Death by Ram Attack: A Case Report from Greece and a Brief Review of the Literature

A case of a ram attack that caused injuries to a 73‐year‐old man is presented. The deceased survived the attack and had the opportunity to speak with a friend over the phone before being transferred to the hospital. After a 21‐day hospitalization, the patient passed away. A postmortem examination was performed to ascertain the cause of death. The autopsy findings are presented along with a brief review of the literature. Attacks by agricultural animals (or livestock) around the world are reported in the scientific literature. Fatalities from ram attacks are extremely rare. The need to implement specific codes in the ICD system, relevant to each animal attack, appears to be of great importance, in order to allow tracking of animal‐related deaths.     

An Unusual Case of Predation: Dog Pack or Cougar Attack?

Injuries produced by animals are capable of leaving severe patterns and in some cases may result in the death of the attacked individual. Law enforcement authorities may come to erroneous conclusions about the source of the bites based on their awareness of animals present and similarities of the injuries to the untrained eye, with dreadful consequences. Expertise of a carnivore biologist and an odontologist that indentifies the particularities of bite marks may be useful for identifying the attacking species. We present the investigation of a fatal dog pack attack involving a 43‐year‐old man in Bell Ville (Argentina) where the evidence provided by a forensic dentist and a biologist was categorical for establishing the animal species involved. Because of the unusual characteristics of the wounds and the initial hypothesis made by local authorities of a cougar attack, habits and specific patterns of both dog pack and cougar predation on humans are discussed.     

Perineal‐Vaginal Injuries in Children: Accident or Abuse?

Abstract: A large number of conditions have been mistaken for abuse. Differentiating accidental injuries from inflicted injuries is important in the management of injured children. In this work, the authors describe two cases of accidental perineal‐vaginal injury in children. In case 1, a 4‐year‐old girl suffered a vaginal tear caused by violent stretching during play; in case 2, a 3‐year‐old girl had minor lacerations of labia minora and majora. The intervention of a multi‐specialist team including a forensic pathologist and forensic psychiatrist was the key factor in being able to exclude abuse by third parties in the described cases.. This leads to the appropriate recommendations to be adopted in the forensic medicine setting.     

Fatalities Due to Indigenous and Exotic Species in Florida

Florida's climate is suitable for many potentially hazardous animals, including both indigenous and exotic species, which are frequently kept as in zoos or as pets. This has resulted in many unforeseen fatal encounters between animals and the ever expanding human population. While the literature and knowledge pool for more common types of deaths referred to medical examiner/coroner's offices is abundant, the appreciation of wildlife and exotic pet‐related deaths is far less widespread. We report seven animal attack‐related deaths that occurred in Florida. The inflicted injuries included blunt and sharp force injuries, asphyxia, drowning, and envenomation. The underlying cause of death, however, was always a result of the human/animal interaction and in many cases related to human error and failure to appreciate the potentially dangerous behavior of nondomesticated species. These cases illustrate the varied circumstances and pathophysiologies associated with deaths due to indigenous and exotic species and the importance of the multidisciplinary approach in the medicolegal investigation of these cases.     

A Fatal Leopard Attack

Abstract: A rare case of a big cat fatal attack is presented. A male leopard that had escaped from its unlocked cage attacked a 26‐year‐old male zoo worker. The man sustained penetrating injuries to the neck with consequent external bleeding. The man died while being transported to the hospital as a result of the injuries sustained. The wounds discovered on the victim’s body corresponded with the known methods of leopard attacks and with findings on the carcasses of animals killed by leopards in the wild. The conclusion of the medicolegal investigation was that the underlying cause of death was a bite wound to the neck which lacerated the left internal jugular vein, the two main branches of the left external carotid artery, and the cervical spine. The cause of death was massive external bleeding. Special attention is paid to the general pattern of injuries sustained from big cat attacks.     

Subdural Hemorrhage,a Retrospective Review with Emphasis on a Cohort of Alcoholics

Subdural hemorrhage (SDH) is a common cause of death. As external evidence of injury may be absent, an autopsy is frequently needed to detect it. We conducted a 3‐year review of SDH from the New York City Office of Chief Medical Examiner, with emphasis on a cohort of alcoholics. Our study population of 1942 included 1588 alcoholics. Of the alcoholics, c. 8% had SDH (26% of the total number of SDH). Of the alcoholics with SDH, 57% had associated brain injuries. As alcohol intoxication is frequently associated with aggressive and violent behavior, we are concerned that 6% of alcoholics in our review had no autopsy or imaging studies. It is possible that a portion of these may have had a SDH due to an unrecognized inflicted injury. We recommend that autopsies be performed on all alcoholics without a clear cause or mechanism of death.     

Causes and Mechanisms of Death in Fatal Water Buffalo Attacks

Deaths due to buffalo attack have not been well described. A 72‐year‐old man was trampled by a water buffalo (Bubalus bubalis) while attempting to move the animal within an enclosed area at an abattoir. At autopsy, there were numerous injuries involving the chest, head, neck, and left upper arm. Blunt force injury had resulted in multiple rib fractures with a flail chest and fracture/dislocation of the mid‐cervical vertebrae caused either by physical crushing by the animal against the walls of the enclosure or by stomping. There was also evidence of crush asphyxia with bilateral conjunctival hemorrhages and petechial hemorrhages. In addition, there was a deep degloving injury of the upper left arm compatible with goring by one of the buffalo horns. While large animal attacks may result in death from multiple injuries, careful dissection and examination of specific injuries at autopsy may clarify the complex interaction of lethal mechanisms.     

Penetration Depth of Projectiles Fired from a Replica of Colt Navy of 1851 in 20% Gelatin Blocks Correlated with Fatal Injuries Assessed in an Autopsy of a 78‐Year‐Old Man

Pursuant to the Polish Weapons and Ammunitions Law, muzzle‐loading black powder weapons, manufactured before 1885, or their replicas, as well as suitable projectiles, can be possessed legally without registration and special licenses. The aim of the study was to assess the penetration depth of projectiles fired from a black powder weapon, replica of Colt Navy of 1851, in 20% gelatin blocks and to compare the obtained results with the actual injuries found on autopsy of a 78‐year‐old man who had committed suicide. In the experiments, we used the black powder weapon and ammunitions, as well as gelatin blocks serving as a soft tissue model. We ascertained that solid spherical projectiles fired from black powder weapons cause extensive injuries, especially in the initial segment of the wound canal. Additionally, based on the presence and location of the wad in the wound canal, the distance from which the shot was fired can be determined.     

Animal-related fatalities--part I: characteristic autopsy findings and variable causes of death associated with blunt and sharp trauma

Animals may be responsible for an array of potentially lethal injuries. Blunt force injuries characteristically involve larger animals such as cattle or horses that may kick, crush, or trample a victim causing head and facial injuries. Farm workers in particular are at high risk of lethal injuries involving the head and torso. Significant blunt trauma may be found in vehicle occupants after collisions with large animals such as camels or moose. Rarely, zookeepers may be crushed by particularly massive animals such as elephants. Sharp force injuries usually involve carnivore bites, most often from dogs with a "hole and tear" pattern of wounding. Injuries from animals such as alligators and sharks may have a significant component of crushing. Incised wounds may result in death from exsanguination and air embolism. On occasion, blunt or sharp trauma from animal activity may be confused with postmortem damage or with inflicted injury from an assault.     

An unusual case of child head injury by coat hanger*

Traumatic brain injury is the leading cause of morbidity and mortality among children suspected of child abuse. Penetrating cranio-facial injuries are generally rare in the pediatric age group and are caused by both accidental and inflicted mechanisms. We report an unusual case of a 2-year-old female who was admitted to a pediatric emergency room with an industrial stainless steel coat hanger impaled in her skull. Pertinent clinical forensic medicine examination, coupled with home inspection and interviews by the local law enforcement, revealed a horrible episode of domestic violence.     

Recent Firing Range Suicides in South Australia

Abstract: Two cases are reported from South Australia, where deaths occurred that were due to single self‐inflicted gunshot wounds to the head in individuals who were visiting indoor firearm ranges. Case 1: A 54‐year‐old man visiting an indoor firing range placed a .357 magnum handgun to his head and fired one shot. Case 2: A 23‐year‐old woman who was being instructed in firearm usage at an indoor firing range placed a 9 mm handgun to her head and fired one shot. In both cases, deaths were due to cerebral laceration with skull fracture. Firing ranges may be utilized by individuals who are seeking weapons for suicide attempts, and suicide may be successfully undertaken at such locations even while a victim is under direct supervision. In jurisdictions, where firearm ownership is strictly legislated, it may be that clubs can inadvertently provide access to firearms for this type of activity.     

Sickle Cell Trait Mimicking Multiple Inflicted Injuries in a 5-Year-Old Boy

Abstract:  Sickle cell disease (SCD) and sickle cell trait (SCT) can be associated with sudden unexpected death in the pediatric population, usually due to pulmonary complications occurring within the acute chest syndrome (ACS). Musculoskeletal complications can occur and are classically limited to bone infarcts. The occurrence of bone pathology centered upon the epiphyseal growth plate in SCD/SCT is extremely rare, and multiple such injuries in a single patient have not been previously reported. Herein, we describe a case of sudden unexpected death in a 5-year-old child with undiagnosed SCT due to the ACS, with widespread epiphyseal and periosteal bone lesions mimicking multiple inflicted injuries at autopsy. This case highlights the importance of clinicopathological correlation and is the first to describe SCT pathology as a mimic of nonaccidental injury.     

Manual and Automated Cardiopulmonary Resuscitation (CPR): A Comparison of Associated Injury Patterns,

The purpose of this study was to identify and compare patterns of trauma associated with AutoPulse^® CPR and manual CPR. Finalized autopsy records from 175 decedents brought to the Harris County Institute of Forensic Sciences were reviewed, 87 received manual‐only CPR, and 88 received AutoPulse^® CPR (in combination with manual CPR as per standard protocol). The characteristic pattern observed in manual‐only CPR use included a high frequency of anterior rib fractures, sternal fractures, and midline chest abrasions along the sternum. The characteristic pattern observed in AutoPulse^® CPR use included a high frequency of posterior rib fractures, skin abrasions located along the anterolateral chest and shoulder, vertebral fractures, and a few cases of visceral injuries including liver lacerations, splenic lacerations, and hemoperitoneum. Knowledge of the AutoPulse^® CPR injury pattern can help forensic pathologists differentiate therapeutic from inflicted injuries and therefore avoid an erroneous assessment of cause and manner of death.     

Discrepancies in Death Certificates,Public Health Registries,and Judicial Determinations in Italy

The death certificate is mandated by civil law and serves as a medical‐scientific document useful for biostatistics and epidemiological research. For a variety of reasons, death certificates can be misclassified. We reviewed data from self‐inflicted deaths collected over an 8‐year period by the Forensic Institute of the University Sacro Cuore of Rome (Italy). Four hundred and thirty‐five of 2904 were classified as self‐inflicted deaths (15%). The comparison with death certificates processed by the local public health authority (ASL) and by the Italian National Census Bureau (Istat) and with the judicial investigation results available in the Italian Penal Court archive shows some discrepancies. One‐hundred and twenty‐four of 435 deaths were not considered to be self‐inflicted but due to a crime (29% overrecording suicide) with a higher reduction for women, suggesting that it is easier to confuse a murder for suicide in female cases. Any discrepancies between the mortality and crime data are discussed in details.     

The Need for an Interdisciplinary Approach in Forensic Sciences: Perspectives from a Peculiar Case of Mummification

The finding of a mummified body raises many problems, also because of the limits of the medico‐legal investigations in case of mummification. Psychological autopsy and behavioral analysis have demonstrated a significant impact in case of equivocal death. The mummified corpse of a woman was found sealed in a wardrobe during the death investigation of a 36‐year‐old man, later discovered to be the woman's son. The woman's corpse was well preserved and no external injuries were found. Autopsy could not ascertain the cause of death. The state of the premises and the writings on the walls offered an opportunity to investigate the man's psychological profile and to better understand how the events might have taken place. The role of an accurate investigative analysis of the crime scene is a cornerstone of forensic pathology and the case presented underlies the importance of an interdisciplinary approach in forensic sciences.     

Familial Vehicular Murder‐Suicide

A certain number of single‐vehicle crashes into stationary roadside objects such as trees are thought to be occult suicides. However, is it possible that some cases of multiple deaths within a family in similar crashes are due to unrecognized familial murder‐suicides? A 39‐year‐old woman and her 11‐year‐old daughter are reported who died of injuries following a vehicle impact with a tree. Unusual behavior of the mother leading up to the crash, and assessment at the scene, raised the possibility of this being a nonaccidental event. However, difficulties in retrospectively determining the intent of a driver in a vehicle crash, and the nonrecording of, or lack of separate coding for murder‐suicides on registers, make determination of the incidence of these types of events extremely difficult. It may be that this is a subcategory of murder‐suicide that is underdiagnosed and so is not being registered on central motor vehicle crash databases.     

Motor Vehicle Occupants,Neck Injuries,and Seat Belt Utilization: A 5‐Year Study of Fatalities in New York City

Abstract: Despite the implementation of numerous safety devices in automobiles, vehicular occupant fatalities following collisions remain common. We reviewed all fatalities of vehicular occupants in New York City over a 5‐year period on whom autopsies were performed (437) to determine the incidence of neck injuries and correlate them with seat belt utilization; 26.5% had neck injuries (mild to severe) and only 10.3% of these occupants were confirmed to be wearing seatbelts. Of those that had documentation of seat belt utilization there were twice as many neck injuries in the unbelted group. We highlight two cases of submarining with severe neck injuries that were related to automatic 2‐point shoulder harness restraints without engagement of the lap belt.     

Deaths Due to Child Abuse: A 6‐Year Review of Cases in The Cook County Medical Examiner's Office

Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.     

An Unplanned Complex Suicide by Multiple Blank Cartridge Gunshots and Cutting

Blank firing guns are readily accessible in most countries due to an absence of legal regulations. These weapons are capable of causing lethal injuries. We report a rare case of secondary (unplanned) complex suicide committed with a knife and blank cartridge pistol. A 59‐year‐old man was found dead with three superficial incisions in his neck and a gunshot wound to the chest. The external examination revealed an entrance wound in the left chest region consistent with contact shooting. The appearance of a muzzle imprint suggested two discharges. The autopsy showed a slightly hemorrhaged but otherwise intact pericardium, blood in the pericardial sac, and a channel‐like defect in the anterior wall of the left cardiac ventricle. The cause of death was attributed to cardiac tamponade. To the best of our knowledge, this is the first reported case of unplanned complex suicide involving an unmodified blank firing gun.     

Skull and Encephalic Injuries Caused by Beach Umbrellas: Case Reports and Review of Literature

This study reports two unusual cases of skull‐encephalic injuries in bathers that were caused by violent impacts with beach umbrellas. The first case concerned a 36‐year‐old man who, while lying on a sun bed, was struck on his left temple by a beach umbrella, which had been blown away by a gust of wind. The second case concerned a six‐year‐old child who was struck on the right temporal region while he was playing on the sand. Both subjects died. A review of the literature was carried out. Various skull and brain injuries caused by several objects were found, but no injuries caused by beach umbrellas were detected. There were only cases of injuries caused by normal umbrellas. These cases showed that several objects can be responsible for traumas causing skull and brain injuries, therefore forensic investigation must be supplemented by circumstantial data.