...there is much within this text that is of direct relevance to the current undergraduate curriculum, and all clinical medical students would benefit from this knowledge. This textbook, however functions well as both an introductory text and a detailed reference text, and as such should find its way on to the shelves of medical college libraries...
Knight's Forensic Pathology by Pekka Saukko, Bernard Knight. Hard Bound, 8" x 10.5".
Arnold Publications, A member of the Hodder Headline group, 338 Euston Road, London, NW1 3BH, UK. Tel: + 44 (0)20 7873 6000. Fax: + 44 (0)20 7873 6299. Publication Date January 30, 2004. 720 pages, 550 colour and black & white illustrations, ISBN-10: 0340760443 ISBN-13: 9780340760444, Price $220.50 (UK Sterling Price: £169.00)
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Introductory comments from Editor-in-Chief Dr. Anil Aggrawal and some Excerpts from the book:
I had the good fortune of meeting the legendary Bernard Knight during my Commonwealth Medical Fellowship tour of Great Britain in 1989-1990. I clearly remember the first day I met him - on Thursday, July 12, 1990. I had almost grew up on his books (Legal Aspects of Medical Practice, Forensic Medicine co-authored by Cedric Keith Simpson and Autopsy - The Memoirs of Milton Helpern, the World's Greatest Medical Detective) and always had a great desire to meet him. When I met him on July 12 (at 3.30 pm to be exact), I found him exactly the person I had dreamt of - gentle, erudite, a great scholar, kind hearted and having a strong Welsh accent. He asked me if I was free the next day and although I wasn't, I was so keen to spend some time with him that I said I was. He said that we could go to Cardiff high court the next day and that pleased me very much. However the next day (13 July), the case was cancelled and we didn't go there.
So keen was I to meet Knight, that next day I got up very early and by 8.45 am I was in the department. In no time he became very friendly and presented me with three of his books as gifts and reprints of several of his papers. He then took me to Heath hospital, where he treated me to a hearty 7 course lunch. After the lunch, he even took me to the medical bookshop, so he could buy me his atlas, but unfortunately it was not available. After this Professor Knight took leave of me. This small meeting left an indelible impression on me. Even today every moment spent with him is deeply etched in my memory.
A little about his life. Bernard Knight was born in Cardiff, where he has spent most of his life. Not many people know that he started out as a farmer. But later he became a medical student and qualified as a doctor in 1954. Five years later, he moved into forensic pathology and soon began working for the Home Office. In 1966 he joined the legal profession as a barrister and by 1980, the University of Wales College of Medicine had appointed him Professor of Forensic Pathology: a post he held for sixteen years (till 1996) before his eventual retirement.
One of the books presented to me by Dr. Knight was a crime thriller "The Expert", which was written under the pseudonym Bernard Picton. I read it in one go and found it to be an excellent book. A background of forensic pathology indeed placed Professor Knight in an ideal position to write murder mystery stories. He told me that it was a pastime for him. After his retirement in 1996, it has now become a career. I suspect this is one reason, he is not devoting enough time to him excellent book on Forensic pathology which is now looked after mainly by Saukko.
Later, when I returned to India, I kept in touch with him through letters and I continually implored him to write a book of his actual cases, much on the lines of Keith Simpson's "Forty years of murder", a book which I deeply admire. I firmly believe that a similar book from him would be an instant hit with the general public and forensic pathologists alike, but somehow he kept on procrastinating on this project.
He has, of course, published many medical textbooks and in the 1970s, even wrote several historical novels based in Wales. Bernard's knowledge of life in the 12th century, shown in these latter works, later joined forces with his pathological expertise to bring us the acclaimed 'Crowner John' series of medieval detective stories. His main "Crowner John" stories are 1. The Sanctuary Seeker (1998), 2. The Poisoned Chalice (1998), 3. Crowner's Quest (1999), 4. The Awful Secret (2000), 5. The Tinner's Corpse (2001), 6. The Grim Reaper (2002), 7. Fear In The Forest (2003), 8. The Witch Hunter (2004), 9. Figure of Hate (2005), 10. The Elixir of Death (2006) and 11. The Noble Outlaw (2007)
Knight's Forensic Pathology has been with us for more than a decade. The first edition came in 1990 and the second in 1996. Knight's forensic pathology broke new grounds in the sense that for the first time perhaps, more emphasis was given on actual observations than on conventional wisdom. For instance, in the second edition, while discussing air embolism, Knight had this to say on page 342:
"The head should be dissected first, not to detect air bubbles in the cortical veins, as almost every textbook erroneously states, but to look for air in the cerebral arteries. Descriptions and photographs of air segments in the cerebral veins are part of the mythology of forensic pathology, handed on uncritically from one book and one author to another. There is no way in which air bubbles can reach the pial veins of the brain surface. They cannot get there via the venous system as there is no way in which they could struggle against the flow in jugular veins, pass through the complex arrangement of intracranial venous sinuses retrograde to the circulation and dispose themselves over the cortical surface. Neither can they reach the same veins by penetrating the capillary bed of the brain, in the rare of instances of arterial air embolism. As was demonstrated over 30 years ago, these bubbles are artefacts and can be seen in many routine autopsies where there can be no question of air embolism."
After reading these lines, one wonders why one did not think of this before. This makes so much common sense. But perhaps all of us are too afraid to challenge age old beliefs. Knight - to the best of my knowledge - is the first forensic scientist to take all these age old "rotten" beliefs by their horns and throw them out of the forensic arena. It is not for nothing, that if you turn to almost any paper on forensic pathology today in almost any journal and more often than not, you would find his book as one of the references.
Knight goes on further to expand on air embolism on page 432 when discussing abortion deaths due to air embolism. This is what he has to say of the established procedure to detect air embolism:
"The classic method . is to open the heart chambers in situ under water poured into the pericardial sac. Escaping air bubbles are then said to be indicative of air embolism, though the technique is by no means as reliable as past authors have claimed. In fact if the post-mortem interval is short, in terms of a few hours, then any fatal air embolism will almost always be quite apparent from the frothy contents of the right ventricle when it is opened in the usual way. Appreciable delay allows absorption of air, as can be proved by the failure to find air in the heart on dissection, even after radiology has clearly indicated its presence. Of course, where any degree of decomposition has set in, which may be on the first day after death in hot countries, gases of putrefaction completely negate any chances of proving air embolism."
So convinced is Knight of the uselessness of traditional methods of detecting air embolism that on page 433 he again says this:
"The usual instructions in most forensic textbooks for opening the head first, carefully removing the calvarium and minutely inspecting the cerebral veins for air bubbles can be totally disregarded, as this is yet another example of forensic mythology repeated from one book to the next, without critical evaluation. As discussed in Chapter 13, air embolism cannot occur in the cerebral veins and it was proved many years ago that air bubbles in those veins are artefacts caused by removing the calvarium.
Talking more of his lashing out at common but erroneous beliefs, while talking of signs of asphyxia on page 350 (in the second edition), he says:
"Descriptions of an abnormal fluidity of the blood seen at autopsy in asphyxia deaths are part of forensic mythology and can be dismissed with little discussion. Post mortem clotting in the heart and eventual dissolution is a most erratic process, as is the eventual dissolution of those clots by the action of fibrinolytic enzymes. It is irrelevant in the diagnosis of asphyxia."
In India, I know for sure - as I have been teaching forensic medicine to undergraduates for more than 30 years - that we go out of our way to teach students the differences between an antemortem blister (produced by a burn) and a postmortem blister (produced by putrefaction). One of the answers that fetches students full marks is this, "An antemortem blister contains an exudate rich in protein and chloride, while a postmortem blister mostly contains air, and if it at all contains some fluid, it is mostly a transudate very poor in protein and chloride." I must confess, I never found this fact very convincing, but always hesitated to say so to my colleagues, lest they think I was not up to the mark in my knowledge of forensic pathology. But Knight goes ahead and takes this fact head on. On page 310 (2nd edition), he goes on to write this:
"Traditionally most authors claim that differentiation can be made between an ante-mortem and a post-mortem blister by an analysis for protein and chloride in the fluid. The blister formed in life is said to contain more protein and chlorides, but no absolute figures are offered and the author has yet to meet a pathologist who does this as a routine. One suspects that the test is another of the apocryphal procedures that have been handed down from textbook to textbook without verification."
Another big traditional belief - certainly in India - is the usefulness of hydrostatic test in determining live or dead birth. I have conducted this test a number of times in proven alive and dead births both and have found this test to be ambiguous. Yet, I was always hesitant in saying so, believing that I may have been conducting the test inaccurately. But this is what Knight has to say about this test on pages 442-3 (second edition):
"The complicated instructions offered in many textbooks concerning cutting the lung into lobes and then into pieces, squeezing them with knife blades and even pressing them underfoot on the mortuary floor before floating them, all smatter of black magic and are a complete waste of time. Worse, they can simulate a false sense of scientific validity and even to an eventual miscarriage of justice."
Honestly, Knight's book always appeared to me like a whiff of fresh fragrant air, in the damp, dark world of forensic pathology, so full of old myths, beliefs and superstitions. Since 1990, this book has always been by my elbow and I always refer to this whenever I need to research on some fact. In fact, so positively am I influenced by Knight and his book, that I decided after some careful thought, that it was not possible for me to give, what many would call a fair review. So I looked around and looked for a person who could look at the book with a more neutral angle. I did not have to look far. Dr. Vrinda J. Bhat, a noted academician and Associate Professor of Forensic Medicine at the Kasturba Medical College, Manipal (South India) and Editor-in-chief of the Journal of Karnataka Medicolegal Society (JKAMLS) agreed to review this book for us. This is what she has to say about the book.....
The style of this 3rd edition has undergone a complete revamp! - and it looks stunning! The layout and style of the text is also more pleasant to the eye, and this edition has lost the 'bland' look and feel of the last edition. Most of the illustrations are now in full color, and there have been hundreds of new additions, with some familiar photographs having been retained, and there is now a collection of images that rivals most textbooks, and even most atlases. The third edition of Knight's Forensic Pathology continues to be the definitive international postgraduate textbook for forensic pathologists, covering all aspects of the medico-legal autopsy, including the cause and time of death, interpretation of wounds and every other facet of the investigation of a fatality. The emphasis is on the practical application of knowledge and research findings, and continues its traditions of clarity and succinct presentation.
While the book had only Bernard Knight as the sole author till second edition, in third, Dr. Pekka Saukko has been roped in from the University of Turku. Interestingly the name of the book also gets changed from "Forensic Pathology" to "Knight's Forensic Pathology" indicating the enormous success of the earlier two editions; so much so, that the publishers now hope to sail through the third edition merely using Knight's name. In another first, Bernard Knight, after whom the book is named becomes the second author while Pekka Saukko becomes the first. It perhaps indicates that the book is destined the way Taylor in the West and Modi in the East went - getting edited in future by other authors than the original one.
In the preface to this 3rd edition, the authors (Saukko and Knight) stress the need for caution and the avoidance of over-interpretation, and the reader is reminded of the limitations of interpretation throughout the text. For example, post mortem changes such as rigor mortis and lividity, as well as decomposition and temperature changes can be of use in formulating a post mortem interval. However, some experts have been dogmatic about the inferences that can be drawn from these phenomena, and Knight and Saukko attempt to provide evidence based conclusions about the utility of such findings.
The reader is left in little doubt that the range of autopsy findings can only give a very basic estimate of post mortem interval, and that there are so many variables in operation that previously held 'rules of thumb' can only be very broad 'guestimates'.
Knight advised his readers in the preface of the 2nd Edition, that his text draws on the writings of the 'great' pathologists and morbid anatomists, and each subject is meticulously referenced with the original papers that form the basis of modern forensic pathological principles. This principle is continued in this 3rd edition, although the style of the referencing has changed.
In the previous edition, references were to be found at the end of each subsection, allowing quick access to the relevant papers. Now they have been combined in a familiar manner at the end of each chapter. This ensures that each chapter flows in more readable style.
The inclusion of the chapter on sudden natural deaths, the findings in such cases, and in particular the histological features of, for example early myocardial infarction etc, coupled with advice on cause of death formulation are of great value for non-forensic pathologists carrying out autopsies within a medico-legal framework.
The chapter on wound identification is excellent, and benefits from many new illustrations - including more clinically relevant images of wounds in the living. All students undertaking their emergency medicine and trauma rotations should read this chapter so that they can correctly distinguish a laceration from an incised wound.
In the current medical curriculum, forensic pathology, and forensic medicine receive scant attention, and the market for textbooks in this subject, previously examined by all medical schools as a matter of routine, has suffered in a similar fashion. This is shame, because there is much within this text that is of direct relevance to the current undergraduate curriculum, and all clinical medical students would benefit from this knowledge. This textbook, however functions well as both an introductory text and a detailed reference text, and as such should find its way on to the shelves of medical college libraries.
-Vrinda J. Bhat
Associate Professor of Forensic Medicine
Kasturba Medical College,
Manipal (South India)
Dr. Vrinda J. Bhat, Associate Professor of Forensic Medicine at the Kasturba Medical College, Manipal (South India) and Editor-in-chief of the Journal of Karnataka Medicolegal Society (JKAMLS). She has been the lady Representative in the Indian Medical Association - Udupi-Manipal Chapter, in the years 2002-03 and 2004-05 and the honorary Secretary of the Indian Medical Association- Udupi-Manipal Chapter, in the year 2005-06. She won the best Paper Award in the Oral Presentation Category for Faculty at XIV Annual Conference of Karnataka Medicolegal Society (KAMLS) held by the Department of Forensic Medicine, Karnataka Institute of Medical Sciences, Hubli on 1st and 2nd July 2006. Dr. Bhat can be contacted by clicking here.
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