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7/13/2008

AN INTRODUCTION TO
FORENSIC PATHOLOGY
By Howard W. Oliver, D.O.

This is hemopericardium as
demonstrated by the dark
blood in the pericardial sac
opened at autopsy. Penetrating
trauma or massive blunt force
trauma to the chest (often from
the steering wheel) causes a
rupture of the myocardium
and/or coronary arteries with
bleeding into the pericardial
cavity. The extensive collection
of blood in this closed space
leads to cardiac tamponade.
Sometimes a sudden deceleration injury in a vehicular accident produces
a tear in the aorta. This usually happens just distal to the great vessels. If
one's parachute fails to open, the tear is usually at the root of the aorta.

Massive abdominal blunt force injury often leads to liver injury, since it is
the largest internal organ. Note the multiple lacerations seen here over the
capsular surface of the liver. Damage to abdominal organs with lacerations,
crush injuries, and rupture.

Blunt force trauma to the head often leads to skull fractures. The orbital plate of
the base of the skull demonstrates multiple fractures (arrow) seen here in a
patient who fell backwards. The force of the blow was transmitted forward (a
contra-coup injury pattern).

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Blunt trauma to the head


can be suggested by scalp
contusions with subgaleal
collection of blood, as
shown here.

A direct traumatic blow to the head may produce the pattern of skull fractures
seen here at the vertex.

Here is an example of a contusion to the arm. The blunt force injury ruptures
small blood vessels in dermis and underlying soft tissue, resulting in
extravasation of red blood cells. Initially, the contusion appears dull red to blue,
but over time the red cells are broken down, releasing bilirubin and heme
(which is processed by macrophages to hemosiderin), to give the yellow-brown
hue seen here after a week.

This is an example of a patterned abrasion of the abdomen by scraping along a


rough sooted and rusty surface of a metal tank during a fall. The pattern may
give some indication of the nature of the surface and the direction of the
force.

This is an example of an abrasion of the skin of the leg. Note the irregularity
of the superficial tearing of the epidermis.

This is a superficial laceration of the forehead. Note that the skin surface is
broken. There are some small tags of skin where the surface was irregularly
torn.

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An incision has clean, straight edges made by a sharp object such as a knife.
Lacerations are produced from a more irregular object and appear as irregular
broken areas.

An Oil Red O stain demonstrates the fat globules within the pulmonary arterioles. The
globules stain reddish-orange. The cumulative effect of many of these globules throughout
the lungs is similar to a large pulmonary embolus, but the onset of dyspnea is usually 2 to
3 days following the initiating event, such as blunt trauma with bone fractures.

From several days to a week following the event initiating fat embolism
syndrome, there may be loss of consciousness from lesions evidenced by the
"brain purpura" as shown here. Numerous petechial hemorrhages are produced
by fat emboli to the brain, particularly in the white matter. Subsequent to this
there can be brain edema with herniation.

The rounded clear holes seen in the small pulmonary arterial branch in this section of lung
are characteristic for fat embolism. Fat embolism syndrome is most often a consequence of
trauma with long bone fractures. It can also be seen with extensive soft tissue trauma, burn
injuries, severe fatty liver, and very rarely with orthopedic procedures.

The capillary loops of this glomerulus contain fat globules in a patient with fat
embolism syndrome.

With cerebral fat embolism syndrome, there is loss of consciousness. Note the
multitude of petechial hemorrhages here, most in white matter. Cerebral edema
and herniation may follow.

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Seen here with Oil red O stain in a peripheral cerebral artery branch are globules
of lipid. This is fat embolism syndrome.

Shaken baby syndrome occurs most commonly when a young male left alone with
the baby loses self-control because of the baby's crying and begins shaking the
infant. Such injuries can be inflicted on small children as well. Seen here are the
retinal hemorrhages at autopsy that document this condition.

Shaken baby syndrome describes a pattern of neurologic injuries caused by violent shaking
of an infant. An infant's head is proportionately large in comparison to the infant's body,
and the neck musculature is not well-developed, so shaking will cause the head to flop
back and forth, producing extensive intracranial (often subdural) and retinal hemorrhages
and can be fatal.

The forces generated by violent shaking or rotational injury (as in a passenger ejected from
a moving vehicle) can produce stretching of axons in cerebral white matter. The force may
be strong enough to shear off axons, the ends of which retract into globoid shapes that
appear with this silver stain of white matter as "retraction balls".

Mechanical asphyxia, including strangulation, can be marked by the appearance


of petechial hemorrhages on the conjunctiva, as shown here.

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There are few grossly visible features of drowning. A frothy fluid may exude from
mouth and nose. Prolonged immersion may produce skin wrinkling. Seen here are
bilateral petrous ridge of temporal bone hemorrhages that may occur in
association with drowning.

Drowning may not produce extensive findings. In fact, in 10 to 15% of cases, intense
laryngospasm may even prevent water from entering the lungs. In the case shown here, a
child drowned in a fresh water canal, and some of the plant material in the water was
aspirated into a bronchus.

Sudden infant death syndrome (SIDS) occurs between 1 month and 1 year of age, with a
peak incidence at 3 to 4 months. The cause is unknown, but may relate to delayed
neurologic development. The rate varies from about 0.5 to 5 per thousand live births. SIDS
deaths can be decreased if the baby does not sleep prone, as shown here with the doll in
the lower frame.

Note the bright "cherry red" or bright pink lividity to the hand. Carbon monoxide (CO)
poisoning is a form of asphyxia that results when CO is inhaled, diffuses across alveoli, and
binds tightly to hemoglobin. Poorly ventilated houses with faulty heaters, housefires, and
motor vehicle exhaust are the most common sources. Even small atmospheric
concentrations of CO are dangerous, because CO binds to hemoglobin 200 times more
avidly than oxygen. Drowsiness and headache occur at carboxyhemoglobin concentrations
between 10 and 20%. Levels from 20 to 30% can be fatal to persons with pre-existing
cardiac or respiratory disease. Levels above 30 to 40% can be fatal to anyone. Similar lividity
could be the result of cyanide poisoning or monofluoroacetate poisoning.

When core body temperature falls below 35 C (95 F), this is a condition known as
hypothermia. Loss of body heat can occur in a variety of situations, including falling into
the cold waters of Loch Ness shown here. Lack of clothing and shelter, even in temperate
climates, can predispose to hypothermia. There are no specific gross or microscopic
findings with this condition.

When the ambient temperature of the environment increases considerably, a condition


known as hyperthermia can occur. A hot, dry location is an obvious place for hyperthermia,
particularly if the person hiking does not carry adequate water. However, an enclosed space
such as an auto or a building can present a risk, particularly for infants or aged persons. In a
heat-related death, core body temperature is found to be at or above 40.6 C (105 F).

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Thermal burn injuries occur with a hot local environment. The burned skin seen here over
the torso and head of a child occurred from a fire. The treatment and prognosis depend to a
great extent upon the extent of the burn injury -- the total body surface area (TBSA)
involved. Other factors include age of the patient, underlying diseases, and the presence of
an "inhalation injury" from breathing in hot gases, which typically occurs with fires in an
enclosed space such as a building.

Thermal burn injuries can be classified as "full thickness" or "partial thickness" based upon
the ability of the skin to regenerate. In the partial thickness burn seen here, there are still
skin adnexa in the dermis that are viable and from which new epithelium could grow.

Thermal burn injuries can occur from hot objects or liquids. Seen here is an amputated
hand that was rendered non-viable by a severe scalding injury with exposure to hot
water.

The viable skin at the left merges with an area of full thickness thermal burn injury
without any viable epithelium either on the surface or in dermal appendages. The patient
would require a skin graft to this area for recovery.

This man accidentally grabbed a high voltage electrical line, producing the entrance wound
injury seen above on the palm of the hand, with subsequent soft tissue damage and
swelling extending to the forearm. The appearance is similar to a localized burn. Below on
the dorsum of the hand can be seen the wounds produced as the current exited the hand.

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This coronal section of cerebrum shows marked compression of the ventricles and
flattening of gyri from extensive edema. This young man was climbing a 5000 meter
mountain peak and ignored the warning sign of a persistent, worsening headache.
Marked pulmonary edema may also occur. Affected persons must get to a lower altitude.

A rare complication seen at term during or shortly after labor in pregnancy resulting in
sudden death is amniotic fluid embolism. Amniotic fluid may gain access to uterine veins
following a tear in the placental membranes and embolize to the lungs, producing acute
dyspnea with cyanosis and shock. Fetal squames, lanugo hair, vernix, and mucin can
embolize to small pulmonary arteries. Seen here are epithelial squames in a peripheral
pulmonary artery.

Are you safe in your humble abode? There are areas of the planet where natural seepage
of radon gas from soils can be trapped in structures such as houses. There is a small
increase in the risk for lung cancer as a result. Less well-ventilated structures such as
residential housing tend to trap more radon gas than commercial or public buildings.

The "works" of an intravenous


drug user are demonstrated
here. A key part of forensic
pathology is scene investigation.
The appearance of the scene of
injury or death can help explain
how the injuries occurred or
provide evidence for prosecution
of criminals.

The bags of cocaine seen here in the stomach were swallowed by the victim as a form of
concealment. This method is also used by persons smuggling drugs. A latex condom is
typically used as a container. Occasionally, the container ruptures or leaks, and a drug
overdose ensues, as happened here.

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Trauma can be produced in a variety of ways. Here is the hand of a person with a cocaine
intoxication who entered a state of "excited delerium" and began breaking doors and
windows, leading to these severe lacerations and blood on the fingers.

The white circular and irregular scars are from "skin popping" or subcutaneous injection
of drugs of abuse. Complications include abscess formation, skin necrosis, and possible
pneumothorax if an injection site over the thorax is used.

The subcutaneous hemorrhage in the antecubital fossa at the elbow, revealed by multiple
incisions made at the time of autopsy, is evidence that this was an injection site for drugs.

Alcohol is metabolized at a constant rate of 11-22 mg/dL/hr by alcohol dehydrogenase in


the liver. In general, once the blood ethanol concentration has reached 0.1 gm% (100
mg/dL, or 100 mg%, or 0.1 g/dL), the alcohol dehydrogenase enzyme system is saturated,
and further ethanol consumption will increase the blood concentration.
In most states in the U.S., legal intoxication while driving a vehicle is defined at 0.08%.
Some degree of impairment can begin at 0.03%, and reaction times are impaired above
0.07%. Above 0.3%, stupor and coma can occur, and deaths may result from levels above
0.4%. The most common form of fatal drug overdose is ethanol ingestion.

Methanol poisoning is not common and is usually accidental. Methanol is metabolized


at one-fifth the rate of ethanol, making it more toxic. Acute methanol poisoning is
characterized by weakness, nausea, vomiting, headache and epigastric pain, but not
typically inebriation. Metabolic acidosis occurs. The toxic metabolites damage the
retina, and permanent blindess may result from ingestion of only 10 mL, while fatalities
occur with as little as 30-60 mL. Lethal blood levels occur at 0.08% (80 mg%).

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This scene illustrates the mechanism for "defense wounds". Such wounds result from an
attempt to ward off the assailant. The victim holds up forearms and hands in front of the
body.

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Here is a typical "defense wound" on the forearm of the victim of an assault with a sharp
weapon, producing the laceration.

Seen in this clay model is the pattern of a stab wound from a double edge knife on the
left and a single edge knife on the right.

This is a stab wound with a single


edge blade. Note the sharp point of
the blade at the left and the notch
of the opposite side of the knife at
the right. The shape of stab wounds
can vary considerably, depending
upon whether the incision is along
the axis of, or perpedicular to,
Langer's lines. Those perpendicular
will tend to pull apart and gape
open, while those parallel to the
lines of stress will tend to remain
slit-like.

Here are defense wounds on the hand of a victim whose assailant was attacking with a
knife.

The Bowie knife shown here illustrates a single edge knife with a hilt.

This is a single-edge blade stab


wound in which there is a "hilt"
mark at the left. The sharp blade
edge is at the right.

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This is an autoloading, semi-automatic pistol. The detachable magazine that holds 17


rounds is placed into the grip.

This is a revolver, which holds six rounds.

These diagrams depict the basic features of cartridges used in guns. The primer, when
struck by the firing pin, ignites the powder. It is the residue left by the primer that is
characteristic for a fired round, because it leaves traces of lead, antimony, and barium.

A rifle is a firearm with a long barrel, which gives the larger rounds more accuracy and
range. The energy of the fired bullets is enormous. The .308 caliber copper jacketed
bullets fired by this rifle can blow a hole in plate steel 1/4" thick.

The gunshot residue deposited in a gunshot wound can be detected by using scanning
electron microscopy coupled with energy-dispersive x-ray microanalysis to demonstrate
the characteristic elemental pattern of the primer residue with lead, antimony, and
barium, typical for many cartridges, as shown in this diagram.

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The appearances of the most common handgun and rifle rounds are shown here. In
general, it is difficult to tell from the wound exactly what round was used.

Bullets fired from a gun will have "striae" (linear grooves) imparted as a consequence of
traversing the barrel, and these marks help to identify the weapon. Comparison of bullets
involves "class" (caliber and rifling) and "individual" characteristics based upon burrs or
imperfections in the barrel, particularly the muzzle, that impart specific markings, or striae,
to fired bullets. Individual characteristics are used to determine whether a specific gun was
used in a crime. The sets of bullets shown here are from the same class, but deformations
in recovered bullets (the right of each pair) can complicate comparison.

When bullets strike a target, there can be considerable deformation and fragmentation.
In this case, the lead bullet has become markedly deformed and has separated from the
copper jacket at the right.

Much of the damage done by a bullet results from the tumbling motion and the
cavitation in the tissue. This is the bullet track in clay of a .38 caliber round,
demonstrating that the wound track is much larger than .38 inches (closer to 3 inches).

This is an contact gunshot


entrance wound. Since the barrel
contacts the skin, the gases
released by the fired round go into
the subcutaneous tissue and cause
the star-shaped laceration. Note
also the grey-black discoloration
from the soot, as well as the faint
abrasion ring.

An abrasion ring, formed when the force of the gases entering below the skin blow the
skin surface back against the muzzle of the gun, is seen here in this contact range
gunshot wound to the right temple.

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The abrasion ring, and a very clear muzzle imprint, are seen in this contact range
gunshot wound.

This is a contact range gunshot entrance wound with grey-black discoloration from the
burned powder.

The upper diagram illustrates


the basic differences between
the skin appearance of a
contact, close (intermediate),
and distant (indeterminant)
range gunshot wound. The
appearance of the wounding
characteristics in the skull is
shown in the lower diagram in
which there is bevelling of the
skull outward away from the
direction of origin of the bullet.

The surface of the skull demonstrates the heavy soot in this contact range entrance wound,
as well as radiating fracture lines. The direction of fire was thus toward the back of this
picture.

Histologic examination of the entrance wound site on the skin demonstrates black gunshot
residue and coagulative necrosis.

This is an intermediate range gunshot entrance wound in which there is powder "tattooing"
around the entrance site.

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Powder tattooing is seen in


this intermediate range
gunshot wound. The actual
entrance site is somewhat
irregular, because the bullet
can tumble in flight.

Displayed here is an entrance at the left and an exit at the right. This particular bullet
struck at an angle to produce the ovoid entrance. Exit wounds vary considerably in size
and shape because the bullet can be deformed in its transit through the body. There
may be no exit wound at all if the bullet's energy is absorbed by the tissues. Some
bullets (such a "hollowpoint") are designed to deform so that all their energy will be
converted to tissue damage and not exit.

Here is a slit-like exit wound. The projectile became deformed and flattened while
traversing the body, producing a laceration upon exit. Note that there is no powder or
soot visible in this exit wound.

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