Tuesday, June 21, 2005

Terri Schiavo's Autopsy: The Blind Spot

by Sherry Eros, MD and Steven Eros

HIGHLIGHTS OF PART ONE:

  • By reference to the medical literature adduces evidence that a substantial portion of the loss in Terri's brain weight observed postmortem may have been due to the dehydration to which she was subjected.
  • By reference to the medical literature adduces evidence that Terri's much-vaunted total cortical blindness may also be attributable to dehydration.
  • Refutes the Medical Examiners' suggestion that their autopsy findings are "very consistent with" the PVS diagnosis and for years Terri Schiavo was unable to see, recognize her family, think, or exercise any of the other higher mental functions that distinguish human life.
  • Refutes the Medical Examiners' suggestion that their autopsy findings prove that Terri Schiavo suffered irreversible brain damage and would not have benefited from rehabilitation.
  • Critiques poor medical and scientific reasoning and misleading statements by the Medical Examiners who performed the autopsy, as well as by the mainstream media and medical experts who supported the Medical Examiners' misinterpretation of the findings.

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LINKS TO RELATED ARTICLES

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Terri Schiavo: The Locked-in State
... What Terri Taught Us
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PROOF: Judicial Filibusters Violate U.S. Constitution
... Every Senate has the right to make its own Rules, but not its own Constitution
.

Confusion now hath made his masterpiece. - Shakespeare

INTRODUCTION

...thinking apparatus shriveled and shrunken, withered and liquified ... eyes merely appear to follow the actions of people and things around her ... completely blind, taking-in nothing and recognizing nothing ... appears to be responsive, but actually braindead; seemingly intelligent behaviors are nothing more than reflex movements.

Is this a description of Terri Schiavo? -- No.

As we demonstrate below, this description fits not Terri but the entire mainstream news media and the vast majority of the medical and legal experts who have commented on the Terri Schiavo "Report of Autopsy" issued on June 15, 2005 by the Florida District Six Medical Examiner.

Whatever the results of the Medical Examiner's (ME's) report may indicate about the condition of Terri Schiavo at the time of her death, we know from the mainstream media's hyped reporting that America's leading news outlets and reporters are mindlessly ill-informed, wilfully blind, thoroughly unprincipled, and miserably unschooled in the basic principles of medicine, the scientific method and statistics.

The news reports that the liberal media spewed-out on the Schiavo autopsy reveal little or nothing about whether Terri was braindead, blind, and incapable of feeling pleasure or pain. But they certainly yield insights into the sorry intellectual, moral and politicized state of the liberal media as well as the armies of medical and legal experts who prostitute themselves by shamelessly dispensing legally unsound and medically unsupported misinformation and disinformation without adequately informing themselves on the facts of the case.

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What follows is Part One of a critique of the Autopsy Report and accounts of it in the media. This and each successive Part of the analysis presents a single issue in Q & A form.

This part of the Q & A series deals with the ME's diagnosis of Terri Schiavo as being in a persistent vegetative state (PVS).

Specifically, it questions the claim that the ME's Autopsy Report confirmed, or lent to support to, the PVS diagnosis. The news conference held by the ME that accompanied the release of the Autopsy Report left the widespread impression with the press and the public that the report provided conclusive proof that Terri was "braindead," unconscious," incapable of feeling any pain or pleasure, and unable to think, wish, will or recognize anyone or anything.

A copy of the official ME's report is available here, and here.

Streaming video of the ME's news conference discussing the Autopsy Report is available here.

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"INCONSISTENT WITH" THE TRUTH

Before proceeding with the analysis of the Autopsy Report on the PVS question, it is essential to understand a certain category of medical and statistical terminology the use of which by the ME and the media is responsible for generating so much of the public's current confusion regarding the ME's autopsy findings.

Principal among these is the term "consistent with" as utilized by the ME. "Consistent with" is sometimes amplified by "very" as when The New York Times Editorial of June 16, 2005 quotes the ME as explaining that the autopsy findings were "very consistent with" a persistent vegetative state (PVS):

Although the autopsy could not definitively establish that Ms. Schiavo was in a persistent vegetative state, the findings were deemed "very consistent with" that diagnosis.

What The Times and the rest of the liberal media and the medical experts "very consistently" confused, in a manner "not consistent" with being truthful and factual, is the fact that the term "consistent with" is as close to meaningless as you can get in medical terms. To say that a given finding is "consistent with" a particular diagnosis is just about the weakest connection you can make, diagnostically speaking. "Consistent with" is about a hair's breadth short of stating, "There was absolutely no relationship at all."

Just as a statistical correlation between two events is useless in establishing a causal connection, so the fact that a medical finding is "consistent with" a diagnosis is virtually meaningless in establishing what precisely the diagnosis might be.

The only really meaningful way to use the term is in excluding a diagnosis, in those cases where you can determine that the laboratory or autopsy findings are "not consistent with" such-and-such a diagnosis. Here the negative is of use in establishing either: (1) the data enables a given etiology or diagnosis to be "ruled-out" or excluded; or (2) through an arduous process of elimination, all known "consistent with" alternatives may be excluded, leaving only one as the presumptive explanation or cause for purposes of making the diagnosis.

Nearly 100 per cent of the time, when physicians say that a given test result, autopsy finding or other piece of data is consistent with a given diagnosis or determination, that very same finding is also "consistent with" a different, or even directly contrary, conclusion.

To say that a decedent's fractured skull is "consistent with" murder does not lend any substantive support to the notion that the decedent was murdered, since the same fracture may be, and often is, "consistent with" the contrary conclusion that the decedent was not-murdered (for example, fell and hit his head).

Applied to the Terri Schiavo case, when the ME states or implies, for example, that his findings were "consistent with" her having been in a PVS for many years prior to her death, every single one of those findings was equally "consistent with" the conclusion that she was not-PVS prior to her death.

When the scientific and medical data is equally consistent with both x and non-x as in the Schiavo case, then it is utterly meaningless to suggest, as the ME appears to have implied (predictably leaving the liberal mainstream news media to infer) that the data supports or establishes one or the other as true. Something meaningful has been said only when the physician or the ME can use data to "rule-out" something, by finding that the data is "not consistent with" such-and-such a diagnosis, or cause of death.

If the ME had said, for instance that the autopsy findings are "not consistent with" Terri Schiavo having been able to think, feel enjoyment and pleasure, or feel pain, then that would have represented a meaningful finding. Adding "very consistent with" PVS is as meaningless as saying that a woman's weight increase is "very consistent with" her being very pregnant. A woman is either pregnant or not pregnant, and a person is either conscious or not conscious. Nothing in the ME's autopsy findings rules-in or rules-out the one any more than the other. For a professional ME of many years experience to suggest otherwise is highly misleading and scientifically reprehensible. Yet The New York Times Editorial of June 16, 2005 directly quotes the ME as stating that his findings were "very consistent with" the PVS diagnosis. If true, the ME's actions would be "very consistent with" an extreme deficiency in scientific integrity and adherence to basic medical standards.

For purposes of understanding the Autopsy Report, the term "consistent with" should be considered nothing more than a wild guess or a hunch--at its best the epistemological equivalent of a loose correlation in terms of its level of certainty.

No responsible physician would ever perform surgery or administer medication merely based on the fact that one or more of his findings for the patient is "consistent with" a given disease or diagnosis. If the findings are "consistent with" two or five or ten different diagnoses, then before embarking on a risky course of surgical or other treatments, the ethical physician is first obliged to rule-out all but one. In the present case, the autopsy findings are perfectly "consistent with" two perfectly contrary diagnoses, PVS and not-PVS, and to claim that the postmortem findings somehow lend additional support to the PVS diagnosis in the Terri Schiavo case would be the height of medical fraud and duplicity.

The ME's responsibility for widespread misinterpretation of the autopsy findings in the liberal mainstream media is not diminished merely because he also drily and perfunctorily stated deep in the text of the formal print version of the Autopsy Report that "PVS is a clinical diagnosis arrived at through physical examination of living patients."

More serious reporters interested in accurate accounts would hav been able to discern the absence of evidence for PVS in the ME's printed Autopsy Report, but political enterprises such as CBS News, The New York Times, The Washington Post, The Los Angeles Times, the AP and nearly all of their politicized reporters, columnists, and editorial staffs who handled the story ran with the "consistent with" line of fraudulent reporting instead. Consequently, nearly the entire print and broadcast media distributed wildly inaccurate and intentionally misleading accounts of the postmortem findings that went uncontested, such as those below:

Q & A

Does the Autopsy Report confirm that Terri Schiavo was in a persistent vegetative state (PVS)?

MEDIA ACCOUNT:

The AP reported on June 15, "An autopsy on Terri Schiavo backed her husband’s contention that she was in a persistent vegetative state, finding that she had massive and irreversible brain damage and was blind, the medical examiner’s office said Wednesday."

Newsday went further, claiming in its "Health & Science" section that Terri Schiavo's brain was nothing but a mangled bundle of dead scar tissue, reporting that her "autopsy revealed that her brain was reduced to half its normal size and filled with scarred, dead tissue - evidence to medical examiners and neuropathologists that she was unable to carry out higher thinking."

The Washington Post's David Brown and William Branigin reported that, "The autopsy essentially supported Michael Schiavo's contention that his wife's brain damage was irreversible and that she had no cognitive ability."

Jim Axelrod reporting for the CBS Evening News: "It's the most widely anticipated autopsy in recent memory and the results couldn't be clearer." Proclaimed Axelrod, "That meant lost tissue, and lost tissue meant lost functions.

The night of the Autopsy Report release, Alan Colmes on Fox News Channel's Hannity & Colmes program said, "The Pinellas-Pasco medical examiner, Jon Thogmartin, joined by Dr. Stephen Nelson today, described the condition as very consistent with a persistent vegetative state."

Likewise an ecstatically deranged Keith Olbermann of MSNBC opened his program by blurting-out, "The autopsy of Terri Schiavo is complete. She was in, and had been in, a persistent vegetative state. She had massive and irreversible brain damage." He manically backed-up his bold claim by asserting that the ME and other medical authorities had put their reputations and even their medical licenses on the line, "And if you do not believe those doctors, you have to be willing to believe that they would be willing to lose their licenses and jobs if they were proved to be incorrect."

NBC Today Show's Matt Lauer on June 16 may have been the one to pronounce the final, definitive medical judgment, asserting with oracular certainty, "The long-awaited autopsy report on Terri Schiavo was released on Wednesday. It concluded that she was in a persistent vegetative state, suffered from severe and irreversible brain damage."

On MSNBC's Scarborough Country, conservative Joe Scarborough thus seemed willing to throw the towel in at last, conceding, "And this is what they came out with. They said, when she died, Terri Schiavo, before she died, of course, had no brain activity."

What was most striking about the news reports was the smugness and certainty with which the purported scientific "facts" of the case were misreported. As printed in the Washington Post, famed science columnist Ellen Goodman disclosed, "No amount of treatment or rehabilitation would have reversed her condition. There was no doubt about it." Displaying her storied fact-checking abilities, Goodman added, "Now we know beyond any doubt that Terri Schiavo couldn't smile. Does this fact change even one opinion?"

MEDICAL EXPERTS' COMMENTARY:

Newsday claims to have consulted two anonymous "brain specialists" whose conclusions seemed to completely contradict the ME's Autopsy Report. According to Newsday reporter Jamie Talan, "The autopsy of Terri Schiavo found extensive damage throughout her brain, according to two Florida brain specialists who read the report. She lost all or most of her ability to think, recognize people and objects, and perform the simplest actions." Talan claims these two unsourced experts (she does not inform us whether they are neurologists, psychologists, or correspondence school grads) reported to her on the state of Schiavo's cerebral cortex. According to these "experts" there was, "Sever [sic] damage, with little gray matter left in the area responsible for thinking, remembering, math and higher thought. This suggests a persistent vegatative [sic] state." -- We only hope that their medical knowledge and Jamie's reporting skills exceed her ability to spell and her Newsday editors' ability to edit and verify unnamed sources.

Interviewed on the CBS Evening News with Bob Schieffer (see article with video link), just after release of the ME's Autopsy Report, Dr. Douglas Miller, Director of Neuropathology at New York University Medical Center, had this exchange with CBS's Jim Axelrod concerning the Schiavo autopsy findings:


Dr. MILLER: This person could not perceive things from the outside at a conscious level, neither pain nor thirst nor who was around her.

Unidentified Man: (From videotape, speaking to Terri Schiavo) Open your eyes up! Good, good job!

AXELROD: So that familiar piece of videotape Schiavo's family and friends pointed to as evidence she was aware, has another definitive explanation according to...

Dr. MILLER: She was not aware, and appearances to the contrary in the videotape that was shown over and over and some of the accounts, those were reflexes.

We know how Senate Majority Leader Bill Frist was excoriated in the media for merely suggesting that, while she was alive, Terri Schiavo may not have merited the PVS diagnosis based on his observation of videotaped recordings of her apparent conscious responsiveness.

Yet Schieffer and Axelrod are wildly ecstatic upon hearing Miller's method of error-proof PVS diagnosis-at-a-distance based on nothing more than postmortem findings in an Autopsy Report. The CBS duo never inquire of Miller whether he viewed the entire videotape (rather than just clips of a few seconds length shown on the network news shows). They are undoubtedly aware that he was rendering an expert opinion and expressing absolute certainty on the PVS diagnosis, without having ever examined the living patient and while relying exclusively on a thoroughly misleading and self-contradictory ME remark on the Autopsy Report. Yet the NYU medical expert continues to express absolute certainty on the PVS diagnosis to a ravenous Axelrod, denying with the certainty of a medieval authority even the slightest possibility that others, from family members to expert neurologists, consistently observed conscious responses in Terri Schiavo:

AXELROD: Not possible, at least medically speaking, says Miller. In fact, she was blind.

Dr. MILLER: [Those who claim Terri was conscious and responding to her environment] were seeing what they wanted to see, which is common and unfortunate."

In a June 16, 2005 broadcast segment, CBS's Axelrod, sensing the problem in concluding from postmortem autopsy findings to Terri's clinical function while alive, presses the NYU neuropathologist Dr. Miller on the postmortem brain weight finding's significance for the PVS diagnosis:

AXELROD: That meant lost tissue, and lost tissue
meant lost functions.

Dr. DOUGLAS MILLER: Wouldn't recognize anybody's face, wouldn't recognize anybody's voice, wouldn't respond to stimuli in anything but a reflexive way.

AXELROD: This autopsy is conclusive about that?

Dr. MILLER: In my opinion, yes.

This sort of desperate effort by Schieffer, Axelrod, et al to accumulate and promote fraudulent data that confirms a preconceived notion based on purely political motivation is reminiscent a similar effort by another recent divinity at CBS, Dan Rather. While CBS News anchor, Dan Rather became the point man for a scandalous journalistic effort that ultimately cost him his job and his reputation, the attempt to defeat the Republican incumbent in his presidential bid based on fraudulent memos from an obviously unreliable source. CBS appears to have figured-out that phony journalistic accounts and pseudo-expert opinions on the Autopsy Reports of already euthanized women provide a safer route to political success for the "news" organization.

We would like to know which one is the medical fraud: Dr. Frist, who spent an hour or more viewing the court-sanctioned videotaped examination of Terri Schiavo and merely raised a question about the PVS diagnosis; or Dr. Miller of NYU, who probably never viewed the extended tape of the live patient and who made a definitive PVS diagnosis based on the postmortem findings of the ME who himself wrote in the Autopsy Report that no conclusion as to PVS is legitimate based on the postmortem findings? -- We think it is obvious which of the two is more deserving of the prize for Outstanding Fraud of the Year. The only problem is that the right to the prize is being claimed by so many other medical experts, and by Bob and Jim and the rest of the integrity-challenged mainstream media.

LEGAL OPINION:

The principal blog on legal aspects of the Schiavo case, Abstract Appeal, states that: "The medical examiner's report explains that whether someone is in a persistent vegetative state is a clinical diagnosis that his office cannot evaluate after her death. However, the report does offer findings that are relevant to the PVS diagnosis."

On MSNBC's The Abrams Report, a less scrupulous but thoroughly mindless Dan Abrams felt sufficiently vindicated to dictate to his viewers, "Terri Schiavo's autopsy is complete. It sure seems her husband was right, that Terri was in a persistent vegetative state."

MEDICAL EXAMINER FINDINGS:

In the official print version of the Autopsy Report the ME, Dr. Jon Thogmartin, asks and answers: "Was Mrs. Schiavo in a persistent vegetative state (PVS)? - This can't be determined posthumously, though the findings of the autopsy were not inconsistent with this diagnosis: PVS is a clinical diagnosis arrived at through physical examination of living patients."

In spite of this caution lying unconscious in the print version of the ME's own Autopsy Report, Stephen Nelson, MD (consultant neuropathologist to the Medical Examiner and author of a major section of the Autopsy Report) reportedly did not hesitate to comment at the news conference in which the Autopsy Report was released: "There's nothing in her autopsy report, in her autopsy, that is inconsistent with persistent vegetative state."

At this June 15th news conference, Nelson also remarked that the Autopsy Report's findings are "very consistent with persistent vegetative state."

According to Keith Olbermann, Dr. Nelson also concluded that Terri Schiavo "would not have been able to form any cognitive thought--meaning no thinking, no emotion, no recognition of people. She couldn't have swallowed, and she was blind."

It is astonishing that both of the Medical Examiners principally responsible for the Autopsy Report acknowledge in the print version that it is illegitimate to use postmortem findings to retroactively make the clinical diagnosis of PVS, and yet in speaking to the press they make a point of repeatedly and consistently violating their own prohibition. In spite of the fact that the written report appears to have been cleansed of the more extreme forms of scientific dishonesty evident at the news conference, subtler manifestations are nonetheless apparent in the written report as well.


OUR REPLY TO THE MEDICAL EXAMINER'S SPIN OF THE AUTOPSY REPORT'S OBJECTIVE FINDINGS

As Thogmartin and Nelson clearly state in the written Autopsy Report, it is impossible to confirm a diagnosis of PVS postmortem--on the basis of an their own autopsy. As explained above, to say that the autopsy is "consistent with" persistent vegetative state is utterly devoid of meaning because it is just as true that the autopsy is "consistent with" Terri's having been in a conscious state of one level or another.

Therefore it was extremely misleading, and even medically reprehensible, for either ME to have stated to the press that the autopsy results are either "consistent with" or "not inconsistent with" a PVS diagnosis, without in every instance where the topic of PVS arose, emphasizing and repeatedly cautioning the press in the strongest possible terms that such a statement must not be misinterpreted as lending support to the PVS diagnosis. This caution appears not to have been given at the news conference.

The use of "consistent with," "very consistent with" and "not inconsistent with" decoupled from a blaring warning against misinterpretation provided the unscrupulous and politically-motivated members of the liberal mainstream media an opening to produce thoroughly dishonest reports and editorial commentary. Blindly led by the political machines of The New York Times and The Washington Post as well as CBS and MSNBC, many news outlets dispensed intentionally falsified news and commentary leaving the clear impression with the public that somehow the Autopsy Report either directly confirmed the PVS diagnosis, or excluded the possibility that Terri Schiavo was minimally--or more than minimally--conscious.

Having flooded the airwaves and filled the newspapers with this sort of junk medicine and junk reporting, aided and abetted by the ME and other willing accomplices among medical experts lacking any scruples, the liberal mainstream media prepared the ground for the next stage of the Crusade for Death, a series of fraudulent polls such as those conducted prior to Terri Schiavo's being euthanized. Legitimate polling data on the significance of the Schiavo case will, as before, go unnoticed in favor of the usual phony push-poll technique of manipulating public opinion.

We contend that this is more than a minor sin of omission on the ME's part; it is tantamount to a supersized-Big Lie. Without pretending to know what was in the minds of Drs. Nelson and Thogmartin, we might with justification raise the question whether this was a knowing and intentional deception on their part, particularly since the text of the Autopsy Report itself carefully had been scoured to rid it of any such misleading verbiage.

It bears repeating that Nelson's irresponsible statements to the press are all the more egregious in light of his own concluding statement in the written Autopsy Report, in which he pronounced clearly that "Neuropathologic examination alone of the decedent’s brain—or any brain, for that matter—cannot prove or disprove a diagnosis of persistent vegetative state or minimally conscious state."

We are convinced that Nelson either knew, or should have known, that his irresponsible and misleading "consistent with" and "not inconsistent with" statements to the press would predictably lead them to conclude that the autopsy directly supported the diagnosis of PVS. Dr. Thogmartin sat there and did nothing to contradict, or even qualify, what his colleague Dr. Nelson had to say.

The press and the public cannot be expected to know that beginning with the pioneering work of the great nineteenth century neurologist and neurophysiologist Duchenne it has been clear that clinical diagnoses and assessments of the quality and extent of the mental and motor functioning of the brain and the nerves, and the muscles they control, can only be obtained in the living patient, not postmortem. This applies not only to the higher mental functions but also to complex movements and expressions, from smiling and eating, to tracking visual objects. We know far too little about the functioning of the brain and particularly about its plasticity to be confident in drawing such inferences from autopsy findings.

ORIGINAL OBSERVATIONS ON THE AUTOPSY REPORT:

With Specific Reference to the PVS Diagnosis

Medical Examiner & The Media: Bulimia of the Brain.

The principal finding by the ME that was interpreted by the media and medical experts as supporting the PVS diagnosis was Terri Schiavo's brain weight. The ME's Autopsy Report disclosed that at the time of death Terri's brain weighed 615 grams, barely half the normal brain weight. The ME refers to sex, age, weight, and height differences without providing any data on the breakdown for these categories, and there is no supporting data on the standard deviations or correlations with level of brain function in severely brain-damaged patients. The impression is left with the press and the public that there is hardly anything left of Terri's brain that works, and that the autopsy findings conclusively prove that all of the important centers of cognitive and other high-level human functioning including volition, emotion, sense perception and feeling pain were utterly disabled if not destroyed.

Yet as we indicate below, the regions that govern cognition and emotion were largely intact in Terri's brain, and we have uncovered new findings in the medical literature suggesting that at least a large portion of the reduction in the weight of Terri's brain is likely attributable to the dehydration process to which she was subjected in being euthanized.

As we illustrate below, the media mimicked the ME in consistently mischaracterizing the degree of Terri's brain damage and the purported significance of her brain weight postmortem. The use of brain weight to support the PVS diagnosis may turn out to be as much of a fiction as the scandalous misattribution of her weight loss prior to 1990 to an imaginary diagnosis of bulimia for purposes of her husband's lawsuit. While the ME was at pains to refute the evidence for the fraudulent bulimia claim in the Autopsy Report, he merely substituted for it an equally absurd claim that Terri was in a PVS based on a spurious diagnostic entity invented for the ME's purpose--what might be termed "shrunken brain syndrome."


Shrunken, Shriveled, Withered, Liquified.

The media had a field day kicking around Terri's brain. It was common for the press to characterize her brain as if she were a victim of a head-shrinking tribe in deepest, darkest Africa. Before the autopsy, Terri's brain was frequently described as "liquified" by certain of the more refined members of the press corps, as if it had been removed, whipped-up in a blender, and then poured-back into her skull.

"Reporting" for NPR'S All things Considered on March 24, 2005, the celebrated liberal brain scientist and plagiarist Nina Totenberg remarked that "Terri Schiavo has been in a persistent vegetative state, that her cerebral cortex has been liquified, that she cannot feel, sense or think, and that she has no chance of recovery." And the entrancing Nina knows what that's like, no doubt from personal experience.

The release of the Autopsy Report on June 15, 2005 has unleashed an orgy of celebration in the media and Democratic Party circles over the diminutive size of Terri's brain postmortem, many of the characterizations being extraordinarily vicious and mean-spirited.

MSNBC presented an uplifting AP report about plans for releasing photographs of Terri's brain, citing "George Felos, Michael Schiavo's attorney, as revealing that Michael Schiavo plans to release autopsy photographs of her shrunken brain in the near future."

The Washington Post painted a delightful portrait of its own, enlightening its readers with the insight that, "A meticulous study of the organs, fluids, bones, cells and medical records of the Florida woman who became a cause celebre over the ‘right to die’ also found that her brain was severely shriveled and weighed about half that of a normal adult's."


Not to be outdone,
The New York Times offered its own enchanting image, "An exhaustive autopsy found that Terri Schiavo's brain had withered to half the normal size since her collapse in 1990 and that no treatment could have remotely improved her condition, medical examiners said on Wednesday."

The earlier false account of "liquification" of Terri's brain notwithstanding (hydrocephalus ex vacuo due to brain atrophy is the actual process in which the space previously occupied by the atrophied tissue is replaced by cerebrospinal fluid), the finding of decrease in the size of Terri's brain should come as no surprise given the fact that she was deprived of all liquids and food for the two week period immediately prior to her death.

The brain no less than the rest of the body is composed largely of water. Common sense dictates that there will be significant weight loss in all organs under circumstances of extreme longterm dehydration.

Recent research confirms what common sense suggests, demonstrating that even shortterm dehydration lasting merely hours can produce substantial decrease in brain volume and, we might expect by extension, brain weight. At this point it is impossible to determine to what degree Terri's presumed loss in brain weight is attributable to longterm cerebral atrophy vs. nearly two weeks of total dehydration. Even a basic standard of decency, integrity and respect for truth would surely suggest, however, that the ME should have exercised more caution rather than heedlessly contributing to the utterly predictable "shrunken brain," "shriveled brain" "withered brain" stories that completely dominated the reporting.

In an article published just this year in the leading journal, Neurology, Dr. Duning and colleagues report that even shortterm dehydration lasting 16 hours can produce a significant decrease in brain volume in excess of a half of a per cent. Not directly answered in this study is the question whether the rate of decrease in brain volume due to dehydration directly corresponds to the overall bodily loss of weight, though this is certainly likely. In any case, common sense suggests that much of the loss of weight in Terri's case might be explained as a consequence of longterm dehydration over the two week period after her feeding tube was disconnected and she was denied any hydration or sustenance of any kind. The ME omitted all data on overall weight loss as a result of dehydration from the Autopsy Report on Terri Schiavo, though the report does indicate Terri's weight at the time of death was 112 pounds, providing a basis for comparison if she was weighed prior to removing her feeding tube.

Recovery of Mental Function: Evidence from Hemispherectomy.

Every week it seems there is a story in the media about the amazing brain with its ability to recoup from injuries due to its marvelous functional plasticity. This extraordinary capacity of the brain permits an injured brain region that controls for instance language or music or intellectual ability or motor function to effectively "relocate" itself to alternate uninjured areas and rebuild from scratch seemingly lost capacities and connections. In recent years and months any number of television programs have been aired and a veritable barrage of articles written concerning individuals with intractable seizure and other neurologic disorders who have undergone a procedure known as hemispherectomy in which all or most of the diseased side of the brain is removed surgically.

Clearly, hemispherectomy patients suffer an extreme loss in brain weight (approaching the 50% loss supposedly suffered by Terri) even though in cases where the alternate method of functional hemispherectomy is used, something less than the full half of the brain is removed. These operations are usually highly successful, especially in children, most of whom regain normal intellectual, language and other functioning.

This is not at all to suggest that a PVS diagnosis is always unwarranted in patients who suffer an extreme degree of brain atrophy resulting in a loss of a large percentage of the brain's volume or weight. Yet it is just as impossible to conclude from a postmortem finding of low brain weight that the patient was PVS prior to his death.

With respect to the question of PVS, Terri's autopsy is perfectly incapable of providing instructive answers. While a marked loss of brain weight or volume after surgery or other brain insult is "consistent with" PVS, it is equally "consistent with" a minimally conscious state or even a fully conscious state. The level and state of consciousness is a function of a variety of factors most of which are not meaningfully illuminated by an autopsy--or brain weight. Most hemispherectomy patients return to a fully conscious state, with restoration of cognitive and other abilities, despite suffering loss of half, or nearly half, of their brain weight. At least as important as the brain's weight is the determination of which areas of the brain are lost to surgery, trauma or other forms of insult.

Error Rate in PVS Diagnosis.

As noted many times during the course of the controversy over whether to euthanize Terri, the diagnosis of PVS is subject to an error rate as high as 43 per cent even when the evaluation is done in living patients, according to a study by leading investigators and carried out at the Royal Hospital for Neurodisability, London and published in the British Medical Journal. Should life and death decisions be made on the basis of a diagnostic category misapplied in nearly one out of every two cases?

Postmortem assessments of PVS are completely illegitimate and anyone such as Dr. Miller of NYU who treats postmortem data as sufficient to establish a conclusive diagnosis of PVS is practicing junk medicine. What basis does Dr. Miller have to appear on CBS Nightly News to ridicule family, friends, and physicians who carefully studied Terri Schiavo when she was alive and reached the contrary conclusion? Did Dr. Miller ever examine her during her life? Did he ever read her entire patient record? Did he view the full videotapes of her being examined by neurologists who are disability experts? Did he read their reports or listen to their comments?

Some of the more irresponsible diagnosticians with purported "expertise" in assessing consciousness may even have a demonstrable track record of 100 per cent misdiagnosis rate in PVS. This will be demonstrated in a future publication in which we will discuss the diagnosis of PVS in Terri's case.

We maintain that for all of the above reasons it was misleading for the ME to employ the language of "consistent with" to suggest to the press and the public that the weight of Terri's brain was of substantive evidentiary value on the PVS question.

We also contend that Dr. Nelson's comparison in the Autopsy Report of the weight of Terri's brain to that of another patient, Karen Ann Quinlan, is equally misleading and liable to being criticized as intentionally deceptive. To the best of our knowledge, Karen Ann Quinlan died naturally of pneumonia and was not euthanized by means of longterm dehydration. It would therefore seem that for this reason alone there is little if any basis for comparison. The reference to Karen Ann Quinlan in the Autopsy Report appears to be gratuitous; yet another possible example of intentional misrepresentation and deception meriting inquiry as to its significance and motivation.

Irreversibility of Brain Damage: non sequitur.

We were extremely disappointed in the intellectually dishonest comments of Medical Examiner Dr. Jon Thogmartin on the issue of Terri's putatively irreversible brain damage. The ME stated that, "This damage was irreversible, and no amount of therapy or treatment would have regenerated the massive loss of neurons." This account is a prime example of a non sequitur, falsely suggesting that the antecedent somehow supports the consequent.

Now, by definition, since neurons cannot be regenerated in the living human brain, when neurons die there is no way they can be regenerated. This is true of every person alive, not just Terri Schiavo, since in varying degrees we have all suffered a limited quantity of non-regenerable neuronal death. For most of us the loss of a certain number of neurons over the course our lives is not noticeable until we reach an advanced age. To state that Terri's neuronal loss, as being irreversible, is somehow special, or particularly significant, is therefore completely misleading. All neuronal loss is "irreversible," as Dr. Thogmartin well knows.

Patients who undergo major brain surgery and victims of serious head injuries and other brain insults and disease processes have all suffered significant death of neurons none of which can be regenerated. In consequence, to this extent they have all suffered "irreversible brain damage." But the vast majority can recover significantly from their temporary loss of motor or mental function, without meriting anything like a PVS diagnosis.

Once again, the ME is being at best unintentionally misleading and at worst intentionally deceptive by making the utterly meaningless and even tautological statement that, "This damage was irreversible, and no amount of therapy or treatment would have regenerated the massive loss of neurons." In doing so he leaves the clear impression with the press and the public that there is something special, final and irreversible about the effect on mental functioning of the death of neurons in Terri's particular case.

Out of the "fact" that Terri has allegedly sustained some unique type or extent of neuronal loss "consistent with" PVS, the ME creates the utterly false impression that this proves beyond doubt that in fact Terri was braindead and that in all of the areas of mental and motor functioning she would never have received any benefit from therapy while she was alive.

These two points are completely distinct and the distinction needs to be maintained by any legitimate ME issuing an Autopsy Report, if he is to avoid the accusation of extreme negligence and irresponsibility, or worse: (1) autopsy data on the distribution and quantity of neuronal damage in the brain, all of which entails permanent and irreversible loss of neurons; and (2) whether the patient can recover function through medication, surgery, rehabilitation, or the natural healing process.

Dr. Thogmartin appears to have utterly confused the two concepts in a manner that can only be described as reprehensible for being extremely negligent and misleading in an official charged with the objective, factual, and accurate assessment of the cause of death in Terri Schiavo's case. If this is true, he deserves the sharpest possible criticism, even if he claims that his extremely misleading statements were not designed to deceive. It is difficult to imagine, however, that he did not anticipate how these reckless remarks would have been received, interpreted and deployed by the rabidly pro-death mainstream media.

It must be said that, in the Thogmartin-Nelson Autopsy Report and news conference, no less than in the media reports, the facts of Terri's case have been consistently stated in a slanted and tendentious way to suggest that the postmortem evidence is confirmatory of PVS and irreversible loss of all conscious function, something that can hardly ever be established by postmortem data. This includes the opportunity for Terri to regain the ability to eat and drink by mouth, as we will explain in a subsequent section of this Q & A series.

Perhaps the most deplorable medical commentary on the Schiavo case in general, and the Autopsy Report in particular, has come from the renowned forensic pathologist Dr. Michael Baden. On Fox's show,
On The Record With Greta Van Susteren, Baden mystically intuited from the 2005 autopsy findings, "The damage occurred in a few minutes in 1990, [her brain] shrunk down to less than half its size and all of the cells for consciousness, all of the cells for seeing, she was blind all this time, all the cells that could recover and give her more function just disappeared."

PVS vs. Preservation of the Frontal and Temporal Lobes.

What went largely unreported in the media is the interesting section of the Autopsy Report entitled, "Neuropathology Macroscopic Description," written by Dr. Nelson, wherein he coldly observes without comment that, "The changes seen were striking in their appearance, and global in their distribution. They predominantly involved the border zone ("watershed") areas and were most severe in the occipital lobes, with relative preservation of the frontal and temporal lobes." The ME also remarks, "The frontal temporal and temporal poles and insular-cortex demonstrated relative preservation."

While Nelson here does nothing to quantify "relative preservation," it is worth noting that the "relative preservation" of the frontal and temporal lobes speaks, if anything, against the diagnosis of a PVS state and is certainly "consistent with" higher cortical functioning with consciousness of some degree. This finding is of no evidentiary value on the PVS question apart from the fact that it makes it all the more illegitimate for any medical expert or the media to conclude from the Autopsy Report to a PVS diagnosis. As meaningless as this term "relative preservation" may be, the preservation of these brain regions makes the autopsy "consistent with" consciousness. This includes anything ranging from a minimally conscious state, to some variant of the "locked-in syndrome" in which the paralyzed patient is conscious, but unable to move or form meaningful sounds--essentially a prisoner trapped in his own body. Clearly this fact alone does not dictate that Terri had to have been cognitively "normal" or even conscious at all. Nor does it prove, as one medical ethicist has suggested through WorldNetDaily, that "What this tells us is that her cortex retained function." As noted above, such determinations are entirely outside the scope of postmortem data and can be made only through examination of the living patient.

NEW EXPLANATION FOR TERRI's PUTATIVE CORTICAL BLINDNESS: DEHYDRATION.

There is yet another potentially spurious interpretation of the objective data by the ME in the Autopsy Report: his suggestion that Terri suffered from total cortical blindness predating her death. Cortical blindness involves severe neuronal loss in the brain's visual cortex despite eyes that are anatomically and structurally healthy and intact .

The clear implication is that court-ordered videotapes of neurologic examinations from 2002 in which Terri Schiavo clearly appears to track visual objects, and visually recognize and react to people in her environment are examples of merely coincidental reflex movements being misinterpreted as visual and other conscious mental responses due to wishful thinking on the part of those wanting to keep her alive.

"Her vision centers of her brain were dead," the ME claimed. Thogmartin continued, "Therefore, Mrs. Schiavo had what's called cortical blindness. She was blind, could not see."

The clear implications of the ME's assertion (not to mention its mocking, hymnal tone) are: (1) that Terri was totally blind for the weeks, months and years prior to her death; and (2) that the widespread impression that she had vision and the capacity to track objects and even recognize people is a complete fiction or delusion on the part of her supporters, including neurologists who are experts in disability assessment. The statement, "She was blind, could not see," is senseless if limited to the period after her death or even the two week period where she was dying of dehydration. The ME's claim makes sense and has significance only if he was referring to the years and months prior to her death when she was being sustained by a feeding tube and her supporters were fighting to keep her alive.

Whatever his thought process, it is certain that the ME's contention that Terri suffered from cortical blindness predictably left the absolutely clear and unmistakable impression with the press and the public nationwide and worldwide that for years and years prior to her death Terri was totally blind and never saw or recognized anybody. Here the ME was contradicting the claims of parents, siblings, and friends who interacted with her, and several of the physicians and neurologists specializing in disability assessment who very thoroughly examined her level of mental, sensory and motor functioning back in 2002.

Leaving aside the claims of her supporters that Terri was sighted, prior to removal of her feeding tube and particularly back in 2002 when she was videotaped seemingly responding to visual stimuli, there are several factors that call into question both the ME's diagnostic interpretation and his personal motivation in communicating it:

(1) It is necessary to point out that it is virtually impossible for an autopsy to firmly date the onset of cortical blindness in a case such as Terri's. The mere fact that a decedent has massive neuronal damage to the occipital lobes at the time of autopsy does not prove that all or any such damage was present one month, one year, or one decade prior to death. On these grounds alone, we can say that Dr. Thogmartin was unwarranted in interpreting the findings as he did. Thogmartin all but dictated to the press that, back in 2002 when the court-sanctioned videotapes were made of her clearly appearing to track visual objects, this was all an illusion, and: "She was blind, could not see." We may cite on this question no lesser authorites than the two MEs, Drs. Thogmartin and Nelson themselves, as acknowledging in their written Autopsy Report that it is not legitimate or reliable to retroactively diagnose the clinical state in a living patient using that patient's postmortem findings--particularly when the higher mental, sensory and motor functions are in question.

(2) There is nothing in the autopsy findings that negates the possibility that, having sustained a severe anoxic insult to her brain in 1990 (or at some later stage) causing major damage to her occipital lobes, Terri suffered for years not from total cortical blindness but from some degree of what is known as cortical visual impairment. To use the language of the ME, it is perfectly "consistent with" the postmortem findings that the damage to her occipital lobes occasioned a less-than-complete blindness. There are several possible causes of occipital lobe damage capable of causing cortical blindness or cortical visual impairment, one of which is elevated pressure due to hydrocephalus. -- To repeat, the postmortem finding reported by the ME, of "hypoxic damage and neuronal loss in her occipital lobes which indicates cortical blindness," is by no means proof that Terri was totally blind either in 2002 or even early in 2005 prior to implementation of the dehydration order. While this postmortem finding is "consistent with" longterm total cortical blindness, by no stretch of the imagination does it provide proof that she was totally blind during the years, months or even weeks prior to her being euthanized by dehydration. The fact is, there is every reason to suspect that Terri Schiavo had partial vision for years prior to the execution of the dehydration order.

(3) Lastly, we suggest it is also possible, according to recent reports in the medical literature such as this, that the devastating dehydration to which Terri was subjected during the last two weeks of her life, might have exacerbated her already existing cortical visual impairment. This dehydration, producing varied neurotoxic effects not at all limited to the loss of basic brain weight and volume referenced above, may have induced an ischemic insult in the occipital cortical region thereby occasioning significant neuronal loss that was magnified as the effects of dehydration progressed. It is not our intent to explain the actual mechanism that might have led to the objective autopsy finding of pervasive damage to the occipital lobes, but merely to remind the ME, the press and the public that such a postmortem finding does nothing to prove the existence of total cortical blindness prior to the inception of the dehydration process. -- What might have been the effects of dehydration on Terri’s visual cortex, and did the dehydration process hasten the demise of already vulnerable brain structure? -- Based on the autopsy, there is reason to believe that back in 1990, Terri's visual cortex had borne the brunt of the anoxic attack in which she sustained profound damage to the occipital lobes and proximate regions of her brain. We may speculate that the already impaired visual centers of her brain were therefore most vulnerable to subsequent insults such as the severe dehydration that caused her death when her feeding tube was disconnected. Accordingly, what the ME found at autopsy may reflect the accelerated effects of extreme dehydration within the last two weeks of her life upon the already diseased visual cortex rather than what would have been the state of Terri's visual cortex had she not been deprived of fluids and feeding through her feeding tube.

All of the above evidence suggests that the Medical Examiners, Drs. Thogmartin and Nelson, likely went into the autopsy process with the preconceived notion that Terri Schiavo was in a persistent vegetative state (PVS), incapable of any human mental functioning or even feeling pain, despite convincing evidence to the contrary. By bending and breaking the rules and standards of science and medicine, including those contained in their own Autopsy Report, they convinced themselves of the veracity of what they already knew prior to autopsy, and identified data such as reduced brain weight and cortical blindness that supported their preconceived conclusions. They then set about systematically providing the press with their manufactured "evidence" for the PVS diagnosis, knowing that the impatient liberal mainstream media was primed to spread these lies to the public in order to advance their political and social agenda.

CONCLUDING POSTSCRIPT TO AN UNSCIENTIFIC AUTOPSY REPORT: A MEDICAL "WILDING"

The ME's Autopsy Report, and the reporting on it, provide an object lesson in media and medical misinformation and deliberate distortion, amounting to a "medical wilding" with Terri as its victim.


On virtually every issue of importance to her family and public policy, the ME's Autopsy Report lent itself to misinterpretation and misuse. If our analysis is correct, the statements to the press by the ME were tendentious, negligent, and irresponsible in the extreme, and their PVS inferences from the limited facts and objective findings of the autopsy were consistently unsupported and designed to deceive. The contrast between their reckless remarks at the news conference, and the somewhat more carefully stated facts presented in the print version of the Autopsy Report, further support the suspicion that they were pursuing an agenda in their presentation but wanted to hide behind more cautious formulations in the formal report.

Their distorted interpretations of the facts both in the print version and particularly in the news conference directly contributed to wildly misleading reports in the liberal mainstream media and the other pro-death propaganda mills.

In our opinion, the Pinellas County Medical Examiner Dr. Jon Thogmartin and the consulting forensic neuropathologist Dr. Stephen Nelson, the Medical Examiner of Polk County, who jointly produced the Autopsy Report deserve criticism no matter what their explanation. Either they intentionally deceived the public with comments that lent themselves to predictable misuse by the politically motivated liberal mainstream media, or they were incompetent and negligent in not anticipating the consequences of their confused, misleading and equivocal statements.


Their unscientific interpretation of the facts and their biased presentation was irresponsible in the extreme. Cautionary statements buried deep within the text of the Autopsy Report do not provide adequate cover for a presentation that in the overall sense followed an arc of untruth and provided ammunition to those in the media engaged in an aggressive assault on the truth for political purposes. In most cases this was due to Thogmartin and Nelson ignoring their own cautions against drawing unscientific inferences about the functional capacity of Terri Schiavo's mind and body during her lifetime, based on the physical state of her brain at the time of autopsy.


The strategy of the liberal mainstream media and the biased medical experts on whom they relied for cover in analyzing and interpreting the facts, is the scientific equivalent of the proverbial cheating husband caught in the act by his wife. The husband, caught in flagrante dilicto, says, Look, honey, what are ya gonna believe, what I tell you or your own lying eyes?


The media promulgated the deception that everyone’s eyes really did lie, that the videotapes clearly showing Terri recognizing her relatives and expressing pleasure and pain were the product of delusions and hallucinations. Armed with the ME's misleading interpretation of the postmortem data, the media was convinced it had a license to purvey the Big Lie that Terri Schiavo was merely a mindless lump of withered matter, a mere vegetable, incapable of thought, will or emotion and even incapable of feeling pain--functioning merely by the same reflex jerking seen in a recently severed frog’s leg.

Some frog, some leg.

It is the liberal mainstream news media that is braindead and beyond resuscitation. They are the ones who have suffered total blindness, who are permanently and totally incapable of seeing or recording or reporting reality. Their minds and souls and senses are completely withered, neuronally dead, irremediably and irreversibly so. They are sustained by their corporate feeding tubes and financial life support, dying a very slow, slow death without feeling any twinge of pain or remorse. Yet in their case no judicial authority exists to order mercifully that the plug be pulled. The autopsy report is yet to be written.

LINKS TO RELATED ARTICLES

Terri Schiavo: The Locked-in State

... What Terri Taught Us

.

PROOF: Judicial Filibusters Violate U.S. Constitution

... Every Senate has the right to make its own Rules, but not its own Constitution

.

RETURN TO HOMEPAGE

84 Comments:

Blogger Jesuspower said...

Yes! I am not the only one!
I hope you don't mind, I linked to this post on my an article on my site. Just thought you would like to know.
http://apathyonline.net/2005/06/schiavo-autopsy-report/

11:54 PM  
Blogger Sue Bob said...

You are right Dr. Eros, I should said that the autopsy does not rule out the possibility that her cerebral cortex retained function. Point well taken and lesson learned.

Jerri Lynn Ward aka Sue Bob

11:36 AM  
Blogger Peggy Snow Cahill said...

I read the autopsy report, and noted many of the things you mentioned. But why was her toe missing?

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9:36 PM  
Blogger Maggie said...

Dr Sherry,

I am in Australia and I have not had time to read what you have written. It is my bedtime and I will now have to wait until tomorrow night before I can read what you have to say. From the quick flick through your comments, I am here to ask two questions:

1. I wanted to do a question and answer from a lay person's point of view on my own blog. Will you be willing to participate?

2. May I use the comprehensive information that you have provided in my own blogs.

I am personally not negative about the M.E. report, even though I do think that there are some obvious errors. Overall, I think that Thogmartin has done what was expected of him but has left the way open to hammer the one who has joined the dark side of the Force.

As a lay person I am struggling with the terminology, but I do have the assistance of my own doctor in this matter.

As one who has had soft tissue injuries as a result of trauma, not abuse, I have some understanding of the issues that have been raised. For instance I am quite happy to take Thogmartin apart over his responses concerning the bone scan report. It is significant that the Ghoul Felos team did not provide the actual scan. I do not know what the practice might be in the USA but here in Australia I own my x-rays and bone scans, and I have the actual film from both bone scans that have been performed.

On my own blog I had been dealing with the Dr. Walker testimony on the bone scan. Only last week I realised that I had not completed that task because I had not got to the real absurdity of some of the questions that he was asked. Where I take issue with Thogmartin is that he went along with the Fox/Felos idea that a bone scan can detect osteoporosis. In Thogmartin's defence however, he has recognized the most likely cause for Terri's knee pain as H.O. - heterotrophic ossification. I now have a better understanding of this condition and am going to suggest that this is a sign of early trauma to Terri's knees. This is something that I want to discuss on my blog.

7:12 AM  
Blogger Maggie said...

Dr Eros,

I have so many questions that need to be raised about the content of the autopsy report. Since I am not medically inclined, but have suffered some trauma from injury, I have taken a very keen interest in the autopsy findings (much to my amusement I discovered something about myself that is not just a female thing when it comes to difficulty reading maps and not knowing the difference between left and right)

I want to raise a question regarding what has been totally ignored by the MSM regarding the regeneration that was in fact going on in Terri's brain.

What is of interest to me are the comments on page 15 of the report. Since I do not understand the language of the report I am interested in undertanding more fully what the ME meant by stating that one type of cells was replaced by the functioning of another type of brain cell. The exact terminology is: the lost Purkinje cells were replaced by reactive Bergman astroglia. What does that mean?

4:52 AM  
Blogger pc93 said...

Post the following to as many blogs asking them to feature it as a regular post.. also when contacting jeb via fax and e-mail include this, and also spread as far and wide as possible:

Michael Schiavo's 30-70 Minute Gap Exploded Away Regarding 911 Call Seeking Assistance for Terri Schiavo

Charts prove a much larger gap in which Michael Schiavo did not seek help and also prove his various testimonies are merely concocted stories made up while under oath,.

Michael Schiavo asserts on Terri Schiavo's tombstone that she departed this earth on February 25, 1990 but failed to tell that to the medical malpractice jury when seeking and winning millions of dollars for her care. Charts explode away 30-70 minute gap mentioned by authorities regarding Terri's "collapse" and time Michael Schiavo waited in seeking help and add an additional 2 hour gap. In fact Michael's accounts proven to be no more than stories hiding his complicity in her collapse. See the charts:

http://tekgnosis.typepad.com/tekgnosis/2005/06/terri_schiavo_c.html

10:17 AM  
Blogger WICatholic said...

I am going to have to read this over and over in order to remember it well. I am impressed, as much of what I was thinking as I heard the ME is what you have said here, much more thoroughly, of course, as I am a nurse, not a physician.

I am concerned also about the cortical blindness aspect of the autopsy and news briefing.

In looking for the origin of a news article about a neurologist named Dr. Thomas Zabiega, MD debunking the autopsy, I came across your very excellent lengthy article. I will tell others about it on my own blog. God bless!

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