A ten-year-old girl suddenly died on a playground, after repeated syncopal attacks during the preceding two years. Post-mortem examination revealed the left coronary artery to have arisen by a separate ostium from the right sinus of Valsalva, then coursing to the left between the route of the aorta and the pulmonary trunk where it divided as usual. There was no narrowing of the coronary-artery lumen and the wall was normal. The sudden death is explained by a rise in pressure in the root of the aorta with valve-like closure of the coronary artery. This anomaly should be thought of in other wise unexplained syncopal attacks in children or juveniles during physical exertion. The exercise ECG is apparently not helpful diagnostically. Operative treatment is possible.

Aorta, Thoracic↗

PubMedDate not supplied

[Fatal incidences during arrest of highly agitated persons].

We report on four cases of sudden circulatory arrest during the physical restraint of extremely excited and repugnant men by the police. Three persons died, and one became apallic. The excited states resulted from acute schizophrenic disorder in one case, from intoxications (ethanol and drugs including cocaine respectively) in two others, and from encephalitis in the fourth case. In only one case one of the police officers was condemned for involuntary mansloughter, responsability was excluded in the remainder. Similar lethal events in "excited delirium" are given in the American literature, the main etiologic factors being acute psychosis and cocaine intoxication. Most of these events occurred, differing from ours, under "hogtying" which is a technique of physical restraint in a prone position with the wrists and ankles bound behind the back. These events are thought to be cardiac in origin and to result from oxygen-consuming motor hyperactivity, excessive catecholamine release, and impaired breathing. Police officers are recommended to restrict all measures of restraint to a mininum in extremely excited persons, and to avoid any compression of the trunk or neck. A continuous monitoring for vital signs is postulated in order to recognize a medical incident as quick as possible.

Adult↗

PubMedDate not supplied

[Fatal child abuse (caused by physical violence) in Germany during 1 January 1985 to 2 October 1990. Results of a multicenter study].

UNLABELLED: No reliable data are available on cases of lethal child abuse (by active force) in the area of Federal Republic of Germany prior to reunification (the former West Germany). In a multicenter study we therefore examined the police and court records for such cases occurring in the period 1 January 1985 to 2 October 1990 in nearly the entire area of Federal Republic of Germany. RESULTS: The study center received information on 58 cases of lethal child abuse. Extrapolated to all institutes of legal medicine, this corresponds to 62 cases in all of West Germany in the period studied. An approximately equal number of unreported cases should be added to this figure. Including unreported cases, at least 20 cases of lethal child abuse occurred per year; thus only one in every two cases ever came to light. Almost two thirds of the victims were younger than one year old. At autopsy 59% exhibited signs of repeated abuse at autopsy. By far the most common cause of death was direct impact from a blunt object, usually to the head. Mostly, the male person to whom the victim relates most closely (father, stepfather, partner of the mother) has killed the child. Twenty-one of the 74 persons charged saw the charges against them dropped or were acquitted due to lack of evidence; 51 received sentences ranging from one year probation to life. In the remaining two cases the outcome of the trial was unknown. Signs of abuse were readily apparent at autopsy in almost all cases. The high number of unreported cases underscores the need to educate medical students and practicing physicians to be on the look-out for signs of abuse and argues for an increase in the rate of autopsy.

Autopsy↗

PubMedDate not supplied

[Fatal child neglect in West Germany 1 January 1985 to 2 October 1990. Results of a multicenter study].

UNLABELLED: Up to now reliable data were available on cases of lethal child neglect in the area of the Federal Republic of Germany prior to reunification (the former West Germany). In a multicenter study we therefore examined the police and court records for such cases occurring in the period from 1 January 1985 to 2 October 1990 in nearly the entire area of Federal Republic of Germany. RESULTS: The study center received information on 19 cases of lethal child neglect. Extrapolated to all institutes of legal medicine, this corresponds to 20 cases and thus 3.5 cases a year in the whole of West Germany in the period studied. There is to be added a dark-field which cannot be limited more precisely. However, the cases of fatal child neglect might have occurred much more seldom than fatal child abuse caused by use of physical violence. Slightly more than half the victims were younger than 1 year, the oldest one was 7 10/12 years old. Most frequently the children died of starvation and thirst. Mostly the mothers/nursing mothers killed the child alone or together with the victim's father/stepfather. In the majority of the cases there was not a close affection between parents and child. Nearly 30% female/male perpetrators suffered from chronic alcohol abuse. Only 15 (= 56%) of 27 female/male perpetrators were sentenced to imprisonment (period between 7 months on probation and 10 years). Mitigation circumstances existed for nearly half the persons sentenced to imprisonment. It is true that child neglect is a rarer crime, but the experts of legal medicine always have to indicate errors made during the external inspection of the corpse (among others failures to see indications of neglect).

Cause of Death↗

PubMedDate not supplied

[Distribution of morphine and morphine glucuronides in body tissue and fluids--postmortem findings in brief survival].

An intoxication following administration of morphine, tramadol and atracurium in a suicide case is reported. The route of administration and the amount of the particular drug were known from the investigation of the death scene and the findings of the postmortem examination. Tramadol was present in the gastric contents as well as in blood, liver, kidney and brain samples, whereas the drug could not be detected in muscle. All body fluids and tissues investigated contained morphine as well as its 3- and 6-glucuronides with the exception of muscle tissue. The concentrations of morphine and its glucuronide metabolites were determined by LC/MS following solid phase extraction. Interestingly, the concentration of M6G in brain, liver and kidney were close to the concentration of M3G in the particular tissue. This phenomenon might be explained by a preferential hydrolysis of M3G or by a preferential formation of M6G postmortem. Measurement of morphine and M6G in femoral blood and cerebrospinal fluid may be a useful indicator in rapid deaths.

Autopsy↗

PubMedDate not supplied

[Electrocution accident with three-week survival].

A 55-year-old man was found unconscious with ventricular fibrillations at his working place near a power press. CPR was successful. After three weeks of intensive care the patient died of ischemic brain damage. The first suspected diagnosis of myocardial infarction was revised when typical current marks were detected on both palms. At the working place the top of a lubricating grease container was found to be energized due to a technical damage: There is a round, multiple-pole plug mounted upon the container top the proper orientation of which is coded by a set of five plastic nipples. All the nipples had been abraded by longlasting mechanical stress, so that the plug could be connected in a variety of possible orientations. In actual fact, the incorrect orientation caused a voltage of up to 240 V to the container top.

Accidents, Occupational↗

PubMedDate not supplied

[Criteria for differentiating self- or other-inflicted injuries of alleged or real victims].

A synoptic study of six cases of self-inflicted sharp force injuries is presented, where young, mostly female people had simulated assaults to gain sympathy or other personal advantage. The morphological distinctives of simulated assault wounds from such of real assault are worked out and the common situative and motivative background is cleared up.

Crime↗

PubMedDate not supplied

[Cytologic findings as indications: morphologic and immunohistochemical identification of human brain tissue on the clothing of a murderer].

A case was described in which a murder was concealed by burning the body. The suspect confessed to committing the crime after being informed that human brain tissue in form of slimy stains as well the same blood group as the victim had been identified on his clothing. Slimy stains (approx. 2 x 3 mm) were identified as brain tissue by sectioning on the cryostat together with the bits of wool fiber. Morphologically, nerve cells were clearly identifiable, particular by demonstrating Nissl's bodies. Application of anti-human serum protein and an anti-human cerebrum serum confirmed this finding and augmented it by confirming that the brain tissue was of human origin. The unusual character of this case and the methods used prompted the authors to publish these findings. The available literature is discussed.

Blood Stains↗

PubMedDate not supplied

[Catecholamines, myofibrillary degeneration of the heart muscle and cardiac troponin T in various types of agony].

The stress of agony (the death struggle) induces a rise in serum catecholamines. High doses of catecholamines cause myofibrillar degeneration (MFD), a form of cardiac injury. Severely damaged cardiac myocytes release troponin T (TnT), a myofibrillar cardiac protein, into the circulation. We studied serum catecholamine levels, MFD and TnT in 119 medico-legal autopsy cases. Catecholamine levels increased with the duration of agony: In the instantaneous death cases, the levels were similar to levels in humans at rest, whereas the levels in prolonged agony were comparable to concentrations found in humans in acute maximal stress. Still, it was not possible to infer the duration of agony from the catecholamine level in an individual case. The exceptionally high dopamine levels found in the group 'resuscitation and/or intensive care before death 'were most likely caused by antemortal treatment with dopamine. Slight MFD was diagnosed in nearly all hearts; its severity was neither related to catecholamine levels nor to duration of agony. TnT, not found in blood of healthy people, was present in nearly all postmortem samples, indicating autolytic effects. Heart blood contained more TnT than femoral blood. We could not detect a relationship between the serum cardiac troponin T level and MFD; but cardiac deaths had significantly higher levels of TnT in heart blood than deaths from other causes. The postulated interrelation between catecholamines, MFD and TnT was not evident from the results.

Biomarkers↗

PubMedDate not supplied

[Errors in treatment of soft tissue phlegmon : expert assessment and forensic evaluation].

In ten cases of soft part phlegmons resulting in death (8) and amputation (2) respectively, various types of medical malpractice were evident. The diagnosis was missed, or the disease was correctly diagnosed but underestimated. Typical therapeutic mistakes were the omission of bacteriological investigations and of the proper antibiotical therapy, a delayed hospital admission, or a delayed or insufficient surgical intervention. These errors however could never be proved to have caused the unfavorable outcome in view of the doubtful prognosis of soft part phlegmons even under proper treatment. Thus, evident malpractice never resulted in a condemnation for bodily injury or involuntary manslaughter.

Adult↗

PubMedDate not supplied

[Self-mutilation with a double-blade razor].

A 26 year old female simulated an assault by inflicting herself multiple series of skin cut wounds by a double blade razor. The skin lesions produced by this unusual instrument are presented. The overall trauma pattern was characteristic of self-infliction.

Adult↗