumes.

An explosion and fire on the ship that ruptured or burned the tanks carrying these compounds would be a disaster of the first

order. Injury and death would occur throughout the harbor. Treatment of victims is difficult and not very successful,

Another possibility would be Dieldrin. It is banned in the United States since the 1974 Environmental Protection Agency Act, but it is manufactured in Europe. A white crystalline solid that comes as a spray, powder, or dust, it absorbs through the skin or lungs. When it is heated, it releases an extremely toxic chloride gas. Symptoms, which can begin in twenty minutes, include headache, dizziness, nausea, vomiting, sweating, seizures, and death. As with sarin and parathion, treatment is symptomatic and marginally beneficial.

Any of these would fit your needs and would produce widespread and dramatic injuries and death.

Are Some Poisons Absorbed Through the Skin?

Q: Is it true that your skin absorbs some poisons? If so, what are some common ones?

A: The skin is our largest organ. More than simply a "jacket to keep everything inside," it is a living entity that is affected by many things, both internal and external. Many internal diseases manifest changes in the skin, as do things that contact it from the outside. Sunburn, bumps, bruises, scrapes, and irritative chemicals are some common ones.

Yes, chemical substances, including some medicines and poisons, are absorbed through the skin. Many medicines are now available in transdermal delivery systems. Adhesive patches can deliver nicotine for smoking cessation, nitroglycerin for angina, clonidine for hypertension, and scopolamine for motion sickness, just to name a few.

Heavy metals such as antimony, mercury, and lead pass through the skin and can result in chronic poisoning. DDT, chlordane, paraquat, malathion, and other pesticides cross the skin barrier and

can cause acute and chronic problems. Cyanide readily slips through and can be very deadly.

An interesting historical note is that Ludwig van Beethoven may have died from plumbism (lead poisoning). Recently evaluated samples of his hair contained one hundred times the normal level of lead. His exposure could have come from pewter dishes and drinking vessels, leaded paint, or perhaps from water pipes, which contained lead in his day. However, another source could have been a glass harmonica. This instrument, which produced a hypnotic wet crystal sound, was invented by Benjamin Franklin in 1761. He demonstrated the instrument to Beethoven and Wolfgang Amadeus Mozart on his visit to France during the American Revolutionary War. Both composers later wrote music for the instrument.

The glass harmonica consisted of various-sized blown glass bowls arrayed along a spindle that rotated while the player placed moistened fingers on the bowls. Leaded paint was applied to the bowls to differentiate the various notes each would produce. Perhaps the lead that invaded Beethoven's body entered through his fingers or from licking them to keep them moist, which was necessary to produce the sounds.

The symptoms of chronic plumbism include psychiatric and neurologic problems, deafness, and eventually death. It sounds a lot like Ludwig. Wolfgang, too, for that matter.

Does Jimsonweed Make an Effective Poison?

Q: Can an adult die from drinking a strong tea made with jimsonweed?

fight Bacon's Rebellion in 1666 in Jamestown, Virginia, ran out of food and ate the berries of this plant, resulting in a mass poisoning.

The plant has white or purple funnel-shaped flowers and possesses an unpleasant odor. It also has a very unpleasant taste, so tea may not work. Perhaps you might consider a more aromatic drink such as mulled cider or a Manhattan (it contains vermouth and bitters, which might mask the taste, particularly if it was the victim's third or fourth drink).

The entire plant is poisonous, and when burned, the fumes are toxic. A tea made from the leaves and/or seeds is particularly toxic. In your scenario you could boil several of the plants in a pot of water until a strong liquor remained. Add this to any drink, and it would be very toxic.

The poisonous ingredients are hyoscyamine (mostly), hyoscine, and atropine. They are in the belladonna alkaloid family, with the prototype being the belladonna plant, or deadly nightshade, as it is also called.

Death may take several hours, depending on the strength of the tea and the amount ingested. Symptoms are those of atropine poisoning: vertigo, blurred vision, dilated pupils, headache, rapid and weak pulse, drowsiness, mania, delirium, confusion, disorientation, dry mouth and eyes, extreme thirst, flushing and a burning sensation of the skin, seizures, and finally coma and death.

In medical school we learned the signs and symptoms of atropine poisoning as follows:

Blind as a bat (dilated pupils and blurred vision) Red as a beet (the skin may become red and burn) Dry as a bone (the dry eyes and mouth) Mad as a hatter (the mania and delirium)

As you see, you have numerous symptoms and signs to work with. These can occur in almost any combination, since people react differently to the toxins.

How Does the "Posture" of Strychnine Poisoning Work?

Q: I am writing a mystery where the murdered character has been given a lethal dose of strychnine via eyedrops and dumped in a field where he dies. He is then buried by the killer. The body is found approximately three weeks later. I have read that strychnine poisoning causes a classic death grin on the face of a victim, blue coloring of the skin, and bowing of the back muscles, which is evident on a corpse after death. Am I correct about this? I want my victim to reflect the obvious postmortem symptoms of strychnine poisoning so that when the body is discovered, the M.E. recognizes these conditions and suspects strychnine as the cause of death. Is waiting three weeks for discovery of the body too long for this to be feasible? How about the use of eyedrops to administer strychnine? What's the average time and dosage for it to take effect and start seizures?

A: First, let's look at strychnine. It comes from several types of plants and their seeds. One source is the dog button (Strychnos nux-vomica), which grows in tropical areas, such as India and Hawaii. It is a colorless, odorless crystalline powder with a bitter taste. It can absorb through the stomach, the lungs, the skin, and the conjunctivae (the pink part) of the eyes.

The problem with your chosen method of delivery of this poison is one of dosing. The lethal amount of strychnine is between 100 and 120 milligrams (mg), and it would be difficult to concentrate the powder sufficiently so that a couple of drops in the eye would be lethal. Perhaps you could put it in the saline solution the victim uses to wash his eyes if he is a contact lens wearer. This would be more plausible since irrigating his eyes with the tainted

solution after removing his contacts might supply enough of the drug to do him in. A more realistic choice would be to add it to food or drink, but I do like the idea of introducing the poison through the eyes. It's a good twist.

Strychnine works in ten to twenty minutes, and its effects are very dramatic. It is a neurologic toxin that attacks the central nervous system and typically causes seizurelike muscular activity before death. It does not cause true grand mal seizures, which result from chaotic electrical impulses in the brain. Rather, strychnine attacks the nerves that enervate the muscles.

Symptoms begin with the victim's developing a stiffness in his neck and face, followed by spasms in his arms and legs. Any sound or movement can trigger a wave of erratic and powerful muscular contractions. These spastic contractions increase, and the large muscles of the back begin to contract, pulling the body into an arched position (a posture called opisthotonus). These symptoms are similar to those found in tetanus. The victim dies of asphyxia since he cannot breathe.

At death the victim usually has an arched back, eyes wide open, and the mouth pulled into a broad grimace—called the death smile, or risus sardonicus. This is the stuff of nightmares.

Rigor mortis typically sets in immediately in deaths associated with violent muscular activity, as is seen in strychnine poisonings, so that the body is frozen in this posture. The reason that rigor occurs quickly is that the violent contractions of the muscles consume the intramuscular enzymes (predominately adenosine triphosphate, or ATP). In typical rigor mortis it is the depletion of these enzymes that causes the muscles to contract, producing the rigid phase of rigor. In situations such as strychnine poisoning or deaths associated with seizure activity, this depletion of the ATP occurs more rapidly, so that the rigid phase of rigor occurs more quickly. Over the next twenty-four hours, as the muscles decompose, they lose their contractile property, causing the relaxation phase of rigor.

Your victim will thus have a very quick onset of the rigid phase and will hold this strychnine posture—arched back, grimacing smile, eyes wide—for twelve to twenty-four hours or so. Then, as the rigor resolves, the muscles will relax, and the face and body will, too. So three weeks won't work. He would look like any other three-week-old corpse, and the M.E. would have to perform toxicologic tests to determine the presence of strychnine.

What Is the Lethal Dose of Strychnine in Humans and in Various Animals?

Q: I have a question about strychnine as a poison. What dosages would kill a mouse, a rat, a cat, a dog, a monkey, and then a human? My criminal is going to do some experiments that will ultimately lead to his poisoning his victim.

A: The lethal dose in the average adult human is 100 to 120 milligrams (mg). The average adult weighs 70 kilograms (kg), or about 154 pounds (1 kg equals 2.2 lb). That calculates to a lethal dose of 1.4 to 1.7 mg per kg, or 0.65 to 0.78 mg per lb. So if we take an average lethal dose of 0.7 mg per pound, we can estimate the following lethal doses:

This assumes that strychnine works in these various mammalian species in the same way, which it probably does. Regardless, these should be ballpark numbers.

Is There a Poison That Causes Stomach Distention and Death?

Q: For a short story I'm writing I'd like the victim, who is pregnant, to die with a distended stomach. Whatever poison I use has to be put into a drink. Could lead poisoning lead to a quick death? I've read that the effect is slow and progressive. What would be the effect on the fetus? And what would be the best source of lead that could be camouflaged in a drink?

A: Lead can be used as an acute poison, but it is more of a cumulative poison. Chronic exposure causes a multitude of medical problems and ultimately death. A large dose taken orally could do the trick but would be difficult to hide in a drink. Toxic forms would be lead carbonate, lead monoxide, and lead sulfate. The most toxic would be lead arsenate because it contains arsenic. It is a white powder and is found in many pesticides and veterinary tapeworm medicine. This could be dissolved in a drink and would do the trick. For that matter, arsenic would, too. A popular poison for centuries, it has become a cliche, as you know, but it works.

Acute arsenic poisoning causes a breakdown of the lining of the stomach and intestines with bleeding. It inflames the blood vessels and causes them to leak. This leads to gastrointestinal (GI) bleeding and pulmonary edema, which is the accumulation of fluid in the lungs. Also, vomiting, abdominal pain, and diarrhea, sometimes bloody, can occur. Finally, delirium, seizures, coma, and death occur.

Another choice might be mercury. Found in thermometers and

some batteries, it is readily available. It is more potent if the vapors are inhaled rather than if it is ingested. It has a low boiling point of about 40 degrees centigrade and 104 degrees Fahrenheit. (Water boils at 100 degrees C. and 212 degrees F.)

Water containing mercury could be boiled. The vapors would enter the air, and the victim would inhale them and die fairly quickly. Symptoms would be nausea, vomiting, abdominal pain, salivation, fever, cough, shortness of breath, and a metallic taste in the mouth. The reaction time is almost immediate. With ingestion the reaction time is about a half hour, and symptoms are similar.

Another very good choice that could fit your scenario is carbon tetrachloride (carbon tet for short). It is found in dry cleaning agents, household spot removers, and some fire extinguishers. Its effects are increased when taken with alcohol. This colorless liquid has a distinctive and strong odor that must be masked. Symptoms are abdominal pain, nausea, vomiting, dizziness, confusion, shortness of breath, shock, coma, and death. It also has a low boiling point, and so a vapor as described above could be produced and would be immediately toxic. Its boiling point is 77 degrees C. and 171 degrees F.

Any of these could also be toxic for the fetus, and, of course, if the victim died, the fetus would, too, unless an emergency cesarean section was performed.

Although any of these would work, I think mercury or carbon tet would be best. I particularly like the idea of a vapor, but that doesn't fit your original plot idea.

How Deadly Are Death Cap Mushrooms, and What Do They Do to the Victim?

Q: In my story a murder is committed by feeding the victim a death cap mushroom. I need to know how quickly it acts and what reactions the victim would have before death.

A: The death cap mushroom (Amanita phalloides) is the most dangerous of the mushrooms. In fact, the entire Amanita family is to be avoided. Other toxic species are the fool's mushroom (A. verna), the death angel (A. virosa), and the smaller death angel (A. bis-poriger).

The death cap grows in the southeast United States and prefers damp forested areas. The others prefer dry pine forests or mixed wooded areas and lawns. Their cap colors vary from pale green to yellow-olive in the coastal United States and Europe and to white or light brown in the remainder of the United States. All have white gills with white spores on the underside of their caps.

The death cap is so toxic that a single mushroom can kill. The two main toxins found in these mushrooms are amanitin, which causes a drop in blood sugar (hypoglycemia), and phalloidin, which damages the kidneys, liver, and heart. Symptoms are slow in onset, typically beginning six to fifteen hours after ingestion, and they may be delayed as much as forty-eight hours. In general, the later the onset of symptoms, the worse the chances for survival. This is because the toxins go to work on the liver and other organs almost immediately, but the late onset of symptoms delays the seeking of medical help.

Symptoms usually begin with stomach pain, nausea, vomiting, and bloody diarrhea. When the liver is involved, jaundice will impart a yellow hue to the skin. The victim may then lapse into a coma. As the kidneys fail and as dehydration progresses due to vomiting and diarrhea, the potassium level in the blood can rise abruptly and lead to cardiac arrest and death.

Treatment is often not helpful because, as stated above, by the time help is sought, the toxins are already working their mischief in the body. Regardless, the first order of business is to pump the stomach to remove any residual mushrooms. This would help only in the first four to six hours. After that, the mushrooms have been digested and are no longer in the stomach. The victim is moni-

tored with blood tests for hypoglycemia, elevated potassium, and abnormal liver and kidney function. These problems are treated as they arise. Otherwise, hope and prayer are suggested.

A quicker-acting toxin is the panther mushroom (A. pantherina) or the fly agaric mushroom (A. muscaria), both members of the Amanita family. They come in a variety of colors, from yellow to red to orange to grayish brown, and often have white patches on their caps. These contain several different poisons. Choline and muscarine cause a drop in blood pressure and pulse, nausea, dizziness, profuse sweating and salivation, tearing of the eyes, and diarrhea. Ibotenic acid and muscimol cause dizziness, headache, seizures, blurred vision, muscle cramping, loss of balance, coma, respiratory failure, and death.

The symptoms typically begin from half an hour to three hours after ingestion. Treatment is similar to the above measures plus the use of atropine to block the effects of the muscarine and choline. Atropine must be given intravenously. Typically, 0.5 to 1 milligram is given every hour as needed to keep the heart rate and blood pressure within normal ranges.

What Drug Available in the Nineteenth Century Could Be Used to Make a Victim Pliant but Awake?

Q: In my story, my protagonist needs to transport a captive by rail in 1889 Europe. What drug would keep the victim semi-mobile but helpless over a weeklong railway trip?

A: I think your best bet would be one of the opium derivatives. Laudanum (tincture of opium) and morphine were widely available. In fact, during the last half of the nineteenth century, laudanum, opium, and morphine were the drugs used most often for suicide in England. These drugs were commonly used for pain, sedation, and to calm crying babies. They weren't controlled substances as they are today. It wasn't until 1909 that an international commission took the first steps toward regulating opium.

Laudanum was probably first created by the great physician Paracelsus. It was the addiction of Samuel Taylor Coleridge (1772— 1834) and Sir Walter Scott (1771-1832), who used it to relieve his long-standing abdominal pain from what was likely chronic gallbladder disease.

Opium is a white powder, while the tincture is a liquid. Either could be added to food or drink. The victim would be sleepy, lethargic, and manageable, and the dose could be easily adjusted to give the desired effect. When the victim begins to "lighten up," another dose could be given. The villain could pass off the victim's symptoms as illness rather than drugs, and no one would probably be the wiser. And when the drug is stopped, the victim would return to normal and would likely have only a fuzzy memory of events.

What Were Some Common Poisons Available in Medieval Europe?

Q: What would be some common poisons available to my medieval poisoner? What are their effects?

A: There were many very effective poisons available during the medieval period and before. These are the common ones:

Arsenic: Arsenic is a metal that is grayish in color in its pure form. Most often it is found as arsenic trioxide, which is a white powder. It can easily be added to food, where it is unlikely to be detected.

This was the favorite poison of the treacherous French queen Catherine de Medicis. She also apparently used aqua toffana or aquetta di Napoli, which was a mixture of arsenic and cantharidin.

Another interesting use of arsenic was in venin de crapaud. Arsenic was fed to toads or other small animals, and after they died, the carcasses were cooked to produce juices. These were added to the food or drink of the victim, with extremely toxic results.

Acute poisoning causes severe gastric burning, nausea, vomiting, and bloody diarrhea. The victim's blood pressure drops, and he becomes weak, dizzy, cold, clammy, and confused, and may develop seizures. Death follows these painful and dramatic events.

Belladonna (Atropa belladonna): This is a plant, and it is also called deadly nightshade. One of the active chemicals in belladonna is atropine. The name "atropine" comes from one of the three Greek Fates, Atropos, who wielded the shears that cut the thread of human life. Other active compounds include scopolamine, hyoscyamine, and hyoscine.

One effect of belladonna is to dilate the pupils, and it is from this that its name arose. Women would use a drop in each eye to dilate their pupils, which was thought to enhance their beauty. "Belladonna" means beautiful woman.

All parts of the plant are toxic when swallowed, and symptoms begin within an hour or so of ingestion. The signs and symptoms of atropine poisoning include dilated pupils, blurred vision, dry mouth and eyes, fever, flushed skin, abdominal cramping, confusion, disorientation, seizures, and cardiac arrest.

Cantharidin (Cantharis vericatoria): Also called Spanish fly, it is a tasteless white powder that can be easily secreted in food or drink. Symptoms appear immediately after ingestion. Cantharidin is very irritative to every tissue it contacts, and when it is filtered from the bloodstream by the kidneys, it causes irritation of the urinary tract and thus was felt to be an aphrodisiac. In larger doses it can cause severe burning and blistering of the gastrointestinal and urinary tracts, and lead to abdominal pain, nausea, vomiting of blood, bloody diarrhea, painful and bloody urination, convulsions, a rapid pulse, a drop in blood pressure, shock, and death.

Foxglove (Digitalis purpurea): A beautiful flowering plant it is also

called the fairy cap, fairy bells, and fairy thimbles. These plants are the natural source of digitalis, a medication that has been in use for over a century in the treatment of heart failure and certain cardiac arrhythmias.

All parts of the plant are toxic. Symptoms of poisoning begin in a half hour or so. The victim experiences headache, nausea, vomiting, muscle cramping, shortness of breath, dizziness, palpitations, and finally death from cardiac arrest.

Hemlock (Conium maculatum): This is the poison that reputedly killed Socrates. All parts of the plant are poisonous, particularly the fruit during flowering season. The active toxin is coniine, which is a neurotoxin that paralyzes muscles much like curare. Symptoms begin in a half hour, but death may take several hours.

The first symptom is typically a loss of muscular strength, which progresses. Muscle pain and paralysis follow until the respiratory muscles fail and death ensues from asphyxia.

Henbane (Hyoscamus niger): This is also called insane root, fetid nightshade, and poison tobacco. All parts of the plant contain hyoscyamine, a chemical also found in belladonna, and thus the signs and symptoms of poisoning with henbane are similar to those of atropine toxicity. The onset of symptoms occurs in approximately fifteen minutes.

Poisonous mushrooms were also widely available.

What Are the Effects of Rhubarb Ingestion?

Q: One of my characters is fed raw rhubarb leaves torn up in a salad as an attempt to poison her. How soon would she react, and what would the reaction be? If she is taken to the hospital, what treatment would she receive? Are there any long-term complications? What is the recovery period?

A: Rhubarb (Rheum rhaponticum) contains oxalic acid, which is the toxic substance in poisonings. It is found in the leaves and also in the stalks of several subspecies of rhubarb. Oxalic acid causes problems in two ways. The first is topical injury due to its irritant effects, and the second is "internal," occurring after it is absorbed into the body

Oxalic acid is very irritating to the GI tract and causes mouth, throat, and esophageal pain as well as weakness, shortness of breath, stomach pain with nausea, vomiting, and possibly bleeding. Because there is a delayed onset of symptoms, your victim may not know something was wrong for several hours after eating the leaves. This delay is part of what makes rhubarb so treacherous. If it caused vomiting to occur more quickly, less internal damage would result, since the vomiting would empty the stomach. The amount of the oxalic acid that gets absorbed is directly related to how long the rhubarb remains in the stomach. Less time, less absorption, less internal problems.

These internal problems are due to the chemical properties of oxalic acid. When oxalic acid is absorbed into the bloodstream, it reacts with calcium in the blood to form calcium oxalate. This reaction consumes the blood's calcium, and the level of calcium falls to low levels. Since calcium is necessary for the proper electrical function of the heart, these low levels can cause cardiac arrest and death. Also, the calcium oxalate produced in the bloodstream by this chemical reaction is filtered through the kidneys, where it can clog up the microscopic tubules and severely damage the kidneys. This can cause burning urination and lead to permanent loss of kidney function. Dialysis and/or kidney transplantation may be required.

The first steps in treatment consist of emptying any residual plant from the stomach and neutralizing any oxalic acid to prevent its absorption. The more quickly this is done, the better. Forced vomiting, using an emetic (a drug that causes vomiting), or stom-

ach lavage (washing out the stomach with a tube inserted through the nose and into the stomach) will remove any residual plant product. A common emetic is ipecac syrup. A couple of teaspoons given orally will cause vomiting in five to ten minutes. Then milk or any other calcium-containing liquid can be given orally or via the lavage tube. This binds up, or reacts with, the oxalate before it gets absorbed. In this way the calcium oxalate is formed in the stomach rather than in the bloodstream, where it works its worst mischief, and can be lavaged away.

Also, calcium in the form of calcium gluconate is given by a slow intravenous (IV) drip to raise the calcium level in the blood to normal. Large amounts of IV fluids are given to flush the kidneys and remove any oxalate before it can damage them.

In the emergency room your victim would likely have a thick rubber lavage tube passed through her nose and into her stomach. The stomach would be lavaged with milk or calcium citrate. An IV would be placed for calcium gluconate infusion and to give several liters of D5NS (5 percent dextrose normal saline solution), and blood tests would be run to evaluate kidney function and assess blood calcium levels. An EKG would be done immediately, and she would be admitted to the ICU for monitoring of her cardiac rhythm.

Prognosis and long-term problems would depend on the degree of exposure and the rapidity of treatment. Recovery could be as short as twenty-four hours if treatment is effective and no cardiac or kidney complications occur, and she could have no long-term problems. Or she could suffer cardiac arrest and undergo CPR. She could suffer kidney failure and require short- or long-term dialysis, or she may need a kidney transplant at a later date.

Does Selenium Make an Effective Poison?

Q: I read recently about a murder case involving selenium and might want to use this in my current novel. What is

selenium, and how does it work as a poison? What are the symptoms of poisoning, and if the intended victim survived, what medical treatment would be required?

A: Selenium is a nonmetallic element in the same chemical family as sulfur, oxygen, polonium, and tellurium. It is an essential element for life, and its deficiency can lead to various medical problems, the most important being cardiomyopathy (a weakening of the heart muscle). Interestingly, Marco Polo may have discovered the first cases of selenium poisoning when he described a disease called "hoof rot," which occurred in horses in the Nan Shan and Tien Shan Mountains of Turkestan. The soil in that area is rich in selenium.

Selenium poisoning is rare, although it does occur in industrial situations. Its principal applications are in the manufacture of glass, ceramics, photoelectric cells, semiconductors, steel, and vulcanized rubber. The most toxic forms are selenium dioxide (Se0₂) and selenious acid (H₂Se0₄).

Acute poisoning is most often lethal. The ingestion or inhalation of selenium dioxide or selenious acid (found in gun bluing solutions) can cause a dramatic drop in blood pressure, due to its toxic effects on the heart muscle, and a dilation (opening up) of the blood vessels throughout the body, which can lead to cardiac arrest and death. It can cause severe burns to the skin and the lining of the mouth as well as the lungs, where bleeding and pulmonary edema (lungs filling with water) may result. A reddish pigmentation of the teeth, hair, and nails coupled with a garlic-like odor on the breath are typical of acute poisoning.

Chronic poisoning occurs with long-term, low-level exposure. The victim's skin may develop a reddish hue, and a pruritic (itchy) scalp rash may appear. The hair becomes brittle and breaks easily or falls out. The nails become brittle and display red or yellowish white transverse or longitudinal lines. The breath smells of garlic, and the victim may complain of a metallic taste in the mouth. Nausea, vomiting, fatigue, irritability, emotional lability, depression, tremors, and muscle tenderness may also occur.

The diagnosis of selenium poisoning, either in the living or at autopsy, is made by testing the victim's blood and urine for increased selenium levels. At autopsy, findings would likely include congestion in the lungs and kidneys, patchy scarring and enlargement of the heart, edema and swelling of the brain, and a orange-brown discoloration of the skin and internal organs.

For those who survive, treatment consists of stopping any chronic exposure and using intramuscular doses of dimercaprol (also called BAL, or British Anti-Lewisite). BAL acts as a chelating agent by binding the selenium and removing it from the body via the kidneys. The usual schedule is the injection of 3 to 5 milligrams per kilogram of body weight every four hours for two days, every six hours on the third day, and then every twelve hours thereafter for ten days.

For your purposes, either an acute or a chronic poisoning could work, depending on whether you want the character to die right away or slowly over a month or so. Gun bluing solutions contain lethal amounts of selenious acid, and a couple of tablespoons added to food or drink could kill the person in a couple of hours. Adding a little here and there day by day would accomplish a chronic poisoning. The victim would gradually become sicker. His appetite would disappear, his weight would drop, and nausea and vomiting would occur. His hair would fall out, and he would become weak, short of breath, and irritable. His hands would develop a tremor, and he might develop heart failure and pulmonary edema. His doctor might diagnose heart disease or gastroenteritis or even the flu. Selenium poisoning would never enter his mind. He would treat him with digitalis and diuretics or suggest fluids, aspirin, and rest. As the condition progressed, the victim might be hospitalized and then die of progressive heart failure. Since death from heart failure is a common occurrence, the death would likely be written

off to plain old heart failure—that is, until your protagonist became suspicious and tracked down the true cause of the victim's demise.

How Quickly Would Someone Die After Drinking Alcohol Laced with Xanax?

Q: One of my characters crushes Xanax tabs and then adds the powder to another's Scotch. Both men have been drinking. Would the Xanax interact quickly with the alcohol to depress the central nervous system? How much should be used to achieve the desired effect? Would there be any immediate reaction to the mix (that is, vomiting)? What would the specific symptoms be as the character slips into unconsciousness, and how soon would death occur?

A: Xanax (alprazolam) is a short-acting sedative in the benzodiazepine family (along with Valium, Halcion, Restoril, Ativan, and others). It is a relatively safe sedative, but when mixed with alcohol, it can be deadly. Of course, it depends on the dosage of both the Xanax and the alcohol as well as the underlying health, size, and age of the victim. People with chronic lung or heart disease are more susceptible, as are the young and the old.

Xanax comes in white oval tablets of .25 milligram (mg), 0.5 mg (peach), and 1 mg (light blue). It also comes in a white oblong 2 mg tablet. It dissolves easily and is well absorbed by the GI tract. It reaches its peak effect about one to two hours after ingestion, but its effects would begin to appear in less than half an hour.

Now to your specific questions:

Yes, it would begin to act quickly—a half hour or perhaps less if the victim consumed a large amount of alcohol beforehand. The victim would become lethargic and have slurred speech, poor coordination, and confusion. He might stagger and even fall. He would

speak slowly with a thick tongue, and his words may not make sense. In short, he would appear very intoxicated. He would soon lose consciousness, after which his respirations would decline and finally cease. Death would then follow in a few minutes.

The rapidity with which this process unfolds would depend on many factors, but if you give him an hour, you'll be okay. More is better, but as little as thirty minutes would also work.

One problem with Xanax is that it requires several tablets to do the trick. This depends, of course, on how much alcohol the victim downed. If he is intoxicated before the loaded drink is given, less Xanax is required. If your killer crushes ten of the 2 mg tablets, that should do it. If the victim is already intoxicated, he likely won't notice any alteration in the taste of his drink. This is particularly true if you use some flavored concoction rather than Scotch.

What Substance Can Be Added to a Fire-Eater's "Fuel" to Cause a Sudden and Dramatic Death?

Q: I want to kill off a street performer, a fire-eater in Madrid, by substituting or adding a substance to the clear liquid these people swish in their mouth and then blow out to be ignited. Since they don't actually swallow the liquid, I need something that is very deadly, won't alter the clear nature of the liquid, and hopefully won't be immediately detected when the liquid enters the mouth. Also, I'd like the death to be relatively quick and dramatic.

A: Cyanide is quick, nasty, and very effective. It kills instantly. The person will suddenly become short of breath, may clutch his chest as if having a heart attack, may suffer a seizure, may foam at the mouth, and will definitely fall over dead. Since cyanide is a metabolic poison, which means it poisons the body's cells so that they

cannot use oxygen, even if some bystander began CPR or other life-saving measure, the victim would die anyway. Effective CPR would supply blood and oxygen to the tissues, but the cyanide would prevent the tissues from using the oxygen, so death would be the result regardless.

Cyanide comes as a powder in the form of potassium cyanide (KCN) and sodium cyanide (NaCN). It dissolves easily in most liquids and requires only a tiny amount to be deadly. It has a slight bitter almond smell and taste, which would be undetectable in the flammable liquid.

In your scenario the fire-eater would take a mouthful of the liquid and within a few seconds clutch his throat or chest, spit out the liquid, gasp for breath, cry out for help, collapse to the ground (with or without a seizure), and die quickly.

One caveat: The person handling the cyanide should not let it contact his skin since it is readily absorbed through the skin. The use of rubber gloves would be safest.

Cyanide is used in metal plating and tanning and can be obtained from many chemical supply houses or stolen by your villain from any place that plates jewelry or uses it in other ways.

MEDICAL MURDER

How Can Someone Who Is Undergoing Heart Surgery Be Murdered?

Q: I need help with a hospital scene. The bad guys decide to execute a very successful and powerful enemy while he is in the hospital undergoing a heart bypass operation. The plan is a strike against the hospital's primary and redundant power sources, effectively imperiling all patients in the hospital or wing, not just the intended. Now the questions: How does one take down the hospital power grid and its backup systems? Where is the most ticklish point of the bypass surgery to have a power loss?

A: Most hospitals have backup generators that switch on automatically when the power supply is interrupted. I suspect that most of these systems are computer controlled, so your villain can approach the problem in several ways.

He could attack the computers and effectively shut down both the main power and the backup generator at will. A good hacker could tamper with the control program, and then they could be shut off on command—maybe by remote control with a wireless modem.

Or he could disengage or disable the backup and then cut the main power supply by severing the hospital's incoming power line or knocking out the local power station. That would deal with the power supply to the entire hospital but would not completely resolve your problem.

In cardiac surgery the patient is typically placed on a heart-lung machine, which acts as his heart and lungs by circulating and oxygenating the blood while the operation is being performed. The pump is dependent on a power supply to function, but these gadgets have both an internal backup battery supply as well as a hand-crank system for just such power loss situations. This means that your bad guys would have to tamper with the heart-lung pump itself. They would need to damage or disconnect the battery or its cables, or mangle the gears and pulleys that are part of the hand-crank system.

These heart-lung machines are typically kept within the surgical suites (operating rooms) of the hospital, an area that has restricted access. Still, someone with knowledge of the layout could sneak in, especially at night when fewer staff members are on duty.

Or an insider could be involved. The best person for this would be either someone in the bioengineering department (called biotechs for short) or one of the technicians who run the heart-lung machine (called pump techs).

The biotechs maintain and repair most of the medical gadgetry in the hospital. Some techs can fix anything, while others have to call in repairmen from the various manufacturers or independent biomedical repair companies more frequently. Your tech could be the insider, or the accomplice could be the outside tech he called in. Either would work.

Most major medical centers have pump techs on staff, while smaller hospitals contract to outside companies for techs who come in and work on a case-by-case basis. The in-house techs have easy access to the machines any time they aren't in use. For the contracted tech, things would be more difficult. Since he goes into the OR only when a case is scheduled and since there are always several nurses and operating room technicians around preparing for surgery, he would have to be fairly slick to tamper with the backup systems. It's possible, just more difficult.

The best time to attack the power supply would be during the operation. That is when the patient/victim would be most vulnerable. If your villains could accomplish their tampering after the patient/victim is "on bypass," on the heart-lung machine, a loss of power would be potentially fatal. During the surgery, the heart is stopped by a combination of cooling the blood and delivering a large dose of potassium. (We call this "cold cardioplegia.") After the operation, the heart-lung machine rewarms the blood and washes out the potassium; then the heart resumes beating on its own. This takes ten to fifteen minutes or more to accomplish.

If the power and the backup systems failed, the surgeon would be left with only internal cardiac massage to maintain blood flow and keep the patient alive. Internal cardiac massage is simply squeezing the heart rhythmically with your hand. The surgeon would then begin giving the patient warmed blood and intravenous fluids in an attempt to rewarm the patient and wash out the potassium. This would be difficult and could take as much as half an hour to an hour without the aid of a functioning heart-lung machine. But this is what they get the big bucks for. Failure to do so would certainly result in the patient's death, which is what you want.

Of course, the patient/victim could survive this event or not, as you wish. Either way is plausible. If he is to survive, the surgeon must give the warmed blood and fluids rapidly, close up any of the coronary arteries he had been working on, close up the patient's chest, and get him to the ICU as quickly as possible. Meanwhile, the biomedical people would work frantically to repair the machine.

This is good stuff, an exciting scene.

What Dose of Morphine Would Kill a Man Undergoing Cancer Treatment?

Q: My victim is in the final stages of metastatic lung cancer and is taking morphine intravenously at home, administered by a pump. For a 145-pound male who is seventy-six years of age, what might a typical dosage be? Would twice that amount cause a deadly overdose?

A; Metastatic lung cancer can be a very painful disease. Cancers that originate in the lung often metastasize (spread) to the liver, the brain, and the bones. In medical jargon these metastatic lesions are often referred to as "mets." Brain mets tend to enlarge within the closed space inside the skull and also cause swelling of the surrounding brain tissue. The net effect is a rise in intracranial (inside the skull or cranium) pressure. This can cause severe continuous headaches. Mets to bones such as the ribs and the spine can be extremely painful. For this reason narcotics such as morphine sulfate (MS), Demerol, Dilaudid, and others are commonly used. In an individual with terminal cancer the risk of addiction is of little concern.

The chosen analgesic (pain reliever) may be given by intermittent injections or by use of one of the automated methods. Continuous infusion pumps and patient-controlled analgesia (PCA) are commonly employed in this circumstance. The former is by definition a continuous infusion of fluid containing the sedating drug, usually MS. PCA is a system of IV delivery that allows the patient to control the timing of delivery within preprescribed parameters. Here, a syringe filled with the MS is placed in an automatic injector that is attached to the patient's IV line. The injector delivers a prescribed amount of the drug when the patient depresses a handheld button. Parameters are set to limit the amount that can be

requested per hour. Within these limits, the patient may use as much or as little as he feels is necessary.

As with many medications, the dosing of MS is determined by the patient's weight. The dosing schedule in most patients ranges from 0.2 to 0.4 milligram (mg) per kilogram (kg) of body weight per hour and then is titrated (a gradual increase in dose) upward as needed. Since one kilogram equals 2.2 pounds, your 145-pound (66 kg) patient would require approximately 13 to 26 mg per hour. However, in patients who have been on the continuous drip or PCA for weeks or months, tolerance to the drug develops, just as it does in addicts. Therefore, larger and larger doses are needed to obtain the same sedating and pain-relieving effect. Some patients in this situation require doses as high as 500 mg per hour, which is enough to kill even the strongest person not habituated to the drug.

In large doses MS depresses respiration and drops the blood pressure. If enough is given, the recipient will stop breathing, his blood pressure will fall to dangerously low levels, and he will die from apnea (absence of breathing) and shock. The dose required to kill someone depends on the rate of delivery, the underlying medical condition of the victim, and whether the victim has developed tolerance to the drug.

Doubling the dose at any given level may or may not be enough to be lethal. For example, if a patient was receiving 60 mg per hour and the rate was doubled to 120 mg per hour, it probably wouldn't do him in, though it certainly could do in a debilitated man with terminal lung cancer. Raising it to 240 mg per hour (quadruple) probably would work. A half hour to two or three hours at this increased rate may be required to do the victim in.

On the other hand, if given as a single injection, an extra 20 to 40 mg might be enough. Since the person on a drip of 60 mg per hour receives 1 mg per minute, giving 20 to 40 mg over a few seconds is a large increase in dose and would probably work. MS works rapidly, within a minute or so, when given as a bolus (a single, rapid injection), so you are actually increasing the dose from 1 mg per minute to 41 mg per minute—a huge increase that would likely cause apnea and shock almost instantaneously.

So either markedly increasing the rate of administration (by increasing the drip rate or the concentration of the drug per cubic centimeter of fluid, or both) or giving a bolus of the drug would accomplish your goal in this situation.

Additionally, patients with lung cancer often have sicker lungs, not just from the cancer itself but from surgery that removes part or all of one lung and radiation therapy or chemotherapy, which may damage the good lung tissue. In this case, even smaller amounts might work.

I suggest either quadrupling the rate or giving 40 mg as an IV bolus, depending on which scenario fits your story best.

Can a Transfusion Reaction Be Used for Murder?

Q: In my story an elderly and seriously ill man is murdered by a nurse who switches the blood he is to receive, causing a reaction that kills him. How does this reaction occur, and what symptoms would the victim have?

A: Transfusion reactions come in many varieties. They may be as mild as a rash or perhaps chills and fevers, or be so severe as to cause death. First let's look at why these reactions occur.

The red blood cells (RBCs) are the carriers of oxygen from the lungs to the tissues and of carbon dioxide from the tissues to the lungs. This is accomplished by using the hemoglobin inside the RBCs. The RBCs also have antigens on their surface, and they are at the root of transfusion reactions.

These antigens are designated either A or B. From these our blood-typing system (ABO system) has been derived. Type A blood lias only A antigens, type B only B antigens, type AB both, and type O neither.

Simple, so far. But the serum of the blood (the liquid part) also carries antibodies. It is the reaction of these antibodies with the antigens of the transfused blood that causes problems.

Type A serum (that is, the serum of people with type A blood) has anti-B antibodies. Type B has anti-A antibodies. Type AB has neither. Type O has both anti-A and anti-B antibodies.

Reactions occur when blood with the right antigen is given to a person with the its corresponding antibody. For example, if a type A person (who has anti-B antibodies in the serum) receives type B blood (which has the B antigen on its RBCs) or type AB blood (which has both A and B antigens), an adverse reaction will occur because the anti-B antibodies in the recipient's serum will react with the B antigens on the transfused RBCs. This is a transfusion reaction. The result is agglutination, or clumping, of the blood cells and the release of several harmful chemicals that cause the symptoms and signs of this basically "allergic" reaction.

It gets more complicated than this because there are other antigen/ antibody problems with blood matching such as the well-known Rh factor, which is either positive or negative, and many others, mostly named after the physicians that discovered them. Your blood type is typically expressed only in terms of the ABO and Rh systems. For example, a person who is A-positive has type A blood and the Rh factor antigen is present, while a person who is O-negative has type O blood and the Rh factor is absent.

Because of the multitude of potentially problematic antigens, blood is typed and cross-matched prior to transfusion. This tests the blood that is to be given directly against the recipient's blood to determine if any antigens and antibodies exist that might cause the blood to be incompatible and thus lead to reactions. In very emergent situations such as gunshots, stabbings, or automobile accidents where the victim is bleeding to death and there isn't time to do a complete cross-match, type-specific blood is given. A person's blood type can be determined in a few minutes, but cross-matching may take hours. In these cases a type A person receives type A blood, and everyone hopes for the best.

In your story I would suggest that you have your victim be type A and have the nurse switch the blood to type B. This would definitely cause a reaction. The patient would develop fever, chills, and a diffuse, irregular red rash over his entire body. This could begin within minutes or be delayed for a few hours. This type of reaction would not likely result in death.

However, your victim could develop a full-blown anaphylactic allergic reaction, which would be the above symptoms plus swelling of the face, lips, hands, and feet, shortness of breath, low blood pressure, and severe shock with pallor, cold and clammy skin, and a bluish tinge (called cyanosis) to his lips, fingers, and toes. He would ultimately suffer cardiac arrest and death. Since this represents the severest form of allergic reaction, anaphylaxis would develop fairly quickly after the blood was infused.

If the victim survived an anaphylactic reaction, there is a strong probability that his kidneys would be severely and irreparably damaged, requiring dialysis. This damage results from the kidneys' attempt to filter the clumped RBCs from the blood. The iron found in the hemoglobin molecules of the RBCs is particularly toxic to the kidney tissues.

Can a Bee Sting Kit Be Altered to Result in the Death of the User?

Q: I have a scene in which someone who is allergic to bee stings dies after being given a shot from his bee sting kit. Is there a substance that when combined with medicine in the bee sting remedy would prove fatal?

A: The deadly allergic reaction that follows bee stings in susceptible individuals is called anaphylaxis. It is a severe allergic reaction that causes spasm of the lung's bronchial tubes (breathing airways), which basically causes a severe asthmatic attack with shortness of breath and wheezing. Anaphylaxis also is associated with a profound drop in blood pressure, leading to shock. Without treatment, death can quickly follow.

Common causative agents of anaphylaxis and other allergic reactions include antibiotics (penicillin, sulfa), local anesthetics (lido-caine, procaine), antisera (gamma globulin, tetanus), foods (nuts, shellfish, eggs), iodine (used in certain X-ray exams), and insect stings (yellow jacket wasps, honeybees, fire ants). When an allergic individual is exposed to the allergenic substance, the reaction may be immediate and profound.

The emergent treatment is an injection of epinephrine (adrenaline), which is the substance in the bee sting kits that allergic persons should keep on hand. Epinephrine reverses many of the allergic processes immediately. The person is then transported to the hospital, where further treatment is carried out that typically consists of oxygen, medications for blood pressure support, antihistamines (such as Benadryl), and steroids.

One way to do the victim in would be to replace the epinephrine with water. He would then succumb to the bee sting.

Another way would be to tamper with the concentration of the epinephrine. Reducing it would probably not work since the net effect would be a partial treatment, which might be enough to allow the victim to reach the hospital. It would be better to increase the concentration.

Epinephrine is basically speed. If given in large amounts, it can cause marked elevation of the blood pressure and deadly changes in cardiac rhythm that can kill almost instantly. The emergency bee sting kits are called Epipen Auto-Injectors and contain 0.3 cc of epinephrine at a 1:1000 dilution. This means that each cc of the medication contains 1 milligram (mg) of epinephrine. Thus, the delivery of 0.3 cc yields a dose of 0.3 mg.

Increasing the dose by a factor of five or ten—a dose of 1.5 to 3 mg—could cause the desired result (cardiac arrhythmia and death), especially if given intravenously. In your scenario, giving either multiple injections (not practical) or tampering with the drug concentration in one of the injectors would do this. Substituting a more concentrated solution of epinephrine could work. The beauty of this approach is that no new drug is required, and the coroner might assume that the victim died from the standard dose of epinephrine, which can rarely happen, or from the allergic reaction itself. Of course, if the coroner tested the residue in the auto-injector, he would likely be able to determine that the concentration of the drug had been altered. But maybe not.

If you want to add another drug, any speedlike product would do the trick, since the effect of the epinephrine and the other drug would be additive. Many of these are readily available. Cocaine (basically a speedball when mixed with an amphetamine such as epinephrine), crystal methamphetamine, and perhaps the rave drug Ecstasy, which is methylenedioxymethamphetamine, would work.

The effect of this would be to raise the blood pressure and heart rate severely and rapidly, which could precipitate a heart attack. Also, these drugs can cause spasm of the coronary arteries, which could lead to a heart attack. Or the combination could cause a fatal change in heart rhythm. Cocaine and crystal meth are notorious

for causing spasm of the coronary arteries and for precipitating deadly arrhythmias. In this case immediately after injection of the speedball the victim would feel warm and flushed, his heart would pound, and he might experience chest tightness or pressure, clutch his chest, and collapse. Or in the case of a sudden arrhythmia he might simply collapse with no warning symptoms at all.

Can Insulin Be Used for Murder? How?

Q: For my story, I need to know how easy it would be to kill someone with insulin. I know it can't be taken by mouth, but can it be given in an IV? Would the insulin overdose be detected in an autopsy? How much insulin would it take to kill an adult who is not diabetic?

A: Insulin, which is produced in the pancreas by specialized cells called islet cells, is necessary for life. These islet cells constantly "read" the sugar level in the blood and secrete insulin as needed. The cells of the body require insulin in order to take in sugar from the bloodstream, metabolize it (break it down), and produce energy.

Diabetics often have a deficiency of insulin or a faulty system for release of insulin from the pancreas. Untreated, this leads to elevated blood sugars, altered cellular sugar utilization, and a host of problems including diabetic coma and death.

Excess insulin causes the rapid uptake of sugars by some cells and leaves none for the brain, thus leading to a hypoglycemic (low blood sugar) coma, brain damage, or death. Rare insulin-producing tumors can also cause profound hypoglycemia. And diabetics who give themselves too much insulin or don't eat enough after taking insulin can end up in the same situation.

Since the brain, heart, and other organs need sugar for the energy to function, when the blood sugar level drops below 60 or so,

symptoms of hunger, nausea, sleepiness, headache, and confusion appear. When the sugar falls further (30 to 50, say) all these symptoms worsen, followed by coma, brain damage, and ultimately death. Also, cardiac arrhythmias may appear and lead to death.

Now to your questions.

No, insulin cannot be taken orally. Digestive enzymes that break down food also digest insulin. Yes, insulin can be given by IV or added to an IV infusion of fluids. We do this from time to time to control very brittle (hard to control) diabetics who are in extreme circumstances.

For your purposes an IV "push" dose of 50 to 100 units of insulin would do just about anyone in. A lesser amount probably would, too, but to be sure, 100 is a good number. It would work in less than a minute or two. It could also be given intramuscularly (injected into a muscle) or subcutaneously (injected beneath the skin, which is the method diabetics use to give themselves daily doses) and would have a slightly slower (fifteen to twenty minutes or less before the person lost consciousness) but still deadly effect.

Yes, the coroner would be able to detect the excess insulin and the very low blood sugar at the postmortem exam. Of course, if the victim was a diabetic, he may write it off to an unfortunate incident. This happens to insulin-dependent diabetics all too often. Since your victim is not a diabetic, the presence of high insulin levels and low blood sugar would prompt a search for an insulin-secreting tumor of the pancreas, and when none was found, homicide would become the likely cause.

Would Denying a Diabetic Insulin Cause Death or Just Illness?

Q: For my story, I want to know whether a murder could be committed by substituting water for the insulin of a diabetic. What would happen to the victim, and how

long would it take? Would the coroner be able to determine what had happened?

A: Yes, a murder could be carried out in this fashion, but the victim would have to be an insulin-dependent diabetic. Let me explain.

Diabetes is separated into two broad types. One is called adult-onset, non-insulin-dependent, or Type 2 diabetes. The pancreas in this situation produces insulin, though usually in reduced amounts. These people do not require insulin and are typically managed with diet and possibly medications. The drugs used in this circumstance either enhance the body's sensitivity to insulin or promote insulin production and release by the pancreas.

The second type of diabetes is called juvenile-onset, insulin-dependent, or Type 1 diabetes. The pancreas in these people produces little if any insulin, and they require insulin to survive. Often when you hear on the news that a child is missing and needs to be found quickly because he or she needs important medicines, the problem is juvenile diabetes.

In a Type 1 diabetic, tampering with or diluting the insulin or preventing the victim from getting it could lead to diabetic ketoacidosis, coma, and death. It may take a few hours or several days for the victim to get into trouble, depending on how much insulin is needed, how severe the diabetes is, and other factors.

The symptoms of rising blood sugar and impending diabetic coma are fatigue, shortness of breath, nausea, thirst, excess urination (the high sugar in the blood is filtered through the kidneys and acts as a diuretic, causing a sudden increase in urine volume and leading to dehydration), lethargy, somnolence, confusion, and finally coma and death.

At autopsy the M.E. would find elevated blood sugar and acidosis, which would lead him to conclude that the victim died from diabetic ketoacidosis. He would not be able to determine why the victim didn't take his insulin or why he took an inadequate amount. That said, the M.E. would not only examine the victim but also all the evidence collected at the scene that might bear on the cause and manner of death. He could test the insulin bottle found in the victim's house and discover that it had been diluted, which might lead him to consider homicide as the cause of death.

Is There a Lethal Substance That When Given to a Patient Might Appear to Be a Hospital Blunder Rather than a Homicide?

Q: have a killer (fictional, of course) who is attempting to murder a hospitalized patient by putting some material through the IV while he sleeps. What readily available substance could he use to make the hit look like a hospital blunder rather than a homicide?

A: In the hospital setting, many drugs are available that would surely fit your story requirements.

Any of the muscular paralytic agents would work. This class of drugs paralyzes all the muscles, including those used for respiration. The victim would stop breathing and die. Since these drugs work on all the muscles, he would not be able to move or speak or cry for help. Anectine and Pavulon are examples. Anectine (succinyl-choline chloride) comes in multidose vials of 10 cc that contain 20 milligrams (mg) per cc of the drug. Give the entire 200 mg through the IV and paralysis will occur in a matter of seconds. Pavulon (pancuronium bromide) comes in 10 cc vials with 1 mg per cc of the drug. Again, give the entire vial intravenously.

Almost any narcotic or barbiturate (barbie) would also work. In large doses they depress and can even stop respiration, and they are available in most hospital wards and/or pharmacies.

Common narcotics include Morphine (MS, or morphine sulfate), Demerol (meperidine hydrochloride), and Dilaudid (hydro-morphone hydrochloride). Once again, overkill is the operative word, so very large doses should be given intravenously to assure the desired effect. For MS give 100 mg; Demerol, 250 mg; and Dilaudid, 20 mg.

The two most common injectable barbies are pentobarbital (trade name Nembutal) and sodium phenobarbital. Giving 2 to 5 grams of pentobarbital or 500 to 1000 milligrams (1/2 to 1 gram) of phenobarbital would do anyone in.

The problem with all of these drugs is that they are traceable. And since they work by stopping respiration, it would take a couple of minutes for the victim to die, which allows time for the nurse to discover the person is in trouble and begin lifesaving measures. Thus, the patient would have to be on the ward and not in the ICU or Coronary Care Unit where they have cardiac and respiratory monitors that sound a warning if respiration drops. On the wards these devices are used less often, and the nurses aren't always in eye contact with the patients, so the victim could die before anyone knew about it.

Another option would be injecting potassium chloride (KC1) intravenously. This is the truly lethal part of lethal injection executions. It stops the heart immediately. A dose of 50 to 100 milli-equilivents (meq) pushed rapidly intravenously will kill anyone. Milliequivalents is a chemistry term that would be very difficult to explain, and you don't really need to know this to craft a credible scene. It comes in vials that contain 40 meq per cc. It is easily available in a hospital, and right or wrong is often left lying around. It is commonly given to patients with low potassium levels as part of their IV fluid infusion—at slower rates than an IV push, of course. This would be traceable in that a high potassium level in the blood would be found at autopsy. That said, it could still be written off as a medical error, and the nurse could get blamed.

A better bet would be to use a drug that the victim is already taking and simply give him a large dose. This could easily be deemed a medical error. For example, if the victim had heart disease and was taking one of the antiarrhythmic drugs (commonly used medications that treat abnormal cardiac rhythms), giving a large dose could kill him, and finding a high level in the victim's blood at autopsy might be interpreted as physician or nurse error. Examples of these drugs would be quinidine and procainamide. Give 1,000 mg of either by rapid IV injection, and the victim's heart would come to a standstill in a minute or two.

Another possibility would be digitalis, a common cardiac medication. Digitalis is manufactured under several trade names. The most common is Digoxin, and the typical daily oral dose is 0.25 mg. Giving 2 mg intravenously would kill almost anyone in a few minutes by causing a deadly change in cardiac rhythm. Again, this could appear to be a nursing error.

What Drugs or Medicines Will Become Deadly When Combined with an MAO Inhibitor?

Q: I have a female character who recently had a face-lift. She does fine through the surgery and is released with antiinflammatory and pain medications. Two days later she dies because of a severe reaction to her medications. An autopsy discovers that someone substituted one of her medications for something dangerous. I was thinking of MAOI. Will this work? Can you give me the names of the medications prescribed and the substitute that would kill her?

A: The answer is very complex, but I'll try to keep it as simple as possible.

The monoamine oxidase inhibitors (MAOIs) are a strange group of drugs and very treacherous. So much so that most physicians avoid using them, and many of the older MAOIs are off the market. However, some still exist and are used in the treatment of depression.

Nardil (phenelzine sulfate) is still around and is a very potent MAO inhibitor. It comes as a shiny orange pill with "P-D 270" stamped on it in brown lettering. The tablet contains 15 mg of the active compound.

The physiology of MAO inhibitor action is very complex, and I won't bore you with the details. The important thing is that if these drugs are given with certain other drugs and foods, severe and potentially lethal reactions can occur.

The most dangerous drugs to combine with the MAOIs are the sympathomimetics. These are the adrenaline or speedlike drugs. Cocaine, epinephrine (often used with local anesthetics to lessen bleeding; an example is lidocaine with epinephrine that dentists use frequently), pseudoephedrine (found in Sudafed and Actifed), amphetamines (found in nearly every diet pill), and certain serotonergic drugs can cause serious reactions. Most decongestants, asthma inhalers, cold medicines, and diet pills contain these or similar compounds that can lead to deadly interactions.

Also, foods that contain high concentrations of tyramine, L-tryptophan, or dopamine can cause dangerous reactions. These include aged cheeses, dry sausages (pepperoni, hard salami), pickled herring, fava beans, beer, wine, liver, yeast extract, and even caffeine and chocolate.

Now you can see why the MAOIs have fallen into disfavor. There are simply too many substances that can interact with them and cause lethal complications.

The most deadly reactions include the following:

Hypertensive crisis: The blood pressure (BP) shoots up rapidly to very high levels—250 to 300 over 100 to 130 wouldn't be unusual. This can cause confusion, disorientation, headache, blurred vision, seizures, loss of consciousness. It may lead to a stroke, a bleed into the brain, or a heart attack. Treatment is the administration of 5 mg of phentolamine intravenously to lower the BP rapidly.

Hyperpyrexia: The acute and severe elevation of body temperature. Temperatures of 106 to 108 and higher may occur. Any time

the body temperature rises above 106, brain cells begin dying in fairly short order and death follows. Treatment is an ice water bath.

In your scenario it would be easy to substitute two of the victim's medications with Nardil and any of the currently available diet pills such as Meridia (silbutramine hydrochloride monohy-drate, which is supplied in capsules: blue/yellow is 5 mg; blue/ white is 10 mg; yellow/white is 15 mg) or Fastin (phentermine hydrochloride, which is supplied in 15 and 30 mg capsules). For the most potent lethal effect, begin the Nardil several days (two to eight or more) before giving the diet pill. A hypertensive crisis could ensue rapidly, and the victim would suffer a stroke or cardiac arrest. This could occur within twenty to thirty minutes or up to several hours after the medication was taken.

The victim would develop a severe headache, blurred vision, dizziness, nausea, shortness of breath, confusion and disorientation, perhaps chest pain, perhaps a nosebleed from the high BP, and then collapse and die. These events could occur over several minutes to a few hours, whichever works for you.

As I said, this is a complex topic but an interesting question.

Follow-up Question and Answer

How Does a Physician Distinguish Between a Drug-Induced Fever and One from an Infectious Process?

Q: Could the elevated temperature be misdiagnosed as an infection at first? What would an autopsy pick up in such a situation?

A: Yes, the elevated temperature could lead the M.D. down the wrong road and probably would. An adage in medicine is that "common things occur commonly." A person with very high fever and lethargy or coma or seizures or other neurologic symptoms

would be assumed to have an infection first—particularly an infection of the brain such as meningitis or a brain abscess. Only after these were ruled out would other things be considered. And in the real world a drug interaction with MAOIs in a patient who wasn't taking those medications would not likely even come to mind. Therefore, it would be found only if the M.D. taking care of the victim obtained a drug screen and it appeared there.

The tests to rule out the infections mentioned above could include blood cultures, CT or MRI brain scans, a spinal tap to examine the cerebrospinal fluid for infectious critters and white blood cells, and an EEG (brain wave test), for starters.

In your scenario the victim could collapse or suffer a seizure and be taken to the ER, where her temperature would be found to be 106 and the workup for a brain infection would then ensue. Her blood pressure would likely be very elevated, which can also happen in brain infections if the brain swells and the intracranial pressure (pressure inside the skull) rises. The victim could die in a few hours, which would automatically make it a coroner's case. Anyone who dies within twenty-four hours of hospital admission must at some level be reviewed by the coroner.

The M.D. wouldn't know if the cause of death was indeed an infection or not. The coroner would perform a postmortem exam, find no signs of infection, and would then await the toxicology and other tests before determining the true cause of death. This may take a few days.

Can a Patient Be Killed by the Rapid Injection of Potassium Intravenously?

Q: Does this sound like a credible way for my villain to kill a hospitalized patient? An insulin syringe filled with potassium chloride (40 meq per cc) is injected quickly into an IV line just above the point where the IV's

needle enters the skin. Would there be too much dilution from the IV solution already in the line? If it worked, could this look like a hospital accident if the victim was receiving treatment for dehydration, exposure, and malnourishment? Would he be getting something like potassium chloride to elevate his electrolytes anyway?

A: Absolutely Patients suffering from dehydration and malnutrition often receive IV fluids, which are typically D51/2 normal saline with 40 milliequivalents of KCL per liter. This means a liter (1000 cc) bag of saline which has half the salt (NaCl) of "normal" blood (thus "1/2 Normal Saline") to which 40 meq of potassium chloride (KC1) has been added. It is typically given at 100 to 200 cc per hour, which means the potassium is going at a rate of 4 to 8 meq per hour (40 meq in 1000 cc yields 4 meq per 100 cc).

Giving KC1 faster than 20 meq per hour is dangerous, so the above flow rate is well below that. Pushing 100 meq of KC1 intravenously is obviously way above this, and dilution is nonexistent in "IV push" administration. This dose would stop anyone's heart in seconds.

One caveat: Concentrated KC1 like this burns severely when given, so the patient/victim would react unless he was in a coma or very heavily sedated. Of course he will die quickly, but he would yell out before he fades to black because it burns that severely. Factor this into your plot, and you'll be okay.

Options: The victim could be in a coma or sedated or restrained, and the killer could hold a pillow over his face while giving the KCL. Nurses could be distracted by a Code Blue or an unruly patient at the other end of the hall. The fire alarm could be triggered to create confusion.

If Someone with Tuberculosis Is Smothered, Would There Be Blood on the Pillow?

Q: How would someone look who had been suffocated with a pillow? If the person also had tuberculosis, would the pillow have signs of blood that had been coughed up?

A:Asphyxia by pillow suffocation leaves less evidence than manual or ligature strangulation because bruises or abrasions on the neck are not present. However, asphyxiations of all types typically result in petechial hemorrhages (also called petechiae) in the conjunctivae of the eyes (the pink mucous membranes that line the eyelids and surround the eyeball). The petechiae are small bright red dots or splotches, usually pinpoint or slightly larger in size. When these are found, some form of asphyxiation is likely, and your M.E. or sleuth would determine this quickly.

In addition, most victims of asphyxia have a deep purple color to their skin, particularly the head, neck, and upper body. Also, if the victim struggles, he may bite his tongue, sometimes severely, or may have the attacker's skin and blood under his fingernails.

As far as TB goes, bleeding would be unlikely but possible. TB is an infection of the lungs caused by mycobacterium tuberculosis. This bacterium causes the formation of tubercles (also called granulomas) in the lungs. These are basically small nodules (small round lumps or clumps), microscopic to pinpoint in size, scattered throughout the lungs. They are composed of the bacteria and the various types of white blood cells sent to fight the infection. These tubercles are the body's attempt to wall off or contain the infection.

Occasionally these tubercles will caseate (break down or liquefy), and if so, they may bleed. The patient will then cough up

sputum streaked with blood. We call this hemoptysis. Rarely does the person have severe bleeding.

In your scenario the struggle for air could result in bleeding, but it would likely be streaks of blood, not overt or massive bleeding. The pillow could have streaky bloodstains on it.