Self-inflicted shotgun wounds of the face: surgical and psychiatric considerations

This study reviews the evaluation and treatment of patients with extensive self-inflicted shotgun wounds to the face. Five cases are presented and assessed with regard to reason for suicide, psychological reaction to facial reconstruction, and the potential for social rehabilitation. Mechanisms of injury, acute management, and definitive surgical and psychiatric treatment programs are discussed. Survival is expected for most patients, and carefully planned surgical reconstruction must be coordinated with skilled psychiatric intervention.

Learning and forgetting during posttraumatic amnesia in head injured patients

To investigate forgetting during recovery from head injury, colour slides were initially projected for long durations to ensure acquisition on a recognition test given 10 minutes later. Patients tested during posttraumatic amnesia (PTA) exhibited accelerated forgetting over 32 hours as compared with head trauma patients studied after the period of PTA and normal controls.

A case of self-inflicted leucotomy

A suicide attempt with a gun resulted in left frontal lobe damage in a 19-year-old obsessive man. While intelligence did not suffer and no frontal lobe syndrome emerged, the patient's obsessive rituals were significantly reduced.

Relationship between Russian roulette deaths and risk-taking behavior: a controlled study

A review of medical examiner records yielded data on 19 men and one woman who died playing Russian roulette. The men differed significantly from 95 male suicide victims who died of gunshot wounds to the head on several variables including age, race, ethnicity, religion, citizenship, marital status, living situation, health, and the likelihood of the death being witnessed. The Russian roulette victims were significantly less likely to die in the bedroom, die in the morning, leave a suicide note, and be depressed but were significantly more likely to have alcohol or drugs in their body fluids and to have a previous history of drug and alcohol abuse.

Adolescent suicide. A review of 87 cases of completed suicide in Shelby County, Tennessee

Suicide among adolescents is reported to be on the increase recently, and much attention from the news media to medical circles has been focused on this problem. This paper presents a comprehensive study of 87 completed adolescent suicides occurring between January 1, 1970, and January 31, 1985, in Shelby County, Tennessee. Factors including age, sex, race, and manner of death are examined as well as psychological, sociological, familial, and other environmental influences related to the deaths. In our series, the older white male adolescent dominated the statistics by far, and the most frequent mode of death was by firearm injury to the head. A brief discussion of studies related to suicide in general, and especially to adolescent suicide, is included.

Neurobehavioral outcome after gunshot wounds to the head in adult civilians and children

To assess the quality of long term outcome of civilian gunshot wounds to the head after intensive neurosurgical management, particularly with regard to the possibility of subtle problems due to diffuse injury, we administered neuropsychological tests to six survivors (four adults and two children) at about 1 year after injury. Five patients were moderately disabled, and one patient achieved a good recovery. Residual neurobehavioral sequelae were present in all cases. Defects in long term memory for new information were the most common sequelae, whereas the persistence of linguistic and visuospatial deficits was related to the hemispheric lateralization of injury. In comparison with the outcome reported for patients with closed head injuries who had similar Glasgow coma scale scores, our patients exhibited more severe impairment due to significant focal brain injuries and less evidence of diffuse damage.

Self-inflicted gunshot wounds: lethality of method versus intent

The authors studied 30 patients treated at an urban trauma center for self-inflicted gunshot wounds, most or all of which would have been fatal without emergency treatment. About half the patients had used alcohol or drugs immediately before wounding themselves, and slightly more than half had experienced interpersonal conflict just before the incident. Thirteen of the 30 were women. Only nine were given diagnoses of major depressive episode or dysthymia; none of the patients had written suicide notes. These data indicate that the reported demographic and clinical characteristics of impulsive, violent self-injury must be reexamined.

Low-velocity gunshot wounds in police officers

One hundred forty-five Philadelphia police officers were injured as a result of gunfire during the period from January 1971 to February 1983. Arrests and arrest attempts were the most common causes of these injuries; on- and off-duty accidents were the second most common causes. Twenty fatalities occurred among the 145 officers. Specific medical and surgical management of gunshot wounds depended largely on the location of the wound and the extent of the damage. Analyses of the location of the wounds in this study revealed that many could have been alleviated through the use of body armor, such as bullet-proof vests and lightweight helmets. Of the treatment records of 100 patients completed for evaluation, average hospitalization time was ten days, time without duty averaged 143 days, and limited duty averaged 70 days. Twenty-two persons received permanent and partial disabilities related either partially or wholly to their wounds. Fourteen individuals expressed anxiety about returning to work as police officers, and two received disability retirements for emotional instability. An officer who is aware of the probability of injury while performing a specific task can decide whether to wear an armored helmet or bullet-proof vest at the appropriate time. In the treatment of low-velocity gunfire injury, the physician could use the guidelines reviewed for specific treatment of the injury and thus anticipate the length of time or probability of the individual returning to work. Early recognition of these factors could help to avoid psychologic trauma.

Psychiatric care for patients with self-inflicted gunshot wounds

Self-inflicted gunshot wounds are the commonest form of suicide in this country. Seventeen individuals with such injuries were admitted to a trauma center over a 3-month period. Review of their records showed that psychiatric consultation was requested for only nine of the 13 patients who survived their wounds. Information on alcohol use was missing from half the case records and only six of the 13 survivors received psychiatric care after discharge. Use of guns in suicide attempts may evoke strong feelings in health care providers, resulting in omissions in history taking, evaluation, and follow-up.

Psychological autopsies in court

The crucial concept for defining suicide is intention. A major purpose of the psychological autopsy is to clarify the pre-mortem intentions of the victim, now deceased. This article reports cases in which the issue of suicide vs. accident came to trial because insurance benefits were at issue. Currently, the courts, in considering to what extent mental disorders impair the capacity for intentional self destruction, evaluate each case independently according to its own unique set of facts.

An unusual case of self-inflicted death in childhood

The authors report the details of the case of a ten year old boy whose self-inflicted death by gunshot featured the involvement of a nine year old companion. The authors examine the material from the viewpoints of a possible case of suicide, of a certain case of violent death, and of a case with repercussions on the other child and the community.

Anterior-posterior locus of lesion and personality: support for the caudality hypothesis

Investigated the effects of discrete brain lesions on MMPI performance in well-matched samples of patients with anterior and posterior injuries. Because of the nature of the samples and careful matching for potentially confounding variables, particular emphasis could be given to the study of brain-behavior relationships. Patients with posterior lesions produced a significantly more abnormal composite MMPI profile, had a consistent tendency to produce elevated (70+) individual MMPI scales, and had individual profiles that were universally rated as abnormal using standard criteria. The differential MMPI patterns exhibited by these two samples were compatible with traditionally held clinical hypothesis with regard to distinct personality differences secondary to focal lesions in the caudal plane. It is our conclusion that lesion caudality does have a differential effect upon MMPI performance when factors such as cognitive, motor, and sensory defects are controlled adequately. The implications are that this effect is locus specific and is not necessarily related to the degree of other neurobehavioral impairment, as has been hypothesized previously.

Word and letter reading and the mechanism of the third alexia

Four patients, two with global aphasia and two with Broca's aphasia, demonstrated the seemingly paradoxical ability to read words but not their component letters. Picture naming was only moderately impaired, and repetition of word and letter names was intact, excluding both a generalized dysnomia and an articulatory disturbance as the cause of the literal alexia. Matching tests revealed processing deficits in three of the patients, more severe for letters than for words. Oral reading of word lists showed that short, high-frequency, and picturable words were read best, whereas nonsense trigrams, which require phonetic processing, were the most difficult. The residual reading of patients with severe Broca's or global aphasia and the "third alexia" appears to involve purely visual, nonphonetic mechanisms for word recognition, using posterior left hemisphere or even minor hemisphere centers. Letter reading, by contrast, along with phonetic reading of syllables, appears to be a more specialized, anterior left hemisphere process.

Traumatic transient Klüver-Bucy syndrome

A case of transient Klüver-Bucy syndrome after a gunshot wound through the head is presented. We have found no other case of posttraumatic Klüver-Bucy syndrome described in the literature. The original criteria for the syndrome are reviewed and compared with findings in previously reported human cases.

Methods of suicide and implications for suicide prevention

Examined annual variations in the methods used for suicide in the United States in recent years (1962-1975) by sex and ethnic groups (white males, white females, nonwhite males, nonwhite females). Virtually all of the increase in United States suicide rates between 1962 and 1975 can be attributed to the increase in suicides by firearms. The increase in suicides by firearms, which occurred in all sex-ethnic groups, accompanied marked increases in the availability of firearms, which is a preferred, socioculturally accepted method of suicide in the United States. These results present a mirror image of the reductions in suicide rates in Great Britain and Vienna when the availability of the most preferred method of suicide in those locales (toxic domestic gas) was reduced. The data from this and other studies suggest that the physical availability of the more culturally accepted methods of suicide is a major determinant of suicide rates and that suicides may be prevented by decreasing the availability of the most common methods of suicide to suicidal individuals.

On the relation of injury to pain. The John J. Bonica lecture

Pain is better classified as an awareness of a need-state than as a sensation. It serves more to promote healing than to avoid injury. It has more in common with the phenomena of hunger and thirst than it has with seeing or hearing. The period after injury is divided into the immediate, acute and chronic stages. In each stage it is shown that pain has only a weak connection to injury but a strong connection to the body state.