LAWYER’S GUIDE TO FORENSIC MEDICINE CP Cavendish Publishing Limited London • Sydney LAWYER’S GUIDE TO FORENSIC MEDICINE Second Edition Bernard Knight, CBE, MD, DSc (Hon), LLD (Hon), BCh, MRCP, FRCPath, Dip Med Jur Barrister of Gray’s Inn Emeritus Professor of Forensic Pathology, University of Wales College of Medicine CP Cavendish Publishing Limited London • Sydney Published in Great Britain 1998 by Cavendish Publishing Limited, The Glass House, Wharton Street, London WC1X 9PX, United Kingdom. Telephone: +44 (0) 171 278 8000 Facsimile: +44 (0) 171 278 8080 E-mail: [email protected] Visit our Home Page on http://www.cavendishpublishing.com First published by William Heinemann Medical Books 1982 © Knight, Bernard 1998 First edition 1982 Second edition 1998 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, scanning or otherwise, except under the terms of the Copyright Designs and Patents Act 1988 or under the terms of a licence issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 9HE, UK, without the permission in writing of the publisher. Knight, Bernard Lawyer’s Guide to Forensic Medicine – 2nd edn 1. Medical jurisprudence I. Title 614.1 ISBN 1 85941 159 2 Printed and bound in Great Britain PREFACE The 16 years that have elapsed since the first edition of this book have seen many changes which require significant updating of the text. Some entries have been deleted and others added, to reflect the changing priorities in the interface between medicine and the law. This book has apparently filled a previously vacant niche in lawyer’s libraries – on one occasion, I had the uncomfortable experience of standing in the witness box while both prosecuting and defence counsel, as well as the judge, quoted passages to me from their own copies. Due to restrictions of space, the text is sometimes telegraphic and does not purport to be of great literary quality but, hopefully, the content is useful, comprehensible and free from unexplained medical jargon. Within this small compass, it is impossible to provide references to all topics, but a list of standard forensic medical texts is provided, which will direct the reader to the relevant literature. Bernard Knight Lisvane, Cardiff 1998 v CONTENTS Preface v PART I: ANATOMICAL DRAWINGS 1 Anatomical directions 2 Structures of the thorax and upper abdomen (anterior view) 3 Structures of the thorax and upper abdomen (posterior view) 4 Posterior view of kidneys and spleen (showing relationship to pleural cavity) 5 Structures of the thorax and neck 6 The aorta and its branches 7 Surface outlines of heart and lungs 8 Surface markings of the heart 9 Relationships of female and male genital organs 10 PART II: ALPHABETICAL ENTRIES 11 Abdominal injury 12 Abortion 13 Abortion legislation 15 Abrasions 17 Adipocere 18 Age estimation 19 AIDS 21 Air embolism 21 Air-gun injuries 22 Air passage obstruction 23 Alcohol (ethyl) 24 Alcohol (methyl) 28 Amnesia 29 Amphetamines 29 Anaesthetic deaths 30 Aneurysms 33 Aorta 35 Arm-lock deaths 37 Arteries 37 Asbestos 38 Asphyxia 38 Aspirin poisoning 42 Autopsy 43 Barbiturates 45 Bestiality 45 Bite marks 46 Black eye 47 Bladder 48 vii Lawyer’s Guide to Forensic Medicine Blisters 49 Blood groups 50 Blood pressure 50 Blood splashes 51 Brain death 52 Bruises 54 Burial 56 Burns 57 ‘Café coronary’ 61 Cannabis 61 Carbon monoxide poisoning 63 Cardiac arrest 64 Cardiomyopathies 65 Cerebral haemorrhage 65 Cerebral oedema 67 Child abuse syndrome 67 Child destruction 70 Choking 71 Circle of Willis 72 Cocaine 72 Cold injury (hypothermia) 72 Concussion 74 Consent to treatment 75 Contre-coup injury 76 Cooling of the body 78 Coronary artery disease 80 Coroner, deaths reportable to 83 Cot death 84 Cremation (legal requirements) 85 Creutzfeldt-Jakob disease 86 Cut throat 87 Death certification 89 Death, signs of 90 Decomposition of dead body 91 Defence injuries 92 Dental identification 92 Diatom test in drowning 93 Diffuse axonal injury (DIA) 95 Disseminated intravascular coagulopathy (DIC) 96 DNA 96 Drowning and immersion 97 Drugs and medicines 100 viii Contents Ecstasy 101 Electrocution 101 Embolism 103 Entomology 104 Epilepsy 104 Expectation of life 104 Exhumation 107 Explosion injuries 109 Extradural haemorrhage (or haematoma) 110 Fabricated injuries (self-inflicted injuries) 112 Fat embolism 112 Femur, fracture of 113 Fingernail marks 114 Firearm wounds 115 Foetus (fetus) 118 Foreign bodies 119 Fractures 119 Frontal sinus identification 120 Gangrene 122 General Medical Council (GMC) 122 Glass injuries 124 Glue sniffing (solvent abuse) 125 Haemorrhage 126 Hair 126 Hanging 127 Head injury 128 Heart 130 Hepatitis 132 Heroin 132 Histology 133 Human Tissue Act 1961 133 Hymen 135 Hyoid bone 135 Hyperpyrexia or hyperthermia 138 Hypostasis (post-mortem lividity) 139 Identification 141 Immersion 142 Incised wounds 142 Infanticide 143 Intestine 144 ix Lawyer’s Guide to Forensic Medicine Jaw, injuries to 147 Kicking 148 Kidneys 149 Lacerations 150 Larynx 150 Ligature 152 Live birth 153 Liver 155 Longevity 156 LSD (lysergic acid diethylamide) 156 Malignant hyperthermia 158 Masochistic (sexual) asphyxia 158 Methadone 159 Misuse of Drugs Act 1971 159 Mobility and activity after injury 162 Morphine 163 Mummification 164 Mutilation 164 Myocardial infarction 165 Myocarditis 166 Neck-hold deaths 168 Necrosis 168 Obscure or negative autopsy 169 Patterned injuries 171 Petechial haemorrhages 173 Pneumoconioses 174 Poisoning 177 Positional or postural asphyxia 178 Post-mortem entomology 181 Pregnancy 182 Procurator Fiscal 183 Pulmonary embolism and deep vein thrombosis 185 Rape 188 Reflex cardiac arrest 191 Rib fractures 191 Rigor mortis 192 x Contents Scalds 194 Scalp wounds 194 Scars 195 Semen 196 Sexual intercourse 197 Skeletal identification 198 Skull fractures 199 Smothering 202 Sodomy 203 Solvent abuse 204 Spleen 204 Spontaneous combustion 205 Stab wounds 205 Stature, estimation of 208 Status lymphaticus 208 Sterilisation 209 Still-birth 210 Stomach 211 Strangulation 212 Subarachnoid haemorrhage (or haematoma) 215 Subdural haemorrhage (or haematoma) 218 Sudden natural death 220 Suffocation 223 Tattoos 224 Thrombosis 224 Throttling 225 Thyroid gland 225 Time since death 226 Traffic accidents 230 Transplantation of organs and tissues 234 Trauma and disease 236 Traumatic asphyxia 240 Vagal inhibition (reflex cardiac arrest) 242 Vertebral artery injury 243 Vital reaction 243 Whiplash injury 245 Appendix: Recommended Reading 247 Index 249 xi PART I: ANATOMICAL DRAWINGS Lawyer’s Guide to Forensic Medicine Figure 1: Anatomic A is medial to B Bis lateral to A C is proximal to D D is distal to C al directions 2 Part I: Anatomical Drawings Figure 2:Structures of the thorax and upper abdomen (anterior view) 3 Lawyer’s Guide to Forensic Medicine Figure 3:Structures of the thorax and upper abdomen (posterior view) 4 Part I: Anatomical Drawings Figure 4: Posterior view of kidneys and spleen (showing relationship to pleural cavity) 5 Lawyer’s Guide to Forensic Medicine Figure 5:Structures of the thorax and neck 6 Part I: Anatomical Drawings Figure 6:he T aorta and its branches 7 Lawyer’s Guide to Forensic Medicine Figure 7:Surface outlines of the heart and lungs 8 Part I: Anatomical Drawings Figure 8:Surface markings of the heart 9 Lawyer’s Guide to Forensic Medicine Figure 9: Relationships of female Relationship of female genital organs Relationship of male genital organs 10 PART II: ALPHABETICAL ENTRIES Lawyer’s Guide to Forensic Medicine ABDOMINAL INJURY A blow or kick upon the abdomen can cause severe, even fatal internal injury. There need not be any mark on the skin, especially if clothing is interposed. Though bruising or abrasions may be seen externally, rupture of internal organs can occur with no visible skin mark. Most common injuries Rupture of the spleen (qv) which lies in the left upper part of the abdomen. Fatal haemorrhage may occur from impact on the upper left abdomen or lower ribs. Rupture of the intestine (qv), especially in children as part of child abuse syndrome. The upper small intestine may be lacerated or even divided where it crosses the projection of the spinal column, due to direct blows in the centre or upper part of the abdomen. This can be delayed if the injury first makes the intestinal wall non-viable, then it tears a day or two later. The mesentery, the membranous root of the intestine may be lacerated in a similar fashion, leading to severe haemorrhage. Rupture of the liver (qv) often occurs in traffic accidents and falls from a height due to heavy impact on the abdomen or lower chest. Also seen in kicks to the abdomen. Rupture of the stomach or large bowel, but this happens less often than the above. In all these instances, severe illness or death may be due to: (a) haemorrhage into the peritoneal cavity (the free space around the organs), especially from liver, spleen and mesentery; or (b) infective or chemical peritonitis, with shock when intestine or stomach is perforated into the abdominal cavity. Rarely, death may occur instantaneously from a blow in the central abdomen: this is due to cardiac arrest from so called ‘vagal inhibition’ (qv) and where there are no external or internal signs of violence, the diagnosis rests upon the circumstances and exclusion of other causes. 12 Part II: Abortion ABORTION Synonymous with the older term ‘miscarriage’, meaning the expulsion of a pregnancy from the womb before the 24th week of gestation. Later than this, the process is usually called a premature birth, though these are not legal definitions. A considerable proportion – up to 40% – of fertilised ova fail to proceed to full term, most of them aborting at such an early stage that pregnancy may not even have been apparent. The causes of natural abortion include any severe general illness in the mother, but especially acute fevers, congestive heart disease, hypertension with kidney disease, etc.