3例致命伤后行为能力分析探讨

法医在命案现场勘查中,正确分析致命伤后行为能力至关重要,这对重构现场、准确分析解释现场疑点、判断案件性质等有重要意义,同时也是法医工作中的难点和热点问题。人体受到致命伤后不一定立即死亡,其是否具有行为能力及行为能力的大小受多种因素影响,因此分析致命伤后行为能力要结合现场和案情谨慎考虑推断。通过3例案例对致命伤后行为能力进行分析探讨,得出一些关于致命伤后行为能力的思考和观点,以供同行参考。     

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.     

Fat Transfer and Fatal Macroembolization

Fat embolism is usually associated with long bone fractures or other trauma. The diagnosis is usually clinical, and in most cases, emboli are not fatal and not usually seen on gross examination. At the Los Angeles County Coroner's Office, we autopsied the victim of fatal macroscopic fat embolization to the lungs. The patient died during buttock enhancement surgery when fat from liposuction was injected into her buttocks. Fat embolism from liposuction and fat injection is reportedly rare, and macroscopic embolization is rarer still. Varicose veins can occur in the area of the sciatic notch and are known to cause painful sciatica symptoms. We suggest them as a potential conduit for macroscopic fat to reach the lungs. Simple pre‐operative questioning for sciatica symptoms and possible radiologic study to rule out sciatic varices seem prudent before undertaking buttock‐enhancing surgery. Careful fat injection with pre‐aspiration is always advised.     

Death Due to Coronary Artery Insufficiency Following Blunt Trauma to the Chest

There have been numerous reports of sudden cardiac death following blunt trauma to the chest, but there is lack of such references in forensic literature. It is the court of law which makes decision about trauma precipitating natural events. The forensic pathologist is scientifically trained in the medical field and would be in a better position to give clear picture about the victim's general status at the time of death, exact nature and severity of the illness he is suffering from if any. He can also assess the nature and severity of injuries sustained, and thus, his opinion as to the possible role played by the traumatic event in bringing about the death is valuable. This paper will discuss the mechanism of cardiac injury or possible cardiac injury and sudden death of an apparently healthy 36‐year‐old male following blunt chest trauma sustained during alleged assault by his neighbor.     

“Bubbles”—A Spot Diagnosis

Abstract: Aspiration of blood is a phenomenon observed in violent and natural death scenarios. Bloodstain patterns evolving from expectoration of aspired blood may look suspicious of a violent genesis and thus mislead crime scene investigators. In the present case, a woman was found lying in a pool of blood on the kitchen floor. Furthermore, bloodstains covered her face, clothing, and surrounding furniture and walls. Bloodstain pattern analysis and medicolegal inspection of the suspected scene of crime were carried out and revealed dispersed stains with enclosed gas bubbles in the absence of signs of physical violence leading to the assessment of a natural manner of death. The bloodstains were attributed to expiration of blood because of an internal bleeding. Medicolegal autopsy confirmed the on‐site diagnosis as a fatal esophageal varix rupture was found.     

Biparietal Thinning: Accidental Death by a Fall from Standing Height

Biparietal thinning resulting in bilateral and symmetrical resorption and loss of thickness of the parietal bones is an uncommon to rare condition in the anthropological and clinical literature. This enigmatic condition of unknown etiology was first reported in the 18th century and has been variously described as a nonmetric trait, anatomical variant, anomaly, and pathology. Biparietal thinning presents grossly and radiographically as oval‐shaped depressions in 0.25–0.8% and 0.4–0.5% of individuals and with a higher frequency in females over the age of 60 years. A review of the literature revealed only one example of cranial trauma associated with biparietal thinning and none of fatal trauma associated with this condition. This case reports a rare example of fatal trauma in an elderly man that resulted from a backward fall from a standing height and highlights the increased risk of craniocerebral trauma in individuals with this condition.     

Black Esophagus: Acute Esophageal Necrosis in Fatal Haloperidol Intoxication

Herein, we present a case of 53‐year‐old psychotic woman with acute esophageal necrosis (black esophagus), who was found lying on the floor in the living room of her flat. Pillboxes of antipsychotic drugs were located in the bin. External examination of the body was unremarkable. On internal examination, we found acute esophageal necrosis. Histologically, there was complete epithelial necrosis with focal involvement of muscularis mucosae, dense infiltrate of leukocytes, and ulcerations without any viable cells. There was no evidence of underlying organic diseases or trauma. Toxicological analysis revealed a fatal blood level of antipsychotics (haloperidol, zotepine, and chlorprothixene). Death of the deceased was attributed to fatal intoxication with three various types of antipsychotics. As far we know, this is the first described association between so‐called black esophagus and fatal blood level of neuroleptics.     

Fatal hemorrhage from a periumbilical wound: Stabbing or hemorrhage from a caput medusae?

Varices are the main clinical manifestation of portal hypertension, and their bleeding is the predominant cause of mortality from this condition. Periumbilical varices are known as “caput medusae.” Reports of their bleeding are rare, with only three fatal cases described in the literature. The antemortem diagnosis is relatively simple, while the postmortem diagnosis is more complex. This paper is the first report of fatal hemorrhage from a caput medusae for which the diagnosis was made postmortem, thanks to a complete diagnostic process including scene and circumstances, medical history, and autopsy with detailed histology. The circumstantial analysis showed the presence of a large amount of blood at the scene, blood which originated from a small abdominal wound; an analysis of the subject's clinical data reported that he was affected by portal hypertension. The autopsy revealed some dilated and convoluted veins in the subcutaneous tissue of the umbilical region; a fistula between these veins and the abdominal wound was detected. The histological study confirmed the presence of periumbilical varices, one of them ruptured and connected with the overlying skin. The cause of death was attributed to a massive hemorrhage generated by a periumbilical varix in a patient affected by portal hypertension.     

Death Due to Isolated Jejunal Tear Following Blunt Abdominal Trauma

Small intestinal injury following blunt abdominal trauma has been widely reported. Isolated jejunal tear which is caused by blunt abdominal trauma is rare and is most often seen in road traffic accidents. Here, we report a case of isolated jejunal tear in a 24‐year‐old male truck driver. He was admitted to a tertiary care hospital in a South Indian Metropolitan city with complaints of acute abdominal pain and tiredness following alleged accidental blunt trauma sustained to abdomen due to steering wheel impact. An isolated jejunal tear and adjacent mesenteric contusion and tear were missed by the treating physician even after preliminary investigations, and thus, the conservative management was instituted. The condition deteriorated gradually, and he succumbed to death. The autopsy revealed transverse tear of jejunum almost involving whole of its circumference on the antimesenteric border and peritonitis. Proper use of radio‐diagnostic techniques and timely undertaken explorative laparotomy would have saved the life.     

Occlusion of left and right coronary arteries and coronary sinus following blunt chest trauma

Blunt chest trauma from rapid automobile airbag deployment causing coronary artery occlusion and myocardial infarction is a rare but potentially fatal condition. We present the case of a 37-year-old man who developed extensive anterior and inferior myocardial infarction because of occlusion of both left anterior and right coronary arteries following blunt injury to the chest in a car accident. The patient was scheduled for emergency coronary angiography but left and right coronary ostia were not cannulated because of thrombus formation probably. The patient died, and the autopsy revealed external compression by epicardial hematomas involving separately left and right coronary arteries and the coronary sinus without signs of coronary and/or aortic dissection. To our knowledge, this is the first case presenting occlusion of both coronary arteries secondary to blunt chest trauma causing acute myocardial infarction in a young man without signs of prior coronary artery disease.     

Can Birth Trauma Be Confused for Abuse?

Abstract: An unexpected infant death is usually investigated with a complete autopsy. If evidence of prior trauma is found at autopsy in these cases, suspicion is raised for nonaccidental trauma. In a young infant, the residua of trauma received during birth has the potential to be incorrectly interpreted as nonaccidental trauma. We report a the findings of a 4 1/2‐month‐old‐infant that died unexpectedly with a healing linear skull fracture and a circular lesion over the calvarium found at autopsy. Though this lesion was concerning, the remainder of the autopsy and the histological findings did not support a diagnosis of recent trauma. Review of the literature describing birth injuries made the diagnosis of healing, residual birth trauma more convincing in this case.     

246例高坠案件中坠落高度与损伤分析

目的对高坠案件进行统计分析,为相关鉴定研究提供参考。方法收集上海市浦东地区最近十年来记录有坠落距离的246例高坠案件,对人体损伤的特点进行比较分析。结果自杀高坠的高度显著高于意外高坠的高度(25.70m:13.98m);所有高坠中,头部损伤概率较高(75.2%),颈部损伤概率较低(6.5%);意外高坠的头部损伤概率高于自杀组(89.4%:75.2%)。结论意外高坠的死者比自杀高坠的死者更缺乏四肢对于头部的保护;过低的颈部损伤发现率提示国内法医工作者应该更加重视在高坠案件中的对于颈部损伤的检查。     

Analysis of Forensic Autopsy in 120 Cases of Medical Disputes Among Different Levels of Institutional Settings

Despite advances in medical science, the causes of death can sometimes only be determined by pathologists after a complete autopsy. Few studies have investigated the importance of forensic autopsy in medically disputed cases among different levels of institutional settings. Our study aimed to analyze forensic autopsy in 120 cases of medical disputes among five levels of institutional settings between 2001 and 2012 in Wenzhou, China. The results showed an overall concordance rate of 55%. Of the 39% of clinically missed diagnosis, cardiovascular pathology comprises 55.32%, while respiratory pathology accounts for the remaining 44. 68%. Factors that increase the likelihood of missed diagnoses were private clinics, community settings, and county hospitals. These results support that autopsy remains an important tool in establishing causes of death in medically disputed case, which may directly determine or exclude the fault of medical care and therefore in helping in resolving these cases.     

Death caused by a signal rocket--not an isolated case*

Fatalities related to sporting events are predominantly caused by blunt force injuries especially due to the emotional involvement of crowd, but occasionally other types of trauma are reported as well. A case of very rare trauma caused by shooting with a hand-held parachute signal rocket during a football match is presented. A 17-year-old football fan sustained fatal injuries, a combination of mechanical trauma caused by rocket penetration, as well as extensive thermal burning of the thoracic viscera. Analysis of the event was based on autopsy findings and evidence produced by medicolegal and ballistic experts. Improper use of a hand-held signal rocket, designed for marine distress signals, may cause serious injuries either mechanically, due to explosion, or as a result of thermal discharge. In the reported case, pattern of injuries is discussed, and medical finding corroborated to other available evidence. The presented case is a reminder that the forensic pathologist should be informed accordingly on the type and features of weapon suspected to produce injury, to be able to understand traumatic changes, and look for potential presence of foreign bodies at postmortem examination.     

Fatal Falls from Height in Taiwan

This study conducts an investigation of fatal falls from height, examines gender differences, and compares our findings with those of Western countries. We review deaths in Taiwan caused by falls from height that underwent forensic autopsy from 1994 to 2010. Among the examined cases, 182 were suicide, 156 were accidents, and 18 were homicides. Men who fell from greater heights had a lower probability of fatal head trauma (p = 0.045), and women exhibited a lower fatal head trauma rate when falling from heights of between 10 and 25 m in accident group (p = 0.003). There was no significant difference between cases of falling from greater and lower heights within the suicide group (p = 0.834). Psychiatric illness was only reported in 20.3% and 28.8% cases in suicide and accident groups. Only in male cases was the use of psychotropic substances higher in the suicide groups than in the accident groups (p = 0.047).     

肩袖损伤法医学鉴定研究进展

肩袖损伤是一种临床常见的肩关节病,成因复杂且症状有时不甚明显,缺乏特征性表现,容易被漏诊及误诊。在法医学鉴定中,时常遇到肩袖损伤的案例,判定该类案例是创伤所致、自身疾病抑或属于伤病共同作用导致是目前摆在法医鉴定人面前的难点问题。但因找不到客观的鉴别指标,容易使鉴定工作进入盲区,也时常引起当事人对鉴定意见的质疑,甚至长期的上访缠诉,引发社会的不稳定。基于此,从肩袖解剖结构、损伤机制、临床表现、鉴别诊断及法医学鉴定等方面展开论述,有助于为此类案件的鉴定提供参考。     

Skeletal Trauma Resulting From Fatal Low (≤3 m) Free Falls: An Analysis of Fracture Patterns and Morphologies

The skeletal trauma resulting from fatal low (≤3 m) free falls is poorly researched and understood by forensic practitioners. The aim of this study was to identify the types of skeletal trauma resulting from low falls through investigating fracture patterns and morphologies. Skeletal trauma was analyzed using full‐body postmortem computed tomography scans of 145 individuals who died from a low free fall. Trauma was then contextualized to the variables that influence how a person falls using multiple logistic regression. Results showed fracture patterning primarily involved the axial skeleton and that there were a number of patterns significantly associated with the height fallen, pre‐existing health conditions, and age. Analysis of fracture morphologies showed 108 possible fracture types, six of which were significantly associated with the height fallen. Understanding the skeletal trauma characteristic of low free falls will further inform anthropological interpretations of trauma in cases where a fall may be considered the possible mechanism.     

A Novel Application of Infrared Imaging for the Diagnosis of Death by Fire

This paper demonstrates a novel and simple technique for the diagnosis of death by fire using a digital infrared (IR) camera system. At autopsy, the inhalation of soot by a fire victim is a definite indicator proving a vital reaction during the fire. However, there can be difficulties in confirming the presence of soot because of the relative lack of soot or the similarity in color between soot and surrounding tissues. To evaluate the effectiveness of IR imaging at autopsy, we acquired internal images of the respiratory and gastrointestinal system by both an ordinary color and IR cameras. Using our method, the inhaled soot is visible as black particles or deposits, while the blood is transparent and the surrounding tissue is whitened. This technique enables the detection of normally undiscriminating soot in an ordinary color image. This is the first report suggesting the usefulness of IR imaging in forensic autopsy for the diagnosis of death by fire.     

Injury Patterns Sustained in Fatal Motor Vehicle Collisions with Driver's Third‐Generation Airbag Deployment

The Office of the Chief Coroner for Ontario database for 2011–2012 was used to compare fatal injury patterns in drivers whose third‐generation airbags deployed compared to first‐ and second‐generation airbag deployments and airbag nondeployments with and without seatbelt use. There were 110 frontal and offset frontal crashes analyzed. The small sample size meant that the odds of craniocerebral, cervical spinal, thoracic, and abdominal injuries were not statistically different for airbag generation, deployment status, and seatbelt use; however, the risk of fatal thoracic injuries in third‐ and second‐generation cases was increased. Seatbelt usage in third‐ and second‐generation deployment cases reduced the risk of all injuries except abdominal trauma. High severity impacts and occupant compartment intrusion were frequently observed. The analyses in this retrospective study were challenged by data that were not collated in a standardized way and were limited in details about scene, vehicle, and driver variables.     

Coincidence of Nicolau Syndrome and Rhabdomyolysis: Report of a Forensic Autopsy Case and Review of the Literature

Nicolau syndrome (NS) is a dermatological adverse reaction of intramuscular injections and is caused by several mechanisms. The etiopathogenesis remains unclear, and several hypotheses have suggested a vascular origin. Rhabdomyolysis (RM) is the destruction of striated muscle, with the subsequent release of muscle cell contents into circulation. NS and RM diagnoses may overlap. Herein, we present the autopsy findings of a 40‐year‐old female with NS complicated with RM. On clinical follow‐up, creatine kinase (CK) was 7146 IU/L, and urea and creatinine levels were elevated on the third day after intramuscular diclofenac injection. Possible ischemic process triggered the RM and subsequent acute renal failure. The opportunity for an early diagnosis was missed because the patient delayed seeking medical aid. The prognosis worsened, and the patient died due to secondary sepsis. Early diagnosis of NS before the occurrence of complications is the most important issue in patient education and can be life‐saving.