This House of Grief: The Story of a Murder Trial (14 page)

People who have blacked out are often referred to neurologists, since a common cause
of syncope—a brief loss of consciousness—is a failure of circulation of blood to
the brain. So the first of the Crown’s two medical expert witnesses was Dr John King,
a lean, dry, intensely reserved gentleman in gold-rimmed spectacles, who had been
practising as a consultant neurologist at the Royal Melbourne Hospital since 1975.

Dr King had seen many an individual with chronic obstructive airways disease go into
a paroxysm of coughing, turn purple in the face, become distressed, and have to sit
down; but not a single one of these had actually collapsed on the floor in front
of him. He had seen it happen on a teaching video, but never in real life.

In fact, during thirty years in his specialty Dr King would have come across only
about six cases of coughing followed by a blackout. In each of these, the patient
had reported a blackout to a GP who, wanting to rule out serious conditions like
epilepsy, had sent him along to Dr King for a neurological check-up. Off the top
of his head, Dr King could not remember even one of these six cases who did not have
lung disease. He had diagnosed cough syncope in them only after getting from the
patient a credible history, particularly one corroborated by an eyewitness.

How brief was the loss of consciousness in cough syncope?

Oh, very brief, said Dr King. Unlike an epileptic fit, where the patient can be unconscious
for up to three or four minutes and is often confused and without memory for half
an hour or so, an episode of
cough syncope lasts only five, ten, twenty seconds.
Afterwards the patient is usually rapidly orientated, and can recall what happened
just before he passed out. There exists, too, something called a pre-syncopal episode,
where the paroxysm of coughing can lead to a feeling of being very unwell, light-headed,
dizzy. The sufferer will perhaps sit down and try to control the cough. Vision may
narrow. Stars may be seen. But a blackout can also occur suddenly, without warning.

Mr Morrissey asked whether cough syncope could be accompanied by compulsive activity.
Was it beyond the realms of possibility that a person might maintain his grip on
a steering wheel, or move a steering wheel to direct a vehicle in a certain direction?

Not in a purposeful sense, said Dr King. He may fall on the steering wheel and make
some convulsive movements, but generally the movements seen in a person with cough
syncope are merely ‘repetitive twitching of the limbs’.

Morrissey had dug deep and come up with some case studies from American medical journals.
According to one of these, dated 1953, chronic pulmonary or respiratory diseases
were associated with seventy-five per cent of cases of cough syncope—in other words,
only three-quarters of them. In 1998, the
Aviation, Space and Environmental Medicine
journal had described the case of a forty-one-year-old US Army helicopter pilot who
was driving home from training with his unit. He had a mild cold, with a cough. On
the road he coughed forcefully, experienced tunnel vision and light-headedness, and
passed out. His car hit a tree. He was unconscious only for seconds, and recalled
the incident immediately. He reported no headaches, shortness of breath, loss of
bowel or bladder control, chest pains, tremors, nausea, vomiting or amnesia. His
medical history was notable only
in that he was a smoker and overweight. He had no
chronic airways disease. A third case involved a healthy forty-five-year-old with
the flu who had suffered a cough syncope episode. Had the neurologist read all of
these documents? Yes, he had, replied the impassive Dr King.

Morrissey was driving Dr King back against the wall, but there was a sense of strain
in the cases he was quoting, a sort of thinness. They felt distant, sparse, dredged
up. I looked at the jury. They were concentrating hard. The faces of most were unreadable.
But one of the older women was listening with her head tilted back, the corners of
her mouth pulled into her cheeks, her eyes narrowed to slits: the expression that
in ordinary life prefaces a click of the tongue and a sharp ‘Come off it.’

Ms Forrester, re-examining, drew from these same case studies the fact that most
of the subjects had identified themselves as heavy smokers. The American chopper
pilot had recently been subjected to G-force in the course of his aviation training.
Dr King shrugged calmly. He knew nothing about the effect of G-force on cough syncope.
But he pointed out that most people who reported incidents of cough syncope were
in their forties and fifties, so that thirty-six, Farquharson’s age at the time of
the crash, was perhaps at the lower end of the range. The twitching seen during cough
syncope, he repeated, was ‘involuntary and purposeless’. A person in such a state
would not be capable of the purposeful steering of a car.

At this, the journalists en masse leaned forward to their notebooks, and the ABC
television reporter sprang up and darted out of the court.

…

Professor Matthew Naughton, the Crown’s main expert medical witness, was the only
man I had ever seen wear a pink tie with a tweed jacket. Rimless spectacles hung
round his neck on a black cord. His turned-up nose made him look young, but he had
a real mouthful of a title: Head of the General Respiratory and Sleep Medicine Service
in the Department of Allergy and Respiratory Medicine at Melbourne’s Alfred Hospital.
Mr Rapke led him through a CV of such vast scope and lavish detail that the journalists
could hardly keep straight faces. The reporter beside me, stifling laughter, printed
on my notebook, ‘Are you clever?’ But, as soon as Rapke’s examination began, Naughton
showed himself to be soberingly quiet and modest.

Cough syncope, he said, is a recognised medical syndrome—a very brief loss of consciousness
that follows an episode of intense coughing. The medical literature has described
it for half a century in middle-aged, overweight males who are usually heavy smokers
with underlying heart or lung disease. The mechanism most people accept as its cause
is repetitive coughing that causes pressure within the chest. This pressure impairs
the flow of blood on its way back to the heart from the lungs, so that the heart,
when it contracts, has less blood to pump on its forward way.

‘I have trouble getting my head around this condition,’ said Naughton, ‘because it’s
so nebulous. When I look through the literature on cough syncope, I find an absence
of good quality scientific rationale to back up the validity of the condition. In
twenty-five years as a medical practitioner I have never personally seen it.’

He had asked his respiratory colleagues at the Alfred Hospital ‘in a casual manner’
whether they had experience of cough syncope. They all knew of it as a condition,
but there was only one case that
any of them were personally acquainted with—a young
man who suffered from the severe and chronic pulmonary condition cystic fibrosis
and a neurological condition that impaired blood supply to his brain. The nurses
on the respiratory ward were aware of his vulnerability to cough syncope and had
to try to manage it.

Naughton had also consulted the physiotherapy staff at the Alfred. Part of their
work is to test for the presence of a germ called pneumocystis that is common in
the HIV population—people who, apart from their HIV-positive status and some breathlessness,
are healthy. These patients are asked to inhale a hypotonic saline solution, which
causes them to cough vigorously for up to thirty minutes. A physiotherapist who had
administered this disagreeable-sounding treatment about once a week for ten years
told Naughton she had not seen a single case of cough syncope in all that time.

‘Do people with normal lungs, hearts and brains,’ asked Rapke, ‘suffer cough syncope?’

‘I have never seen a case in which that has occurred,’ said Naughton. ‘Nor have I
seen, in the modern medical literature, objective descriptions in which people have
actually witnessed and monitored a person having cough syncope in which there has
been normal heart, lung or neurological function.’

Now Rapke sharpened the focus. He asked Professor Naughton to imagine himself clinically
faced with a man aged about thirty-seven, moderately overweight, a smoker who said
he went through a packet roughly every three days. He was generally in robust health,
but had been suffering for about three weeks from an infection which commenced in
the upper respiratory tract, then developed lower down, and was being treated with
antibiotics. An ECG taken
‘after a certain incident’ revealed no heart abnormality,
a systolic reading of 140, and a rapid pulse. Seen immediately after the incident
by paramedics and doctors at a hospital, he was not observed to be coughing. He had
taken fluids within two hours of the incident. At the time of the incident, which
he said occurred while he was driving, he was in a seated position. After the incident
he was generally coherent and seemed to be lucid. He had been immersed in cold water,
but had got himself out of the water, waved down a car and conversed with its occupants.

Morrissey jumped to his feet. To say that the man was coherent and lucid, but not
that he was also delirious and
a babbling mess
, was misrepresenting the true situation!

‘I won’t intervene,’ said the judge. ‘Go on.’

No underlying medical illness was known or detected, Rapke continued smoothly. Blood
tests showed no alcohol or drugs in his system. The patient claimed that as he was
driving on a cool, even cold night, he had a coughing fit at the wheel of his car,
and blacked out. Based on these facts, what was Professor Naughton’s professional
opinion of the likelihood that the driver of that car had suffered an episode of
cough syncope?

The professor hardly allowed a pause. ‘Extremely unlikely.’ From Rapke’s description,
the man’s heart and lungs were in reasonably good health. He did not appear to be
disabled by breathlessness. He was plainly not dehydrated. A dehydrated person who
coughs would be more likely to experience changes in the pressure inside his chest—maybe
not a blackout, but a dizziness that doctors call pre-syncopal.

Naughton was quiet and lucid. Rapke stood still and let him go on uninterrupted.

The interior of the car, said Naughton, where the hypothetical man said the coughing
fit had overwhelmed him, would have been much warmer than the air outside. Cold can
often trigger coughing, but this man did not cough after the event, although he was
exposed to cold air and wearing wet clothing. Also, at the time he claimed he had
started to cough, he was seated. A lot of our blood volume is in our abdomen and
legs: cough syncope is more likely to occur if someone is fully upright.

Certainly he had a common-or-garden variety respiratory-tract infection. These happen
every day in society, yet people with colds are not having cough syncope on a day-to-day
basis. A single episode of cough syncope in a relatively warm environment, and one
that was not replicated, struck the professor as highly unusual.

What if this hypothetical man, two days before the crash, asked Rapke, had been observed
to have a severe coughing fit while on his feet? If he had gone red in the face,
but had recovered once he was invited to sit down?

The fact that man had
not
passed out only consolidated the professor’s opinion. All
of us in this room, he said, could cough to the point at which the colour of our
facial skin changed.

He would expect a person with cough syncope to recover consciousness within seconds.
He might feel confused for a few moments. Naughton had read reports of people becoming
‘flaccid’ when they lose consciousness: he let his head and shoulders droop forward,
and flopped his hands apart, palms up, on the rail of the witness stand.

‘In that period,’ asked Rapke, ‘would the person be capable of any purposeful movement?’

‘Not if he was unconscious!’

What did it mean to say that the diagnosis—even a provisional one—of cough syncope
is done ‘on history’?

‘We’re dealing,’ said Naughton, ‘with an extremely rare condition. Ideally we like
to have a collateral history—at least one observer who witnessed the person cough
and black out. But there is no definitive test that confirms or refutes cough syncope,
apart from a classic description.’

‘The accuracy of the diagnosis is, then, solely dependent on the history?’

‘A hundred per cent,’ said Naughton.

‘But,’ said Rapke, ‘if you’ve got only the patient saying it happened, how does one
test the diagnosis?’

‘It’s impossible to test. It relies on the individual providing an accurate history
of what went on.’

…

Mr Morrissey himself was still struggling with spasms of harsh, dry barking that
threatened to overwhelm him, but he was soon roughing up Professor Naughton with
skill and gusto.

‘You’re not an expert in cough syncope? Did you tell the prosecutors, when they
came to you for an opinion, that you’ve never seen it, never written about it, never
diagnosed it, and didn’t know the way an episode would unfold if it happened? Yet
they still called you as a witness?’

Naughton protested. ‘I’ve completed a training in respiratory disease where these
conditions are discussed.’

But Morrissey made him out to have swotted up on cough syncope very recently and
shallowly. Had he not read only one textbook and one article on the condition? Did
he even know how to take a history of a cough syncope episode?

Naughton bristled. ‘I am educated about cough syncope,’ he snapped. ‘I do take a
history of cough syncope when it’s presented to me. Because of its rarity, I don’t
profess to be an expert in it.’

Well, had he read the list of cough syncope case studies that the defence had provided
him with?

‘I did my best,’ said Naughton, ‘but they’re often not electronically available,
and they take some time to locate. A lot of that data is many, many years old.’