The eyes of child abuse victims: autopsy findings.

The authors studied 77 pairs of eyes removed from children who had died of suspected child abuse. Forty-seven of the cases had retinal hemorrhages. Those showing retinal hemorrhages were younger children and had fewer other stigmata of child abuse. Hemorrhages are more likely to occur in cases where the child was shaken or swung than in those with severe direct head trauma. The authors recommend that examination of the eyes be included in the autopsies of all small children who died without an obvious cause of death. Experience in both processing and reading of ocular material is necessary for reliable results.     

Is routine histopathologic examination beneficial in all medicolegal autopsies?

Postmortem examinations are performed for a number of reasons. Medical autopsies are performed at the request of and with the consent of the next of kin of a decedent and are often requested to determine the extent of a disease process or to evaluate therapy. In contrast, medicolegal autopsies are performed by a forensic pathologist primarily to determine cause and manner of death but also to document trauma, diagnose potentially infectious diseases and report them to the appropriate agencies, provide information to families about potentially inheritable diseases, provide information to family members and investigative agencies, and testify in court. As medicolegal and hospital autopsies differ in their purpose, so do they differ in procedure. Medicolegal autopsies often include histologic analysis, but not always, as with medical autopsies. We designed a prospective study to address the question of whether or not routine histologic examination is useful in medicolegal cases, defining a routine case as one where histology would not normally be performed and where the cause and manner of death were readily apparent during the gross autopsy. We reviewed brain, heart, liver, kidney, and lung sections on 189 routine forensic cases and compared the results to the gross anatomic findings. Of the 189 cases, in only 1 case did microscopic examination affect the cause of death and in no case did microscopic examination affect the manner of death. Thus, we feel that routine microscopic examination (performing histologic examination in all cases regardless of cause and manner of death) in forensic autopsy is unnecessary. Microscopic examination should be used, as needed, in certain circumstances but is not necessary as a matter of routine.     

Bleedings into the Anterior Aspect of the Intervertebral Disks in the Lumbar Region of the Spine as a Diagnostic Sign of Hanging

Abstract: Simon’s hemorrhages are ventral intervertebral hemorrhages located beneath the anterior longitudinal ligament that have been described in cases of hanging and tend to appear in the lumbar region of the spine. There are also reports of Simon’s hemorrhages in cases of blunt trauma, asphyxia, drowning, and putrefaction. In a prospective analysis of 2226 autopsies, we found Simon’s hemorrhages in 65 out of 178 cases of hanging and also in 17 cases in a group of 350 controls with various causes of death. The relative frequency of occurrence of Simon’s bleedings in cases of hanging was 37%. Simon’s hemorrhages can be considered an objective vital finding, which is not absolutely specific for hanging. The absence of hemorrhages in intervertebral disks does not exclude death by hanging. This study suggests that Simon’s bleedings in cases of hanging are more frequent in rather young individuals, in cases with free body suspension, and in individuals with minimal degenerative changes in the lumbosacral part of the spinal column.     

Erythrocytes in cervical lymph nodes of the human as a sequela of stasis and/or lymph drainage. Questionable diagnostic significance in strangulation and mechanical injuries of the head

Information on the diagnostic significance of follicular hemorrhage and/or presence of red blood cells in the lymph node sinus was obtained by microscopic investigation of the superficial and deep human cervical lymph nodes. Fifty cases were selected on the basis of the following criteria: (1) cases without strangulation or mechanical head trauma; (2) cases in which death occurred by strangulation without additional mechanical head trauma; (3) cases without strangulation but with mechanical head trauma; (4) cases with strangulation and mechanical head trauma. The usual degree of stasis and hemorrhages and the dilation of the veins and/or capillaries are not sufficient to discriminate between cases with and cases without strangulation. Moreover, erythrocytes, erythrophages, and siderophages were encountered in the lymph node sinus of both cases with and cases without mechanical head trauma. Neither follicular hemorrhage nor the presence of red blood cells in the sinus is therefore diagnostically significant in forensic pathology.     

Histologic appearance of fractured thyroid cartilage and surrounding tissues

Histological appearances of the fractured superior horns (SH) of the thyroid cartilage and their surrounding tissues were reviewed, with particular reference to signs of vital origin of the fracture. Twenty-nine autopsies with either histories or findings indicating asphyxial neck compression, with a total of 39 fractured SHs, and three autopsies with history of suicidal jump from height with a total of two SH fractures, were examined. Fifteen autopsies with finding of 19 artefactually fractured SHs while removing neck organs at autopsy were used as controls. In the cases of neck compression and victims of jump from height haemorrhages, retraction of fractured SH fragments with invagination or squeezing of the perichondrium, contraction bands, contraction band necrosis and 'opaque fibres', in the adjacent muscle fibres could be seen. Fibrin deposition and/or leucocytic reaction were noted in cases where circumstances of death indicated prolonged death struggle (as in incomplete hanging, resuscitation or homicidal neck compression). However, retraction of fractured fragments and invagination of perichondrium between artefactually fractured SH fragments were observed in both control cases and cases with antemortem trauma to the larynx. Many of these histological findings, including haemorrhages and fractures had not been evident at gross examination. We conclude that histological examination of SHs may not only uncover macroscopically overlooked injuries but also may facilitate the clarification of an injury's vital origin.     

Are Peripapillary Intrascleral Hemorrhages Pathognomonic for Abusive Head Trauma?*

Abstract: The American Academy of Pediatrics’ Committee on Child Abuse and Neglect, Section on Ophthalmology, acknowledges that searching for retinal hemorrhages (RHs) in infants only in cases of suspected of abuse creates selection bias. However, they also recommend that postmortem eye removal might not be indicated “in children who have clearly died from witnessed severe accidental head trauma or otherwise readily diagnosed systemic medical conditions.” Although infrequently described in the child abuse literature, peripapillary intrascleral hemorrhages (bleeding in the sclera at the optic nerve insertion)—putatively from severe repetitive acceleration/deceleration forces with or without blunt head trauma—have been considered essentially pathognomonic for abusive head trauma (shaken baby syndrome). We present two neonates who sustained accidental, severe in utero head injuries and had associated extensive RHs and optic nerve sheath hemorrhages with peripapillary intrascleral hemorrhages detected at autopsy. Neither neonate had a documented clinical fundal examination in the intensive care unit.     

Severe Retinal Hemorrhages with Retinoschisis in Infants are Not Pathognomonic for Abusive Head Trauma

The combination of subdural hemorrhage (SDH), retinal hemorrhage (RH), and encephalopathy, or the presence of severe retinal hemorrhages alone in infants, is often attributed to and has been stated to be pathognomonic for abusive head trauma (AHT) or shaken baby syndrome. These beliefs have been challenged, because the same constellation of findings has been identified in accidental head injuries and natural diseases, and most if not all of the studies that support the concept of diagnostic specificity have serious flaws in their methodology. Presented here are two cases of severe retinal hemorrhages with retinoschisis associated with subdural hemorrhage in a natural disease and with severe cerebral edema in an accidental head injury. These cases challenge the dogma that severe retinal hemorrhages with retinoschisis are pathognomonic for AHT.     

Morphometrical analysis of retinal hemorrhages in the shaken baby syndrome

A morphometrical analysis of retinal hemorrhages was performed in cases of physical child abuse including the shaken baby syndrome and in controls (severe head injury, intravital brain death, non-traumatic intracranial hemorrhage, SIDS including cardiopulmonary resuscitation). The extent of the retinal hemorrhages was significantly different between both groups. In all cases of physical child abuse, massive retinal hemorrhages in at least one eye could be found ranging between a maximum value of 19.2 and 73.2% of the entire retinal area. In contrast, only two cases of the control group (severe head injury with skull fractures and intracranial bleeding following traffic accident or fall) showed slight hemorrhages of 3.33 or 1.18% of the retinal area but only in one eye. Therefore, the results provide evidence that massive intraretinal hemorrhages indicate violent shaking — in particular in association with other signs of physical child abuse.     

Reasons, circumstances and results of repeat forensic medicine autopsy

There are only scant literature data on reasons and circumstances of medico-legal second autopsies. The present study includes 12 second autopsies from the period 1992-1997; the first post-mortem examination took place either in the home country (institutes of pathology) or abroad. 7 of the 12 cases of death investigated happened in Germany (exclusively in hospitals) and 5 of them abroad (Netherlands, Romania, Portugal, Libya). Repeat autopsies were ordered by criminal courts (n = 9), private persons (n = 2) and social insurances (n = 1). The main indication was possible medical malpractice (n = 6); acts of violence (n = 3), insurance questions (n = 2) and accidents (n = 1) followed. The time lapse between death and second autopsy was 2-35 days. It was striking, that German institutes of pathology had partially performed autopsies despite the certification of a non-natural death. Clinical autopsies were stopped twice, when evidence of a possible non-natural death occurred. It could be fundamentally stated, that first autopsies in German institutes of pathology had been carefully performed and sufficiently documented. In these cases the second autopsy presented no or only little additional information, as far as the broader taking of (toxicological) samples is not considered. The final medico-legal expertise was then mainly based on the findings of the clinical first autopsy. However, the concurrence of the forensic expert (instead of the clinical pathologist) is undoubtedly essential for the evaluation of these issues involving frequently questions of malpractice. By contrast, the quality of postmortems performed abroad varies widely. 4 of the 5 first autopsies done abroad were regarded as completely or partly insufficient with superficial or almost absent preparation of organs or contradictions in the medical reports, respectively. A repeat autopsy is absolutely necessary in such cases. On the whole, the initial question could be answered in all second autopsies at least in part. This emphasizes the high value of second autopsies and expertises, especially in non-natural cases of death (10 of 12 deaths were finally judged as non-natural).     

Cardiac pathology in 470 consecutive forensic autopsies

Cardiovascular disease continues to be the single most common generic cause of sudden and unexpected deaths. Atherosclerotic coronary heart disease and acute myocardial infarction are the most prevalent forms of fatal cardiac disease observed at autopsy. Other cardiac lesions are frequently listed as causes of death, but the prevalence of such lesions as incidental findings in the general population is unknown. In this study, 470 consecutive forensic autopsies were evaluated for minor and major anomalies. The most frequently observed major congenital finding was floppy mitral valve (5%). Tunneled coronary arteries, considered minor congenital findings, were seen in 29%. Atherosclerotic coronary heart disease was the most common major acquired finding, observed in 16% of cases. Of the 470 hearts, only 8% were considered normal.     

Usefulness of Systematic Histological Examination in Routine Forensic Autopsy*

Abstract: The forensic community does not agree on the need to perform histological examination at forensic autopsy. The aim of our study was to determine the usefulness of systematic standard histology in forensic autopsies. A prospective study was carried out on 428 autopsy cases for which standard histological examination was systematic. Mechanism of death not shown by gross anatomic findings was discovered by histology in about 40% of the cases. Cause of death was established by only histology in 8.4% of the cases. Microscopic findings affected the manner of death in 13% of the cases. Histology provided complementary information about prior medical condition of the deceased in about 49% of the cases. Traumatic lesions were better documented by histology in about 22% of the cases. According to the results of our study, systematic standard histology for the main organs should be used in routine forensic autopsies.     

Histologic evidence of repetitive blunt force abdominal trauma in four pediatric fatalities

In cases of acute fatal child abuse, certain injuries, including cutaneous blunt force trauma, skull fractures, subdural hematomas, intra-abdominal hemorrhage, and retinal hemorrhages are common and well described in the pediatric and forensic literature. These gross findings at autopsy, when taken into consideration with scene investigation and interviews with caregivers, may indicate both a clear manner and cause of death. In such cases, the discovery of additional pathologic changes attributable to older abusive injuries helps support a conclusion of death due to inflicted trauma. We discuss four cases of fatal child abuse in which acute blunt force abdominal trauma was the cause of death. In each of these cases, careful examination with proper sectioning and microscopy of select abdominal tissues revealed that the acute tissue trauma was superimposed on a background of older, healing injury. This older trauma was characterized by classic histologic elements of tissue repair, including fibroblast proliferation, early scar formation, increased vascularity, and hemosiderin-laden macrophages. Iron and trichrome stains were used to confirm the presence of hemosiderin and fibrosis in all four cases, but the recognition of fibroblast proliferation and a reactive vascular pattern was best seen on routine hematoxylin and eosin stains. The gross and microscopic autopsy findings, along with available investigative information, established the diagnosis of chronic physical abuse.     

Resuscitation measures and petechial thymus hemorrhages in sudden infant death

In 45 cases of sudden infant death syndrome (SIDS) in which unsuccessful attempts at resuscitation had been made and in 21 cases without attempted resuscitation, systematic histological investigations were carried out on the thymus. In these investigations, petechial hemorrhages were detected in 82% of the cases with attempted resuscitation and in 76% of the cases without attempted resuscitation. The histological distribution pattern of the petechial thymus hemorrhages did not differ notably between the two groups. The pattern of findings indicates that the hemorrhages had already developed during the death agony and that the typical histological distribution pattern with an increased occurrence of petechial in the cortical zone was altered by massive attempts at resuscitation in individual cases.     

体感诱发电位检查在法医学鉴定中的应用探讨

目的探讨体感诱发电位(SEP)检查在法医学鉴定中的应用价值。方法将60例神经系统外伤(不包括周围神经损伤)并功能障碍者分为脊髓损伤组(33例)和颅脑损伤组(27例),分别进行神经系统查体及SEP检查,并对其结果进行相关分析。结果脊髓损伤组SEP结果33例均表现为异常,异常率100%,且随着功能障碍程度的加重,SEP异常的程度亦加重,两者呈正相关(R=0.72,P<0.01,n=33)。27例颅脑损伤者,仅有9例异常,异常率为33%,功能障碍程度与SEP异常相关性分析(R=0.36,P>0.05)。结论SEP检查是客观评定脊髓功能较为敏感而准确的辅助检查手段;但对颅脑损伤功能障碍的客观评价价值相对有限。     

Healed fractures of the larynx and lingual bone in forensic autopsy]

Laryngohyoid fractures are a frequently investigated matter, especially in the forensic literature. On the other hand, there are only very few (old) forensic reports of such fractures in survived cases. However, healed fractures are not seldom found in forensic autopsies: In a personal series of 1160 forensic autopsies (adult persons) a careful dissection of the laryngohyoid complex was done by 1 investigator. Only a macroscopic examination of the cartilages was carried out; radiographs and histological slices were not regularly made. Therefore only a part of existing old fractures is detectable; for example, healed fissures are not visible with this simple method. Furthermore, asymmetries of the thyroid laminae cannot be declared as posttraumatic without additional examination, because this condition is described as possible anatomic anomaly. From that, the injury frequencies presented here only mark the lower threshold of the existence of such findings. Healed fractures of the upper thyroid horns and the major hyoid horns can be easily detected even in a routine examination, if healing resulted in a fixed dislocation or apposition of bone surrounding the former fracture site. In the present series, this was the predominant localization of old fractures: the upper thyroid horns (43 cases), followed by the hyoid cornua (12 cases), a combination of both sites (5) and cricoid fractures (5). Of the total 65 healed fractures (5.6%), 35 were found in the group of 290 chronic alcoholics (12.1%) and only 3.4% in non-alcoholics. In the subgroup of middle-aged alcoholics, the fracture rate increased up to 19%. However, this group did not present a higher rate of fresh laryngohyoid injuries (not related to strangulation) than the other cases. The old fractures probably resulted from minor "daily" injuries (like falls), which are common, especially in chronic alcoholics. The frequency of such findings should be in mind if an apparently fresh fracture, found in an actual autopsy, should be related to the cause of death: there is a real chance, that this fracture occurred prior, and without causal connection to the factors resulting in death. Therefore a histological examination of the age of this finding is necessary. Cricoid fractures are quite uncommon, except in serious external neck trauma. In 1 of our 5 cases, this fracture was caused by repeated cruelty, finally resulting in death.     

The Infant Injury Database: A Tool for the Study of Injury Patterns in Medicolegal Investigations of Child Abuse

In 2012, the Harris County Institute of Forensic Sciences began prospectively collecting injury data from pediatric autopsies. These data and associated case information from 635 pediatric cases are archived in the Infant Injury Database (IID). This paper introduces the IID to the forensic community and demonstrates its potential utility for child abuse and infant fatality investigations. The database is intended to be a source of evidence‐based research for coroners/medical examiners and clinicians in the recognition and diagnosis of child abuse. RR estimates were employed to quantify the relationship between individual autopsy findings to trauma‐related and nontrauma‐related causes of death. For example, unsurprisingly, the RR of trauma cases with multiple injury types is significantly greater than other causes of death, but the RR results provide a quantitative representation of the relationship. ROC curve modeling of the presence/absence of various injury types performed well at discriminating trauma from other causes of death (AUC = 0.96).     

Unusual Death of a Transvestite: Identification of Crime Weapon and Survival Time*

Abstract: The authors report a case of a transvestite found murdered near his automobile with several lacerated contused wounds to the face and cranial fractures. Autopsy revealed that the cause of death was a serious head trauma with subdural and subarachnoidal hemorrhages. In order to identify the crime weapon, a scanning electron microscopy (SEM) was used which revealed metallic residue on the skin fragments with the same molecular composition of the car paint. As for survival time, antibody anti‐beta‐amyloid precursor protein (APP) was applied to brain fragments and brainstem tissue, allowing for axonal varicosities (which form 2 to 3 h following death) to be observed under the optic microscope. So, by using SEM we understood that the fatal cranial‐encephalic lesions were the result of the victim’s head being repeatedly struck against the car door while anti‐betaAPP led to the understanding that the time elapsed between injury and death was less than 2 to 3 h.     

Nonfracture-associated fatal fat embolism in a case of child abuse

Fatal fat embolism is usually thought of as a sequel to long-bone fracture, although cases secondary to soft tissue injury and atraumatic conditions have been infrequently reported. In this case of a two-year-old child-abuse victim who sustained multiple blunt traumatic injuries without skeletal fractures, pulmonary and systemic (brain and kidney) fat emboli were identified. At autopsy, all thoracic and abdominal viscera were intact; cranial contents exhibited only diffuse symmetrical petechial hemorrhages of the white matter. Because of the severe and widespread nature of soft tissue hemorrhage, and the absence of a grossly discernible cause of death, fat embolism was suspected. Using a combination of frozen section with oil red O staining and formalin-fixed osmium stained tissues, the immediate cause of death was determined to be diffuse fat embolism. Review of the literature reveals a pathophysiologic basis for fat embolism in the absence of fracture, both as a consequence of an acute increase in local pressure at the site of trauma and an alteration of the emulsification of blood lipids during shock. In light of these findings, we present this case to remind the forensic science community to consider fat embolism as the cause of death in cases of blunt-force injury without fracture.