The Burned Body
On gross examination, it is usually impossible to distinguish acute antemor-tem from postmortem burns. Microscopic examination of the burns is not helpful unless the victim has survived long enough to develop an inflammatory response. Lack of such a response, however, does not necessarily indicate that the burn was postmortem. One of the authors VJMD had occasion to examine microscopic slides of third-degree burns incurred in Vietnam, with the patients subsequently evacuated to Japan where they...
Adult Pedestrians
If an adult is struck by a truck with a high front, the situation is the same as with a child. With non-braking or late-braking, the impact to the adult is above the center of gravity and the individual is slammed down and run over. If the truck is braking hard prior to impact, the individual is thrown forward. If adults are struck by an automobile or light truck, rather than a truck with a high front, a different pattern of injuries occurs because victims are impacted below the center of...
Infanticide and Child Murder
Once past the first few days of life, the methods used to commit homicide change radically. In addition, the mother is joined by the husband, boyfriend, or babysitter as possible perpetrators. Most child homicides occur in the first two years of life, the majority in the first year, with a steep decline after the second year. In 1999, 280 children between the ages of 1 and 4 years were murdered in the U.S. The most commonly used weapons were hands, feet, and fists, 123 cases firearms, 39 cases...
SIDS and the Munchausen Syndrome by Proxy
Over the years, a number of causes have been proposed for SIDS. One suggestion was that the episodes of prolonged apnea seen in premature infants are a form frustre of SIDS. This concept was proposed by Steinschneider in an article in Pediatrics in 1972.18 He studied five infants, three of whom were referred to him at about 1 month of age because of cyanotic episodes of undetermined etiology. Two subsequently died of what was called the sudden infant death syndrome three survived. One of the...
Miscellaneous 1
Pieces of glass have been used to cut wrists and throats and to slash people. They have been used in both homicides and suicides. Occasionally, an accidental death will be caused by glass. The authors have seen a number of cases in which an intoxicated individual knocked out a pane of glass with a hand or fist. In the process, as the arm went through the glass, or when it was pulled back, a jagged projection of glass cut the arm, inflicting a deep wound and severing a major vessel, with...
The Eyes and Eyelids
Surgical removal of corneas or the globes of the eyes shortly after death can result in hemorrhage into the eyelids indistinguishable from antemortem traumas Figure 4.7A . Removal of vitreous shortly after death can result in scleral hemorrhage at the puncture site Figure 4.7B . Figure 4.7 A Hemorrhage into eyelids following removal of corneae. B Scleral hemorrhage following removal of vitreous. Figure 4.7 A Hemorrhage into eyelids following removal of corneae. B Scleral hemorrhage following...
Contusions of the Brain
Impact injuries can produce contusions and lacerations of the brain. Contusions are the most frequently encountered traumatic lesion of the brain. Contusions involve the crests of the gyri, but can extend into the white matter as wedge- Figure 6.5 An 18-month-old child with separation of sutures due to severe cerebral edema. Figure 6.5 An 18-month-old child with separation of sutures due to severe cerebral edema. shaped lesions.9 Contusions are more severe when associated with skull fractures...
Gastric Emptying and Digestion
One way of attempting to determine the time of death is by establishing the time interval between eating and death and then finding the time the deceased last ate. A perusal of standard forensic textbooks gives a number of estimations of how long it takes to digest a meal. Spitz and Fisher state that a small meal a sandwich is digested in 1 h and a large meal takes 3-5 h.7 Adelson says gastric emptying depends on the size and content of the meal, with a light meal taking 1 2-2 h to digest, a...
Hemoptysis
A fourth type of sudden, unexpected death due to pulmonary disease is massive hemoptysis Figure 3.15 . There are generally two causes, depending on the population served. First is a tumor eroding into a pulmonary vessel with subsequent massive hemoptysis and exsanguination. In a population with a large number of alcoholics or individuals with impaired immune systems, however, one will see fatal hemoptysis caused by cavernous tuberculosis. Figure 3.15 An 80-year-old female who exsanguinated from...
Traumatic Brain Swelling and Edema
Following significant head injury, whether clinically mild or severe, swelling of the brain can occur. Brain swelling may be focal, adjacent to an area of brain injury or diffuse, involving one or both cerebral hemispheres. Brain swelling is due to an increase in intravascular cerebral blood volume secondary to vasodilatation congestive brain swelling , or an absolute increase in the water content of the brain tissue, or a combination of the two. An increase in tissue water content, or cerebral...
Chemical Asphyxiants
In chemical asphyxia, inhalation of a gaseous compound prevents utilization of oxygen at the cellular level. The most common chemical asphyxiant encountered by a medical examiner is carbon monoxide. Carbon monoxide poisoning is discussed in Chapter 14. Hydrogen cyanide and its salts, potassium and sodium cyanide, are potent, rapidly acting poisons. Cyanide produces cellular hypoxia by combining with the ferric iron atom of intracellular cytochrome oxidase. There is no cumulative effect from...
Lacerations of the Brainstem
Violent hyperextension of the head and neck can cause laceration at the junction of the pons and medulla.18,53 These laceration may be either partial or complete, and are usually associated with fractures of the cervical spine, hinge fractures, or ring fractures.50,53 Occasionally, the injury will not be associated with either cervical or cranial fractures. The only evidence of injury to the brain, aside from the laceration, is generally subarachnoid hemorrhage around the brainstem. While death...
Rigor Mortis
Rigor mortis, or stiffening of the body after death, is due to the disappearance of adenosine triphosphate ATP from muscle. ATP is the basic source of energy for muscle contraction. Muscle needs a continuous supply of ATP to contract because the amount present is sufficient to sustain muscle contraction for only a few seconds. The three metabolic systems responsible for maintaining a continuous supply of ATP in the muscle are the phosphagen system, the glycogen-lactic acid system, and the...
Side Impact Crashes
The second type of collision is the side impact. In fatal crashes involving passenger cars, it is second in frequency to front impacts. These crashes usually occur at intersections when a car is struck broadside by another vehicle going through the intersection at right angles to the first. In such cases, dicing injuries can be found on either one or both sides of a driver, depending on whether the side glass is propelled into the driver the driver into the glass, or both. Side impact crashes...
Gentle Homicides and the Lethal Variant of Munchausens Syndrome by Proxy
Probably the most commonly missed method of homicide in infants and young children is smothering. Based on the authors' experiences, smothering is, after impulse homicides, the second most common type of homicide in infants. In infants, smothering is very easily accomplished. One closes off the child's nose with two fingers, at the same time pushing up on the lower jaw with the palm to occlude the airway. Other methods have involved placing a pillow or towel over the child's face and pressing...
Lacerations
A laceration is a tear in tissue caused by either a shearing or a crushing force Figure 4.8 . Just as with contusions, one can have lacerations of internal organs as well as the skin. Lacerations of the skin tend to be irregular with abraded contused margins. They are caused by blows from blunt objects, falls, or impact from vehicles. The appearance of the laceration may not accurately reflect the instrument that produced it. Thus, a steel rod might produce not only a linear laceration of the...
Urinary Bladder
In adults, the empty urinary bladder is placed entirely within the pelvis, behind the pubic symphysis. When distended, the bladder may extend into the abdominal cavity. In children, the anterior surface of the bladder is in contact with the lower two-thirds of the abdominal wall between the sym-physis pubis and the umbilicus. Beginning at puberty, it slowly begins to descend to its final position in the pelvis. Iatrogenic rupture of the urinary bladder may occur during instrumentation for...
Abrasions
An abrasion is an injury to the skin in which there is removal of the superficial epithelial layer of the skin the epidermis by friction against a rough surface, or destruction of the superficial layers by compression. Antemortem abrasions have a reddish-brown appearance Figure 4.1 and heal without scarring. Abrasions produced after death are yellow and translucent with a parchment-like appearance. They are important to the forensic pathologist in that they indicate where a blunt instrument or...
Severity of Burn Injuries
The severity of thermal injury in an individual depends on Figure 13.2 A and B Radiant heat burns with erythema, blistering of skin and skin slippage continued . Figure 13.2 A and B Radiant heat burns with erythema, blistering of skin and skin slippage continued . Figure 13.2 continued C Cooked skin caused by prolonged exposure to low heat. Figure 13.2 continued C Cooked skin caused by prolonged exposure to low heat. The extent of the burned area The presence of inhalation injuries In living...
Front Impact Crashes
Front impact crashes are the type of crash that most people think of when talking about motor vehicle accidents. Textbooks tend to concentrate on this type of accident, because it is easy to explain and understand. When two vehicles crash head-on, or a vehicle crashes into a fixed object, unless the driver and passengers are restrained, they will continue their forward movement, even though the car has stopped. If unrestrained, the driver's knees will impact the instrument panel the chest the...
Stab Wounds from Weapons Other than Knives
When an individual is stabbed with an implement other than a knife, the stab wound may have a characteristic appearance because of the unusual nature of the weapon. Because ice picks are no longer common household objects, ice pick wounds are rarely seen nowadays. Ice picks produce small, round, or slit-like wounds that can be easily missed or confused with wounds caused by .22-caliber bullets or shotgun pellets Figure 7.8 . A single ice pick wound might be missed on a cursory examination of a...
Spleen
The spleen lies in the left upper quadrant of the abdomen, extending to the epigastric region and lying between the fundus of the stomach and the diaphragm. It is not as frequently injured as the liver because of its well-protected position in the left upper quadrant of the abdomen. Spontaneous rupture of the spleen, unassociated with any significant trauma, is associated with any condition that produces splenomegaly and an increased fragility of the parenchyma. The most common of such...
Spontaneous Pneumothorax of Newborns
One other pulmonary cause of sudden death should be mentioned. This is spontaneous pneumothorax of the newborn.67,68 This entity is relatively uncommon, occurring in 1-2 of live births, and is usually benign, with virtually all term infants having resolution without sequelae, often without the condition's being diagnosed. It should be suspected in any apparently healthy newborn who dies suddenly and unexpectedly in a hospital nursery. An X-ray prior to autopsy will make the diagnosis Figure...
Epidural Hemorrhages
The dura is a gray membrane of connective tissue firmly adherent to the inner surface of the skull. Arteries run along the inner surface of the dura at its point of attachment with the skull. The potential space between the skull and dura is the epidural space, with an actual space, the subdural space, between the dura and brain. The brain, in turn, is enclosed in two thin, transparent membranes the inner pia and the outer arachnoid. The subarachnoid space is between the arachnoid and pial...
Manual Strangulation
Manual strangulation is produced by pressure of the hand, forearm, or other limb against the neck, compressing the internal structures of the neck. The mechanism of death is occlusion of the blood vessels supplying blood to the brain i.e., the carotid arteries. Occlusion of the airway probably plays a minor role, if any, in causing death. Virtually, all cases of manual strangulation are homicide. In the authors' experience, it is the second most common method of homicidal asphyxia. In a study...
Ligature Strangulation
In ligature strangulation, the pressure on the neck is applied by a constricting band that is tightened by a force other than the body weight. Virtually all cases of ligature strangulation are homicides. In the authors' experience, ligature strangulation is the most common method of homicidal asphyxia, though the incidence of manual strangulation follows fairly closely. In a study of 133 homicides caused by asphyxia, ligature strangulation accounted for 48 of the deaths manual strangulation for...
Chemical Changes in Body Fluids
Quantitation of vitreous potassium has been put forward as a reliable method of determining the time of death. It is known that, as time since death increases, so does the concentration of potassium. Sturner and Gantner developed a formula for estimating the time of death based on a uniform Figure 2.10 Tache noire. A and B Postmortem drying of sclera of eyes. Figure 2.10 Tache noire. A and B Postmortem drying of sclera of eyes. increase in vitreous potassium.5 However, this formula has since...
Sexual Asphyxia Autoerotic Asphyxia Autoerotic Deaths
These are asphyxial deaths, principally caused by hanging, in which transitory anoxia is intentionally induced to enhance sexual arousement produced by masturbation.35 Such deaths are rare, with the victim virtually always a male. Only a few cases involving females have been reported.36 The victim is typically found in a private area, nude or partially nude sometimes wearing female clothing. There may be erotic literature, sexual paraphernalia or a mirror opposite the individual so that he can...
Chop Wounds
Chop wounds are produced by heavy instruments with a cutting edge, e.g., axes, machetes, and meat cleavers. The presence of an incised wound of the skin, with an underlying comminuted fracture or deep groove in the bone, indicates that one is dealing with a chopping weapon Figure 7.31 . When the perpetrator pulls out a weapon that has embedded itself in the bone, he might give it a sharp twist, fracturing or breaking off the adjacent bone. In tangential wounds of the skull, chopping instruments...
Smothering
Asphyxia by smothering is caused by the mechanical obstruction or occlusion of the external airways, i.e., the nose and mouth. Deaths such as these are usually either homicide or suicide, very rarely accident Figure 8.1 . The most common form of suicidal smothering is the placing of a plastic bag over an individual's head Figure 8.1 A . If it is heavy plastic, it may be secured at the neck. More commonly, suicides employ the thin, filmy plastic bag used by dry cleaners. Here, there is often no...
Crucifixion
One unusual, historical, form of asphyxia was crucifixion.37 The victim was typically nailed to a cross with nails driven through the wrists into the crossbar and through the feet into the upright post. Death was caused by shock, both hypovolemic and secondary to the pain of nailing, plus dehydration and asphyxia. The weight of the body on the outstretched arms would interfere with exhalation by maintaining the intercostal muscles in an inhalation state. Exhalation would then become primarily...
Hanging
In hanging, asphyxia is secondary to compression or constriction of the neck structures by a noose or other constricting band tightened by the weight of the body. There may be either complete or incomplete suspension of the body Figure 8.13 . Incomplete suspension, with the toes or feet less commonly the knees or buttocks touching the ground, is extremely common. Virtually all hangings are suicidal. Accidental hangings are uncommon and homicidal hangings very rare. Death is caused by...
Fractures of the Skull
The second type of injury that can be incurred is to the skull. In general, whenever a head is either struck with or strikes an object having a broad flat surface area, the skull at the point of impact flattens out to conform to the shape of the surface against which it impacts. As the skull is flattened and bent inward, adjacent, but more distant areas, are bent outward by a wave of deformation consisting of the central area of inbending and the peripheral outbending Figure 6.1 2,3 This...
Traumatic Asphyxia Combined with Smothering
Traumatic asphyxia combined with smothering is a combination of both these entities. It can be accidental or homicidal. An accidental form is overlay, where an infant is placed in bed for the night with either an adult or a larger child. Subsequently, the infant is found dead. During the night, the other individual rolled onto the infant, killing it by a combination of Figure 8.11 A 5-month-old infant killed by python. No petechiae, hemorrhage, or bruising of body. Puncture marks on face have a...
Appearance of Stab Wounds in Skin
The size and shape of a stab wound in the skin depends on the nature of the blade and knife, the direction of the thrust, the movement of the blade in the wound, the movement of the individual stabbed, and the state of relaxation or tension of the skin. The sharpness of a weapon will determine the appearance of the margins of the wound sharp and regular abraded and bruised, or jagged and contused. With a blunt cutting edge, the edges of the wound may be abraded. If an individual is stabbed such...
Incised Wounds
Incised wounds or cuts are produced by sharp-edged weapons or instruments. A knife is the classical example of a weapon used to inflict an incised wound, though, in fact, any instrument with a sharp edge can do so e.g., a piece of glass, metal, or paper. The sharp edge of the instrument is pressed into and drawn along the surface of the skin, producing a wound whose length is greater than its depth. In incised wounds, the length and depth of the wound will not provide information as to the...
Kidneys
The kidneys are situated in the posterior part of the abdomen on either side of the vertebral column behind the peritoneum. The right kidney is usually slightly lower than the left. The posterior surface and upper portion of the right kidney rest on the 12 th rib the left kidney usually rests on the 11th and 12 th ribs. The anterior surface of the right kidney is in contact with the right adrenal gland, liver, and the right colic flexure. The anterior surface of the left kidney is in contact...
Interpretive Toxicology Drug Abuse and Drug Deaths
Toxicology Screens Deaths Ethyl Alcohol Methyl Alcohol Isopropanol Ethylene Glycol Phencyclidine PCP Heroin Lye NaOH Arsenic Cyanide Strychnine Digoxin, Succinylcholine, and Insulin
Reyes Syndrome
Reyes syndrome is an entity of unknown etiology affecting children, in which an upper respiratory tract infection, chicken pox, and, rarely, gastroenteritis are followed by vomiting, convulsion, coma, hypoglycemia, elevated blood ammonia, and abnormal serum transaminase values. Individuals dying of the entity show fatty metamorphosis of the liver, with multiple small fatty cyto-plasmic vesicles in the hepatocytes, myocardial fibers, and tubular cells of the kidneys. These are extremely fine...
Contusions
A contusion or bruise is an area of hemorrhage into soft tissue due to rupture of blood vessels caused by blunt trauma Figure 4.5 . Contusions may be present not only in skin, but also in internal organs, such as the lung, heart, brain, and muscle. A large focal collection of blood in an area of contusion is referred to as a hematoma. A contusion can be differentiated from an area of livor mortis in that, in a contusion, blood has escaped into soft tissue and cannot be wiped or squeezed out, as...
Pancreas 1
The pancreas is located retroperitoneally, closely applied to the posterior abdominal wall. It is composed of a head, neck, body, and tail, with the head lodged in the curve of the duodenum. The neck and body are in proximity to the portal vein, inferior vena cava, and aorta, overlying the body of the second lumbar vertebra. The tail crosses the upper pole of the left kidney, terminating in the gastric surface of the spleen, in contact with the left flexure of the colon. Blunt force injuries to...
Meningitis
Meningitis is an occasional cause of sudden unexpected death.54 Until the late 1980s, most of the victims were children between the ages of 3 months and 3 years, with the organism involved being Hemophilus influenza. Mass inoculation of children with Hemophilus vaccine has resulted in the virtual disappearance of such cases. At present, acute bacterial meningitis is a disease of adults. It is seen in association with infections of the ears and sinuses alcoholism splenec-tomy, pneumonia, and...
Decomposition
Decomposition involves two processes autolysis and putrefaction. Autolysis is the breakdown of cells and organs through an aseptic chemical process caused by intracellular enzymes. Since it is a chemical process, it is accelerated by heat, slowed by cold, and stopped by freezing or the inactivation of enzymes by heat. Organs rich in enzymes will undergo autolysis faster than organs with lesser amounts of enzyme. Thus, the pancreas autolyzes before the heart. The second form of decomposition,...
Valvular Disease
Sudden death due to valvular disease usually involves either mitral valve prolapse floppy mitral valve myxomatous degeneration of the mitral valve or aortic stenosis. Rarely, sudden death will be due to an acute bacterial valvulitis Figure 3.5 . The valve involved is usually the tricuspid valve and the individual an intravenous drug abuser. Figure 3.5 Acute bacterial endocarditis involving mitral and aortic valves in 32-year-old drug addict. Figure 3.5 Acute bacterial endocarditis involving...
Dating of Contusions
The forensic pathologist is often asked the age of a bruise, as such information could be of potential importance in a case. Methods used to age a bruise are 1 histology and 2 color changes. The first method can be disposed of very rapidly. Consistent microscopic dating of contusions has been found to be impossible.3 The method most commonly employed in dating contusions is based on the changes in color a contusion undergoes as it heals. The depth of a contusion and skin pigmentation may affect...
Pulmonary Thromboemboli
Gonzales et al. list asthma and pulmonary embolus as causes of asphyxia.59 These two conditions are not fatal as often as they formerly were, but still represent a significant number of deaths due to respiratory disease. Death from massive pulmonary thromboembolus is due to impaction of dislodged thrombi in the pulmonary artery or its main tributaries Figure 3.14 . Thrombosis has been classically described as being caused by three factors stasis, injury to a vein, and hypercoagulability. Most...
Time of Death
Determination of the time of death is important in both criminal and civil cases. In criminal cases, it can set the time of the murder, eliminate or suggest suspects, confirm or disprove an alibi. In civil cases, the time of death might determine who inherits property or whether an insurance policy was in force. Unfortunately, all methods now in use to determine the time of death are to a degree unreliable and inaccurate. They usually give vague or dubious answers. The longer the postmortem...
Epilepsy
Probably the most common cause of sudden death due to an intracranial lesion is epilepsy. Epileptic deaths constitute approximately 3-4 of all natural deaths coming to autopsy in a medical examiner's office. The estimated incidence of sudden unexplained death among epileptics is 2-17 .43 Very few of these individuals die in status epilepticus. Typically, individuals dying suddenly and unexpectedly of epilepsy are young and show either subtherapeutic levels or absence of epileptic medications on...
Deaths Caused by Motor Vehicle Accidents
Natural Disease as a Cause of Motor Vehicle Accidents Categories of Motor Vehicle Accidents Rear Impact Crashes Seat Belts and Air Bags Air Bags Motor Vehicle Fires Motorcycle Accidents Suicide by Motor Vehicles Determination of Who Was Driving Motor Vehicle-Train Accidents Toxicology in Motor Vehicle Accidents Pedestrian Deaths Relationship between Speed at Impact and Injuries Child Pedestrians Adult Pedestrians References