In some instances, sudden death during or following a struggle can be caused by natural disease that is not diagnosable anatomically. In such instances, a medical history is absolutely necessary to make the diagnosis. Some examples are Wolfe-Parkinson-White syndrome, the prolonged Q-T syndrome, etc. In one case, an interview with the family revealed a history of "fluttering" or "pounding" heartbeats, a "funny pulse," suggestive that the individual had an underlying physiological lesion of the conduction system of the heart predisposing him to develop an arrhythmia.
Most medical professionals, including forensic pathologists, have no experience with individuals who are in the throes of excited delirium. They do not comprehend the violence or the intensity of the struggle. Thus, to restrain a 12-yr-old child during an acute psychotic episode may take four large adults, one to each extremity, while a fifth administers a tranquilizing injection. Nursing articles recommend that, when attempting to physically restrain a violent individual experiencing an acute psychotic episode, at least six individuals be used.13
When someone dies during a struggle, the natural question is why. An explanation involving catecholamines, alpha and beta receptors, and potassium levels, is difficult for most people to understand. Choke holds and positional asphyxia can be demonstrated and are simple to understand, therefore, it is normal to gravitate to this simpler explanation for a death. Even if there is absolutely no evidence of use of a choke hold or positional asphyxia, and the law enforcement or medical personnel deny using either, the denials are sometimes dismissed as a cover-up. The concept of death caused by a choke hold is very popular because, when no evidence of trauma to the neck is found, this would seem to "prove" that the choke hold was "expertly" applied. Of course, use of a choke hold is just a form of manual strangulation. It always amazes me when a 200-lb adult male is allegedly killed with a choke hold without a mark on the throat and no petechiae in the eyes, while a 100-lb woman, manually strangled by an individual twice her weight, is able to put up sufficient struggle so as to have bruises on the neck and petechiae of the conjunctivae and sclerae. Since use of a choke hold is manual strangulation, the individual applying the choke hold must maintain it for close to 2 min to cause cessation of respiration.
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