Review: Vivien Horler

Trace – Case studies of a forensic pathologist in Africa, by Ryan Blumenthal (Tafelberg)

Doctors are notorious for closing ranks when a patient believes they have been wronged by their medical practitioner.

But Dr Ryan Blumenthal, the author of Autopsy and now Trace, isn’t that guy. That’s because he is only too familiar with the sort of mistakes doctors can make – he sees the results on his autopsy table.

He believes many procedures performed today are probably unnecessary, and based “on first-hand experiences where I have witnessed the negative outcomes of such cases”.

The first is a form of surgery for severe acid reflux or heartburn and it glories in the name of laparoscopic Nissen fundoplication.

It involves a few small cuts in the abdomen, then tightly wrapping the top of the stomach round the lower oesophagus to prevent stomach acid from flowing back up. Specialised tools enable the surgeon to perform the procedure through tiny incisions, avoiding a large scar.

But using these tools is “effectively like performing an entire operation with chopsticks”. The results Blumenthal has seen include death from bleeding after a nick in the aorta, infections in the abdomen and injuries to nearby organs including the oesophagus, spleen, stomach and intestines, and damage to the diaphragm.

“In short, I am not a fan of this procedure.”

He’s also dubious about back and neck surgery, saying he believes many doctors are too quick to cut. And he quotes a joke known to many orthopaedic surgeons: “What is the most common orthopaedic procedure? A second back or neck surgery.”

Then there’s surgery to remove the gallbladder in the case of gallstones, which he believes is often unnecessary and should be performed only if they lead to complications. Gallstones are often found in autopsies – most people have gallstones without even knowing it.

He has things to say about body modifications too, like tattoos as well as nose, tongue and lip rings. There is a “danger triangle” in the face, which runs from the corners of the mouth to the bridge of the nose. Fiddling about in this area, including something as small as dealing with a pimple, can lead to a complication called cavernous sinus thrombosis. Popping a pimple in this area can lead to the formation of a rare blood clot, according to the Cleveland Clinic, and is fatal in one in three cases.

Other procedures he warns against include breast augmentation, Brazilian butt lifts, implants under the skin, genital beading (“a penis with multiple subcutaneous penile beads looks quite a lot like a Lunch Bar”) and modifications to the labia (labioplasty), which Blumenthal regards as a form of female genital mutilation.

While this book is said to be about case studies, quite a bit is advice from someone who has seen it all. There is a chapter on “forensic dictums”, based on years of distilled experience. One item is about the fact that most fatal interpersonal violence happens in one of three places: the bedroom, the bathroom or behind the wheel.

“If you and your partner need to have a difficult conversation or disagreement, try to avoid doing so in a confined space. If possible, take it outdoors where there is plenty of fresh air and the environment is calmer.”

Other dictums include:

• Alcohol: drinks with nicknames. “Beware of people who refer to their favourite alcoholic drink the way they speak of a lover.” So avoid people who talk about a Belletjie (Bell’s whisky), Jackie Boy (Jack Daniels), Jimmy J (Jim Beam), Tannie Kriek or Auntie Kriek (Tanqueray gin) or Millo (Amarula).
• If someone is shot in bed or found decomposed on a mattress, destroy the mattress and buy a new one. The best cleaning company in the world will never be able to remove all the trace evidence from the mattress.
• Avoid being out after midnight. “There is a very good reason why your parents or grandparents told you not to stay out too late.” Deaths from car accidents, drunken assaults or murders mostly happen after midnight.

But the book is not all good advice – there are case studies too. Blumenthal’s account makes you realise how fragile life is. Something as minor as a wasp sting can lead to an rare situation in which a severe allergic reaction causes a fatal heart attack. It may be rare, but Blumenthal has performed an autopsy on a man stung in the foot.

He was stung at 2pm and the mark became red and itchy, while the man’s tongue began to swell. He went to a pharmacy and was given anti-allergy tablets. He was also referred to his doctor who injected him with strong anti-allergy medications. Shortly after getting home at 5pm he began vomiting and had chest pains. He died shortly afterwards.

Blumenthal describes conditions around the autopsy table as “messy, muddy, bloody, smelly, greasy, loud, buzzing and and often charred”, and says the stories in the book come from the trenches of forensic pathology. For him, writing them down is the unloading of a heavy burden.

He is concerned that famous cases often focus more on the killer than the victim: “Think of the Oscar Pistorius or OJ Simpson cases. They weren’t called the Reeva Steenkamp or the Nicole Brown Simpson … cases.”

Trace is dedicated to “the voiceless – the real victims”, and Blumenthal says in a prologue that the book is intended for “the ones no one talks about and whose stories unfolded far from the cameras. It is my attempt to give a voice to the unseen, the unheard and the forgotten”.

Noble thoughts. The book is also a fascinating and eye-opening read.