forensic pathology for police, death investigators, attorneys, and forensic scientists

I am also indebted to the various institutions with which I have been associatedthroughout my education and professional career, including the following, whichwere each an important part

Forensic Pathology for Police, Death Investigators, Attorneys, and Forensic Scientists

Joseph Prahlow

Forensic Pathology

for Police, Death

Investigators, Attorneys, and Forensic Scientists

Indiana University School of

Medicine – South Bend and the South

Bend Medical Foundation, Inc

Springer New York Dordrecht Heidelberg London

Library of Congress Control Number: 2009937148

© Springer Science+Business Media, LLC 2010

All rights reserved This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer Science+Business Media, LLC, 233 Spring Street, New York,

NY 10013, USA), except for brief excerpts in connection with reviews or scholarly analysis Use in connection with any form of information storage and retrieval, electronic adaptation, computer software,

or by similar or dissimilar methodology now known or hereafter developed is forbidden.

The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identified as such, is not to be taken as an expression of opinion as to whether or not they are subject

to proprietary rights.

While the advice and information in this book are believed to be true and accurate at the date of going

to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect

to the material contained herein.

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

This textbook was written to the glory of God and is dedicated to my Lord andSavior, Jesus Christ I believe that it is appropriate to briefly share with the readerwhy such a dedication is in order, and how my life’s work has helped me to come to

a better understanding of things eternal My job has helped to confirm for me threespecific insights into life and death

First, by having the unique privilege of being able to actually see inside the cal body of someone, and to then view their tissues under a microscope, I have come

physi-to the conclusion that the human body is an absolute marvel From its anaphysi-tomicstructures visible to the naked eye, all the way down to its smallest molecules, aswell as its complex physiology, the human body is nothing other than spectacular

To suggest that such a marvelous entity, along with all of the other incredible logical forms within our world, somehow randomly came into existence does notmake sense to me The incredible complexity of nature is proof to me that there is ahigher power, a power able to create such complexity, a power who I know as God

bio-I consider life on earth as a gift from this higher power As a Christian, bio-I believe thatGod’s original intent was for us to live in harmony with Him and each other.Second, as a forensic pathologist, I am confronted on an almost daily basis withthe fact that physical death represents an unavoidable part of the entire process of life

on earth We cannot escape death As a Christian, I believe that the human condition

of unavoidable physical death results from the fact that we are sinful beings I see alltoo frequently within my work the fact that human beings have a sinful free will Ibelieve that our sin separates us from God and His original intent to live in harmonywith us

The third insight that my job has provided for me involves the recognition of aspiritual component of life Throughout the history of the world, many humans havebeen aware of and concerned about their mortality Is there a “soul,” a “spirit,” or

a “life-force?” If so, does it die along with the physical body? If not, what happens

to it? Through my work as a forensic pathologist, I have come to understand andbelieve that, without a doubt, there is a soul (spirit, life-force) Dead bodies simplyrepresent “empty shells.” When I work on dead bodies, the true “person” is nolonger present As a Christian, I believe that the human spirit lives on beyond thedeath of the physical body I also believe that what happens to the spirit depends

on one thing That one thing is whether or not, during life on earth, a person has

v

accepted the free gift of Jesus Christ as their Lord and Savior If you believe thatJesus Christ suffered and died, taking your sin on Himself, and then rose from thegrave, defeating sin, then you will live with God for eternity after your physicaldeath on earth This is my belief and faith as a Christian, and it is my prayer foreveryone reading this.

Forensic pathology is a unique profession As a forensic pathologist, I am privileged

to see, on an almost daily basis, the wonders of the human body and the value oflife At the same time, my job affords me the opportunity to see the fragility of life,the ravages of disease, and the unimaginable horrors that are perpetrated on somepeople by their fellow human beings

In recent times, forensic pathology has become very popular within the lic and various media outlets To an extent, this popularity has been beneficial to

pub-my profession, in that more of society has a basic understanding of what we do.However, many misperceptions and myths persist Occasionally, as a result of suchmisperceptions, forensic pathologists are faced with the task of educating the public(such as jurors), as well as other professionals, regarding the fallacies of such myths

My hope is that this textbook will help to correct these misperceptions At the sametime, it is my hope that this text will help to educate its readers about a truly uniqueprofession

There are several outstanding, up-to-date forensic pathology textbooks in tence today For the most part, these texts are written for a specific audience, namelypathologists, or more specifically forensic pathologists Although such texts may

exis-be suitable for many of the professionals with whom forensic pathologists act, none of these fine textbooks has been written specifically for the non-forensicpathologist When I was asked to write this text, it was for the purpose of writingspecifically for the non-forensic pathologist professionals who frequently or occa-sionally interact with forensic pathologists As such, the reader will note that several

inter-of the early chapters in the book address issues that are not ordinarily covered inthe typical forensic pathology textbook, such as general overviews of medicine andpathology, as well as anatomy and physiology

The overall goal of this textbook is to provide police officers, death tors, attorneys, and other forensic scientists with a working knowledge of forensicpathology, in order to better enable these individuals to interact with forensic pathol-ogists during their daily duties Because forensic pathology is an incredibly visualdiscipline, it is necessary to include numerous photographs in this text I am a firmbeliever that providing more photographs is better than providing fewer photographs and color photos are better than black and white As such, this entire book-writing endeavor has created somewhat of a challenge: how can we provide enough

investiga-vii

quality photographs in a format that is affordable to the intended audience? Myhope is that we have succeeded in this endeavor We have attempted to includewithin the textbook itself the minimum number of black and white photographsnecessary to provide a basic understanding of the concepts presented, but we havealso included a computer disc containing color versions of each textbook image.

In addition, the computer disc contains numerous extra color images of additionaltopics/issues, with references to these extra images within the textbook itself.The photos in this text are largely taken from autopsy cases that I performed;however, there are numerous photos from cases performed by my colleagues inIndiana, North Carolina and Texas In most of these instances, I actually saw thecases with my own eyes, as others performed the autopsies Occasional images arefrom cases that were performed by fellow forensic pathologists, but were not per-sonally witnessed by me I have attempted to identify these latter cases throughoutthe text by giving appropriate recognition to the pathologist or office from whichthe photographs originated Every attempt has been made to protect the identity ofthe individuals shown in the photographs, while attempting to illustrate a particularpoint of forensic interest

An attempt has been made to provide as much information as possible within thisbook, recognizing that the text is meant to be an overview of forensic pathology,and not an all-encompassing review of each topic Each chapter provides numerousreferences for additional reading, and an appendix at the end of the book provides

a listing of additional resources My hope is that this text fills a need for a forensicpathology text specifically geared toward those professionals who work alongside

or interact with forensic pathologists

I am indebted to many individuals and institutions for enabling me to produce thisbook I extend my gratitude to my editor, Harvey Kane, and my publisher, Springer,for their patience, encouragement, and professionalism during the entire process.Very importantly, I acknowledge and respectfully express my heartfelt thanks to

my patients, for without them I would not be able to perform my job Death is often avery tragic event, but I believe that it is possible to learn something from every death

To my patients, I offer my heartfelt thanks, and I offer my sincere condolences tothe families and loved ones of those for whom I am privileged to work

I am also indebted to the various institutions with which I have been associatedthroughout my education and professional career, including the following, whichwere each an important part of my formal education: Valparaiso University, IndianaUniversity School of Medicine, including Indiana University School of Medicine –Northwest, the Department of Pathology of Wake Forest University School ofMedicine, North Carolina Baptist Hospital, the Dallas County Medical ExaminersOffice, the Southwestern Institute of Forensic Sciences, and the University ofTexas – Southwestern Medical Center I am grateful to my current employer, asso-ciations, and affiliations, each of which have been supportive of me in my work: theSouth Bend Medical Foundation, Indiana University School of Medicine – SouthBend at the University of Notre Dame, Elkhart General Hospital, Memorial Hospital

of South Bend, and St Joseph Regional Medical Center

I would like to extend a special “thanks” to the administrative support I havehad over the years, including Genoal, Melinda, Connie, Judy, Liz, Stacey, Diane,Melissa, Ann, Jim, Bob, Ann, Diane, Annette, Heather, Peggy, Sandi, and Dianeand her crew I also say “thanks” to my current partners at the South Bend MedicalFoundation: Nicole, Fred, Al, Blair, Frank, Jim, Amobi, Derrick, Luis, Nita, Rick,Kristen, Dave, Bill, Kurtis, John, Odeta, Joyce, Bobbie, and Bob, as well as mycolleagues at the medical school, including Rudy, Jack, Suzie, Carl, Ed, Ken, Molly,Rob, Tracy, Mike, Gary, David, George, Faye, Diane, and Mark

I am privileged to have had the opportunity to work with and learn from manyoutstanding police officers, death investigators and coroners, attorneys, and foren-sic scientists over the years In particular, I would like to thank those with whom Icontinue to work, including toxicologist Prentiss Jones, the coroners and deputycoroners of St Joseph, Elkhart, Fulton, Pulaski, LaPorte, Marshall, and Porter

ix

Counties, as well as police officers from South Bend, Mishawaka, Elkhart, Goshen,LaPorte, Michigan City, Valparaiso, Portage, St Joseph County, Elkhart County,LaPorte County, Marshall County, Porter County, the Indiana State Police, and theMetro-Homicide Unit of South Bend/St Joseph County I would like to specificallythank the autopsy assistants with whom I have worked over the years They performincredible work for very little pay and very little thanks I especially would like

to thank Eddie, John, and Jim from North Carolina, Hamo, Andrew, Joe, Darren,and Sid from Texas, and Wayne, Andre, Chip, Sherri, Suzie, Jared, and Whitney inIndiana

Throughout my career, I have been incredibly blessed by knowing, working with,and learning from many outstanding forensic pathologists I am indebted to each

of them, especially John Pless, Pat Lantz, Gregory J Davis, Don Jason, JeffreyBarnard, and Rick Hoover I am also indebted to the following professional orga-nizations: the American Academy of Forensic Sciences (AAFS), the AmericanSociety for Clinical Pathology (ASCP), the College of American Pathologists(CAP), and the National Association of Medical Examiners (NAME) By partic-ipating in various educational programs, committees, and organizational forumssupported by these organizations, I have had the great fortune of meeting andworking with some of the best people in medicine, forensic sciences, and forensicpathology The following is just a sampling of the colleagues with whom I have hadthe good fortune of working in one capacity or another Most are forensic patholo-gists Sadly, some are no longer with us Some I know well; others not so well Some

I see often Others I see very rarely Some are well-known within the forensic ogy community Some may be considered “giants” in the field Others are relativelyunknown outside of their particular office Each is an outstanding professional.Each is considered a friend I apologize if I have overlooked anyone T Andrew, MAnzalone, J Arden, A Baker, E Balraj, J Barnard, N Batalis, M Bell, L Biedrzycki,

pathol-C Boden, J pathol-Carter, M pathol-Case, J pathol-Cavanaugh, S pathol-Cina, M pathol-Clark, S pathol-Clark, J pathol-Clouse, SCohle, K Collins, S Colvin, S Comfort, S Conradi, T Corey, G Dale, J Davis, GJDavis, GG Davis, J deJong, JS Denton, V DiMaio, G Di Vella, J Dix, M Doberson, DDolinak, E Donoghue, J Downs, L Dragovic, MF Ernst, M Fierro, L Finelli, S Fiore,

C Fligner, M Flomenbaum, D Fowler, R Froede, J Frost, J Gerns, M Gonsoulin,

J Goodin, M Graham, M Greenwald, A Gruszecki, J Guileyardo, K Gunson, WGunther, K Haden-Pinneri, R Hanzlick, A Hart, C Harvey, D Hawley, J Howard, JHunsaker, D Jason, J Jentzen, P Jones, F Jordan, M Kalelkar, W Kemp, R Kohr, PLantz, W Lavezzi, B Levy, D Little, J Luke, C Mallak, J McClain, P McFeeley,

D McNally, F Miller, C Milroy, M Nashelsky, T Noguchi, K Nolte, J Oeberst,

W Oliver, G Peterson, J Pless, JK Pinckard, R Prichard, R Quinton, B Randall,

D Reay, R Reichard, K Ross, L Salzberger, L Sathyavagiswaran, G Schmunk,

D Schultz, MA Sens, C Siebert, G Simmons, S Spotswood, C Stern, D Stewart,

M Super, E Todd, J Townsend-Parchman, S Turner, J Urban, S Wagner, M Ward,

V Weedn, C Wetli, D Wolf, R Zumwalt

Besides being blessed by my teachers and colleagues, I have been blessed byand have learned a great deal from my students throughout my career They help to

keep me humble I have a great deal of respect for them, and I enjoy being able toparticipate in their education.

I would also like to thank my family Starting with my childhood family, I wouldlike to thank my parents, August and Lois, and my siblings for their love and supportthroughout my lifetime Moving on to my own family, I would like to express mylove and thanks to my children, Jacob, Samuel, Noah, Joseph, and Mary Anna Iwould like to proclaim my most sincere appreciation and deep love for my wife,Tamara Thanks for your love and support! Finally, I would like to publicly express

my thanks for my Lord and Savior, Jesus Christ, for His saving grace, and His lovingexample of how to live my life

Part I Introductory Topics

1 Introduction to Pathology 3

Disc Image Legends 15

Selected References 15

2 Introduction to Forensic Sciences 17

Overview 17

Chain of Custody 18

Admissibility of Tests, Evidence and Testimony 18

Expert Witness 18

Forensic Science Disciplines 19

Forensic Pathology 19

Forensic Anthropology 19

Forensic Odontology 19

Forensic Entomology 20

Forensic Toxicology 22

Forensic Psychiatry 22

Trace Evidence 22

Firearms and Toolmarks Examiners 24

Document Examination 25

Fingerprint Evidence 26

Serology/DNA 27

Other Disciplines 29

Disc Image Legends 32

Selected References 32

3 Introduction to Forensic Pathology 35

Overview 35

Duties of the Forensic Pathologist 36

Investigation 37

Autopsy 37

Verification of Identity 40

Documentation of Findings 40

xiii

Death Certification 41

Testifying 41

Consultation 42

Training and Qualifications of Forensic Pathologists 43

Disc Image Legends 46

Selected References 47

4 Death Investigation 49

Introduction 49

Death Investigation Systems Within the United States 50

Overview 50

Jurisdictional Issues 51

Coroner Systems 51

Medical Examiner Systems 52

Mixed Systems 53

Duties of Death Investigators 53

Overview 53

Initial Investigation 54

Scene Investigation 55

Follow-up Investigation 60

Grief Counseling 61

Disc Image Legends 61

Selected References 62

5 Death Certification 63

Introduction 63

Death Pronouncement 66

Cause of Death 68

Manner of Death 71

Disc Image Legends 79

Selected References 79

6 Overview of Anatomy and Physiology 81

Introduction 81

Overview 81

Gross Anatomy 82

Histology 90

Physiology 91

Body Regions and Compartments 92

Specific Organ Systems 92

Integumentary System (Skin) 92

Musculoskeletal System 94

Nervous System 97

Cardiovascular System 104

Respiratory System 106

Gastrointestinal System 108

Hepatobiliary System 111

Reticuloendothelial System (Including the Immune System) 113

Endocrine System 116

Genitourinary System 120

Special Sensory Structures 122

Disc Image Legends 124

Selected References 126

Part II General Topics in Forensic Pathology 7 The Postmortem Forensic Examination/Autopsy 129

Introduction 129

Forensic Versus Hospital Autopsies 130

Investigation 133

External Examination 134

Internal Examination 137

Ancillary Procedures 153

Autopsy Report 154

External Examination Only (Without Autopsy) 156

After-the-Fact and In-Absentia Cases 157

Autopsy Assistants 158

Office Accreditation and Forensic Autopsy Standards 159

Disc Image Legends 159

Selected References 161

8 Postmortem Changes and Time of Death 163

Introduction 163

Early Postmortem Changes 163

Livor Mortis 163

Rigor Mortis 166

Algor Mortis 168

Other Early Postmortem Changes 168

Decomposition 169

Postmortem Injuries 177

Time of Death Estimation 179

Disc Image Legends 182

Selected References 184

9 Identification of Human Remains 185

Introduction 185

Policies for Identification of Bodies 188

Common, Non-scientific Methods of Identification 188

Hospital Identification 188

Visual Identification 188

Scientific Methods of Identification 190

Fingerprint Identification 190

Dental Identification 191

Radiologic Identification 192

DNA Identification 194

Identification Based on Other Unique Features 195

Circumstantial Identification 198

Unidentified Remains 198

Disc Image Legends 200

Selected References 201

Part III Major Causes/Mechanisms of Death 10 Natural Deaths 205

Introduction 205

Infectious Disease 207

Cardiovascular System 208

Congenital Heart Disease 209

Congestive Heart Failure (Heart Failure) 210

Coronary Artery Atherosclerosis 211

Coronary Artery Dissection 214

Other Coronary Artery Disorders 214

Aortic Aneurysms (Abdominal and Thoracic) 215

Cerebrovascular Disease 216

Vasculitis 217

Fibromuscular Dysplasia 217

Myocarditis 217

Hypertensive Cardiovascular Disease 218

Valve Disorders 219

Hypertrophic Cardiomyopathy 220

Dilated Cardiomyopathy 220

Restrictive Cardiomyopathy 222

Deep Venous Thrombosis 222

Conduction System Abnormalities 222

Neoplastic Heart Disease 223

Central Nervous System 223

Congenital Anomalies 223

Cerebral Palsy 223

Infection 224

Seizure Disorders 225

Dementia 226

Cerebrovascular Disease 226

Hypertensive Disease 226

Spontaneous Intraparenchymal Hemorrhage 227

Ruptured Berry Aneurysm 227

Ruptured Arteriovenous Malformation (AVM) 227

Dural Sinus Thrombosis 228

Neoplasia 229

Respiratory System 229

Congenital Anomalies 229

Neonatal Conditions 230

Upper Airway Conditions 230

Pulmonary Thromboembolism 231

Bacterial Pneumonia 231

Aspiration Pneumonia 232

Viral Pneumonia 232

Other Infections (Tuberculosis, Fungi, Parasites) 232

Asthma 233

Chronic Obstructive Pulmonary Disease (COPD) 234

Chronic Lung Disease 235

Pulmonary Hypertension 235

Neoplasia 235

Sarcoidosis 235

Gastrointestinal and Hepatobiliary System 236

Congenital Anomalies 236

Gastritis 236

Peptic Ulcer Disease (PUD) 236

Cirrhosis/Esophageal Varices 237

Mallory–Weiss Tears 238

Other GI Abnormalities 238

Hemochromatosis 239

Pancreatitis 240

Reticuloendothelial and Immune Systems 240

Autoimmune Disorders 241

Leukemia/Lymphoma 241

Immunodeficiency 242

Endocrine System 243

Genitourinary System 244

Bones, Joints, and Soft Tissues 245

Multisystem and Other Disorders 245

Amyloidosis 246

Chronic Alcoholism 246

Diabetes Mellitus 247

Sickle Cell Disease 248

Inborn Errors of Metabolism 249

Other Genetic Disorders 250

Sarcoidosis 251

Psychiatric Disease 251

Disc Image Legends 252

Selected References 254

11 Drug-Related and Toxin-Related Deaths 257

Introduction 257

Investigation of Drug-Related Deaths 258

Autopsy Findings in Drug-Related Deaths 261

Toxicology Issues 263

Death Certification 267

Specific Drugs and Toxins 269

Ethanol and Related Substances 269

Ethanol 269

Ethylene Glycol 272

Methanol 272

Isopropanol 273

Amphetamines and Similar Substances 273

Other Stimulants 274

Barbiturates 275

Cocaine 275

Opiates and Related Substances 277

Morphine 279

Heroin 279

Methadone 280

Fentanyl 281

Other Opiates 281

Psychoactive Drugs of Abuse (Hallucinogens) 282

Marijuana 282

Lysergic Acid Diethylamide (LSD) 282

Phencyclidine (PCP) 283

Mescaline (Peyote) 283

Mushrooms (Psilocybin) 283

Other Hallucinogens 284

Over-the-Counter (OTC) Drugs 284

Acetaminophen 285

Aspirin (Salicylate) 285

Ephedrine/Herbal Ecstasy 286

Other Prescription Drugs 286

Antidepressants 286

Nonbarbiturate Sedative Hypnotic Drugs 286

Antipsychotic Drugs 287

Anabolic Steroids 288

Insulin 288

Volatiles and Inhalants 289

Nitrous Oxide 291

Hydrocarbons 291

Helium and Other Simple Asphyxiants 293

Heavy Metals 294

Arsenic 294

Cadmium 295

Iron 295

Lead 295

Mercury 295

Other Poisons 296

Organophosphates 296

Strychnine 296

Naturally-Occurring Toxins 296

Disc Image Legends 297

Selected References 299

12 Blunt Force Injury Deaths 301

Introduction 301

Classification of Blunt Force Injuries 302

Abrasions 302

Contusions 304

Lacerations 305

Fractures 308

Avulsions 310

Blunt Force Head and Neck Trauma 311

Skin and Mucosal Injuries 312

Subcutaneous Injuries 312

Skull and Facial Bone Injuries 313

Epidural, Subdural, and Subarachnoid Hemorrhage 315

Gross Brain Injuries 317

Microscopic Brain Injuries 320

Neck, Spinal Cord, and Vertebral Artery Injuries 321

Special Topics Related to Blunt Force Injuries 322

Mechanisms of Death in Blunt Force Trauma 322

Delayed Deaths Related to Blunt Force Injury 324

Patterned Injuries 325

Clothing Examination 327

Specific Subtypes of Blunt Force Injury 327

Disc Image Legends 332

Selected References 334

13 Gunshot Wound Deaths 337

Introduction 337

Types of Weapons and Ammunition 337

Gunshot Wounds 343

Entrance Wounds 344

Range of Fire 346

Exit Wounds 351

Graze Wounds 351

Caliber 352

Miscellaneous Features of Handgun Wounds 354

Characteristics of High-Velocity Wounds 354

Shotgun Wounds 356

Miscellaneous Issues 362

Internal Examination 362

Mechanism of Injury 366

Documentation 367

X-Rays 368

Clothing Examination 368

Gunshot Residue 368

Manner of Death Issues 369

Special Weapons, Ammunition, and Circumstances 370

Disc Image Legends 373

Selected References 376

14 Sharp Force Injury Deaths 379

Introduction 379

Stab Wounds 381

Incised Wounds 385

Chop Wounds 388

Special Issues 388

Internal Examination 388

Mechanism of Injury 390

Trace Evidence 390

Clothing Examination 390

Defensive Wounds 391

Hesitation Marks 391

Self-Inflicted Wounds/Suicide 392

“Self-Injurious Behavior” (“Cutting”) 392

Accidental Sharp Force Injuries 393

Direction of Incised Wound 393

Handedness of Attacker 393

X-Rays 394

Decomposition 395

Postmortem/Perimortem Wounds 395

Artifacts 397

Disc Image Legends 398

Selected References 399

15 Asphyxial Deaths 401

Introduction 401

Suffocation 403

Simple Asphyxia (Environmental Asphyxia) 403

Smothering (External Airway Obstruction) 405

Choking (Internal Airway Obstruction) 406

Mechanical Asphyxia (Traumatic Asphyxia) 408

Positional Asphyxia 410

Combination Forms of Suffocation 410

Neck Compression (Strangulation) 411

Hanging 412

Strangulation 415Ligature Strangulation 416Manual Strangulation 417Non-ligature, Non-manual Neck Compression 418Chemical Asphyxia 419Carbon Monoxide 419Cyanide 422Hydrogen Sulfide 423Other Issues 423Autoerotic Asphyxia 423Choking Game 424Restraint Asphyxia 425Combination Asphyxial Deaths 427Drowning 428Disc Image Legends 428Selected References 430

16 Drowning 433Introduction 433Physiology and Mechanism of Death in Drowning 434Scene Investigation 435Autopsy Findings 437Causes of Death Other Than Drowning 444SCUBA Deaths 445Manner of Death 446Disc Image Legends 447Selected References 447

17 Electrical Deaths 449Introduction 449Electrocution 451Mechanism of Death in Electrocutions 453Scene Investigation 453Autopsy Findings 455Low Voltage 455High Voltage 457Other Features 459Lightning 461Non-Lethal Electronic Shock Devices 464Death Certification and Manner of Death 465Disc Image Legends 465Selected References 466

18 Temperature-Related Deaths 469Introduction 469Hypothermia 470

General Features 470Scene Investigation 471Autopsy Findings 471Death Certification 475Hyperthermia 475General Features 475Scene Investigation 476Autopsy Findings 477Death Certification 478Disc Image Legends 479Selected References 479

19 Burns and Fire-Related Deaths 481Introduction 481Burn Types 484Dry Burns 484Radiant Burns 484Scald Burns 485Chemical Burns 487Fire-Related Burns 488Fire Deaths 489Questions to Address 489Autopsy 492Mechanism of Death 496Death Certification 497Fire Investigation 498Cremations 498Disc Image Legends 499Selected References 500

20 Deaths in Infancy and Childhood 501Introduction 501Discarded Fetuses/Infants and Fetal/Infant Deaths

in Unattended Births 502Who is the Mother? 503Was the Fetus/Infant Viable? 503Was the Fetus/Infant Live-Born or Stillborn? 503What Was the Cause of Death? 505Birth-Related Infant Deaths 506Infant Deaths 508Natural Death in Childhood 513Accidental Childhood Deaths 514Suicidal Childhood Deaths 516Homicidal Childhood Deaths 516Classification of Childhood Homicides 526Violent Outburst (Angry Impulse) 527

Negligence/Neglect 527Sadistic Acts of Punishment 528Munchausen’s Syndrome by Proxy 529Unwanted Child 529Unwanted Pregnancy (Neonaticide) 529Spouse Revenge 530Postpartum Mental Disorder 530Acute Psychosis 530Altruism 530Euthanasia (True Mercy Killing) 531Sexual Abuse 531Violent Older Child 532Drug and Alcohol Abuse 532Seizure Disorder 532Innocent Bystander 532Pediatric Autopsy Considerations 533Disc Image Legends 535Selected References 537

21 Miscellaneous Topics 539Introduction 539Aircraft Crashes 540Allergic Reactions (Anaphylaxis) 542Animal Attacks 544Artifacts and Mimics 544Emboli 546Pulmonary Thromboemboli 547Systemic Thromboemboli 548Bone Marrow and Fat Emboli 548Amniotic Fluid Emboli 548Gas/Air Emboli 549Bullet and Other Foreign Body Emboli 550Exhumations 550Explosions and Blast Injuries 554High-Profile Cases 554Homicide by Heart Attack 555In-Custody Deaths 556Mass Fatality Incidents 560Multiple Causes of Death 561Nutrition and Hydration Disorders 562Obesity 563Malnutrition and Starvation 563Vitamin Deficiencies 564Anorexia 564Bulimia 565

Dehydration 565Overhydration 566Food Poisoning 566Occupational Deaths 567Organ and Tissue Procurement Issues 568Postmortem Chemistry Tests 572Postmortem Cultures 574Pregnancy-Related Maternal Deaths 575Product-Related Deaths 578Radiation 578Ionizing Radiation 578Non-ionizing Radiation 580Sexual Assault 580Terrorist Agents 581Biologic Agents 581Chemical Agents 582Therapy-Related Deaths 583Disc Image Legends 586Selected References 588Aircraft Crashes 588Allergic Reactions (Anaphylaxis) 588Animal Attacks 588Emboli 588Exhumation 589Explosions and Blast Injuries 589High-Profile Cases 589Homicide by Heart Attack 589In-Custody Deaths 589Mass Fatality Incidents 589Nutrition and Hydration Disorders 590Occupational Deaths 590Organ and Tissue Procurement Issues 590Postmortem Chemistry Tests 590Postmortem Cultures 590Pregnancy-Related Maternal Deaths 590Product-Related Deaths 591Radiation 591Terrorist Agents 591Therapy-Related Deaths 591

Appendix: Additional Resources and Reference Books 593

Index 595

About the Author

Joseph A Prahlow, M.D is from Valparaiso, Indiana He attended college atValparaiso University, where he received a Bachelor of Science in Biology andChemistry He attended medical school at Indiana University School of Medicine,where he received an M.D degree His Internship and Residency took place withinthe Department of Pathology of Wake Forest University and the North CarolinaBaptist Hospital, where he completed Anatomic Pathology and Clinical Pathologytraining His formal education was completed in Dallas, Texas, where he com-pleted a fellowship in Forensic Pathology at the University of Texas – SouthwesternMedical Center and the Dallas County Medical Examiners Office/SouthwesternInstitute of Forensic Sciences He is Board-certified by the American Board ofPathology in Anatomic, Clinical, and Forensic Pathology

Dr Prahlow currently practices forensic pathology in South Bend, Indiana, where

he is employed by the South Bend Medical Foundation, a large, not-for-profitregional laboratory that provides pathology, laboratory, blood bank, and forensicservices to many communities within Indiana, Michigan, and other Midwesternstates Dr Prahlow spends much of his time performing autopsies for local coroners.Another major part of his job involves teaching the entire basic science pathologycourse to second-year medical students at Indiana University School of Medicine –South Bend at the University of Notre Dame, where he is a professor of pathology

Dr Prahlow enjoys presenting at various local, national, and international meetings,and he has published extensively within the medical/scientific literature

Dr Prahlow recently completed service to the National Association of MedicalExaminers as Vice President, President, and Chairman of the Board He has a similarhistory of service to the American Academy of Forensic Sciences, where he hasserved as the Pathology/Biology Section’s Program Chair, Secretary, and SectionChair He continues to serve both organizations as a member of various committees

He is an active participant in two Pathology organizations as well, the AmericanSociety for Clinical Pathology and the College of American Pathologists In both,his primary role involves participation in various educational activities specificallyrelated to forensic pathology

Dr Prahlow is married to his high-school sweetheart, Tamara He and hisbeautiful wife reside in Southwestern Michigan, where they raise their five children

xxv

Part I Introductory Topics

Introduction to Pathology

They will die of deadly diseases.

Jeremiah 16:4

Abstract This chapter provides a basic description of “pathology,” which literally

means the “study of disease.” Pathology is unique in that the discipline representsone of the “basic sciences” taught in medical school, but it is also considered a medi-cal specialty, a career path chosen by certain physicians The reader is provided with

a description of classic medical education within the United States Much of thechapter deals with describing the specialty of pathology, including training require-ments, the two major branches of pathology (anatomic and clinical pathology), andvarious subspecialty areas

Keywords Pathology · Medicine · Medical school · Anatomic pathology · Clinical

pathology

“Pathology” literally means “the study of disease” and is studied by all physicians

as part of their medical school curriculum It is considered one of medicine’s “basicsciences” (along with gross anatomy, microscopic anatomy (“histology”), physi-ology, biochemistry, pharmacology, etc.) and is usually studied during the secondyear of a student’s four years of medical school training The typical medical schoolcurriculum is shown in Table 1.1

After graduating from medical school, a physician typically participates in tional “postgraduate” training, encompassing the internship and residency years.Physicians choose the type of medical specialty that they wish to pursue as acareer and participate in a residency program for that particular specialty Althoughpathology is an essential “basic science” (as described above) within the traditionalmedical school curriculum, it is also a medical specialty (like pediatrics, radiology,internal medicine, surgery, cardiology, etc.) In other words, a medical student canchoose to become a pathologist, just as another medical student chooses to become

addi-an addi-anesthesiologist, addi-an endocrinologist or addi-an obstetriciaddi-an Table 1.2 shows a list ofvarious medical specialties available to physicians A specialty can be consideredone of three general types: (1) those that are “medical” (meaning “non-surgical”)

3

J Prahlow, Forensic Pathology for Police, Death Investigators, Attorneys,

and Forensic Scientists, DOI 10.1007/978-1-59745-404-9_1,

 Springer Science+Business Media, LLC 2010

Table 1.1 An example of a traditional medical school curriculum (courses may vary depending

on the medical school)

Basic sciences (first two years)

Histology (microscopic anatomy) Physiology

Biochemistry Microbiology Neuroanatomy Behavioral science

Pharmacology Introduction to medicine Genetics

Physical diagnosis Clinical sciences (last two years)

General surgery Surgical subspecialties Obstetrics and gynecology Pediatrics

Psychiatry Anesthesiology Neurology/neurosurgery Primary care

Electives

(Disc Image 1.1); (2) those that are “surgical” (Disc Image 1.2); and (3) those thatare “miscellaneous.” Pathology fits into the “miscellaneous” category; it is relativelyunique within the world of medicine in that it represents a basic science but also adistinct medical specialty

In the United States, there are two types of medical degrees, the MD (doctor

of medicine) and the DO (doctor of osteopathy) In order to graduate from cal school, and then continue in formal postgraduate medical training (residency)and become licensed to practice medicine, there are certain “board examinations”which a medical student must take and pass For MD training, the examinations,referred to as the United States Medical Licensing Examination (USMLE), encom-pass three steps, two of which are usually taken during medical school, and a thirdwhich is taken after at least one year of postgraduate training The examinations areadministered by the National Board of Medical Examiners (NBME) A similar set

medi-of examinations is administered to DO students/physicians by the National Board

of Osteopathic Medical Examiners (NBOME) The use of the term “medical iner” in the context of the NBME and the NBOME is totally different from the use

exam-of the term as it applies to forensic pathology and death investigation

Table 1.2 Medical specialties (incomplete listing)

“Medical specialties”

Internal medicine General medicine

Gastroenterology Liver, pancreas, stomach, intestines

Endocrinology Glands (pituitary, thyroid, etc.)

Family practice General medicine

Emergency medicine Emergencies and urgent care

Sports medicine Sports injuries

Physical medicine and rehabilitation Rehabilitation

“Surgical specialties”

General surgery Surgical disorders

Cardiothoracic Heart, lungs, and chest

Orthopedic Bones, joints, and muscles

Obstetrics and gynecology Females

Otorhinolaryngology Ears, nose throat

Neurosurgery Brain and spinal cord

“Miscellaneous specialties”

Anesthesiology Anesthesia and/or pain management

Interventional radiology Non-surgical therapies

Occupational medicine Workplace health

Preventive medicine Disease/injury prevention

Psychiatry Behavioral and psychological disorders Radiation oncology Radiation treatment of cancer

To become a pathologist, a student must first receive a medical degree (MD orDO) from a medical school Following medical school, the physician must thensuccessfully complete a residency in pathology Currently, the typical pathology

residency training program lasts four years and involves two basic branches ofpathology: clinical pathology and anatomic pathology.

Clinical pathology can be considered “laboratory medicine.” The various tal and medical laboratories are under the direction of pathologists, while the bulk ofthe work is performed by laboratory technologists and technicians Typical laborato-ries include the chemistry laboratory (where items such as electrolytes, cholesterol,and other substances are measured in the blood or other body fluids, such as urine)(Fig 1.1), the microbiology laboratory (where various tests are performed in order toidentify infectious organisms, such as bacteria, fungi, and viruses), the hematologylaboratory (where “blood counts” are performed, determining various issues related

hospi-to red and white blood cells and other blood fachospi-tors) (Fig 1.2), and the blood bank(where blood typing and matching allows for safe blood transfusions to occur) Anemerging laboratory field involves molecular genetics, where identification of genes(DNA) and their products plays a role in disease diagnosis, prognosis (the expectedoutcome), and therapy As directors of the clinical pathology laboratories, pathol-ogists play a major role in attending to the medical needs of physicians and theirpatients

Fig 1.1 An automated

chemistry machine in the

clinical pathology laboratory

Fig 1.2 A blood smear, as seen via a microscope The round cells with no nuclei are red blood

cells The slightly larger cells with nuclei are white blood cells, including a neutrophil on the left

and a lymphocyte on the right The small structures are platelets

Anatomic pathology is the second of the two major branches within the medicalspecialty of pathology The term “anatomic” refers specifically to the structure (or

“morphology”) of tissues and organs Chapter 6 provides an overview of normalanatomy Pathologists, in their role as anatomic pathologists, deal with recognizingand diagnosing abnormal, or diseased anatomy A tissue or organ that is afflictedwith a disease undergoes various changes, such that its gross (naked-eye) appear-ance, microscopic (histologic) appearance, and function are altered Pathologistsrely on the gross and microscopic appearance of diseased tissues, as well as variousother laboratory tests, to render diagnoses There are three basic components withinanatomic pathology: surgical pathology, cytology (also called cytopathology), andautopsy pathology

Surgical pathology involves the gross and microscopic evaluation of tissuesremoved by surgical means Whenever a person has a surgical biopsy performed, or

an organ removed via surgery, the removed tissue is sent to the surgical pathologylaboratory, where, after the specimen has become “fixed” in formalin (a preserva-tive solution containing formaldehyde), pathologists or their assistants dissect thespecimen (Fig 1.3 and Disc Images 1.3 and 1.4) and submit samples of the tissue(Fig 1.4) to the “histology laboratory.” Here the samples are “processed” by his-totechnologists via a procedure utilizing various chemicals (Fig 1.5), such that thesamples end up embedded in paraffin wax (Figs 1.6 and 1.7) The histotechnolo-gists then cut extremely thin sections of the tissues (Fig 1.8), place the sections onglass slides (Fig 1.9), and stain them for viewing under the microscope The usualstain that is used for histologic examination is hematoxylin and eosin (referred to

as an H&E stain) although there are numerous other “special stains” that can beutilized The pathologist views the glass slides via the microscope (Fig 1.10) andrenders diagnoses, based on the microscopic anatomy that is seen (Figs 1.11, 1.12,1.13, 1.14 and Disc Image 1.5) The microscope allows pathologists to visualize thetissues and cells at various magnification powers By evaluating tissue specimens

Fig 1.3 Gross examination and dissection of a surgical pathology specimen (a portion of lung)

Fig 1.4 Samples of tissue placed into plastic “cassettes” for processing

Fig 1.5 Processing machines in the histology laboratory

Fig 1.6 A histotechnologist embedding a tissue section in paraffin wax

Fig 1.7 A tissue section embedded in paraffin, ready to be sectioned (cut into extremely thin

sections)

Fig 1.8 A histotechnologist using a microtome to cut a section of tissue from the paraffin tissue

block

Fig 1.9 A histotechnologist placing the tissue section onto a glass slide

Fig 1.10 A pathologist viewing a slide via a microscope

grossly and under the microscope, surgical pathologists answer very important tions regarding patients’ conditions: Is it an infection? Is it a tumor? Is it benign(non-cancerous) or is it malignant (cancer)? What kind of cancer is it? Is it low-grade (slow-growing) or high-grade (rapidly-growing)? Did the surgeon remove all

ques-of the cancer? Are the lymph nodes involved? Most pathologists spend much ques-oftheir time performing their surgical pathology duties

Cytology, or cytopathology, is similar to surgical pathology in that pathologistslook at glass slides under the microscope in order to make diagnoses and answerquestions similar to those listed above In contrast to histology slides, where tissueshave been processed, embedded in paraffin wax, and cut into thin sections, cytology

Fig 1.11 An example of the appearance of a histology slide (normal fallopian tube) viewed under

the microscope at low-power magnification (approximately 20×)

Fig 1.12 A fallopian tube viewed under the microscope at medium-power magnification (40×)

slides are composed of cells that have been scraped off of a tissue’s surface or rated (sucked) out of a solid or fluid-filled tissue using a needle, and then stained(Fig 1.15)

aspi-Autopsy is the third component of anatomic pathology The autopsy can be sidered a surgical procedure that is performed on a dead body and which involvescutting into the body, removing the organs, and dissecting the organs, with or with-out subsequent microscopic examination of tissue/organ sections There are twobasic types of autopsies: hospital (medical) autopsies and forensic (medicolegal)

con-Fig 1.13 A fallopian tube viewed under the microscope at high-power magnification (400×)

Fig 1.14 A fallopian tube viewed under the microscope at very high-power magnification

on individuals whose deaths meet the legal requirements for being a death that is

Fig 1.15 An example of the appearance of a cytology slide (breast cancer) viewed under the

microscope

to be officially investigated by the local governmental death investigation agency(medical examiner or coroner – refer to Chapter 4) Typically, this includes anydeath that is caused by something that is not considered a natural disease, as well

as any death that is sudden, unexpected, or suspicious Occasionally, medicolegalautopsies are performed by hospital-based pathologists who have received limited,little or no formal training in forensic pathology In other jurisdictions, these types

of cases are performed by forensic pathologists, who have special expertise in theinvestigation of sudden, unexpected, and violent deaths (see Chapter 3)

Most pathologists receive structured pathology residency training in bothanatomic and clinical pathology (Disc Image 1.6), but occasional pathologists onlyparticipate in one area or the other Whatever the case, to become “Board-certified”

in pathology, a physician must first successfully complete a pathology residency

at an institution that is appropriately accredited by the Accreditation Council forGraduate Medical Education (ACGME), and then pass a Board examination admin-istered by the American Board of Pathology (ABP) Certificates are available forboth anatomic pathology and clinical pathology Pathologists are sometimes referred

to as the “physicians’ physician,” a physician to which other physicians come tofind answers to diagnostic problems As such, an important aspect of pathology isthe participation in educational conferences with other physicians (Disc Image 1.7)

In each of the two basic areas of pathology (anatomic and clinical), a gist can also participate in additional formal training within a “fellowship” program,usually after completing residency, to gain further expertise within any of a num-ber of “subspecialties.” Table 1.3 shows the various basic components of anatomicand clinical pathology disciplines and Table 1.4 lists the Board-certifiable “sub-specialties” available within each discipline Fellowships are available in variousother pathology subspecialty areas, such as surgical pathology, without an officialsubspecialty Board certification available Such fellowships are used to gain furtherexperience and training in a particular discipline Following successful completion

patholo-of the fellowship training and, if applicable, the passing patholo-of a subspecialty Board

Table 1.3 Pathology disciplines

Clinical pathology Anatomic pathology

Blood banking

Molecular

Table 1.4 Board-certified subspecialties within pathology

Clinical pathology Anatomic pathology

Medical microbiology Pediatric pathology

Blood banking/transfusion medicine Dermatopathology

Molecular genetic pathology Neuropathology

examination administered by the ABP, the pathologist is then Board-certified withinthat specific pathology subspecialty

The certifying agencies for MD and DO degrees are the NBME and NBOME,respectively, while the certifying body for pathology and its subspecialty areas is theABP The reader should be aware that there are various international degrees thatare considered analogous to the MD and DO medical degrees Likewise, there areinternational credentials that are similar to the certifications in pathology granted bythe American Board of Pathology Some international degrees and credentials may

be considered equivalent to those obtained in the United States; however, this is notalways the case The reader should also be aware that the term “Board certification,”

as it applies to pathology and forensic pathology, should only be accepted when suchcertification is conferred by the American Board of Pathology Further discussion

of this issue will be presented in Chapter 3

As with every medical specialty, there are numerous organizations that exist topromote the pathology specialty, offer continuing medical education opportunities,and act as an advocate agency for pathologists Some of the larger organiza-tions are the College of American Pathologists (CAP), the American Society forClinical Pathology (ASCP), the United States and Canadian Academy of Pathology(USCAP), and the International Academy of Pathology (IAP) Subspecialties withinpathology also have organizations geared toward their particular subspecialty Theleading forensic pathology and death investigation organization is the NationalAssociation of Medical Examiners (NAME) A larger organization which encom-passes all forensic science disciplines, not just forensic pathology, is the AmericanAcademy of Forensic Sciences (AAFS)

Disc Image Legends

Disc Image 1.1 “Medical” specialties include family practice, internal medicine,pediatrics, and other non-surgical specialties (Photo courtesy of Department

of Pathology, Wake Forest University and North Carolina Baptist Hospital,Winston-Salem, NC)

Disc Image 1.2 “Surgical” specialties include any specialty that involves the formance of surgery (Photo courtesy of Department of Pathology, Wake ForestUniversity and North Carolina Baptist Hospital, Winston-Salem, NC)

per-Disc Image 1.3 A pathologist dissecting a portion of colon removed for cancer.Disc Image 1.4 A portion of colon with cancer (note the mass that protrudes abovethe level of the surrounding tissue)

Disc Image 1.5 A medium-power microscopic section showing normal colon (left) adjacent to colon cancer (right).

Disc Image 1.6 Pathology residents using a multi-headed microscope during theirtraining (Photo courtesy of Department of Pathology, Wake Forest University andNorth Carolina Baptist Hospital, Winston-Salem, NC)

Disc Image 1.7 A pathologist presenting at an educational conference (Photo tesy of Department of Pathology, Wake Forest University and North CarolinaBaptist Hospital, Winston-Salem, NC)

cour-Selected References

The Accreditation Council for Graduate Medical Education www.acgme.org

The American Academy of Forensic Sciences www.aafs.org

The American Board of Pathology www.abpath.org

The American Society for Clinical Pathology www.ascp.org

The College of American Pathologists www.cap.org

The International Academy of Pathology www.iaphomepage.org

The National Association of Medical Examiners www.thename.org

The National Board of Medical Examiners www.nbme.org

The National Board of Osteopathic Medical Examiners www.nbome.org

Prahlow JA, Vogel DG Pathology: Myths and Truths The New Physician 1994; September: 51–52.

The United States and Canadian Academy of Pathology www.uscap.org