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Sir Bernard Spilsbury A Survey and Catalogue of His Autopsy Case Cards From the Wellcome Library, London

Megan L. Walmsley, BSc and Matthew John Almond, DPhil

Spilsbury’s career was as lecturer in forensic medicine at Abstract: During his lifetime, Sir Bernard Spilsbury was referred to as University College Hospital, London, School of Medicine the ‘‘father of forensic medicine.’’ He became a household name as a for Women and St Thomas’ Hospital. He also acted as home result of several famous cases. Several articles have been written about office pathologist. He was knighted at Buckingham Palace on his life and work, but an objective assessment has proved difficult be- February 15, 1923, and in 1933, he served as president of the cause of the lack of available material that Spilsbury himself produced. Medico-Legal Society. On September 3, 1908, Spilsbury married His main legacy has been a series of case cards, but for many years these Edith Caroline Horton with whom he lived at 31 Marlborough were unavailable to the researcher. In 2008, a collection of some 4000 of Hill, London NW8 from 1912 until the bombing of London in Spilsbury’s case cards was bought by The Wellcome Library in London 1940, during which one of his sons, Peter, was killed. A second and therefore entered the public domain. In this article, we report our son, Alan, died of tuberculosis in 1945. It is thought to be de- study of 650 of these cards. We discuss trends in Spilsbury’s work and pression over the deaths of his sons and concerns regarding several specific cases in more detail. These cards allow an objective his financial position that led to his suicideVby carbon monox- view to be taken of Spilsbury’s everyday work, and we feel that some ide (CO) poisoningVin his laboratory at University College reappraisal of his legacy is now timely. London on December 17, 1947. Key Words: forensic pathology, forensic science, autopsy, Spilsbury, Some 30 years ago, in this journal, Eckert5 reviewed Wellcome Library Spilsbury’s career and his famous cases, and this report em- Y phasizes that Spilsbury’s impact on medicolegal science was (Am J Forensic Med Pathol 2013;34: 185 194) immense. Eckert pointed out that Spilsbury’s work contributed greatly to the regaining of confidence in expert witness testi- mony by both the judiciary and the public in England, although he life of Sir Bernard Spilsbury has been well documented his international reputation was never so strong, partly because Y T elsewhere.1 4 However, it is perhaps useful to mention here of his reluctance to collaborate widely.5 During his career, some of the major events of his life and to note that his more Spilsbury certainly introduced methods that nowadays would be famous cases have previously been reviewed in this journal.5 regarded as essential in any forensic investigation. He devel- These cases led to him becoming a household name at the oped the use of ‘‘murder bags’’ to store evidence and strongly height of his career and to being referred to as the ‘‘father of encouraged the use of gloves, tweezers, bags, and test tubes for forensic medicineVthe greatest forensic expert of all time.’’2 collecting evidence to try to avoid contamination. Spilsbury He was born on May 16, 1877, at 35 Bath St, Leamington Spa, published little, although such writings as he left have been the eldest of 4 children of James SpilsburyVa manufacturing discussed in previous articles in this journal,6,7 which describe chemistVand his wife Marion. In 1899, he graduated with a Spilsbury’s lectures on ‘‘The Medico-Legal Significance of bachelor of arts degree in natural science from Magdalen Col- Bruises,’’ ‘‘Some Medico-Legal Aspects of Shock,’’ and 2 short lege, Oxford. He enrolled as a medical student at St Mary’s case reports on ‘‘Sudden Death From Inhibition’’ and ‘‘A Hat Hospital, Paddington, and graduated MBBCh (Bachelor of From a Fatal Case of Shooting.’’ Although these works allow Medicine, Bachelor of Surgery) in 1905. He obtained his master some aspects of Spilsbury’s work and personality to be con- of arts degree from Magdalen College in 1908. Upon qualifying sidered, they describe very specific topics and do not provide a in 1905, he was appointed resident assistant pathologist at truly balanced overview of his career. To date, most of the in- St Mary’s Hospital. This post required him to perform autopsies formation on Spilsbury’s career has come from a number of V following sudden deaths in line with the request that had very biographies with more personal information being given in a recently been made by London County Council that 2 patholo- 1961 address to the Royal Society of Medicine by Keith gists should be appointed at each hospital in the region to per- Simpson who had worked with Spilsbury during the last form such work. He was strongly influenced during this time by 12 years of his career.8 In this address, Simpson refers to the his colleague Dr Pepper, who had encouraged Spilsbury to focus fact that Spilsbury was seen by many to have become, in his on the field of pathology while he was still a medical student. later career, inflexible and uncompromisingVperhaps even to believe himself infallible. Certainly, Spilsbury’s reputation has suffered since his death.2,9,10 It is said that he would never admit Manuscript received September 26, 2012; accepted December 5, 2012. to mistakes and often came to judgments that were felt to be From the Department of Chemistry, University of Reading, Whiteknights, beyond those justified by the evidence. Questions regarding his Reading, United Kingdom. The authors report no conflicts of interest. objectivity have been raised, and his ‘‘virtuosic’’ performances Reprints: Matthew John Almond, DPhil, Department of Chemistry, University both in the mortuary and courtroom have been criticized.2,9,10 of Reading, Whiteknights, Reading RG6 6AD, United Kingdom. E-mail: Recent concerns have focused on his insistence on working [email protected]. alone and his failure to submit articles for peer review, to en- Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0195-7910/13/3403Y0185 gage in academic research, or to train students. This has led to DOI: 10.1097/PAF.0b013e318288757f accusations that it was his reputation rather than objective

   

science that led juries to give so much credence to his evidence. to fully catalogue cards at 5-year intervals between 1911 and He also left no textbook and published very little in the aca- 1926 and to carry a general survey of the cards from 1931. This demic sphere. These points are explored by Burney and starting point (1911) was chosen as it was the first year that Pemberton11 in a recent article that focuses on the ‘‘Thorne’’ Spilsbury became a household name following the ‘‘Crippen’’ case of 1925, where the defendant, Thorne, upon conviction for case in 1910.3,17Y19 By cataloguing cards at 5-year intervals, it murder, commented that he was a ‘‘martyr to Spilsburyism.’’ In was hoped that an overview of Spilsbury’s work would emerge Burney and Pemberton’s article, Spilsbury is referred to as ‘‘a and that changes in the type of case studied or the conclusions new creature on the forensic landscapeVthe ‘celebrity pathol- drawn by Spilsbury would become apparent. In Figure 1, a ogist.’’’ It is certainly true that even today Spilsbury’s cases can series of Spilsbury’s case cards relating to the autopsy of provoke comment and debate in the UK national press.12Y14 E. Gerard in the case of Rex v Voisin and Roche, 1917, are This approach to forensic science is contrasted with the modern reproduced. These cards have been reproduced by the kind approach of trace-oriented crime-scene analysis and team-based permission of the Galleries of Justice, Nottingham. It may be pathology, which has displaced the authoritative status of the seen that some problems present themselves in interpreting the lone pathologist. Until very recently, however, it has been dif- data on these cards. First is the matter of reading Spilsbury’s ficult to make a truly objective assessment of Spilsbury’s career handwriting. Second, there is the problem of interpreting the because of the lack of primary source material. abbreviations used by Spilsbury, which are unique to him and Spilsbury’s main legacy is in fact a series of case cards,15,16 which he did not publish. We have produced a list of all of the noting the autopsies that he carried out between 1905 and 1946. abbreviations that we encountered, and these are reproduced These cards are each 12.5 Â 7.5 cm, written front and back in Table 1. We hope that this list will be of use to future scholars in Spilsbury’s ‘‘almost impenetrable handwriting.’’2 Asmall of Spilsbury’s work. In Table 2, we reproduce 1 page of the collection of these, describing his more famous cases, has catalogue (January to March 1911) that we produced to illus- been held at the Galleries of Justice in Nottingham.15 However, trate the information that we obtained from the cards and how in 2008, a much more substantial collection of around 4000 we documented this information and to show the type of case of these cards was discovered in a lost cabinet and was sold that Spilsbury investigated. It is not possible here to reproduce to The Wellcome Library in London. These cards detail cases the whole of our catalogue, but this is available to readers from from the Home Counties and London County for the period the authors on request. 1905 to 1932. A gift of a further tranche of cards, covering the years 1933 to 1944 (with gaps for 1939 and 1940) with a very RESULTS AND DISCUSSION few cards for 1945 and 1946, was made to The Wellcome Library From our catalogue of Spilsbury’s cases from 1911 to in 2009.15 1931, we first report some general trends; we will then look in These cards are perhaps the only resource remaining that more detail at a number of specific individual cases. The first can give a key to the work of this controversial figure. They trend that we investigated was the most common cause of allow for the first time a more objective assessment of reported death (Table 2). In 1911, this is anesthetic deathVwith Spilsbury’s work to be made and for his wider contributions to 35% of all deaths arising from this. Nowadays, anesthetic death pathology to be assessed. The recent possibility for public ac- is rare. By 1931, coronary heart disease has taken over as the cess to these case cards also makes a study of this material very most common cause of death, and this, of course, is still a major timely. Accordingly, in this work, we have made a full catalogue killer. In other words, the 1931 data have a much more ‘‘mod- of all of the cards from the Wellcome collection for the years ern’’ look to it than do the 1911 data. Second, we calculated the 1911, 1916, 1921, and 1926. In this article, we comment upon average and noted the oldest ages of the deceased of the cases our findings in terms of both Spilsbury’s career and the devel- studied by Spilsbury. This is listed in Table 3 and illustrated opment of forensic pathology in the early 20th century. in Figure 2. Both show a steady general increase over the period 1911 to 1931 in line with known life expectancy trends. In MATERIALS AND METHODS studying the reference cards, we also noted that several cases It was clear at the outset that to read, interpret, and cata- give ‘‘stat. lymph.’’ as the cause of death. This is Spilsbury’s logue every one of the 4000 cards available at The Wellcome abbreviation for ‘‘status lymphaticus,’’ thought to be constitu- Library would be beyond the scope of our survey. As such, tional abnormalities including hyperplasia of the lymphoid tis- some degree of selection was necessary. We decided therefore sues and thymus gland that could place pressure on the trachea

FIGURE 1. Case cards of E. Gerard; Rex v Voisin and Roche, 1917 (kindly provided by the Galleries of Justice, Nottingham).

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TABLE 1. A List of Abbreviations Used by Sir Bernard Spilsbury TABLE 1. (Continued) in the Case Cards That Have Been Examined in This Work Abbreviation In Full Abbreviation In Full Tuber Tuberculous Abdom Abdominal Ut Uterus Ac Acute Vent Ventricle Adm Admitted Amput Amputation Anaes Anesthetic and cause sudden death. This condition has been discussed at 20 Art Artery some length and is now known to be non-existent. Many of Cavs Cavities these cases occur where an anesthetic has been administered, and they can probably be added to the list of anesthetic deaths, Chr Chronic emphasizing the unreliability of early anesthetics. In Table 4, we Condit Condition summarize the most common causes of death reported by Cong Congested Spilsbury for the cases that he investigated in the years 1911, Congen Congenital 1916, 1921, and 1926. Conseq Consequence It is also of interest to note the number of cases studied by Coron Coronary Spilsbury and how variable this is from year to year. For ex- Decomp Decomposition ample, for 1926, there are only 18 case cards, whereas for 1931 Degen Degeneration the collection consists of 12 boxes of cards or some 350 cases. Dig Digested Moreover, the amount of detail given on the case cards is very Dil Dilated variable. In some cases, for example, the cards include anno- tated diagrams of injuries, whereas others are very brief. In Dise Disease 1931, in particular, perhaps because of the volume of work, Embol Embolism hardly any of the cards include a ‘‘history’’ section, where Ext External Spilsbury noted details of the deceased’s life indicating possible Fallop Fallopian contributory factors to their death. In general, the cards are Frac Fractured written in a casual, almost informal style, certainly not in the Haem Hemorrhage style of a formal pathologist’s report. Hist History In Table 5, we have reproduced our findings from a num- Hosp Hospital ber of Spilsbury’s reference cards for the years 1911, 1916, Ht Heart 1921, and 1926. Again this is not a comprehensive list. It is Hydroceph Hydrocephalus intended to illustrate the range of cases that came to Spilsbury’s attention and to show trends and developments that occurred Int Internal during these 20 years. We feel, however, that this gives a fas- Intest Intestinal cinating insight into the work of a forensic pathologist in the Kids Kidneys early years of the 20th century. Lacer Laceration In 1911, it is probably the huge number of anesthetic deaths Lt Left that stand out most prominently to the modern reader. Chloroform Malign Malignant is particularly hazardous as an anesthetic, especially to children Mening Meningeal whose body mass is low as it is prone to cause cardiac arrhythmia. Misad Misadventure The action of chloroform can also be delayed as noted, for exam- Mus Muscle ple, in the cases of A. W. Hamer (4/12/1911), T. F. Foster (4/19/ Nour Nourished 1911), and J. Chandler (4/20/1911). These children were aged 3 and 2 months, 5 and 11 months, and 6 years, respectively, and their Obs Obstruction autopsies were carried out by Spilsbury in a period of just 8 days. Op Operation All had had operations on their noses and/or throats. New anes- Pass Passage thetics were being introduced, but these were themselves not Pept Peptic without hazard. H. Przedecki (4/13/1911) died of the use of Perfor Perforated veronal (a barbiturate). There were also many other hazards asso- Perit Peritonitis ciated with medical treatment at that time. A case of mercury Precip Precipitate poisoning is noted (F. Hawker: 4/11/1911). Although Spilsbury Prev Previous does not elaborate, mercury compounds were often used to treat Pulmon Pulmonary sexually transmitted diseases. Another aspect of note that emerges Pups Pupils from Spilsbury’s work is that what would nowadays be termed ‘‘forensic science’’ is clearly beginning to be developed for the Regurg Regurgitate n reconstruction of crimes. The case of A. I. Linfold (4/29/1911) is Resp Respiration interesting because it shows that in this murder investigation Rt Right Spilsbury is considering the angle and position of a wound to de- Rupt Ruptured termine that the murderer stood behind the victim. Sept Septic In 1916, we note the 5 females who died of TNT (trinitro- Spl Spleen toluene) poisoning: E. Deebank, reported as the first fatality from Stat. lymph. Status lymphaticus handling TNT powder (3/17/1916); D. Willis (10/17/1916); A. Marsh (8/22/1916); L. E. Gibson (10/11/1916); and E. Mead

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TABLE 2. Page 1 of the Catalogue That Has Been Produced in This Work Following Inspection of Sir Bernard Spilsbury’s Case Cards for the Years 1911, 1916, 1921, 1926, and 1931

Date of Autopsy Name Sex Age Cause of Death Other Notes Author’s Comments 1/16/1911 Britten, W. M 35 yr Anesthetic death From tracheostomy wound 1/28/1911 Boize, L. W. M 35 yr Toxic goiter 1/28/1911 Saunders, E. M 14 yr CO poisoning Spilsbury noted an ‘‘overpowering suffocating smell’’ 1/30/1911 Potter, B. F 4 yr Misadventure and stat. lymph. Given anesthetic Stat. lymph. now disregarded 2/3/1911 Lamb, K. F 49 yr Choked on regurgitated vomit material while under anesthetic 2/6/1911 Penney, E. M. F 17 yr Pneumonia and pleurisy No ptomaine poison PtomaineVearly theory on cause of death from food poisoning; now obsolete 2/9/1911 Larrance, A. F 26 yr Rupture of right frontal lobe 2/13/1911 Alleyne, M. F 48 yr Anesthetic death Gallstone operation 2/20/1911 Barne, R. M 57 yr Acute intestinal obstruction Copious vomiting after anesthetic administered 2/21/1911 Teague, E. F 29 yr Heart failure Full-term pregnancy, Puerperal feverVserious form puerperal fever of septicemia contracted by woman during/shortly after childbirth 3/4/1911 Eames, S. W. M 14 yr Anesthetic death Acute appendicitis 3/7/1911 Mason, G. M 5 mo Pneumonia and Emaciated Age in month denoted by emphysema fraction of 12ths; emphysema associated with smokers and old age, not babies This table shows cases that Spilsbury examined between January 16, 1911, and March 28, 1911.

(10/13/1916). In 1916, World War I was at its height, and the ingested as attempted cures for sexually transmitted diseases. production of high explosives including TNT had enormously A. M. Goodwin (8/11/1916) died of use of the arsenic compound expanded. The munitions factories were, of course, largely KharsivanVdioxydiamido-arseno-benzoldihydrochloride. H. staffed by women. Women also suffered terribly from attempted Jackson (8/22/1916) and A. Moss (10/27/1916) also died, and abortions, many of which caused death. Some of these were in- L. Roberts (10/21/1916) fared no better from use of neosalvarsan, vestigated by Spilsbury, and some led to prosecutions (eg, L. F. which had been introduced in 1912 as a less toxic alternative to Ellender [5/5/1916], Hamilton [6/15/1916], G. L. Patterson other arsenic treatments. Spilsbury notes that he discovered arse- [4/29/1916]). There is terrible human suffering behind the nic in all major organs and 9 mg of neosalvarsan in total in the few lines written on the cards by Spilsbury: ‘‘Criminal abor- body. We note also the 2 who were killed (M. Coventry and B. tion, probable injection of scalding fluid into uterus.’’ Rex v Stockwell [3/23/1916]) when they were given strychnine rather Holmes, posed as doctor (G. L. Patterson [4/29/1916]); Rex v than butyl chloride hydrate by their chemist and E. M. Beckerson Olley, criminal abortion, insertion into cervix of pieces of gum (7/29/1916) who died of starvation after being recommended elastic catheter (Hamilton [6/15/1916]). As in 1911, there are to fast by H. Bundec who claimed to be a hydropathist. Bundec several cases where arsenic or mercury compounds have been was subsequently convicted of manslaughter. We also note B. A.

TABLE 3. Most Common Cause of Death, Average and Oldest Ages at Death of Individuals Whose Autopsies Were Performed by Spilsbury for the Years 1911, 1916, 1921, 1926, and 1931

Percentage of Deaths Percentage of Autopsies Most Common Recorded as Most Average Age of Oldest Carried Out on Year Cause of Death Common Cause, % Deceased, yr Deceased, yr Children (918 yr), % 1911 Anesthetic death 35 31 68 54 1916 Septicemia and peritonitis 13 29 76 29 1921 Poisoning 14 34 74 21 1926 Pulmonary embolism 33 38 78 22 1931 Coronary artery disease 22 46 87 13

   

cases, blood concentrations of CO are now being reported by Spilsbury, although the ‘‘Haldane’’ method used may in fact give results that are not completely accurate because of the erroneous belief at that time that CO had no reaction in the body except that with hemoglobin.21 A homicide caseVthat of V. Rainlow (11/12/ 1916)Vwhere the cause of death is given as shock from immer- sion in water is highly reminiscent of the ‘‘brides in the bath’’ case on which Spilsbury had worked a year earlier. Spilsbury’s autopsy showed no trace of poison in the body, and he discounted death by drowning because there was no watery fluid or froth in the lungs. In 1921, we note again the precise scientific nature of many of Spilsbury’s investigations. Carbon monoxide concen- trations are given for CO poisoning cases (C. L. Busby [12/2/ 1921], E. F. Stead [12/14/1921]), the exact mass of morphine FIGURE 2. Graph illustrating the average and oldest age of the (13.05 g) found in the body of R. M. Leslie (4/1/1921) is stated. deceased from Spilsbury’s cases for the years 1911, 1916, 1921, In a case of potassium cyanide poisoning, tests for hydrogen 1926, and 1931. cyanide (HCN) have been made, and it is noted that the stomach contents were alkaline. In the case of I. M. Hall (8/15/1921), a suicide case who had died of CO poisoning, Spilsbury notes Pantrey (5/1/1916) who died in childbirth and Spilsbury’s the mummification and presence of maggots. This type of subsequent autopsy, which led to a successful manslaughter observation has developed into an area of studyVforensic prosecution of the doctorVDr HeskinVwho, Spilsbury notes, entomologyVwhich is now of wide importance. In 2 murder separated the child but did not attempt to remove the afterbirth cases (S. Seabrooke [1/29/1921] and H. J. Blackmore [3/18/ and was drunk at the time. Outside the munitions factories, there 1921]), Spilsbury gives detailed notes about the nature of the were other industrial accidents including the worker (E. Norvell weapon used from his investigation of the wounds, and in the [1/27/1916]) who died of chronic lead poisoning after cleaning case of Blackmore, annotated diagrams of the injuries are given. lead batteries. These cases emphasize the lack of regulationV Medical treatment remained hazardous in 1921. There are in particular health and safety regulation at the time. In 1916, a number of anesthetic deaths including E. Laker (12/22/1921) Spilsbury begins to investigate a number of cases that arise from who died when StovaineVthe first synthetic local anestheticV motor accidents. For example, J. Sloughgrove (11/7/1916) dies was injected into her spine. W. A. Overin (6/10/1921), M. R. as a result of being knocked down by a van with fractured ribs Hare (7/6/1921), and G. B. Grave (12/23/1921) also died fol- and spine. Cases of electrocution also begin to be seen such as lowing the administration of anesthetics. C. King (5/25/1921) L. G. Marsh (11/27/1916). World War I makes little obvious died after oil of Chenopodium was used to treat amebic dys- impression on Spilsbury’s work outside the cases of TNT poi- entery. W. M. Bolton (9/26/1921) died having taken HgCl2 soning, which have already been mentioned. However, there are tablets. J. Bird (2/4/1921) died of shock following the removal a few cases that come to his attention, for example, A. E. Pearce of his teeth. E. Whittle (5/26/1921) died of a tumor; we note (11/16/1916), who was wounded in warfare but died of goiter, here the use of radium, presumably as a treatment, which had brought on according to Spilsbury’s notes by Graves disease as been introduced into the tumor. a result of shock. Likewise, L. E. Stock (10/17/1916) is reported Modern life was also presenting new hazards, and in 1921, as being a private in the army who was wounded. Spilsbury’s we note the case of P. C. Sweeney (10/1/1921), who was trapped reported cause of death is given as stat. lymph. in a lift and crushed. In 1926, we note also 2 cases of electro- An interesting point to note is that between 1911 and 1916, cution. F. W. Graham (8/23/1926) died of a fractured skull fol- more accurate scientific methods are being used. In CO poisoning lowing a fall caused by electrocution; J. B. Edward (8/27/1926)

TABLE 4. Statistical Summary (Expressed as Percentages of Total Deaths) of the Most Common Causes of Death of Individuals Whose Autopsies Were Performed by Spilsbury for the Years 1911, 1916, 1921, 1926, and 1931

1911 1916 1921 1926 1 Anesthetic death (35) Heart/cardiovascular disease (11) Heart/cardiovascular disease (18) Heart/cardiovascular disease (39) 2 Poisoning (20) Poisoning (8) Poisoning (15) Electrocution (11) 3 Heart/cardiovascular disease (7) Peritonitis (7) Choking/asphyxia (12) Shock (11) 4 Stat. lymph. (7) Septicemia (6) Anesthetic death (9) Choking/asphyxia (5) 5 Pneumonia (5) Pneumonia (4) Septicemia (6) Bullet wound (5) 6 Congenital defect (infant) (4) Choking/asphyxia (4) Peritonitis (5) Hemorrhage (5) 7 Cut throat (suicide) (4) Congenital defect (infant) (3) Head injury (murder) (4) Stat. lymph. (5) 8 * TNT poisoning† (3) Failed abortion (3) Anesthetic death (5) 9 * Anesthetic death (3) Cancer (3) Burns (5) 10 * Failed abortion (3) Hemor

   

TABLE 5. Catalogue of Selected Autopsies Carried Out by Sir Bernard Spilsbury for the Years 1911, 1916, 1921, and 1926

Date of Autopsy (Month/Day/Year) Name Sex Age Cause of Death Other Notes Author’s Comments 1/28/1911 Saunders, E. M 14 yr CO poisoning Spilsbury noted an ’overpowering suffocating smell’ 2/21/1911 Teague, E. F 29 yr Heart failure Full-term pregnancy, puerperal fever Puerperal feverVserious form of septicemia contracted by woman during/shortly after childbirth 3/7/1911 Mason, G. M 5 mo Pneumonia and Emaciated Age in months denoted by fraction of 12ths; emphysema emphysema associated with smokers and old age, not babies 4/8/1911 Snell, C. D. M 17 yr Stat. lymph. Operation for nasal obstruction; cocaine given Cocaine has anesthetic effects 4/11/1911 Hawker, F. F 18 yr Mercury poisoning 4/12/1911 Hamer, A. W. M 3 and 2 mo Delayed chloroform Operation on nose and throat poison 4/13/1911 Przedecki, H. F 27 yr Veronal poisoning VeronalVbrand name for barbital, hypnotic, used until the mid-1950 4/19/1911 Foster, T. F. M 5 and 11 mo Delayed chloroform Tonsillectomy poison 4/20/1911 Chandler, J. F 6 yr Delayed chloroform Tonsillectomy and adenoidectomy poison 4/29/1911 Linfold, A. I. F 22 yr MurderVcut throat Rex v Pateman murder, diagram of injuries included. Spilsbury noted from the angle and position of the injury that it was a right cutting motion, from which he interpreted that the assailant stood behind the victim to inflict the wound. Chlorine used. 5/16/1911 Bonden, C. M 40 yr Acute ammonia Misadventure; stomach contents examined poisoning 11/24/1911 Hooper, E. M 38 yr Laudanum Letters and checks found laudanumV10% opium, 1% morphine poisoningVsuicide 1/27/1916 Norvell, E. M 57 yr Chronic lead Worked with lead, cleaning batteries, poisoning for example 2/2/1916 Bradshaw, J. H. M 38 yr Peritonitis Perforated stomach lining 2/10/1916 Bourne F NB Hemorrhage and Body found in brown paper parcel fractured skull under seat of railway carriage 2/12/1916 Barry, E. M. F 49 yr Blow in the pit of Page of lavatory floor read in her hand the stomach ‘‘I have burst a blood vessel in my brain’’ 3/17/1916 Deebank, E. F 49 yr TNT poisoning 1st fatal case of handling powder 3/23/1916 Covenly, M. F 28 yr Strychnine poisoning Chemist’s mistake, given instead of butyl chloride hydrate 3/23/1916 Stockwell, B. F 34 yr Strychnine poisoning As above, died together 4/11/1916 Minton, A. T. M 54 yr Gas gangrene Spread through wound of right arm, Gas gangreneVbacteria produces gas possible amputation within gangrenous tissues, usually Clostridium

   

4/12/1916 Crozier, E. P. M 35 yr Leprosy 4/25/1916 Collins, A. M. F NK Placenta praevia Hemorrhage at full term Placenta praeviaVplacenta grows over cervix 4/29/1916 Patterson, G. L. F 24 yr Shock Criminal abortion, probable injection of scalding fluid into uterus. Rex v Holmes, posed as doctor 5/1/1916 Re: Pantrey, B. A. F NK Manslaughter Rex v Dr Heskin; drunk doctor separated child but did not attempt to remove after birth 5/5/1916 Re: Ellender, L. F. F 29 yr Misdemeanor Rex v M. Fedderman, supplying noxious substances with intent to procure miscarriage 5/10/1916 Brissonetti, A. M 25 yr Intestinal obstruction Diaphragmatic hernia caused by previous passage of a bullet; French Canadian soldier 5/12/1916 Coward, L. F 29 yr Chronic Bright disease Evidence of criminal abortion 5/27/1916 Gleig, J. R. M 40 yr Meningeal hemorrhage Consequence of a fracture to base of skull and laceration of mid meningeal artery; knocked down 5/31/1916 Unknown M NK Unknown Decomposition too advanced; body in box at Fenchurch St Station 6/14/1916 Williams, C. C. M 51 yr Mouth cancer Paget disease; while excavating in Falklands, Paget disease of the boneVone leg rock landed on his head, death attributed to this longer than the other 6/15/1916 Re: Hamilton F NK Shock Rex v Olley; criminal abortion, insertion into Gum-elastic catheters were made by d cervix of pieces of gum elastic catheter issolving plant gums onto woven silk tube 6/19/1916 Blanchet, M. F 29 yr CO poisoning Suicide; CO in blood 68%, H6 Using Haldane gas analysis apparatus, created 1889 7/7/1916 Unknown F NB Brain hemorrhage Fractured skull; found in box 7/9/1916 Abrahams, E. A. F 31 yr CO poisoning CO in blood 68% Haldane method, as above 7/10/1916 Willis, D. F 22 yr TNT poisoning Worked with TNT; jaundice 7/13/1916 Glenville, E. F 36 yr Acute peritonitis Septic infection of uterus; passed crochet hook in herself and took pills 7/13/1916 Alison, C. M 15 yr Pulmonary embolism Appendicectomy 7/29/1916 Beckerson, E. M. F 49 yr Starvation Rex v H. BundecVconvicted. Recommended HydropathistVcures disease by internal and victim to fast from food, said he was a hydropathist external use of water 8/22/1916 Jackson, H M 40 yr Cerebral syphilis Accelerated by injection of Kharsivan 9/26/1916 Goodwin, A. M. F 26 yr Acute arsenic poisoning Consequence of administering organic arsenic KharsivanVdioxydiamido-arseno- compoundVKharsivan benzoldihydrochloride 9/26/1916 Jackson, E. F 50 yr Exsanguination And shock as a consequence of injuries to chest and pelvis, road accident 10/6/1916 Jones, A. E. J. M 2 and 6 mo Blunt force trauma Concussion and head injuries, several bruises. to head Rex v Mrs Jones for murder 10/17/1916 Stock, L. E. M 26 yr Stat. lymph. Private in the army, wounded. 10/17/1916 Smith, F. W. M 45 yr Hemorrhage Of ulcer in duodenum and mitral stenosis and chronic lead poison 10/18/1916 Unknown F NB PDA Almost full term, found wrapped in garments 10/19/1916 Snell F NB PDA Stillborn

   

TABLE 5. (Continued)

Date of Autopsy (Month/Day/Year) Name Sex Age Cause of Death Other Notes Author’s Comments 10/20/1916 Theobald, M. A. F 2 and 5 mo Exsanguination Shock consequence of abdominal injuries, crushing and severe injury to right arm. Murder against some person or persons unknown 10/21/1916 Roberti, L. F 26 yr Neosalvarsan poisoning Arsenic in all major organs examined, NeosalvarsanVavailable in 1912, superceded more 9 mg neovarsan toxic salvarsan as treatment for syphilis 10/27/1916 Moss, A. M 62 yr Arsenic poisoning Administered in form of Kharsivan 10/21/1916 Methafer, F. R. F 9 yr Cirrhosis of liver Obscure cause: syphilis? TNT? Spilsbury makes suggestions, but does not come to a conclusion 10/31/1916 Wilson, C. F 41 yr Breast cancer Diseased heart muscle. Cancer accelerated None of my research suggested that breast cancer by pregnancy is accelerated by pregnancy; survival may be lower than in nonpregnant women due to difficulty or delay in diagnosis 11/7/1916 Sloughgrove, J. M 68 yr Shock and blood loss Knocked down by van; fractured ribs, spine 11/12/1916 Rainlow, V. F 21 yr Shock from immersion MurderVRex v Robinson. No watery fluid or in water froth in lungs; no poison on analysis. 11/16/1916 Pearce, A.E. M 41 yr Exophthalmic Wounded by shrapnel in warfare Exophthalmic goiterVGraves diseaseV goiterVshock autoimmune disease, commonly affecting thyroid 11/17/1916 Jackson, C. R. M 67 yr Hemorrhage of stomach Accelerated by accident in January, struck cancer on right side 11/27/1916 Michael, V. M. F 39 yr Veronal poisoning 11/27/1916 Marsh, L. G. M 22 yr Electrocution 11/29/1916 Hopkinson, M. F 41 yr Graves disease Shock of motor bus accident 1/8/1921 Bishop, E. W. F 16 yr Stat. lymph. No evidence of electrocution, but electric heater found over legs of body in bath 1/29/1921 Seabrooke, S. F 71 yr Blood lossVmurder Conclusion: linear wounds caused by rod like surface, but rounder surface for irregular wounds, eg, knob of poker or head of hammer. Great violence 2/4/1921 Bird, J. M 45 yr Shock Consequence of removal of teeth; suffering from tongue cancer 3/18/1921 Blackmore, H. J. M 61 yr Meningeal Fractured skull, brain concussion. Rex v Thorne. hemorrhageVmurder Spilsbury included annotated diagrams of injuries. Extensive notes. ConcludedV at least 19 blows to head, possibly more 3/19/1921 Shaw, L. D. M 38 yr PoisonVsuicide Morphine. 13.05 g found in body 3/23/1921 Miles, A. C. M 16 yr Abscess left frontal Consequence of a blow over the left front blow. lobe of brain Spanner used 3/25/1921 Hoydonk, H. F. G. M 20 yr Poison Potassium cyanide. Alkaline stomach contents, tests for HCN

     

4/1/1921 Leslie, R. M. M 54 yr Poison MisadventureVexcess dose of morphine and hyoscine 5/25/1921 King, C. M 38 yr Poison Oil of chenopodium; suffered from amebic Oil of chenopodiumVused in treatment dysenteryVtropical diseases of worm diseases 5/26/1921 Whittle, E. F 38 yr Chest tumor Introduced radium in tumorVmediastinal MediastinalVgroup of structures in the thorax 5/31/1921 Murphy, V. S. M 24 yr Hemorrhage Left pleural cavity consequence of a stab. Rex v ElliottVmanslaughter 6/10/1921 Overin, W. A. M 60 yr Anesthetic death Operation for removal of ‘‘cauliflower-like growth from palate’’ 6/11/1921 Moores, P. M. F 20 yr Shock and blood loss AbortionVprobably scalded uterus; 5Y6 mo pregnant 6/29/1921 Coffey, J. M 38 yr Hemorrhage Operation to stop bleeding of perineum wound. Papilla of VaterVopening of bile duct Jaundice induced cancer of duodenum and pancreatic duct into duodenum and papilla of Vater 7/6/1921 Hare, M. R. F 39 yr Asphyxia Regurgitated stomach contents in air passage under anesthetic. Operation to relieve abdominal distention following miscarriage 7/14/1921 Edwards, F. G. M 48 yr Anesthetic death Operation on crushed finger 8/15/1921 Hall, I. M. F 46 yr CO poisonVsuicide Mummification, infected with maggots 8/19/1921 Cartor, N. L. F 41 yr Acute septicemia Abortion at 3 mo. Self-inflicted 8/19/1921 Moss, E. J. M 10 mo Asphyxia Drowned by accident, fell in washing bucket

8/20/1921 Tong, A. F 35 yr Poison Camphor poisoning and nicotine CamphorVterpoid C10H16O, used in cough mixtures

9/26/1921 Bolton, W. M. F 36 yr PoisonVmisadventure HgCl2 tablets; mercury poison 10/1/1921 Sweeney, P. C. F 64 yr Asphyxia Compression of larynx and trachea caused by external pressure. Caught in lift 10/2/1921 Busby, C. L. F 70 yr Asphyxia CO poisoning. HaldaneV56%Y60% 12/14/1921 Stead, E. F. F 26 yr CO poison HaldaneV60%Y70% 12/22/1921 Laker, E. F 49 yr Anesthetic death Cancer of the rectum. Given stovaine injection StovaineVfirst synthetic local anesthetic in spine 2/23/1926 Grave, G. B. M 53 yr Anesthetic death Chloroform anesthetic given for cancer of the rectum operation 8/23/1926 Graham, F. W. M 35 yr Fractured skull and Consequence of a fall following electrocution. brain injury Electric burns noted; 415 V 8/27/1926 Edward, J. B. M 18 yr Electrocution No burns of other external evidence. Fell when running and grasped electric fence wire 9/8/1926 Margenson, G. F. M 16 yr Bullet wound to head Accidental. Revolver German Mauser semi-smokeless cartridges. 32. Weapon not touching wound because no singeing or blackening. Blood spatter 9/28/1926 Chapman, G. W. F 18 yr Shock Removal from neck of uterus something previously inserted to procure abortion. Rex v Leroux 10/12/1926 Manwin, N. E. F 24 yr Shock Criminal abortionVRex v Drs Holden and Webster NB indicates newborn; NK, age not known; PDA, patent ductus arteriosus (a type of congenital heart defect in which blood vessels that bypass the lungs fail to close as the infant is born).

     

died when he fell while running and grasped an electric fence. large amount of reference material now in the public domain it is In 1926, there are still deaths as a result of criminal abortions, possible to make an appraisal based on objective evidence. for example, G. W. Chapman (9/28/1926) and N. E. Manwin (10/12/1926). Although World War I had ended some 8 years ACKNOWLEDGMENTS previously, its legacy lives on in the case of G. F. Margenson The authors thank Chris Hilton from The Wellcome Library (9/8/1926) who was killed, reportedly accidentally, with a (London) and Bev Baker from the Galleries of Justice Library German Mauser pistol. In this case, Spilsbury shows his knowl- (Nottingham) for help in accessing source material. edge of gunshot wounds in that he concludes that the weapon was not touching the wound because there was no singeing or REFERENCES blackening. He also notes the blood spatterVagain a field that 1. Evans C. The Father of Forensics: How Sir Bernard Spilsbury Invented has now developed into a highlyimportant part of many murder Modern CSI. London, UK: Icon Books; 2008. investigations. 2. Rose A. Lethal Witness: Sir Bernard SpilsburyVThe Honorary CONCLUSIONS Pathologist. Stroud, UK: Sutton Publishing; 2007. It is perhaps inevitable that Spilsbury’s reputation has 3. Robins J. The Magnificent Spilsbury and the Case of the Brides in the largely been based on his famous cases. These made him a Bath. London: John Murray; 2011. household name during his lifetime, but have also led to ques- 4. Browne DG, Tullett EV. The Scalpel of Scotland Yard: The Life of tions about the scientific accuracy of his work in more recent Sir Bernard Spilsbury. New York: E. Dutton and Co; 1952. times. It has been the lack of scientific papers or textbooks written by Spilsbury and the fact that he did not train students in 5. Eckert WG. Sir Bernard Spilsbury. Am J Forensic Med Pathol. 1981;2;179Y182. his methods that has meant that an objective review of his work has been very difficult. The public availability of his case cards 6. Eckert WG. The writings of Sir Bernard Spilsbury: part I. Am J Forensic at The Wellcome Library changes this situation. It is now pos- Med Pathol. 1984;5:231Y238. sible to monitor how his work progressed on an almost daily 7. Eckert WG. The writings of Sir Bernard Spilsbury: part II. Am J basis, and by looking at these more routine cases that did not Forensic Med Pathol. 1985:6;31Y37. impinge on the public consciousness, perhaps a more balanced 8. Simpson K. Sir Bernard Spilsbury. Medicolegal J. 1961;29:182Y189. picture of Spilsbury’s work begins to emerge. We have made 9. Steel E. A biography of Dr Crippen. Lancet. 1948;252:80. only a preliminary survey of these case cards. In total, we have looked at about 650 of the 4000 case cards that were sold to The 10. Rose A. Lethal witnessVan address given to the Royal Society of Wellcome Library in 2008. Of these, we have studied about 300 Medicine, 2009. Available at: http://www.medico-legalsociety.org.uk/ in detail. Even with this incomplete sample, some clear con- articles/lethal_witness.pdf. Accessed September 25, 2012. clusions emerge. First, we note Spilsbury’s immense capacity 11. Burney I, Pemberton M. Bruised witness: Bernard Spilsbury and the for hard work. In 1931, for example, he reports on no less than performance of early twentieth century English pathology. Med Hist. 350 cases in the year. He introduced rigorous scientific meth- 2011;55:41Y60. odology to his cases. Concentrations of blood CO and masses of 12. Foster P. Doctor Crippen May Have Been Innocent. London: The poisons found within the body are reported. Areas of forensic Times; 2007. investigation are utilized such as studying the growth of mag- 13. Cockcroft L. US Scientists: Dr Crippen Was Innocent. London: The gots on a body, studying blood spatter, and noting the presence Daily Telegraph; 2007. or absence of scorch marks around gunshot wounds. Perhaps more importantly, his work drew attention to various areas of 14. Aaronovitch D. I’ll Eat My Hat if Dr Crippen Was Innocent, OK?. London: The Times; 2008. poor and sometimes illegal medical practice and poor industrial safety in an age when processes were not so regulated as in ours. 15. Morgan RJ. Sir Bernard Spilsbury’s card index. J Forensic Sci Soc. Without clearly establishing the cause of death in many of these 1994;34:268Y269. cases, it would not have been possible to pursue prosecutions 16. Index cards of pathological investigations conducted by Spilsbury. of those who had acted illegally, for example, those carrying out Archive material. Available at: http://library.wellcome.ac.uk/. illegal abortions, drunken doctors, and pharmacists accidentally 17. Randall L. The Famous Cases of Sir Bernard Spilsbury. London: giving out poisons rather than medicines. Moreover, without Nicholson and Watson; 1936. such work, the dangers of anesthetics may not have been properly 18. Browne DG, Tullett EV, Tullett T. Bernard SpilsburyVHis Life and recognized, and industrial hazards may not have been identified Cases. London: Harrap; 1951. and corrected. Clearly, Spilsbury was sometimes unclear about cases (and often he admits this), and he must sometimes have 19. Cullen T. The Mild Murderer: The True Story of the Dr Crippen Case. been wrong. Some of his medical diagnoses would not stand the Boston, MA: Houghton-Mifflin Co.; 1977. test of time, for example, his belief in stat. lymph. He attributes 20. Dodwell HB. ‘‘Status lymphaticus,’’ the growth of a myth. Clin Pathol some causes of cancer and the autoimmune disease, Graves dis- Gen Pract. 1954:149Y151. ease, that nowadays would not seem plausible. But we believe 21. Torrance RW. Haldane and indifferent gases: O2 secretion or CO that it is timely to reappraise the work of Spilsbury, as with such a excretion? Respir Physiol. 1996;106:109Y113.

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The Importance of an Anthropological Scene of Crime Investigation in the Case of Burnt Remains in Vehicles 3 Case Studies

Davide Porta, BSc, Pasquale Poppa, BSc, Valeria Regazzola, BSc, Daniele Gibelli, MD, Daniela Roberta Schillaci, MD, Alberto Amadasi, MD, Francesca Magli, MSc, BA, and Cristina Cattaneo, MD, PhD

cause and manner of death, as well as for personal identifica- Abstract: Inspection of a crime scene is a crucial step in forensic tion, due to the loss of the morphological facial features and the medicine, and even the methods taught by forensic anthropology are alterations of features and marks on the body.6,7 Many parts of essential. Whereas a thorough inspection can provide crucial informa- the human body are likely to survive even at extremely high tion, an approximate inspection can be useless or even harmful. This temperatures, especially the denser bones and those covered by study reports 3 cases of burnt bodies found inside vehicles between a thick layer of soft tissues.8 A modern adult cremation leaves 2006 and 2009 in the outskirts of Milan (Italy). In all 3 cases, the victim an amount of incinerated bones of about 1600 to 3600 g with an was killed by gunshot, and the body was burnt in the vehicle to destroy average of 3000 g.9 signs of skeletal injury and prevent identification. In every case, the For all these reasons, the role of the scene of crime inves- assistance of forensic anthropologists was requested, but only after the tigation with a complete recovery of bone fragments becomes inspection of the body at autopsy showed that the remains were in- crucial, more than in other contexts: a scrupulous analysis of the complete, thus making it more difficult to determine the identity, cause, remains is certainly very useful in cremation cases not only for and manner of death. A second scene of crime inspection was therefore the identification of the victim but also to define the cause performed with strict anthropological and adapted archeological meth- and the manner of death. In particular, at the time of the in- ods by forensic anthropologists to perform a more complete recovery, spection, the accurate collection and sorting of the material are proving how much material had been left behind. These cases clearly critical and often essential steps for the success of the entire in- show the importance of a proper recovery and of the application of fo- vestigation. This concerns mainly bones: in fact, whereas soft rensic anthropology methods on badly charred bodies and the impor- tissues are often completely destroyed by fire, the bony tissue can tance of recovering every fragment of bone: even the smallest fragment survive even at extreme temperatures (although with relevant can provide essential information. Thus, a precise coordination, a cor- morphological alterations) and may still preserve macroscopi- rect and thorough recovery of bone fragments, and an anthropological cally and microscopically specific signs related to the subject’s approach are crucial for many issues: analysis of the scene of crime, biological profile, to pathological deformations, to surgery or reconstruction of the corpse, and reconstruction of the perimortem even lesions.10Y17 Among the debris one can find during the events. scene of crime investigation, every bone or fragment of bone can Key Words: forensic sciences, forensic anthropology, crime scene be crucial and can provide relevant information. investigation, carbonization, charred remains The following cases concern 3 different ‘‘cremations’’ that Y took place inside cars in the outskirts of Milan, Italy, in a time (Am J Forensic Med Pathol 2013;34: 195 200) interval between 2000 and 2009, to show the importance of an adequate analysis of the crime scene and recovery in cases of charred bodies. In these cases, lack of anthropological expertise ome of the most difficult cases forensic pathologists usually on site by legal authorities led to an incomplete recovery. Only Shave to deal with are charred bodies. As a matter of fact, this upon the second examination were all the human remains col- is a fairly usual method used to conceal a body or make it lected after appropriate search and sieving. unrecognizable. However, the high temperatures reached within a fire are usually not capable of completely destroying a body, CASE A but may lead to significant alterations of the morphology and structure of human tissues.1Y5 In this context, the radical During the summer of 2007, a burnt car (Alfa Romeo 147) morphostructural alterations, which are often caused by heat, was found in a field in the outskirts of Milan. During the in- may represent a serious hindrance to the development of many vestigation, a charred body was found inside, in a prone posi- aspects of the investigation: first, for the reconstruction of the tion and on the back seats of the car (Fig. 1A). During the first inspection, only some articulated parts of the 18 Manuscript received February 3, 2012; accepted May 22, 2012. body, mostly burnt and calcined (Crow-Glassman scale level 4), From the LABANOF, Laboratorio di Antropologia e Odontologia Forense, were recovered: precisely, the entire splanchnocranium and parts Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di of the neurocranium (calcined, in fragments, and with many Scienze Biomediche per la Salute, Universita` degli Studi di Milano, Italy. parts of the cranial vault missing), the entire spinal column, The authors report no conflicts of interest. Reprints: Cristina Cattaneo, MD, PhD, LABANOF, Laboratorio di sternum, part of the left thorax, left clavicle and scapula, the Antropologia e Odontologia Forense, Sezione di Medicina Legale e delle entire pelvic girdle, proximal epiphysis and proximal part of the Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, diaphysis of both humeri, right and left femurs, proximal Universita` degli Studi di Milano, Italy. E-mail: cristina.cattaneo@ epiphysis, and proximal part of the diaphysis of tibiae and fib- unimi.it. Copyright * 2013 by Lippincott Williams & Wilkins ulae. This inspection led to the recovery of approximately 70% ISSN: 0195-7910/13/3403Y0195 of the entire skeleton. The trunk was still covered by completely DOI: 10.1097/PAF.0b013e318288759a charred soft tissues, with exposition of the rib cage. Only the

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FIGURE 1. Case A. Charred corpse inside the car (B) and division of the car during the second inspection (A). The dotted lines indicate the areas of the gear and the posterior seats. The continuous lines indicate the profile of the corpse. larger and more visible parts of upper and lower limbs were re- epiphysis of right and left radii and ulnae, some metacarpals and covered from the car. phalanges of the hands, right patella, distal epiphysis of right The body was then subjected to autopsy, but many parts tibia and fibula, right talus, right calcaneus, and metatarsals and were obviously missing. One never knows where useful infor- phalanges of the right foot (Fig. 2, AYC). The material recov- mation for identification and reconstruction of manner of death ered was about 25% of the skeleton. The thorough investigation may come from (eg, a distal phalanx with a cut mark), so one of the scene led to the discovery of a fragment of fabric (that must attempt to recover the entire skeleton. In fact, the help of could have been used as a ligature) near some disarticulated feet forensic anthropology became obvious for a correct recovery of bones, and several bony fragments (recognized as portions of a the entire skeleton. The team managed by the forensic anthro- left shinbone) melted with the bottom of the car. More impor- pologist started with a second inspection of the car, dividing the tantly, the recovery of fragments of the cranial vault allowed for vehicle into 4 parts: the area of the driver’s seat was identified as a reconstruction of the skull. In particular, the recovery of a part ‘‘1,’’ and the other areas with the following numbers up to 4 in a of the frontal bone (5 cm in width) made it possible to recon- clockwise direction. During the recovery, the middle portion of struct a particular and roughly round lesion, suggesting a gun- the car (around the gear lever) and the area under the posterior shot entry wound, on the glabella, with a diameter of 6 mm seats were further divided, because of the high amount of ma- (Fig. 3). A second similar lesion was found on the right parietal terial found (Fig. 1B). After a thorough sieving of all the ma- bone, near the sagittal suture, with a diameter of 9 mm. Thus, terials recovered inside the car, this inspection led to the the collection of further parts of the skull during the second identification of several bony remains: they were totally cal- inspection (eg, pars frontalis) allowed for an identification of at cined, mostly in fragments and scattered on the floor of the car. least 2 gunshot entry wounds. The following bony parts were recovered during the inspection: parts of the frontal and cranial vault (maximum size 6 Â 6 cm, CASE B minimum size 3 Â 1.5 cm), fragments of many left and During the summer of 2000, a completely charred body right ribs, the distal epiphysis of both humeri, the proximal was found lying inside a partially burnt Mercedes Vito van. The

FIGURE 2. Case A. Comparison between bony fragments recovered in the first inspection on the left and in the second inspection on the right (A) and the inside of the car before (B) and after (C) the second inspection. White arrow = distal femoral epiphysis.

     

These procedures added many elements to the reconstruc- tion of the victim’s body, making it more complete. In fact, the inspection led to the recovery of many further bony parts: the missing part of the maxilla; many calcined parts of the left ribs; calcined parts of the diaphysis and the distal epiphysis of both radii and ulnae and many parts of charred carpals, metacarpals, and phalanges; and the medial part of the charred diaphysis of the right femur, the diaphysis of the left femur, both cal- cined patellae, parts of the charred diaphysis of both tibiae and fibulae, and many charred and fragmented parts of the feet (Fig. 6, AYC). Globally, forensic anthropologists found a further 25% of the skeleton. Many fragments of burnt and calcined human bones could not be referred to specific body parts because of the bad preservation of the remains. At this point, it was possible to compare the data ob- tained from anthropological investigations with antemortem data from an identity suspect. As a matter of fact, the com- parison of antemortem dental radiographs and postmortem radiographs of the prosthesis (recovered during the second in- vestigation) led to a positive identification (Fig. 5, B and C). Furthermore, because of the presence of the bullet jacket found inside the van during the second inspection, the victim was presumed to have been shot.

CASE C FIGURE 3. Case A. Gunshot entry wound on the glabella. The This case concerns a burnt body found in a car (Volkswagen fragment of frontal bone (white arrow) was recovered during the Golf), left in a woody area in 2005. The body appeared seated in second inspection. the driver’s position, largely destroyed by fire, with many charred and calcined parts, particularly the cranium, upper and lower limbs, and exposition of charred intestines (Crow-Glassman scale body was found in a supine position, behind the anterior seats 18 and in a diagonal line with respect to the major axis of the level 3). The first inspection led to the recovery of the main vehicle (Fig. 4). The corpse consisted mainly of an apparent body parts and the clearly visible remains (Fig. 7). vertebral column, thorax, hip bones, and charred soft tissue The material recovered during the first inspection and (Crow-Glassman scale level 4).18 During the first inspection, subjected to autopsy was about 75% of the skeleton and was the clearly visible body parts were recovered. The corpse was composed of large portions of the splanchnocranium and neu- severely damaged by the fire, with exposition of the rib cage rocranium partially charred and calcined; the complete thoracic, and cervical vertebrae, amputation of upper and lower ribs, abdominal, and pelvic regions, with both clavicles and scapulae, and absence of most of the skull. The body parts still covered the entire sternum, and all the ribs, vertebrae and pelvic girdle; by charred tissues were less damaged, whereas all the parts coming from upper and lower arms or from the head were to- tally calcined. The material recovered during the first inspection on which the autopsy was performed was composed of 32 calcined frag- ments of the skull, partly from frontal, parietals, temporals, and occipital (maximum size 4 Â 6 cm, minimum size 2 Â 2 cm) without any anatomical relationship, almost the entire splanchnocranium; both clavicles, right scapula, manubrium of the sternum, all the right ribs, the entire spinal column and the pelvic girdle; of the upper limbs, both entire humeri, the prox- imal epiphysis and the diaphysis of the left and right radii and ulnae; of the lower limbs, the proximal and distal epiphysis of the right femur, the proximal epiphysis of the right tibia, and the proximal epiphysis of the left tibia. The skeleton was approxi- mately 70% complete. The assistance provided by the forensic anthropologist consisted in 2 more inspections, conducted in a methodical and scrupulous way. First, the entire van was divided into 3 sections: anterior, middle, and posterior (Fig. 4). The inspection led to the recovery of several bony fragments, a fixed dental prosthesis, 4 central and superior teeth, and the jacket of a bullet deformed by the action of heat (Fig. 5A), along with materials belonging to FIGURE 4. Case B. Division of the van in 3 areas during the the metallic and synthetic frame of the van. There was a sub- second inspection (a = anterior, m = middle, p = posterior), sequent phase of recovery and cataloguing, followed by sieving position of the corpse inside the vehicle (arrow and dotted line), and identification of the fragments. and body parts recovered during the first inspection.

     

FIGURE 5. Case B. Jacket of a bullet found during the second inspection (A). Comparison between radiographs of the dental prosthetic device found in the vehicle (B) and antemortem odontological radiographs (C). of the upper limbs, the proximal epiphysis of the right humerus, sections: respectively, anterior, middle, and posterior. The an- the proximal epiphysis and the diaphysis of the left humerus, terior section was further divided into 3 subsections: one near and the diaphysis of the left radius and ulna; and of the lower the body, the second including the driver’s seat, and the last limbs, the proximal epiphysis and the diaphysis of both femora including the passenger’s seat. The middle section included (still articulated with the pelvic girdle and covered by charred the posterior seats, and the posterior section, the luggage van tissues), the proximal epiphysis and the diaphysis of the left (Fig. 7). tibia and fibula, and the tarsal bones of the left foot. As in the The sieving of all the collected material brought to the previous cases, because of the incompleteness of the remains, a recovery of 2 monoradicular dental roots, 2 projectiles, and further inspection by forensic anthropologists was considered further bony fragments (Fig. 8, AYC), that is, many charred and strictly necessary, to collect more information about the victim’s calcined parts of the skull, including parts of frontal, parietals, identity, the cause, and the manner of death. temporals, occipital, and mandible (mandibular symphysis, left The second inspection was structured in 2 phases: a first condyle, and left ascending ramus) with a maximum size of step of recovery and sieving of the material found on the scene 8.5 Â 6 cm and a minimum size of 2 Â 2 cm; in the upper and then the complete study of the collected bones in the lab- limbs, the diaphysis and distal epiphysis of the right humerus, oratory. The former was organized by dividing the vehicle into 3 the entire right ulna, the distal epiphysis of the left humerus, the

FIGURE 6. Case B. Comparison between the bony fragments recovered in the first inspection on the left and in the second inspection on the right (A) and the inside of the car before (B) and after (C) the second inspection.

     

in the lower limbs, both patellae, the diaphysis and the distal epiphysis of the right tibia, the entire right fibula, the distal epiphysis of left tibia and fibula, both tali, and proximal and distal phalanges. Many fragments of burnt and calcined human bones were not referable to specific body parts because of their small dimensions. The second inspection led to an accurate recovery of about 20% of the skeleton. The second scene of crime investigation was important for the bullets found but especially for another issue: an informant, supposed to be involved in the case, had said that the victim’s hands had been chopped off at the wrist before burning the car. To verify the reliability of this witness, the judge wanted to know whether this were true. The remains told a different story: there were no signs of cut marks on the distal portions of radii and/or ulna (recovered the second time around), which would have inevitably been visible. In fact, cut marks can be seen even after charring.11Y13 In this case also, the second systematic inspection per- mitted the forensic anthropologist to recover several human fragments and important elements, useful for the reconstruction of some of the perimortem events. DISCUSSION The 3 cases clearly show how adequate recovery and fo- rensic anthropology may be essential in cases where the pa- thologists have to face badly preserved remains and where the inspection of the crime scene is a critical step: the presence of burnt bodies is a clear example. In every case, recovery of small fragments left behind at FIGURE 7. Case C. Division of the car in 3 areas (a = anterior, the first scene of crime inspection was crucial for specific as- m = middle, p = posterior) and corpse in the driver’s seat of the pects of the case: finding gunshot wounds or elements crucial car (arrow). The dotted lines indicate further areas of division: for identification or the absence of cut marks. driver seat, passenger seat, and posterior seats. These cases underline how, because fire can lead to ex- treme alterations such as charring of the soft tissues, shrinkage, proximal and distal epiphysis of right radius and ulna, and many and fragmentation of the bones, the analysis of the scene has parts of carpals, metacarpals, and phalanges. In particular, all 10 to be conducted with a complete, precise, and standardized distal phalanges were recovered, and the second metacarpals, method, which includes the collaboration with experts in hu- the lunates, and the right capitate were clearly recognized; and man forensic osteology. Ideally, forensic anthropologists should

FIGURE 8. Case C. Comparison between bony fragments recovered in the first inspection on the left and in the second inspection on the right (A) and the inside of the car before (B) and after (C) the second inspection.

     

always take part in the recovery and selection of the remains and 14. Bohnert M, Rost T, Faller-Marquardt M, et al. Fractures of the base of apply their abilities to recognize fragmented human remains or the skull in charred bodiesYpost-mortem heat injuries or signs of to distinguish between human and animal remains or between mechanical traumatisation? Forensic Sci Int. 1997;87(1):55Y62. 19 human remains and environmental contamination. Therefore, 15. Herrmann NP, Bennett JL. The differentiation of traumatic and the inspection of a crime scene, especially in these cases, has to heat-related fractures in burned bone. J Forensic Sci. 1999;44(3): be conducted by a team of specialists along with forensic 461Y469. anthropologists,20Y28 because even the smallest bony fragment, 16. Hausmann R, Betz P. Thermally induced entrance wound-like defect which may appear unimportant to the eyes of an inexperienced Y observer, can bring fundamental information to a case. of the skull. Forensic Sci Int. 2002;128(3):159 161. 17. Tsokos M. Heat-induced post-mortem defect of the skull simulating an REFERENCES exit gunshot wound of the calvarium. Forensic Sci Med Pathol. 2011; 7(2):227Y228. 1. Eckert WG, James S, Katchis S. Investigation of cremations and severely burned bodies. Am J Forensic Med Pathol. 1988;9(3):188Y200. 18. Glassman DM, Crow RM. Standardization model for describing the 2. Bohnert M, Rost T, Pollak S. The degree of destruction of human bodies extent of burn injury to human remains. J Forensic Sci. 1996;41(1): Y in relation to the duration of the fire. Forensic Sci Int. 1998;95(1): 152 154. 11Y21. 19. Cattaneo C, DiMartino S, Scali S, et al. Determining the human origin 3. DeHaan JD, Nurbakhsh S. Sustained combustion of an animal carcass of fragments of burnt bone: a comparative study of histological, and its implications for the consumption of human bodies in fires. immunological and DNA techniques. Forensic Sci Int. 1999;102(2Y3): J Forensic Sci. 2001;46(5):1076Y1081. 181Y191. 4. Christensen AM. Experiments in the combustibility of the human body. 20. Ohira H, Yamamuro Y, Kitagawa Y, et al. Effective appropriate use J Forensic Sci. 2002;47(3):466Y470. of dental remains and forensic DNA testing for personal identity 5. Thompson TJ. Heat-induced dimensional changes in bone and their confirmation. Leg Med (Tokyo). 2009;11(suppl 1):S560YS562. consequences for forensic anthropology. J Forensic Sci. 2005;50(5): 21. Hill AJ, Lain R, Hewson I. Preservation of dental evidence following Y 1008 1015. exposure to high temperatures. Forensic Sci Int. 2011;205(1Y3):40Y43. 6. Eckert WG. The medicolegal and forensic aspects of fires. Am J 22. Gre´vin G, Bailet P, Quatrehomme G, et al. Anatomical reconstruction of Y Forensic Med Pathol. 1981;2(4):347 357. fragments of burned human bones: a necessary means for forensic 7. Chao TC. Forensic investigation of deaths due to fire in mass disaster. identification. Forensic Sci Int. 1998;96(2Y3):129Y134. Ann Acad Med Singapore. 1992;21(5):649Y655. 23. Bennett JL, Benedix DC. Positive identification of cremains recovered 8. Mayne Correia PM. Fire modification of bone: a review of the literature. from an automobile based on presence of an internal fixation device. In: Haglund Wd, Sorg MH, eds. Forensic Taphonomy: The Postmortem J Forensic Sci. 1999;44(6):1296Y1298. Fate of Human Remains. Boca Raton, FL: CRC Press; 2006:275Y286. 24. Bassed R. Identification of severely incinerated human remains: the 9. McKinley JI. Cremations: expectations, methodologies and realities. need for a cooperative approach between forensic specialities. A case In: Roberts CA, Lee F, Bintliff J, eds. Burial Archaelogy: Current report. Med Sci Law. 2003;43(4):356Y361. research, Methods and Developments. BAR Ann Arbor, MI: University of Michigan; 211;1989:65Y74. 25. Thompson TJ. Recent advances in the study of burned bone and their implications for forensic anthropology. Forensic Sci Int. 2004; 10. de Gruchy S, Rogers TL. Identifying chop marks on cremated bone: Y a preliminary study. J Forensic Sci. 2002;47(5):933Y936. 146(suppl):S203 S205. 11. Pope EJ, Smith OC. Identification of traumatic injury in burned cranial 26. Park DK, Park KH, Ko JS, et al. The role of forensic anthropology in the bone: an experimental approach. J Forensic Sci. 2004;49(3):431Y440. examination of the Daegu subway disaster (2003, Korea). J Forensic Sci. 2009;54(3):513Y518. 12. Marciniak SM. A preliminary assessment of the identification of saw marks on burned bone. J Forensic Sci. 2009;54(4):779Y785. 27. Ubelaker DH. The forensic evaluation of burned skeletal remains: a synthesis. Forensic Sci Int. 2009;183(1Y3):1Y5. 13. Poppa P, Porta D, Gibelli D, et al. Detection of blunt, sharp force and gunshot lesions on burnt remains: a cautionary note. Am J Forensic Med 28. Blau S, Briggs CA. The role of forensic anthropology in Disaster Victim Pathol. 2011;32(3):275Y279. Identification (DVI). Forensic Sci Int. 2011;205(1Y3):29Y35.

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Suicide Due to Four Speargun Shots A Case Report

Alessandro Bonsignore, MD, Luca Vallega Bernucci, MD, Marco Canepa, MD, and Francesco Ventura, MD, PhD

CASE REPORT Abstract: In the literature, only a few cases of deaths related to the use of atypical firearms are present and even more rare are cases of A 75-year-old man fought with a colleague at work, then suicide due to multiple lesions. locked himself inside his office. The police arrived on the scene In the present case, the authors report a rare occurrence of suicide and ordered him to open the door but, moments later, they heard due to 4 speargun shots, 3 to the chest and 1 to the head. muffled, confused noises and then silence. A complete forensic approach led to attribute the death to acute When firemen knocked down the door they found a 45-cm cardiac failure due to hemopericardium after the injury of the left cor- speargun in his right hand with the weapon’s 40-cm harpoon onary artery. lodged in his right temporal region, next to the pericranium; Scene investigation and autoptic findings allowed authors to hy- there were also multiple wounds to the chest. The emergency pothesize that injury to the head was a last attempt of suicide, elapsed service performed several resuscitation attempts without any during the progression of cardiac tamponade. result. With this report, the authors would like to share knowledge with the Afterward, during scene investigation, the man’s body was forensic community about speargun-related lesions distinguishing them found lying on his back near a pool of blood (Fig. 1, A and B). from the very similar ones produced by cold steels. Detectives, owing to the features of the lesions, hypothe- It also shows how it is possible to survive for some time after being sized that the man had repeatedly loaded and fired the weapon. shot by such a weapon. An autopsy was performed 48 hours after the exitus to evaluate the cause of death. Gross examination revealed a break Key Words: suicide, atypical firearms, speargun, multiple wounds of the scalp on the right temporal region 2 cm upper-front the (Am J Forensic Med Pathol 2013;34: 201Y204) auricle; beneath this first lesion, there was a linear and hori- zontal puncture wound of the skull, 1.5 cm long with extended edges (Fig. 2A). On the left side of the chest, there were 3 circular puncture wounds (diameter, 0.7 cm each) rounded by an ecchymotic ring (Fig. 2, B and C), respectively, located in the following: n evaluating the methods used in producing cuts and stab Iwounds, along with their distinguishing features, forensic pa- thologists should pay particular attention in cases of death oc- -0.5 cm from the marginosternal line, in the second infracostal curring through the use of unusual weapons. space (A); In the literature, only a few cases of murder, suicide, or -1 cm from marginosternal line, in the third infracostal space (B) accidental death involving atypical firearms such as darts1Y3 or -close to the preceding one, 1 cm laterally (C). harpoons4Y10 are described. Examination of the skull showed 1 puncture wound of the In particular, only a small number of reports concerning scalp with hemorrhagic infiltration of pericranium on the right the use of crossbows and spearguns are present and even more temporal region (Fig. 2D). rare are cases of suicide due to multiple lesions.11,12 Subdural and subarachnoid hematoma, edema and serum- These events are extremely uncommon as the victim typi- hematic intraventricular liquid were also present ipsilaterally. cally has to reload the weapon several times before firing the At the second infracostal space, beneath wound A, the lethal shot. harpoon had chipped the upper edge of the third left rib. In the present case, the authors report a rare occurrence of On the left side of the chest, next to the external lesions, suicide due to 4 speargun shots, with multiple wounds to the soft tissues showed hemorrhagic infiltration (Fig. 3A); once head and chest. the sternum was removed, left hemothorax (1500 mL) was discovered. Deep below the second wound (B), the harpoon had per- forated the left lung at the intralobar fissure, generating a small 0.5-cm hole surrounded by hemorrhage (Fig. 3B). Manuscript received April 23, 2012; accepted December 5, 2012. After perforating the skin, by the third wound (C), the From the Department of Legal and Forensic Medicine, University of Genova, Genova, Italy. harpoon passed through the upper edge of the lower lobe of The authors report no conflicts of interest. the left lung. Reprints: Francesco Ventura, MD, PhD, Department of Legal and Forensic Lesion A continued through pericardium, left auricle Medicine, University of Genova, Via A. de Toni 12, 16132 Genova, Italy. (Fig. 3C), puncturing the anterior wall of the left coronary ar- E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins tery, causing a massive hemopericardium (Fig. 3D). ISSN: 0195-7910/13/3403Y0201 The death was attributed to acute cardiac failure due to DOI: 10.1097/PAF.0b013e318288b0ed hemopericardium after the injury of the left coronary artery; in

201

     

FIGURE 1. Scene investigation (A) after emergency service resuscitation attempts; (B) detail of (A) showing the 3 wounds on the chest; (C) detail of the harpoon after being removed from the skull; and (D) Mares Speargun next to the pool of blood.

FIGURE 2. Linear and horizontal puncture wound of the skull, (A) 1.5 cm long with extended edges, in the right temporal region; (B and C) left side of the chest with 3 circular puncture wounds (diameter, 0.7 cm each) rounded by an ecchymotic ring at different magnification; and (D) hemorrhagic infiltration of pericranium on the right temporal region.

     

FIGURE 3. Soft tissues showing (A) hemorrhagic infiltration on the left side of the chest at the 3 points of harpoon penetration; (B) intralobar fissure of the left lung perforated with the evidence of a small 0.5-cm hole surrounded by hemorrhage; (C) hemorrhagic infiltration of the left auricle; and (D) hemopericardium. addition, other significant remarks were left hemothorax, sub- Feature of injuries to the chest suggested that lesion A dural, and subarachnoid hematoma. caused hemopericardium and cardiac tamponade. Perforating injuries to the chest and the head were made by Therefore, it seemed that injury to the head was a last at- sharp-end items, compatible with the harpoon found on the tempt of suicide, elapsed during the progression of cardiac crime scene. tamponade; in fact, there was insufficient subarachnoid bleeding and no brain lesions to lead to immediate death. In other cases presented in the literature,8,9 it has been DISCUSSION shown how it is possible to survive for some time after being shot by a similar weapon. With this report, the authors would like to share knowledge A speargun shot has less kinetic energy than a normal with the forensic community about speargun-related lesions. firearm bullet, so it is possible that more shots are required to It is necessary to describe the weapon used before pro- achieve death, especially if vital centers are not involved. ceeding to an analysis of the injury pattern. Moreover, due to poor handling of the speargun, it is dif- The speargun is an atypical firearm which uses an air- ficult for those who attempt suicide to succeed at the first at- compressed or propelled elastic mechanism. Unlike normal tempt. In this case, considering that speargun needs of a manual firearms, it causes cutting and stabbing wounds which are more reload for every shot, man survived enough to get 4 shots. similar to cold steels. On the basis of crime scene and autopsy findings, Public The Mares Speargun (Fig. 1D) found on the scene had a Prosecutor’s reconstruction consisted in a 3-times shot to the pneumatic mechanism; it was 50 cm long including the harpoon chest and a last fourth 1 to the head, while cardiac tamponade (Fig. 1C), the latter having around 1 cm maximum diameter. was going on. There were multiple wounds, 3 of which were at the left chest and 1 at the head. After hitting the third left rib (A), the harpoon was deflected through pericardium, left auricle and it ended in a CONCLUSIONS lesion of the anterior wall of the left coronary artery, leading to Despite spearguns are classified between firearms, even if hemopericardium. unusual ones, it is important to know that injuries can be very Two more shots perforated the pulmonary parenchyma (BYC). similar to those produced by cold steels. The fourth shot to the right temporal region perforated the Characteristics of the weapon (ballistics and mechanisms), skull, coming close to the brain and tearing vascular structures, associated with the shape of harpoons, influence the potential causing mild leptomeningeal hematoma. related damage.

     

To study unusual firearms and their lesions, an accurate 6. Windle-Taylor PC. Transorbital injury from a harpoon involving the description is fundamental to define specific parameters, and paranasal sinuses. ORL J Othorhinolaryngol Relat Spec. distinguish them from common firearms injuries.13 1978;40(5):278Y284. Moreover, as well as other similar cases described in the 7. Costantinides F, Russo V, Altamura BM. Speargun injures: a case of 14 literature, behind small and mild wounds can be hidden more wilful murder. Acta Med Leg Soc (Liege). 1989;39(1):73Y76. serious and acute damage, so that detectives may suspect which 8. Abarca-Olivas J, Concepcio´n-Aramendı´aLA,Ban˜o-Ruiz E, et al. kind of weapon have been used, especially if it is not found Perforating brain injury from a speargun. A case report. Neurocirugia during the scene investigation. (Astur). 2011;22:271Y275. A thorough examination can be useful for a fast identifi- cation of the weapon involved and its potential damage even 9. Lo´pez F, Martı´nez-Lage JF, Herrera A, et al. Penetrating craniocerebral for surgeons in case of emergency that requires immediate injury from an underwater fishing harpoon. Childs Nerv Syst. operation. 2000;16:117Y119. 10. Ferna`ndez-Melo R, Mora`nAF,Lo`pez-Florez G, et al. Penetrating head REFERENCES injury from harpoon. Case report. Neurocirugia (Astur). Y 1. Grellner W, Buhmann D, Giese A, et al. Fatal and non-fatal injuries 2002;13:397 400. caused by crossbows. Forensic Sci Int. 2004;142(1):17Y23. 11. Za´topkova´ L, Hejna P. Fatal suicidal crossbow injuryVthe ability to act. Y 2. Smyk D. Crossbow injuries: a case report. J Forensic Leg Med. J Forensic Sci. 2011;56(2):537 540. 2009;16(6):343Y345. 12. Opeskin K, Burke M. Suicide using multiple crossbow arrows. Am J 3. Karger B, Bratzke H, GraQ H, et al. Crossbow homicides. Int J Legal Forensic Med Pathol. 1994;15(1):14Y17. Med. 2004;118(6):332Y336. 13. Ventura F, Blasi C, Celesti R. Suicide with the latest type of slaughterer’s 4. Hefer T, Joachims HZ, Loberman Z, et al. Craniofacial speargun injury. gun. Am J Forensic Med Pathol. 2002;23(4):326Y328. Y Otolaryngol Head Neck Surg. 1996;115(6):553 555. 14. Ventura F, Rocca G, Ventura A, et al. Suicide with ‘‘Flobert shotgun’’: 5. Walpole B. Speargun injury. Aust Fam Physician. 1985;14(7):701. case report. Am J Forensic Med Pathol. 2011;32(4):321Y323.

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Vallecular Rupture With Cervical Spine Fracture After a Failed Hanging Suicide Attempt

Joong Keun Kwon, MD, PhD, Seong Rok Lee, MD, Ho Min Lee, MD, Jung Min Lee, MD, and Jong Cheol Lee, MD, PhD obvious lesions of the large airway or major cervical vessels Abstract: Hanging is a common method of suicide. We present a case of (Fig. 1A). After physical examination by a neurosurgeon, the vallecular rupture and cervical spine fracture without an external wound patient was admitted to the intensive care unit of the department of after a failed hanging suicide attempt. Surgical treatment involved poste- neurosurgery. The patient was conservatively managed for 3 days, rior fusion of C2 to 3, followed by repair of the vallecular rupture via during which time the subcutaneous emphysema surrounding the an external approach. The patient recovered with no residual physical or neck became progressively worse. The patient was then referred mental sequelae. for a complete head and neck examination using a fiberoptic la- Key Words: suicidal hanging, hanging injury ryngoscope, which revealed vallecular rupture and no remarkable abnormalities of laryngeal structures. An additional CT scan of (Am J Forensic Med Pathol 2013;34: 205Y206) the neck revealed a massive emphysema dissecting the parala- ryngeal and prevertebral soft tissues, vallecular rupture, and hyoid anging by ligature strangulation results in force to the neck bone fractures (Fig. 1B). Hregion because of the weight of the body.1 The incidence of We decided to perform a staged surgical treatment. First, suicide by hanging is increasing worldwide, and most victims are Y a tracheostomy was performed to prevent additional air leakage males younger than 40 years with a history of suicide attempts.1 3 and damage to the larynx and trachea during intubation. A pos- In the United States, hanging suicide is the second most common terior fusion of C2 to 3 was then performed. Three days later, the method of suicide, accounting for 14% of such events.3 vallecular rupture was repaired via an external approach. Under Suicide hanging injuries include hyoid bone fractures, general anesthesia with the patient in a supine position, neck ex- laryngotracheal fractures, carotid injuries, and cervical spine ploration identified hyoid bone fractures and vallecular rupture. fractures. The most common larynx ruptures are laryngotracheal Primary closure for the ruptured vallecular mucosa and removal separation, supraglottic rupture (thyrohyoid membrane), and of the mid portion of the fractured hyoid bone was performed subglottic rupture (cricothyroid membrane).2 (Fig. 2). The postoperative course was uneventful, and the pa- The present report describes a rare case of a failed hanging tient was decannulated after 4 weeks with excellent functional suicide. The resultant injuries were vallecular rupture and a outcomes. cervical spine fracture. We describe the management and post- operative outcome for this patient. DISCUSSION Hanging-related trauma varies according to the movement and acceleration of the body. Body weight and falling distance CASE REPORT have been described as the most important factors contributing to A 38-year-old male patient was admitted after an attempted death by hanging.4 In the present case, the patient had attempted a suicide by hanging. The incident occurred at the patient’s work- long fall, but coworkers had grabbed the rope, thereby limiting the place. The patient had tied a rope to a banister of the fifth floor fall to 1.5 m. stairs and jumped into a stairwell. However, coworkers quickly Previous studies of hanging neck injuries report that the most grabbed the rope such that the length of rope from the banister frequent injuries are muscle hemorrhage due to direct pressure to the running noose was only 1.5 m. He was taken to the and indirect stretching of the muscles.5 The reported frequency of emergency department of the Ulsan University Hospital, Ulsan, solid neck structure fractures varies from 0.8% to 75.3%.3Y6 The Republic of Korea. On arrival at the emergency department, he most commonly fractured structures are the hyoid bone and thy- was stable without any external wounds. The blood pressure was roid cartilage. The occurrence of fractures is greatly affected by 117/77 mm Hg, respiratory rate was 22 breaths per minute, pulse the age of the subject as calcification reduces the flexibility of rate was 112 beats per minute, and oxygen saturation was 97% at cartilage. In the present case, hyoid bone fracture was followed by room air. The patient was conscious, had no voice change, and vallecular rupture. no neurologic deficit. A cervicothoracic spinal computed tomo- The most common indicators of laryngeal rupture are he- graphic (CT) scan with 3-dimensional reconstruction revealed a moptysis and emphysema. The presence of these indicators cervical spine fracture (C2) and subcutaneous emphysema but no should always warrant a prompt fiberoptic laryngoscopic ex- amination. The present patient showed stable vital signs and no Manuscript received August 10, 2012; accepted January 17, 2013. From the Department of Otorhinolaryngology, Ulsan University Hospital, airway compromise. However, the observation of massive em- University of Ulsan College of Medicine, Ulsan, Republic of Korea. physema around the neck at presentation resulted in an imme- The authors report no conflicts of interest. diate otolaryngologic examination. The lack of external wounds Reprints: Jong Cheol Lee, MD, PhD, Department of Otorhinolaryngology, indicates the high stretching and tensile strength capability of Ulsan University Hospital, Jeonha 1-dong, Dong-gu, Ulsan, 682-714 Republic of Korea. Email: [email protected]. skin, and a significant resistance against dissection by blunt Supplemental digital contents are available for this article. Direct URL trauma. Although we used a staged surgical approach, com- citations appear in the printed text and are provided in the HTML and PDF bined operations would have been undertaken if there had been versions of this article on the journal’s Web site any sign of airway compromise. (www.amjforensicmedicine.com). * Cervical spine injury is rare, but must be evaluated as soon Copyright 2013 by Lippincott Williams & Wilkins 5,6 ISSN: 0195-7910/13/3403Y0205 as possible. Injuries to cervical vessels such as carotid artery DOI: 10.1097/PAF.0b013e318288b109 dissection or obstruction can occur as a result of hanging. In this

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FIGURE 1. A cervicothoracic spine 3-dimensional CT scan showing fractures of the anteroinferior aspect of the body (solid arrow) and left posterior tubercle of the transverse process of C2 (open arrow; A). A neck CT scan revealing a hyoid bone fracture (arrow) and vallecular rupture with massive cervical emphysema (B). Figure 1 can be viewed online in color at www.amjforensicmedicine.com.

FIGURE 2. Intraoperative photographs showing vallecular rupture (open arrow) with hyoid bone fracture (solid arrow; A), and after primary closure of the vallecular mucosa with the removal of the mid portion of the fractured hyoid bone (black arrow; B). Figure 2 can be viewed online in color at www.amjforensicmedicine.com. case, no such lesions were revealed by CT imaging. Carotid sinus This case may be benefit for the management of the hanging stimulation by hanging may cause circulatory collapse. In addi- victims, even if they have multiple fractures and ruptures tion, only 2 kg of tension on a ligature is needed to block jugular around neck. veins, and diminished brain perfusion can be seen in all hanging cases. A study of hanging injuries demonstrated that nearly 90% REFERENCES of victims who reached hospital alive survived with a low inci- dence of poor neurologic outcome.1 Thus, aggressive resuscita- 1. Penney DJ, Stewart AHL Parr MJA. Prognostic outcome indicators Y tion and management of hanging victims is justified. In contrast, following hanging injuries. Resuscitation. 2002;54:27 29. delayed presentation to a medical facility, a low Glasgow coma 2. Schro¨der T, Stoll W, Rudack C. Complete supraglottic rupture after score at presentation, and cardiac arrest at the scene are predictors attempt of suicidal hanging. Otolaryngol Head Neck Surg. of a poor outcome.1 2006;134:1051Y1052. The present case was unusual because it is rare that a person 3. Uzu¨n I, Bu¨yu¨k Y,Gu¨rpinar K. Suicidal hanging: fatalities in Istanbul attempting to commit hanging suicide from a great height is res- retrospective analysis of 761 autopsy cases. J Forensic Leg Med. cued. The patient had vallecular-hyoid complex fracture with 2007;14:406Y409. cervical spine fracture. After appropriate management with staged 4. To¨ro K, Kristo´f I, Keller E. Incomplete decapitation in suicidal operations for cervical spine fractures and vallecular rupture, the hanging - report of a case and review of the literature. J Forensic Leg patient completely recovered without residual physical or mental Med. 2008;15:180Y184. sequelae during follow-up. 5. Nikolic S, Micic J, Atanasijevic T, et al. Analysis of neck injuries in CONCLUSIONS hanging. Am J Forensic Med Pathol. 2003;24:179Y182. We report a rare case of failed hanging suicide attempt and 6. Sua´rez-Pen˜aranda JM, Alvarez T, Migue´ns X, et al. Characterization of its presentation of vallecular rupture and cervical spine fracture. lesions in hanging deaths. J Forensic Sci. 2008;53:720Y723.

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Systemic Thromboembolism After Deep Vein Thrombosis Caused by Uterine Myomas

Supawon Srettabunjong, MD, LLB, MSc, MTox

medication, alcohol, or illicit drugs. She was separated from her Abstract: A systemic thrombus embolization after deep vein thrombosis family and had lived with a friend for a few years. According to (DVT) caused by uterine myomas is very rare. The authors recently had her friend, she had been healthy except for leg swelling and pain, experienced this association in a single 46-year-old Thai woman with aggravated by standing or walking for some time. The only lab- previous healthy history and no other known risk factors for development oratory investigation on admission revealed a hemoglobin level of DVT. On arrival at a nearby small hospital, the deceased had presented of 10.0 g/dL with normal red blood cell morphology and white with an abrupt onset of right hemiparesis, and 34 hours after admission blood cell count and platelets of 563,000/mm3. to the hospital, she suddenly developed a cardiopulmonary collapse and At autopsy, external examination of the deceased revealed a was pronounced dead. Autopsy examination revealed that her death was woman of moderate built, measuring 165 cm in height and 55 kg attributed to massive pulmonary thromboembolism with systemic embo- in weight, with mild congestion of her face and conjunctiva. Mild lization through coexistent patent foramen ovale after DVT of her bilateral central and peripheral cyanosis was still present. There was no lower extremities caused by uterine myomas. evidence of injury in the neck region. Her right ankle and calf were Key Words: deep vein thrombosis, foremen ovale, pulmonary swelling and pitting edema. No signs of injury were detected. thromboembolism, systemic thromboembolism, uterine myoma Internal examination disclosed normal scalp and skull. The brain Y weighed 1300 g. Cut surfaces of fixed brain showed recent is- (Am J Forensic Med Pathol 2013;34: 207 209) chemic infarction in the left thalamic region, consistent with 1 to 2 days’ duration of cerebral infarction. Gross cerebral arteries eep vein thrombosis (DVT), the most common form of ve- appeared normal. Examination of the chest cavity showed no D nous thromboembolism, is a rare complication of uterine evidence of trauma. The heart weighed 380 g with engorged myoma. There have been few reports on this association published coronary arteries. Examination of the heart revealed a patent fo- in English-language literature listed in MEDLINE and PUBMED 1Y12 ramen ovale (PFO) with a maximal aperture of 0.6 cm (Fig. 1). databases. The blood clot may then be dislodged and carried in There was a mild dilatation of right ventricle and tricuspid-valve the bloodstream to the lungs, known as a pulmonary thromboem- ring that was consistent with acute right ventricular failure. In- bolism (PTE), and to other visceral organs (eg, brain, heart, and tracardiac thrombus was not observed. Gross sections of the heart kidney), called a systemic thromboembolism (STE). Systemic demonstrated no appearances of old or recent infarction. The aorta thromboembolism is a very rare event and occurs only in certain and the coronary arteries revealed no atherosclerotic changes. No individuals. Recently, the authors had experienced a sudden and apparent thromboemboli were found in major pulmonary arteries. unexpected death due to acute massive PTE with STE after lower The right lung and the left lung weighed 650 g and 530 g, re- extremity DVT secondary to 2 uterine myomas in a single middle- spectively. Cut surfaces of both lungs revealed marked conges- aged Thai woman. tion and edema with multiple fresh thromboemboli of various CASE REPORT sizes filled in pulmonary vessels (Fig. 2). A single 46-year-old nonsmoking Thai woman presenting with dyspnea and a sudden onset of right hemiparesis was readily sent to a nearby small hospital. Thirty-four hours after admission, she abruptly developed cardiopulmonary collapse and was pro- nounced dead. Her family was suspicious about her death. The medicolegal death investigation then commenced, and the deceased was subsequently taken to the Forensic Medicine Department, Faculty of Medicine, Siriraj Hospital, for further examination. At scene, mild congestion of the deceased’s face and con- junctiva was found. Mild central and peripheral cyanosis was also detected. Swelling and pitting edema of her right ankle and calf was evident. No evidence of injury was found. According to her family, she had neither any previous medical history nor other known risk factors of DVT. Her family relevant medical his- tory was unremarkable as well. She had not taken any forms of

Manuscript received January 2, 2013; accepted February 22, 2013. From the Department of Forensic Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand. The author reports no conflict of interest. Reprints: Supawon Srettabunjong, MD, LLB, MSc, MTox, Department of Forensic Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. E-mail: [email protected]. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0195-7910/13/3403Y0207 FIGURE 1. Gross view of a PFO with a maximal aperture of DOI: 10.1097/PAF.0b013e318298a456 0.5 cm (arrow).

207

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FIGURE 2. Gross view of cut surfaces of both lungs (A, left lung, and B, right lung) revealing marked congestion and edema with multiple fresh thromboemboli (arrows) of various sizes filled in pulmonary vessels.

Examination of the abdominal cavity disclosed no signs of was confined in the left side, thus supporting the notion that injury. Two large firm smooth-surfaced pelvic masses, sized 19 Â uterus mass was often localized more in the left side of the 13 Â 8.5 cm and 17 Â 12 Â 8 cm of the right and left mass, re- uterus than in the right. The individual ages ranged from 35 to spectively, with combined weight of 1820 g were found (Fig. 3). 51 years including the present case, and the least weight of The right mass was the enlarged uterus itself, and the other was uterine myoma caused DVT was 800 g.1Y11 contiguous to the uterus at its left side just above the cervix. The The present case had no other known risk factors of DVT, right kidney weighed 120 g, and the left kidney, 110 g. There were except 2 large uterine myomas. Each myoma had a long vertical multiple areas of recent infarction appearing from external sur- shape, thus its fundus might have compressed one of the pelvic faces to internal regions of both kidneys. The remaining internal veins leading to DVT in her both legs. The extensive thrombus organs were otherwise unremarkable. No pelvic vein thrombosis was found in the right leg, which may probably be the result of was detected. On opening the deep veins of both legs, extensive her sleeping position and the larger size of right myoma, venous thrombosis of right leg involving distal femoral, popliteal, suggesting that the lodged thromboemboli were most likely posterior tibial, and peroneal veins was present, whereas the throm- generated from DVT of the left leg. Although most individuals bosis of left leg was detected only in some parts of distal femoral with lower extremity DVT are clinically silent, the symptoms and popliteal veins. No evidence of remote or recent deep vein presented when having extensive distribution include pain, injury of both legs was detected. edema, and heaviness aggravated by standing or walking, as in Histologic examination of the lungs disclosed multiple fresh the present case. thromboemboli of varying sizes filled in the small vessels with marked congestion and edema. Histologic appearance of the brain was consistent with 1 to 2 days’ duration of infarction. Multiple areas of recent infarction were also observed in both kidneys. Sec- tions of both pelvic masses demonstrated uniform, benign spindle cells consistent with leiomyomata with no evidence of necrosis. Central vein necrosis in the liver and intense acute congestion in the spleen was detected. There were minimal changes of myo- cardial infarction with fresh thromboemboli seen in the heart vessels. Thromboemboli in the lungs, brain, and heart consisted of fibrin and red blood cells but not fibroblasts (Fig. 4). The cause of death was attributed to massive PTE with sys- temic embolization through coexistent PFO after extensive lower extremity DVT caused by 2 uterine myomas.

DISCUSSION Although there are only 14 cases on the association be- tween DVT and uterine myomas published in the literature,1Y12 such associations have been well recognized. Occasionally, a large uterine myoma can cause compression of the pelvic veins leading to persistent pressure on pelvic veins that induces FIGURE 3. Gross view of 2 large firm smooth-surfaced myomatous masses, sized 19 Â 13 Â 8.5 cm and 17 Â 12 Â 8cm chronic venous stasis in the pelvis and lower extremities. Blood of right and left mass, respectively (arrows), with combined stasis of the pelvic veins is therefore a major etiologic factor for weight of 1820 g. The right mass was enlarged leiomyomatous DVT in the pelvic region and/or in the lower extremity, either uterus itself, and the other was contiguous to the uterus at its left Y unilateral3,5 11 or bilateral.1,2,4,7,12 Nearly all of unilateral DVT side just above the cervix.

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FIGURE 4. Microscopic view of thromboemboli (arrows) in the pulmonary vessels (A), in the heart vessels (B), and in the brain vessels (C), consisting of fibrin and red blood cells, but not fibroblasts (hematoxylin and eosin staining; original magnification, Â40).

Systemic thromboembolism is a very rare incidence and 4. Falcone M, Serra P. Massive pulmonary embolism in a woman with occurs only in certain individuals with concomitant PFO, a leiomyomatous uterus causing pelvic deep venous thrombosis. Ann Ital frequent remnant of the fetal circulation found in approximately Med Int. 2005;20:104Y107. 13 one fourth of the general population. Having a PFO and a 5. Yonezawa K, Yokoo N, Yamaguchi T. Effectiveness of an inferior vena DVT thus places an individual at high risk for paradoxical caval filter as a preventive measure against pulmonary embolism. Well-recognized paradoxical embolism of thrombus thromboembolism after abdominal surgery. Surg Today. across a PFO causing cryptogenic stroke in the young also 1999;29:821Y824. 14 presented. Fresh thromboemboli are susceptible to fragmentation 6. Stanko CM, Severson MA, Molpus KL. Deep venous thrombosis during transit through the contracting right ventricle, producing associated with large leiomyomata uteri. A case report. J Reprod Med. multiple smaller emboli, which can readily run across the passage 2001;46:405Y407. of PFO to other remote organs such as brain, as in this case. 7. Phupong V,Tresukosol D, Taneepanichskul S, et al. Unilateral deep vein In conclusion, STE is a very rare complication of uterine thrombosis associated with a large myoma uteri. A case report. myomas. To the author’s knowledge, such a case has been previ- J Reprod Med. 2001;46:618Y620. ously reported in the literature in only 1 case.12 The present case 8. Hawes J, Lohr J, Blum B, et al. Large uterine fibroids causing is probably the second case of STE secondary to uterine myomas mechanical obstruction of the inferior vena cava and subsequent reported in the literature. This case report not only illustrates the thrombosis: a case report. Vasc Endovas Surg. 2006;40:425Y427. association of uterine myoma and DVT with subsequent PTE/ STE but also raises awareness of possible symptomatic thrombo- 9. Bonito M, Gulemi L, Basili R, et al. Thrombosis associated with a large Y embolic disease. Accordingly, a middle-aged woman with uterine uterine myoma: case report. Clin Exp Obstet Gynecol. 2007;34:188 189. myoma deserves special attention as a possible etiologic contrib- 10. Khilanani R, Dandolu V. Extensive iliac vein thrombosis as a rare utor to DVT with subsequent dislodgement that can cause a seri- complication of a uterine leiomyoma: a case report. J Reprod Med. ous condition or even sudden death. 2007;52:537Y538. 11. Tanaka H, Umekawa T, Kikukawa T, et al. Venous thromboembolism diseases associated with uterine myomas diagnosed before REFERENCES hysterectomy: a report of two cases. J Obstet Gynaecol Res. 2002;28:300Y303. 1. Dekel A, Rabinerson D, Dicker D, et al. Thrombosis of the pelvic veins 12. Srivatsa A, Burdett J, Gill D. A 35-year-old woman with uterine fibroids associated with a large myomatous uterus. Obstet Gynecol. and multiple embolic strokes. Neurology. 2005;64:1479Y1480. 1998;92:646Y647. 13. Hagen PT, Scholz DG, Edwards WD. Incidence and size of patent 2. Chong YS, Fong YF, Ng SC. Deep vein thrombosis in patients with foramen ovale during the first 10 decades of life: an autopsy study of large uterine myomata. Obstet Gynecol. 1998;92:707. 965 normal hearts. Mayo Clin Proc. 1984;59:17Y20. 3. Nishikawa H, Ideishi M, Nishimura T, et al. Deep venous thrombosis 14. Wu LA, Malouf JF, Dearani JA, et al. Patent foramen ovale in and pulmonary thromboembolism associated with a huge uterine cryptogenic stroke: current understanding and management options. myomaVa case report. Angiology. 2000;51:161Y166. Arch Int Med. 2004;164:950Y956.

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