FOREWORD

The main objectives of ÑPractising in Forensic Medicineì, a brief textbook, are to optimize the practical learning of foreign students and to compilate medico­legal practice of most countries according to these law. The textbook contains original illustrations which reflect the everyday activities at the Institute of Forensic Medicine, Faculty of Medicine of the P. J. äaf∙rik University at Koöice, Slovakia.

Autors.

FRANTIäEK LONGAUER, Assoc. Prof., MD, PhD, Head of the Institute of Forensic Medicine, Faculty of Medicine of the P. J. äaf∙rik University at Koöice, Slovakia.

NIKITA BOBROV, MD, PhD, Assistant Professor of the Institute of Forensic Medicine, Faculty of Medicine of the P. J. äaf∙rik University at Koöice, Slovakia.

PETER L¡BAJ, MD, medico­legal expert of the Institute of Forensic Medicine, Louis Pasteur University Hospital at Koöice, Slovakia.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com CONTENTS

1. WHAT IS FORENSIC MEDICINE?...... 3 2. MEDICO­LEGAL SYSTEMS. THE STRUCTURE OF A DEPARTMENT OF FORENSIC MEDICINE.. 5 3. MEDICAL ASPECTS OF DEATH...... 8 4. CHANGES AFTER DEATH...... 11 5. IDENTIFICATION...... 16 6. EXTERNAL AND INTERNAL EXAMINATION OF THE DEAD BODY. EXHUMATION...... 20 7. BLOOD STAINS, GROUPS, DNA AND IDENTIFICATION...... 23 8. THE EXAMINATION OF WOUNDS...... 26 9. EFFECTS OF INJURY...... 31 10. REGIONAL INJURIES...... 35 11. FIREARM AND EXPLOSIVE INJURIES ...... 39 12. MURDER, SUICIDE OR ACCIDENT? ...... 46 13. TRANSPORTATION INJURIES...... 49 14. ASPHYXIA AND PRESSURE ON THE NECK AND CHEST ...... 54 15. IMMERSION AND DROWNING...... 57 16. INJURY DUE TO HEAT, COLD AND ELECTRICITY...... 59 17. SUDDEN AND UNEXPECTED DEATH FROM NATURAL CASES...... 63 18. MEDICO­LEGAL ASPECTS OF PREGNANCY AND ABORTION...... 65 19. DEATH AND INJURY IN INFANCY ...... 68 20. SEXUAL OFFENCES...... 72 21. FORENSIC HISTOPATHOLOGY ...... 74 22. MEDICAL MALPRACTICE ...... 76 23. GENERAL ASPECTS OF POISONING ...... 78 24. MEDICO­LEGAL ASPECTS OF ALCOHOL ABUSING...... 82 25. DRUGS OF DEPENDENCE AND ABUSE...... 87 26. THE DOCTOR AND THE LAW...... 90 REFERENCES ...... 92 GLOSSARY ...... 93

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 1. WHAT IS FORENSIC MEDICINE?

þ Forensic medicine (synonym: legal medicine) is a fundamental and independent part of medicine dealing with the interaction of medical science and practice with the law. The practice of using the terms "forensic medicine" and "medical jurisprudence" ha s led to considerable confusion as to their correct meaning. These definitions are closely related but somewhat different: Ø Medical jurisprudence is that part of law which is concerned with the regulations governing the professional practice of the doctor of medicine. Ø Forensic (or legal) medicine is that part of medical science which is employed by the legal authorities for the solution of legal problems. Theoretically all branches of medicine may be included in this definition and any doctor who te stifies in court in his professional capacity can be considered a practitioner of forensic medicine. But the term is us u­ ally restricted to that specialized branch of medical knowledge used by physicians officially employed by the local government of a community when they investigate suspicious and violent deaths, or non­fatal cases such as rapes, sexual offenses or abortions which may subsequently come before the courts. The word "forensic" means "situated on forum romanum". Historically this famous market­place of an­ cient Roma played an important part in law and administrative activities that time. Forensic medicine provides a tight connection between medical science and the law. Medical science can assist the administration of justice in: Ø civil matters Ø criminal matters. Forensic medicine is dealing with living and dead people, in order to solve these problems: w examination and evaluation of injury (disease) w effects of injury (disease) w cause of death w identification of living and dead w paternity w pregnancy and abortion w medical malpractice etc. Branches of medicine which assist in medico­legal problems are: anatomy, histology, pathology, dentistry, physiology, biochemistry, pharmacology, traumatology, resuscitation, haematology, genetics, microbiology, obstetrics, paediatrics, psychiatry, sexuology etc. Forensic medicine borrows methods of investigation from various natural and other sciences: anthropo­ logy, biomechanics, analytical chemistry, entomology, criminology etc. Forensic medicine has its own branches: traffic medicine, alcohology, forensic thanatology, forensic toxi­ cology, forensic genetics, forensic anthropology etc. (see tab. 1). Forensic medicine participates in prevention of negative social phenomena: Ü criminal violence towards health and life Ü traffic and working accidents Ü chronic alcoholism Ü drug abuse Ü suicides etc.

The main tasks of forensic medicine 1. Autopsies in cases of: Ø violent deaths Ø sudden and unexpected deaths Ø "mors in tabula" Ø deaths caused by medical malpractice Ø exhumation.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 2. Clinical seminars and case analyses (regularly with the Departments of Traumatology, Neurosurgery, Intensive Medicine, Emergency Medicine). 3. Medical reports and statements, expert opinions. 4. Forensic toxicology and drug analysis (living and dead persons). 5. Forensic serology, haematology and genetics (examination of blood and other biological materials and DNA profiling for identification). 6. Forensic alcohology (the measurement of alcohol in blood, urine and other biological fluids). 7. Forensic anthropology (identification of decomposed or skeletalized human remains by anthropological methods). 8. The presence at the scene of crime. 9. Participation in mass disasters. 10. Investigation of living persons (examination of wounding, injury and trauma, pregnancy and abortion, sexual offences, abuse of alcohol and drugs of dependence etc.) 11. Pregradual and postgradual education. 12. Scientific research.

Traffic medicine Alcohology Forensic thanatology Anatomy Forensic toxicology Histology Forensic genetics Pathology Forensic anthropology Dentistry Physiology Anthropology Biochemistry branches Pharmacology Biomechanics Traumatology Analytical FORENSIC MEDICINE Resuscitation chemistry Haematology problems Genetics Entomology Microbiology Criminology Virology Examination and evaluation of injury Parasitology (disease) Obstetrics Effects of injury (disease) Paediatrics Cause of death Identification of living and dead Psychiatry Paternity Pregnancy and abortion Medical malpractice Tab. 1. Relations between forensic medicine and other sciences.

1. What is forensic medicine? 2. What problems concerning living and dead people solves forensic medicine? 3. What are the main tasks of forensic medicine? Practical task: Visit the library of the Institute of Forensic Medicine, see literature, database records and Internet links on forensic medicine. PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 2. MEDICO­LEGAL SYSTEMS. THE STRUCTURE OF A DEPARTMENT OF FORENSIC MEDICINE

There are three main medico­legal systems in the world: 1. The coroner system (adopted both in the USA and in the ex­British empire countries). 2. The system of medical examiners (adopted in the USA, European, African and Asian countries). 3. The system of medico­legal departments (adopted in some European countries and in Slovakia, too).

The coroner system In the United States the medical investigation of fatal cases is done most often by an elected official of the county known as a coroner. In a few states, however, similar functions are performed by a physician known as the medical examiner who is an appointed officer of the county or municipal government. þ Coroner ­ is an elected and trained person, not obligately a physician, who examines dead bodies and investigates cause and manner of death in medico­legal cases. In many areas of the USA the coroner is also a funeral director. The coroner system in England and some states of the USA, this system has its own 800­year history. Originally the coroner (crowner) was appointed by the British King to represent the Crown as its magistrate in a certain district. The coroner typically is elected by popular vote for a term of office which varies from two to four years. The coroner is subordinated to a sheriff. The duties of a coroner are: w investigation of all cases of suspicious or violent death which have occurred in his district, that in­ cludes: Ø visiting the scene of death Ø assisting to physician to issue the death certificate Ø performing an autopsy (if the coroner is also a physician) or delegating a physician to perform an autopsy Ø making a provision for all necessary additional analyses and investigations (toxicological, hi s­ tological, serological etc.) w examination of allegedly psychopatic individuals (if the coroner is also a physician) w monitoring of the health of person in gaols w presentation of medical testimonies as a witness in a court w performing of other medico­legal activities usually directed by a sheriff. Nowadays the coroner system in practice has shown itself not to be entirely adequate for the duties it must perform. There are several disadvantages: Ø the laws which regulate the coroner's duties are not precise especially in defining the kinds of cases which come under his jurisdiction Ø in most communities previous knowledge of law and medicine is not considered essential for coroner but the main criterion is belonging to the predominant political party. The coroner like most elected officials is vulnerable to pressure from politicians Ø the coroner­funeral director may take great care not to investigate properly the case and man­ ner of death that may offend a family and thus cost them business or potential votes in the next election Ø the local coroner's magistrate cannot conduct a medico­legal investigation successfully for the purpose of determining the cause, circumstances and mechanism of death without special quali­ fications both in law and in medicine due to chronic lack of funds. Generally the coroner's medical representatives are not always competent in complicated cases.

The system of medical examiners The first suggestions of the medical examiner system are to be found in the archiatri populares of the Ro­ man Empire, where official physicians were appointed for certain districts to treat wounded and sick pe r­ sons. Later, in the Europe of Middle Ages the archiatri served the community as medical practitioners, army surgeons, police doctors and medico­legal experts. The Constitutio criminalis Carolina enacted by the Em­ PDF created with FinePrint pdfFactory trial version http://www.fineprint.com peror Charles V (1530) described the importance of medical examiners in the cases of infanticide, abortion, poisoning, fatal wounds and other forms of bodily injury. þ Medical examiner ­ is the professional physician who can solve both medical and legal problems con­ cerning cause and manner of death, performs autopsies and advances his medico­legal work because on ef­ fect of increased specialization. In the present the working place of medical examiner is the Office of Chief Medical Examiner in big cities of most states in the USA and some countries of Europe (Scotland, France), the Office should be opened non­stop day and night with a medical examiner on duty always present. The duties of medical examiner are: w investigation of the scene of death (together with a police, but independently of policemen) w analysis of circumstances of death with taking the names of witnesses w issuing the death certificate w performing the autopsy and necessary additional examinations w preparing the report of case investigation w representing as a subpoena witness in a court. The medical examiner system uses to be work satisfactorily. The fact that the medical examiner is respo n­ sible for determining the cause of death and issuing the death certificate tends to make him especially car e­ ful and responsible in carrying out his medico­legal investigations. F In the USA 12 states have coroner system, 22 states and the District of British Columbia have medical examiner system and 16 states have both coroner and medical examiner system.

The system of medico­legal departments The medico­legal service in most European countries is built on the system of Departments of Forensic Medicine. The Department of Forensic Medicine is the basic entity for services in forensic medicine. At the universities, there are Institutes of Forensic Medicine with additional tasks as education and research. These Institutes are often regional centers for toxicology and forensic chemistry as well as for forensic serology, haematology and genetics (because of very expensive equipment and methods). A Department (Institute) of Forensic Medicine has following sections: 1. Administrative and managing section 2. Section of autopsies 3. Section of microscopic diagnostic (histology and histochemistry, trichology, mycology etc.) 4. Section of toxicology and forensic chemistry (see fig. 1) 5. Section of alcohology (two independent labs with different methods ­ in some countries this section is involved in toxicology) 6. Section of serology, haematology and genetics 7. Section of examination of living persons (may be present in the regional department of police) 8. Section of fotodocumentation (macrofotography, microfotography, video­ and x­ray documentation) 9. Section of archiving with computer database and library. The Chief of Department (Head of the Institute) should be a highly­experienced and recognized forensic doctor. The Deputy Chief is a primary doctor who manages routine tasks. The secondary doctors subordi­ nate to the Chief are divided into two groups: Ø forensic doctors with specialization, having the right to work as a doctor­expert Ø forensic doctors without specialization. The high­qualified personnel includes: heads of laboratories, forensic engineers, biologists, pharmacists, students' tutors. The middle­qualified personnel includes: laboratory assistants, nurses, washers, cleaners etc. F The recommended overall ratio of forensic doctors is 1 doctor to 100 000 citizens.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig.1. Gas chromatography and mass spectrometry analysis in the Section of toxicology and forensic chemistry. F A forensic doctor performs full investigation of a case, but examining of a dead body at the scene of death and issuing of death certificate is mostly a duty of a doctor­examiner in hospitals and a general practitioner outside the hospital. The safety measures on medico­legal departments The medico­legal department is a risky working area with the great incidence of infectious diseases (tube r­ culosis, AIDS, all types of hepatitis) particularly in autopsy room. The toxic, flammable and explosive su b­ stances are used in laboratories, there is a lot of electrical equipment used for laboratory processing, visual investigation and demonstration. Thus, each person involved into the medico­legal activity or learning the forensic medicine and medical law has to be aware of possible danger and observe the necessary safety measures: Ø to wear a white cloak during visiting the department Ø to avoid touching any surface and equipment with naked parts of the body in the autopsy room. Always be on alert for sharp objects (needles, knives, cut metals as well as broken glass) Ø remember, that all body fluids are potentially infectious Ø prohibit eating, drinking, smoking, applying makeup at any place of the Department (Institute) Ø not to use electrical facilities without allowing Ø to know the location of emergency way and emergency exit in a case of fire Ø to wash and disinfect hands after visiting any laboratory or autopsy room Ø not to attend autopsy room after obtaining defects of skin or fresh wounds (even after tooth extraction!), during pregnancy and if the person had not got preliminary vaccinations (partic u­ larly against TBC and hepatitis). The person involved into the learning process at the Department of Forensic Medicine is asked to sign following declaration: "I hereby certify, that I was instructed about protection and safety measures".

1. What are the definitions of "coroner" and "medical examiner"? 2. What is the structure of a Department of Forensic Medicine? 3. What are the general safety measures on a Department of Forensic Medicine? Practical task: Visit the main sections and laboratories of the Institute of Forensic Medicine. PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 3. MEDICAL ASPECTS OF DEATH.

Medico­legal investigation of death is a usual task of forensic doctor, but all doctors come into contact with death in their professional work. þ Death is not simply the state of life absence, but is a process of life fading in a viable organism, which is characterized by irreversible cessation of vital functions and definitive stopping of metabolism. þ Dying is relatively complicated process caused by severe damage of vitally important organ or body sy s­ tem leading to the reduction and cessation of main vital functions. Dying and death are regular biological events and philosophically the man authenticity means whether the person adopts the possibility of death as the aspect of continuity of life (Socrates, Plato, Augustin, Heide g­ ger). þ The science of dying and death is thanatology (Thanatos is a god of dead sleep in the ancient Greek mythology). The main branch of this science is forensic thanatology.

Stages of dying process The first stage of dying is agony. Agony has such features: w brain function disorders (delirium, unconsciousness) w motility disorders w reducing of heart function w interrupted breathing w decreasing of body temperature w fading of reflexes w distinctive face expression (facies Hippocratica). 2. The second stage of dying is a clinical death. This is a condition (at environmental temperature +20 ∞C not longer than 3 ñ 7 minutes) of relatively reversible cessation of main vital functions and prograding hypoxia of whole organism. 3. The third stage of dying is a somatic death. Due to hypoxia neurons of cerebral cortex die, the process of dying become irreversible, and it would be correct to equate definitions "somatic death", "brain death" and "true death". The concept of brain death is very important both ethically, legally and in relation to organ transplantation. 4. The fourth, last stage of dying is a cellular death, that means cessation of respiration and metabolism of the body tissues and cells with those further autolytic changes (see also tab. 2).

Pronouncement of death: general aspects In most states the pronouncement of death is a task of the physician or the coroner. Here are the signs of indisputably true death: 1. Dilated pupils which do not react to light. 2. The absence of all reflexes. 3. Cessation of respiration with absence of breath sounds on auscultation, and a lack of clouding on a bright surface (small mirror) held in front of the nose and mouth. 4. Cessation of circulation, confirmed by absence of carotid pulse and heart sounds for one to three minutes. 5. Completely flat brain wave tracking on electroencephalography (EEG) may be required for final proof. 6. Postmortal changes: early or late.

Criteria for diagnosing brain death in clinics (more exact and distinctive terms: brain­stem death, cortical death, whole brain death): 1. The patient is in deep coma. 2. The patient is on mechanical ventilation. 3. The irremediable brain damage may be estimated by computer tomography (CT). 4. Such diagnostic tests for brain­stem death must be positive:

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ø absence of pupillar and corneal reflexes (the spinal reflexes may be persistent) Ø absence of vestibulo­ocular reflex Ø no motor responses of cranial nerves to painful stimuli Ø no respiratory movements when the patient is disconnected from the ventilator Ø no gag reflex to a catheter introduced into the larynx and trachea. 5. The electroencephalography and carotide angiography show definitive cessation of cerebral activity and circulation (see tab. 2). The estimation of brain death is to be a legal basis of performing cadaveric tissue and organ donation for transplantation purposes. But in some countries law states that the deceased during life or surviving rela­ tives have to indicate their agreement to donation.

LIFE DYING DEATH

danger of death INJURY Stop of principal Death of individual Biological (total) ILLNESS vital functions (brain death) death

AGONY VITA MINIMA

CLINICAL DEATH Stopped brain circulation Postmortal (angiography) changes

Unconsciousness Breathing ñ 0 Isoelectric EEG Reflexes ñ 0

Resuscitation is Isolated surviving necessary! of organs and tissues

VITAL REACTIONS SUPRAVITAL REACTIONS general local TRANSPLANTATION

Decision about time of death

Tab. 2. The dying process (modified by Krsek, [9]).

Medical certificate of cause of death. After doctor's decision the person is dead, according to the legal system of a particular country, he is re­ quired to issue a medical certificate of cause of death (death certificate, see fig. 2). In some countries the doctor must have seen and treated the patient shortly before the death to be able to issue a death certificate. But in other countries (and in Slovakia too) any doctor who examined the body after death may provide a certificate (see fig. 3). The physician (or coroner) must answer those questions and write down those data: 1. Who is this who lies dead? 2. When and where did he come to his death (date, time)? 3. What are determining particulars (age, occupation, marital status)? 4. Cause of death: I. a) Disease or condition directly leading to death b) Other disease or condition leading to (a) c) Primary disease or condition. II. Other significant conditions contributing to death, but not related to the disease or condition causing it. PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 2. The certificate of cause of death adopted in Fig. 3. The certificate of cause of death adopted in the USA. Slovakia. An internationally standard system of certifying the cause of death has been adopted by World Health Or­ ganization (WHO) for almost all countries. The WHO has classified all diseases, conditions and types of violence in its International Classification of Diseases (ICD). Each disease has its own 4­digit ICD nu mber. The doctor is mainly expected to express what was the manner of death. Medico­legal classification dif­ fers two types of death manner: natural death and violent death. 1. Natural (non­violent) death ñ is such death manner, where the cause of death is known as definite di­ sease or unknown yet, but violent factors are excluded. These are three subtypes of the natural death: 1.1. Expected death ñ caused by clinically estimated and properly treated severe disease or its complic a­ tions. 1.2. Sudden death is a rapid natural death, in which the cause of death is unknown (cannot be discovered without autopsy). Sudden death can be: Ø instantaneous (a cardiovascular death due to ventricular arrhythmia and cardiac arrest). Ø not instantaneous (with peculiar premortal signs which are: chest pain, difficulty of breathing, weakness etc.) Ø a case of founding dead individual. It is necessary to investigate whether such an individual had serious health disturbances. 1.3. Unexpected death is a death where a known disease was successfully treated or the patient is in reco­ very but this disease unexpectedly causes death. If the autopsy showed that the cause of death is another unknown disease, there is a sudden death. FThe term of ìphysiological deathì is known as the cessation of vital functions in advanced age. This term is rather theoretical, because nobody knows an old person without any disease that may lead to death. 2. Violent death ñ is such death manner where the cause of death is evident violence or complication after violent act committed. These are three subtypes of the violent death: 2.1. Suicide (self­murder). 2.2. Homicide (murder). 2.3. Accident (transportation, mass disaster, job, sport, home). Those three subtypes may be caused by: Ø blunt force injury Ø mechanical asphyxia Ø sharp force injury Ø electrical injuries Ø firearms and explosive injuries Ø intoxication Ø thermal injuries Ø medical malpractice (see Chapter 22).

1. What are the definitions of death and dying? 2. What are the stages of dying process? 3. What kinds of death manner according to medico­legal classification do you know? Practical task: Perform an external examination of dead body in the autopsy room, issue a Death Certificate. PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 4. CHANGES AFTER DEATH

Within a short time after death the significant changes begin to occur: at first on a cellular level, then be­ coming obvious to the naked eye. These are changes after death or postmortal changes. The doctor must be aware of the nature of these changes: Ø to be sure of a somatic death Ø to avoid mistaking for signs of an unnatural death Ø to determine the time of death (how long the person may have been dead). The postmortal changes are of two types: 1. Early postmortal changes 2. Late postmortal changes (post­mortem decomposition).

Early postmortal changes Ü Segmentation of columns of blood in the vessels of retina (ophthalmoscopic finding). Ü Softening of eyeballs (loss of intraocular tension). Ü Drying of thin skiny layers (lips, scrotum, see fig. 4), cornea, eye conjunctiva and sclera with its discoloration appearance of triangle brownish­black areas (Tache noire, Beloglazov's spots, see fig. 5).

Fig. 4. Postmortal drying of lips. Fig. 5. Postmortal drying of sclera and conjunctiva.

Ü Regurgitation of gastric content. Ü Paleness of skin and conjunctivae. Ü Rigor mortis (stiffness of muscles) − fusing of actin and myosin into a gel by depletion of glycogen, ceasing of re­synthesis of ATP and accumulation of lactic acid with simultaneous influx of calcium through injured membranes that leads to post­mortem muscle rigidity. The development of stiffness de­ pends on: w temperature (because of chemical nature of process) w physical rest or exertion (exhaustion) before death. Breaking of muscle stiffness in joints (during manipulation with dead body) is irreversible Rigor mortis of small smooth muscles in the skin is visible as goose flesh (cutis anserina).

Features of rigor mortis in an "average" environment: ­ rigor first detectable within : 1 ñ 4 hours in the face 4 ñ 6 hours in the limbs ­ increasing of the rigidity up to: 6 ñ 12 hours ­ secondary flaccidity apparent from: 24 ñ 50 hours after death.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com There is a simple rule of death timing, working in average circumstances:

If a body... time after death is: feels warm and is flaccid less than 3 hours feels warm and is stiff 3 – 8 hours feels cold and stiff 8 – 6 hours feels cold and flaccid more than 36 hours

Ü Post­mortem hypostasis (synonyms: lividity, suggilation) ñ pink to bluish zones on the dead body surface (back, buttocks, thighs, calves, back of the neck; in hanging ñ legs and hands). Principles of these formation are: Ø cessation of the circulation Ø influence of gravity on red cells Ø the blood seek the lowest levels within the vascular system (skin, organs). Colour of hypostasis and factors of dependence: w dark pink, deep purple or blue (congestive hypoxic conditions) w cherry­pink (carbon monoxide poisoning) w brick­red (cyanide poisoning) w brownish (methaemoglobinaemia) w bronze (anaerobic septicaemia) w bright pink over the large joints (hypothermia). Pale areas in the fields of contact of the body with a hard support (shoulders, buttocks). On the other side within hypostasis post­mortem skin haemorrhages (petechiae, ecchymoses, blood blisters) may be revealed. Visibility of hypostasis: ­ onset 2 ñ 3 hours after death ­ became "fixed" and could not move or push out after 24 hours (due to haemolysis, thicke­ ning) ­ persistence until decomposition. Value of hypostasis in forensic practice: Ø as an index of time since death (unreliable) Ø indicating that the body has been moved after death Ø can indicate the cause of death (poisoning, infection, hypothermia) Ü postmortal cooling of the body. "Temperature plateau" from few minutes to 2 ñ 3 hours (setting up a heat gradient between the core and the surface of the body) exists according Newton's Law of cooling. After this plateau of variable duration (heat generated by anaerobic metabolism approximately matches heat loss), the body cools at 0,6 ñ 0,8 ∞C/hour in the first 3 hours, at 1 ∞C/hour in the 4 ñ 12 hours, and at 0,5 ∞C/hour for the rest of the time after death. Influence on the rate of cooling: a) the body mass (weight) b) the mass / surface area ratio (this ratio is minimal in children) c) the posture of the body d) the clothing e) obesity f) emaciation g) oedema h) environmental temperature i) wind, draughts, rain and humidity j) premortal hypothermia or premortal hyperthermia (infections, brain haemorrhage) Temperature measurements (deep rectal temperature, see fig. 6) are the best means of estimating the post­ mortem interval. The time after death is calculated by Henssge­Madea's nomogram (fig. 7). PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 6. Measurement of the rectal temperature of a corpse. Note visible lividity and its abcense at the places of contact with a hard surface.

Fig. 7. The relating nomogram of the death time by temperature commonly used in Western Europe (devised by C. Henssge and B. Madea)

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Supravital (postvital, transvital) reactions þ Supravital reaction is the lasting ability of some organs, tissues and cells to keep physiological proces­ ses during some time after death. The most common supravital reactions are: w response of the pupils to drugs (atropine, scopolamine) w muscular reactivity: ­ mechanical (contraction after knocking or pinching) ­ electrical (Faraday's current) w cellular reactions (mobility of spermatozoa, vital staining of blood cells etc.) F The hair, beard and nails do not continue to grow after death!

Late postmortal changes (post­mortem decomposition) The late postmortal changes are the result of chemical (enzymatic), bacterial and fungal attack and pred ation of animals. These changes are: autolysis, putrefaction, mummification, adipocere, skeletalization and post­ mortem injuries. Ü Autolysis is a postmortal delivering of intracellular enzymes and the cellular decomposition in a way of self­digestion. þ Ü Putrefaction is usual reductive process of postmortal moist decomposition with contribution of gut bacteria leading to liquefaction of the soft tissues and gas formation in those tissues. Putrefaction beginning: w in temperate climate ñ 3th ñ 4 th day after death w in tropics, in hot summer ñ within hours. Signs of putrefaction (see fig. 8, 9): ­ greenish abdominal wall, ­ body swelling due to gas formation ­ outlining of the superficial veins ("marbling") ­ skin blisters and separation of the epidermis ­ protrusion of the tongue and eyes ­ bloody fluid is squeezed out of the mouth and nostrils.

Fig. 8. Onset of putrefaction. Note Fig. 9. Onset of putrefaction. Note also the marbling and squeezing of bloody fluid out presence of maggots. of the nostrils. PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 10. Molds on the face in advanced putrefaction. Fig. 11. Post­mortem injuries of the face and nose by rats.

Ü Mummification is a process of dessication of the body in dry warm conditions with a draught of air. Partial mummification of fingers is a common finding in putrefaction too. Ü Adipocere is a substance created by hydrolytic converting the dead body fat to a waxy compound similar to soap in wet conditions. F The body parts with adipocere are valuable for obtaining good samples for histological examination. Ü Skeletalization is a process of conversion of a dead body to a skeleton. In temperate climate most of the soft tissues will decay after 1 ­ 2 years, tendons and ligaments survive longer, thus the articulated sceleton will be formed. After some year the skeleton become disarticulated. In the sandy soil bones may remain in a good condition for centuries, but in a wet and acid soil the bones become soft and va­ nish within 20 years. Hair, nails and teeth are resistant parts of a body and remain intact and available for forensic examining during at least 20 years. Ü Post­mortem injuries. Dead bodies can obtain injuries after death. The most common are: ­ devastation by molds and plants (fig. 10) ­ devastation by insects (ants, flies, beetles) ­ injuries by domestic animals (dogs, cats, pigs) ­ injuries by wild animals (mice, rats, foxes, see fig. 11) ­ injuries by birds ­ injuries by fishes and crustaceans (only in the water). The post­mortem injuries have no vital reaction (bleeding, inflammation, thrombosis etc.)

1. What is the definition of supravital reaction? 2. What are influential factors of postmortal cooling? 3. What kinds of early and late postmortal changes do you know? Practical task: Describe early postmortal changes in autopsy room, estimate the time of the death.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 5. IDENTIFICATION

þ Identification (in general) is the process of equality estimation of different compared events, subjects and persons by those specific and characteristic individual features. What are the common principles of identification? 1) There are two groups of objects in the process of identification: indetified objects (living persons, corpses, objects of evidence, other things) and identifying objects (records, photos, descriptions, radio­ grams). 2) The objects of identification are divided into two groups: changeable and non­changeable. 3) The identification is the process of both analytical and synthetical approaches and methods. 4) Each comparising sign must be learned in dynamics. Degrees of identity: I. Proved identity. II. Probable identity. III. Doubtful identity. IV. Identity excluded. The identification of persons may be of 2 main types: the identification of living subject and the identifica­ tion of dead subject (whole corpse or remains). Ü The identification of living subject. Reasons when the identification as actual: Ø coma Ø amnesia Ø infancy Ø mental defect Ø language barrier Ø other reasons: i.e. the suspected criminal refusing to inform police about himself, but it is ne­ cessary to estimate the exact age and other characteristics of person (cases of immigration, in­ heritance in which a willful concealment or imitation of identity is observed). Ü The identification of dead subject (whole corpse, remains) to be performed in the cases of: Ø criminal death (homicides) Ø mass disaster (air crash, earthquake, fire etc.)

Fig. 12. Identification of a person by the old fracture Fig. 13. Identification of a person by peculiar tattoos. of skull (arrow). There are several possibilities concerning objects of such an identification: w fresh, intact corpses (see fig. 13)

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com w extremely destroyed (devastated) corpses w progressive putrefaction (decomposition) of bodies w skeletalized human remains (see fig. 12) Identification has its own specialised tasks for forensic physician, pathologist, other experts (forensic odontologist) and in general for any doctor. The main method of identification is comparison of document a­ tion (records) and data obtained, and the common result of identification ­ confirming or excluding a person.

The main steps of identification process 1. Morphological identification by: w clothing ñ height w jewellery ñ weight w personal things ñ general physique (sex, race, occupation, social status) w cosmetics (on the eyes, lips, nails). 2. External examination (sex, age, height, weight, racial pigmentation, racial and ethnic facial appearances, color of eyes and hair, size and shape of the nose, mouth and ears, scars, skin blemishes and birthmarks, congenital defects, deformities, prior injuries, tattoos, occupational marks or injuries. 3. Dental examination (anomalies of the teeth, types, materials, shape, surfaces of restorations). 4. Internal examination and microscopic examination of selected organs F Eye and hair color is darking after death! Assesment of the age: Ø general appearance Ø arcus senilis iridis et corneae Ø wrinkling of the skin Ø arthritic changes Ø dental status Ø ossification centres (x­ray examination).

Dental identification Dental identification is performed by a dentist experienced in forensic work. Advantage of teeth is that the dental tissue is the hardest and most resistant tissue in the body (even in cases of total decomposition or s e­ vere fire). The main principle is a comparison of: ­ postmortem dental examination form ñ antemortem data ­ postmortem radiographs ñ antemortem x­ray. F The dental identification is of great value in the cases of missing persons and mass disaster (after air crash it is necessary to check the passenger list and not to harry up with proclaiming dead persons ñ the list may be incor­ rect). The dental identification is based on such main elements: w Identifying features of the dentition and oral tissues: missing teeth, supernumerary teeth, abnormalities in jaw relationships and arrangement of the teeth, congenital or occured defects of the teeth and suppoting tissues. w Identifying features of dental restorations and replacements: the heat­resistant dental materials (gold, porcelain) as well as remains of natural teeth can be found even in the ashes of bodies after cremation. w Post­mortem identification by means of dental records. Dentists invariably maintain records for each patient. If an individual, during his entire lifetime, has always attended the same dentist, there is a good chance that his dental record may be complete. An incompleteness in records may cause difficulty in the evaluation of evidence. The degree of correspondence is always negative where the victim really has the tooth had being extracted by the dental record (fig. 14) w Age determination by teeth. For the first it is inevitable to remove teeth together with the alveolar part of jaws (fig. 15).. Then the longitudinal slice of the isolated tooth is prepared and examined (fig. 16). The sites of evidence showing age changes are following: ­ degree of occlusal wear, abrasion of the tooth crown (A): A0, A1, A2, A3. PDF created with FinePrint pdfFactory trial version http://www.fineprint.com ­ amount of secondary dentine in the pulp chamber (D): D0, D1, D2, D3. ­ gum attachment around the neck of the tooth (G): G0, G1, G2, G3. ­ translucency of the root (T): T0, T1, T2, T3. ­ amount of secondary cementum at the root apex (C): C0, C1, C2, C3.

Fig. 14. Comparison of dental and postmortal record shows incorrespondence and excluded identity because of presence of the tooth (arrow) which was really extracted by the record ( T, see upper) of a dentist.

Fig. 15. Sectioning the maxilla and removing of its Fig. 16. Tooth slice ready alveolar part for subsequent teeth examination [18]. for age determination. Explanation of A, D,G, T, C see in the text [18].

By Gustafson method of age determination using tooth section (slice) the arbitrary points of crown occlusal wear (abrasion, A), the amount of secondary dentine (D), level of the gum (G), and the amount of secondary cementum (C) may be calculated by following Gustafson's equation.

Age (years) = 11,43 + 4.56 × sum of points (A,D,G,C) PDF created with FinePrint pdfFactory trial version http://www.fineprint.com F Note that the degree of dental root translucency (T) doesn't present in this equation. Thus the maximal possible sum of points is 12 (3 + 3 + 3 + 3).

Fig. 17. Sites of evidence showing age changes of a tooth by Gustafson. A ñ crown abrasion, D ñ secondary dentine, G ñ gum level, T ñ translucency of the root, C ñ secondary cementum. Degrees are increased from 0 to 3.

The graphical appear of the Gustafson's equation is following:

70

60

50 d

l 40 o

s r a e 30 Y

20

10

0 0 2 4 6 8 10 12 Sum of points

Graph 1. Dependence of the estimated age on the sum of Gustafson's points A, D, G, C after examination of dental slice of identified person.

Fingerprints are mainly a matter for police. Preparing of wrinkled, putreified or desquamated skin of fi n­ gers for this procedure is the task of a doctor. Tattoos have a great significance in the recognition of the bodies of unknown persons (see fig. 13). Skeletalised remains. The first problem in any examination of such a case is find out whose body it was. Remember that identification of remains by distraught relatives is notoriously unreliable. See also fig. 12. Every kind of examiners has its own questions: w anatomist...... Ö.Ö. ARE THESE BONES? w anthropologist...... Ö.... ARE THESE BONES HUMAN? w forensic doctor...... ÖÖÖ.. WHAT SEX? WHAT AGE? WHAT RACE? etc.

1. What are the common principles of identification? 2. What are the degrees of identity? 3. Describe the main steps of identification process. Practical task: Perform an external examination in the autopsy room, note all signs of identification. PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 6. EXTERNAL AND INTERNAL EXAMINATION OF THE DEAD BODY. EXHUMATION.

At the scene is very important to document where was the body found, position of the body, postmortem changes, temperature of the room etc. All items, that might be helpful in later investigation, are removed for later toxicological or biological examination (e.g. bottles, knives, syringes). The steps of external examination: 1. Observation on body colour, weight, height, eye colour, hair, size and shape of the nose, mouth and ears and dental examination ­ position, rotation, anomalies of the teeth, types, materials, shape, surfaces of rest o­ rations. 2. Postmortem changes (stiffness, body cooling, lividity, signs of decomposition). 3. Vital reactions and traumatic lesions (petechial hemorrhages, cyanosis, edema, abrasions, contusions, la­ cerations, ligature mark, finger marks, nail marks, bite marks, needle marks, scares, congenital defects, de­ formations, tattoos, cut or stab wounds, gunshot wounds, fractures etc.) þ Vital reaction ­ evidence for injury in living organism (local and general: inflammation, bleeding, embo­ lism, necrosis, carbone monoxide in the blood, soot in the airways during a fire etc.)

Internal examination. Autopsy. þ Autopsy (synonym: necropsy) ñ full post­mortem external and internal examination of the body with the objective to estimate the cause, manner and mechanism of death (fig. 18).

Fig. 18. A corpse at the Section of autopsies.

The autopsy is a highly specialized procedure which should ideally be taken only by the experienced medico­legal pathologist, who accomplished such requirements as: ­ working on department of pathology or forensic medicine ­ experience in the techniques of autopsy PDF created with FinePrint pdfFactory trial version http://www.fineprint.com ­ postgraduate training and passing exams: first degree (pathology) and second degree (foren­ sic medicine). But in reality we know, that in most countries, especially outside of metropolitan centers autopsies are done by persons without postgradual training or any extensive practical experience in medicine as applied to the problems of law and justice. This can lead to unfortunate results, because a poorly performed autopsy may be worse than no autopsy at all. Even experienced pathologists must understand the peculiar problems and objectives of legal medicine if the desired information is to be obtained.

The value of autopsy: 1. Certification of death may be incorrect or inaccurate in 50 % of cases. 2. Autopsy will ascertain the cause of death and should prevent concealment of homicide. 3. It is source of other informations, that can be helpful in process of identification (surgical intervention, blood ñ taken for grouping and DNA profiling).

Classification of autopsies: 1. The anatomical autopsy: for academic interest, teaching and research purposes . 2. The clinical (pathological) autopsy, which will be done if the cause of death is known. The autopsy co n­ firms the diagnosis and discovers the extent of the lesions, exacts complications. 3. The medico­legal autopsy, which discovers following things: a/ the identity of the body b/ the cause of death c/ the nature and number of injuries d/ the time of death e/ the presence of toxic substances (poisons) in the body f/ the expectation of duration of life for insurance purposes g/ the presence of natural disease and its contribution to death, especially where there is also trauma h/ the interpretation of the mechanism of death i/ the interpretation of injuries, either criminal, suicidal or accidental j/ the interpretation of any other unnatural conditions, including those associated with surgical and medi­ cal procedures.

The first well­authenticated medico­legal autopsy in Europe was performed in Bologna in Northern Italy in 1302. The examiner was Bartolomeo de Variagiana, who was assisted by another physician and three sur­ geons. The subject was a nobleman supposed to have died of poisoning. In 1562 a full­complete judicial autopsy was performed in Paris by Ambroise ParÈ and around the end of the sixteenth century the autopsy of medico­legal cases begin to be generally practiced.

There are several important points of autopsy performing: 1. The dead body must be definitely identified before autopsy. 2. Where definite crime or suspicion exists, the doctor should visit the scene of the death. 3. The body should be examined with the clothing. The clothes must be carefully retained for police lab o­ ratory examination. 4. The body should be photographed both at the scene and in mortuary first with the clothing and then after its removal. 5. Access must be given to police of forensic scientists before and during the autopsy for their collection of trace evidence (fibres, hair, blood, nail clippings, saliva, semen etc.) 6. In a medico­legal autopsy the external examination often means more than internal dissection. 7. The external appearances must be recorded by photos, video, sketches and description, the nomenclature of injuries must be accurate. 8. The biological material (blood, urine, pieces of organs) must be taken for histological, toxico logical, se­ rohematological and other investigations.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 9. The internal examination must be complete and always include three cavities (thoracic, abdominal and cranial) or more (spinal column cavity, middle ear cavity). Not to allow to carry out even a part of autopsy to a mortuary attendant (mortuary technician) or to untrained porter. Those eyes and hand cannot replace those of doctor when viewing original appearances.

Exhumation þ Exhumation is a medico­legal procedure when a dead body has to be removed from its grave in the cases when autopsy needs to be performed. It happens usually when some facts or allegations have arisen and the original cause of death has become doubt (see fig. 19). Several months or even years after burial may still allow a useful autopsy to be carried out, because the corpse may be in a relatively good condition: the decay desintegration may be minimal. The grave, headstone and coffin must be identified, in the case of toxicologial suspection the samples of soil and grave­water are taken from above, below and at the sides of coffin, as well as a control sample from a distant part of the cemetery. The autopsy in an exhumation takes the same form as any other, though may have to be modified according to the condition of the corpse.

Fig. 19. A corpse in the opened coffin post exhumationem. Note the signs of advanced putrefaction.

1. What are the steps of external examination of the dead body? 2. What is an autopsy? Classification of autopsies. 3. Describe the process of exhumation. Practical task: Describe late postmortal changes in the autopsy room. Note the main steps of exumation (on videorecord).

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 7. BLOOD STAINS, GROUPS, DNA AND IDENTIFICATION.

The blood is the main fluid of the human organism. It contents in the heart and blood vessels. Bleeding happens mainly from the open wounds, sometimes from natural openings, such as mouth, nostrils, ears, anal orifice, vagina. Blood stains may show us the manner (the type) of death. Where we have to look for blood stains? Ü Site of blood stains I: wall, ceiling, ground, other objects (see fig. 20, 21). Ü Site of blood stains II: skin and / or clothing The blood is flying through the air (spattering). The blood drops and spatters form blood stains on the sur­ face. The pattern depends on the angle of impact and height of falling: w right angle ­ circular stain (spiked edges are the signs of forcible contact, regular edges are the signs of low height dropping) w oblique angle ­ tapering stain (the sharp, dentate end pointing in the direction of trav el). Oval stain may be too. w a small separate globule in front of the stain (resembling an exclamation mark) Ü Sliding movement during or after the bleeding lead to formation of smears of blood. This may be re­ sult of agonal movements of victim or trace (mark) during attempts of criminal to hide a victim. Ü Direct patterns of blood (indicate the shape of a weapon, fingerprints on a door, a wall, stepmarks on a floor etc.) Ü Runnels of blood (often dried) always passing vertically down (indication of the original posture of a person) Ü Pool (puddle) of blood. Can be revealed under or near the corpse. Direct contact with blood­stained objects is also important (skin, hair, clothing, hands (especially nails), weapons)

Fig. 20. Blood stains on the rolling­pin which caused Fig. 21. Collection of traces of evidence with fatal head injury. different blood stains at the Section of serology, haematology and genetics.

There are three main questions for blood stain analysis: 1. Is this a blood? Detection of suspect blood stains by methods of orientation: w non­specific: benzidene test (see fig. 22), fluorescent test, chemiluminescent test etc. w specific: Kastel­Meyer test, Bertrand test, Takayama test etc. 2. What blood is this? Distinguishing human blood from animal blood by such methods: w immunological tests w gel precipitation (see fig. 23) and gel electrophoresis

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com w fluorescent­antibody techniques 3. What type of human blood is this? Examination of blood groups and individual systems: w red cell antigens w serum proteins w red cell enzymes w DNA profiling.

Fig. 22. The old dryed blood stain with spiked edges. Fig. 23. Gel precipitation of the suspected stain with A part of the stain was undergone benzidene test the human antiserum (A ñ control, B ñ investigated (arrow). sample). Arrow shows the zone of precipitation.

Blood grouping can be used Ø To show whether blood stains could ñ or could not have come from a particular suspect of victim. Ø To assist in identification of fragmented human remains. We can examine not only blood but bone marrow, lymphatic nodes etc Ø To help resolve paternity and inheritance disputes. Ø To resolve which baby belongs to which mother. We know cases of exchanging of newborn infants in hospitals by mistake.

DNA identification This modern method was initially discovered by Professor Jeffreys at Leicester University in 1984. Advantages of DNA identification method: Ü the most powerful tool to discriminate between individuals. Ü sequence of bases is unique with exception of uni­ovular twins. Ü in paternity testing ñ positive identity can be made, rather than the exclusions possible with blood group methods. F Any fluid or stain material containing nucleated cells may be suitable for DNA profiling.

Samples for investigation: Ø 5 ñ 15 ml of blood is usually taken Ø in case of sexual offences fluid from vagina is taken by pipette, swabs can be used, too Ø hairs with cellular material in the root bulbs Ø saliva (or spittal) is not always sufficient for satisfactory profiles Ø DNA profile can also be obtained from other tissues as muscle etc. Ø in case of delay in getting it to laboratory, sample in plastic tube should be frozen at ñ20 ∞C.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com The main steps of the method: 1. Separation of DNA from other components. 2. Long strands of DNA are cut into millions of small pieces at predetermined points by using enzymes. 3. DNA fragments are sorted according to size using a gel and electric current. The smaller molecules move quickly through the gel. 4. The fragments are transferred to a membrane and then identified by using either mono or multi­locus probes, which are short chains of DNA linked to a radioactive isotope. 5. A film sensitive to radiation, is placed over the membrane. An exposed areas on the film shows where the probe has combined with DNA fragment. The developed film is called an autoradiograph (see fig. 24)

F Autoradiograph carrying a series of bars of varying density and spacing, like the bar (linear) code, for pricing articles in stores.

Fig. 24. DNA autoradiograph. A case of suspected sexual assault. Lane A contains control DNA markers (BRL Life Technologies), lane C is the blood sample of the alleged victim, lane D ñ the blood sample of the suspected, lane E ñ a sperm sample of the suspected, lane B contains the washcloth extract of the alleged victim. Note a match between lane D and lane E and abcence of match between lane E and lane B. The charge attempt failed [3].

1. What are the main questions for blood stain analysis? 2. In which medico­legal cases can be used blood grouping? 3. What are the main steps of DNA identification? Practical task: Visit the section of serology, haematology and genetics, see the main methods of identifi­ cation of persons by blood stains.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 8. THE EXAMINATION OF WOUNDS

Almost any doctor may be called upon at some to examine a person who has suffered a wound. Whether the patient as alive or dead, whether the injury is trivial or severe, whether the cause is accident, suicide or homicide, such an examination may have serious medico­legal importance. Each examination of wounds may have serious medico­legal importance. The purpose of the examination of any wound can be summarized as an attempt to answer these questions: 1. When it was caused: before, at the time of or after death? 2. How it was caused? 3. What caused it? 4. What amount of force was required to produce it? 5. What degree of injury has resulted from it and whether it has influenced death or caused disability?

Such fundamental rules must always be observed: 1. The doctor would not neglect any injury however small; it may be important later. 2. Besides treating the injury, basic data have to be recorded. Where the victim is dead, doctor has time to make a full examinaton and record. 3. The doctor has to make a good description and, if necessary, photographs with a scale, sketches, schemes with a measurement as well as videorecords. Radiographs may be important. The thing is, that simple me­ mory for details is rapidly lost. In cases of fatal termination, the actual lesions (injuries) can be retained at autopsy by forensic doctor. 4. Wounds should be measured with a ruler, rather then guess by eye. In traffic accidents, shootings and stabbings is useful to measure the height of the injuries above heel level as well as angles of wound channels and traces by three­dimensional method. The observation must include such an information: Ø the site of wound / wounds in relation to neighboring anatomical landmarks Ø the shape of wound and its edges Ø the size of wound (length, width resp. diameter and depth) Ø the description of wound from without inward: surface, underlying tissues, deep structures and viscera Ø the analytical conclusion on the mechanizm of wounding: which object, which force, and which direction of impact may cause this wound. 5. The doctor must examine the whole body and preserve the clothing of the victim. 6. Foreign materials have to be taken for laboratory examination. 7. Blood samples for grouping and DNA analysis, respectively blood, urine and other biological fluids for alcohol or drug estimation would be taken.

The law and wounding. Definitions "wound" and "injury" are not distinguishable in law and no strict difference separates them. But a small difference exists: þ The definition "wound" suggests that the lesion was caused by a deliberate action; in some countries "wound" means obligately a breach of the skin (but this excludes bruises of skin and damage of internal or­ gans without a marks on the body surface). þ The definition "injury" suggests that the lesion arised from any cause including pure accident.

Some other law and forensic terms concerning the wounding: þ Assault ­ is the threat of an attack or the actual attack (synonym: battery); the attacking person is an "as­ sailant". þ Homicide ñ generally deliberate or non­accidental killing caused by other person. þ Murder ­ is a homicide, when killer either intends to kill or intends to cause severe injury (grievous bo­ dily harm).

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com þ Manslaughter ­ is a homicide, when killer has no intent to cause death or severe injury, but the killing was the result of an unlawful act or a negligence or when the killer was provoked by the actions of the vi c­ tim; in some countries (excluding Britain) the manslaughter means any accidental killing even causing death by the reckless driving of a car. þ Infanticide ­ is the killing of a new­born infant at the age up to 1 year old (see also: neonaticide, fili­ cide). þ Justifiable homicide ­ is the killing as a judicial execution in those countries where capital punishment still exists, and also is a killing by a police officer to prevent serious offence or to defend themself. þ Excusable homicide ­ is the killing of an assailant in self­defense, though theoretically only comparable force must be used, for example, a person attacked by someone using his fists is not entitled to shoot him dead.

Classification of wounds The wide classification of injuries (wounds) is a difficult task. From the general point of view the wounds are divided into 6 groups [by GROMOV, 1970]: 1. Job wounds (in plants, works, mines, agriculture). 2. Transportation wounds (by car traffic, railway, aircraft, boats). 3. Outdoors wounds (falling down on a ground, injuries by falling things and the most wounds outdoors). 4. Home wounds (the most wounds indoors). 5. Military wounds (wounds during the war and wounds of military men in usual time). 6. Sport wounds (injuries of sportsmen). From the forensic point of view all injuries may be classified into three groups: 1. Ante­mortem injuries. 2. Agonal injuries. 3. Post­mortem injuries.

Morphologically all wounds can be classified into four main types, as even injuries from strangling, shooting and explosions are combinations of these four: 1. Abrasions (scratches, grazes, impact marks, pressure marks). 2. Bruises (contusions, ruptures of blood vessels beneath the skin or into the tissues) 3. Lacerations (splits, tears, gashes). 4. Incised wounds (cuts, slashes and even stabs). To produce an accurate and legally useful medical record of a wounding case, a proper understanding of the nomenclature of wounds is required. Ü Abrasions are the most superficial type of injury concerning the mechanical damage of epidermis or entering the dermis (see fig. 25). Characteristics of abrasion: w most informative (retain the pattern of the causative object) w not life­threatening w mechanism of formation ñ tangential impact or vertical impact (crush) w causes of abrasion may be different ñ an object striking the skin (a blow from a fist), the body hit­ ting a stationary surface (falling, flinging to the roadway by a car). Kinds of abrasions: Ø linear abrasion (scratch in everyday language), Ø broad abrasion (graze, brush abrasion, "gravel rash", "friction burn"), Ø patterned abrasion (the grid of a car radiator, the embossed ridges of a haedlamp). Ü Bruises are the sequels of blunt injury which are characterized by damage of blood vessels (extrava­ sate into the surrounding tissues, see fig. 26). These localization is mostly under the skin (deep bruising can occur in any tissue or organ). Bruises do not reproduce the pattern of the causative object (exception: "intradermal bruising" caused by the tread of a tyre in a traffic accident).

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 25. Abrasions on the back of a pedestrian Fig. 26. "Railway" parallel linear bruises on the thrown across a rough road surface. back due to impact of a round stick.

Ü Lacerations are the most dangerous injuries of a body. These features: Ø splitting or tearing wound (bleeds profusely, ragged edges, crushing and bruising along the edges, crossing tissues strands Ø fibrous bands, vessels, nerves etc. in the depth of wound (fig. 27). Ø mechanism of formation: blunt injury passes through the full thickness of the skin as a sequel of impacting of a blunt object (see fig. 28), rolling or grinding movement (run over, dragging, stretching, crushing in a "sandwich" fashion).

Fig. 27. Laceration of the head scalp. Note fibrous Fig. 28. Small laceration on the hand ñ the defense bands in the depth. wound.

Ü Incised wounds are injuries from knives, razors, broken glass, metal edges and any object with a cut­ ting edge (stiff paper, grass). They are of 2 main types: slashed wounds and stab wounds. Ø slashed wounds have the length greater than the depth (tangential slices), may be result of ac­ cidental or suicide attempts and less dangerous than stabbing (except transsection of large ves­ sels, see also fig. 29) Ø stab wounds have the depth is greater than the length, may be result of a movement with any sharp­pointed weapon (knife, chisel, bayonet, sword, scissors, screw­driver, file, poker, metal rod, railing, sliver of glass, see fig. 30). Characteristics of stab wounds: ­ a stab wound is usually slit­like ­ the wound is not the same size as the blade (elasticity, taper of the blade, depth of penetra­ tion) ­ the wound may be longer because of the "rocked" knife

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com ­ the wound is "V­shaped" or "swallow tail shaped", if the knife is twisted ­ a single­edged knife cause a wound, which may have one end pointed, the other square or blunt ­ bruising or abrasion may occur from the hilt­guard ­ the depth of the wound may be greater than the length of the blade (on the abdominal or chest wall) ­ a wound from a closed pair of scissors is like a shallow "Z", a sign for a flash of lightning. F Stabbing is the most common method of homicide. A frequent question to medical witnesses in court: "What is the force required to cause a stab wound?"

F Relevant facts in stabbing: 1. The sharpness of the tip of the weapon is most important. If penetration is once through the most resistant skin, the sharpness of the rest of the edge is much less important (no additional force is required). 2. The faster the movement, the easier it is to penetrate. 3. Very little force (from a little finger alone) is needed to push a sharp knife through the skin stretched across ribs. 4. A person can easily transfix themselves by falling or walking onto a sharp knife held by another person.

Fig. 29. Slashed wound of the breast. Fig. 30. Multiple stab wounds of the chest.

Examination of bite marks þ Bite mark is the combination of bruise, laceration and / or incised wound, that are usually made on skin of victim with teeth by animal or human assailant as well as by victim as self­defense.

There are following problems with the interpretation of bite marks: Ø resistance and elasticity of the tissues Ø degree of body curvature of the body surface Ø lapse of time (bites exist only 4 ñ 36 hours).

Types of bite marks: w Aggressive type ­ teeth as a weapon, bite is forceful and rapid. w Sexual type ­ teeth are used to grip during sucking, suck marks are visible as petechiae, bite is forceful and slow.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Bite marks are possible in

Assaults Child Abuse

Nonsexual Sexual Multiple incidents Single incident

Perperator Bites

Forcible Voluntary Old New

Homosexual Heterosexual Adult Child

Compare of bite marks Ø Human ñ U­shaped, more blunt. Ø Dog ñ narrow squarish arch, anteriorly prominent pointed marks produced by canines. Ø Cat ñ small rounded arch with puncture marks made by canines bite is often associated with scratch marks. Ø Rodent ñ small bites with long grooves caused by the central incisors.

Common sites of bite marks localization:

NON­SEXUAL HETEROSEXUAL HOMOSEXUAL

arm breast breast leg neck upper back fingers cheek axilla hand arm genitalia ears abdomen nose

Main methods of forensic investigation of bite marks: w Taking a swab from bite mark, from intact control area, victim saliva and unused. w Photography ñ at least 3 views, with scale, UV photography. w Infants should be examined under UV light w Measurements and comparisons one to one photograph­dental model w Taking impressions and wax bites (if suspects are available).

1. What is the difference between definitions of "injury" and "wound"? 2. What kinds of homicide from the forensic point­of­view do you know? 3. What are the morphological features of stab wounds? Practical task: Describe all types of wounds in a case of violent death in the autopsy room (or on videore­ cord)

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 9. EFFECTS OF INJURY

Any injury of a living organism starts processes and mechanisms of defense and adaptation, these evalu ation has a great medico­legal importance. The sequelae of trauma may be acute (strongly incompatible with life) and less acute. What are the less acute sequelae of trauma? 1. Haemorrhage. 2. Infection. 3. Embolism. 4. Adult respiratory distress syndrome (ARDS)

Haemorrhage (bleeding) May be classified into 2 types: Ø External bleeding: ­ from lacerations ­ from incised wounds Ø Internal bleeding: ­ into body cavities ­ into organs The dangerous sequeae of bleeding: 1. Actual blood­loss è haemorrhagic shock, hypotension and circulatory collapse. 2. Bleeding within the skull and space­occupying effect upon the brain. Compensatory mechanisms: Ø constriction of the arteriolar bed Ø increase of the heart rate. F The time that elapses from trauma to shock is hard to estimate retrospectively!

Arterial bleeding is most dangerous. When an artery completely severed (transsected) less bleeding is ob­ served due to retraction by elastic coats. When an artery partly transsected (or lacerated) more bleeding o c­ curs. The basic question for a doctor­expert: How soon a victim must have collapsed or become incapable of some activity following trauma?

Infection Infective consequences can still occur especially in situations where rapid and effective treatment is not available. The common possible risks are: w anaerobic infection (Clostridium perfringens, Clostridium tetani) w aerobic purulent infection (Staphylococci, Streptococci, Colibacillaceae, Pseudomonas, Proteus) w "septic shock" from exotoxins originating in unsuspected foci of infection.

Embolism þ Embolus is a foreign bolus (solid, liquid, gaseous) migrating through the vascular system to lodge at a bifurcation. Kinds of emboli are: Ø fat embolus Ø bone marrow embolus Ø air (gase) embolus Ø thrombo­embolus PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ø foreign body in a vessel Ø amniotic fluid in a vessel. þ Fat embolism is a sequel to tissue trauma (after hours or even a day). Origin of the fat ñ adipose tissue, bone marrow or plasma fat. Occurence ñ in almost every injury involving bone or subcutaneous tissue. Grading of fat embolism: from I (slight) to IV (severe) degree. Fat embolism is a common sequence in a crushing effect. Pulmonary fat embolism ñ a filtration effect of lung capillaries recognised histologically. The generalised (systemic) fat embolism ñ fat globules penetrate the lung vessels into the systemic circul a­ tion. Embolism of vital organs occurs frequently, the kinds are: Ø brain embolism (purpura). This kind of embolism is undoubtfully fatal (see fig. 31) Ø kidney embolism (see fig. 32) Ø myocardium embolism Ø embolism of the skin Ø embolism of the retina. Consequences of embolism ñ small haemorrhages (petechiae), micro­infarcts.

þ Air embolism ñ kind of embolism regarded as a cardiac embolism which is characterized by the evidence of frothy bubbles of air in the right atrium, ventricle and pulmonary arteries, is a common sequence of wounding of cervical veins. The minimum fatal volume of air in blood vessels is probably 100 ml.

Possibilities: 1. Opening the large veins in the neck (cut throat, thyreoidectomy etc.) 2. The head above the level of the chest (suction effect). 3. Criminal abortion. 4. Empty infusion (transfusion) bottles (air forced through the drip tube). 5. Barotrauma of the lungs (accidents of divers). The peculiar type of air embolism is nitrogen gas embolism in a decompression disease (suffering divers, high altitude flyers).

Thrombo­embolism. Pulmonary thrombo­embolism ñ the most common consequence of injury. The focus is almost commonly in the deep leg veins. The main causative factors are: w increase in the coagulability of the blood w inactivity of the victim (slowing the blood flow in the legs and causing pressure on the calves from lying) w predisposition: trauma, surgical operation, immobility in bed, childbirth etc. Parts of thrombus break off and are swept to the heart and impact in the pulmonary arteries and its branches. Pulmonary red infarcts sometimes occur.

Foreign body embolism. May be observed in the systemic veins and / or lungs. Foreign bodies are insoluble. They commonly consist of: w contaminant material in injected drugs of dependence (crushed tablets, heroin diluted or "cut" with starch, talc etc.) w bullets or shot­gun pellets (rarely).

In histology can be find: Ø foreign body granulomata of the lung Ø doubly­refractile material visible under polarised light.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 31. Fat embolism of the brain. Note the signs of Fig. 32. Histological view of the kidney fat embolism. "cerebral purpure". Fat droplets in glomerular capillaries. Sudan III staining. Magnification 420×.

Amniotic fluid embolism This is a complication of childbirth. Principle: the amniotic fluid escapes into the maternal circulation. Consequences of the amniotic fluid embolism are: w blocking of the pulmonary capillaries w DIC (disseminative intracapillary coagulation). Diagnostics: histologically ñ fetal squames, lanugo, vernix lipoid and meconium (special staining for kera­ tin squames in multiple sections of lung).

Adult respiratory distress syndrome (ARDS) ARDS is a complication of most traumatic or stressful incidents. The appearance of lungs is distinctive: these are shock lungs. The main causes of ARDS are: w aspiration of gastric contents w heavy impacts on the thorax w near­drowning w irritant gases w blast injuries to the chest w infection and systemic shock. Clinical features: dyspnoea, hypoxaemia, progressive respiratory insufficiency. At autopsy one can see oedematous and stiff lungs. Histological examination of lungs reveals intra­alveolar exsudates, hyaline membranes, haemorrhage, cellular proliferation and sometimes interstitial fibrosis (in long survival).

Bone fractures Bone fractures are the common sequences of blunt force injuries. The cause may be of three types: w direct violence (the force acts on a bone deformating it by compression, distension or pitch and produces an injury). The typical situations are transportation injuries: the tibia and fibula, for example, may be broken across at right angles to the shaft as a result of direct impact by an automobile bumper. w indirect violence (injury is produced at a distance from the point of application of a blunt force). Such injuries occur: Ø in various types of falls, in a case of falling down onto the heals the fracture of hip bone or even skull base is possible Ø in car accidents, where driver's knees impact on a dashboard the fracture of hip bones is common.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com w proper muscular action. In some cases rapidly intermittent contractions of the muscles (electric shock, epilepsia) may cause bone fractures especially if the bones exhibited an appreciable amount of osteoporosis. According to anatomical regions we can divide bone fractures into six groups: ­ skull fractures ­ pelvic fractures ­ spine fractures ­ fractures of upper extremities ­ chest fractures ­ fractures of lower extremities.

Punching and kicking Punching is a blow with the clenched fist, a peculiar type of the blunt force directed commonly at the upper part of the body of the victim. The resulting injuries are: ­ bruising ("black eye") ­ abrasions ­ lacerations of the lips, eyebrows, cheeks ­ fractures of the nose, jaws, teeth, zygoma and even skull base (commonly ethmoidal bone) ­ damage of the brain (commonly commotion) ­ damage of internal organs (rupture of the liver, intestine) Kicking is a blow with the shod or bare foot. This type of blunt force injury is usually more severe than punching due to heavier weight and faster speed of a swinging leg and the hardness of a shoe. The targets for kicking are: ­ lower extremities and perineum (if the victim is standing) ­ the face, neck, sides of the chest and abdomen (if the victim is lying on the ground). The common injuries in kicking are the same as in the punching, but more severe.

Defence injuries Defence injuries are the characteristic injuries on the victim's body which indicate that the victim interfered in the assault and attempted to defend himself. These injuries are divided into two groups: w active defence injuries: bruising and lacerations of fists due to defensive punching, incised wounds on the palms and fingers due to gripping the blade in the fist. w passive defence injuries: bruises, abrasions and lacerations of the outer side of forea rms (sometimes with the fracture of forearm bones), the outer side of thighs, the back of the hands which indicate the victim's passive protection. The peculiar passive defence injury in stabbing is a deep incision across the web of the palm between thumb and index finger.

Activity after wounding The important question the forensic doctor has to solve is a survival and activity of a victim after severe (even fatal) injury. In such cases a person who is shortly going to die from wounds may be able to defend himself, to run, to drive a car etc. The most common items are: Ø ability of a victim to act after fatal blunt force injury of the head. Ø ability of a victim to act after fatal gunshot wound. Ø ability of a victim to act after fatal stab or slash wound. Many cases showed that such an ability depends on various factors: rapidity of blood loss, possibility of air embolism occuring, involvement of brain vital centers, presence or absence of the stabbing weapon in the wound, influence of alcohol consumpted and so on.

1. What are the less acute sequelae of trauma? 2. What kinds of embolism do you know? 3. What are the main causes of ARDS? Practical task: Describe the main sequelae of trauma in the autopsy room.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 10. REGIONAL INJURIES

Topographically all injuries can be described by reference to certain parts of the body. It has a great si g­ nificance in explanation the mechanism of injury. Damage to the head, spine, chest, abdomen and limbs has a particular medico­legal significance.

Head injuries Why the head is especially vulnerable? 1. It is the heaviest part of the body (relative to its size) 2. Its position is unstable (depends on the tone of the neck muscles). Head injuries may be divided into: w scalp injuries w skull fractures w intracranial haemorrhage w brain damage. Ü Scalp injuries The scalp is very vascular and bleeds profusely. The underlying skull acts as an anvil. There are following types of scalp injuries: Ø laceration (on the edges a zone of crushing and bruising, hairs and fibrous strands cross the depth) Ø oedema and haematoma Ø scalpation (tearing of a large flap after tangential force impact). Examples are: ­ influence of a rotating wheel in traffic accidents ­ long hair entangled in a machine. F The hair of victim must be shaved away for a good view and photograph! Ü Skull fractures The skull can withstand distortion without fracture in dependence on age. A distortion can cause severe damage of cranial contents (see fig. 33, 34). Skull fractures have following features: Ø They are harmless Ø They indicate a severe force impacted Ø They can indicate the direction and point of impact.

Fig. 33. Depressed fractures and longitudinal Fig. 34. Radiograph of the linear skull deformation of the skull (arrow shows the direction fracture (arrow). of impact). Traffic accident.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Morphological classification of skull fractures: w linear fracture (see fig. 34) w "hinge fracture" (across the base of the skull) w depressed fracture w "spider web" pattern w "ring fracture". From biomechanical point of view skull fractures are of two groups: 1. Primary fractures ñ caused by direct force impact, localized near the point of impact 2. Secondary fractures ñ caused by transmitted force (i.e. fractures of orbital roof after a fall onto the back of the head) F Secondary fractures are the common finding in infants and children in cases of child abuse.

Ü Intracranial haemorrhage This is an important clinical and pathological finding leading to various disabilities and often fatal. There are several types of its localization: w extradural (epidural) haemorrhage (space­occupying lesion ñ not always with fracture. Origin: usually ramus posterior a. meningeae mediae. Symptoms sometimes after hours or a day: temporary concussion, "lucid interval", coma ñ possible treatment negligence). See also fig. 35. w subdural haemorrhage (more frequent in the elderly an in children after an impact upon the head or "shaken baby". Origin: communicating [connecting] veins (vv. communicantes cerebri). Mecha­ nism: rotation or "shear" stress, in cases of "battered baby" chronic subdural haematoma may be re­ vealed) w subarachnoid (intermeningeal) haemorrhage (in association with brain cortex bruising or la­ ceration. Origin: arterial vessels beneath the arachnoid or vertebro­basilar vessels (rr. frontales, tem­ porales, parietale et occipitales). Possible mechanism: blow to the side of the neck. Differential di­ agnosis: with a rupture of a berry aneurysm ñ direct irritant effect on the brain­stem in subarachnoid haemorrhage).

Fig. 35. Epidural haemorrhage as a sequence of Fig. 36. Brain contusions as a sequence of blunt blunt force injury. force injury (arrows).

Ü Brain damage Various types of lesions can affect the brain substance, such are: w oedema (sequel to head injury, develops within minutes and leads to rising of intracranial pressure è effects on the brain­stem è death. The most common findings are: ­ distortion of the brain anatomy: "coning", herniation, imprints of skull bones on base of the brain ñ secondary haemorrage, necrosis ­ histologically: fluid in the extracellular spaces, spongious tissue patterns.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com w concussion (commotio cerebri) w contusion (mechanisms: rotation, acceleration, deceleration, "shearing stress". Localization: from cortical surface deeper down, corpus callosum, peduncles, brain stem; lateral surface of the hem i­ spheres, temporal and frontal poles, base of the frontal lobes: "coup" and "contre­coup" (from the French: "coupe" et "contre­coupe") caused presumably by a vacuum producing during fast acce­ leration ñ deceleration for a fraction of a second, see also fig. 36, 37) w laceration (more severe ñ direct mechanical damage of brain matter) w diffuse axonal injury (damage) (non­visible gross damage è "shearing stresses" within the brain substance, particularly corpus callosum è broken axons è "retraction balls" demonstrable micro­ scopically by silver impregnation of axons or by immunohistochemistry [neuron specific enolase, β­amyloid precursor protein] ñ earliest finding 3 hours after injury). See also fig. 38, 39.

Spinal injury This type of injury is most common in fatal road traffic accidents. Its possible localization: ­ atlanto­occipital joint ­ vertebral body and intervertebral discs ­ cervical spine ­ vertebral arches ­ thoracic spine ­ vertebral transverse processes.

Fig. 37. Brain contusion and traumatic Fig. 38. Microscopic view of the brain diffuse axonal intraparenchymal haemorrhage (arrow). injury. "Retraction balls" of broken axons in corpus callosum (arrow). Silver impregnation by Palmgren. Magnification 400×.

Fig. 39. Transmission electron microscopic pattern of diffuse axonal injury of the human brain. The retraction ball contains multivesicular structures. Magnification 4200 ×.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Kinds of spinal injury: ­ transsection ­ disruption ­ "whiplash" injury ­ fractures (with dislocation). Mechanisms of injury: ­ compression ­ extension ­ angulation ("wedge" fracture). Sequelae of injury: ­ crush or damage of the spinal cord ­ paraplegia or quadroplegia (risk of subsequent ascending urinary infection) ­ paralysis of the respiratory motor outflow.

Chest injuries The chest suffers several types of injury, such as: w blunt impact w compression w penetration. Ü The most common results of chest injuries are fractures. They are divided into: Ø fractures of ribs ("flail chest" ñ multiple or serial fractures è fractured ends penetrate into the pleura, lungs, heart F Fractures of ribs are the common result of intensive cardiopulmonary resuscitation. Ø fractures of sternum Ø fractures of thoracic spine. Ü Stab wounds (homicidal or suicidal è fatal internal haemorrhage and may involve the abdomen through diaphragma). Ü Pneumothorax (from any penetrating injury. Diagnosis: radiologically and clinically in living, by opening of the chest under water in deceased ­ air in pleural cavity and collapsed lung).

Abdominal injuries The abdominal injuries are various, the most common classification looks subsequently: Ü tearing of the mesentery or intestine (kicks or traffic accidents è haemorrhage or peritonitis) Ü rupture(s) of the liver (also in the depth of the organ ñ kicking or impact against the steering wheel è subcapsular haemorrhage or intraperitoneal bleeding) Ü ruptures of the spleen (a rapid surgical intervention is inevitable) Ü damage of the pancreas, bladder (fractures of the pelvis), kidneys and male urethra Ü stab wounds (lead to severe internal haemorrhage or subsequent peritonitis).

Neck injuries The most common suicidal or homicidal injuries of the neck are cutting and stabbing. These wounds have many vital targets especially cervical vessels: Ø jugular veins (the most dangerous is air embolism) Ø carotid vessels (the most dangerous is external profuse bleeding).

1. What is the classification of head injuries? 2. What is the brain damage characterized by? 3. What kinds of chest and abdominal injuries do you know? Practical task: Describe injuries of head, chest and extremities in the autopsy room (or on videorecord). PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 11. FIREARM AND EXPLOSIVE INJURIES

Firearm injuries Using of firearms both in army and in criminal activities or terroristic acts is an important medico­legal problem. Firearms are the most common mode of death in homicide in several countries. Types of firearms: Ü Shot guns. Main details are: stock, lock with extractor, breech, barrel. Usual guns are two types: single­barrel and twin­barrel, they have a smooth bore, the opened end of the bore is called "muzzle". Shot guns usually fire a large number of small spherical lead shot or pellets (some ammunition contains only a few or a single projectile, see fig. 40, 42).

Fig. 40. The main parts of twin­barrel shotgun.

Fig. 41. The parts of rifle (pistol) cartridge. Fig. 42. The parts of shotgun cartridge.

Ü Rifled weapons: revolvers, "automatic" pistols, rifles, military weapons (fig. 43, 44). May be short (revolvers, pistols) and long (rifles, machine­guns). These features: w fire one projectile at a time (the projectile is on fig. 41) w the barrel has spiral grooves and "lands" w self­loading (by trigger pressure, bolt or gas pressure).

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 43. The main parts of semi­automatic pistol.

Fig. 44. The main parts of revolver.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Morphological components of firearm injuries

Ü Entrance wound is penetrating or perforating defect of the surface (commonly skin) according to the place of projectile introducing to the body. Entrance wounds can be divided into four broad categories: 1. Contact wound: Ø hard contact wound Ø loose contact wound Ø angled contact wound. 2. Close range (near contact) wound. 3. Intermediate range wound. 4. Longer range wound. Commonly the contact entrance wound on the skin has following surrounded zones or limbs (from inside to outside, see fig. 45, 46): w limb of friction soiling ñ has a grayish or brownish color w limb of skin abrasion and contusion ñ has a red­brown color (and is a sign of vital reaction!) w zone of searing and sooting ñ has a black color w zone of gunpowder tattooning ñ has a black to grayish color.

Ü Exit wound is perforating or lacerating defect of the surface (commonly skin) according to the place of exiting the projectile from the body.

Fig. 45. The main components of firearm discharge. Fig. 46. Surrounding limbs of the close range entrance wound

Ü Wound channel is a channel between entrance and exit wounds in the body. Due to pulsation and contusion of surrounding tissues the wound channel may be wider than the firearm caliber. Ü Perforating firearm injury is the type of injury, when both the entrance and the exit wounds are present, the projectile exited the body. Ü Penetrating firearm injury is the type of injury, when the projectile is situated within the body: entrance wound and wound channel are present, exit wound is absent. Ü Graze firearm injury is the non­severe firearm injury, when the wound channel is absent, the entrance and exit wounds are contacted with each other on the surface (skin) of the body, the subcutaneous tissue is not involved. Ü Tangential firearm injury is the firearm injury, when the wound channel is opened to the surface, the entrance and exit wounds are contacted with each other on the surface (skin) of the body, extending to the subcutaneous tissue.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Characteristics of shot­gun wounds 1. A contact wound: w the muzzle touching the skin and the muzzle mark will be present w circular abrasion (the gas presses the skin up against the muzzle ñ not a recoil mark) w entrance wound: circular, over a bone ñ ragged (due to gas rebound) w pink area from carbon monoxide (CO) around the entrance wound w wad inside the wound w head: huge ragged exit wound (with ejecting the brain, see fig. 47).

Fig. 47. Suicidal shot­gun wounding of the head. The entrance wound is on the chin, face is devastated The exit wound is on the forehead. Note the partial ejecting of the brain.

2. A close range wound (distance is a few centimeters to 20 cm): w no muzzle mark w smoke soiling, powder tattooing (cannot be washed off) w burning of skin and hairs. 3. Wound at intermediate ranges (20 cm ñ 1 m): w powder tattooing persists (see fig. 49) w burning persists w irregular wound rim ("rat­hole" ñ the spread of shot begins). 4. Wound at longer ranges (2 ñ 30 m): w satellite pellet holes around the central wound (average 20 cm across for each 10 m of distance, see fig. 48). At long ranges the uniform peppering of shot is observed and thus the shooting is not always fatal. Exit wounds in the chest or abdomen are rarely observed. PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 48. Shot­gun wounds of the heart. Note entrance Fig. 49. Scanning micrograph of ball gunpowder on wounds of the apical part caused by pellets (arrows). the skin. Magnification 500×.

Characteristics of wounds from rifled weapons 1. A contact wound: w the entrance wound is circular (over a bone is star­shaped ñ gas­rebound splitting, see fig. 50, 51) w a muzzle mark presents w escape of smoke w local burning of skin and hair w redness of carbon monoxide staining w surrounding bruising. 2. A close range wound (distance is within 20 cm): w circular or oval (an angle) hole (smaller than the diameter of the projectile, see fig. 50) w smoke soiling, powder burns, skin and hair burning w abrasion collar around the entrance wound w surrounding bruising. w exit wounds: stellate appearance, irregular, large defect, no burning, smoke or powder soiling 3. At longer ranges (up to several kilometers): w beyond 1 meter: no smoke soiling, burning or powder tattooing w larger, irregular entrance wound (lost of gyroscopic track of projectile) w exit wound: stellate appearance, irregular, large defect, no burning, smoke or powder soiling. Physical mechanism of shooting channel formation: damage by transferring energy laterally along the track è forming of a cavity, the walls of which pulsate with decreasing amplitude (brain, liver). Gunshot wounds on the bones, both entrance and exit (particularly in the skull) commonly have a funnel­ like shape with a funnel extension towards the direction of shooting (fig. 53). PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 50. Entrance (up) and exit (down) wound of the Fig. 51. Two contact entrance wounds of the chest forearm. Close range wounds. over the nipple (arrow).

Fig. 52. Star­shaped entrance wound of the head (left Fig. 53. Funnel­like pattern of the entrance wound temporal area). Suicide. on the inner surface of the skull. Note corresponding linear fractures (arrows).

The doctor's duty in cases of firearm injuries 1. In the living: Ø saving life. Ø notes of the original appearances of shooting wound before cleaning and operative procedures. Ø preserving of foreign bodies and biological material (especially skin around the wounds after surgical cleaning!) for further investigation. 2. Post­mortem examination: Ø preservation of lead shot, bullets Ø removing and keeping of the skin around the entrance wound (without formalin fixation, refrigerating, preparing tests for powder residues, e. g. Lunge's test for nitrits) Ø photograps, drawnings with accurate measurements of wound should be done. Radiographs may be important Ø clothing of the victim should be preserved Ø blood samples for grouping, DNA analysis, alcohol or drug estimation should be taken Ø report to the police.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Explosive injuries Terrorism and warfare as well as using of explosive substances (fuel, gas) in everyday practice lead to many deaths from explosive injuries. These devices may be of three types: military bombs, terrorist bombs and explosive devices. Spaces with cumulation of large amount of explosive substances (propan gas, coal dust) are also dangerous. The post­mortem examination of an explosion victim involves two main objectives: identification and reconstruction of the events. Ü Identification procedures of explosion victims are the same as those for identification in general, but certain complications occur due to dispersion of body parts by the blast, for example, the jaws and fingers may be blown off and must be retrieved for identification by dental comparison or fingerprints. Ü Reconstruction of events includes getting answers on such questions: Ø What was the type and amount of explosive substance? Ø Where had been the explosive situated before event? Ø What type of initiator and firing system were used? Ø Was the explosion deliberate or accidental? Ø Had the explosive device an envelope (casing), what things were used as secondary projectiles? Ø What is the mechanism of explosive injuries. Ø What injuries were fatal? Ø What traces of evidence are available to make a conclusion about the case? The mechanism of explosive injuries includes: ­ burns from the near effect of the explosive and subsequent conflagration ­ physical fragmentation, disruption and laceration of the victim (at the explosive pressure more than 700 kilopascals) ­ massive hemorrhages in the lungs due to shock wave (barotrauma), see also fig. 84 ­ ruptures of some organs and structures (bronchi, alveoli, tympanic membrane, rectum etc.) ­ missile injuries from parts of the bomb casing and from adjacent objects and fragments projected by the explosion ­ peppering (impregnation), bruises, abrasions, lacerations by small fragments, debris and dust propelled by the explosion ­ all types of injury due to collapse of buildings, roofs,walls damaged at the explosion

Fig. 54. Explosive injuries of legs. The victim carried a plastic bag with Danubite.

1. What are the main characteristics of shot­gun wounds? 2. What is a doctor's duty in cases of firearm injuries? 3. What are objectives of post­mortem examination in explosion cases? Practical task: Describe entrance wound and fill­in a transmittal letter after taking samples of skin in fatal gunshot wounding for histological and chemical investigations.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 12. MURDER, SUICIDE OR ACCIDENT?

The medical cause of death requires special legal classification into the "manner of death" and "circumstances of death". The doctor's and preliminary police investigator's duty in such cases is to establish whether is it homicide, suicide, accident or natural cause of death. In many cases the doctor will decide between accident, suicide or murder if eye­witnesses, traces of evidence and other circumstational findings are deficient. Thus, the knowledge of different evident factors may help to differentiate manners of death described. It is necessary to differentiate murder, suicide and accident in the cases of firearm injuries, sharp injuries, several types of asphyxia and poisoning.

Firearm injuries Most of European countries have strict laws concerning the possession of firearms, but in the USA weapons are universally available in the community, therefore the percentage of deaths due to guns cause the majority in the USA. There are several rules for differentiation murder, suicide and accident in shooting cases: 1. If the range of the discharge is beyond victim's arm's length, the shooting cannot be suicide. F Some mechanical device to reach the trigger by self­murder may be used! 2. If no weapon is present at the scene of death then suicide is almost excluded, unless someone else removed it. 3. Suicides use "sites of election": forehead, temples, the mouth, under the chin and the region of the heart. The "restricted sites" are: the eye, the back of the head, the abdomen: F It is not true that right­handed people always shoot themselves in the right temple and nowhere else! 4. Generally one shot to be fired in a suicide (there are exceptions). 5. Women rarely shoot themselves. A useful rule is "A shot woman is a murdered woman until proved otherwise". 6. It is difficult to differentiate accidental shooting from homicide without knowing circumstances. 7. In homicide wounds are inflicted on an inaccessible parts of dressed body, on "restricted sites". The wounds may be multiple, some of them are not fatal. The back of the head, neck, auricular region, large joints, region of liver and the eye are traditional "execution sites" in terrorism or assassination.

Sharp injuries There are several rules for differentiation murder, suicide and accident in sharp injuries: 1. The very distinctive mark of suicidal (or self­mutilating) is repetition of impacts and evidence of tentative (trial) incisions which are mostly parallel and close together. 2. The most usual places in suicide are: Ø inner surfaces of wrists and elbows Ø throat, frontal and lateral parts of the neck Ø cardiac area of chest (the victim firstly pulls the clothing aside!) Ø epigastral and umbilical area of abdomen (historically characteristic for suicides of Japanese Empereur's warriors). 3. In right­handed victims the cuts on throat are often deepest on the left side and pass obliquely tailing off to the right. 4. Self­inflicted sharp injuries may be often associated with severe mental illness of a victim. 5. Stab wounds are most common means of homicide. Homicidal stab penetrate the closing, localize on inaccessible parts of the body (back), sometimes on the head, wounds of active and passive defense of the victim can be find on the hands or wrists. 6. Fatal accident stab wounds are caused by falling through windows or glass doors, the circumstances play a great rule.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Hanging, strangling and suffocation There are several rules for differentiation murder, suicide and accident in "asphyxial" deaths: 1. Hanging is almost always suicidal, more common in men but is not unusual in women. Homicidal hanging is very rare (victim must be incapable to defend himself, drunk or drugged). The ligature mark in that cases is obliquely rising across the neck to the place where knot is situated. FIn a case of suicide with subsequental hanging there are no vital reactions in the zone of strangulation! 2. Self­strangulation is virtually impossible with the hands (self­throttling), but is not uncommon by ligature and inserted simple device such as bottle, stick or cooking­spoon. The accidental strangulation is happened in the cases of cloth dragging into pulling or rotating mechanisms.

Fig. 55. Self­strangulation by towel ligature and inserted bottle.

3. The strangulation by ligature (strangling) is commonly murder, but by hands (throttling) is always murder. In ligature strangulation the mark on the neck is generally horizontal (perpendicular to the long axis of the body). In throttling bruises and abrasions caused by fingers and nails are evident on the neck. 4. The accidental hanging may be a result of "masochistic" or "sexual asphyxias" in men which are indulging in sexual fantasies produced by temporary cerebral ischaemia. See also: sadism and masochism in the glossary. 5. Choking on food, dentures or other foreign bodies is almost always accidental. 6. Homicidal suffocation by soft fabrics, pillows, cushions and plastic sheets almost never leaves any signs, only if sufficient pressure was exerted one can see abrasions and bruises on the face.

Drowning 1. Where clothing has been taken off and left on the river bank or sea­shore, hat and spectacles are also taken off, suicide may be presumed. 2. A full examination is necessary to exclude natural cause of death. 3. Injuries sustained before entering the water may point to homicide.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 4. The finding of tied hands and legs as well as a load (bricks, stones, heavy metal things) connected to the body generally indicates murder, but there are exceptions: some self­murders may try to prevent themselves from swimming by this means. F It must be demonstrated that the bonds on the limbs were capable of being tied by the victim itself.

Poisoning The poisoning is the common manner of women's suicide. Circumstances are important, such as: Ø suicide notes Ø obtaining of drugs or toxic substances shortly before the death Ø preceding psychical disturbances, emotional stress, living problems. 1. Where a medical substance has been used, the amount remaining in the container must be checked with the normal dosage and the date of supply by the pharmacist (sometimes a death from medicinal overdose is not deliberate). 2. Chronic poisoning by arsenic, mercury and other toxic substances unless due to some unrecognized contamination is more likely to be homicidal. 3. The poisonings by mushrooms, organophosphoric compounds, methanol and ethylenglycol almost always are accidental. F The proper toxicological analysis (with taking of appropriate samples) should be done!

Mass disasters and the doctor All disasters may be classified into two groups: 1. Natural disasters (earthquake, hurricane, flood, drought) 2. Disasters caused by people's activity (aircrush, mass intoxications, explosions, wars)

The doctor must observe following rules for to be prepared to act in cases of mass disasters: w To compose pre­existing plan of activities w The first duties of a doctor in mass disaster are: ­ treatment of casualties ­ saving of living persons ­ secure of place of disaster. w Solution of tasks for forensic medicine: ­ labeling of the bodies, biological parts, objects ­ photodocumentation and schemes in situ ­ packing and transportation of the victims ­ establishment of temporary mortuary (truck regrigerators, skating rings, warehouse, garages) ­ external examination and autopsy ­ determination of cause of death ­ identification ­ reconstruction and investigation of causes. Medico­legal investigation involves multidisciplinary teams, that are of two types: Ø premortal team Ø postmortal team.

1. What are the differences between murder and suicide in shooting cases? 2. What is the difference between strangulation mark in case of hanging and strangling? 3. What are duties of a doctor in mass disasters? Practical task: Describe a strangulation mark in the autopsy room and conclude whether it was homicide or suicide.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 13. TRANSPORTATION INJURIES

A wide group of injuries is in association with any form of transport. The most common are: road, rail and air traffic injuries.

Fig. 56. The main parts of a car (frontal­side view).

Fig. 57. The main parts of a car (rear­side view).

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Road traffic injuries. Classified by dependence on people and vehicle density as well as traffic patterns into 4 types: Ü Pedestrian injuries. Ü Car occupant injuries. Ü Motor cycle injuries. Ü Pedal­cycle injuries.

Pedestrians. Pedestrians may be struck or runned over by a: Ø motor car (details of a car see on fig. 56, 57). Ø van Ø goods vehicle Ø truck Ø bus Ø coach Ø 2­wheeled motor vehicle (i.e. motor cycle) Ø goods vehicle Ø pedal cycle The proportion of fatal injuries among all road accident victims depends on road traffic regulations and discipline. Pedestrians accounted for about 20 ñ 30 % of road fatalities (the countries of the European Union and the US under 20 %, the Slovak and Czech Republic and Hungary almost 30 %). Another relations: ­ the pedestrian fatalities per 100 000 population (The Netherlands are the best with 1.3, Hungary 6.7) ­ relation to the total number of vehicles registered. The most common age group are ­ children under 15 years, ­ aged over 70 years. Most injuries derive from accidents in which one vehicle is in collision with one pedestrian and most collisions involved a motor car. The mechanism and extent of injury will vary according to w the nature of the vehicle (the shape of collided parts), w its speed and direction of motion, w the location of first contact of pedestrian on vehicle, w the weight and size of the victim and his/her position (standing, walking, running, bending down etc.). Kinds of collision: A ñ contact below centre of gravity (the head is moving towards the vehicle) B ñ contact at centre of gravity C ñ contact on the whole height of the body by a high­fronted vehicle (translational movement only) D ñ contact above centre of gravity (the head is moving away from the vehicle) Location of the first contact of pedestrian on vehicle: Ø front of the car (84 %) Ø front nearside wing Ø offside Ø rear Position of the vehicle to the pedestrian: Ø fronto­lateral position (most common ñ over 80 % of all collisions) Ø fronto­frontal position Ø fronto­dorsal position PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ø contact with the offside (hit and fall, seize and tow, pull under the vehicle) etc. F Note: The human body can be divided into 3 mechanical elements by the possibility of flexion of knees and hips but in one level only!

1. Stroke (hit). The mechanism of injury can be classified into Ø primary impact (stroke by the bumper to the leg or pelvis) Ø secondary impact (the head, shoulders and chest is thrown against the bonnet, windscreen or windscreen surround) Ø tertiary impact (the person falls off the front of the car and finelly the road surface or at high speed ñ 60­ 100 km/h ­ he may be projected over the top of the car coming to rest on the roadway behind) Ø further impact (throw against a passing vehicle or solid object) Special injury (caused by a falling tree, pillar and transported objects or by the trailer) 1.1. Primary injury (impact of the vehicle) in the case of fronto­lateral position: ­ surface imprint injuries (abrasions, bruises or lacerations) ­ leg injuries (fractures through the tibia and fibula, damage of the knee joints), see fig. 58 ­ pelvic injuries (fractures) ­ rib fractures, injuries of internal organs (lungs, liver, spleen) ­ head injuries (laceration of the scalp, skull fractures, brain contusions ñ Ñcoupì, Ñcontrecoupì and lacerations, diffuse axonal injury, intracranial haemorrhage) ­ neck injuries (disruption of the atlanto­occipital joint) ­ spine injuries (fractures, disruption of intervertebral discs) è cord damage è paraplegia F The front part of a car performs "scooping­up" effect, especially in adults. Children have the center of gravity lower! 1.2. Secondary injury (striking the road surface): ­ broad grazed abrasions on one side of the trunk and limbs often contaminated by grit F How fast was the car going? The examination of the injuries cannot give an estimate of speed. Such opinions are left to the police traffic investigators.

2. Running over. A wheel (under­carriage) passes over the head, chest, abdomen or pelvis. The main injuries are: Ø ruptures of internal organs (see fig. 61) Ø "flaying injury" (large areas of skin and subcutaneous tissue are split on leg, arm or scalp mostly due to rotation of the motor wheel against the body lain on the ground producing a pocket containing blood, limited by muscle fascia; in French ­ "dÈcollement"), see fig. 59. Ø tyre marks (imprint abrasions or bruises).

Fig. 58. The typical "bumper­fracture" of shanks in Fig. 59. Mechanism of flaying injury. Note the a pedestrian. Note the level of impact (arrows). splitting of skin and subcutaneous tissue.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Car occupants Frontal accidents: the car strikes with another vehicle or with a stationary object. The mechanisms of injuries are: Ø deceleration (during fractions of a second) of a car and anybody (anything) contained inside including driver and passengers Ø acceleration as a result of hit from behind Ø combined acceleration ñ deceleration in the most traffic accidents Ø side­impact Ø rolling over.

The front­seat occupants (unrestrained) usually suffered from such hits: w face and head ñ windscreen glass (ejection out the vehicle), frames and side­pillars w chest ñ fascia (instrument board), steering wheel. Aorta: tearing by momentum of the heart w knees ñ parcel shelf (glove compartment) w legs (driver) ñ brake and clutch pedals, w hips ñ fascia (transmitted stress) w head hyperflexion or hyperextension injury (if no head­restraints, headrests). This mechanism with a damage of cervical spine and cervical cord is known as "whiplash" injury.

þ Acceleration injury ñ type of injury in transportation accidents when the vehicle is hit from behind and vehicle occupants are thrown backwards striking the vehicle parts behind them, the great over­extension of cervical spine commonly appears; also a type of injury of pedestrian hit with the fast moving car.

þ Deceleration injuryñ type of injury in transportation accidents when the vehicle strikes another moving or stationary object and vehicle occupants are thrown forwards striking the vehicle parts in front of them, the great over­flexion of cervical and thoracic spine commonly appears.

The rear­seat passengers may be thrown against the backs of the front seats or against the front­seat occupants and far against the windscreen or out through the burst­open doors.

Motor cycle injuries. The most common injuries are on the head (in spite of crash­helmit!), on the back and spinal column, on the chest and on the legs.

Pedal­cycle injuries. Caused by: w impact by cars and trucks (primary impact), w falling from a relatively high position (secondary impact). The most common is head and chest damage.

Medico­legal examination in road traffic accidents: Ø body (all injuries recorded, measured ñ distances from the heel!) Ø clothing (tears, soiling by oil, grease or road dirt) Ø broken glass, paint flakes, metal, rust, foreign material (preservation for the police!) Ø tyre marks Ø blood (alcohol, drugs, identification). F A particular attention during examination and effective activity in the case of a "hit­and­run" car is nece ssary!

Railway injuries. Can to be obtain as a result of: w mass disasters: derailment of a train, collapse of a railway bridge, collision of trains

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com w accidents (railway­workers, passengers, pedestrians) w suicides (putting the head or a trunk across a rail).

Significant features of railway injuries: Ø very severe mutilation (pieces of body, see fig. 60) Ø soiling by axle grease and dirt from wheels and truck (grayish­black colour). Possible mechanisms of railway injuries: ­ passengers fall from a train at speed è repeated impacts and rolling è multiple injuries ­ squeezing between the buffers (railway­workers) è thorax completely crushed ­ strike of a pedestrian (pedestrians) by a train ­ electric shock (electrified lines).

Fig. 60. Decapitation in a railway injury. Fig. 61. Multiple lacerations of the spleen in a road traffic accident (arrows).

1. What is the classification of transportation injuries? 2. What are the characteristics of the primary and secondary traffic injuries? 3. What are the objects of medico­legal examination in transportation injuries? Practical task: Describe injuries in fatal transportation accident and measure the height of injuries over the heel of deceased.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 14. ASPHYXIA AND PRESSURE ON THE NECK AND CHEST

True asphyxia is to be always obstructive (a somewhat barrier prevents access of air to the lungs). Traditional morphological signs of asphyxia: w congestion of the face (obstructed venous return) w oedema of the face (raised venous pressure) w cyanosis (head and neck / chest pressure ñ syndrome of blue mask) w petechial haemorrhages (skin ñ face, lips, behind the ears; eyes ñ conjunctivae). F Petechiae on the pleura, epicardium and thymus ñ no evidence of external respiratory obstruction! Functional signs of asphyxia: w increased efforts to breathe w deep laboured respirations, cyanosis and congestion, petechiae w loss of consciousness, convulsions, evacuation of bladder, vomiting w cessation of respiration, dilatation of pupils, cardiac arrest. Suffocation. This condition has two possibilities: 1. Absence or reduction in the oxygen content of the inspired air (accumulation of carbon dioxide ­ wells, farm silos, wine­cellars etc.) 2. Mechanical obstruction of external respiratory orifices ("smothering" by plastic bag, pillow, ha nd ñ impossible to diagnose retrospectively at autopsy without bruises and abrasions). F Other evidence of history and toxicology has to be taken into account!

Choking is the result of internal obstruction of the air passages. There are two possibilities: 1. An object (substance) is impacted in the pharynx or larynx. This leads to: Ø severe respiratory distress, Ø vaso­vagal cardiac arrest (silent death). Inhaled objects: dentures, teeth, toys, coins, food (bolus, the special term: mors e bolo), vomiting masses. 2. Gagging ­ a soft object is pushed into the mouth (the victim is silenced). F Note over­usage of the term "aspiration of vomit" as the sole cause of death!

Pressure on the neck There are several types of the fatal neck pressure: 1. Manual strangulation − "throttling". This is a mode of homicide by a man against a woman (sometimes a sexual attack) or by a man against a child (rarely women against a child or man against a man). Performance: one hand or both hands, from front or from back. The grip may be changed! External signs in throttling: Ø abrasion Ø bruises (disc­shaped areas from finger pressure) Ø linear scratches from fingernails Ø signs of venous obstruction ( blueness, swelling and congestion of the face) Ø showers of petechiae Ø bleeding from nose and ears. F All these signs are present after prolonged pressure on the neck. Absence of several signs may be evaluated as a case of rapid death (squeezing of the carotid sinuses ñ continuous pressure about 15 ñ 30 seconds is enough). F 15 ñ 30 seconds is a minimal determination with which a strangler held on to his victim; this time period has also a legal significance! PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Internal signs in throttling Ø congestion Ø petechiae on the epiglottis and pleura Ø neck muscle haemorrhage Ø fracture of the upper horns of the thyroid cartilage Ø fracture of the hyoid bone (greater horns ñ not in young people) 2. Ligature strangulation (strangling). This is a type of mechanical asphyxia when a constricting band is tightened around the neck. Commonly this manner of strangulation is homicidal, rarely suicidal or caused by a machine. Types of ligature: w rope w cable w wire w scarves w string w dog's lead w stockings w pieces of cloth. The ligature mark is a vital piece of evidence. It may reproduce the pattern of the strangulation object. It goes around the whole circumference of the neck almost transversally (without a rising peak to a suspension point!) Petechial haemorrhages at the margin of ligature mark are the signs of a vital reaction. The victim tried to pull off the ligature, thus scratches and bruises on the neck may be found. 3. Hanging. This is a kind of strangulation where the strangulative pressure is produced by the weight of the body itself. Commonly it it suicide (see fig. 62). Positions of body hanging: w fully erect posture (free­swinging position) w sitting position w kneeling position w half­lying position. Possible suspension points in hanging: ­ tree branch ­ cross­beam ­ door­handle ­ water­pipe ­ bed­knob ­ chandelier hook.

Fig. 62. Suicidal hanging with a skipping­rope. The Fig. 63. Transverse ruptures of the carotid vascular soft fabric has been inserted under the rope. wall in hanging (arrows).

The ligature mark in hanging goes around the neck obliquely rising from front to back. It may be classified by two criteria: Ø closed / unclosed ligature mark (in relation to whole neck circumference) PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ø typical / atypical ligature mark (in relation to knot position: typically the knot is on the back side of the neck). F It is necessary to examine the intimal layer of common carotid arteries in hanging. Peculiar transverse ruptures (rupturae Amussati) of the vascular wall may be revealed (see fig. 53). 4. Traumatic asphyxia. This is a fixation of the thorax by external pressure which prevents respiratory movements mainly in accidents and mass disasters (earthquake, war, terroristic actions). People being buried in (or under): collapsed trenches, bunkers of sand or grain, overturned vehicles, fallen walls, collapsed buildings. The classic signs of congestion, cyanosis and petechiae are seen in their most gross form. There are also injuries from the compressing agent.

5. Sexual asphyxia (masochistic practices). The victims are commonly men between puberty and middle­ age. Mode: using masks, pads, envelopment in plastic on the face, self­suspension and semi­strangulation to cause partial cerebral ischemia and erotic fantasies. Associated signs are: transvestism, rubber fetishism, pornography, bondage. Death must be regarded as an accident. See also: sadism and masochism in the glossary.

6. Reflex cardiac arrest (vagal inhibition). Situations which may cause reflex cardiac arrest (tense emotion and use of alcohol or drugs sensitises the victim!): w dilating the cervix during criminal abortion w cold water or food striking the glottis w trauma to the testes w sudden immersion in icy water w sudden pressure on the neck (very important!) w sudden terror.

The reflex pathway in sudden pressure of the neck:

Stimulation of the carotid sinus and adjacent baroceptors

impulses ascend in the afferent fibres of the glosso-pharyngeal nerves

linking to the nucleus of the vagal nerve in the brainstem

parasympathetic impulses descend in the vagus nerve and its cardiac branches

fatal bradycardia

total cardiac arrest

1. What are the morphological and functional signs of asphyxia? 2. What is the difference between hanging and strangling? 3. What situation may cause the reflex cardiac arrest? Practical task: Describe the syndrome of "blue mask"in the autopsy room or on the videorecord.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 15. IMMERSION AND DROWNING

Bodies recovered from water: w died of natural causes before entering the water w died of natural causes in the water w died of hypothermia in the water w got fatal injuries before entering the water (murder victims, hitting a bridge, boat etc.) w got fatal injuries after entering the water (striking rocks, hit by boats, propellers; sharks and crocodiles) w died from submersion ("shock" due to cold water ñ reflex cardiac arrest) w died from true drowning (aspiration of water, without submersion, too). Signs of immersion (no drowning, just being in water!): Ø macerated skin (white, wrinkled, "washerwoman's fingers" are evident, see fig. 66) Ø more advanced putrefaction (because of a longer time of discovery) ñ the body floats Ø signs of devastation by animal predators Ø post­mortem injuries (underwater). Mechanism of drowning (more correctly "death in the water") is of two types: w vagal inhibitory reflex (drunken persons, suicides).ñ "dry drowning" w true drowning (hypoxia, electrolyte and fluid changes in dying organism) ñ "wet drowning". The modern medicine do not differentiate longer drowning in fresh­water from drowning in see­water because this is unimportant from the survival or clinical point of view. The important difference is between natural waters and adjusted, mainly chlorinated waters (swimming pools). The chlor is aggressive against the pulmonary surfactant and so it can influence the chance of successful reanimation of the victim. However, fresh­water has the ability to denature surfactant, too.

Fig. 64. Plume of froth in true drowning. Fig. 65. Sand in the trachea and bronchi in drowning (arrow). Post­mortem findings: Ø plume of froth (in and around mouth, nostrils), composed of water, plasma, protein, mucus, surfactant (fig. 64). The froth may be tinged with blood from ruptures of small pulmonar vessels. Also sand in the throat, esophagus and air passages can be revealed (fig. 65) Ø over­distention of lungs (emphysema aquosum), see fig. 67 Ø blurred haemorrhages of pleura (Paltauf's spots). Laboratory tests: w chemical analysis of the blood separately from the right and left side of the heart. The diluted blood in the left atrium and ventricle contains lesser concentration of blood compounds (urea, creatinin ev. alcohol) as on the right side PDF created with FinePrint pdfFactory trial version http://www.fineprint.com w diatom test (acid digestion). For true drowning evidence it is necessary to find diatoms not only in the lungs, but in the liver, kidneys, brain and bone marrow (see fig. 68).

Fig. 66. Macerated skin (the "washerwoman's Fig. 67. Histological pattern of emphysema aquosum fingers"). caused by the fresh water. in a case of true drowning. Hematoxylin and eosin staining. Magnification 300×.

Fig. 68. Scanning micrograph of diatoms in the lungs of immersed body. Magnification 1500 × [8].

1. What are the possible causes of death of persons found in the water. 2. What are the signs of immersion? 3. What laboratory tests prove drowning? Practical task: Issue a transmittal letter after taking samples of lungs, liver, kidneys and bone marrow for investigation of diatoms in drowning.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 16. INJURY DUE TO HEAT, COLD AND ELECTRICITY.

Heat, cold, electricity, low and high pressure, ionizing radiation are physical agents, that may cause of severe injury and even death.

Injury due to heat Temperature over + 50 ∞C can cause damage to living tissue for the short time. If the heat is dry (e.g. fire or hot thing), the damage is called a burn, if the heat is moist (e.g. steam or water) ñ the damage is called a scald. The parameters of important in burning or scalding: w temperature w time w contact surface area. Grading of thermic injuries: I degree: erythema and blistering (vesiculation). II degree: destruction of the whole thickness of the dermis. III degree: destruction of dermis and subepidermal tissues (muscle, bone) and in the case of dry heat ­ carbonisation (charring), see fig. 70

þ Scalding is a thermic injury caused by hot steam, water or other liquid, where no charring appears (see fig. 69). The common victims are: w children (pull kettles, cooking pots) w drunk and old persons in the bathroom w persons in the washing­room and kitchen w workers in industry (steam turbines, boilers). Body areas covered by clothing may be damaged stronger, because fabric holds the hot liquid. Burning also are graded by its severity and extent. The damaged body area is calculated by "rule of nine":

Head and neck 9 % of body surface

Upper extremity 9 % of body surface

Lower extremity 18 (2 x 9) % of body surface

Chest and abdomen 18 (2 x 9) % of body surface

Back and buttocks 18 (2 x 9) % of body surface

Genitalia and perineum only 1 % of body surface

The average palm of a doctor occupies cca 1 % of body surface, the number of "palms" on surface area is equal to the percentage of body damaged area. Poor prognosis is expected in adults when over 50 % body area is damaged, children and old people may die with 20 % burns of body area. F Inhalation of smoke, noxious gases and hot air is very dangerous because of damaging of respiratory pa ssages mucosa. In such a case the prognosis is worse.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Differentiation of burns: w ante­mortem (red margin as a sign of vital reaction) w post­mortem (blisters with aquaeus fluid content, no protein). F Note the possibility of a burned victim after homicide (destruction of evidence of ante­mortem injury!)

Examination of burned bodies recovered from fire Ü Cherry­pink skin due to carboxyhaemoglobin. Ü Black soot particles in the: ­ nostrils ­ mouth ­ larynx ­ trachea ­ bronchi proves that the victim breathed after the fire began. Ü Signs of other vital reactions (thromboses, bleedings etc.) Ü Burned body must undergo x­ray examination (to look for bullets, lead­shot, metallic foreign bodies, fractures etc.)

Causes of death: 1. Destructive effects of heat. 2. Asphyxia. 3. Shock. 4. Burning of air passages (inhalation injury). 5. CO and other noxious gases toxicity. 6. In surviving: renal failure, toxaemia or infection.

Fig. 69. Scalds on the trunk and limbs. Note the Fig. 70. Burns with the charring of the lower intact blister (arrow). abdominal region and splitting of the skin (arrow).

Injuries on the burned bodies w strangulation w shooting wounds w stab wounds etc. w post­mortem injuries: Ø splitting of the skin Ø "heat haematoma" in the skull PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ø heat­cracking damage of the skull. F The true epidural haematoma as a sequence of a vital injury will not contain carboxyhaemoglobin (COHb)!

Cold injury The main reason of cold injuries is prolonged hypothermia, mainly in the winter time. Hypothermia is of two kinds: general and local. Its incidence and prevalence: w mountaineers, hill­walkers w swimmers w victims of marine disasters w drunken people w old people and children are vulnerable w "hide­and­die syndrome" w persons with thyroid deficiency (thermoregulatory disturbances) w persons after using of phenothiazine drugs. The signs of hypothermia: 1. Clinical effects of hypothermia is observed below 35 ∞C body temperature. Cessation of shivering below 32 ∞C body temperature and the death occurs at 28 ∞C (even with a treatment). 2. "Frost­bite" ñ infarction of the periferal digits (necrosis beyond a line of inflammatory demarcation), necroses on chin, external ears and nose skin. 3. Bright pink (brown­pink) areas over joints (rarely blisters). The cause is a little uptake of oxygen from oxyhaemoglobin and haemolysis. 4. Stomach: numerous brown­black chain­like acute ulcers (Vishnevsky's spots) due to stress, cessation of vegetative nervous centers in solar nervous plexus (plexus coeliacus). 5. Sludging of blood è micro­infarcts (brain, haemorrhagic pancreatitis). F The victims often take of some or all of their clothing (illusory feeling warm before the death)!

Electrical injury Electric current acts mechanically, thermally and chemically simultaneously. This type of injuries may be classified into two types: 1. Industrial electrical injury. 2. Domestic electrical injury. The essential factors are: Ø voltage (V) Ø current (mA) Ø resistance (Ohms) Ø time of contact.

Fig. 71. The "electrical sign" on the finger (arrow) Fig. 72. The fern­like pattern of electrical burn in and metallization of the fingernail. lightning injury (arrow). PDF created with FinePrint pdfFactory trial version http://www.fineprint.com While voltage in definite electrical network is constant, the resistance and current may change in accordance with Ohm's Law. The time of contact define the amount of Joul's heat to cause thermic injury. The points of contact in electrical injury are: w the entry point (contact with current­carrier conductor, commonly hand touches an electrical appliance or a live conductor), see fig. 71 w the exit point (contact with ground (earth, zero­conductor) or other surface via other hand or feet). The direction of electrical current through the body is of great importance. The most dangerous area: crossing the thorax (cardiac arrest or respiratory paralysis). F Tissue resistance falls in wet conditions. Blood and nerves have minimal resistance, but epidermis, bones and tendons are of high resistance. The average resistance of the dry human body in average conditions ñ 5000...8000 Ohms.

Mechanisms of electrical injuries 1. The "hold­on" effect: muscle spasm, if the current reaches about 30 mA è cardiac arrhythmia. The current of 50 mA or more for a few seconds causes fatal ventricular fibrillation. 2. In rare cases ­ respiratory paralysis occurs (because of spasm of diaphragm and intercostal muscles). 3. Primary brain­stem paralysis (the current enters the head by workers on trolley or electric railway wires). 4. The electrical lesion in high voltages ­ extensive and severe burns, the patterns of "crocodile skin" appear, electrical lesion acts as a thermal lesion. 5. The "electrical signs" on contact points are naturally burns, there can be: Ø a blister on the skin surface Ø a raised rim with a concave center Ø an areola of pallor Ø "spark burn": a central brown keratin nodule. Ø metallization of electrical sign is a common thing due to electrical arch fusing of a conductor during the contact. The skin is avaliable for investigation under scanning electron microscope and for identification of a definite conductor.

Death from lightning Regards as an accident during strike of lightning from cloud to earth. The voltage in the lightning channel is 2 ñ 5 millions of volts, the duration of strike is a few milliseconds. The victim's position in lightning: directly under the strike or closely adjacent to it. Lesions are of several type: Ø electrical lesions Ø burns Ø damage by compression wave (hot air). Findings during the examination: ­ stripping of clothing ­ burns ­ fractures and gross lacerations ­ defects of tympanic membrane and middle ear bones ­ magnetisation and fusion of metallic objects belonged to victim (jewelleres, coins, watch) ­ "leaf­, fern­ or branch­like patterns" on the skin, which may be disappeared in a certain time, see fig. 72.

1. What is the "rule of nine"? 2. What are the signs of hypothermia? 3. What findings can be present during the examination in the case of lighting injury? Practical task: Using the "rule of nine", measure the damaged area of skin in burning (scalding), note the grading of thermal injuries in the autopsy room.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 17. SUDDEN AND UNEXPECTED DEATH FROM NATURAL CASES

þ Sudden death is a rapid natural death, in which the cause of death is unknown (cannot be discovered without autopsy). Sudden death can be of three types: Ø instantaneous (a cardiovascular death with ventricular arrhythmia and cardiac arrest. On examination impact abrasions of the face of deceased are often revealed as a result of falling down) Ø not instantaneous (signs are: chest pain, difficulty of breathing, weakness, vomiting, collaps, unconsciousness) Ø founding dead individual. In fact, these individuals have a serious disease. þ Unexpected death is a death where a known disease was successfully treated or the patient is in recovery but this disease unexpectedly causes death. If the autopsy showed that the cause of death is another unknown disease, there is a sudden death. By some opinion a sudden and unexpected death is the same. Sudden death occurs in each age but it is most common in elderly people. The male : female ratio is about 7 : 3, by females is the average age higher than by males. Psychical or physical stress should be co nsidered as an initiating factor. The diagnosis of sudden death can be temporary because of the autopsy di scovers an unnatural death (e.g. fatal poisoning). Where sudden or unexpected deaths are concerned, they are usually reportable to the authorities for medico­legal investigation, in spite of that fact the majority of these deaths are due to natural causes. Studies have shown that there is up to 60 % variation between the clinician's presumptive diagnosis of the cause of death and the lesions displayed at autopsy. That is why determining a right medico­legal differential diagnosis of the cause of death will assist the legal authorities and help medical statistics. The causes of sudden and unexpected death are divided into several groups depending on the damaged system of the body: 1. Lesion of cardiovascular system. 2. Lesion of central nervous system. 3. Lesion of respiratory system. 4. Lesion of gastrointestinal system. 5. Gynaecological conditions.

Lesion of cardiovascular system w Heart and coronary arteries diseases: Ø acute coronary insufficiency ñ spasm, complication of atheroma (rupture, subintimal haematoma, thrombosis) Ø myocardial infarction (possible rupture è haemopericardium), see fig. 73 Ø myocardial fibrosis è cardiac aneurysm Ø papillary muscle rupture Ø hypertensive heart disease Ø primary myocardial disease: ­ myocarditis ­ cardiomyopathies ñ a diverse group of diseases of both known and unknown etiology which are characterized by myocardial disfunction ­ degenerative conditions. w Diseases of the arteries: Ø failure of valves (e.g. aortic stenosis) Ø ruptured aneurysm: ­ of the aorta (aneurysm may be atheromatous or dissecting) ­ of intracranial arteries (berry aneurysm) ñ a relatively common cause of sudden collapse and rapid death in middle­aged people leading to fatal subarachnoidal haemorrhage (fig. 74). The berry aneurysm is usually a weak spot in the vessel wall of basal, middle or anterior PDF created with FinePrint pdfFactory trial version http://www.fineprint.com brain artery (aa. basilaris, cerebri media, cerebri anterior) commonly situated at places of branching. The role of direct trauma in rupturing an aneurysm is in dispute. Ø cerebral haemorrhage ­ is a sudden bleeding into brain substance or ventricles commonly associated with significant hypertension. The most vulnerable artery is the thalamo­striate artery (a.thalamostriata [Charcot artery]). Ø cerebral thrombosis, embolism and infarction Ø mesenteric thrombosis and embolism with infarction of the gut Ø pulmonary thrombo­embolism ­ an important cause of sudden death, it is common and mostly under­diagnosed. 80 % of pulmonary thrombo­embolism have a predisposing cause such as: ­ trauma ­ surgical operation ­ bed rest and forced immobility. Lesion of central nervous system (see also diseases of the arteries) The most common cause of sudden death due to lesion of central nervous system is epilepsy. Predominantly the cause of the death is fatal cardiac arrhythmia during epileptic attack. Other causes of death in epilepsia are: drowning in epileptic attack (in bath­tub, river, brook, pool), head injuries in epileptic attack, mechanical asphyxia by own tongue (rarely). Lesion of respiratory system Ø pulmonary embolism (see also diseases of the arteries) Ø pulmonary infection Ø unrecognized pulmonary malignant tumor Ø bronchial asthma. Lesion of gastrointestinal system Ø bleeding from a peptic ulcer Ø perforation of a peptic ulcer Ø intestinal gangrene due to strangulated hernia or torsion. Gynecological conditions Ø abortion (death from vagal shock, haemorrhage and infection) Ø ruptured ectopic (tubal) gestation with intraperitoneal bleeding.

Fig. 73. Myocardial infarction of the interventricular Fig. 74. Ruptured berry aneurysm of the middle septum, sectioned (arrows). brain artery (arrow).

1. What is the difference between sudden and unexpected death? 2. What lesions of cardiovascular system may lead to sudden death? 3. What are risky factors of pulmonary thrombo­embolism? Practical task: Describe visible signs of atherosclerosis on the dissected heart in a case of sudden death.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 18. MEDICO­LEGAL ASPECTS OF PREGNANCY AND ABORTION

There are great variations in interpreting of medico­legal aspects of pregnancy and abortion due to geographical, social and religious differences. þ Pregnancy is the state which occurs in the female when an ovum, discharged from ovary into the genital tract, is fertilized by a spermatozoon in the male semen introduced. The normal duration of pregnancy is about 40 weeks or 280 days (10 lunar months). It is legally important to show if a woman is, has been or could be pregnant in following reasons: w complicated relations between man and woman ­ claim of divorce ("adulter"), breach of promise to marry, illegal taking away a woman w alleged criminal abortion w cases of infanticide or concealment of birth w the civil matter about the estate of dead husband (pregnancy of the wife may affect the disposition of property) w pregnant woman may be excused attendance as a witness in a court w pregnancy of a convicted woman may postpone or cancel the execution of capital punishment. Diagnosis of pregnancy is based on subjective and objective signs, which are chronologically divided into the first, second and third trimester. The most common subjective signs are: Ø cessation of menstrual flow Ø quickening (subjective sensations of fetal movements) Ø nausea (and vomiting) Ø emotional disturbances F A woman may attempt to simulate menstruation by sprinkling blood from some other source on her clothing or pads, so the full examination of those blood stains is necessary! The most common objective signs are: Ø positive laboratory rapid "kit tests" Ø enlargement of uterus (see fig. 75) and its ballotment inside the abdominal cavity Ø ultrasound and radiological evidence of the fetus Ø palpation of the fetus at about 16 weeks of gestation Ø fetal heart sounds at 24 weeks of gestation Ø enlargement of breasts, areolae and nipples.

Artificial insemination and in­vitro fertilization Many medico­legal problems have arisen because of the development of methods of artificial initiating of pregnancy. þ Artificial insemination is the production of pregnancy in a woman by introducing seminal fluid directly into the cervix of uterus by means of cannula. There are two types of artificial insemination: 1. Artificial insemination by husband (AIH) 2. Artificial insemination by donor (AID). While AIH has no legal or ethical problems, AID should be obtained from a known donor who must be "unknown" the same time. If AIH has been unsuccessful, the full written consent of AID from the man and woman (if they are married) or from the woman (if without a partner). The donor must not be relative, he should be over 18 years old and preferably have his own children. Tests for absence of chronic diseases and familial abnormalities should be carried out before donation. Some religions (Roman Catholic Church) totally outlaw AID. þ In vitro fertilization is a method which allows to fertilize in vitro ova removed laparoscopically and to return them subsequentally to uterus. A multiple ovulation caused by medicines has performed before the fertilization. There are following possibilities of such method: PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ø the woman's own ova to be fertilized by her husband's sperm and re­introduced into her uterus Ø the woman's own ova to be fertilized by a donor sperm and re­introduced into her own uterus Ø the woman's own ova to be fertilized by her husband'sperm and returned to another ("surrogate") woman's uterus Ø the woman's own ova to be fertilized by donor sperm and returned to a surrogate woman's uterus Ø an infertile woman may have another woman's ova implanted to her, fertilized either by her husband or by a male donor. The problem of "sparing embryos" remaining after completing the procedure is also a great medical, ethical and social problem.

þ Abortion is the premature expulsion of the fetus from the uterus at any time before its term of gestation is complete. Medically and pathologically the term "abortion" is applied to the termination of pregnancy during the first three months (fig. 76), while an abortion occuring during the middle period of pregnancy is designated as "miscarriage", and after 7th month is called a premature birth. Abortions may be divided into five categories: 1. Spontaneous abortions 2. Accidental abortions 3. Legal termination of pregnancy. 4. Self­induced criminal abortions. 5. Criminal abortions induced by another person.

Fig. 75. The uterus in the 14th Fig. 76. The human fetus in the 12th week of week of gravidity. Note corpus gestation after artificial termination of pregnancy. luteum graviditatis, arrow.

Legal termination of pregnancy It's often called "therapeutic abortion", but this term is not exact. Some states have "abortion on demand", where any woman has the right to end her pregnancy, so this termination can hardly be called "therapeutic". The legal termination of pregnancy must be performed only in a hospital and only by a registered doctor. There are four conditions as the reason for the termination of pregnancy: 1. That the demand of a woman is obtained (up to 3 months of gestation). If the woman has under 16 years old, the agreement of her parents is desirable. In such case this kind of medical service is not free of charge. 2. That the continuance of pregnancy would endanger the health (or even life) of the woman. 3. That the continuance of pregnancy would involve danger to the physical and mental health of any existing children of the woman's family.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 4. That there is a substantial risk that if the child were born, it would suffer from physical or mental abnormalities.

Criminal abortion þ The criminal abortion is a deliberate ending of a pregnancy by woman herself or by another person unlawfully, outside any legal provisions adopted by the State Law. w Self­induced criminal abortion occurs when the woman attempts to end her pregnancy by following means: Ø mechanical means: ­ direct violence on the lower part of abdomen ­ bicycle and horse­riding ­ hot baths ­ the insertion of long instruments (syringes, pipettes, cannulas, sticks, bicycle spokes, needles etc.) into the cervix of uterus Ø chemical means: ­ drugs and toxins (ergot, lead, quinine) ­ hormones (pituitrin, prostaglandins, other ecbolics) ­ purgatives (jalap, croton oil, colocynth) w criminal abortion induced by another person may be performed by doctor­gynaecologist, doctor­ non­gynaecologist, medical worker or by layman. The method commonly involves both mechanical (curettage, suction, drainage) and chemical means. F The criminal abortion without fatal consequences made by a doctor is also called "illegal abortion".

Concerning consequences of criminal abortion two groups of cases are regarded: non­fatal and fatal cases. w non­fatal cases of criminal abortion. These cases are classified in law as felonies automatically with the revoking of license to the doctor being involved the case. The evidence necessary to establish the crime of non­fatal abortion. The woman is sent to as a patient to a hospital for examination and curation. w fatal cases of criminal abortion. The most common causes of death are: Ø haemorrhage from local genital trauma (mostly perforations of vagina or uterus) during clumsy instrumental interference Ø sepsis due to unsterile instruments and retained products of conception Ø shock associated with the haemorrage or with the dilatation of cervix in unanaestheti zed woman Ø air embolism (the air reaches the venous circulation through placental bed during instrumental interference) Ø later complications: womb gas gangrene, pulmonary thrombo­embolism (due to pelvic vein thrombosis), intravascular coagulopathy, renal failure.

The doctor's duty on scene of criminal abortions Ø If the act was performed by woman itself the doctor must give her all necessary medical care. Ø To notify coroner (medical examiner) or police about the case. Ø Pieces of tissue found at the scene of an abortion must be collected and sent to the laboratory for histologic and serologic examination. Ø In hospital, if a laparotomy or other operation is performed, careful records should be made, all injuries of genitals and other abdominal viscera must be described.

1. What are definitions of pregnancy and abortion? 2. What is the criminal abortion? 3. What is doctor's duty on scene of criminal abortion?

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Practical task: Investigate the sperm microscopically and by acid phosphatase test. 19. DEATH AND INJURY IN INFANCY

The great majority of child murders occurs in the first two years of life. In the most cases the murder of a child is its parent. There are also natural cases of still­birth.

Still­birth þ The still­born child is a child of more than 28 weeks' gestational age which after being completely expelled from the mother, did not breathe or show any signs of life (see fig. 77, 78). The circumstances of still­birth are that the child may die before onset of labour, after onset of labour or during the process of birth itself. The still­born child is: ­ discoloured (pinkish­brown or red) ­ with dessquamation of the skin ­ with soft and slimy tissues ­ with over­riding skull plates ­ with partial collapse of the head.

Fig. 77. The gravidal uterus in the term of 30 Fig. 78. The same case. Fetus in the uteral cavity died months. Mother died of eclampsy. Note the "shock of common asphyxia. kidney" (arrow).

Infanticide þ Infanticide is a form of homicide commonly defined as the deliberate killing of a child occuring in the first year of its life. þ Filicide is general term for killing of a child by its parent (both mother and father, see fig. 79, 80). þ Neonaticide is the deliberate killing of a new­born child within 24 hours of its birth by its mother. The killing must take place during a very limited period (not later than after the first feeding and swaddling of the infant). But if the fetus dies before actual birth, these cases are not included in the term of neonaticide, and of course, if the fetus died in utero and it undergoes maceration, that obviously is not neonaticide.

The medico­legal questions in that cases are: 1. Was the child fully matured? 2. Was the child born alive? 3. Did the child survive after birth? 4. The identity of the body. 5. What was the cause of death? 6. How long has the body been dead? PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 79. Throttled newborn infant. Infanticide. Fig. 80. A detail of previous figure. Scratches on the neck caused by fingernails of the mother.

In relation to legal medicine, neonaticide must be considered in different countries: ­ as a type of homicide ­ as a murder in peculiar circumstances (woman's disturbance by the effects of childbirth or lactation) ­ as a committed manslaughter. F Mostly the punishment for mother who killed her new­born infant is somewhat slighter than in the case of "usual" homicide.

Physical abuse of children (true child abuse) Legal medicine classifies these cases as "child or baby battering" and "non­accidental injury". The main characteristics of these cases are: w they are very common w there is a various threshold between legitimate parental punishment w they are mostly non­fatal: Ø 60 % recure Ø 10 % end in death Ø many cases end in permanent damage (neurological defects from brain injury) w the murder commonly is a single episode of deliberate killing w fatal child abuse is a culmination of repeated injury w manual violence in most cases is proved (the exceptions exist) w the incidence in any age, but mostly under two years of age w sexual abuse is usually observed in an older groups of children w statistically most risk in the "lower middle social classes": Ø no association with material deprivation! Ø often only one child in a family! w the most common physical lesions are on the skin and skeleton. "The skin and bones tell a story that the child is either too young or too frightened to tell" (a medical proverb).

The characteristics of injuries 1. Bruising ­ the cardinal sign (always suspicion in children younger than walking age and requires a satisfactory explanation):

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com w bruising around the large joints (uppper arms, forearms, wrists, ankles, knees as the signs of gripping by adult) w bruises on the face ("black eye"), ears, lips, neck, lateral thorax, abdomen, buttocks, thighs are suspicious if the doctor reveals: Ø finger­tip discoid marks of different ages (by colour changes) Ø slap marks Ø pinch marks Ø knuckle punch marks Ø instrument marks (belts, straps, canes, pieces of wood, electric flex etc.) 2. Skeletal lesions (the full skeletal survey to be required!): w fresh fractures (skull, limbs, ribs in one line) w evidence of previous damage (callus formation, subperiostal calcification of haematomata) 3. Eyes and mouth injuries: w eyes: vitreous haemorrhage, dislocated lens, detached retina (ophthalmoscopy!) w lips: bruised or abraded, lacerated by contact with the tooth edges (as a sequel of blows to the face) w mouth: torn frenulum inside the upper lip, tangential blow across the mouth, a feeding bottle rammed between lip and gum. 4. Head injuries (most frequent cause of death): w subdural haematoma. The mechanism is: Ø direct impact (see fig. 81) Ø vigorous violent shaking (heavy and unsupported head, "shaken baby syndrome") Ø skull fracture (haematoma under the scalp) as a result of: ­ throw against a hard surface (floor) ­ punch, heavy slap Ø cerebral oedema Ø diffuse axonal damage. 5. Visceral injuries: w gut crash w mesentery laceration w liver and spleen rupture w kidney decapsulation w urinary bladder rupture. 6. Other lesions: w burns, scalds on the skin; the instruments are: hot iron, hot water, burning cigarette (see fig. 82)

Fig. 81. A bruise with focal abrasions on the head of Fig. 82. The same case of a child abuse. Multiple a child caused by stick beat done by parent. scars of a buttock caused by burning cigarettes.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com w bites (the help of forensic odontologist is needed).

Child sexual abuse (CSA) The CSA is defined as the involvement of dependent, developmentally immature children and adolescents in sexual activities they do not truly comprehend, to which they are unable to give informed consent or which violate social taboos of family roles. The diagnosis and management of CSA is a multidisciplinary one!

Child abuse and neglect (CAN) The CAN is a major problem in paediatrics, social medicine and forensic pathology. It is often hard to prove even prolonged act of child neglect, and failure to thrive to clear this condition is observed: w in association with non­organic changes ñ in 70 % of cases (in a half of cases the neglect is suspected) w in association with organic changes ñ in 30 % of cases. Forms of abuse: Ø physical abuse ñ caused by parents Ø mental abuse ñ caused by guardians Ø sexual abuse ñ caused by custodians. Hospitalization for a minimum of one week gives us a possibility for presumption of neglect (emotional or nutritional deprivation) is necessary. In the child neglect some main conditions are refusal, such as: Ø necessary subsistence Ø education Ø medical or surgical care Ø other care (mental). Death may occur through complications: Ø sepsis Ø respiratory infection Ø acidosis Ø shock (dehydratation, hyperthermia, hypothermia). F The incidence of lethal form of Munchhausen's syndrome by proxy (repeated smothering of the child into unconsciousness). Tardieu described classic cases in Paris a century earlier.

Sudden Infant Death Syndrome (SIDS) Synonyms: cot death, crib death. Regarded as a case of small infant dying with no apparent cause. Autopsy fails to reveal an adequate cause of death. The critical age: from 2 weeks to 2 years old. Incidence: 1 in 500 live births, there is a slight preponderance of males. Incidence markedly greater in twin pairs, premature and low birth­weight infants, colder and wetter months (seasonal variations), lowest social classes (poor housing). The child is perfectly well or with only trivial symptoms being put in the sleeping place at night, to be found dead in the morning Autopsy findings: petechiae on the pleura, pericardium and thymus. Cause of SIDS is unknown (multi­factorial?) There are several theories: the most adoptable is the theory of prolonged sleep apnoea. Doctor's duty: support of the family by explanations. Prevention: cardio­pulmonal monitoring, revealing of risky groups and factors.

1. What are legal­medical characteristics of infanticide. 2. What are the forms of child abuse and neglection? 3. What are the risky factors and possible cause of SIDS? Practical task: Describe skin and skeletal injuries in the case of true child abuse.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 20. SEXUAL OFFENCES

The examination of alleged sexual offences, in both females and males, both victims and accused persons. both alive and dead persons is one of the most difficult tasks in forensic medicine. The criminal and social consequences of sexual offenses make the responsibilities of the doctor very heavy indeed. The classification of sexual offences: 1. Rape. 2. Indecent assault. 3. Indecent exposure. 4. Indecency with children. 5. Incest. 6. Bestiality. 7. Homosexual offences.

Rape Rape is the most common ant most serious sexual offence, still carrying the death penalty in some some parts of the world. þ Rape is defined as unlawful sexual intercourse by a man with a woman by compulsion through force, threats or fraud. The New York Penal Code, 2010, defines rape as an act of sexual intercourse of a man with a female not his wife, against her will or without her consent. "Unlawful" means without valid consent of a woman, either because the woman did not give any consent at all, or because her consent was invalid, because she was too young or her mental state was deficient. There is one general feature: a woman wouldn't be a wife to a man, because sexual intercourses were held to be part of a part of the marriage contract. "Sexual intercourse" means the penile insertion, if this is only just between the labia, but for a definition of charge of rape the some degree of penile introduction is necessary sign. An orgasm or ejaculation of semen is not relevant, only some degree of penetration. "Consent of a woman". In more countries the age of consent is 16 years. Below the age of consent sexual intercourse is always unlawful. "Force". The meaning of force in relation to rape need not necessarily indicate physical restraint by a man. Even the fear of such violence is sufficient for succeeding the charge of rape as well as threatening the victim with a knife, gun and other means. Where a man uses alcohol and drugs to subdue a woman in order to have sex with her, it can be defined as rape, if she was physically or mentally incapable of forming decision about consent. Ü Indecent assault. When the penis doesn't pass between the labia, a charge of rape cannot succeed, but any sexual offence, called an "indecent assault". For example a particular risk exists in medical practice in relations "doctor ­ patient" especially the doctor is a man and a patient is a woman.

Ü Indecent exposure. This is a sexual misbehavior known as "flashing" or "exhibitionismus", where a man or a woman displays his genitals in public. This is fairly harmless and calls more for restraint and psychiatric treatment of the offender than harsh measures.

Ü Indecency with children. This is more serious sexual offence, where the man (rarely woman) prey on small children, not to assault them, but in the framework of certain play, to handle or masturbate his (or her) sexual organs.

Ü Incest. This is an ancient and widespread sexual offence, consisting of sexual intercourse between close relatives.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ü Bestiality. This is a sexual intercourse with animals, including birds, either vaginal and anal (cloacal in birds!). Sometimes the victims (animals) are tortured and killed in the process of sexual intercourse. The veterinary doctor plays an important role in the detection and identification of animal secretions and hairs found on a suspect. The prosecution is rare, although the bestiality is a common thing, especially in the country­side.

Ü Homosexual offences. In many countries the sexual acts between men are illegal, but the situation was changed since the beginning of movement for homosexuals' rights. Thus in some countries homosexual activity in private is not illegal (unlawful) between consenting adults over 21 years. Homosexual act between men is called "pederasty" or "sodomy", the active man is called a "pedicator" or "buggery", the passive is "pederast". Homosexual act between females is called "lesbianism" an is no criminal offence unless it offends against public decency.

The doctor's duty in the examination of sexual offences wWriting down the history of a case. wGeneral physical examination. Conditions are: Ø third person (better a woman) should be present Ø full record of the examination (date, time, place, details of the victim, names of those present) Ø the history should cover the event complained of and also details of menstruation, pregnancies and sexual activity in the past Ø apparent age should be compared with real age (dress, make­up and manner might have misled a young man to think the girl was over the age of consent) Ø clothes worn during the attack are required for science examination. The victim have to undress standing on a large piece of brown paper (1,5 × 1,5 m) to preserve all traces of evidence falling down Ø full body surface inspection (genital injuries may be minimal or absent) Ø abrasions, bruises, bite marks, blood stains, semen, mud or other foreign material should be noted Ø pubic hair (combed out ñ victim's hair can be mixed with aggressor's) Ø visual inspection of the vulva and anus, swabs taken from those parts (ano­genital area is scanned for redness, abrasions, bruises, lacerations and swelling) Ø in very young children the vaginal walls may be bruised, lacerated or even perforated Ø liquid in the vaginal tract should be collected (pipette, small tube, swab) Ø venous blood sample for grouping, alcohol, drugs, DNA profile Ø fingernails ñ searching for blood or skin tags (woman can scratch her attacker, blood grouping or DNA profile can be done). The doctor may rarely be in position to say that rape occurred, but he should provide information on these questions: 1. Was the woman virginal? 2. Has there been sexual intercourse in the distant past? 3. Has there been recent sexual intercourse? 4. Are there general injuries in the genital region? 5. If so, are they consistent with consenting, if enthusiastic intercourse? 6. Are they indicative of forcible sexual intercourse ? w Examination of an alleged assailant. The same general scheme should be used.

1. What is the classification of sexual offences? 2. What is the doctor's duty in the examination of sexual offences? 3. What information concerning the woman ñ victim of sexual assault the doctor has to provide? Practical task: Describe the procedure of taking vaginal samples by pipettes and swabs and fill­in a transmittal letter for sending them for serological and microscopical investigation PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 21. FORENSIC HISTOPATHOLOGY

þ Forensic histopathology is a branch of forensic medicine dealing with the microscopic investigation of pathological causes, complications and mechanisms of death in different organs and tissues of human body. The histological examination has its own features such are: w certain superiority over the macroscopic observation w long­term preservation of organs or organ sections w methodological completness w possibility of verifying the assertions by other doctors w higher level of medical work and documentation w the formation of basis for further considerations. Omitting the histopathological examination may lead to following risks: Ø the case appears sufficiently "clear" Ø quick "settlement" of a case (no extra fee) Ø knowledge of the necessity of a histological examination is absent. The practical application of forensic histopathology is oriented to the following questions: 1. Is the certain histological finding vital or post­mortem induced? 2. What is the cause of the finding? 3. What chronological, causal and pathogenetical connections can be established?

Value and significance of histopathological data: Ü Group 1. Findings permit an independent assessment of the causal connections between the condition and etiology (tuberculosis, abortion etc.). The etiological manner is also of great significance in the case of poisoning by ethylenglycole due to formation of oxalate crystals in the kidney (fig. 83) Ü Group 2. Findings only have a significance in association with further premises (fresh hemorrhages in the deep soft parts of the neck)

Fig. 83. Histopathological pattern of ethylenglycole (brake fluid) poisonong. Note oxalate crystals in kidney tubules (arrows) and severe vacuolar dystrophy. Hematoxylin and eosin staining, polarizing microscopy. Magnification 360×.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ü Group 3. Unspecific, informative findings neither singly nor in combination exclude other possibilities of causal explanation (vascular congestion, pulmonar emphysema, cerebral edema, necrosis). See also fig. 84.

Fig. 84. Barotrauma of the lungs due to exlosion of TNT. Note patterns of acute emphysema (right), subpleural collapse and disruption of interalveolar septa (left). Hematoxylin and eosin staining. Magnification 360×.

What are the problems and risks of the histological investigation properly? Ø Subjectivity Ø Individual diversity of tissue reactions Ø Uniformity of tissue reactions Ø Little value of quantitative evaluation Ø Artifacts Ø Postmortal decomposition.

1. What is forensic histopathology? 2. What are positive features of histological examination? 3. What is the value of histopathological data? Practical task: Perform the investigation of histological samples in myocardial infarction, fat embolism and acute ischemic tubular necrosis of kidney ("shock kidney"). Visit the section of histology.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 22. MEDICAL MALPRACTICE

þ Medical malpractice is a medico­legal phenomenon which covers all defects in the professional behavior of doctors. It divided into two types: 1. Medical negligence, where the standard of medical care given to a patient is considered to be inadequate 2. Professional misconduct, where personal professional behavior falls below that which expected of a doctor. As regards law, generally medical malpractice may be ethical, civil and criminal. w ethical malpractice: violations of the principles of medical ethics which might subject the medical practitioner to disciplinary action by his professional society w civil malpractice: this form generally concerns of cases of monetary remuneration ñ"money damages" and careless doctors. Before a patient can succeed in a civil action for negligence against doctor, he must prove that: Ø the doctor had a duty towards him (and) Ø that there was a failure in that duty of care (which) Ø resulted in physical or mental damage. w criminal malpractice is the result of performing illegal operations, violation of narcotics laws, falsifying records or reports on patients as well as fatal mistakes in diagnostic and treatment. The liability formula of Five "D" in malpractice where negligence is charged in a court looks as follows (after W. U. SPITZ, [15]):

Plaintiff must prove

Duty

Dereliction (Breach of Duty)

Direct Cause (Legal Cause, Proximate Cause)

Damage (Legal Injury) ______Defenses: Contributory Negligence, Assumption of Risk etc.

Defendant must prove

The main types of medical negligence are: Ü In obstetrics and gynaecology: w brain damage in the newborn due to hypoxia from prolonged labour w failed sterilization by unsuccessful tubal ligation in unwanted pregnancies w complications of hysterectomy (ureteris ligation, vesicovaginal fistulae).

Ü In orthopaedics and accident surgery: w missed fractures w undiagnosed intracranial haemorrhage w missed foreign bodies in wounds and eyes

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com w inadequately treated injuries w discharge of ill patients, instead of admission to hospital.

Ü In general surgery: w delayed surgical diagnoses w retention of instruments and swabs in operation sites w operation on the wrong side of body, wrong organ or even wrong patient w unsatisfactory plastic surgery.

Ü In general medical practice: w failure to visit a patient w failure to diagnose certain medical condition w failure to refer a patient to hospital or specialist opinion w toxic results of drug administration w allowing suicidally inclined patients in psychiatric wards to kill themselves.

Ü In anaesthesiology: w brain damage from allowing hypoxia to occur w neurological damage from spinal or epidural injections w incompatible blood transfusion w periferal nerve damage from splinting during infusion w incorrect or excessive anaesthetic agents w allowing awareness of pain during anaesthesia.

Ü General medical errors: w failure to act on radiological and laboratory reports w inadequate clinical records and failure to communicate with other doctors involved in the treatment of a patient.

Professional misconduct The general level of ethical behavior, morality and competency is stated by the Hippocratic Oath, declaration of Geneva and proclamations of the World Medical Association. However, the professional behavior of a doctor may lead to allegations of misconduct. The doctor's professional career is dependent upon various systems of registration and licension, thus the best way to control professional misconduct is to examine the doctor's fitness to remain an accredited physician by various tribunals. In many countries the government, through its Ministry of Health, regulates licensing and removes doctors who have misbehaved.

1. What is the definition of medical malpractice? 2. What are the main types of medical negligence? 3. What is the essence of professional misconduct? Practical task: Perform the external and internal examination of fresh surgical wound and evaluate completness and correctness of surgical treatment.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 23. GENERAL ASPECTS OF POISONING

þ Poison is any substance, which being entered to the organism in relatively small amount may cause its chemical damaging, pathologic condition and even a death. þ Poisoning (from the general point of view) is a damage to the tissues by any chemical agent. Poisons biologically are of two main groups: 1. Quantitative poisons. Any substance can act as a poison in a sufficient and increased quantity (therapeutic agents or remedia in excess of the prescribed dose or even a water has been drunk in a huge amount). For such a substances, especially for drugs, exists a proportion, which is called "RISK ­ BENEFIT" ratio (relation between the THERAPEUTIC EFFECT and the TOXICITY). For hard drugs this ratio is poor. 2. Qualitative poisons. They are harmful in such small doses and have no treating effect (for example: cyanids, mercury, pesticides). Clinical toxicology cases of poisoning have a certain occurrence ñ 1 in each 7 admissions to hospital (14 ñ 15 %). In that cases it is necessary to do these steps: w to collect data of history of case w to learn and observe physical signs w to perform analysis of body fluids and tissues (urine, blood, stomach content). Poisoning from the point of view of forensic doctor may be of three types: 1. Accidental poisoning ñ most common. 2. Suicidal poisoning (suicidal gesture) ñ common. 3. Homicidal poisoning ñ rare.

Accidental poisoning w individual (a child is eating medicinal tablets in mistake for sweets, a drunken person is drinking a pesticide or ethylene glycol anti­freeze from a beer­bottle in mistake for beer) w faulty gas­appliances (CO, lack of oxygen) w agriculture (paraquat, organophosphorus compounds [parathion]) w mass industrial disasters (contaminated cooking oil in Spain, dioxin gas in Italy and India, blast­ furnace gas in East Slovakian Ironwork [11 victims]).

Suicidal poisoning w mostly appears in advanced communities w easy obtaining of toxic drugs and agricultural products w decreased using of corrosive agents (acids, alkalia) ñ painful!

Homicidal poisoning w the cases are rare (traditional weapons are arsenic and cyanide) but: Ø new intention: immobilization instead killing of the victim for robbing (using benzodiazepines or narcotic analgetics mixed with alcoholic and non­alcoholic drinks) Ø the newest intentions: ­ euthanasy (the death as a will of patient) ­ legal punishment (the fatal dose of hard somniferous drug intravenously instead shooting down or hanging).

The toxic and fatal dose There are several questions concerning the estimation of a total dose of poisoning agent: 1. How long between taking the drug and death? 2. What is the absorption rate? 3. What is the detoxification rate? PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 4. Is that rate constant? 5. Is the drug completely absorbed? 6. Does the drug diffuse uniformly (variation between aqueous and lipoid body compartments)?

F Different people have a wide range of individual sensitivity or resistance to a given substance with variation from time to time. It is inevitable to build large computer databases in toxicology laboratories.

The doctor's duty in suspected poisoning The main task is the management of the situation in the most effective way. The steps are: 1. Early recognising the possibility of poisoning. 2. Instituting primary treatment, if the victim is alive. 3. Identifying and retaining any drugs or possible poisons. 4. In the case of death: full co­operation with the police in the investigation : Ø pick up data of full medical and psychiatric history Ø to estimate the schedule of drugs prescribed in the recent past Main signs for the recognition of poisoning: w sudden vomiting and / or diarrhoea, changes of eye pupils, skin and mouth corrosions w unexplained coma w knowledge of a depressive illness in the past w rapid onset of a neurological or gastrointestinal illness (occupational exposition to chemicals)

The collection and storage of samples for toxicological analysis "Establishing continuity of evidence" means to ensure full identification. The doctor must do these things: 1. Venepuncture with placing the blood into an appropriate tube. 2. Labeling of the tube with: Ø patient's name Ø address (hospital number) Ø date and time of taking blood Ø doctor's signature 3. Taking the biological samples for toxicological investigation. 4. Labeling of the plastic bag or box for transport. 5. Medical notes (time and nature of the sample, the name of the person to whom it was given). Samples required for toxicological analysis: w BLOOD in such amounts: Ø 15 ml in a plain tube Ø 5 ñ 10 ml in a tube containing an anticoagulant Ø 5 ml in sodium fluorid tube for alcohol estimation. w URINE ñ 20 ñ 30 ml (with no preservatives) w VOMIT AND STOMACH CONTENTS placed in glass screw­topped jars, plastic tubes or containers F At autopsy some laboratories request the stomach wall (for investigation of adhering tablet debris) w FAECES ­ 20 ñ 30 g in suspected heavy metal poisoning (arsenic, osmium, mercury, lead) w LIVER, OTHER ORGANS AND FLUIDS: Ø liver: at least 100 g placed in a clean container Ø bile Ø kidney (a half of organ is enough) Ø lung (solvent abuse) placed in an impervious bag to avoid escape of toxic vapour Ø vitreous body of the eyeball PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ø putreous fluid, living maggots in the case of advanced putrefaction and devastation of the body by maggots (to the glass screw­topped jars). w HAIR AND NAIL CLIPPINGS are available to prove antimony, arsenic or thallium intoxication for many years after death. Neutron­activation analysis of hairs is to be done to determine the time of poison administration. F Avoid contamination of taking samples!

Main methods of toxicological investigation: 1. Screening (qualitative) methods: Ø express­methods with indicative papers and solutions Ø method of fluorescence polarization immunoassay (Eclaire­Merck, see fig. 85) Ø qualitative chemical reactions.

Fig. 85. Preparing of samples for the screening method of fluorescence polarization immunoassay performing by the Eclair­Merck device.

2. Semiquantitative methods: Ø thin­layer chromatography (see fig. 86) Ø densitometry. 3. Quantitative methods PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ø gas chromatography (GC) Ø high performance liquid chromatography (HPLC, see fig. 87) Ø mass spectrometry (MS)

Fig. 86. Thin­layer chromatogram which demonstrates positivity of cannabinoids in the urine (compare the 3rd, 4th, 5th and 6th columns, the control extract of cannabis ñ white arrow, the stains corresponding metabolites of cannabis in urine ñ black arrows).

Fig. 87. The investigation by high performance liquid chromatography in the Section of toxicology and forensic chemistry.

1. What are definitions of poison and poisoning? 2. What is the doctor's duty in suspected poisoning? 3. What are the main methods of toxicological investigation? Practical task: Describe the procedure of taking samples for toxicological analysis and fill­in a transmittal letter for sending them to the laboratory.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 24. MEDICO­LEGAL ASPECTS OF ALCOHOL ABUSING

Alcohol is a central psychotropic substance and we regard it as a quantitative poison for nervous system. The most widespread alcohol for consumption is ethylalcohol (EA) or ethanol. Almost all alcohol is produced by enzymatic reaction of yeasts on a vegetable substrate containing sugar. The direct fermentation provides only 12 ñ 15 % vol. ethylalcohol concentration, the higher concentrations (40 ñ 60 % vol.) can be achieved with following destillation. EA provides such psychological effects: Ø feeling of well being Ø depresses brain function Ø lessening muscular control and coordination EA in the organism is broken down by: Ø alcoholdehydrogenase (ADH, mainly in the liver) Ø microsomal ethanol oxidising system (MEOS) Ø catalase The average speed of elimination of alcohol from blood is 0,11 ñ 0,25 g/kg per hour. Any kind of drink, which is considered to be an alocoholic beverage by law in Slovakia must contain at least 0,75 vol.% of ethylalcohol. Calculation of EA level in the blood The blood alcohol concentration (BAC) is an important criterium for analysing violency, assaults and accidents and for decision on impairment of ability to drive. The level of BAC up to 0,2 g/kg (according to new scale of units ñ up to 4,34 mmol/l) is cosidered for negative. The legal limit of BAC for drivers in Slovak republic is up to 0,3 g/kg (6,51 mmol/l). The new scale of units estimates for ethylalcohol concentration 1 g/kg = 21,7 mmol/l.

An equation for calculation of BAC estimates:

g EA BAC (g/kg) = ññññññññññññññññññ ñ β60 , where m × f

g EA ñ the amount of pure alcohol consumpted (in grams) m ñ the weight of body (in kilograms) f = 0,7 in men, f = 0,6 in women ñ a reducing factor

β60 = 0,11 ñ 0,25 g/kg (average 0,15 g/kg) ñ an alcohol elimination speed per hour.

Stages of drunkenness by BAC The intensity of EA action in organism depends on: Ø the actual BAC Ø the trend of BAC curve Ø the age Ø the duration of using alcohol before Ø the type of brain activity Ø the actual physical and psychical condition.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Ist stage BAC = 0,31 ñ 0,50 g/kg ñ condition after consumption of alcohol, laboratory proof the person have used alcohol. IInd stage BAC = 0,51 ñ 1,00 g/kg ñ underdrunkenness. Reduced inhibitions, talkativeness, laughter, slight sensory disturbance, impairment of driving and similar skills.. IIIrd stage BAC = 1,01 ñ 1,50 g/kg ñ light grade of drunkenness. Incoordination, unsteadiness. IVth stage BAC = 1,51 ñ 2,00 g/kg ñ medium grade of drunkenness. Nausea, ataxia. Vth stage BAC = 2,01 ñ 3,00 g/kg ñ heavy grade of drunkenness. Vomiting, stupor, possibly coma. VIth stage BAC = 3,01 g/kg and more ñ acute alcohol intoxication with stupor, coma, danger of aspirating vomit. At BAC more than 4,00 g/kg ñ danger of death due to cessation of nervous breathing center and metabolic disturbance.

Pathologic consequences of prolonged heavy drinking w alcoholic hepatitis and hepatic cirrhosis w brain damage (loss of dendritic spines, Wernicke and Korsakoff syndroms, cerebellar atrophy) w pancreatitis (acute and chronic) w cancer of esophagus, throat, and larynx w gastrointestinal bleeding from ulcers, varices, gastritis w fetal alcohol syndrome w neuropathy w cardiomyopathy (is not common) w rhabdomyolysis (seldom dramatic, but probably contributes to long­term wasting) w hangover, tremulousness, seizures, delirium tremens on withdrawal ("green devils", "rats", "pink elephants on parade" etc.) w losing job, family, friends.

Investigation of alcohol level in breath This investigation has an orientative value for the decision on impairment of driving and performing some qualified skills (bus, train and plane driving, building, mine working). The investigation is performed by: w indicator tubes (Alcotest, Detalcol). These tubes allow to perform only orientative investigation of the alcohol in breath. Principle of these work is based on oxidative­reductive chemical reaction of alcohol wapors with kalium bichromate in sulfuric acid (content of a tube). The whole tube system consists of the mouth­piece, indicator tube and rubber airbag (see fig. 88).

Fig. 88. Indicator tube system DETALCOL Fig. 89. Digital alcometer Dr‰ger Alcotest 7410, the consisting of mouth­piece (1), indicator tube (2) whole view (A) and the upper part with the and rubber airbag (3). disposable mouth­piece (B).

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com w digital electronic alcometer (currently used by road police). The alcometer utilizes the air of man's deep exhalation, measures photometrically the concentration of alcohol in the air and then recalculates the concentration obtained to the blood alcohol concentration (BAC). The modern alcometer (see fig. 89) has a high measurement accuracy (due to electrochemical sensor), digital display, integrated datalogger, and data communication interface for transmitting data to PC or to printer. The unit provides digital display, high capacity of 300 tests from each battery charge, car adaptor, data memory, short resistance plastic housing. The calibration interval of the alcometer is six months. For measurement of alcohol level disposable mouth­pieces are used. In the case of positive or suspicious level of BAC the exact laboratory investigation of BAC needs to perform.

Laboratory investigation of alcohol The toxicologic labs use two independent methods of quantitative estimation of alcohol in various biolog ical fluids (mainly in blood and urine). These methods are: w Widmark oxidative titration method (the alcohol dehydrogenase method can be used in a substitution). This method is not high­specific: detects not only EA, but methanol, isopropanol and all reductive substances also. Principle of the Widmark oxidative reaction is the exothermic oxidative­reductive chemical reaction of alcohol with the precise amount of kalium bichromate in sulfuric acid. The rest of kalium bichromate is calculated by subsequental method of iodometric titration. The chemical equations of such reactions are following:

C2H5OH + K2Cr2O7 + 4H2SO4 è CH3COOH + Cr2(SO4)3 + K2SO4 + 5H2O + O2

K2Cr2O7 (the rest) + 6KJ + 7H2SO4 è Cr2(SO4)3 + 4K2SO4 + 7H2O + 3J2

J2 + 2Na2S2O3 • 5H2O è NaJ + NaS4O6+ 10H2O

w gas chromatography (see fig. 90). High­specific method, detects all mentioned substances, but distinguishes them from ethanol.

F Remember that during the putrefaction process of the human body can be produced endogenic ethylalcohol by bacteria in concentrations up to 1,0 g/kg (21,7 mmol/l). Drinking and driving: impairment of ability to drive Medical conditions affecting driving: w Fatigue w Illness: Ø cardiovascular system (infarction, arrythmias, syncope) Ø diabetes (hypoglycaemia, impaired vision, neuropathy) Ø epilepsy Ø nervous system (stroke, Parkinson's, multiple sclerosis, defness, vertigo, cerebral tumor) Ø mental illness ( psychosis, psychopathy, low IQ) Ø vision ( diplopia, bicolour vision, impair dark adaptaion) Ø head injury and locomotor problems ( weakness, stiffness, post traumatic epilepsy, loss of contraction) Ø ageing (frequent medical examinations from age 70) w Drugs: Ø prescribed drugs (tranquillisers, anti­depressants, anti­histamines, narcotics, analgesics, barbiturates) Ø illicit drugs (opiates, cannabis, hallucinogens) w Drunkenness (actual BAC over 0,3 g/kg).

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 90. Preparing of the blood samples for alcohol investigation by "head­space"gas chromatography at the Section of Alcohology.

The steps of examination of a suspected drunk person 1. Medical history (anamnesis): Ø epilepsy (?) Ø diabetes (?) Ø current medical treatment (?) 2. Examination on memory condition: chronological account of events that day. 3. Food and drink: Ø when was the last meal taken? Ø what alcohol intake is admitted to? 4. Demeanour: state of clothing, soiling with vomit. 5. Pulse, blood pressure, respiration. 6. Examination on central nervous system reflexes: ­ nystagmus ­ finger to finger ­ finger to nose ­ walking a straight line ­ turning rapidly ­ standing on one leg

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com ­ standing on both legs with eyes closed ­ picking up small object from ground. 7. Eyes: ­ suffused conjuctivae ­ inequality of size of pupils ­ reaction to light and accommodation ­ visual acuity. 8. Breath odor: ­ smell of alcohol, cannabis, solvents or ketones. 9. Injuries. 10. Taking a sample of blood. For alcohol investigation both the living and the dead, the blood is sending to the laboratory in a gray­top (sodium fluoride anti­bacterial, anti­enzyme) tube. Keep the sample in the refrigerator. 11. Urine: taking for investigation to a gray­top tube if necessary. 12. Counting average BAC using modern software (e.g. ALCOPRO, EZ­ALC, see fig. 91).

Fig. 91. The pattern of typical BAC­graphs screening by ALCOPRO software.

F The doctor has to exclude any illness which may mimic alcoholic intoxication (head injury, hyper­ and hypoglycaemia, carbone monoxide poisoning etc.)

1. What is the definition and pathophysiological characteristics of ethylalcohol intoxication? 2. What are the stages of drunkenness according to blood alcohol concentration (BAC)? 3. What are the steps of examination of a person suspected to be drunk? Practical task: Visit the section of alcohology. Calculate the driver's blood alcohol concentration towards actual time of event in the case of traffic accident using ALCOPRO software.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 25. DRUGS OF DEPENDENCE AND ABUSE

Drug abuse is a world­wide problem: from the "drug baron wars" in South America to the death of solitary drug user in a public toilet in any European city. The main tasks of forensic medicine is to recognize and prove the fact of drug abuse and to reveal a kind of drugs of dependence and abuse. Drugs (see fig. 92) may be taken by different routes: w by injection w by sniffing w via rectum or vagina w by inhalation w by smoking w orally. Physical lesions are apparent, particularly a loss of weight, due to: Ø lost appetite Ø lack of money Ø avitaminosis Ø intercurrent infections.

Fig. 92. Collection of illegal drugs used as standard substances in toxicological investigation.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Tolerance, idiosyncrasy, dependence and withdrawal symptoms þ Tolerance is the condition, when large doses of remedy or poison no longer have the effect that they had originally (increasing doses need to be given for the same beneficial effect). The effect of tolerance is observed in the case of taking amphetamines, barbiturates, benzodiazepines, drugs of morphine­heroin­ methadone group. Most of the drugs of dependence exhibit tolerance. þ Idiosyncrasy is the condition, when abnormally small amounts of a substance may cause dramatic or even fatal effects. Greatly it has neurological or allergical matter.

þ Dependence is the condition in the case of using legal and illegal drugs, when the substance takes a participance in metabolism, and the organism needs the constant presence of that drug by using for its own normal function. The drugs of dependence are: alcohol, nicotin, analgetics, all kinds of banned drugs. Dependence means inability of the user to give up the habit, it can develop within 1­2 weeks even after 1 injection of a potent drug.

þ Withdrawal symptom is the sequel of dependence. This is a complex of general signs such us headache, psychical lability, total arrogancy and a desire to use the drug of dependence immediately (alcohol, opiates an so on). Withdrawal symptom may be of two subtypes: Ø physiological: fear and anxiety, muscle twitching, yawning, sweating, lacrimation, tremors, "goose flesh" of the skin, cramps, diarrhoea, incontinence, restlessness, insomnia, tachycardia, hypertension Ø psychological.

The dangers of drug dependence Ø repeated injection of drugs leads to vein thrombosis, phlebitis, fibrosis, abscesses, fat atrophy and necrosis, chronic myositis (dark, hard and cord­like veins under the skin and silvery linear scars as well as depressed areas on the limbs) Ø injection of crushed unsterile tablets causes microemboli, giant cell granulomata and abscesses in the lung and liver Ø use of shared syringes and needles is a risky factor to obtain hepatitis B, HIV virus infection, infective endocarditis, septicaemia Ø poor nutrition and reduced resistance è pulmonary tuberculosis, pneumonia Ø accidents Ø death from poisoning (and accidental death, too, see fig. 93).

The monitoring of present drug scene at schools The monitoring of present drug scene at the secondary schools is of great importance for obtaining an information about the situation at the drug scene, alcohol abusing, smoking and knowledge of youth on threatening danger of drug abuse. In Koöice, Slovakia, for example, the experience in using drugs have had 12 % of boys and 7,2 % of girls. 57,2 % of boys at schools. The positive correlation between smoking and using of alcohol, smoking and using of drugs; using of alcohol and using of drugs was found. The analysis of age structure showed the existence of two risky groups: the first one in which 50 % of boys and 29 % of girls use the alcohol is 12,5 to 13,5 years old, the second group in which 12 % of boys and 7 % of girls have already experienced a drug is 13,5 to 14,5 years old. The existence of these two risky age groups requires preventive anti­drug measures inevitably, especially in a form of selection and preparing of the students within the framework of so­called "peer­program".

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com Fig. 93. Cocain in special hermetic rubber containers for storing in stomach and guts while travelling. Death was caused by breaking of one container in the stomach.

Brief classification of drugs of dependence w Opiates: heroin (diacetylmorphine), morphin and other opioids (codeine (dimethylmorphine), dihydrocodeine, papaverine, pethidine, dipipanone, methadone, dextromoramide, pentazocine, cyclizine, diphenoxylate, dextropropoxyphene etc.) w Barbiturates and other hypnotics (cyclobarbitone, amylobarbitone, phenobarbitone, barbitone etc) w Amphetamines (dextramphetamine, methylamphetamine, MDMA (methylenedioxymethampheta­ mine or "Extasy" etc.) w Cocaine ("Crack" ñ heating cocaine together with sodium bicarbonate) w Cannabinoids (marihuana, hashish) w Hallucinogens (LSD ñ lysergic acid diethylamide, psilocybin, phencyclidine) w Solvents (toluene, ethylene chloride, carbon tetrachloride, benzene, halon, trichlorethane, xylene, trichlorethylene etc.)

1. What are main routes of entering drugs to the human organism? 2. What are dangers of drug dependence? 3. What is the common classification of drugs of dependence? Practical task: Visit the section of toxicology and forensic chemistry. Evaluate a gas chromatography ­ mass spectrometry report on cannabinoids.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com 26. THE DOCTOR AND THE LAW

Forensic documentation

Ü Autopsy report. This document is issued by forensic doctor after medicolegal investigation of dead person. It consists of: Ø the general data of dead person ñ name, surname, age, affiliation, address, and other types of identification (in Slovakia ñ the born number) Ø the data of doctors who performed the autopsy (note that the autopsy is performed by two doctors) Ø clinical diagnosis (only in cases of a death in hospital) Ø type of death and type of autopsy Ø external examination ñ postmortal changes, violency marks, external patological signs Ø internal examination ñ cranial, thoracic and abdominal cavity, ev. other cavities (middle ear cavity, spinal column cavity, orbita and cavity of joints) Ø results of additional laboratory investigations ñ toxicological (including alcohol), serological, microbiological, histological Ø definitive diagnosis: cause of death, the main disorder (trauma, illness, intoxication etc.), co m­ plications, other changes, which were not in dependence on death.

Ü Expert opinion. An expert opinion can be made only by specialist­expert, who accomplished all requierements given by the law. In order that doctor could become an expert of forensic medicine he has to: Ø work on department of forensic medicine Ø pass rigorous exams: first degree (pathology) and second degree (forensic medicine). The authority of such an activity is given to him by court. The expert opinion concerns both living and dead persons. Doctor may be withdrawn from the case if prosecutor or lawyer insists. Everything must be absolutely true in this document. False or reckless stat e­ ments may lead even to criminal prosecution.

The structure of an expert opinion. Part 1. Introduction Ø Doctor­expert: affiliation, address. Ø Patient or deceased ­ name, address, age. Ø Who requested the report. Ø Where and when the examination (ev. necropsy) took place. Ø What basic documents and investigations were the source of expert opinion. Part 2. Findings and diagnoses Ø Brief account of the reason for the examination and short note of the circumstances. Ø Given questions. Ø History by the patient / from clinical records / police. Ø Physical examination / external and internal examination. Ø Results of additional investigations: toxicological, serohaematological, histological etc. Ø Medico­legal interpretation of revealed circumstances of the death: whether they are in acco r­ dance with finds and diagnoses obtained Ø Explanation of mechanism of death. Part 3. The expert opinion itself ñ conclusion Part 4. Signature, seal Ø Medical reports and statements for police, judges, lawyers and government. Ø Photographs, videorecords, drawing schemes. PDF created with FinePrint pdfFactory trial version http://www.fineprint.com The doctor in a court The doctor may play the role of medical witness or doctor­expert in a court. The particular sequence of his steps in these conditions is following: w The first stage: making a statement, which is a medical report. The report contains a declaration usually signed and witnessed by a police officer, this declaration makes a doctor liable for criminal prosecution and makes a document legally acceptable in court w The second stage: a written statement plays a certain part in a court (the presence of a busy doctor is unnecessary) w The third stage: where a doctor is summoned to appear as a court witness. The doctor will be called to the witness­box and in religious countries must "take an oath", swearing on a religious book (B i­ ble, Koran etc.) The doctor is asked to confirm the evidence which was written in his statement. Af­ ter that the defense lawyer will rise to "cross­examine" the doctor. A doctor also may be called to as­ sist the defense. KENNEDY (1986) defined the main characteristics of doctor­witness and doctor­expert in court [10]: Ø the doctor must be ready to present his opinion at any time Ø the doctor must be precise Ø the doctor must be brief Ø the doctor must be coherent and should not use difficult Latin medical terms Ø the doctor must realize his responsibility Ø the doctor must control his behavior.

1. What are the main parts of autopsy report? 2. What is the structure of expert opinion? 3. What are stages and requirements of doctor's representation in court? Practical task: Absolve the computer test and special picture quiz in Forensic Medicine.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com REFERENCES

1. DIMAIO V.J.M.: Gunshot Wounds. Elesevier, New York ­ Amsterdam ­ London, 1985, 331 p. ISBN 0­444­00928­0 (in English). 2. DIMAIO D.J., DIMAIO V.J.M.: Forensic Pathology. CRC Press, Inc., Boca Raton ­ Ann Arbor ­ London ­ Tokyo, 1993, 503 p. ISBN 0­8493­9503­8 (in English). 3. FARLEY M.A., HARRINGTON J. J.: Forensic DNA Technology. Lewis Publishers, Inc. Chelsea, MI 1991, 250 p. ISBN 0­87371­265­X (in English). 4. GRESHAM G.A.: A Colour Atlas of Forensic Pathology. Wolfe Publishing, Ltd., London, 1975, 304 p. (in English). 5. GROMOV A.P.: Lectury Course on Forensic Medicine. Medicina, Moscow, 1970, 312 p. (in Russian). 6. Handbook of Forensic Science. U.S. Department of Justice, Federal Bureau of Investigation, U.S. Government Printing Office, Washington, D.C. 1994, 122 p. (in English). 7. HENSSGE C., MADEA B.: Methods for Estimation of the Time of Death on Corpses. Max Schmidt ­Rˆmhild, L¸beck, 1988, 268 p., ISBN 3­7950­0624­4 (in German). 8. JANSSEN W.: Forensic Histopathology. Springer, Berlin ­ Heidelberg ­ New York ­ Tokyo 1984, 402 p., ISBN 0­387­12466­7 (in English). 9. KAFKA J., LONGAUER F. S˙dna psychiatria a s˙dne lek∙rstvo pre pr∙vnikov, Koöice, 1992, 194 s. (in Slovak). 10. KENNEDY W.A.: The psychologist as expert witness. In: Curran W.J. et al. (Eds), 1986, p. 487 ­502. (in English). 11. KNIGHT B.: Simpson's Forensic Medicine. Oxford University Press, Inc. London ­ Sydney ­ Auckland, 1997, 211 p. ISBN 0­340­61370­X (in English). 12. MASON J.K.: The Pathology of Trauma. Edward Arnold, London­Boston­Sidney­Auckland 1993, 367 p., ISBN 0­340­54820­7 (in English). 13. MCLAY W.D.S.: Clinical Forensic Medicine. Pinter Publishers, London, 1990, 349 p. (in Eng­ lish). 14. ROBIN H., MICHELSON J. B.: Illustrated Handbook of Drug Abuse. Recognition and Diagnosis. Year Book Publishers, Inc., Chicago ­ London ­ Boca Raton, 1988, 187 p., ISBN 0­8151­ 5871­8 (in English). 15. SPITZ W.U.: Spitz and Fisher,s Medicolegal Investigation fo Death. Guidlines for the Appli­ cation of Pathology to Crime Investigation. 3. Edition. Charles C Thomas, Springfield, Illinois, 1993, 829 p., ISBN 0­398­05818­0 (in English). 16. VOREL F. (ED.): SoudnÌ lÈkaˉstvi. Grada Publishing, Praha, 1999, 600 s. ISBN 80­7169­728­1 (in Czech) 17. WETLI CH.V, MITTLEMAN R.E., RAO V.J. An Atlas of Forensic Pathology. ASCP Press, Chi­ cago, 1999, 286 p., ISBN 0­89189­430­6 (in English). 18. WHITTAKER D.K., MCDONALD D.G.: A Colour Atlas of Forensic Dentistry. Wolfe Publishing, Ltd., London, 1989, 134 p. (in English).

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com GLOSSARY þ Abortion ñ premature expulsion of the embryo or the fetus from the uterus at any time before its term of gestation is complete. Medically and pathologically the term "abortion" is applied to the termination of pregnancy during the first three months, while an abortion occuring during the middle period of pregnancy is designated as "miscarriage", and after 7th month is called a premature birth. þ Abrasions ñ the most superficial type of injury concerning the mechanical damage of epidermis or ente­ ring the dermis. þ Acceleration injury ñ type of injury in transportation accidents when the vehicle is hit from behind and vehicle occupants are thrown backwards striking the vehicle parts behind them, the great over­extension of cervical spine commonly appears; also a type of injury of pedestrian hit with the fast moving car. þ Adipocere ñ substance created by hydrolytic converting the dead body fat to a waxy compound similar to soap in wet conditions. þ Adult respiratory distress syndrom (ARDS) ñ complication of most traumatic or stressful incidents with a distinctive appearance of lungs (shock lungs). þ Air embolism ñ kind of embolism regarded as a cardiac embolism which is characterized by the evidence of frothy bubbles of air in the right atrium, ventricle and pulmonary arteries, is a common sequence of wounding of cervical veins. þ Artificial insemination ñ production of pregnancy in a woman by introducing seminal fluid directly into the cervix of uterus by means of cannula. þ Asphyxia ñ suspension of breathing and animation due to failure of the supply of oxygen. þ Asphyxia (true) ñ obstructive condition which is characterized by existing of somewhat barrier preven­ ting access of air to the lungs. þ Assault ñ unlawful violence used against another person, which is characterized by the threat of an attack or the actual attack. þ Assailant ñ an attacking person using unlawful violence. þ Autolysis ñ postmortal delivering of intracellular enzymes and the cellular decomposition in a way of self­digestion. þ Autopsy (synonym: necropsy) ñ full post­mortem external and internal examination of the body with the objective to estimate the cause, manner and mechanism of the death. þ Battery ñ the actual attack of an assailant towards the victim. þ Bestiality ñ sexual intercourse of a man with animals. See also zoophilia. þ Bite mark ñ combination of bruise, laceration and / or incised wound, that are usually made on skin of victim with teeth by animal or human assailant as well as by victim as self­defense. þ Brain death ñ irreversible damage of the brain incompatible to life, mostly after hypoxia, intracranial haemorrhage, brain trauma or poisoning. Important in relation to organ transplantation. þ Bruises ñ sequels of blunt injury which are characterized by damage of blood vessels (extravasate into the surrounding tissues). þ Burn ñ thermic injury caused by dry heat (fire, hot thing), in severe cases charring may appear. þ Coroner ñ elected and trained person, not obligately a physician, who examines dead bodies and investi­ gates cause and manner of death in medico­legal cases. In many areas of USA the coroner is also a fu­ neral director. þ Criminal abortion ñ deliberate ending of a pregnancy by woman herself or by another person unlaw­ fully. þ Death ñ is not simply the state of life absence, but is a process of life fading in a viable organism, which is characterized by irreversible cessation of vital functions and definitive stopping of metabolism. þ Deceleration injury ñ type of injury in transportation accidents when the vehicle strikes another moving or stationary object and vehicle occupants are thrown forwards striking the vehicle parts in front of them, the great over­flexion of cervical and thoracic spine commonly appears; also a type of injury in cases of falling down from the heights. þ Dependence ñ condition in the case of using legal and illegal drugs, when the substance participates in metabolism, and the organism needs the constant supply of that drug necessary for its own normal function.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com þ Diatoms ñ microscopic unicellular algae (about 25 000 species), varying in size from 5 to more than 500 µm, having a silica skeleton. They are found in all types of water (fresh, brackish and salt) and have an importance in medico­legal investigation of drowning. A sample of water where the drowning was thou­ ght must be also taken for comparison of species similarity. þ Diffuse axonal injury (DAI) ñ gross traumatic damage of the brain, non­visible by naked eye, which is characterized by appearance of broken axons and "retraction balls" particularly in corpus callosum, de­ monstrable microscopically by silver impregnation of axons or by immunohistochemistry (neuron speci­ fic enolase, beta­amyloid precursor protein) ­ the earliest finding 3 hours after injury). þ Doctor as a witness in court ñ 1) An "ordinary witness" or a "witness as to fact": as person who from actual presence knows of the occurrence of some fact or event (nothing about medical practice). 2) A "professional witness": as person who gives some factual information as evidence from his medical prac­ tice, strictly connected to the case (pay attention to secret personal dates!). þ Doctor as an expert in court ñ experienced doctor who gives an expert opinion as person with special skill or knowledge in a particular field. þ Drowning ñ 1) True drowning: death from aspiration of large volumes of water or another fluid into the lungs. 2) Death after submersion caused by a vagal inhibitory reflex. þ Embolus ñ foreign bolus (solid, liquid, gaseous) migrating through the vascular system to lodge at a bi­ furcation. þ Entrance wound ñ penetrating or perforating defect on the surface (mostly skin) according to the place of projectile introducing to the body. þ Euthanasy ñthe violent death caused by a doctor as a will of a patient. þ Excusable homicide ñ killing of an assailant in self­defense (only comparable force must be used). þ Exhumation ñ medico­legal procedure, when a dead body has to be removed from its grave in the cases when autopsy needs to be performed with the objective to estimate the cause, manner and mechanism of the death. þ Exit wound ñ perforating or lacerating defect of the surface (mostly skin) according to the place of exi­ ting the projectile from the body. þ Fat embolism ñ consequence of tissue trauma (after hours or even a day) which is characterized by deli­ vering of fat droplets to the bloodstream. Origin of the fat ­ adipose tissue, bone marrow or plasma fat. Occurrence ñ in almost every injury involving bone or subcutaneous tissue. Grading ñ from I (slight) to IV (severe) degree. þ Fertilization in vitro ­ method which allows to fertilize in vitro ova removed laparoscopically and to return them subsequentially to uterus. þ Filicide ­ general term to killing of a child by its parent (both mother and father). þ Flaying injury ("dÈcollement" in French) ñ severe injury where large areas of skin and subcutaneous tissue are split on leg, arm or scalp mostly due to rotation of the motor wheel against the body lain on the ground. þ Forensic histopathology ­ branch of forensic medicine dealing with the microscopic investigation of pathological causes, complications and mechanisms of death in different organs and tissues of human body. þ Forensic medicine (synonym: legal medicine) ­ fundamental and independent part of medicine dealing with the interaction of medical science and practice with the law. It is that part of medical science which is employed by the legal authorities for the solution of legal problems. þ Gagging ñ obstruction of the mouth with a soft object that is pushed in (in order to silence the victim). þ Gerontophilia ñ abnormal sexual orientation to elder persons. þ Graze firearm injury is the non­severe firearm injury, when the wound channel is absent, the entrance and exit wounds are contacted with each other on the surface (skin) of the body, the dermis is not involved. þ Hanging ñ kind of strangulation where the strangulative pressure is produced by the weight of the body itself. þ Homicide ñ generally deliberate or non­accidental killing caused by other person. þ Homosexuality ñ sexual attraction to persons of the same sex. þ Homosexual offence ñ unlawful sexual act between men ("pederasty", "sodomy") or between women ("lesbianism") by compulsion forse, threats and froud.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com þ Child sexual abuse (CSA) ñ involvement of dependent, developmentally immature children and adoles­ cents in sexual activities they do not truly comprehend, to which they are unable to give informed consent or which violate social taboos of family roles. þ Choking ñ result of internal obstruction of the air passages. þ Identification ñ process of equality estimation of different compared events, subjects and persons by those specific characteristic individual features. þ Idiosyncrasy ñ condition, when abnormally small amounts of a substance may cause dramatic or even fatal effects. Greatly it has neurological or allergical matter. þ Incest ñ ancient and widespread sexual offence, consisting of sexual intercourse between close relatives. þ Incised wounds ñ injuries from knives, razors, broken glass, metal edges and any object with a cutting edge. They are of two main types: slashed wounds and stab wounds. þ Indecency with children ñ sexual offence, where the man (rarely woman) prey on small children, not to assault them, but in the framework of certain play, to handle or masturbate his (or her) sexual organs. þ Indecent assault ñ any sexual offence where the penis does not pass between the labia. þ Indecent exposure ñ sexual misbehavior known as "flashing" or "exhibitionism", where a man or a wo­ man displays his / her genitalia in public. þ Infanticide ñ killing of an infant at the age up to 1 year old (see also: filicide, neonaticide). þ Injury ñ lesion arised from any cause including pure accident. þ Justifiable homicide ñ killing as a judicial execution in those countries where capital punishment still exists; also is a killing of the assailant by the police officer to prevent serious offence or to defend him­ self. þ Lacerations ñ splitting or tearing wounds crossing tissues strands with irregular margins and fibrous bands, vessels, nerves etc. in the depth. þ Manslaughter ñ homicide, when killer has no intent to cause death or severe injury, but the killing was the result of an unlawful act or a negligence or when the killer was provoked by the actions of the victim (voluntary manslaughter). The killing also may be a result of negligence and carelessness, especially in traffic accidents (involuntary manslaughter). þ Masochism ñ sexual permutation which is characterized by gratification derived from physical abuse at the hands of others and pleasure derived from being abused and humiliated, where a person in order to feel a sexual excitement prefers condition of painful stimulation on him / her and submission. þ Medical examiner ñ professional physician who can solve both medical and legal problems concerning cause and manner of death, performs autopsies and advances his medico­legal work because on effect of increased specialization. þ Medical jurisprudence ñ that part of law which is concerned with the regulations governing the profes­ sional practice of the doctor of medicine. þ Medical malpractice ñ medico­legal phenomenon which covers all defects in the professional behavior of doctors: medical negligence and professional misconduct. þ Mummification ñ process of dessication of the body in dry warm conditions with a draught of air. þ Murder ñ homicide, when killer either intends to kill or intends to cause severe injury (grievous bodily harm). þ Near­drowning ñ if drowning is survived, the event is referred to as a near­drowning. þ Necrophilia ñ sexual permutation which is characterized by abnormal sexual orientation to dead persons (corpses). þ Neonaticide ñ deliberate killing of a new­born child within 24 hours of its birth by its mother. The killing must take place during a very limited period (not later than after the first feeding and swaddling of the infant). þ Pedophilia ñ abnormal sexual orientation to children. þ Penetrating firearm injury is the type of injury, when the projectile is situated within the body: entrance wound and wound channel are present, exit wound is absent. þ Perforating firearm injury is the type of injury, when both the entrance and the exit wounds are present, the projectile exited the body. þ Poison ñ any substance, which being entered to the organism in relatively small amount may cause its chemical damaging, pathologic condition and even a death. þ Poisoning ñ damage to the tissues, organs and whole organizm by a harmful chemical agent. PDF created with FinePrint pdfFactory trial version http://www.fineprint.com þ Post­mortem hypostasis (synonyms: lividity, suggilation) ñ pink to bluish zones on the dead body sur­ face (back, buttocks, thighs, calves, back of the neck; in hanging ñ legs and hands) appearing due to gra­ vitation and passive cumulation of the blood in lowest parts of the body. þ Pregnancy ñ condition which occurs in the female when an ovum, discharged from ovary into the genital tract, is fertilized by a spermatozoon in the male semen introduced. The normal duration of pregnancy is about 40 weeks or 280 days (10 lunar months). þ Putrefaction ñ usual reductive process of postmortal moist decomposition with contribution of gut bacteria leading to liquefaction of the soft tissues and gas formation in those tissues. þ Rape ñ unlawful sexual intercourse (homo­ or heterosexual) usually by a man with a woman by compul­ sion through force, threats or fraud. þ Reflex cardiac arrest (vagal inhibition) ñ cessation of heart function due to overload vagal impulsation. Situations which may cause reflex cardiac arrest are: tense emotion and use of alcohol or drugs, immersion þ Rigor mortis (synonym: stiffness of muscles) ñ post­mortem muscle rigidity due to fusing of actin and myosin into a gel by depletion of glycogen, ceasing of re­synthesis of ATP and accumulation of lactic acid with simultaneous influx of calcium through injured membranes. þ Rolling­over ñ traffic accident situation when a vehicle can roll over and causes severe injuries of pas­ sengers, especially if they do not wear seat­belts. þ Running­over ñ traffic accident situation when a motor wheel passes over the body. þ Sadism ñ sexual permutation which is characterized by gratification from inflicting pain on others and enjoyment gained from mistreating others, where a person in order to feel a sexual excitement causes painful stimulation and even injuries to his / her partner. þ Scalding ñ thermic injury caused by hot steam, water or other liquid with the temperature over 50 C up to 100 C, where no charring appears. þ Sexual asphyxia ñ partial or total asphyxia caused by hanging, strangulation or covering the facial orifi­ ces performed the way to cause partial cerebral ischemia and erotic fantasies, often with the combination of bound extremities or other masochistic devices. Death must be regarded as an accident. þ Skeletalization ñ process of conversion of a dead body to a skeleton. þ Still­born child ñ child of more than 28 weeks' gestational age which after being completely expelled from the mother, did not breathe or show any signs of life. þ Strangling (ligature strangulation) ñ type of mechanical asphyxia when a constricting band is tightened around the neck (homicide, suicide or caused by a machine). þ Sudden death ñ rapid natural death, in which the cause of death is unknown (cannot be discovered without autopsy). þ Sudden Infant Death Syndrome (SIDS, synonyms: cot death, crib death) ñ death of small infant com­ monly in its bed in the night during the sleep with no apparent cause and with the signs of apnoe. þ Suicide (synonym: self­murder) ñ act of intentionally taking one's own life, a type of violent death where a victim causes deliberate fatal injury to himself. þ Supravital reaction ñ lasting ability of some organs, tissues and cells to keep physiological processes during some time after death. þ Tangential firearm injury is the firearm injury, when the wound channel is opened to the surface, the entrance and exit wounds are contacted with each other in the skin of the body, extending to the dermis. þ Thanatology ñ the science of dying and death (Thanatos is a god of dead sleep in the ancient Greek mythology). The main branch of this science is forensic thanatology. þ Throttling ñ manual strangulation (always homicide). þ Tolerance ñ the condition, when large doses of remedy or poison no longer have the effect that they had originally (increasing doses need to be given for the same beneficial effect). þ Traumatic asphyxia ñ fixation of the thorax or abdomen by external pressure which prevents respiratory movements mainly in accidents and mass disasters (earthquake, war, terroristic actions). þ Unexpected death ñ death where a known disease was successfully treated or the patient is in recovery but this disease unexpectedly causes death. þ Vital reaction ñ evidence for injury in living organism (local and general: inflammation, bleeding, embolism, necrosis, carbone monoxide in the blood, soot in the airways during a fire etc.)

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com þ Whiplash injury ñ severe traumatic injury of cervical spine and spinal cord due to quick acceleration­ deceleration of the head in transportation accident (victims are mostly drivers and passengers in a car). þ Withdrawal symptom ñ mental or physical disturbance suffered by a drug addict when he is deprived of his usual amount of drug of dependence, a complex of general signs (headache, psychical lability, total arrogancy) and a desire to use the drug immediately. þ Wound ñ the lesion which was caused by a deliberate action; in some guides "wound" means obligately a breach of the skin. þ Wound channel ñ a channel between entrance and exit gunshot wounds in the body. þ Zoophilia ñ sexual permutation which is characterized by abnormal sexual orientation to animals.

PDF created with FinePrint pdfFactory trial version http://www.fineprint.com