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Paradoxical undressing in fatal hypothermia (Homo tirolensis)
1285
experience that can be gained by eliciting and interpreting clinical symptoms and signs, as well as in learning the value of management and decision making, are vitally important. Nevertheless, as indicated by McManus et al, changes in clinical practice have meant that to ensure that students continue to benefit from these attachments and to obtain the necessary exposure in training, some alterations in work patterns are required. There is no doubt that we must take up the challenges imposed by healthcare delivery to ensure that our doctors of the future do not suffer from inadequate exposure to clinical practice as undergraduates. Department of Surgery, University College London, Rayne Institute, London WC1 E 6JJ, UK 1.
I. TAYLOR
Taylor I, Johnson IDA. Surgery in the undergraduate curriculum—a statement by the Association of Professors of Surgery. Br J Surg 1990; 77: 822-23.
SiR,—Those of us who fear that teaching students in general will have an adverse effect on progressive education can take heart, for it seems that in an erudite hospital environment they need no longer learn the biochemical testing of urine and the details
practice
of urine microscopy. Thus an important part of the clinical examination would seem to be regarded as superfluous. 21 Common Road, North Leigh, Oxfordshire OX8 6RD, UK
E. N. WARDLE
Paradoxical undressing in fatal hypothermia
(Homo tirolensis) SIR,-We were closely involved in the inspection of the site of discovery and the recovery of the Homo tirolensis. An interesting forensic detail supports the assumption that the man died of hypothermia. The mummy was found stripped to the waist when it was released by the glacier.1 The rest of the body was partly clad in furs. There is conclusive glaciological evidence that the mummy was immersed in the glacier in this state and that its position was not changed by subsequent movements of the glacier. Forensically, the immersion of the body in the prone position with bare upper body can be explained as paradoxical undressing in hypothermia.2 Often before death by hypothermia, the victims paradoxically remove part of their clothing because of a sudden feeling of warmth. In addition, mental confusion often leads to uncoordinated movements, such as crawling. We do not know whether the mental confusion with paradoxical undressing is a cause or a result of hypothermia. This behaviour is not limited to inebriated victims. We believe that paradoxical undressing in the cold and the discovery of the victim in the prone position as a consequence of uncoordinated movements are additional clues that the ice-man died of hypothermia and not of a natural cause, such as myocardial infarction. Institute of Forensic Medicine, Univensty of Innsbruck, A-6020 Innsbruck, Austria
E. AMBACH
1.
Zissernig E. Bericht über das Internationale Symposium "Der Mann im Eis—Ein Fund aus der Steinzeit Tirols", Innsbruck, Austria, 3 to 5 June 1992. In: Spindler K, ed. Veroffentlichungen der Universitat Innsbruck,vol 187, 1992. 2. Bedin B, Vangaard L, Hirvonen J. "Paradoxical undressing" in fatal hypothermia. J Forms Sci 1979; 24: 543-53. 3. Albiin N, Eriksson A. Fatal accidental hypothermia and alcohol. Alcohol Alcohol 1984; 19: 13-22.
Reproductive freedom for refugees SiR,—Your April 10 editorial on reproductive freedom for refugees, including Bosnians, is welcome. We participated in 1992 and 1993 in three separate human rights missions to the republics of former Yugoslavia,l-3 and we take issue with several of your points. We do not regard Bosnia as a third-world country. Before the conflict, Yugoslavia was negotiating entry to the European Community. Most refugees in the former Yugoslavia are housed with host families and so are indistinguishable from the general
population. A few
are located in the densely populated camps to which you refer. Most healthcare for refugees is provided by existing overstretched services and not separately in the camps. Women and children may be separated from men who are fighting, in detention camps, missing, or dead. In reviewing the needs of refugees, you fail to consider their strongly held religious and cultural views. For example, natural methods of family planning are not discussed. These may be the only option available to Catholics. Women in this region are used to the widespread availability of western medical services and oral contraception. The difficulty here is that services and supplies often no longer exist. Rape in this conflict is widespread and continuing. However, accurate statistics on pregnancy after rape are unavailable and the numbers often cited are unreliable. There are legal restrictions on the availability of abortion at different gestations. The use of hand-held vacuum aspiration which you recommend as a method of termination of pregnancy in the first trimester assumes a stable refugee population. In our experience, this equipment is not widely available or functioning in the centres that we visited. In addition, some women who are pregnant after rape may be detained until pregnancy is far advanced, or they may be in transit for weeks. There are few supplies of the prostaglandins necessary for late abortion. You draw attention to infection with HIV. There is no evidence that it is a major problem in this situaton.4,5 There are refugees in and from all the republics of former Yugoslavia. Men and children have also been raped and sexually abused in this and other conflicts. Their needs have yet to be addressed.
Medical Directorate, North East Thames Regional Health London W2 3QR, UK
Authority,
MARY E. BLACK
Department of Genitourinary Medicine, Royal London Hospital Trust, London E1
GRETA FORSTER
Section of Forensic Psychiatry, St George’s Hospital Medical School, London SW17
GILL MEZEY
Geiger J, Black M, Crane T, Sonas J, Sugg N, Woodal J. Blood, threats and fear: ethnic cleansing in the republics of former Yugoslavia. Boston: Physicians for Human Rights (in press). 2. Report of the team of experts on their mission to investigate allegations of rape in the territory of former Yugoslavia, Jan 12-23, 1993. New York: United Nations, E/CN.4/1993/50. 3. Warburton A. Report of mission into treatment of the muslim women in the former Yugoslavia. February 1993 Copenhagen. 4. Aids cases reported to the World Health Organisation. Geneva: WHO, Wkly Epidemiol Rec March 31, 1993. 5. Annual health statistics report. Yugoslavia years, 1986-1991. 1.
Acupuncture SIR,-Your reviewer Dr Lewith takes a favourable view of P. E. Baldry’s book Acupuncture, Trigger Points, and Musculoskeletal Pain (April 17, p 1010). This approval is well deserved: the book gives an excellent overall account of acupunture. However, the
implication emerges that the redefinition of acupuncture in terms of modern physiology rather than those of traditional Chinese medicine somehow enhances its credibility: "acupuncture", writes Lewith, "has become a much more acceptable treatment". Advances in medicine, especially during the past century or thereabouts, have taken place against a background of observation and experience; and, more recently, of rigorous scientific research and scrutiny. This has been the way forward. The current vogue in alternative or complementary medicine is disturbing. Of course its practitioners with their sympathetic approach must often help people, but their methods of diagnosis and treatment are largely untested by proper scientific analysis. Acupuncture itself has been investigated by more than one controlled clinical trial in the treatment of rheumatoid arthritis with negative results. In my large experience of patients with rheumatic diseases, I have met hundreds who have received acupuncture. In none can I recall any instance of worthwhile therapeutic benefit. You could of course argue that the
experience that can be gained by eliciting and interpreting clinical symptoms and signs, as well as in learning the value of management and decision making, are vitally important. Nevertheless, as indicated by McManus et al, changes in clinical practice have meant that to ensure that students continue to benefit from these attachments and to obtain the necessary exposure in training, some alterations in work patterns are required. There is no doubt that we must take up the challenges imposed by healthcare delivery to ensure that our doctors of the future do not suffer from inadequate exposure to clinical practice as undergraduates. Department of Surgery, University College London, Rayne Institute, London WC1 E 6JJ, UK 1.
I. TAYLOR
Taylor I, Johnson IDA. Surgery in the undergraduate curriculum—a statement by the Association of Professors of Surgery. Br J Surg 1990; 77: 822-23.
SiR,—Those of us who fear that teaching students in general will have an adverse effect on progressive education can take heart, for it seems that in an erudite hospital environment they need no longer learn the biochemical testing of urine and the details
practice
of urine microscopy. Thus an important part of the clinical examination would seem to be regarded as superfluous. 21 Common Road, North Leigh, Oxfordshire OX8 6RD, UK
E. N. WARDLE
Paradoxical undressing in fatal hypothermia
(Homo tirolensis) SIR,-We were closely involved in the inspection of the site of discovery and the recovery of the Homo tirolensis. An interesting forensic detail supports the assumption that the man died of hypothermia. The mummy was found stripped to the waist when it was released by the glacier.1 The rest of the body was partly clad in furs. There is conclusive glaciological evidence that the mummy was immersed in the glacier in this state and that its position was not changed by subsequent movements of the glacier. Forensically, the immersion of the body in the prone position with bare upper body can be explained as paradoxical undressing in hypothermia.2 Often before death by hypothermia, the victims paradoxically remove part of their clothing because of a sudden feeling of warmth. In addition, mental confusion often leads to uncoordinated movements, such as crawling. We do not know whether the mental confusion with paradoxical undressing is a cause or a result of hypothermia. This behaviour is not limited to inebriated victims. We believe that paradoxical undressing in the cold and the discovery of the victim in the prone position as a consequence of uncoordinated movements are additional clues that the ice-man died of hypothermia and not of a natural cause, such as myocardial infarction. Institute of Forensic Medicine, Univensty of Innsbruck, A-6020 Innsbruck, Austria
E. AMBACH
1.
Zissernig E. Bericht über das Internationale Symposium "Der Mann im Eis—Ein Fund aus der Steinzeit Tirols", Innsbruck, Austria, 3 to 5 June 1992. In: Spindler K, ed. Veroffentlichungen der Universitat Innsbruck,vol 187, 1992. 2. Bedin B, Vangaard L, Hirvonen J. "Paradoxical undressing" in fatal hypothermia. J Forms Sci 1979; 24: 543-53. 3. Albiin N, Eriksson A. Fatal accidental hypothermia and alcohol. Alcohol Alcohol 1984; 19: 13-22.
Reproductive freedom for refugees SiR,—Your April 10 editorial on reproductive freedom for refugees, including Bosnians, is welcome. We participated in 1992 and 1993 in three separate human rights missions to the republics of former Yugoslavia,l-3 and we take issue with several of your points. We do not regard Bosnia as a third-world country. Before the conflict, Yugoslavia was negotiating entry to the European Community. Most refugees in the former Yugoslavia are housed with host families and so are indistinguishable from the general
population. A few
are located in the densely populated camps to which you refer. Most healthcare for refugees is provided by existing overstretched services and not separately in the camps. Women and children may be separated from men who are fighting, in detention camps, missing, or dead. In reviewing the needs of refugees, you fail to consider their strongly held religious and cultural views. For example, natural methods of family planning are not discussed. These may be the only option available to Catholics. Women in this region are used to the widespread availability of western medical services and oral contraception. The difficulty here is that services and supplies often no longer exist. Rape in this conflict is widespread and continuing. However, accurate statistics on pregnancy after rape are unavailable and the numbers often cited are unreliable. There are legal restrictions on the availability of abortion at different gestations. The use of hand-held vacuum aspiration which you recommend as a method of termination of pregnancy in the first trimester assumes a stable refugee population. In our experience, this equipment is not widely available or functioning in the centres that we visited. In addition, some women who are pregnant after rape may be detained until pregnancy is far advanced, or they may be in transit for weeks. There are few supplies of the prostaglandins necessary for late abortion. You draw attention to infection with HIV. There is no evidence that it is a major problem in this situaton.4,5 There are refugees in and from all the republics of former Yugoslavia. Men and children have also been raped and sexually abused in this and other conflicts. Their needs have yet to be addressed.
Medical Directorate, North East Thames Regional Health London W2 3QR, UK
Authority,
MARY E. BLACK
Department of Genitourinary Medicine, Royal London Hospital Trust, London E1
GRETA FORSTER
Section of Forensic Psychiatry, St George’s Hospital Medical School, London SW17
GILL MEZEY
Geiger J, Black M, Crane T, Sonas J, Sugg N, Woodal J. Blood, threats and fear: ethnic cleansing in the republics of former Yugoslavia. Boston: Physicians for Human Rights (in press). 2. Report of the team of experts on their mission to investigate allegations of rape in the territory of former Yugoslavia, Jan 12-23, 1993. New York: United Nations, E/CN.4/1993/50. 3. Warburton A. Report of mission into treatment of the muslim women in the former Yugoslavia. February 1993 Copenhagen. 4. Aids cases reported to the World Health Organisation. Geneva: WHO, Wkly Epidemiol Rec March 31, 1993. 5. Annual health statistics report. Yugoslavia years, 1986-1991. 1.
Acupuncture SIR,-Your reviewer Dr Lewith takes a favourable view of P. E. Baldry’s book Acupuncture, Trigger Points, and Musculoskeletal Pain (April 17, p 1010). This approval is well deserved: the book gives an excellent overall account of acupunture. However, the
implication emerges that the redefinition of acupuncture in terms of modern physiology rather than those of traditional Chinese medicine somehow enhances its credibility: "acupuncture", writes Lewith, "has become a much more acceptable treatment". Advances in medicine, especially during the past century or thereabouts, have taken place against a background of observation and experience; and, more recently, of rigorous scientific research and scrutiny. This has been the way forward. The current vogue in alternative or complementary medicine is disturbing. Of course its practitioners with their sympathetic approach must often help people, but their methods of diagnosis and treatment are largely untested by proper scientific analysis. Acupuncture itself has been investigated by more than one controlled clinical trial in the treatment of rheumatoid arthritis with negative results. In my large experience of patients with rheumatic diseases, I have met hundreds who have received acupuncture. In none can I recall any instance of worthwhile therapeutic benefit. You could of course argue that the