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1 Pseudobulbar Palsy and Pseudobulbar Palsy is a

2 situation where the higher center is

3 non-functioning, but not completely destroyed.

4 And a person may be intact otherwise and they

5 have sudden outbursts or crying or laughter and

6 yet be conscious.

7 This is what we call a release

8 phenomenon because the higher centers of the

9 brain, the neocortex, override the lower centers

10 and our emotions in the hypothalamus and the

11 thalamus which is a subcortical mechanism.

12 So when you have a patient who has

13 Pseudobulbar Palsy who has bilaterial strokes,

14 for example, who may be consciously interacting

15 with you and talking, they will have sudden

16 outbursts of laughter or crying they can't

17 control and the reason for that is because the

18 higher centers are not functioning very well at

19 all and so they can't monitor the lower centers.

20 In the lower centers their emotions

21 comes to some extent. Their expression of

22 emotion is from the thalamus and the hypothalamus

23 group, subcortical mechanisms are not monitored

24 anymore by the higher centers. That's what we

25 called a release phenomenon.




602



1 There's also the release phenomenon in

2 neurology. And the vegetative state is an

3 extreme form of the release phenomenon because in

4 the vegetative state the higher centers are

5 essentially non-functioning all together. The

6 cerebral cortex and the thalamus and the

7 hypothalamus to a large degree, depending on the

8 patient, is functioning normally.

9 So it could have these expressions of

10 moaning and groaning and laughing and crying and

11 tearing, expressing without relationship to

12 anything is a form of Pseudobulbar Palsy, in its

13 most extreme form of Pseudobulbar Palsy.

14 So it's essentially the subcortical

15 mechanism acting on their own without any

16 stimulus per se or spontaneously.

17 Q. Now you mentioned the word a couple of

18 times subcortical. What do you mean by that?

19 A. The brain is in two major parts; the

20 cerebral hemispheres and the brain stem. In the

21 cerebral hemispheres there are two major parts,

22 the cerebral cortex, which is the outer layer of

23 the brain matter also called the neocortex, and

24 then you have the subcortical areas like the

25 thalamus and hypothalamus which is the deeper




603



1 gray mass areas.

2 And so we'll often in neurology use the

3 cortical lesion and subcortical lesions in the

4 localizing. In the situation we're talking about

5 here, the patient in a vegetative state

6 essentially has no neocortical functioning at

7 all. None.

8 But the subcortical area, the thalamus

9 and the hypothalamus and related areas may be

10 normal and may be functioning fairly normal so

11 there's a huge disparity between no neocortical

12 functioning, the outer layer, and the subcortical

13 functioning, which may be fairly normal.

14 That's why you can explain the moaning

15 and groaning and smiling of a vegetative state

16 patient because this is a release phenomenon and

17 the thalamus and the hypothalamus may be

18 functioning fairly normal.

19 Q. What area of the brain is associated

20 with cognition?

21 A. Cognition is the neocortex, the outer

22 layer of the gray matter, if you will, of the

23 cerebral hemisphere which is the highest level of

24 the cortex.

25 Q. What is a brain stem mediated response?




604



1 A. A brain stem mediated response is a

2 response that is entirely at the brain stem level

3 that you can have some kind of response which you

4 can explain by going through the brain stem or

5 the subcortical areas together. And you don't

6 need a neocortex to get this response.

7 Q. Can patients in a vegetative condition

8 swallow saliva or handle their saliva?

9 A. Yes.

10 Q. Why is that?

11 A. Well, because that's a -- the

12 swallowing reflex per se, the reflexes is the

13 brain stem mediated reflex in the medulla. And

14 the vast majority of patients in a vegetative

15 state swallow saliva through the swallowing

16 reflex.

17 It may not be perfectly normal and

18 they're certainly prone to having aspiration

19 pneumonia, which is one of the major causes for

20 death, but the vast majority can swallow. They

21 have a reasonably normal swallowing reflex.

22 They can't swallow in terms of whole

23 swallowing process, but there are essentially

24 normal swallowing reflexes in terms of a reflex.

25 Q. If because a patient can swallow saliva




605



1 is it -- because a patient in a persistent

2 vegetative state can swallow saliva, does that

3 mean that such a patient can eat naturally?

4 A. No.

5 Q. Do patients in a persistent vegetative

6 state retain any vision and eye movement?

7 MS. ANDERSON: I'm sorry, vision or

8 what?

9 MR. FELOS: Eye movement.

10 THE WITNESS: Yes, to a variable degree

11 depending on the patient they can have eye

12 movements and they can have vision in the

13 sense that there could be a stimulus coming

14 into the eye where we get a response. And

15 you could have what's called visual-oriented

16 reflex, like an auditory reflex. And some

17 patients in a vegetative state have them and

18 some don't. Some have it to a variable

19 degree. But it's not uncommon to have a

20 visual-oriented reflex which is brain stem

21 and/or subcortically mediated in patients in

22 a vegetative state.

23 BY MR. FELOS:

24 Q. Now, what's the difference between the

25 primitive visual-oriented reflexes and sustained




606



1 visual pursuit?

2 A. Sustained visual pursuit or visual

3 tracking is where the patient will follow you

4 with their eyes from one side to the other and

5 usually patients who come out of vegetative state

6 you see them when their eyes are opened 100

7 percent of the time. They have all the time.

8 So sustained visual tracking is where

9 they follow you with their eyes from one side to

10 the other. They follow using anyone. They can

11 follow some people more than others, but they go

12 from 180 degrees back and forth.

13 And it's -- when they come out of the

14 vegetative state it's overwhelming and obvious to

15 everyone. Now --

16 Q. Excuse me, let me just ask a question.

17 Have you ever witnessed a patient

18 emerge from a vegetative state?

19 A. Yes, I have.

20 Q. Go on then. You were talking about the

21 sustained visual pursuit when that happens.

22 A. So sustained visual pursuit or visual

23 tracking is a cortical -- neocortically mediated

24 response where there's enough neocortex involved

25 so they actually follow -- when they have some




607



1 degree of vision which is cortically mediated so

2 they can follow you from one side of the room to

3 the other.

4 And usually it's on a consistent basis.

5 And usually they said when someone emerges from a

6 vegetative state to the next level, the first

7 sign and the most consistent sign of evolving is

8 sustained visual pursuit.

9 And it's very obvious to most everyone.

10 And there's always an exception to every rule and

11 sometimes it could be difficult, but the vast

12 majority, I'd say 95 percent of the time when

13 they evolve from a vegetative state they do

14 visual pursuits 95, 100 percent of the time.

15 Their eyes are open and it's obvious to everyone

16 that they can see.

17 Q. Now, do patients in a vegetative

18 condition have a response to painful stimulus?

19 A. Yes, they do.

20 Q. Okay. And what type of responses do

21 they have?

22 A. It can vary a great deal from no

23 response at all to when you painfully stimulate

24 them they have all sorts of involuntary reflex

25 movements where they flex their arms in a flexor




608



1 response which is called decorticate posturing.

2 They could have decerebrate posturing.

3 Their legs could move and stiffen out usually

4 which is extension posturing. Sometimes they

5 grimace and sometimes they won't.

6 Sometime they can appear restless and

7 move about in a random fashion. So it really

8 varies from one patient to another. And it also

9 varies because sometimes patients in a vegetative

10 state can fall asleep. If they're asleep it's

11 not a valid examination. You have to have them

12 when their eyes are open to do a valid

13 examination.

14 So it can really vary. Sometimes they

15 will -- sometimes they will have grimacing and no

16 abnormal movements. Other times they'll have

17 abnormal movements with decorticate posturing and

18 extension posturing.

19 They'll often have rigidity of their

20 neck. Their neck will stiffen. Sometimes their

21 neck will actually come forward in a flexor

22 response.

23 So it's quite common. It just varies

24 with some individuals. Some could have grimacing

25 and no movement. Some could have a lot of




609



1 movement and no grimacing.

2 Q. The fact that a patient in a vegetative

3 state responds to a painful stimulus, does that

4 mean that the patient is aware of pain or

5 experiences pain?

6 A. Well --

7 Q. In a cognitive sense?

8 A. When you say "respond" you're looking

9 at the patient and you see how they respond and

10 you see what's a voluntary or involuntary

11 response. That essentially means you look for an

12 involuntary like decorticate posturing. There

13 are certain things that are voluntary,

14 lateralizing reflexes and pushing away a --

15 Q. Excuse me. What is a lateralizing

16 reflex?

17 A. Well, one thing you can do in a patient

18 in a vegetative state you can pinch them on one

19 arm. I usually pinch them underneath their arm

20 like this quite briskly and they have -- they may

21 move that side or they may move both sides in

22 decorticate posturing.

23 Sometimes they'll move one arm and you

24 can't tell whether it's voluntary or

25 involuntarily. But one thing which is a cortical




610



1 response is if you pinch him on this side and

2 they take the other hand and come across the

3 midline toward this area that is a lateralizing

4 response.

5 A lateralizing response is cortical

6 mediated. So when you examine a patient look for

7 decorticate or decerebrate posturing. You look

8 for flexing of the neck. You look for signs that

9 they're interacting with you, their reaction in

10 their face.

11 You look for certain things like a

12 lateralizing response, where they actually come

13 across the other side and localize in one area or

14 they push you away, which it's hard to separate

15 from decerebrate posturing or they pull away from

16 you in a voluntary way or they say ouch, stop

17 that or something anywhere from one or the other.

18 So you're always looking for voluntary

19 versus involuntary responses. Sometimes it's

20 obvious what they're doing either voluntary or

21 involuntary. Sometimes it's hard to tell the

22 difference between the two because there's always

23 a gray zone.

24 But you're always looking to see if the

25 response is voluntary meaning conscious or




611



1 involuntary. So the word response should never

2 be used by itself. Response means involuntary or

3 voluntary.

4 Some people say, for instance, can a

5 person in a persistent vegetative state respond?

6 They can do all sorts of things that are

7 responsive, but they're involuntary.

8 Q. Dr. Cranford, is there any correlation

9 between neurodiagnostic tests and a persistent

10 vegetative state condition?

11 A. Yes.

12 Q. What is that correlation, if any?

13 A. Well, there are some general

14 correlations. And the general correlations are

15 not as specific as other ones, but a general

16 correlation, for example, would be an EEG.

17 An EEG or brain wave test which is

18 measuring the cortical activity of the cortex.

19 There's a general correlation between a coma and

20 the vegetative state in the sense that the deeper

21 the coma the slower the EEG, the more abnormal

22 EEG, as a general correlation.

23 There's also correlation in the fact

24 that in a vegetative state the patient in a

25 vegetative state has usually a very abnormal EEG,




612



1 but there are exceptions and some can look

2 somewhat normal.

3 So there's a general correlation

4 between the two. If you saw a person in a

5 vegetative state who had a reasonably normal EEG

6 you would say, Wait a minute. Something doesn't

7 fit here very well. That's one.

8 There's all sort of studies --

9 Q. Let's see a CT scan. Is there any

10 correlation between a CT scan and a condition of

11 persistent vegetative state?

12 A. Yes, there is after the first few

13 years, because after the first few years you

14 begin to see more atrophy of the brain, shrinkage

15 of the brain. And as a general correlation in

16 the sense that the longer they're in a vegetative

17 state, the more severe the shrinkage of the

18 brain.

19 And so it's usually severe to extreme.

20 There could be variations on that. So there

21 should be correlation between the CAT scan, as a

22 general rule, and the vegetative state. The

23 longer they're in a vegetative -- although in

24 five or 10 years there's no more brain to shrink

25 really except the brain stem secondarily shrinks.




613



1 So you can't shrink it much more

2 anymore after five or 10 years. So it just

3 levels off after a while.

4 Q. Can a patient in a persistent

5 vegetative state have a CAT scan that looks

6 nearly normal?

7 A. In the early stages they may, but after

8 a year or two if you see a CAT scan that's fairly

9 normal in a person in a vegetative state, then

10 you better think twice about the diagnosis and

11 that's something that we use a great deal as a

12 general indicator of irreversibility.

13 Q. What's a SPECT scan, Dr. Cranford?

14 A. My understanding of a SPECT scan is

15 it's a measure single photon way of dealing with

16 and it measures blood flow basically, but it

17 measures blood flow to the brain.

18 Q. Is there any correlation between a

19 SPECT scan or what would show up on a SPECT scan

20 in a persistent vegetative state condition?

21 A. Yes. It's a general correlation in the

22 sense that patients in a vegetative state usually

23 have an abnormal CAT scan -- an usually generally

24 abnormal CAT scan, but --

25 Q. We're talking about the SPECT scan.




614



1 A. I'm sorry, the SPECT scan.

2 Q. Okay.

3 A. Usually there's a general correlation.

4 The literature talks about the general

5 correlation in that most patients in a vegetative

6 state will have a reduction in blood flow,

7 sometimes 10, 20 percent. Sometimes it's 40 to

8 50 percent.

9 There's a general correlation, but you

10 can have a perfectly normal SPECT scan in a

11 vegetative state that's well-documented in the

12 literature, so there isn't a necessary

13 correlation between the two. And that's not the

14 test that you would used for correlating the

15 vegetative state.

16 Q. Now, I wanted to ask you about recovery

17 of consciousness when a patient is in a

18 vegetative state. You mentioned before that

19 you've experienced patients emerging from a

20 vegetative state.

21 How does the factor of time interact

22 with the possibility of recovering consciousness

23 from a vegetative state?

24 A. You asked me the test to correlate and

25 I didn't mention the most important test to




615



1 correlate the vegetative state --

2 Q. Well, if you want to, go ahead and

3 answer that. Go ahead.

4 A. Well, the test that correlates best

5 with the vegetative state per se, not just

6 irreversibility, is the PET scan, positron

7 emission tomography.

8 And that measures radioactivity in the

9 cortex which is a high correlation between the

10 metabolism of the cerebral cortex in various

11 parts of the brain and the functioning of the

12 brain.

13 And there had been quite a few studies

14 done which show a very high correlation between

15 an abnormal PET scan measuring metabolism in the

16 neocortex in patients in a vegetative state.

17 That's by far the most specific test,

18 the most highly accurate test to correlate a

19 patient in a vegetative state with a laboratory

20 study.

21 Q. Okay. Regarding the recovery from

22 consciousness, what factors does time play in the

23 possibility that a vegetative state patient may

24 recover consciousness?

25 A. The three most important factors are;




616



1 age, which is number one. The cause of the

2 vegetative state, number two. And the time. And

3 of the three, time is by far the most important

4 factor in recovery from the vegetative state.

5 Q. Okay. And can you explain why time is

6 an important factor?

7 A. Well, just from an empirical standpoint

8 in reviewing the literature and looking at large

9 series, patient reports in a vegetative state and

10 looking at unusual recoveries from the vegetative

11 state, and looking at the empirical studies

12 that's in the large clinical studies -- the four

13 large clinical studies when you review those you

14 find that after three months in a vegetative

15 state from hypoxic ischemia encephalopathy, lack

16 of oxygen or lack of blood to the brain, that any

17 meaningful recovery after three months is

18 extraordinarily rare.

19 There have been recoveries to the point

20 of severe disability, but there's never been one

21 single case beyond three months in a vegetative

22 state from hypoxic ischemic encephalopathy

23 meaning good recovery.

24 From head trauma --

25 Q. You used the phrase hypoxic ischemic




617



1 encephalopathy. What does that mean in layman's

2 terms, Dr. Cranford?

3 A. Hypoxic means lack of oxygen like from

4 a respiratory arrest. Ischemic means lack of

5 blood from a cardiac arrest. And when a person

6 has a cardiac arrest whatever it precipitated,

7 whether their heart stops or whether they stop

8 breathing and then their heart stops it usually

9 ends up hypoxic ischemic encephalopathy.

10 So it's very hard in individual cases

11 after cardiac arrest to distinguish how much is

12 hypoxia and how much is ischemia. And for all

13 practical purposes, it doesn't make any

14 difference.

15 So, in terms of your heart stops or

16 they stop breathing and they're resuscitated, but

17 their brain has brain damage, we call that

18 hypoxic ischemic encephalopathy. That's a

19 general term with encephalopathy meaning damage

20 to the brain.

21 Q. What's the difference between hypoxic

22 ischemic encephalopathy and anoxic ischemic

23 encephalopathy?

24 A. For all practical purposes those words

25 are used interchangeably from most people. Oxic




618



1 means oxygen. A means none. And H-Y-P or H-Y

2 means decreased. So to used them precisely,

3 anoxic encephalopathy would be no oxygen to the

4 brain.

5 Hypoxic would be decrease of oxygen,

6 but I don't think most of us use that term

7 precisely. And most people use those terms

8 interchangeably. Some just use anoxic and some

9 use hypoxic. They're interchangeable for all

10 practical purposes.

11 Q. Now, you distinguished a vegetative

12 patient who has suffered hypoxic ischemic

13 encephalopathy from one who has suffered a head

14 trauma in terms of recovery.

15 What is the basis for that distinction?

16 A. Well, two major ones; you look at the

17 clinical studies and you can see there's a

18 difference, a major difference.

19 And, secondly, the mechanism of injury

20 of the two you could help explain it that way,

21 but if you look at the studies and review all the

22 studies of the major series on the vegetative

23 state and the literature and you look at all the

24 books on head injury you find there's a

25 difference in age.




619



1 There's not a difference in age with

2 hypoxic ischemia because at three months out it

3 doesn't matter if you're an infant or a young

4 adult or an old person. At three months out your

5 chance of any meaningful recovery are miniscule

6 to the point of non-existent.

7 But in head trauma there is a

8 difference in age. The younger you are and

9 younger is a very general term, 25, 30 or

10 whatever and especially in infants and children,

11 especially children, they can recover up to one

12 year from head trauma.

13 You have documented cases,

14 well-documented cases, of patients who have been

15 in a vegetative state for up to six months to one

16 year in children and young adults who recover

17 completely.

18 Q. And that's in the case of trauma?

19 A. Trauma.

20 Q. As opposed to hypoxic or anoxic

21 ischemic encephalopathy?

22 A. Yes. In adults, whatever adults means,

23 but whatever adult means usually within six

24 months. If you have an adult say beyond the age

25 of 40 or 50 and they're in a vegetative state at




620



1 six months out, the chances are miniscule of any

2 meaningful recovery.

3 Where if you're a child or a young

4 adult, then you have to wait up to one year. So

5 there's a major difference between the two in

6 terms of recovery, number one. And there's also

7 a major difference in age with head trauma

8 because there's not a major difference in hypoxic

9 encephalopathy.

10 Q. Now, in the research that the

11 Multi-Society Task Force performed, what is the

12 latest verifiable recovery of consciousness they

13 observed in a patient that had hypoxic ischemic

14 encephalopathy?

15 A. There were two cases that we found in

16 the literature that are what we call outliers.

17 There's a term -- an outlier means an exception

18 to the exception. There are exceptions to the

19 rules, but there are -- we found five

20 well-documented outliers in the literature on

21 those rules that I just gave you.

22 Q. Uh-huh.

23 A. And two were hypoxic, two are traumatic

24 and one was sub arachnoid hemorrhage. Those are

25 well documented. They made a variable degree of




621



1 recovery. The longest well-documented recovery

2 of a patient in a vegetative state was in a

3 presumed persistent vegetative state from hypoxia

4 ischemia was a case in New Mexico by

5 Dr. Rosenburg at 17 months.

6 And my own patient, Sergeant David Mac,

7 who recovered at 22 months after hypoxia ischemic

8 encephalopathy. So those both were extreme

9 exceptions to the rule I just gave you because

10 both of them remained conscious and regained

11 cognitive functioning to the point of 95 to 100

12 percent normal.

13 They ended up locked-in, essentially,

14 but they both regained essentially full cognitive

15 functioning 95 to 100 percent of normal at those

16 times and those are both well documented.

17 Q. Now, regarding the survival rate for a

18 patient in a persistent vegetative state, is

19 there any difference in the survival rate for

20 younger patients as opposed to older patients?

21 A. Yes. The older you are past -- we

22 didn't say in the task force as far as numbers,

23 we just said generally say past 40 or 50, the

24 older you are the less survival rate you have.

25 The younger you are -- except in infants. For




622



1 some reason infants have a low survival rate, but

2 beyond infancy through childhood and into young

3 adulthood those patients live longer as a general

4 rule than older patients or infants.

5 Q. And for a young adult, what might be

6 the expected survival rate from a persistent

7 vegetative state?

8 A. The task force report said the survival

9 rate for overall was two to five years. And the

10 chances of survival beyond 10 years was uncommon.

11 And the chance of survival beyond 15 years was

12 extremely rare, as admitted one in 15,000 or one

13 in 75,000.

14 But there's been a lot of dispute about

15 survival rates. And that section -- that section

16 is one of the most subject to dispute because

17 there are outliers. There are exceptions to the

18 rule that have lived longer than that.

19 So there's been a lot of disagreement

20 about survival rates in patients in a vegetative

21 state. So what I would normally say is they live

22 beyond the first year with mortality about 30 to

23 40 percent and then they live five, 10 years

24 usually and then a majority of them die within 10

25 years, but there's a significant minority that




623



1 they may live longer than 10 years.

2 Q. Have there been any patients in a

3 persistent vegetative state that have survived

4 more than 15 years?

5 A. Yes.

6 Q. How long have they survived?

7 A. I know of several. The longest

8 reported survival -- the two longest survival was

9 a patient from Florida named Elaine Espisido

10 (phonetic) from Tarpon Springs, Florida. I can

11 use her name, it's public knowledge, at 37 years

12 and some days.

13 Then the other one was Rita Grene from

14 Washington, D.C., who was a nurse. And, I'm

15 sorry, I always have to think back to how long

16 she lived, 47 years in a vegetative state. I

17 actually examined Rita Grene to see if she was in

18 a vegetative state.

19 Q. Now, is a diagnosis of persistent

20 vegetative state primarily a clinical diagnosis

21 or a diagnosis made by neurodiagnostic tests?

22 A. It's primarily a clinical diagnosis,

23 but it's confirmed, if you will, by laboratory

24 studies to some degree. Depending on the

25 circumstance, sometimes it could be highly




624



1 confirmatory, sometimes less confirmatory.

2 So like everything else in medicine you

3 have a correlation between clinical findings and

4 the laboratory studies. So the laboratory

5 studies are considered confirmatory. In some

6 cases they're more helpful than others.

7 Q. Is a persistent vegetative condition

8 misdiagnosed any more or less than any other

9 clinical neurological conditions?

10 A. I don't know if I can answer that

11 generally, but, yes, there has been concerns

12 about the misdiagnosis of a vegetative state,

13 both in terms of false positives and false

14 negatives.

15 Q. And what are those concerns?

16 A. Well, the concern -- there are several

17 concerns. I think the most important concern

18 that people have is on the course of

19 irreversibility. In other words, someone may be

20 severely brain damaged and they may be in a

21 vegetative state, a true vegetative state, for

22 say two months, six months and then end up

23 recovering completely.

24 So you think that not only in a

25 vegetative state, but they'll never recover




625



1 permanently. So the most serious mistake would

2 be a false positive diagnosis of saying they're

3 in a vegetative state and it's irreversible, it's

4 permanent. Then they recover completely and

5 we'll use Sergent Mac or we'll use Dr.

6 Rosenburg's case to say these are unusual cases.

7 So permanent is one thing where you

8 say, yeah, I think this patient is in a

9 vegetative state. They'll never recover and then

10 later, six months or a year longer they start

11 recovering and they recover a lot.

12 Q. Uh-huh.

13 A. The other type of false diagnosis,

14 false positive diagnosis in people that you are

15 concerned about is saying, well, I think they're

16 in a vegetative state and you examine them and

17 find out they're not in a vegetative, they're

18 really minimally conscious or they have more

19 interactivity with their environment or they're

20 even locked in.

21 So that's not a question of

22 irreversibility, that's a question of their

23 condition. So their condition may be vegetative

24 or minimally conscious for years or locked in for

25 a long time. Also if someone examines him, but




626



1 in a different way and then calls in a specialist

2 and says, Well, they're not really vegetative,

3 they're -- they do interact with the environment.

4 They're minimally conscious or they're more than

5 minimally conscious or they are even locked in.

6 So obviously diagnosing a patient being

7 in a vegetative state where they're unconscious

8 versus a patient who is locked in who is fully

9 conscious would be a drastically terrible thing

10 to do. So that's the one side.

11 The other side is where you diagnose

12 patients as being -- having a chance of recovery

13 that had no chance of recovery. That's a false

14 negative diagnosis. And someone who is concerned

15 about that, too, where a patient is in a

16 vegetative state for a prolonged period of time

17 where there's no chance of recovery and their

18 family is told they have a chance of recovery.

19 That's just totally false information and/or they

20 not only have a chance for recovery, but there's

21 treatment that we can give these patients where

22 there's no treatments that can help them. That's

23 what I would call a false negative diagnosis.

24 Along that line would be, again, the

25 question of permanency. Do they have any chance




627



1 of recovering at all? And for somebody to be in

2 a vegetative state for a prolonged period of time

3 like I told you and a physician comes along and

4 says, I think they have a chance of recovery is

5 probably totally false. That would be a false

6 negative diagnosis of irreversibility.

7 And likewise we have patients who come

8 along who are clearly in a vegetative state who

9 are diagnosed by physicians and others that say,

10 no, they're interacting with the environment.

11 They're really there and they're really not

12 there. There's a lot of mistake in diagnosis

13 which is a false negative diagnosis of the

14 vegetative state.

15 So you have the four major categories

16 all of which would be concerning any physicians

17 working in this area of accuracy of the

18 diagnosis, overdiagnosis or underdiagnosis of the

19 vegetative state. False positive. False

20 negative.

21 And the key thing that you have to

22 separate the condition versus permanency. Those

23 are two things that get mixed up together. And

24 that's really important to separate one from the

25 other. For instance, a person may be minimally




628



1 conscious or locked in for years and have no

2 chance of recovery and yet they're not

3 vegetative.

4 On the other hand, somebody may be

5 vegetative and will not have a good chance of

6 recovery and so in the early phases, particularly

7 the first three to six months, you wouldn't want

8 to make a false positive diagnosis of

9 irreversibility if there's any chance of

10 recovery.

11 So when you're talking about diagnosis

12 or misdiagnosis of the vegetative state we have

13 to distinguish between the condition itself

14 versus the reversibility of it. And a lot of the

15 articles in the literature don't do that and

16 that's very important to distinguish those two

17 areas.

18 And when you try to distinguish those

19 are 10, 20 years and somewhat unsuccessfully, but

20 those are crucial distinctions.

21 Q. Did you have an opportunity,

22 Dr. Cranford, to examine Theresa Schiavo?

23 A. Yes.

24 Q. Do you recall when you did examine her?

25 A. No, I would have to look -- no. I




629



1 think it was -- no, it was the day before the

2 trial that we had recently. I don't remember,

3 but I think it was July. I don't remember the

4 exact date --

5 Q. Now --

6 A. -- of this year.

7 Q. Prior to your examination of Theresa

8 Schiavo, did you have an opportunity to review

9 any information?

10 A. Yes.

11 Q. Can you tell us what information you

12 reviewed?

13 A. Well, I reviewed some selected medical

14 record. I reviewed some reports from

15 neurologists. I reviewed some material you sent

16 me relating to the legal proceeding and

17 depositions and so forth accordingly.

18 I didn't review the CAT scan, but I was

19 aware of the CAT scan that had been done

20 previously. I just reviewed the general medical

21 records and some of the medical legal stuff that

22 you had sent me.

23 Q. Do you recall reviewing Dr. Gambone,

24 the Ward's treating physician, his comprehensive

25 medical evaluation?




630



1 A. I've got that right here. I thought

2 that was after I testified. I can't remember

3 whether that was the first time or the second

4 time. I reviewed that.

5 Q. But you have reviewed that?

6 A. I did review that, yes.

7 Q. Now, have you actually reviewed the

8 films from the July 2002 CT scan?

9 A. Yes, I saw those when I examined Terri

10 Schiavo in, I think, July of 2002.

11 Q. Now, after your examination did you

12 receive any additional materials to review?

13 A. Yes, quite a bit.

14 Q. Did you review the reports from the

15 EEGs performed on Terri Schiavo?

16 A. Yes, they were performed after my

17 initial examination, yes.

18 Q. Did you review the report of the SPECT

19 scan?

20 A. Yes, I did.

21 Q. Did you review the report of the

22 ultrasound of the carotid artery?

23 A. Yes, I did.

24 Q. Did you review the subsequent blood

25 work done on Terri Schiavo?




631



1 A. Yes.

2 Q. Did you review the videos taken of

3 Dr. Hammesfhar and Dr. Maxfield's examinations of

4 Terri Schiavo?

5 A. Yes.

6 Q. Now, I wanted to ask you first, do you

7 have an opinion whether the results of Terri's

8 EEGs are consistent with a patient in a

9 persistent vegetative state?

10 A. Yes, I have an opinion.

11 Q. And what is that?

12 A. That EEG is consistent with a

13 vegetative state.

14 Q. How about the -- do you have an opinion

15 regarding the SPECT scan?

16 A. Yes.

17 Q. What is that?

18 A. That is consistent with vegetative

19 state.

20 Q. I would like you to step down for a

21 moment and take a look at the blowup of the CAT

22 scans, if you could.

23 A. (Witness complies).

24 Q. Dr. Cranford, on our left we have a

25 blowup of the 2002 CT scan and on the right a




632



1 blowup of the 1996 CT scan. First let me ask you

2 when did you have or have you had an opportunity

3 to review the 1996 CT scan?

4 A. I reviewed the report previously, but I

5 didn't get a chance to see it until now.

6 Q. Okay. Did you have an opportunity to

7 see that before the proceedings this morning?

8 A. Yes.

9 Q. Okay. First of all, how would you

10 describe the 2002 CT scan?

11 A. How would you what?

12 Q. How would you describe it? Is it

13 normal? Abnormal?

14 A. Well, it's about as abnormal that you

15 could get in terms of showing massive atrophy and

16 shrinkage of the higher centers of the brain in

17 terms of the cerebral cortex, in terms of the

18 size of the ventricles, in terms of the shrinkage

19 of the neocortex, in terms of secondary changes

20 in the thalamus and brain stem. They are shrunk,

21 too, which is secondary.

22 So this is as bad as you could get

23 because I think what you're seeing here in the

24 neocortex is just probably gliotic tissue.

25 There's probably no viable tissue left in terms




633



1 of neurons. They're viable tissue in terms of

2 gliosis --

3 Q. You used the words gliotic tissue and

4 gliosis, could you explain what those terms mean?

5 A. Well, in the neocortex which is the

6 higher centers of the brain like in here and

7 here --

8 Q. Okay. You're referring to image?

9 A. I can't read that.

10 Q. That's Image 15?

11 A. Okay.

12 Q. All right.

13 A. Image 15, right. In Image 15 if you

14 look at it you can try to see what is clearly

15 neocortex or cortical tissue that you see here

16 and some of it here. And I don't think you can

17 shrink more than that.

18 And you have two basic type of cells in

19 the neocortex, you have the neurons, which are

20 the ones that have functioning which is about 60

21 percent of the metabolism in the neocortex and

22 you have the glial cells, which are the

23 connective tissue.

24 Q. Uh-huh.

25 A. And when you have brain damage like




634



1 this you lose the neuron and related tissue, but

2 you still have gliosis or scar tissue left. And

3 when you look at a scan like this you hardly can

4 shrink more than this because this is probably --

5 you can't say for sure, but that's probably

6 gliotic tissue here. And it's such severe,

7 severe atrophy or shrinkage of the cerebral

8 hemispheres that it's extremely profound

9 shrinkage of the thalamus and --

10 Q. Now, you mentioned something about

11 shrinkage of the thalamus; is that correct?

12 A. Yes, and that's harder to gauge, but

13 the thalamus --

14 Q. What image did you notice that?

15 A. If you look at the Image 13 -- no, 13

16 and 14, this here is subcortical tissue which is

17 either the thalamus or the basal ganglia or the

18 hypothalamus. It is abnormal, but it's there.

19 It's really hard for me to say -- and

20 that's abnormal, but it's hard for me to say the

21 degree of shrinkage because we know from

22 examination that Terri has hypothalamic

23 functions.

24 So it's hard for me to gauge that so.

25 It's abnormal. Then if you look at -- the other




635



1 thing is the ventricles. They're just huge.

2 These ventricles are huge. Of course this is

3 what we call hydrocephalus, actually it's called

4 hydrocephalus ex vaco which means that the

5 ventricles are enlarged not because there is

6 pressure inside the ventricles, but because the

7 rest of the brain had shrunk.

8 So with this combination here this is a

9 classic case of hydrocephalus ex vaco where the

10 ventricles are just huge. They can't hardly be

11 any larger than they are.

12 And so the correlation between the

13 atrophy of the higher centers and the ventricles

14 size is a correlation and the brain stem, as is

15 seen in sections five, six and seven here, is

16 shrunk, which is a secondary problem because

17 they're not primarily damage to the brain stem,

18 but it's shrunk to some degree so that's

19 abnormal.

20 Q. What's the significance of having

21 shrinkage in the brain stem?

22 A. One thing that it would indicate would

23 be that it's secondary demyelination, that means

24 the cortex had been damaged for so long that the

25 fiber track running through there are shrinking,




636



1 too.

2 So that's what's secondary

3 demyelination so the neurons, the cell bodies in

4 here may be perfectly normal --

5 Q. You're pointing to the brain stem?

6 A. Yes, sections five, six and seven. The

7 neurons may be normal. We know she has brain

8 stem functions, so even though it's shrunk

9 there's still normal neurons in there.

10 Q. Okay. Now, I want to bring your

11 attention to the 1996 CT scan of the Ward. How

12 will you describe that scan?

13 A. They're the same. There is no

14 difference except this one has very poor

15 resolution. When you look at this scan you can

16 see that this one is much sharper in definition

17 than this one.

18 Whereas this -- let's see, section --

19 well any section up here, if you look at section

20 15 on the 2002 scan, you see the difference

21 between the brain matter -- I'm sorry, between

22 the dark black, which are the ventricles, and the

23 white, which is what is left of the neocortex.

24 And here it's very poorly defined. And

25 also this is just a poor resolution -- this is




637



1 what we call grainy. So it's just poorly

2 defined. So they are essentially the same.

3 There's no difference between the two except this

4 is a grainy one and this is not.

5 Plus, if you look at this one there's

6 interference. When you see these lines running

7 here there's interference with something, whether

8 it's metallic or not. This is a cardinal feature

9 of interference.

10 This is not from the brain. This is

11 from some artifact outside the brain or

12 something. I'm not sure what it is right here

13 running through here.

14 So this is a poor resolution of a CAT

15 scan because of interference. So the whole thing

16 is just grainy. You can define it as well. But

17 they're the same. There is no difference between

18 the two. This is just a much more precise highly

19 defined CAT scan and this is just a poor

20 resolution grainy CAT scan.

21 Q. Dr. Cranford, in your opinion -- do you

22 have an opinion comparing these two CAT scans

23 whether the 2002 CT scan shows that Terri

24 Schiavo's brain has regenerated?

25 A. I have an opinion, yes.




638



1 Q. What is that?

2 A. It doesn't show that.

3 Q. Thank you. You could resume the

4 witness box, Dr. Cranford.

5 MS. ANDERSON: Your Honor, I move to

6 strike that opinion as improper foundation

7 both as to his qualifications and to the

8 form of the foundation.

9 MR. FELOS: It seemed like a very

10 straightforward question to me, Your Honor.

11 THE COURT: What predicate is missing?

12 MS. ANDERSON: He did not establish

13 that Dr. Cranford, first of all, is

14 qualified to read CT scans. Merely being a

15 neurologist doesn't qualify you to offer an

16 expert opinion on that kind of comparative

17 analysis, number one. He has not testified

18 that he has any special training in the

19 reading of the brain scans.

20 Number two, Mr. Felos did not elicit

21 through the proper formation of that

22 question an opinion within a medical -- a

23 reasonable degree of medical certainty or

24 probability.

25 THE COURT: That's true. The objection




639



1 will be sustained.

2 BY MR. FELOS:

3 Q. First, Dr. Cranford, what experience do

4 you -- first, what experience do neurologists

5 generally have in reading CT scans?

6 A. A great deal of experience. It's a

7 daily, weekly thing.

8 Q. And what experience do you have?

9 A. I've reviewed thousands and thousands

10 of CAT scans in the last -- well, CAT scans have

11 only been around for 10, 15 years, but I don't

12 have any idea how many, thousands and thousands

13 and hundreds and hundreds. Well, more than

14 hundreds and hundreds. I mean, I review CAT

15 scans several per week, so it's very common.

16 Q. Dr. Cranford, do you have an opinion,

17 within a reasonable degree of medical certainty,

18 as to whether the 2002 CAT scan shows a

19 regeneration of Theresa Schiavo's brain?

20 A. Yes, I do.

21 Q. What's that?

22 A. It doesn't show any -- it doesn't show

23 any regeneration.

24 Q. Dr. Cranford --

25 MS. ANDERSON: Move to strike the




640



1 opinion, Your Honor, on the same previous

2 grounds with the exception of the correction

3 to the form of the question. General

4 experience in looking at CT scans does not

5 make him an expert.

6 THE COURT: Overruled.

7 BY MR. FELOS:

8 Q. Dr. Cranford, when brain tissue dies

9 and is dead, can it regenerate?

10 A. No, not the neurons.

11 MR. FELOS: Your Honor, I'm going to

12 next have Dr. Cranford go through his

13 examination of the Ward which is on the

14 video which I believe is approximately 35 or

15 40 minutes.

16 So if the Court was looking for an

17 opportunity for a short break this may be

18 it.

19 THE COURT: This may well be it. Let's

20 stand in recess for 15 minutes. Doctor,

21 during this recess you're still technically

22 on the witness stand, so please do not

23 discuss this case or your testimony with

24 anybody.

25 THE WITNESS: Yes, sir.




641



1 THE COURT: You can talk, you can talk

2 about the weather in general and things, how

3 nice it is to be out of Minnesota when it's

4 snowing, but please discuss this case with

5 anybody.

6 THE WITNESS: Yes, sir.

7 THE COURT: Thank you.

8 THE BAILIFF: All rise. The Court

9 stands in recess for 15 minutes.

10 (Thereupon, there was a 15-minute break.)

11 THE COURT: Please continue, Mr. Felos.

12 MR. FELOS: Thank you, Your Honor.

13 BY MR. FELOS:

14 Q. Dr. Cranford, we're going to proceed to

15 running the videotape of your examination.

16 There's a monitor in the witness box right there

17 that you can watch that, please. I'm going to be

18 asking you questions as the tape is running.

19 Feel free to tell us what you're doing on the

20 tape as it proceeds.

21 Dr. Cranford, what's the significance,

22 if any, of the arm position of Terri Schiavo

23 here?

24 A. That's the typical posturing. She has

25 severe contractures which is typical. Flexor




642



1 response or what we call a decorticate response

2 and this is what happens in a patient who has

3 been in a vegetative state for years.

4 The contracture occurs where you see

5 how the wrist is flexed and the left one is not

6 quite as flexed. And the arms are flexed at the

7 elbow. I think I may have requested him to go in

8 close to look at her face from this standpoint.

9 Just looking at what she does

10 spontaneously because at times she will

11 spontaneously smile or moan or groan without any

12 stimulus whatsoever. At the beginning you saw a

13 second or two it looked like a semi-smile or

14 something right in the beginning without any

15 stimulus.

16 She has a right gaze preference. The

17 eyes are looking, I use the word looking in a

18 general sense. They're looking straightforward.

19 It is hard to note if she is looking at anything,

20 but they don't appear to move around very much.

21 She has movement of the mouth which is

22 spontaneous. Anytime you used the word

23 spontaneous you have to make sure there's no

24 auditory or visual stimulus in the background

25 which could cause some of these things.




643



1 Q. Raise the volume a little bit. Thank

2 you.

3 A. Her facial expression does change

4 somewhat. It looks like a small smile when her

5 mother comes close. In the beginning it looked

6 like her eyes stayed open longer for a moment

7 there.

8 Q. Dr. Cranford, did you ask the mother

9 whether she was able to elicit any consistent

10 responses from Terri?

11 A. Yes, I did.

12 Q. And what did she say?

13 A. She said at the time, no, she was not

14 able to elicit any consistent response.

15 Consistent in the sense that it's consistent and

16 reproducible, you know. I didn't say that

17 specifically to her, but I asked her is there

18 anything that you can do to show consistent

19 responding and she said no.

20 Now, the mother is closer and you can

21 see the eyes -- she's falling asleep a tiny bit.

22 When you see the eyes initially look toward the

23 mother somewhat, but then they drift away.

24 And so it's hard to separate just an

25 auditory stimulus where the eyes looked toward




644



1 the stimuli versus focusing on somebody and

2 recognizing somebody versus just the eyes

3 drifting away.

4 You see the eyes are not really

5 focusing, they're looking in different ways, but

6 they're not focusing on the mother per se. You

7 see spontaneous movements of the mouth again.

8 So she doesn't have visual fixation.

9 She's not focusing on her mother per se. The

10 eyes are looking not away from the mother, but

11 they're not looking at her mother. They're

12 fairly close in terms of the face that would

13 indicate to me that she does not have visual

14 fixation, at least not consistently or not enough

15 to even consider the remote possibility of being

16 outside a vegetative state.

17 But at times the eyes do look towards

18 her mother and it looks at those particular

19 moments that she is really looking at her mom.

20 So you have to put the totality of the exam

21 together with other observations by other people

22 over the period of years and see if there's any

23 consistent reproducible changes.

24 Right there now, for example, it looks

25 like she's looking right at her mother, but then




645



1 her eyes drift away. So one could misinterpret

2 that easily to say that she has visual fixation,

3 but she does not in any sense have any visual

4 fixation, except I think her visualwriter reflex,

5 which we can demonstrate later.

6 Q. Dr. Cranford, do we know why Terri is

7 making the moaning sounds at times thus far in

8 the tape?

9 A. Well, it could be spontaneous. It

10 could be in reaction to the mother's voice. It

11 could be in reaction to movement or touching her.

12 I can't tell if the mother is touching her. One

13 could argue it could be related to the specific

14 mother's voice as opposed to others, but I think

15 she has a non-specific response other times.

16 So it could be either spontaneous or it

17 could be in response to the voice which could set

18 off a non-specific stimuli causing the

19 Pseudobulbar Palsy, which is the moaning or

20 groaning which often occurs. And that moaning or

21 groaning can be precipitated by movement, by

22 touch, by voice sometimes, but there's no

23 consistent response when you look at this and the

24 other tapes by the other doctors. There's never

25 any consistent way you could correlate them




646



1 together very well.

2 What you like to do is correlate a

3 specific response -- I'm sorry, correlate the

4 specific response from the specific stimulus that

5 would be content sensitive in the sense of her

6 family doing something differently than other

7 people are doing or some specific response.

8 That's what you're looking for in a

9 patient like this, to find something that is

10 context specific, and then a specific response to

11 that stimulus that you can correlate. That's

12 what we mean by consistent and reproducible. It

13 doesn't have to be every time.

14 Although visual tracking in a patient

15 in a vegetative state if they're not in a

16 vegetative state she should be tracking 95

17 percent of the time. Once she starts to close

18 her eyes the exam becomes invalid because in a

19 way she may be dozing slightly, so she may be

20 sleeping slightly. So the whole exam becomes

21 somewhat invalid when she closes her eyes because

22 she's sleeping slightly.

23 MR. FELOS: Could you raise the volume,

24 please. Thank you.

25 THE WITNESS: Sometimes patients will




647



1 show an auditory oriented brain stem reflex

2 and you call out the name from one side to

3 the other and it looked that way for a

4 second or two. She may or may not have

5 them, but I never saw any consistent

6 demonstration even at that brain stem

7 mediated response of looking towards sound

8 for a second or two.

9 As you can see here with the mother on

10 the other side she's not looking at her

11 mother, she's not attending to that. Her

12 voice isn't changing.

13 Now she's grimacing a little bit and

14 she's not turning toward the mother at all.

15 Now, she may have random turned. Her head

16 is turned to the right.

17 I think you'll see later she has a

18 visual orient reflex and you'll see the head

19 and the eyes will follow this multi-colored

20 balloon for some reason, but the eyes are

21 not looking toward the mother.

22 So you're seeing no visual pursuit and

23 no visual fixation. Now the eyes look a

24 little bit that way, but then they go back.

25 This is what we -- this is classic for a




648



1 vegetative state without any visual pursuit

2 and with no visual tracking at all.

3 When you see something like that,

4 visual tracking alone, you have about a 95

5 to 99 percent actually the patient is in a

6 vegetative state when you see that by

7 itself.

8 Now she has a startled response and you

9 can see the eyes close. So the question is,

10 can she hear? She can't hear, but sounds

11 could get in and that's a brain stem

12 mediated response which is very constant in

13 a vegetative state or in a case with severe

14 brain damage where they have a startled

15 response.

16 If you clap louder every time she will

17 have a startled response. It's different

18 from a normal human being because they may

19 startle once, but after you do it a couple

20 of times they won't startle anymore. She'll

21 startle not every time, but almost every

22 time you clap the hands and the louder you

23 clap them the more she may close her eyes.

24 So that's a brain stem mediated

25 response, a startled response. It's a




649



1 classic finding in patients who have severe

2 brain damage and in a vegetative state with

3 their eyes open. It's very, very common to

4 have a startled response like that.

5 Sometimes the whole body may flex out

6 and the neck may arch. Sometimes the eyes

7 will close, but she has a consistent

8 startled response which is a very abnormal

9 response indicating severe brain damage in

10 the higher centers.

11 MS. ANDERSON: I'm sorry, I couldn't

12 hear your answer.

13 THE WITNESS: Indicating she has -- she

14 has a consistent startled response

15 indicating damage in the higher centers of

16 the brain.

17 BY MR. FELOS:

18 Q. Go ahead.

19 A. Now, again, you could take a snippet of

20 this over a few seconds and see the mother

21 interacting. It looks like when she did that she

22 looked right at her mother for a few seconds.

23 So it's not the few seconds that

24 counts, but it's the overall film and the overall

25 observation of others to find consistent and




650



1 reproducible responses over a period of time, not

2 just a few seconds.

3 You can take any patient in a

4 vegetative state and by clipping segments either

5 a few seconds or a few minutes make it look like

6 they're interacting. Normally make it look like

7 they're smiling normally, but that's not a fair

8 assessment of the overall condition of the

9 patient, but that can almost always be done.

10 I'm trying to get the mother -- the

11 mother is trying as best as she can to show

12 persistent tracking or some pursuit to the one

13 side or fixation on a consistent reproducible

14 fashion, not just for a few seconds. She

15 unfortunately just does not do that. She at

16 times looks at her mother, but that's for a few

17 seconds.

18 I'm trying to stimulate her because if

19 she closes her eyes the exam becomes invalid at

20 that point. If they're sleepy -- you can't

21 continue the examination when their eyes close.

22 She became a little sleepy. Most of the exam she

23 was awake.

24 Now and then you see a patient in a

25 vegetative state who are asleep during the exam




651



1 and it just doesn't work.

2 Q. Doctor, I would like you to stop

3 commenting just for a few moments and then I will

4 ask you a question.

5 A. Okay.

6 Q. What is happening there, Dr. Cranford?

7 A. Well, I touched her by her neck and she

8 started smiling or it looked like she smiled. I

9 think that's a nonspecific response. It may have

10 been related to that stimulus of touching her,

11 but if it was -- and then the smile is not

12 content specific.

13 That's important to that saying a smile

14 doesn't mean she's happy. A smile means that she

15 was touched or she was stimulated in some way

16 which is a nonspecific stimulus. It certainly

17 wasn't the fact that she recognized me or she

18 could get --

19 Q. Did a moan accompany that smile?

20 A. Pardon?

21 Q. Did a moan accompany that smile?

22 A. Yes, a little bit of a moan. So these

23 are classic nonspecific responses that you see in

24 a vegetative state patient which is

25 characteristic of the syndrome of Pseudobulbar




652



1 Palsy.

2 I'm trying to see if she'll track in

3 any consistent way. At that point I think she

4 has a visual-oriented reflex. I think she

5 actually saw something in the sense of bracing

6 that immediate response. She was following, I

7 think, the balloon.

8 So I would call that a positive trial

9 not in terms of visual tracking, but as I saw it,

10 I thought she looked up and down and to the right

11 and left related to this multicolored balloon on

12 one of the three trials.

13 And I was trying to reproduce that some

14 more and I wasn't able to reproduce that after

15 that. I do think that was not random. I don't

16 think she is responding to a command, but I

17 thought for a few seconds there, 5 or 10 seconds,

18 her eyes were going up and down, to the right and

19 to left trying to follow that multicolored

20 balloon.

21 Q. Now, what, if any -- you said you tried

22 to repeat that without success. The

23 inconsistency of response to that, does that have

24 any particular significance?

25 A. Yes. Again, it would mean that she's




653



1 not visually tracking. She's not fixating, but I

2 think if you could get some stimulus in front of

3 her eyes, which is either loud or colorful or

4 something then this is something getting through

5 to the brain stem and maybe to the thalamus which

6 is causing her eyes to reflex and follow for a

7 few seconds.

8 I think when you see the father the

9 next day -- I'm sorry, later with Dr. Maxfield

10 when he didn't do a neurologic exam you could see

11 the father doing the same thing that I did and I

12 think this is a visual-oriented reflex.

13 I think it's brain stem mediated. So

14 if you get in a certain position in her vision

15 she will follow something for a few seconds. I

16 think that's a brain stem median reflex which you

17 see in patients in a vegetative state.

18 Q. What are you doing when you're saying

19 to her focus here, focus there?

20 A. I'm trying to give her a pure verbal

21 command. When I was on her right side and I

22 would say, look to the right, she can't do this

23 comprehensively, but I'm trying to give her a

24 pure verbal command to see if she'll respond.

25 Patients in a vegetative state who come




654



1 out of vegetative state when you start giving

2 them a verbal command they will sometimes respond

3 just to the verbal command without sound, without

4 noise and without direction. That's what I was

5 trying to do there was shifted from visual

6 tracking to a verbal command.

7 Q. Now you're back to the balloon again

8 here?

9 A. I did three trials with the balloon.

10 See, she doesn't look up except when I bring that

11 balloon in. When I bring that balloon in the

12 only time she consistently looks up is when I was

13 putting that balloon there and going upwards.

14 So I think that's more than just

15 random. It's not visual fixation. It's not

16 visual pursuit, but I think something is getting

17 through to the visual centers of the brain stem

18 that she's acting in a reflex fashion, but

19 following it at that point in time with that

20 balloon.

21 I was focusing on the eyes. I made a

22 mistake where I should have made it clear what I

23 was doing in the background because I really

24 think you should focus on the eyes to see if she

25 had visual pursuit because that's so critical in




655



1 the diagnosis.

2 But somehow with the videography, I'm

3 not used to doing it this way, I didn't make it

4 clear what my commands were. So this is my error

5 in the examination because it should be clear to

6 everybody what I was doing.

7 I'm trying to do visual threat. I

8 didn't think she responded to visual threat to

9 me, but Dr. Greer and I think Dr. Bambakidis said

10 that she did respond to visual threat. So

11 there's a minor difference of opinion between

12 myself and Dr. Greer and Dr. Bambakidis because I

13 believe their examination said she did respond to

14 visual threat when I put my fingers in front of

15 her eyes. I didn't see that, but the other

16 doctors did.

17 That wouldn't change the diagnosis, but

18 that's something that you look for, visual

19 threat. Now what that is, that is a startled

20 response. When I called her name out she's

21 hearing a loud sound like a clap and she's

22 closing her eyes every time.

23 That could easily be -- somebody could

24 misinterpret that, but by shouting louder that is

25 just like clapping with your hands. That's a




656



1 nonspecific response and she's closing her eyes

2 so that's a startled response. The majority of

3 the patients in a vegetative state will have a

4 startled response.

5 Here's a smile again. I'm not sure

6 what I'm doing at this point in time. Terri has

7 severe contractures, so to spend a huge amount of

8 time examining her arms and legs is just a total

9 waste of time in the sense that she has severe

10 contractures.

11 She can't move them very far because

12 it's an irreversible change in the ligaments and

13 tendons which occurs over a period of time in

14 these patients. So when I tried to move it

15 whether they move 10 degree or 20 degrees or 30

16 degrees means absolutely nothing because you

17 can't get it up.

18 I'm trying very hard there to move it

19 down. So this is irreversible contractures.

20 There you have a movement which could be

21 voluntary or involuntary, you can't tell, but the

22 left arm is moving up and that by itself cannot

23 be said with any -- that's usually a reflex

24 response.

25 You can't say for sure, but since I'm




657



1 not on that side, it's not a fending response.

2 She's not withdrawing from me on that side per

3 se. It could be interpreted that way.

4 Again, you would have to put the whole

5 exam together. If you find something unusual you

6 have to put it together with everything else.

7 You're seeing she has severe contractures there

8 as well.

9 I'm trying very hard to unflex the

10 elbow and I can't do it. So these are severe

11 contractures. This is classic position of the

12 feet called equinovarus. They always go downward

13 like they're always turned in.

14 In any patient in a vegetative state

15 after a year or two will almost invariably have

16 this posturing which is irreversible. There is

17 nothing that you can do about it. There is no

18 treatment of any type that will materially change

19 that.

20 She definitely has less contractures at

21 the knee, so I can lift it up like that. She has

22 some degree of contractures, but you can see it

23 is easier for me to lift up at the knee than

24 elsewhere.

25 She has more contractures on that side.




658



1 As you can see I'm trying to bend it. So I could

2 bend it a fair amount, so it's typical that at

3 the knees you have less contractures at the knees

4 during flexion or extension.

5 She has some contractures in what we

6 call the adduction when I'm trying to push the

7 legs apart that increases resistence to tone. I

8 did not have my reflex hammer because I can't get

9 it through security anymore because of 911. It

10 looks like a weapon.

11 So I'm always looking for a reflex

12 hammer and they gave me something there. So I'm

13 trying to test her Babinski response --

14 Q. What are you testing for there?

15 A. In the Babinski response the big toe

16 should go up, but what I'm saying is invalid

17 because she had such severe contractures that the

18 toes go down and there's some movement of the

19 toes, but this is basically an invalid response

20 which is what you would expect that there is no

21 good response.

22 That would be a sign of severe damage

23 to the pyramidal tract, P-Y-R-A-M-I-D-A-L. So

24 that's invalid. I'm just doing this for

25 completeness sake. There is no response. It




659



1 really doesn't mean anything per se.

2 That's not a very good reflex hammer,

3 but the reflexes don't mean a lot of different --

4 I think Dr. Greer and Dr. Bambakidis find

5 hyperflexion in the upper extremity. These

6 reflexes are present. It really doesn't mean

7 much one way or the other.

8 In other words, if they were hypoactive

9 or hyperactive it wouldn't mean anything at this

10 point in time. The contractures would prevent

11 the reflexes. I really didn't attempt to reflex

12 in the upper extremities. I think Mr. Bambakidis

13 and/or Dr. Greer did and they did find

14 hyperreflexia.

15 Since I didn't have a reflex hammer I

16 didn't do that. I'm trying to see if you can

17 actually see the pupils react to light. That's

18 very difficult to do because you see the black

19 pupil with the light shrinking in it and it's

20 very hard with a video camera to see that.

21 Q. Do you recall whether Theresa's pupils

22 reacted?

23 A. Oh, yeah, they reacted to light.

24 That's a brain stem reflex. I think

25 Mr. Bambikidis and Dr. Greer found --




660



1 Q. What's the significance of her pupils

2 reacting to light?

3 A. That means that that part of the brain

4 stem related to pupilar reaction to light is

5 normal. That's a brain stem mediated response.

6 In the vast majority of patients in a vegetative

7 state will have a normal pupilary reaction to

8 light.

9 I really tried hard to demonstrate

10 that, but I didn't do a very good job. But they

11 react to light. That's what Dr. Bambakidis and

12 Dr. Greer found as well. I certainly didn't do a

13 very good job on that eye. You can't see it.

14 But that's a normal response in anybody

15 vegetative or otherwise.

16 Now it sounds cruel when I say that or

17 insensitive, but what I'm trying to do is

18 stimulate her while her eyes are open because if

19 she falls asleep a little bit you can't do

20 anything from that point.

21 Anything that you do at that point

22 except maybe test reflexes is invalid because

23 you've changed the level of consciousness because

24 she has a right -- she has to go to sleep

25 sometimes.




661



1 That's the classic flexor response of

2 the upper extremities bilaterial decorticate

3 posture and flexor response in the upper

4 extremities. The legs don't move much then they

5 come down very slowly, so that's a classic

6 decorticate or flexor response in the upper

7 extremities due to a painful stimuli.

8 Q. Do you have an opinion as to whether or

9 not that moaning was in response to that painful

10 stimuli?

11 A. No, I think it may have been because

12 sometimes when you stimulate her you get more of

13 a moan. Certainly you could have a moan and the

14 interesting thing is she didn't grimace.

15 Sometimes you can see grimacing when you do

16 painful responses.

17 And I think another thing that

18 indicates that she's clearly in a vegetative

19 state is the fact that she doesn't grimace at

20 all. If she felt that you might think she would

21 grimace -- grimacing is found in the vegetative

22 state, too. When you see a patient like this

23 that doesn't even grimace at all then that's even

24 further evidence of a vegetative state, I think.

25 And I have tried to see if she would




662



1 grimace. She certainly had an abnormal response

2 in terms of the upper extremities bilaterial.

3 There's another abnormal response. The arms are

4 really abducting away from the body at the

5 shoulder more.

6 You don't want to really painfully

7 stimulate them. Even though they're unconscious

8 you don't want to painfully stimulate them any

9 more than you have to. So you try to balance in

10 any exam between doing adequate painful

11 stimulation and not doing any at all. Obviously

12 could you get more with a painful stimulation

13 than otherwise.

14 That's the sucking reflex. I'm

15 touching and she sucks every time. That's a sign

16 of severe brain damage, not necessarily

17 vegetative, but she has a sucking reflex. She

18 has increased jaw jerk when I do that. Sometimes

19 the jaw goes out and that's a sign of brain

20 damage, not every time.

21 It could be done better with a reflex

22 hammer. So a sucking reflex and increased jaw

23 jerk like that combined with the suck reflex,

24 that's a sign of severe brain damage, not

25 necessarily vegetative per se, but severe brain




663



1 damage.

2 Now, I'm scratching the palm of her

3 hand, you'll have to take my word to see, to see

4 if she has a palmar mento reflex which is

5 movement of the chin on here or here, depending

6 on which side I'm here.

7 So you have to look here and assume

8 that I'm scratching her palm to see if she has

9 that reflex. I didn't see any palmar mento

10 reflex at all with any movement of the chin.

11 That's in the same category as the sucking and

12 increased jaw jerk.

13 Now I'm touching between her eyes.

14 This is glabellar sign --

15 Q. What are you testing for here?

16 A. The normal response is you adapt and

17 you stop closing your eyes. If you persist, like

18 she's doing, and continue to close her eyes every

19 time, that's an abnormal sign, an abnormal

20 cortical bulbar sign that goes along with the

21 sucking reflex and that's abnormal.

22 Normally a person who is conscious or

23 has brain damage will adapt to that and no longer

24 do that. So she has what we call three or four

25 problems in the cortical bulbar signs which by




664



1 itself does not indicate she's in a vegetative

2 state. It only indicates that she has severe

3 damage to the higher centers of the brain.

4 Now, I went to the other side to do the

5 palmar mento so I was pointing to the area on the

6 right chin where it should pucker if he had an

7 abnormal palmar mento. I don't think I saw it on

8 either side. I went from the left side to the

9 right side.

10 I'm trying to increase the auditory

11 stimulus so she may respond and look at me.

12 Q. You're on her right side?

13 A. Yes. I'm looking for an auditory brain

14 stem reflex where she'll look to the right for a

15 second or two. That's not even consistent. That

16 would be compatible with the vegetative state.

17 She doesn't do that on a consistent base. I

18 really can't like, unlike a visual-oriented

19 reflex, that she has a brain stem auditory

20 reflex.

21 She doesn't do it consistently. She

22 does it sometimes, with her mother she does, she

23 will look that way which could be a reflex, but

24 she doesn't do it consistent enough so we could

25 say she has a brain stem -- now she has a




665



1 startled response. You notice every time I

2 shouted loud and fast she closes her eyes.

3 Since visual tracking is so important I

4 was trying to get her to respond in a way that

5 would indicate she is not unconscious. It would

6 indicate something outside the vegetative state.

7 So I spent a fair amount of time during my

8 examination to see if she has things that I would

9 call consistent visual pursuit or visual tracking

10 or visual fixation which is cortically mediated

11 without any reservation whatsoever.

12 She does not have that. She does have

13 the visual-oriented reflex, which you've seen a

14 couple of times. Which I can see later on the

15 film with her father.

16 Now we're trying it again. I don't

17 remember exactly what I did in the trials with

18 the balloons. I was trying to reproduce what I

19 did before. In other words, I thought I got a

20 fairly consistent response from this multicolored

21 balloon.

22 I guess you would have to be right --

23 see, this is a visual reflex. You have to be

24 right in the precise area of the retina for this

25 to focus on the right area to get this response.




666



1 If you're not in the right area you don't get it.

2 But this was not like the other trial I

3 had. This is just random movements. I was

4 trying to reproduce the visual-oriented reflex

5 that I produced before.

6 Again, you have to take my exam in the

7 totality with all of the other examinations, too.

8 You can't just say my exam alone per se even

9 though she does have visual tracking that she

10 might not have it another time. She doesn't have

11 it.

12 Since you don't know exactly what I'm

13 doing it's not totally fair to draw a definitive

14 conclusion from what I'm doing. I didn't make it

15 clear enough by speaking into the microphone

16 exactly what I was doing which I should have

17 done.

18 It's not fair to draw any major

19 conclusions when you can't know exactly what I'm

20 doing in relationship to what she's doing. I

21 didn't realize my microphone wasn't picking up my

22 voice as well as it should. That was an error on

23 my part. The microphone should have been very

24 clear what I was doing, even if you can't see it

25 I could describe it.




667



1 I was looking at PEG site. G-tube, I

2 guess, in the stomach as opposed to the PEG.

3 Same thing, essentially, tubing to the stomach.

4 Now here you get a response, it may be

5 related sounds. It could be related to his

6 voice. I think it's nonspecific because the eyes

7 stay open longer and she doesn't blink as much.

8 I don't think that's awareness of any

9 sense of the word, but I think it could easily be

10 misinterpreted as awareness. Now there you see

11 the eyes -- when the eyes went to the left when

12 he said Theresa the eyes went over for a second

13 or two.

14 They remained for a second or two, but

15 they're not focused on him, I don't think. You

16 can't tell that for sure. I would expect that

17 more consistent when you have a brain stem

18 auditory orienting reflex where the eyes would go

19 towards sound.

20 I think response to a voluntary command

21 is important to see if she just responds just by

22 saying something. Obviously this is not a

23 complete exam, but to see if she responded. I

24 didn't expect that I would get any response.

25 You could do this for half an hour, an




668



1 hour without getting any better response than you

2 do now. But you can't say from just a few

3 seconds because sometimes she responds and she'll

4 never respond. You have to put the case together

5 in its totality, like we discussed before.

6 Plus she has severe contractures so

7 could have paralysis. So in looking for someone

8 with severe contractures to move is severely

9 handicapped by the fact that she can't move

10 because of the contractures.

11 That was a reflex response. I don't

12 know if she was stimulated when I said we're all

13 done or what, but both sides came up on that,

14 that's a decorticate response.

15 Her neck is rigid to some extent and

16 sometimes you can see rigidity of the neck which,

17 again, is classic for an hypoxic injury. It

18 doesn't indicate a neck injury at all. So

19 there's nothing to indicate a neck injury here

20 per se.

21 See how much rigidity she has in her

22 neck? She has a fair amount of stiffness.

23 Actually it's spasticity rather than rigidity is

24 the proper term.

25 I'm just trying to get some visual




669



1 pursuit or some brain stem auditory-orienting **

2 reflex or something to indicate the pursuit of

3 visual fixation. She just has that visual orient

4 reflex, but she doesn't have anything consistent

5 in any way remotely would be considered by a

6 neurologist as visual tracking.

7 There is the startled response again.

8 You can see the mouth opening and the eyes

9 closing.

10 Q. Thank you. Dr. Cranford, do you have

11 an opinion, within a reasonable degree of medical

12 certainty, as to whether or not Theresa Schiavo

13 is in a persistent vegetative state?

14 A. She is certainly in a persistent

15 vegetative state depending on how the word

16 persistent is used, yes, I do.

17 Q. Okay. Do you have an opinion, within a

18 reasonable degree of medical certainty, as to

19 whether or not there are any treatments that can

20 improve Theresa Schiavo's neurological condition?

21 A. Yes.

22 Q. What is that opinion?

23 A. My opinion is it's beyond bizarre.

24 It's incredibly strange and boggles the

25 imagination that anyone can come along after




670



1 being in a vegetative state after 12 years and

2 say with any treatment -- it has to be totally

3 bogus, completely bogus to come along after 12

4 years in a vegetative state --

5 MS. ANDERSON: Objection, Your Honor.

6 Move to strike. This is improper opinion

7 testimony.

8 MR. FELOS: It's not improper at all,

9 Your Honor.

10 THE COURT: Well, it's de facto

11 commenting on another expert's opinion in

12 this case. So let's stick with what he

13 believes from a medical perspective. The

14 objection will be sustained.

15 MS. ANDERSON: Move to strike that

16 answer, Your Honor.

17 THE COURT: Well, I'm not going to

18 strike all of it. I will strike from the

19 word bogus. I think the phrase beyond

20 belief after 12 years is probably

21 reasonable. We'll strike everything after

22 the word bogus.

23 BY MR. FELOS:

24 Q. Dr. Cranford, would hyperbaric oxygen

25 therapy improve Theresa Schiavo's neurological




671



1 condition?

2 A. No.

3 Q. Why not?

4 A. She's been like this for 12 years. No

5 treatment would improve it at all. Hyperbaric

6 oxygen, for the most part, when it's used in

7 patients with severe brain damage has no chance

8 of recovery in those situations, so, no.

9 Q. What would be the effect in Theresa

10 Schiavo's brain of increasing oxygenation?

11 A. Absolutely none. I mean, in terms of

12 the brain itself?

13 Q. In terms of her cognitive abilities?

14 A. None. It's beyond belief to think that

15 HBO would work in any way, in any shape or any

16 fashion.

17 Q. Is hyperbaric -- to what extent, if

18 any, is hyperbaric oxygen treatment of brain

19 injured patients like Theresa Schiavo accepted in

20 the medical community?

21 A. At this stage it's not accepted at all.

22 Period. You wouldn't have any reputable

23 neurologist or neurosurgeon or rehabilitationist

24 would ever remotely argue that hyperbaric oxygen

25 would be valued at this point in time.




672



1 Q. Do you have an opinion as to whether

2 using vasodilators in Theresa Schiavo's brain

3 would have any chance of helping her recover

4 neurological function?

5 A. Yes, I do.

6 Q. What's your opinion?

7 A. No. No. There is no way in the world

8 after 12 years vasodilation therapy could really

9 be of any value.

10 Q. Does vasodilation therapy have some

11 benefit in treating brain-injured patients?

12 A. It's not been proven that there's

13 literature at the beginning on several different

14 types of stroke physiology and therapies at the

15 beginning when there's a functional possibility

16 for recovery it's not used, but it could be.

17 So it could be considered perhaps bona

18 fide clinical research to do therapy by

19 vasodilator therapy or other therapy in the early

20 stages where there's some chance of recovery.

21 Q. When you say "early stages" what time

22 period are you talking about?

23 A. Seconds to minutes to days to possibly

24 weeks or months, but beyond that, no.

25 Q. Is the use of vasodilators for




673



1 treatment of brain injury like in a patient like

2 Theresa Schiavo who is years out from acute

3 trauma generally accepted in the medical

4 community?

5 A. It's not accepted at all. Not even

6 close.

7 Q. In your opinion, would hormone

8 replacement therapy be of any benefit in helping

9 Theresa Schiavo's neurological condition?

10 A. No.

11 Q. Why not?

12 A. Well, because she has severe

13 irreversible brain damage 12 years out to an

14 extreme high degree of certainty nothing would

15 help her condition at this point in time.

16 Q. Do you know of any existing treatment

17 utilizing stem cells that could improve Theresa

18 Schiavo's neurological condition?

19 A. Absolutely not. Not at 12 years out

20 with severe brain damage with this degree of

21 structural damage being in a vegetative state for

22 12 years. No, it never will. Ever.

23 Q. Are stem cells being -- at this time

24 are stem cells being applied to individuals with

25 brain damage?




674



1 A. Not to this extent, no.

2 MR. FELOS: I have no other questions,

3 Your Honor.

4 THE COURT: Thank you. Rather than

5 starting and then stopping in 30 minutes why

6 do we go ahead and let's take our lunch

7 break now. Okay.

8 MS. ANDERSON: I'm for it.

9 MR. FELOS: Thank you, Your Honor.

10 THE COURT: All right. Let's be in

11 lunch recess until one o'clock. Doctor,

12 once again, you're still under the

13 admonition not to discuss your case with

14 anyone.

15 THE WITNESS: Yes, sir.

16 THE BAILIFF: All rise. Court is in

17 recess until one o'clock.

18 (Thereupon, Court was in recess for lunch.)

19 THE COURT: You made proceed,

20 Ms. Anderson.

21 MS. ANDERSON: Thank you, Your Honor.

22 CROSS-EXAMINATION

23 BY MS. ANDERSON:

24 Q. Dr. Cranford, have you ever called

25 yourself Dr. Humane Death?




675



1 A. I would call myself a lot of different

2 things, but I don't remember that one per se.

3 Q. You don't remember saying to an AP

4 reporter --

5 A. Oh, I could have. I could have used

6 that phrase.

7 Q. Let me finish my question. Back in

8 1991, You could call me Dr. Humane Death?

9 A. Oh, I could have said that, sure.

10 Q. You don't disagree with that, do you?

11 A. No.

12 Q. Now, can the killing of a patient ever

13 be morally neutral?

14 A. No.

15 Q. Have you ever spoken to the Hemlock

16 Society?

17 A. Yes.

18 Q. Do you remember making the following

19 statement at the Sixth National Conference on

20 Voluntary Euthanasia back in September of 1992 in

21 Long Beach, California, and I'm quoting, Now, I

22 do believe that physician-assisted suicide and

23 euthanasia are both forms of killing because I

24 use killing in a morally neutral sense.

25 A. In a morally what?




676



1 Q. Neutral sense; do you remember making

2 that statement?

3 A. Yes.

4 Q. Now, over the years you have testified

5 in a number of quite high profile cases; have you

6 not?

7 A. Yes, I have.

8 Q. You testified in the Nancy Cruzan case

9 that went to the U.S. Supreme Court, didn't you?

10 A. Yes, I did.

11 Q. And in the Supreme Court, the court

12 adopted a clear and convincing standard of proof

13 in these cases; did they not?

14 A. They did.

15 Q. And that was followed in the Wendland

16 case in California in which you also testified,

17 correct?

18 A. The U.S. Supreme Court didn't adopt the

19 clear and convincing evidence standard. They

20 said the states were free to adopt a clear and

21 convincing evidence standard --

22 Q. Are you quite sure of that, Doctor?

23 A. I'm quite sure of that. Very sure of

24 that. You misquoted --

25 Q. In fact, didn't they reverse on that




677



1 very point, that clear and convincing evidence

2 had not been shown?

3 A. They --

4 MR. FELOS: Your Honor, I object.

5 Dr. Cranford is here to testify as to the

6 medical condition of prognosis of the Ward,

7 not to interpret United States Supreme Court

8 opinions.

9 THE COURT: Well, what does a medical

10 expert's opinion on a legal opinion help?

11 MS. ANDERSON: Judge, I'm exploring his

12 bias. He has also testified and this is a

13 fact and he's coauthored a couple of law

14 review articles in this very area.

15 THE COURT: Well, that's fine, but

16 he -- the case before the U.S. Supreme Court

17 I don't believe he argued.

18 MS. ANDERSON: No, he didn't argue it,

19 but he testified at the trial court on it.

20 THE COURT: That's fine, but I don't

21 think that he's the one that should tell me

22 what the U.S. Supreme Court did or didn't

23 do.

24 BY MS. ANDERSON:

25 Q. Well, let me ask you that question.




678



1 You are critical, you have been critical of the

2 clear and convincing standard; have you not?

3 A. Yes, I have.

4 Q. And you testified I think in the Brophy

5 case that came out of Massachusetts, you

6 mentioned that earlier, correct?

7 A. Yes, I did.

8 Q. You found him to be in a persistent

9 vegetative state, correct?

10 A. A permanent vegetative state is the

11 term that I used.

12 Q. Do you recall your testimony in that

13 case?

14 A. From 1986?

15 Q. In Volume II, Page 184 of the trial

16 transcript in this case, Question: How would

17 you, after your examination and your review of

18 Mr. Butler's report how would you diagnose

19 Mr. Brophy's condition?

20 Answer: As persistent vegetative

21 state.

22 Does that refresh your --

23 A. Yes, but I prefer the term permanent

24 vegetative state now.

25 Q. So your view has changed, you mean?




679



1 A. Yes, it has.

2 Q. I see. Did you likewise testify in the

3 Christine Brusalacchi case that arose in

4 Missouri?

5 A. I was heavily involved in that case.

6 I'm honestly trying to remember whether I ever

7 testified at any point in the courtroom

8 proceedings.

9 Q. Do you recall a hearing in which the

10 Court was deciding whether to move that patient

11 to Minnesota where you could do an examination on

12 her?

13 A. Yes, there were a couple of proceedings

14 in Missouri on the Brusalacchi case, yes.

15 Q. Did you also testify in the case of

16 Roldalpho Torrez in Minnesota?

17 A. I didn't testify in Brusalacchi.

18 Q. You did not testify in Brusalacchi?

19 A. I don't believe that I testified. I

20 was very involved in that case, but I don't

21 believe I actually testified in court on that

22 particular case.

23 I may have submitted a brief -- I'm

24 sorry, not a brief. I may have submitted a

25 statement, but I honestly do not recall that I




680



1 testified in court on the Brusalacchi case. I

2 think that's in error, ma'am.

3 Q. So the transcript reflecting your

4 testimony would be some sort of error?

5 A. Well, I don't remember testifying in

6 Brusalacchi.

7 Q. That's fine. You also testified in

8 California in the case of Robert Wendland?

9 A. Yes, I did.

10 Q. You were critical of the California

11 Supreme Court's outcome in that; were you not?

12 A. Yes, I was.

13 Q. And that opinion was issued last

14 August?

15 A. Yes.

16 Q. It came down on the favor of permitting

17 Mr. Wendland to live?

18 A. Yes, it came down on that side. That's

19 correct, yes.

20 Q. Unfortunately Mr. Wendland had died;

21 had he not --

22 A. Yes, he did.

23 Q. -- during the pendency of the case in

24 the California Supreme Court?

25 A. Yes, he did.