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In the last years, the discussion concerning the causes of infantile subdural hemorrhages became controversial. Many authors still suppose that child abuse is the predominant cause of such cases. On the other hand, reports presenting series of accidental cases were published, and the fear of an overdiagnosis of the shaken baby syndrome has been expressed. Our autopsy material concerning all lethal head injuries of infants and toddlers from 2 decades was reviewed. 17 of these 64 cases were characterized by the following: history of no trauma or only an insignificant event; children found dead or apnoic or in coma; no skull fractures; no focal brain injury; ruptures of several bridging veins but only minimal subdural bleeding. 11 victims were infants (1st year of life) and either 3 were 2 years resp. 3 - 6 years old; 50 % off all lethal head injuries of infants were of this type, while only 25 % resp. 10 % of the following age groups. None of these 17 cases was a result of a minor accident witnessed by unrelated persons. Abuse could be ascertained with a high degree of probability in most cases and remained quite likely in the others. Two different types of subdural hemorrhages should be kept from another: a) patients suffering a moderate head injury from a minor accident which results in a subdural bleeding (from a small intracranial lesion) often do not deteriorate soon after the impact, develop a hemorrhage of significant volume, respond well to therapy and have a good prognosis. b) cases with a history of no or only of an insignificant trauma, infants dead or nearly dead on clinical presentation, often a poor outcome in cases of survival. There is typically no significant subdural bleeding despite multiple bridging vein ruptures in the majority of these cases: the subdural hemorrhage is here only a visible sign of a much more serious and general cerebral alteration, resulting in a rapid increase of intracranial pressure (often complicated by respiratory arrest) which prevents a signifant bleeding into the subdural space. This combination of findings is typically found in victims of massive events (car occupants in high-velocity crashes) and not compatible with a supposition of a minor fall causing this.

Recently the discussion concerning the causes of infantile subdural bleedings (SDB) has become quite controversial. The wide-spread interpretation that most of these cases are the result of abuse, especially by the shaken-baby-syndrome, was doubted, and the role of (even minor) accidental events was emphasized.This situation should be analyzed basing on the official statistics of the causes of death in the city of Berlin (1978-1998) and the autopsy material of our institute (1978-1999).In this period, approximately 440.000 children lived their first year of life in our city. Only 80 violent deaths of infants (up to 1 year old) were recorded in the official statistics, including 27 deaths due to blunt forces, with 24 lethal head injuries as the main group. Only two cases were attributed to "falls under unclear conditions"; all other accidental cases were the results of traffic accidents or falls from a height. No death due to an undoubted minor fall was recorded, nor was any in our autopsy material. We investigated 10 cases of infantile SDB, all without skull fractures and gross brain injuries. Only 1 victim had a SDB of a significant volume; in all other cases only small amounts of blood were present in the subdural space. Bridging vein ruptures were directly demonstrated in 8 cases and were bilaterally in most instances; recently their detection has been simplified by postmortem x-ray using contrast material. All 10 cases were interpreted as typical acceleration-deceleration injuries (as in shaking), although only in 2 cases a confession of this procedure could be obtained.Comparing cases of accidental and non-accidental SDB in the literature, infantile SDB obviously cannot be looked at as a homogeneous entity: two quite different types should be kept separate: the patients suffering from an accidental SDB due to a minor fall mostly do not deteriorate immediately after the trauma, develop SDB of some volume, up to a space-occupying mass lesion, and have often a good prognosis. A lethal outcome is extremely uncommon; we have not observed a single case of an infantile lethal SDB resulting from such a minor injury for more than 20 years. The source of the SDB in those cases currently is unknown in most instances. The second group of infantile SDB includes the well-known group of shaken-baby-syndrome: no adequate history, infants dead or nearly dead on clinical presentation, often a poor outcome if the event is survived, typically no significant volume of SDB, and--according to our experiences--in all cases BV ruptures. This combination of several BV ruptures with no significant subdural bleeding is not compatible with a supposition of a minor fall causing this.

Experimental data and clinical as well as postmortem experiences have indicated that subdural hematomas are less frequent in acceleration injuries in traffic accidents compared to falls or assaults. The present report demonstrates that this does not hold true in the same way for bridging vein ruptures (one of the predominant causes for subdural bleedings). Ruptures of these vessels without subdural bleeding (SDB) are only seldom mentioned in the literature. However, if no SDB is present, no one will look for these structures. In our institute a systematic analysis of the bridging veins in all cases of lethal blunt head injury is made: prior to the careful morphological preparation we investigate these vessels by radiographic imaging after filling with contrast medium. 6 car passengers (age between 4 and 31 years) which suffered a lethal head injury were examined in the last year. 2 victims had impressed fractures with cerebral compression injuries. In 1 case the base of the skull was broken and in 3 cases no skull fracture was present; no serious focal brain injury had occurred in these 4 cases, but 3 victims had signs of diffuse brain injury. In 5 cases a direct impact of the head against the interior of the car was obvious. In 5 cases ruptures of several bridging veins could be demonstrated. In one case (survival for 3 days) a minor SDB (20 ml) was present and the ruptures had been closed by thrombosis; another victim died at the scene. The other 3 victims survived between 4 and 15 hours without developing SDB and without closing of the ruptures by thrombosis. This combination is surprising and shows that our knowledge concerning the relationship between bridging vein ruptures and SDB is restricted. The frequency of bridging vein lesions in severe head injuries is likely underestimated in the clinical as well as in the postmortem literature. A rapid increase of intracranial pressure after the accident resulting in a collapse of the cerebral circulation is probably responsible for the absence of the SDB in the presented cases.

The sites, numbers and lengths of wounds of the skin of the scalp and head caused by blunt injuries (falls from standing position, falls downstairs, blows) in an autopsy series. Analysis of the localization, length and number of wounds located at the head in 305 autopsy cases of falls from a standing position (203 cases), falls downstairs (51 cases) and blows with relatively long materials (51 cases). For the distinction between falls and blows, among several other aspects the so-called rule of the hat-brim-line is described: in cases of falls from a standing position down to a flat bottom, contusions can be expected in or near a line which represents the greatest horizontal circumference of the skull, whereas in cases of blows the contusions lay above this area. Although such a tendency was found in our material, a rule could not be confirmed: only approximately 55% of the wound due to blows were above this line, and in cases of falls from a standing position ca. 1/3 of the wounds were above this area. Only in the (dorso-frontal and parietal) region "top of the head" contusions due to falls from a standing position were quite uncommon. The mean length and length distribution of wounds in the hat-brim-zone was not different between the 3 causes of injuries; in positions above this, wounds due to blows were longer compared to those by falls. In falls from a standing position, only exceptionally more than 1 wound was found, whereas in cases of homicide several or many wounds were common. Single wounds due to blows were only found in cases, in which the victims were knocked down but not killed by blunt forces, and death was caused by other methods (e.g. strangulation or stabbing).

Cases of combined suicide are infrequent findings, especially cases in which each method can be lethal. In interpretation of cases with a multitude of serious injuries it might be impossible to discover minor injuries which had occurred in the course of a preceding confrontation, because they may be masked by the general traumatization. In two cases of suicidal fall from a height neck injuries and petechial bleedings were found. The first case (woman 53 years) was a combination suicide (strangulation by ligature, deep incisions into her wrists, jump out of the window). The intensive petechial bleedings in the face could be explained as a result of ligature strangulation and the fracture of a lower thyroid horn as an indirect fracture resulting of the head traumatization. In the second case (girl, 14 years) petechial bleedings in the face were found. Furthermore the victim had marks on her neck-skin, consisting of well-lined bleedings and scratches, presenting a clear pattern, which could be related to a necklace. An explanation of these injuries as a result of a direct impact could not be given. Something must have happened prior the fall. Informations concerning the last hours before her suicide could not be obtained but a strangulation-attempt (by herself? by others?) must be ascertained. The histological investigation of the skin of this region arised a negative vital reaction, therefore a very short interval between that event and the death was assumed.

In the last few years, some reports claim that petechial bleedings found in the eyelids and conjunctivae of corpses may be resp. are caused by resuscitation efforts (= RES). Nevertheless, the numbers of cases were small and the selection of the cases presented to demonstrate this relation in our opinion was not convincing. In the material of our institute, the rate of autopsies in which the victims had been tried to resuscitate by professionals increased up to ca. 25%, including a substantial number of victims of homicides. If RES alone would cause petechial bleedings, serious problems would arise for the medical expert. We analyzed all cases of a period of 5 years, which were examined by 1 investigator. Among 474 autopsies, RES was done in 144 cases (31%). 19% of these victims presented petechial bleedings, predominantly in the conjunctivae, compared to only 11% in the non-RES group. However, this was not a consistent finding in all subgroups: If the group of acute cardiac deaths of middle-aged persons was taken separately, in the remaining material a statistically significant difference in the petechial rate between cases with and without RES was not present. The analysis revealed an influence of the following factors in the development of petechial bleedings: cause of death, age, constitution (body mass index). In the RES subgroup with the highest rate of petechial bleedings (acute cardiac deaths of persons between 40-60 years; n = 23; rate of petechiae = 50%) the frequency of petechiae could be explained by a combination of such factors. As a second way we investigated all persons in which RES was done in our Medical School during a period of 5 months. In no surviver petechiae were present; in the group of non-survivers (predominantly cardiac deaths), the petechial rate was 16%. According to the statements of the treating physicians, a development of petechial bleedings under RES was not striking in these cases or according to their general experiences. Although such a statement is of restricted value (because petechial bleedings are mostly not obvious without a special look for them), the complete absence of information of this aspect in the clinical literature is striking. If petechial bleedings would be a common consequence of RES, this finding should be well known in intensive care units. According to our experience, a clear causal relation between resuscitation efforts and petechial bleedings in the face is not likely.

Laryngohyoid fractures are a frequently investigated matter, especially in the forensic literature. On the other hand, there are only very few (old) forensic reports of such fractures in survived cases. However, healed fractures are not seldom found in forensic autopsies: In a personal series of 1160 forensic autopsies (adult persons) a careful dissection of the laryngohyoid complex was done by 1 investigator. Only a macroscopic examination of the cartilages was carried out; radiographs and histological slices were not regularly made. Therefore only a part of existing old fractures is detectable; for example, healed fissures are not visible with this simple method. Furthermore, asymmetries of the thyroid laminae cannot be declared as posttraumatic without additional examination, because this condition is described as possible anatomic anomaly. From that, the injury frequencies presented here only mark the lower threshold of the existence of such findings. Healed fractures of the upper thyroid horns and the major hyoid horns can be easily detected even in a routine examination, if healing resulted in a fixed dislocation or apposition of bone surrounding the former fracture site. In the present series, this was the predominant localization of old fractures: the upper thyroid horns (43 cases), followed by the hyoid cornua (12 cases), a combination of both sites (5) and cricoid fractures (5). Of the total 65 healed fractures (5.6%), 35 were found in the group of 290 chronic alcoholics (12.1%) and only 3.4% in non-alcoholics. In the subgroup of middle-aged alcoholics, the fracture rate increased up to 19%. However, this group did not present a higher rate of fresh laryngohyoid injuries (not related to strangulation) than the other cases. The old fractures probably resulted from minor "daily" injuries (like falls), which are common, especially in chronic alcoholics. The frequency of such findings should be in mind if an apparently fresh fracture, found in an actual autopsy, should be related to the cause of death: there is a real chance, that this fracture occurred prior, and without causal connection to the factors resulting in death. Therefore a histological examination of the age of this finding is necessary. Cricoid fractures are quite uncommon, except in serious external neck trauma. In 1 of our 5 cases, this fracture was caused by repeated cruelty, finally resulting in death.

Reported is the case of a 36-year-old man with neurofibromatosis type 1 with lethal haemorrhage from rupture of the left common iliac artery. Histologically and immunohistochemically, no hints on angiodysplasia as a possible cause of bleeding were detected. Considering the literature and the histological findings in the area of rupture, a local weakness of the vascular wall caused by the neighbouring neurofibromatous proliferates was most probably the reason for bleeding.

Among 193 cases of hanging from the years 1978 to 1991 examined in the institute of Forensic Medicine of the Freie Universität Berlin 8 cases with an aspiration of stomach contents had been reported. Herefrom 3 cases were hanging in a "typical" position (suspension point at the back of the head, free suspension of the hanging body) and did not undergo resuscitation. By free suspension of the hanging body the observed massive aspiration of gastric contents only can be explained by an at least partly open connecting passage between the laryngeal entry and the entrance of the oesophagus. The post mortem flowing in of stomach contents as well as a post mortem gastro-oesophageal peristalsis seem not to be able for explicating the findings. Differences in important parameters (e.g. gastric contents, alcoholization) to the cases of hanging without aspiration were not found. Even by free suspension of the body, running noose and point of suspension in the back of the neck sometimes the connection between larynx and oesophagus may stay open, especially when by emesis a high pressure is produced by the stomach.

Is it possible to distinguish between suicidal and homicidal strangulation by the extent of the injuries of the larynx if the results of the police investigations are uncertain? Therefore evaluation of the German publications (115 reported cases of suicidal strangulation) and our own cases (17 cases). Hereafter more intensive injuries of the neck are extremely rare in cases of self-strangulation. Casuistic: Body of a 40 years old woman with signs of strangulation. The husband declared his wife strangulated herself in the bathtub with the belt of a bathrobe. Autopsy: Typical findings of drowning, intensive injuries of the neck tissues and the larynx. Kind and extent of the findings are speaking well for an assault mainly by manual strangulation. Undepending of the medical findings the police investigations are almost excluding a suicide. Condemnation of the husband.

Puncture of a major cervical veins for insertion of a central venous catheter is a standard-method in resuscitation performed in emergency conditions. Even extensive lesion-marks due to punction are customarily seen by medico-legal practitioners, but in detail they may cause difficulties in differential diagnosis, when lesion marks caused by acts of violence directed straight against the neck are to be differentiated. Especially in the primary phase of inquiry about crimes of homicide these injuries due to punction are forensically important. Therefore frequency and methods of resuscitation efforts were evaluated in 453 crimes of homicide, committed in Göttingen and Berlin (subjects given by the Free University). Findings of the present study were that resuscitation measures were taken merely to a rate of 25%, and in proceeding a central venous catheter was not obligatorily inserted, moreover proceeding being regionally different. In Berlin a central venous catheter was inserted in 17 cases out of 77 resuscitated homicidal injuries, the rate being 24 cases out of 36 cases in Göttingen. In altogether 8 crimes of homicide committed by immediate attacks against the neck, a cervical vena was punctured, findings later being extensive effusions of blood marked around the tapped spot. The different ways to perform resuscitation may justify to point also at the forensic interest to discover the facts together with complete diagnosis in cases of crimes of homicide. That is why it may be vindicated to try to find out a proceeding, which does not lessen the effectiveness of resuscitative manoeuvres, yet by means of which forensical concerns are taken into consideration, too.(ABSTRACT TRUNCATED AT 250 WORDS)

A 26-year-old woman came to hospital with an acute abdomen and a history of abdominal pain for about 6 months. She showed signs of peritonitis and ileus and underwent a laparotomy after initial diagnostic procedures. There was massive terminal ileitis with perforation and localized peritonitis. Resection of the affected bowel was performed over 5 1/2 h without surgical or anesthetic complications. Postoperatively several attempts were made to insert a venous catheter via the internal jugular vein, first on the right and then on the left side. The catheter was finally placed and was used for infusions, although there were some signs that indicated a possible arterial position. Neurological disturbances followed the end of anesthesia; 2 h later the catheter was removed because of arterial malpositioning diagnosed by a blood gas analysis. The patient developed brainstem and cerebellar infarctions and died 2 days later. The main postmortem finding was massive swelling and paleness of the cerebellum and brainstem with macroscopically unaffected supporting arteries. The other main arteries of the head and neck were also unremarkable, except for two healing punctures of the left common carotid artery. Further examination revealed an embolism at the top of the basilar artery. The source was macroscopically obscure; stereomicroscopic examination of the heart showed small dark spots behind one fold of the aortic valve caused by parietal thrombosis of the damaged endothelium. The tip of the misplaced catheter had entered this region and caused the lethal embolism.

A 52-years old woman fell downstairs at home and suffered fractures of the left 9. and 10. rib. She was admitted to hospital; a small subcutaneous emphysema was seen over the fractures. Primary radiograph of the chest showed no internal complication. The patient was observed over night on intensive care unit without abnormalities. Next morning she was transmitted to the regular ward; on this way a control chest-radiography was made. A large hematothorax was seen. The radiologist tried to telephone with the surgeon at the new ward, who was not available because of operating. The nurse at phone (novice) misunderstood the message or the correct message was wrong interpreted by the other nurses in the sense that they believed that the patient had a history of (treated) hematothorax, so that no acute treatment was necessary. The surgeon was not informed, when he came later; the patient was brought from the x-ray station and nothing more happened. About 10 hours later the woman died. The radiologist has been condemned by reason of killing due to carelessness; the fine was placed on probation. In the opinion of the court the radiologist--as the only person, who knew the acute and unexpected condition of the patient--rejected against his liability to guarantee the life of the patient, since he not maked quite sure that the woman really received the needful treatment.

The fat content of the liver sinusoidal cells was examined partly systematically partly by selected case groups from 297 cases. While minor grades of lipid content within these cells was found nearly equally spread at all causes of death the most intensive fat accumulation was seen at cases of violent asphyxia.

Injuries of the larynx and hyoid bone resulting from forces other than compression of the neck were found in 129 of 5591 cases (2.3%) of medico-legal autopsies performed between 1978-1987. Victims of blunt trauma showed these fractures in 6.7%, victims of incides or stab wounds in 9.2%, other cases in 0.4%. The results were compared with clinical observations of laryngotracheal trauma.

A 51 years old woman was complaining about pain in the back and headache. Because of sudden change in behaviour she was brought into hospital by her husband. At hospitalization she was unconscious, the first examination showed no hints for trauma. After diagnosis of a bifrontal subdural haematoma intracranial blood was removed twice by neurosurgeons. The woman died six days after hospitalization. The forensic autopsy showed rests of subdural blood and apart of medical intervention no injuries were seen. In the left kidney a carcinoma was found with metastasation in the adrenal glands, the liver, and the dura. The metastasation of the dura had led to destruction of the dural vessels with consecutive subdural bleedings. These hemorrhages probably had been supported by decreased coagulation because of metastasation of the liver. Although such spontaneous non-traumatic subdural bleedings are rare it is obvious that they can cause severe problems by delivering an expert opinion.

Analysis of 70 cases of death after intensive care of different survival time and various causes of death. All persons were intubated and had nasogastric feeding-tubes. Bleedings into the PCA-muscles were found in 50% of all cases (especially in short-term survival: up to 80%). Bleedings in this region are not specifical; there are many possible causes. In 27 cases lesions of the hypopharyngeal wall as the result of pressure by the lying tubes were found up to ulcerations; sometimes just after about 1 day. Frequency and deepness of this lesions increased with the time of survival. Even if the hypopharyngeal wall was intact, there are often circumscripted (histologically detected) destructions inside of the PCA muscle(s), caused in part by the pressure of the tube.

From 1978 to 1988 6431 forensic postmortem examinations have been made at the Freie Universität Berlin. These are about 50% of all p. m. examinations in Berlin (West) of the corresponding period. 22% of these cases were associated with alcohol. On one hand there was an acute influence of alcohol, on the other hand there were indications of chronic alcoholism. A rise of alcohol associated cases or of alcohol concentrations could not be found out.

6 cases of suicide by hanging with delayed death are presented in tables laying out the circumstances and the findings. All the persons involved remained continuously unconscious after initially successful reanimation; two were at this time already dead. The survival times lay between 18 hours and 4 days. In two cases intravital vertebral death occurred. In the other cases death was due indirectly to hypoxial brain-damage which had led to a greater or lesser extent to elective parenchymal necrosis. In 3 of 4 histologically investigated cases there was evidence of extensive cell destruction in the PCA muscle which was, however, not specifically related to the process of hanging since lesions of this nature also occur with other cases of delayed death after reanimation. In 7th case the problems encountered in compiling an expert opinion are discussed in cases where there are no corresponding procedural details. A 44 year old man died 3 weeks after having been submitted to bondage in a brothel at his own request (including binding of the neck). Compression of the throat with emphasis on one side was evident resulting in extensive ganglial cell damage in one half of the cerebral cortex.

Remarkable autopsy findings in persons who had suffocated as a result of closure of the mouth and nose by sand (without the body being buried) induced us to investigate some aspects of this situation by means of a simple experiment. A barrel (diameter 36.7 cm) with a mouthpiece in the bottom was filled with sand to a depth of 15, 30, 60, or 90 cm. The subject tried to breathe as long as possible through the sand, while the amount of sand inspired was measured. Pressure and volume of the breath, as well as the O2 and CO2 content were also measured. A respiratory volume of up to 31 was possible, even when the depth was 90 cm. After about 1 min in all trials, the subject's shortness of breath forced us to stop the experiment. Measurement of O2 and CO2 concentrations proved that respiratory volume in and out of the sand shifts to atmospheric air without gas exchange, even when the sand depth is 15 cm. Sand aspiration depended on the moisture of the material: when the sand was dry, it was impossible to avoid aspiration. However, even a water content of only 5% prevented aspiration, although the sand seemed to be nearly dry.

Eleven cases are reported in which death occurred because of suffocation as a result of occlusion of the respiratory tract by sand (without thoracic compression: 3 cases) or being buried alive (8 cases). Two tables demonstrate the findings and circumstances in the events. Three cases are described in detail. A 22-year-old woman was manhandled by blows and kicks to the head and neck. She became unconscious and her head and neck were covered by a layer of sand so that she suffocated. A 42-year-old man was smothered, while unconscious, in a prone position with his face in the sand, after hard blows to the head by two culprits. A 17-year-old girl finally died by chocking. Previously the culprit had pressed her face into the ground, so that she aspirated particles of soil. The question of vital reactions during aspiration of sand was investigated by microscopic examination of the content of the air passage and by destroying parts of the lungs by sulphuric acid. Minimal aspiration of sand occurred in all cases. Although the postmortal remains were left in the ground, there was no postmortem penetration of sand into the air passage. Histological examinations were carried out to support the diagnosis of violent suffocation. In some cases, there were remarkable findings (mobilization of alveolar cells, hepatocelullar hydropic degeneration), but there were no typical or unanimous findings that pertained to all cases.

A 26-year-old motorcyclist bounced against the side of a turning car with about the speed of 70 km/h. On admission to the clinic, he was awake with stable circulation. The main injuries were contusion of the chest with pneumothorax on the right side, blunt trauma of the abdomen without hematoperitoneum, and a fracture of the right femur. There was no visible trauma of the head, but only circumscribed cutaneous bleeding on the right side of the neck. About 16 h later, he showed an alteration in his level of consciousness and gradually "malignant" cerebral infarction of the left hemisphere with increasing intracranial pressure developed. Brain function began to cease and death occurred on the 4th day. The autopsy revealed neither traumatic damage to the skull, brain or cervical spine, nor were there pathological findings in the cerebral vessels. The main damage consisted of multiple dissections of the inner wall of the left internal carotid artery and the left medial cerebral artery. Proceeding from a temporarily sealed tear of the extracranial vessel, a large intramural hemorrhage had occurred between the media and adventitia and had compressed the lumen completely. The intracranial portion was closed by expanding thrombosis. These lesions are of indirect origin and are the result of vast overstretching of the arteries by the head turning over the edge of the top of the car. The victim was found at once after the crash with his body hanging the deeply dented side of the car and the head (with the helmet on) on the roof.

The inner soft tissues of the larynx (i.e., true vocal cord, false vocal cord, paralaryngeal space) were examined by special preparation of the larynx: thyroid cartilage was detached from the cricoid and the laryngeal cords, which could then be examined. Bleeding (not visible before) was found in 18 of 40 cases of persons killed by throttling or choking; bleeding occurred whenever blunt trauma of the throat had taken place (n = 8). Hemorrhage develops even in cases without damage to the laryngeal skeleton; this bleeding can result from direct compression of the larynx (large and not well defined bleeding) and can originate indirectly (small hemorrhages mostly in the vocal muscles). The finding of hemorrhages like this can help to demonstrate that the victim has undergone a violent attack on the throat.

A post mortem examination of a 29 year-old man who had committed suicide by shooting himself in the head revealed pronounced discoloration of the contents of the intestines and an intensive odour of garlic from the organs. Chemical examination gave no indications for pesticides; the coloring matter was identified by electrophoresis as a constituent of beetroot.

A 62-year old man was found killed by multiple blows against the face and head; near the victim a hammer with broken grip, a bended saw (weight 142 g), and in the possession of the doer two hatchets. Some straigt, parallel, horizontal wounds in the face with smooth lips and straigt incisions of the maxilla first were interpreted as violations by hatchet. The culprit confessed attacks by hammer and saw, but not by hatchet. Experimental blows with a saw like the used on the leg of a corpse showed an unexpected result: it was possible to produce wounds of the soft-tissues and the bone similar to those by hatchets.

An 86-year old woman suffered blows with a forearm in a cast against the face and the neck. She was found dead some days later in a sitting position with heap of vomit beneath the corps. Autopsy showed extended haematoma and excoriations of the left side of the face and the neck. The mandibula and the left zygomatic arc were broken, just as the greater horns of the hyoid and the left upper and lower horne of thyroid cartilage. The main finding was a massive haematoma of the inner soft tissues of the larynx with a severe stenosis of the lumen. The haematoma was demonstrated by frontal section of the larynx, an unusual method in routine examination. Since this section was used in the autopsy especially of persons that died by strangulation, little bleedings in the false and true vocal cords were found in some cases.

Detailed report of 5 cases of violation with gas or warning firearms, 3 of them lethal. In one case a modified weapon (elongated barrel) and steel bullets were used, resulting in shot of the head with retained missile and lethal bleeding. In the other cases, regular weapons (8 or 9 mm cartridges) were used for contact shots; violation occurred only by the effect of powder gases. One of these cases was a suizide (lethal temporal gunshot), in the other cases shots by another person: a) shot against the arm with large soft-tissue damage (survived); b) and c) shot against the neck with exceeding rupture of the soft tissues, minimal damage of the neck arteries and in one cases bilateral tears of the hypopharynx. In this case a delayed death after primarily well operated injury occurred after 12 days by bleeding into the airways from ruptured external carotid artery.

The intrinsic muscles of the larynx were prepared in 265 forensic postmortems (death by strangulation: 73; other violent deaths: 93, natural death: 79, others: 20) for a histological examination. Muscle-fiber alterations were found in the (macroscopically normal) PCA muscle in most cases where the persons were of middle age or older. There were abnormalities such as rows or clumps of nuclei (also inside muscle fibers), the accumulation of lipofuscin pigment, focal or total necrosis of muscle fibers with or without predominant histiocytic infiltration, atrophic muscle cells, and fibrosis. The changes were mostly mild (normal muscle cells predominated) but clearly visible. If there had been acute damage to the larynx (for instance, death some time after attempted strangulation), these preexistent alterations must be taken into consideration when interpreting the microscopical findings.

Examples for data processing in forensic medicine: special functions of text programs as mail-function or working with flourishs allow effectual working of printed forms or simple making of bills with adjustment of all individual data and automatic calculating. Based upon a frame of the always necessary text passages and 15 data files of flourishs (one belonging to each letter) an autopsy report was builded up. Using th database program dBase III plus the postmortems of the last 10 years (nearly 6000 cases) were registered (about 50 variables). Evaluation followed from a selfmade program, which supplies two sides tables. The organization of the bibliography (beginning already in subscription) and the administration of (several thousand) dia slides was managed by this database program too.

Report on 3 cases of intraoperative death during total hip replacement in treatment of transcervical fracture of the femur, using acrylic bone cement. The patients were two female (83 and 87 years-old) and one male (78 years old), who suffered from a sudden fall at home. Autopsy revealed massive fat embolism (FE) of the lung and in one case also in the other organs; in 2 cases this FE was the cause of death alone, in the third case together with an unusual severe coronary heart disease (heart weight 700 g). Discussion of the medico-legal aspects, i.e. the coincidence of FE of different causes (traumatic, by operation, by reanimation). Reflections on the certainty to attribute the death to specific (in particular deficient) technical factors.

The 202 deaths connected with burns in 1976-1986 included 134 in which death occurred during the fire. In 49 cases the face was so badly charred that it was not possible to judge whether hemorrhage had occurred in the eyelids and/or conjuctivae. Such blood extravasation was seen in 14 of the remaining 85 cases, taking the form of petechiae in some cases and in others the form associated with more extensive extravasation, in some cases hemolytic. No other features known to cause such hemorrhages were present, so that they are attributed to the burning process itself. Signs of extensive pronounced burns were found in 13 of these cases, and it seemed that high-degree burns on the neck and trunk with less severe burns on the head were particularly likely to be associated with such hemorrhages. In most cases the flames had quickly come into direct contact with the body (clothing, bed or chair had caught fire), leading to rapid death, as documented by the fact that usually very little or no soot at all had been aspirated and by the low level of carbon monoxide intoxication (max. COHb 22%). One plausible explanation for the development of hemorrhage is the supposition first expressed over 20 years ago that when the circulation is maintained rapid burn-induced shrinkage of the skin of the neck has the effect of strangulating the victim; hemorrhage of eyelids and/or conjunctivae in such cases be could regarded as a vital reaction to the effect of fire. This is particularly significant, insofar as evidence of hemorrhage of this kind was found predominantly in bodies in which other vital signs indicative of the effects of burning were sparse and slight or even totally absent. In addition, specific examination of the laryngeal area revealed congestion-induced extravasation at various points, as well as petechial hemorrhage in the mucous membrane.

The objects of examination were two legs and two arms that were recovered at different times from waters traveled on by motor ships. The right leg was exarticulated at the hip joint, as was the right arm at the shoulder joint. Identification was complicated since both thumbs were exarticulated at the basal joints; the fingers II to V, respectively, were partially amputated. Identity (57-year-old vocational school teacher) could be established nevertheless by a number of anatomic findings (such as Dupuytren's contracture, coxitis, hallux rigidus), the blood group "O" was tatooed on the inner side of the left upper arm. The results of the laboratory examinations were only of limited use due to advanced decomposition (beginning formation of adipocere). Special attention should be given to the fact that on the same part of the corpse there were signs of defensive corpse dismemberment and injuries from a ship's propeller as well. Under no circumstances can an examination of the bones, after thorough maceration, be dispensed with; X-ray examinations are also imperative in cases of this nature.

The case of an 47-year-old man is reported, who was injured in a fight while under the influence of alcohol. The culprit knocked him down and stamped several times on the left side of his head. The victim became unconscious. At the hospital, subarachnoid hemorrhage and massive ventricular bleeding was diagnosed via CT. Despite the implantation of a ventricular shunt, there was repeated massive cerebral pressure and arterial bleeding. Brain death occurred after 8 days. The main finding at autopsy was nearly complete disruption of the left inferior posterior cerebellar artery as the source of the lethal bleeding. The histological examination showed some additional, incomplete ruptures of this vessel and of the left intracranial vertebral artery. This is a typical result of "minor head injuries" sustained in fights: arterial rupture (ipsilateral) as a result of overstretching. Fracture of the left zygomatic arch and maxilla; no skull fracture; no primary traumatic brain damage. The extracranial carotid arteries were intact. When the vertebral arteries were examined (in the undamaged cervical spine), there was a surprising finding: distant dissection of the right vertebral artery between C1 and C2, which perhaps occurred as a result of compression (contralateral to the impact) of this region.

Sixty-one cases of hemorrhaging of the laryngeal muscles are reported among 86 deaths due to compression of the neck (strangulation by ligature and/or with the hands, blunt force); the results of histological examinations of these cases (laryngeal muscles; hemorrhaging of the cervical muscles and tongue in numerous cases) are discussed, as well as 55 comparative cases (natural, violent death) with regard to vital changes from the hemorrhaging aspect. Although sanguineous infiltration of the laryngeal muscles can occur after death (prone position), it differs macroscopically and in some cases also microscopically from the vital type: extensive bleeding on the inside of the larynx or dorsally above the larynx (PCA muscle), possible combined with histologically detectable ruptures of muscle cells, must be viewed as the result of laryngeal compression suffered when still alive. No clear-cut evidence of emigration or infiltration of leukocytes was found in the cases of immediately fatal strangulation, but there was occasional evidence (6 cases) when protracted maltreatment had taken place. Although there was no clear correlation with age, sex, type of impact, cause of death, or amount of laryngeal bleeding, in 25 of the 61 cases leukocytes were sometimes detectable in enormous amounts within the extravasation; the ratio exceeded that to be expected from the composition of the blood. Findings of this nature have also been made in cases of vital bleeding in other violent or natural deaths; they are not a cell reaction in the proper sense but, when distinctly marked, a vital event--at least in the laryngeal region. These findings can support the assumption of the amount of hemorrhaging in deaths in which the survival time was inadequate for a leukocyte emigration. In 20 cases such findings were combined with localized leucocytosis, which is regarded as an early vital reaction.

A 44-year-old man had suffered from cholecystolithiasis with recurrent jaundice for many years, and a cholecystectomy was carried out. Because of a radiomanometric obstruction of the common bile duct, the intra- and extrahepatic bile ducts were also scanned. One day after the operation the jaundice increased (serum bilirubin max. 742 mumol/l). The cause of the icterus was found in a small biliovenous fistula, and diverse surgical and angiological attempts to resect or close the fistula failed. In the third postoperative week renal failure developed, followed by a disturbance of coagulation and insufficient respiration and circulation. The man died 33 days after the operation. Autopsy showed massive jaundice, gastrointestinal bleeding, and cholemic nephrosis. Extensive preparation of liver resulted in a 20 X 8 X 15 mm fistula in the right lobe 9 cm proximal to the choledochotomy and anastomosing a thin branch of the right hepatic duct and a small hepatic vein. Long-time bilhemia resulted from this fistula and entailed renal failure and finally death. The fistula obviously resulted from scanning the bile ducts when the catheter was accidentally deviated into a biliary duct that was too small.

A method of preparing the larynx in forensic cases is described especially when death occurs by strangulation (manually or using some form of ligature). After the usual dissection of the hyoid bone and the upper horns of the thyroid cartilage, the complete larynx is clipped and fixed in formaldehyde overnight. The first part of dissection after that is to cut away the thyroid gland and the remaining muscles in front of the larynx, except for the cricothyroid muscle and the esophagus and hypopharynx from the back of the larynx. The complete thyroid cartilage is dissected out, and then a horizontal cut is made through the cricoid cartilage. Median-sagittal halving of the remaining larynx completes the gross dissection. Arytenoid cartilages are exposed by dissection of the arytenoid muscles and opening the cricoarytenoid joints. Now all parts of the laryngeal skeleton and all articulations are examined, and all muscles and soft tissues are visible and can be clipped for histological examination.

Report of two cases of strangulation by hand. There were large submucous bleedings of the larynx (both sides of conus elasticus) of symmetrical arrangement, near the vocal processes of the arytenoid cartilages. They are believed to be the result of the violent contact of the vocal folds during laryngeal compression; perhaps while the arytenoid cartilages were subluxated inwards and downwards. Bleedings like this indicate the closure of the airway. In one case (50-year old woman) the ossified cricoid was broken; in the other (21-year old woman) the elastic laryngeal skeleton was intact, but large bleedings of the deeper tissues of both vocal folds indicated the vehement compression too. The analysis of 110 cases of attack against the neck (strangulation by hand -n = 30- or ligature -n = 30- alone or together -n = 32-; blunt force: n = 8, other types: n = 10) showed in 7 additional cases less typical but similar bleedings, especially in strangulation by hand.