DiMaio's Forensic Pathology

Vincent J.M. DiMaio, D. Kimberley Molina

• Publisher: CRC Press
• Year: 2021
• ISBN:
  9781000389159
• Edition: 3
• Topic: Droit
• Subtopic: Droit médical

The first two editions of Forensic Pathology have been highly touted as the definitive, go-to text reference on forensic pathology and this latest edition is no exception.

DiMaio's Forensic Pathology, Third Edition is fully updated to include the many advancements that have occurred in the field over the last 20 years since the last edition was published. Joining Dr. Vincent DiMaio is practicing forensic pathologist Dr. Kimberley Molina who brings her expertise to the latest edition of this all-time best-selling work. Historical chapters have been reviewed and updated, and the natural disease and toxicology chapters have been streamlined, so as to expand on the new improvements in the field. New content includes discussions on chronic traumatic encephalopathy, sudden unexplained infant deaths, deaths in the elderly and blast injuries – among other topics. Chapters incorporate changes to death investigation, forensic DNA typing and other relevant fields relative to forensic pathology and determination of death. In addition, the third edition includes an entirely new – and long-sought-after – chapter summarizing Dr. DiMaio's world-renowned expertise on gunshot wounds.

Key Features

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• Includes over 400 full-color images illustrating key concepts

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• Boasts new chapters on gunshot wounds, mass fatality incidents and the application of forensic science principles to forensic pathology practice

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• Provides updated and expanded coverage of medicolegal death investigation, postmortem changes, time of death, deaths in custody, deaths in the elderly and drug-related deaths

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• Presents new research and advanced techniques, ranging from chronic traumatic encephalopathy to new and emerging drugs

DiMaio's Forensic Pathology, Third Edition maintains its concise, easy-to-read format with completely updated references and over 400 full-color demonstrative photographs and photomicrographs to illustrate concepts – making it appealing not only to forensic pathologists, but also law enforcement personnel and attorneys. This highly anticipated work continues Dr. DiMaio's long legacy of producing invaluable educational and professional resources.

Medicolegal Death Investigation 1

Nothing matters but the facts. Without them, the science of criminal investigation is nothing more than a guessing game.

—Blake Edwards

Forensic pathology is a branch of medicine that applies the principles and knowledge of the medical sciences to problems in the field of law. The major duties of a medicolegal system in handling deaths falling under its jurisdiction are:

• To determine the cause and manner of death
• To identify the deceased, if unknown
• To determine the time of death and injury
• To collect evidence from the body that can be used to refute or corroborate an account of how the death occurred
• To document injuries or lack of thereof
• To deduce how the injuries occurred
• To document any natural disease present
• To determine or exclude other contributory or causative factors to the death
• To provide expert testimony if the case goes to trial

Deaths that come to the attention of the office of the medical examiner or the coroner generally fall into the following categories: violent deaths (accidents, suicides and homicides), suspicious deaths, sudden and unexpected deaths, deaths without a physician in attendance and deaths in an institution. There are, of course, variations to these categories, depending on the local jurisdiction.

Definition of Death

Because of advances in medical science, what was formerly not a problem has now become one – the definition of death. In simpler times, death was defined as the permanent cessation of cardiac and/or respiratory function. Today, instrumentation can keep a heart beating and an individual breathing in spite of the fact that if this machinery were turned off, heart and respiratory activity would cease. This has brought about the concept of brain death. There is extensive literature on this subject, and the definition of brain death in adults and children is not necessarily the same.¹

The declaration of an individual as brain dead, with all the requirements to be met, is mostly of academic interest to the medicolegal system in that a case is not reported until a clinician has pronounced the individual dead. However, cases do sometimes occur where the pronouncement of brain death can be obscured by the concomitant presence of sedative medications that may also impact the cause and manner of death.²

Other issues that may arise are the procurement of organs or the moving of brain-dead individuals. In most jurisdictions, if harvesting of organs is intended and family permission has been obtained, and if the case is to be a medical examiner's or coroner's case, prior to the removal of the organs, approval must also be obtained from the medical examiner or coroner. This is because, once the individual is “dead,” he or she comes under the medicolegal jurisdiction. Procurement of organs without such consent of the medicolegal authority could be interpreted as interfering with the duties of the medicolegal system and could, therefore, constitute a crime. The procedure for obtaining permission to procure the organs after pronouncement of death is a matter of routine in most medicolegal systems. A strong relationship between medical examiner/coroner offices and the local organ procurement organization is paramount in maintaining best practices for both entities. The importance of organ procurement and transplantation is well understood by medical examiner/coroner offices and, with proper coordination and communication, organ procurement can often be performed without interfering with the subsequent medicolegal examination of the body.

Another issue the authors have seen is when an individual who has been declared brain dead has been transferred outside the jurisdiction of the medicolegal authority for the purpose of organ procurement. Once the organs are procured and the machines turned off, the question arises of who will perform the examination of the body. Because the body has been moved out of the legal jurisdiction where it was pronounced dead, does it have to be moved back to that jurisdiction or does the medicolegal authority in the area where the body is now located take jurisdiction? Does this medicolegal authority have the legal right, since the individual “died” in another jurisdiction? While there may be subtle differences depending upon jurisdiction, for the most part, the medicolegal authority where the death was pronounced retains the jurisdiction for investigation. Such issues are best settled beforehand with conferences involving the organ procurement organizations and other medicolegal entities.

One other minor point should also be mentioned. An individual may be pronounced dead, yet be maintained on a life support system for 2–3 days after pronouncement. This has sometimes resulted in confusion in the documentation of the date of death, though this is more a problem of bureaucracy than science.

Death Certification — Cause, Manner and Mechanism of Death

Two of the most important functions of the medical examiner's or coroner's office are the determination of the cause and manner of death. Clinicians, lawyers and the lay public often have difficulty understanding the difference between cause of death, mechanism of death and manner of death. Simply put, the cause of death is any injury or disease that produces a physiological derangement in the body that results in the death of the individual. Thus, although differing widely, the following are causes of death: a gunshot wound to the head, a stab wound to the chest, adenocarcinoma of the lung and coronary atherosclerosis.

The mechanism of death is the physiological derangement produced by the cause of death that results in death. Examples of mechanism of death would be hemorrhage, septicemia and cardiac arrhythmia. One must realize that a particular mechanism of death can be produced by multiple causes of death and vice versa. Thus, if an individual dies of massive hemorrhage, it can be produced by a gunshot wound, a stab wound or a malignant tumor of the lung eroding into a blood vessel. The reverse of this is that a cause of death, for example, a gunshot wound of the abdomen, can result in many possible mechanisms of death, for example, hemorrhage or peritonitis.

Medical examiners often have to review death certificates produced by clinicians. Not infrequently, the cause of death is listed as “cardiac arrest” or “cardiopulmonary arrest.” Simply stated, this means that the heart stopped or the heart and lungs stopped. Experience tells us, however, that when any individual dies, the heart and lungs stop. These are not causes of death and, to a degree, are not even mechanisms of death. Yet, clinicians continue to list these diagnoses on the death certificate, and some government organizations accept them as causes of death.

The manner of death explains how the cause of death came about. Manners of death can generally be categorized as natural, homicide, suicide, accident or undetermined. The authors also use the category “unclassified.” Just as a mechanism of death can have many causes and a cause can have many mechanisms, a cause of death can have multiple manners. An individual can die of massive hemorrhage (the mechanism of death) due to a gunshot wound to the heart (the cause of death), with the manner of death being homicide (somebody shot the individual), suicide (they shot themselves), accident (the weapon fell and discharged) or undetermined (one is not sure what occurred).

The manner of death as determined by the forensic pathologist is an opinion based on the known facts concerning the circumstances leading up to and surrounding the death, in conjunction with the findings at autopsy and the laboratory tests. The autopsy findings may contradict or agree with the account of how the death occurred. Thus, if the story is that an individual shot himself and the autopsy reveals a gunshot wound to the back inflicted from a distance, there is obviously inconsistencies between the account and the autopsy and further investigation is warranted. If, however, it is a contact gunshot wound of the temple, then the autopsy findings are consistent with the account. It must be realized that the manner of death can be changed if subsequent information that alters the circumstances surrounding the death is discovered. Thus, if we have an individual found with a contact gunshot wound to the temple, with no weapon present and no history of any suicidal threats, one might then conclude that this case is a homicide. If, subsequently, it turns out that the individual had a clinical history of suicidal ideations after embezzling a half a million dollars from his company being indicted by the grand jury, and his body was found by his wife, who removed a gun and suicide note from the scene, the manner of death would be changed to suicide.

Just because a forensic pathologist makes a determination as to the manner of death does not mean that it will be accepted by either families or other agencies. The authors have certified homicides in a number of cases that police agencies have determined to be accidents. Sometimes, families will challenge a manner of death opinion and go to court to have it overturned. In most instances, the court will support the medical examiner. The medical examiner should not be upset, however, if the court rules the manner of death differently, because juries, especially in cases of suicide, do not necessarily utilize the same medical knowledge, training or experience as the medical examiner and may base their opinion more on emotion and supposition. For example, if a widow, challenging a medical examiner's opinion of suicide so that she can collect insurance, brings two young children to the trial, it would not be surprising if the jury should decide to rule the death an accident, no matter how much objective evidence had been presented to the contrary.

Occasionally, there are cases in which the cause of death would ordinarily be considered natural, but the manner is homicide, for example, a homeowner who surprises a burglar, engages him in a violent struggle and then collapses and dies of a heart attack. The mechanism of death is a cardiac arrhythmia and the cause of death is severe coronary atherosclerosis, but the manner of death is homicide, as the arrhythmia was brought on or precipitated by the struggle. Some individuals will even determine a case to be a homicide even if there is no physical struggle, just sufficient psychological stress to have precipitated the arrhythmia and death, though this can be controversial.

While manner of death is mainly determined by circumstances, the autopsy findings can still be important in making the determination of the cause of death. For example, in one case, a young woman stood at the end of a pier, placed a gun to her chest and pulled the trigger. The bullet struck her in the chest and she fell backward into the harbor. Her body was subsequently pulled out of the water by a police boat. At autopsy, she had a through-and-through gunshot wound of the left breast, with the bullet producing only soft-tissue injury and not entering the chest cavity. The actual cause of death was drowning with the manner of death of suicide.

The undetermined manner of death is used when there is insufficient information about the circumstances surrounding the death to make a determination, or, in some instances, when the cause of death is unknown. Thus, if one finds the skeletonized remains without evidence of trauma, one cannot say whether the manner of death was accident, homicide or suicide, because the cause of death is not known. In other instances, there may be insufficient information concerning the circumstances surrounding the death to explain the manner of death. This situation often occurs in deaths due to drug overdoses such as the case when individual may have a long history of overmedicating but, at the same time, has also previously attempted suicide. Is this a case of suicide or did the individual just take too much medication inadvertently, because that was his or her normal habit?

In some instances, based on the circumstances surrounding a death, a manner of death can be determined without a cause of death. For example, the decomposing body of a 32-year-old female was found in a ditch 2 mi from her burglarized house. She was clad in pajamas, barefoot (with the soles of her feet clean), and her hands were bound behind her back. An autopsy failed to reveal a cause of death. The cause of death was ruled undetermined; the manner homicide. The manner of death was based on the circumstances surrounding the death and not the autopsy findings. In some jurisdictions, the term “homicidal violence” is used as the cause of death, though the connotation...