Handbook of FORENSIC PATHOLOGY
Second Edition
Vincent J.M. DiMaio and Suzanna E. Dana
Boca Raton London New York
2006 by
Suzanna E. Dana and Vincent J.M. Di Maio
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742
© 2006 by Suzanna E. Dana and Vincent J.M. Di Maio
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works Version Date: 20131021
International Standard Book Number-13: 978-1-4200-0922-4 (eBook - PDF)
This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher cannot assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint.
Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers.
For permission to photocopy or use material electronically from this work, please access www.copyright. com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged.
Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.
Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com
To my children, Dominick and Samantha DiMaio
—Vincent J. M. DiMaio
and
To my parents, Rose and Fieldon Thomas Dana —Suzanna E. Dana
2006 by Suzanna E. Dana and Vincent J.M. Di Maio
by
Suzanna E. Dana and Vincent J.M. Di Maio
Preface
In the preparation of this handbook, every effort was made to provide the pathologist-in-training with an up-to-date, concise manual detailing the many varied aspects of forensic pathology. Specialized areas such as forensic anthropology and forensic odontology have been mentioned but not dealt with in detail. The core principles in most other areas of the field are included and are presented in a fashion that allows for rapid assimilation. We have tried to address problems and questions that commonly arise during instruction of pathology fellows, residents, and medical students. It should be kept in mind that the information (descriptions, time periods, processes, etc.) presented in this handbook relates to the most common findings; however, variations will occur.
The field of forensic pathology can be an exciting and fulfilling one, especially if the doctor is well trained. It is our hope that this handbook will provide such instruction.
V. J. M. Di Maio Chief Medical Examiner
Bexar County, Texas Professor, Department of Pathology
University of Texas Health Science Center San Antonio, Texas
S. E. Dana Forensic Pathologist
Clinical Associate Professor, Department of Pathology University of Texas Health Science Center San Antonio, Texas © 2006 by
Suzanna E. Dana and Vincent J.M. Di Maio
by
Suzanna E. Dana and Vincent J.M. Di Maio
1
I. FIVE CATEGORIES OF MEDICOLEGAL CASES
•Violent deaths, i.e., nonnatural deaths (accidents, suicides, and homicides)
•Suspicious death, i.e., those that may be due to violence
•Sudden and unexpected deaths
•Unattended deaths, i.e., those in which a physician is not in attendance
•Deaths in custody
Individual jurisdictions may modify these categories, either expanding or contracting them.
A.PREVALENCE OF MEDICOLEGAL CASES
1.In most communities, approximately half of all deaths are reportable to a medicolegal office.
2.Of these, half (approximately 25% of all deaths ) will be accepted as medicolegal cases.
3.The rest are generally unattended deaths of individuals under the care of a physician who is willing to sign a death certificate, e.g., deaths in hospices, at home, etc.
4.Even if a case is not accepted, a written record of the report containing details of the death should be made and retained.
B.THE OBJECTIVES OF A MEDICOLEGAL EXAMINATION OF A BODY ARE:
1.To determine the cause of death
2.To determine the manner of death
3.To document all findings
by Suzanna E. Dana and Vincent J.M. Di Maio
4.To determine or to exclude other factors that may have contributed to the death or how the manner of death should be classified
5.To collect trace evidence from the bodies in criminally related cases
6.To positively identify a body
C.IN ADDITION, THE PATHOLOGIST MAY SUBSEQUENTLY BE CALLED UPON TO:
1.Testify in court to the findings
2.Interpret their significance, how they occurred, and the nature of the weapon used (if any)
3.Determine time of death
D.A MEDICOLEGAL AUTOPSY DIFFERS FROM A ROUTINE HOSPITAL AUTOPSY IN SEVERAL RESPECTS (TABLE 1.1).
TABLE 1.1 Differences between Hospital and Medicolegal Autopsy
Hospital AutopsyMedicolegal Autopsy
Requires consent of next of kinIn most U.S. jurisdictions, does not require consent of next of kin
Purpose: To confirm suspected cause of death, as teaching tool, or to assess effectiveness of treatment
Identity of deceased usually known
Purpose: To determine or document cause of death or to rule out unsuspected cause of death in criminal cases
Identity may not be known; information obtained at autopsy may be used to arrive at positive identification
Evidence usually not collectedEvidence collected and preserved for possible use in court proceedings
Time of death usually knownTime of death may not be known, and autopsy
Medical records usually available prior to autopsy
Extent of autopsy may be limited at next of kin request
External exam less critical than internal exam
findings may be helpful in estimating time of death
Medical records may not be available prior to autopsy
Complete autopsy is the rule instead of exception and includes head and neck exam
External exam more important than internal exam, as a rule
Photos during exam are optionalPhotos required to document wounds and findings
Body may be embalmed prior to autopsy
Toxicology usually not helpful; samples usually not taken
Microscopic sections usually submitted and examined
Body should never be embalmed prior to exam; embalming destroys evidence, introduces artifacts, affects toxicology
Toxicology essential part of exam; results may indicate cause of death
Microscopic sections taken in select cases only, not as a routine part of the exam
II.CAUSE, MECHANISM, AND MANNER OF DEATH
Deaths can be categorized as to cause of death, mechanism, and manner.
A.The cause of death is the disease or injury that produces the physiological disruption in the body resulting in the death of the individual, e.g., a gunshot wound of the chest.
B.It should not be confused with the mechanism of death, which is the physiological derangement due to the cause that results in the death, e.g., hemorrhage.
C.The manner of death is how the cause of death came about.
1.Manners of death are:
•Natural
•Accident
•Suicide
•Homicide
•Undetermined
•Unclassified
2.A classification of homicide does not necessarily indicate that a crime has been committed, as the term homicide is not synonymous with murder. The term homicide just means that one individual killed another.
3.Classification of death as murder is done by a court, not a pathologist.
4.A manner of death is classified as undetermined when after an investigation of the circumstances surrounding a death, a postmortem examination, and appropriate laboratory tests, there is insufficient information to classify the death as natural, homicide, suicide, or accident.
5.Some forensic pathologists use a classification of “unclassified” when the death does not fall into any of the aforementioned manners of death. An example may be a psychotic individual who decides he can fly and attempts to do so off a 200-foot cliff. Such a death is obviously not natural or homicide, but is it suicide or an accident?
6.Deaths formerly termed “therapeutic misadventures” may be listed as unclassified.
7. Figure 1.1 shows the caseload, broken down by manner of death, for a large metropolitan medical examiner’s office (Bexar County, San Antonio, Texas, 2004 statistics). The majority of cases handled are natural or accidental.
III.THE FORENSIC AUTOPSY VERSUS AN EXTERNAL EXAMINATION
A. It is not necessary to perform an autopsy in all medicolegal cases. The reasons for performing an autopsy are varied. The most obvious ones are:
1.To determine the cause of death when it is not known
2.To document injuries
3.To exclude other causes of death
4.To determine or exclude contributory factors to the death. This last reason is why autopsies are performed in most homicides, suicides, and accidents.
B.In some jurisdictions, autopsies are mandated in certain types of death.
C.Autopsies should be performed on all homicides.
D.The extent of the autopsy
1.A complete autopsy, at a minimum, involves removal and examination of the brain, the larynx and hyoid, and the thoracic and abdominal viscera as well as collection of blood, urine, bile, and vitreous, when available.
2.In certain cases one may want to make an even more extensive examination, e.g., incise the legs looking for the source of a pulmonary embolus.
3.As a general rule, either no autopsy or a complete autopsy should be performed. Exceptions occur. These generally involve autopsies limited to the head and are indicated in cases where there is a well-documented self-inflicted gunshot wound
Figure 1.1 ME caseload by manner of death.
of the head and the bullet has not exited. The main purpose of the limited autopsy in this case is recovery of the bullet.
4.All homicides should be completely autopsied.
IV.THREE STEPS OF MEDICOLEGAL DEATH INVESTIGATION
A.First is an investigation of the circumstances leading up to and surrounding the death. One must obtain as much information as possible prior to examining the body.
1.A postmortem examination of a body should never be conducted until one knows the circumstances of the death.
2.Investigation of the circumstances of a death may involve:
a.An investigation of the scene
b.Talking to witnesses, next of kin, and attending physicians
c.Obtaining past medical records or police reports
3.In cases where homicide is suspected, one should talk to the police to find out any special examinations or tests that they may desire.
4.The circumstances of a death may determine to some degree the extent of the subsequent postmortem examination. Thus, a complete workup for rape would be conducted on the body of a young girl found seminude in an isolated area but not if she was fully clothed and shot while walking home from a store.
B.Second is the examination of the body, whether it be an autopsy or an external examination.
C.Third is the performance of laboratory tests (including but not limited to toxicology, ballistic test firings, etc.).
V.HANDLING OF BODIES AT THE SCENE
A.It is at the scene that the correct handling of the body begins. If this is not done, physical evidence on the body can be lost or altered and sham evidence inadvertently introduced.
1.Before the body is touched, its position and appearance should be documented photographically and diagrammatically.
2.The body should be handled as little as possible so as not to dislodge physical evidence that may be clinging to it.
3.The hands should never be pried open so as not to dislodge material such as fibers, hair, or gunpowder.
B.Before transportation of the body to the morgue:
1.Paper bags should be placed over the hands to prevent loss of trace evidence. Paper bags should be used rather than plastic, because plastic bags promote condensation on their interior as the body goes from refrigerated to heated environments.
2.The body should be wrapped in a white sheet or placed in a clean transport bag. This is done to prevent loss of trace evidence from the body. It also prevents acquisition of bogus evidence from the vehicle being used to transport the body to the morgue, as this vehicle has probably transported numerous other bodies.
VI.HANDLING OF BODIES FROM A HOSPITAL
A.If the deceased did not die immediately and was transported to a hospital, a number of surgical and medical procedures may have been carried out. Because of this:
1.The complete medical records of the deceased from the time of admission to the time of death should be obtained.
2.In addition, EMS and ambulance transport records should also be obtained.
B.All hospitals in the area served by the medicolegal system should be informed that in all medicolegal cases:
1.No tubing should ever be removed from the body after death, e.g., endotracheal tubes, intravenous lines, and Foley catheters.
2.Injection sites should be circled in ink by the hospital staff to indicate that they are of therapeutic origin and did not antedate hospitalization.
3.Surgical stab wounds should be labeled or described in the medical records.
4.If an injury is incorporated into a thoracotomy or laparotomy incision, this should be noted.
5.If death occurs within a few hours after hospitalization, paper bags should be placed on the hands, just as if the death had occurred at the scene.
6.Any clothing worn by the deceased should be transferred to the medical examiner’s office.
7.All medical records detailing the procedures performed should accompany the body.
8.Any blood obtained on admission to the hospital should be obtained for toxicology. Admission blood obtained for transfusion purposes in trauma cases often is saved for one to two weeks in the hospital blood bank. The blood bank should be queried for retained initial blood samples.
VII.HANDLING OF BODIES AT THE MORGUE
A.On arrival at the morgue, the body should be logged in as to:
1.The deceased’s name
2.The date and time of arrival
3.Who transported it
4.Who received it
B.A unique case number should be assigned to the body. At the time of the autopsy, an identification photo should be taken with the case number prominently displayed in the identification photo.
C.Examination of clothing and external aspect of the body
1.Before examination by the pathologist, the body should not be undressed, washed, embalmed, or fingerprinted.
a.The clothing should not be disturbed, as examination of the clothing is as much a part of the forensic autopsy as examination of the body.
b.Embalming can introduce artifacts, change the character of wounds, and make toxicological analyses impossible or extremely difficult.
2.The pathologist should have x-rays taken if they feel that they may be helpful. X-rays should be routinely taken in:
a.All gunshot wound cases
b.Deaths of infants and young children
c.In the case of decomposed, charred, and unidentified bodies
d.Explosion victims
3.The next step is to recover any trace evidence on the clothing or the body.
a.The body is examined with the clothing still on the body.
b.The clothing should be examined for the presence of trace evidence.
c.Following this, the clothing is removed and laid out on a clean, dry surface. The clothing should not be cut from the body except under very unusual circumstances.
d.Attention is paid as to whether defects in the clothing correspond in location to wounds on the body.
4.The body is then examined without the clothing and without cleaning. One should again search for trace evidence. One may want to take photographs of the uncleaned wounds at this time.
5.The body is then cleaned and reexamined for any other wounds that may have been concealed by blood.
a.Photographs of the cleaned wounds should then be taken.
b.The pathologist should go back to the clothing and again correlate any observed trauma to defects in the clothing.
6.The use of a dissecting microscope in the examination of both wounds and clothing is strongly recommended.
D. Photography of wounds
1.At least two photographs of each wound should be taken.
a.One should be a placement shot showing where the wound is in relationship to other body landmarks.
b.The second should be a close-up showing the appearance of the wound.
c.Most individuals take a third shot in between the two extremes.
2.It is helpful if there is a scale and the number of the case in the photograph.
3.If evaluation of the color of a wound is important, then a color standard/ruler should be included in the photo.
E.Internal examination of the body
1.In most cases, a complete autopsy involving the head, chest, and abdominal cavities should be performed. All viscera should be removed and examined.
2.Blood, vitreous, urine, and bile should be retained.
3.In cases of advanced decomposition where these materials are not present, muscle (from the thigh, preferably), liver, and kidney should be retained. These materials can be used for toxicological, serological, or DNA analyses.
F.Laboratory tests
1.After performing the autopsy, the pathologist may wish to have laboratory tests performed to:
a.Aid in determining the cause or manner of death
b.Identify any contributory factors
c.To exclude other causes of death or contributory factors
2.The most common tests ordered in forensic autopsies are:
a. Toxicology. Virtually all medical examiner cases should have toxicology performed. Occasionally, such tests will reveal an unsuspected death due to an overdose of drugs.
b. Histology. Histology does not have to be performed on all medicolegal cases, especially those which are traumatic in nature.
c. Neuropathology. In certain cases, the pathologist may wish to save the brain to be cut by a neuropathologist.
d. Microbiology is occasionally helpful in cases where identification of the precise bacterial agent involved is important.
e. Serology. Testing for antibodies to venom may be helpful in anaphylactic deaths.
f.In other cases, test firings of weapons may be necessary to make range determinations or to determine if a weapon is defective.
G.Prior to release of the body, fingerprints should be taken. It is suggested that at least two sets of prints be made, one for the police and the other for the autopsy file. In homicides, palm prints should also be taken.
VIII.IDENTIFICATION OF BODIES
In medicolegal cases, positive identification of a body should always be made if possible. Identification methods are discussed in more detail in Chapter 4 and in brief below.
A. Nonscientific methods of identification consist of:
1.Identification of a body by relatives or friends
2.Identification based on documents on the body, clothing, scars, or tattoos
3.Identification based on exclusion (“Mary was in the car before it crashed and burned, and only one female body was found in the wreckage”)
B. Scientific methods of identification include:
1.Fingerprints
2.Dental identification
3.DNA testing
4.Comparison of antemortem and postmortem x-rays
C.In the case of decomposed or unrecognizable bodies, scientific methods of identification should be used.
D.If the pathologist is presented with an unidentified body in which attempts at identification have been unsuccessful, prior to its release, the pathologist should:
1.Take identification photos.
2.Chart and x-ray the teeth.
3.Fingerprint the body.
4.Perform total-body x-rays.
5.Retain tissue for DNA analysis.
The Autopsy Report
I.HEADING OF REPORT SHOULD INCLUDE THE FOLLOWING:
A.Unique identification number for the individual being autopsied, usually generated in the autopsy facility and unique to that facility
B. Name, sex, age (with birth date) of the deceased
C. Date, time and physical location of the exam
