Search

Modern forensic medicine was introduced into China during the first decades of the 20th century. The members of China’s first generation of medicolegal experts were soon advocating that medical expertise play a greater role in police and judicial officials’ investigations of suspicious death and homicide cases. While forensic reform in China had parallels with developments in other contemporary societies in which physicians were pushing for a greater role in the law, this process unfolded in China in unique ways, against the backdrop of an older tradition of forensic science that had developed under the Qing dynasty (1644-1911). Central to this tradition was the Records on the Washing Away of Wrongs, a handbook of forensic practice that was written in the 13th century and saw numerous editions and expansions over subsequent centuries. Death investigation in early 20th-century China was defined by “forensic pluralism,” a situation in which the different body examination methods and standards of forensic proof associated with the Washing Away of Wrongs and modern forensic medicine were both accepted by officialdom and society. This article untangles the complexities of forensic practice during this period through the rather unexceptional exchange over a case of suspected drowning that occurred between local officials in Hebei province and Lin Ji (1897-1951), director of the Beiping University Medical School Institute of Legal Medicine. This case reveals the different regimes of forensic knowledge and practice that were used in China during this period as well as the sites at which they interacted.

This paper explores the pathology caused by lightning. It covers the basic physics and mechanisms of injury of lightning strikes followed by a short discussion. The purpose of this paper is to suggest an approach to the investigation and autopsy of a lightning-related death.

The role and contribution of an objective and professional medicolegal death investigation service should be valued and strengthened, especially in countries and communities where institutional and governmental corruption, incompetence, and abuse of power may exist, and where there are weak civil watchdog agencies such as a free press. South Africa is a fledgling democracy and is now at a critical juncture from a sociopolitical perspective. A number of incidents and historical perspectives are presented, all of which have specific relevance to the forensic medical community and which serve to illustrate the importance of ensuring the protection of the rights of vulnerable groups and persons who may easily suffer from disregard and abuse by state agencies and their representatives and which may ultimately impact very negatively on the broader society. Strengthening the organizational and legislative framework within which forensic pathologists can function is vital to ensure effective investigation in matters such as deaths in custody and of institutionalized persons/patients as well as deaths associated with police action and mob killings, to name but a few.

Animals are amongst the most vulnerable of all sentient beings. Animal neglect and abuse may involve a single animal and one person, or hundreds of animals and many people. Animals and people are victims of the same types of fatal injury and severe neglect; however, the anatomy and physiology of different animal species and even breeds of animals are a unique challenge for veterinary pathologists. Identifying and describing external lesions of blunt force trauma and projectile wounds requires that the entire skin be reflected from the animal because fur and feathers partially or totally mask the injuries. Because quadrupeds or birds may react differently to the same traumatic force applied to bipedal humans, extrapolating from medical forensic pathology must be done with caution. Animal abuse, however, does not occur in a vacuum. An established link exists between animal abuse, interpersonal violence, and other serious crimes. Using examples, this paper describes specific injuries in abused and neglected animals in the context of domestic violence, interpersonal violence, mental illness, and drug addiction. Medical examiners should be aware that animal abuse affects not only the animal, but individuals, families, and society as a whole.

It is imperative that medicolegal jurisdictions prepare for the occurrence of a mass fatality incident. Despite the trend to plan for catastrophic and complicated incidents, this analysis of recent mass fatality events seeks to better inform authorities regarding the scale and types of incidents that could potentially impact their jurisdiction. The guidance provided by this study serves as a tool to guide the development of plans, acquisition of appropriate resources, and training of staff. To perform this analysis, data were collected from mass fatality incidents occurring in the United States from January 1, 2000 to December 31, 2016 that resulted in ten or more fatalities. Specific data points were collected for each incident including the date, location, number of fatalities, incident type (e.g., man-made or natural), incident subtype, and description (e.g., mass shooting, hurricane, aviation). A total of 137 incidents fit the criteria for inclusion in the analysis, resulting in a total of 8462 fatalities. The average number of incidents was eight per year during the study period. The analysis demonstrates that most mass fatality incidents (88.8%) result in between ten and 50 fatalities and are variable based on incident type and geographic location. This study includes several large-scale incidents, which as outliers have influenced fatality management operations and preparedness efforts on a national level. In particular, the World Trade Center attack of September 11, 2001 and subsequent remains recovery and identification operations have served to inform the New York City Office of Chief Medical Examiner of the capabilities required to manage a complex, protracted victim identification process involving extensive body fragmentation and commingling. While the World Trade Center attack has been shown to be outside the normal trends of mass fatality incidents, it has nonetheless offered the medicolegal community several invaluable lessons.

As the result of improved death scene investigations and the performance of more thorough and thoughtful pediatric forensic autopsies, there has been a widespread increase in the recognition of asphyxial mechanisms of death as well as lethal natural diseases that might have otherwise been erroneously labeled as sudden infant death syndrome (SIDS) or sudden unexpected infant death (SUID). Although it is fair to state that “more thorough autopsies provide more thorough medical evidence” from which to draw upon when determining cause and manner of death, there is no standard, accepted baseline from which forensic pathologists operate. Although anatomic pathologists are quite accustomed to practicing within well-defined boundaries for specimen (and thus diagnostic) adequacy, forensic pathologists are frequently hesitant to embrace or adopt such concepts. This has made it difficult to evaluate standards of practice in forensic pathology. Recommendations have been developed and published by the National Association of Medical Examiners for the postmortem assessment of suspected infant head trauma. However, significant variation exists in the way autopsies are performed on infants without trauma, such as the common scenario of an infant who has died suddenly and unexpectedly of asphyxial or apparent natural means. A wide variety of autopsy techniques and ancillary studies are available to forensic pathologists, but as survey data indicates, are not consistently used throughout the United States. This paper will discuss the different components of the pediatric autopsy and make recommendations for the best use of available tests and consultation services.

Sudden infant death syndrome (SIDS) has been used as a cause of death for over four decades. It has allowed deaths of infants to be registered as natural. Within this group of deaths, a certain number have been recognized to be homicides from inflicted smothering rather than being natural or accidental deaths. Research has been conducted using confidential inquires to determine how frequent homicide is in cases called SIDS. This paper traces the history of quoted rates of homicide. Early work suggested the figure was between 2-10% of all SIDS cases, though other workers have suggested figures as high as 20-40%. With the fall in the rate of infant deaths following the “Back to Sleep” campaigns, these figures have been reevaluated. If the higher figures were correct that 20-40% of SIDS were homicides, the fall in infant deaths would be expected to be less than it has been. Current data suggests a much lower figure than 10% of current cases, with much lower overall rates of infant deaths.As well as 10% of SIDS cases having been stated to be homicides, a related question is whether multiple deaths classified as SIDS are really homicides. The paper discusses the maxim that one death is a tragedy, two is suspicious, and three deaths indicate homicide. The paper also looks at court cases and the approach that has been made in prosecutions of sudden unexpected death in infancy as multiple murder.

In infants and toddlers (less than four years of age), determination of cause and manner of death often requires a complete autopsy. Few evidence-based guidelines exist regarding optimum nervous system sectioning in this population. Over a six-month interval and using a comprehensive section protocol, we categorized cases having neuropathological findings that were critical (Class A), contributory (Class B), or noncontributory (Class C) to the final cause and manner of death. We further evaluated which sections helped make this determination. Among 53 cases (44 infants, 9 toddlers; 26 girls, 27 boys), Class A neuropathology was noted in nine (16.9%). Seven infants had meningoencephalitis (2/7, 28.6%), craniospinal trauma (3/7, 42.8%), brainstem necrosis suggesting Leigh Disease (1/7, 14.3%), and hydrocephalus in Dandy-Walker malformation (1/7, 14.3%); two toddlers had inflicted craniospinal trauma (2/2, 100%). Class B factors were identified in 11/53 (20.8%), including recent hypoxic-ischemic lesions (2/11, 18.2%), meningitis or dural venous sinus thrombosis in systemic sepsis (2/11, 18.2%), multicystic encephalopathy following peripartum asphyxia (2/11, 18.2%), and microcephaly and delayed myelination (Cri-du-Chat Syndrome) (1/11, 9.09%). Class B also included three toddlers (3/11, 27.2%) with features of hippocampal dysgenesis, two in the setting of febrile seizures. Class C comprised normal brains (3/53, 5.7%), and those with findings of uncertain significance, such as white matter and brainstem gliosis (30/53, 56.6%). The sections most valuable for detection of relevant pathology, and thus recommended for routine sampling, were: 1) bilateral hippocampus; 2) cerebral cortex and leptomeninges; and 3) pons or medulla.

Sudden infant death syndrome (SIDS) became a named entity in 1969 and the term has been used to certify sudden unexpected infant deaths meeting certain demographic, epidemiologic, and pathologic criteria. Since it is a diagnosis of exclusion, there is inherent imprecision, and this has led the National Association of Medical Examiners to recommend that these deaths now be classified as “undetermined.” This historical review article briefly analyzes anecdotal instances of SIDS described centuries ago as overlying, smothering, infanticide, and suffocation by bedclothes followed by a more detailed review of “thymic” causes (i.e., thymic asthma and status thymicolymphaticus) popular in the late 1800s and early 1900s. Before the 1950s, such cases were also often categorized as accidental mechanical suffocation. In the 1940s and 1950s, forensic studies on infants dying unexpectedly revealed a typical pattern of autopsy findings strongly suggestive of natural causation and, after 1969, cases meeting the appropriate criteria were usually categorized as SIDS, a term embraced by the public and by advocacy groups. Research conducted after the 1960s identified important risk factors and generated many theories related to pathogenesis, such as prolonged sleep apnea. The incidence of SIDS deaths decreased sharply in the early 1990s after implementing public awareness programs addressing risk factors such as prone sleeping position and exposure to smoking. Deletion of cases in which death scene investigation suggested asphyxiation and cases where molecular autopsies revealed metabolic diseases further decreased the incidence. This historical essay lays the foundation for debate on the future of the SIDS entity.

Over the last two decades, a diagnostic shift in regards to the certification of sudden deaths in infancy has emerged with reassignment of deaths previously certified as sudden infant death syndrome (SIDS) to a trend utilizing the classification of undetermined or asphyxia. The consequences of this shift outside the medicolegal death investigation (MDI) community is unknown. We surveyed US organizations working in the field of sudden infant death as well as bereaved parents to understand their perceptions of the current diagnostic trends. Two online anonymous surveys were utilized. Sixty-seven organizations and 55 parents with an infant death diagnosis of SIDS, sudden unexplained infant death (SUID), undetermined, or asphyxia participated. Just over 50% (34/67) of the organizations perceived the shift had an effect on their organization including barriers to bereavement support and education. Forty percent (22/55) of parent respondents stated they did not understand the final diagnosis of their infant's death. The highest frequency of themes elicited from parents were frustration that the diagnosis (regardless of terminology) did not fully explain the death, detrimental mental health effects, and negative perceptions towards the medical and public health communities. However, parents of children whose death was classified as SIDS were spared from negative perceptions towards the medical field, described the least amount of confusion, and reported the most instances of positives effects. Legal implications, perceived social stigmas, and research obstacles were also described. Recommendations from this study include the integration of collaborative efforts to combat sudden infant death with all stakeholders, in and outside of MDI, to achieve better understanding and eradication of these tragedies, improved public education, and effective care of all bereaved.

As drug- and opiate/opioid-related deaths continue to rise in the Midwest, we must look at how the type of death investigation in these areas is affected and taxed by the increase. Many states with a large rural component rely on a local coroner system, where death investigation lacks uniformity and requirements for coroner investigative personnel are extremely variable. This has mixed implications for communities and potentially affects law enforcement and prosecution, data collection, and public policy. Both coroner and medical examiner systems benefit from strong leadership, properly trained personnel, and fiscal support. However, operational differences amongst jurisdictions should be addressed so that all stakeholders ultimately receive optimal data. This paper discusses the coroner system of death investigation in one Midwest state (Ohio) in the context of the region's burgeoning opiate/opioid epidemic and suggests opportunities for improvement.

The dramatic increase in drug-related deaths in the last decade has presented fiduciary and logistical difficulties to medicolegal jurisdictions of all types and sizes. New Hampshire, with a centralized state medical examiner system of death investigation, has been confronted with the task of investigating these drug-related deaths against the backdrop of statutory hurdles inhibiting a nimble response to the situation. This has led to a collaborative approach with law enforcement and the state Department of Justice in terms of triaging drug deaths to full autopsy versus external examination with toxicology testing. Preliminary data suggest that between 11 and 13% of suspected drug deaths have an alternative cause of death revealed by autopsy. Positive toxicological findings were documented in 97.5% of cases in which only an external examination was performed; however, some of these cases may have had undetected, significant internal findings that could have accounted for an alternative cause of death if an autopsy had been performed. While the case triage system described has temporarily addressed the acute problem, the issue of the medical examiner's appropriate role in the adequate evaluation of public health and safety remains extant. Furthermore, noncompliance with the National Association of Medical Examiners inspection and accreditation standards puts this agency, and others facing the same issues, at risk of losing full accreditation status until such resource issues are addressed by legislators and other stakeholders in the quality of medicolegal death investigation in the United States.

The Virginia Prescription Monitoring Program (VPMP) has been in effect since 2002, providing reports for prescribers, pharmacists, and other stakeholders in the growing opioid epidemic. The Office of the Chief Medical Examiner is one such stakeholder and has found great efficacy in the program in investigating suspected drug-related deaths. This review examines the origins of the VPMP, its benefits, and limitations for use during death investigation.

Opioid-related deaths have transitioned over the past 15 years, beginning with a steady increase in the incidence of fatal prescription overdoses, followed by a dramatic increase in deaths caused by illicit opioids, namely heroin and fentanyl. These trends in drug-related deaths are identified by medical examiners and coroners who serve an important role in public health surveillance. Medicolegal death investigators, being first responders, often recognize spates of drug-related deaths in real time. While few jurisdictions are unaffected by the epidemic, some medicolegal death investigators may have less experience detecting fatal opioid overdoses. This review will outline many of the medical, behavioral, and physical indicators of a deadly prescription or illicit opioid overdose. All aspects of a thorough medicolegal death investigation will be discussed, including the proper documentation of the scene and evidence handling. Investigative questions and follow-up procedures will also be reviewed.

The medical examiner/coroner (ME/C) death scene investigation systems of the United States play a pivotal role in the current public health crisis created by the expanding drug dependency epidemic in the United States. The first point of recognition of a drug-related death in a community is often the local ME/C agency. This circumstance places these entities in an ideal position to provide surveillance data regarding the epidemiology of drug-related deaths occurring within the jurisdiction of the agency. The ability to surveil for the distribution and determinants among drug-related deaths at the first point of contact enhances the capacity to recognize actionable trends at the local, state, and national levels, including the ability to identify secular (longer-term) trends among various drugs and population subgroups, as well as activity spikes (outbreaks) associated with high-potency formulations and drug combinations. In this article, we describe the development and implementation of an online website that provides public access to a wide array of drug-related death surveillance resources and tools. The website gives users access to a detailed dataset that includes information regarding specific drugs, demographic information pertaining to the decedent, and to investigational findings related to the circumstances of the death. A unique aspect of the database is that it is populated by ME/C agencies and accessed by the public with no intermediary agency, so that the lag time between the identification and investigation of the death as drug-related and community knowledge of the circumstances of the death is minimized. Wide dissemination of accurate drug death surveillance information in an easily accessible and customizable format promotes societal awareness of the drug death epidemic, but also provides information to public health, law enforcement, regulatory, and other community-based organizations that can benefit from the most up-to-date knowledge. We envision a national system of surveillance at the regional ME/C level that would allow for optimal information dissemination and sharing. Such a system would likely allow for more efficacious allocation of resources at the regional and national level.

Splash or spill scald burns may be seen by medical examiners in the setting of intentional trauma or accidental injury. In order to model various scald burn scenarios, an 8-year-old subject dressed in white had colored water spilled or dropped onto her. The results were recorded by video and still photography. Five trials were performed and included: liquid in a cup thrown towards the anterior body surfaces; liquid in a cup thrown towards the posterior body surfaces; a cup of liquid spilled across a table into the lap of a seated subject; a saucepan pulled down onto the anterior torso; and a cup of liquid spilled onto the top of the head. In each of the spill and splash models described above, a large often confluent zone of staining at the site of initial liquid contact with the body was often accompanied by elongate runoff patterns following gravity; droplet staining was often noted on adjacent areas. When seated, an inverted U-shaped staining pattern was on the buttocks. Anticipation of the splash event in one trial resulted in the subject instinctively turning the anterior body away from the oncoming liquid. When presented with a scalded victim, modeling of the reported history may provide a pattern of staining that supports or refutes the explanation offered for the burn. A mobile and neurologically intact subject who can anticipate an incipient scald injury may move prior to and during contact with the liquid resulting in unique staining patterns on multiple surfaces of the body.

The necks of infants and young children are not only anatomically different from adults, but are also supported by much weaker musculoskeletal systems and are therefore prone to trauma as a result of extension/flexion (shaking) or contact trauma to the head. Shaking cervical spine injuries can occur at much lower levels of head velocity and acceleration than those reported for shaken baby syndrome. The proper method for a comprehensive and detailed examination of the neck in pediatric homicide and suspected homicide cases is the en bloc examination of the neck, because the standard examination of the spinal cord not only distorts the anatomical relationship of the cord and osteocartilagenous structures, but also excludes the cervical nerves, ganglia, and the vertebral arteries from being evaluated. Interpretation of gross and microscopic findings using this method requires experience and knowledge of the anatomical relationship and common artifacts, such as epidural, focal intradural, or even isolated nerve hemorrhage to avoid misinterpretation. It is our opinion that this method should be applied to all pediatric homicide or suspected homicide cases, but is not suited for routine or nonsuspicious cases as it will add to the time and cost of medical examiner's operations.

Fractures are commonly found in cases regarded as child abuse. The most commonly encountered fractures are to the ribs and the metaphyses. This paper examines the specificity of the classical metaphyseal lesion (CML) and rib fractures as hallmarks of child abuse. Recently, vitamin D deficiency (rickets) has been proposed as an alternative cause for the appearances typically described in CML. The literature in this area is examined. Rib fractures have also been highly associated with child abuse, particularly posterior rib fractures. As well as metabolic bone disease, resuscitation has been examined as a cause of rib fractures in young children. The current literature remains strongly supportive of rib fractures and metaphyseal fractures being indicators of child abuse.

Established in 1929, Northwestern University’s Scientific Crime Detection Laboratory (SCDL), America’s first independent forensic crime laboratory, undertook a wide range of scientific case work during the 1930s, including toxicology, firearms identification, polygraph testing, the analysis of questioned documents and bacteriology; its mission being to provide Chicago with a world-class forensic science service. Alongside this mission, however, a key ambition of the SCDL’s founders was to forensically educate police officers, legal professionals, and the general public. Convinced that American police were largely ignorant of scientific aids to crime detection and that the public’s lack of forensic awareness led to the destruction and contamination of crime scenes, the SCDL attempted to fashion itself as a “school for manhunters.” But, while the laboratory’s ambitious program of public talks, scientific demonstrations, detective schools, expositions, and radio programs were intended to foster the creation of both a scientifically savvy public and policemen on par with those to be found in Europe, the SCDL encountered a number of significant hurdles to achieving these goals, including the hostility of some high-ranking police officials.

Imaging technologies play an integral role in forensic anthropology cases. Advances in digital photography allow the anthropologist to photo-document the scene and skeletal remains in exceptional detail. Traditionally, radiographs have been used to document remains, potential trauma, and any individualizing characteristics such as healing trauma and frontal sinus morphology. Given technological advances, some forensic anthropologists have begun to incorporate more advanced imaging methods in their case analyses and research, such as computed tomography and three-dimensional (3D) surface scans. These advanced imaging technologies provide a means to document skeletal remains and trauma, and can be used to create 3D replicas of the elements for archival and illustrative purposes. Researchers have begun to develop novel methods for estimating biological parameters from these 3D virtual models, using new variables such as surface areas and volumes, and advanced statistical methods (e.g., geometric morphometric analyses) to quantitatively analyze skeletal variation for sex and ancestry estimation. The use of these technologies in forensic anthropology remains somewhat limited, however, due to required costs, expertise, and the time involved in collecting and processing the data. Newly developed methods require further validation, and some areas of advanced imaging, such as photogrammetry, remain relatively unexplored in the field. Interdisciplinary collaborations between forensic anthropologists and other medicolegal professionals can help alleviate some of these resource constraints and facilitate advancements in forensic case analysis and research.

Anthropologists have a lengthy history using cranial nonmetric traits to assess biological distances between populations. These concepts were adopted by forensic anthropologists to estimate ancestry at the individual level using population-based human variation. However, this method of estimation must adhere to the Daubert guidelines to be applied in the modern court system. To that end, a set of cranial macromorphoscopic traits have been proffered to generate a methodological approach to the estimation of ancestry that can be empirically tested and verified. Additionally, various statistical frameworks, parametric and nonparametric, have been employed to calculate error rates and provide probabilistic statements of the strength of these estimations. Recent studies have further advanced the reliability and validity of macromorphoscopic trait analysis through reference datasets, validation studies, and demonstrable exploration of the complex population histories impacting human variation between and within populations worldwide.

Forensic identification of human remains has long been a core contribution of forensic anthropologists to death investigations. The array and scientific robusticity of the identification methods employed by the anthropologist has evolved in the last several decades, and as with other nonidentification methods, anthropologists have embraced the progression toward the use of validated and statistically defensible methods for identification. This article presents an overview of the role that the forensic anthropologist plays in the identification of human remains and the evolution of anthropological methods of identification.

Medicolegal death investigation requires a multidisciplinary approach to the collection of data from the crime scene to the autopsy table. Law enforcement processing of the indoor crime scene works extremely well for documenting evidence and producing reconstructions of past events. However, outdoor crime scenes require a new set of scene processing protocols — a need primarily derived from the wider array of natural agents, such as plants, animals, soil chemicals, or environmental conditions that will affect the evidence after burial or deposition outdoors. Forensic archaeology provides the principles, practices, and protocols for documenting and analyzing this type of evidence at a variety of outdoor and other complex crime scenes, including large-scale scene searches, surface-scattered remains, buried body features, fatal fires, and mass disaster scenes. Scene recovery protocols require 1) documentation of the context of the scene, including specific location, local flora and fauna, and geological, geographic, and environmental factors and conditions and 2) detailed notation of the spatial distribution of the evidence in order to establish association of evidence to other evidence and to a particular incident. The discipline of forensic taphonomy provides the techniques and conceptual framework to combine these scene-derived data with laboratory analysis of the biological tissues in order to build and test scientific hypotheses regarding the events surrounding death and deposition. The primary assessments resulting from a forensic taphonomic interpretation include scientific estimates of postmortem interval; whether and how remains have been moved, removed, or altered; and ultimately, whether there is an indication of human intervention.

This article focuses on the role of the forensic anthropologist in the identification of migrant remains in the American Southwest. These migrant cases present a unique set of circumstances that necessitate a regional approach to identification. The Pima County Office of the Medical Examiner (PCOME), located in Tucson, Arizona has developed best practices that facilitate high identification rates of migrant deaths. These best practices have provided a foundation for other agencies that are faced with similar issues; namely, developing specific protocols for migrant deaths, working with nongovernmental humanitarian organizations, and sharing information have maximized identification efforts. In 2012, Texas surpassed Arizona in the number of migrant deaths. The Forensic Anthropology Center at Texas State (FACTS) began identification efforts for migrant remains found in Brooks County, Texas in 2013. Informed by best practices from the PCOME, FACTS has made successful identifications. Descriptions of the processes at both the PCOME and FACTS are described in detail.

Forensic anthropologists have made remarkable contributions to the medicolegal investigation of nonaccidental injury in pediatric cases. They have created standard nomenclature for fracture descriptions. Anthropologists have developed novel techniques that increase the sensitivity of the pediatric autopsy. They have performed biomechanical research that enables reconstruction of events surrounding death. Also, anthropology practitioners have developed several reference guides on the subject of nonaccidental injury that are of value to forensic pathologists. These advancements assist forensic pathologists in the accurate classification of cause and manner of death in pediatric cases.

Worldwide, an estimated 415 million people have diabetes mellitus, which results in extensive morbidity and mortality. In order to track the effect of diabetes on mortality statistics, deaths in which diabetes mellitus caused or contributed to death must be recognized, included on the death certificate, and then properly coded for vital statistic purposes. For public health policy, this will help determine the extent of the disease and follow whether deaths increase or decrease. There is variation among death certifiers for when and how diabetes is included on the death certificate and among vital records bureaus as how to code diabetes-related deaths. Case scenarios are presented to highlight the certification issues that arise with deaths related to diabetes mellitus. This area of death certification may benefit from a consensus effort to standardize and enhance certification and coding of deaths due to diabetes in order to improve the reliability of these mortality statistics.

The pituitary gland has an important role in homeostasis and disorders of it can result in endocrine dysfunction and/or produce mass effect on surrounding structures, including the hypothalamus, which can cause significant morbidity and mortality. A definitive clinical diagnosis may be delayed or remain elusive and lead to life-threatening conditions. Specifically, pituitary adenomas, pituitary necrosis, hypophysitis, and abscesses have all been reported in the literature to cause sudden and unexpected death and may only be first encountered at autopsy. Recognition by the forensic pathologist of these rare entities is crucial for appropriate death certification. This review emphasizes the need for a comprehensive, detailed forensic examination, including autopsy and routine histologic sampling of the pituitary gland, in order to ascertain its potential role in sudden unexpected death with no other apparent cause.

Diabetes mellitus is a common condition affecting both adults and children. Long-standing diabetes is associated with cardiovascular abnormalities such as coronary artery atherosclerosis, microvascular changes, hypertension, kidney disease, and heart failure. Its association with heart failure in the absence of coronary artery disease and hypertension was termed diabetic cardiomyopathy in the 1970s and is believed to account for some of the cardiac mortality in diabetic patients. This entity may be implicated as the cause of sudden cardiac death in the small percentage of diabetic patients in which the autopsy fails to demonstrate evidence of nonketotic hyperosmolar coma, diabetic ketoacidosis, or atherosclerotic and hypertensive cardiovascular disease. Molecular and metabolic alterations have been studied to explain the pathophysiology of this disease.

Diabetes mellitus (DM) affects millions of Americans and is a common cause of death. The medical examiner/coroner (ME/C) may be called to investigate the death of a person with DM due to the possibility of a suicide, accident, or even homicide that relates to the treatment or lack of treatment of the disease. The ME/C can ellicit abundant circumstantial information from a death scene investigation and interrogation of devices such as glucometers, insulin pumps, continuous glucose monitors, and insulin injector pens used for the management of diabetes. These devices contain stored information that can very powerfully assist the ME/C in determining the cause and manner of death. This article provides a review of DM treatment and common medical devices used in the treatment and management of DM, offers the ME/C some instruction for interrogating the devices on their own, and highlights the benefits of beholding the information contained within the devices. At the conclusion of this review, the reader should have an understanding of how these devices work, how the information they contain can be accessed, and how useful that information can be in death investigation.

Recovering bodies from water is a common task for any medical examiner or coroner office. Unfortunately, there will be a significant postmortem interval before many of these remains are found. A thorough scene investigation must be undertaken to determine if the location of the death and that of the body recovery are the same. Decomposition in a wet environment differs from that in other settings, both in the changes that occur and the rate at which they occur. It is essential that the forensic pathologist or medicolegal death investigator recognize and appreciate the uniqueness of immersed and submerged remains. The typical decomposition changes proceed more slowly in the water, primarily due to cooler temperatures and the anaerobic environment. However, once a body is removed from the water, putrefaction will likely be accelerated. Postmortem changes are not only affected by water temperature, but also by current as well as obstacles and structures, both natural and man-made, that may interact with the remains. The anaerobic nature of decomposition for wet or submerged remains may result in adipocere formation, a unique and fascinating process that results from incomplete transformation of lipids by bacteria. Insect and animal species feeding on the remains are different for submerged bodies. Postmortem predation may cause external defects that mimic injuries and should be interpreted with care. Forensic pathologists and medicolegal death investigators must be aware of the postmortem changes that may occur with submerged and immersed bodies.

Postmortem changes can both mask and mimic trauma, impairing interpretation of the injuries. Bones, while capable of surviving the postmortem period relatively intact, are not immune from these effects. Without attached soft tissue to aid an examiner, it can be difficult to determine the time frame of a fracture's occurrence (i.e., before death, at death, or after death). Bones are composed of both organic and inorganic material, each of which contribute to the biomechanical properties of the bones. With the loss of organic material, the biomechanical response of bones to trauma changes; however, the organic material can remain a part of the bone for an extended period after death. Bone with intact organic material is wet bone, and bone without the organic material is dry bone, and because of this difference, fractures of wet bone can appear different than fractures of dry bone. Important in distinguishing the two are differential coloration, various features of the fracture itself (e.g., angle, surface, outline), surrounding flaking of the cortex, and incomplete separation of bone fragments from the fracture. However, the changes are not absolute, and determination of the two types of fractures can be problematic. Although the terms antemortem, perimortem, and postmortem have been used to describe the general time frame of fractures in relation to the time of death of the individual, because of confusion among specialties regarding the definition of “perimortem,” its use may best be discontinued in favor of a descriptive approach when fractures are identified in skeletal remains.

The diagnosis of strangulation at autopsy is a persistent challenge for the forensic pathologist. The main difficulty is interpreting the observations made at the postmortem table and deciding whether the observations are a sufficient basis to render an expert opinion that death was caused by external compression of the neck. This may have considerable importance to the criminal justice system and may lead to a conviction for murder. There are five main pitfalls and artifacts encountered in the neck at postmortem examination. These five areas provide the majority of the interpretative difficulties experienced by the pathologist. These challenges include: 1) developmental anatomy of the hyoid bone; 2) triticeous cartilages; 3) Prinsloo-Gordon hemorrhage; 4) postmortem hypostatic hemorrhage; and 5) resuscitation-related neck injury. This review explores these five areas. Awareness of the pitfalls and artifacts in the neck is essential for a satisfactory and evidence-based approach to interpreting observations of the neck at autopsy.

The fatal maltreatment of people that are detained against their will, such as political prisoners and suspected terrorists, can occur in unstable countries. The death of such detainees is often controversial and debated in the media, legal tribunals, and communities. Therefore, there is a need for nonpartisan information about the cause of death of prisoners due to the implications that the data may have about a conclusion that human rights were abused. Autopsies are the only scientific way to prove the cause of death of detainees and to ascertain the truth behind how injuries may have occurred. On this basis, all forensic pathologists ought to be able to interpret the basic injury patterns commonly encountered in torture. The injuries are similar to those found in child abuse, but also include trauma from suspension and “homicide by heart attack” during interrogation. This paper will review the postmortem findings in cases of torture.

The people of Cambodia were subjected to widespread forced migration and labor, disease, starvation, torture, murder, and indeed, genocide over a period of four years during the control of the country by Pol Pot and the Khmer Rouge in the 1970s. While the country awaits some form of justice from the hybrid tribunal hearing cases against a few of the perpetrators of these crimes, it has undertaken to memorialize the dead in visible monuments in order that the people remember and never allow it to happen again. This paper outlines the few forensic investigations which have been undertaken on the remains of the deceased from this period in Cambodia's history. The current status of the legal proceedings and the current death investigation system in Cambodia are also presented. There is a wealth of objective forensic information that can be gathered from analyzing the remains that have been disturbed and placed in monuments (stupas), and also in the undisturbed graves across the country. This information cannot only assist in any legal proceedings, but can aide in training medicolegal experts in Cambodia for the future good of the country and its rule of law.

Hundreds of synthetic substances have been introduced into the illicit drug market over the last ten years, but none of these drugs has had as poisonous a consequence as the emergence of the synthetic fentanyl analogs. Initially, pharmaceutical grade or illicit fentanyl was mixed with heroin, allegedly to boost the potency of the heroin. Then, the amounts of fentanyl spiked gradually increased until the proportion of fentanyl was greater than the proportion of heroin. Ultimately, many overdose cases began consisting of only fentanyl. The emergence of numerous synthetic fentanyl analogs, including acetylfentanyl, butyrylfentanyl, acrylfentanyl, furanylfentanyl and β-hydroxythiofentanyl, which are manufactured in China, were made available to the illicit drug traffickers over the Internet. In July of 2016, the most potent commercially available opioid, carfentanil, started appearing in illicit drug submissions and medical examiner death investigation cases in Northeast Ohio. Postmortem femoral blood carfentanil concentrations are in the picogram per milliliter (pg/mL) range, which is extremely low, and tests the limits of detection for most analytical forensic toxicology laboratories. The interpretation of these low carfentanil blood concentrations in antemortem and postmortem specimens is made difficult due to the overlap in the concentrations between these specimen types. The presence of these powerful synthetic fentanyl analogs presents a challenge to forensic toxicology laboratories preparing to analyze for these substances.

In recent years, there has been a substantial increase in opioid use and abuse, and in opioid-related fatal overdoses. The increase in opioid use has resulted at least in part from individuals transitioning from prescribed opioids to heroin and fentanyl, which can cause significant respiratory depression that can progress to apnea and death. Heroin and fentanyl may be used individually, together, or in combination with other substances such as ethanol, benzodiazepines, or other drugs that can have additional deleterious effects on respiration. Suspicion that a death is drug-related begins with the decedent's medical and social history, and scene investigation, where drugs and drug paraphernalia may be encountered, and examination of the decedent, which may reveal needle punctures and needle track marks. At autopsy, the most significant internal finding that is reflective of opioid toxicity is pulmonary edema and congestion, and frothy watery fluid is often present in the airways. Various medical ailments such as heart and lung disease and obesity may limit an individual's physiologic reserve, rendering them more susceptible to the toxic effects of opioids and other drugs. Although many opioids will be detected on routine toxicology testing, more specialized testing may be warranted for opioid analogs, or other uncommon, synthetic, or semisynthetic drugs.

The United States continues to grapple with an epidemic of opiate/opioid drugs. This crisis initially manifested itself in the use and abuse of opioid pain relievers and has since seen an increase in illicit opiate/opioid drug use mortality. Cuyahoga County (metropolitan Cleveland) has been an area where the crisis has been particularly acute; this paper updates our previous experience. Most notable in the evolution of the drug epidemic has been an increase in mortality associated with fentanyl and an alarming rise in overall deaths, largely attributable to the emergence of fentanyl (a 64% increase in total overdose deaths from 2015 to 2016, with fentanyl increasing 324%). Fentanyl is a synthetic opioid with use in medical analgesia and anesthesia; however, most of the current supply is of clandestinely manufactured origin. Also of concern is the recent appearance of illicit fentanyl analogues, which are briefly described in this report. White males continue to be the most frequent overdose victims in the current crisis. A decrease of age appears to have taken place with the emergence of fentanyl with the most common age group being between 30 and 44 years of age. The majority of decedents are nonurban residents. Educationally, most of these decedents have a high school diploma or less schooling and a significant percentage consists of manual laborers. Medical examiners are an important source of information necessary to develop prevention and interdiction strategies. Challenges faced regarding adequate funding, instrumentation, and staffing are being felt.

The recent surge in drug deaths has focused attention on the diagnosis of drug intoxication as a cause of death. In Maryland, the Department of Vital Records has shown an increase from 649 intoxication deaths in 2012 to 1259 in 2015. Preliminary data for 2016 document 1892 of these deaths. Many of the medicolegal death investigation offices in the United States are facing potential loss of accreditation. There is limited capacity to add more staff due to a lack of appropriately trained pathologists and budget constraints. The diagnosis of this intoxication and the need to autopsy all of these cases is a matter of debate, as many death investigation offices look for alternative means to maintain accreditation. The alternative to adding more staff is to reduce the autopsy caseload. Can this be done without compromising the intent of the medical examiner system and the law? Balancing this with being fiscally responsible may be a very real challenge and one that will test many death investigation systems due to this pandemic of drug deaths. If there is a need to reduce the autopsy caseload, it should be in cases other than where the diagnosis is one of exclusion.

Fatal, allegedly inflicted pediatric head trauma remains a controversial topic in forensic pathology. Recommendations for systematic neuropathologic evaluation of the brains of supposedly injured infants and children usually include the assessment of long white matter tracts in search of axonopathy — specifically, diffuse axonal injury. The ability to recognize, document, and interpret injuries to axons has significant academic and medicolegal implications. For example, more than two decades of inconsistent nosology have resulted in confusion about the definition of diffuse axonal injury between various medical disciplines including radiology, neurosurgery, pediatrics, neuropathology, and forensic pathology. Furthermore, in the pediatric setting, acceptance that “pure” shaking can cause axonal shearing in infants and young children is not widespread. Additionally, controversy abounds whether or not axonal trauma can be identified within regions of white matter ischemia — a debate with very significant implications. Immunohistochemistry is often used not only to document axonal injury, but also to estimate the time since injury. As a result, the estimated post-injury interval may then be used by law enforcement officers and prosecutors to narrow “exclusive opportunity” and thus, identify potential suspects. Fundamental to these highly complicated and controversial topics is a philosophical understanding of the diffuse axonal injury spectrum disorders.

The investigation of vehicular hyperthermia deaths in infants and children requires coordination between the autopsy, clinical history, and scene investigation. Unfortunately, autopsy findings can be limited or nonspecific, clinical history may be unavailable, and details concerning ambient temperature and vehicular temperature may be vague. In cases where hyperthermia is established as the cause of death, the certification of manner of death can be challenging and inconsistent among medical examiners. This article provides an overview of vehicular hyperthermia deaths and the certification of cause and manner of death in these cases.

Estimation of the biological profile of unidentified human remains is a critical component of an anthropologic evaluation of unidentified human remains. The profile is used to search for missing persons that may match the decedent. The individual components of sex, ancestry, stature, and age at death require reliable methods to ensure accurate recording of these biological markers. This article showcases an unidentified skeleton that was misclassified as a female when the original evaluation was done in 1963. The revaluation in 2004 quickly led to resolution of the identity. Methods used today to evaluate the components of the biological profile are reviewed along with a limited review of the historic literature.

While crime laboratories are commonly accredited under programs utilizing international standards, options for forensic anthropologists to do the same were limited, until recently. The American National Standards Institute-American Society for Quality (ANSI-ASQ) National Accreditation Board (ANAB) and the American Association for Laboratory Accreditation (A2LA) both offer accreditation programs for forensic anthropology services using either the International Organization for Standardization/International Electrotechnical Commission (ISO/IEC) 17025 or ISO/IEC 17020 standard. The significant efforts made to specifically include forensic anthropology, and also forensic pathology, in these national programs demonstrate the importance for all practitioners in the field of forensic science to develop and maintain quality assurance programs consistent with international standards. Among the requirements for quality assurance is validation of methods, a practice that was previously identified as needing improvement within the forensic anthropology community.

The analysis of biological specimens for the presence of exogenous insulin is of special interest in select postmortem investigations. Insulin analogues are primarily used to mediate the regulation of blood glucose concentrations; however, their use has also been implicated or suspected as a cause of death in suicides, accidents, and homicides. Toxicological analysis for these compounds is challenging due to the large molecular weight, the limited stability of insulin in whole blood, and complexities associated with sample preparation and instrumental testing. As a consequence, determination of insulin in postmortem specimens is not routinely offered by most forensic toxicology laboratories. Forensic death investigation is further complicated by interpretative difficulties such as the frequent absence of anatomical findings, concentration interpretation in known insulin users, and addressing the impact of chemical instability and postmortem redistribution. There are ongoing efforts, however, to develop and validate robust methods that may be used for this analysis on these challenging samples and that are capable of withstanding scientific and legal scrutiny for forensic use. In this regard, in recent years, methods for the detection of exogenous insulin in postmortem samples have been reported and results of this testing has been published in a handful of cases. The purpose of this article is to review the primary functions of insulin, the disease states associated with the therapeutic use of exogenous insulin, the current state of laboratory testing, and to provide case summaries that summarize the timeline of advancements and underscore the importance of this work.

Diabetes mellitus is a well-recognized risk factor for arterial thrombosis, however its relationship to venous thromboembolism (VTE) in adults is still debated. We report here seven cases of fatal pulmonary thromboembolism in adults with diabetic ketoacidosis as the underlying cause. In four of seven cases, there was no prior diagnosis of diabetes mellitus and patients were newly diagnosed either upon presenting to the hospital in diabetic ketoacidosis (DKA) or at the time of autopsy by the vitreous glucose concentration. None of the patients had family history, recent surgery, recent trauma, long distance travel, or other strong risk factors for VTE. Only two patients had a body mass index greater than 35 kg/m2 and the same two cases had hospital stays that ranged from three to five days. We believe that DKA is a frequently unrecognized and sometimes overlooked risk factor for VTE, particularly in the forensic setting where routine toxicology and vitreous glucose analysis may not be standard practices. We encourage forensic pathologists, medical examiners, and coroners to consider the possibility of diabetic ketoacidosis as a risk factor, and in some cases, the underlying etiology for pulmonary thromboembolism. Additionally, we recommend vitreous glucose testing be performed if there are any signs of DKA or diabetes present, such as acetone in the blood.

While diabetes mellitus (DM) has historically accounted for substantial worldwide morbidity and mortality, new and evolving epidemiologic trends are forcing the scientific community to view it as a type of emerging disease. This review will summarize the pathophysiology of the disease, present an update of current national statistics and changing epidemiologic patterns, discuss how DM might specifically lead to acute deaths falling under the jurisdiction of the medical examiner/coroner, and suggest a medicolegal standard of practice to maximize their capture and reporting.

The fact that the body changes following death must have been known for the whole history of mankind. But myth and superstition surrounded the changes. This led to such entities as the ordeal of the bier being used as criminal proof, even though other forms of trial by ordeal had long been abandoned. The scientific literature in the English language did not start until the late 18th century and was still surrounded with ignorance and some superstition. The main concern of the early writers was the correct determination of death. In the 19th century, an understanding of postmortem changes developed and the first attempts to accurately classify sequences of putrefaction were made. This paper analyzes the early forensic medicine writing and the progress of knowledge to the later 19th century, through examination of forensic medicine textbooks published in the English language.