[Rare causes of iatrogenic pericardial tamponade - 2 case reports].

Two rare causes of iatrogenic pericardial effusions are presented. In the first case, a 61-year-old woman who had undergone laparoscopic surgery for a diaphragmatic hernia was resuscitated without success the next day. As cause of death circulatory failure as a result of post-operative pulmonary embolism was reported. Autopsy results showed that the pericardium and the heart had been sewn to the diaphragm. The suture was torn from the tissue, which caused a hemorrhage into the pericardium and the chest cavity, so that death was diagnosed to be due to cardiac tamponade and hemothorax after an iatrogenic heart injury. In the second case, a 62-year-old man who had developed a massive incisional hernia after treatment of an abdominal gunshot wound underwent open herniotomy with mesh repair. Postoperatively, the man complained about increasing pain and shortness of breath. He was transferred to another hospital for further assessment, where a cardiac tamponade was diagnosed. Autopsy results showed that three of the plastic staples used to fix the mesh had perforated the diaphragm and the pericardium thus injuring the adjacent right ventricle with subsequent perforation and development of a hemopericardium.

Homicide-suicide, double suicide or homicide followed by suicide 2 case reports.

Cases in which several persons who died from an unnatural cause are found together are often difficult. It is necessary to exclude homicide committed by another person and to clarify whether the deaths are the result of a homicide-suicide or a joint suicide of persons wishing to die. Two cases in which couples with gunshot wounds to the head had been found lifeless in their homes are presented. In both cases, the deceased were of advanced ages and suffered from severe pre-existing diseases. Due to the circumstances at the scene, the results of the investigations and the autopsies as well as the suicide notes found, a double suicide was assumed in both cases. The husbands killed themselves after shooting their wives. Based on the presented cases the so-called double suicide and the need for a thorough investigation of the death scene with the problem of differentiating it from homicide-suicide and double homicide are discussed.

[A case of acrania?].

The article reports on the case of a premature and stillborn child. As a first step it had to be clarified whether the child had been alive. The pathological examination of the placenta performed after autopsy could prove a retroplacental hematoma as the cause of death. Furthermore the autopsy revealed a severe skull deformity that would probably have made the survival of the child impossible.

[An unusual bodily injury]. / Eine ungewöhnliche Körperverletzung.

In most cases, bodily harm results from the use of sharp objects or blunt force. This paper deals with a 42-year-old pharmacist who was known to the police and the courts because of several previous convictions for bodily injury. The man had visited a pub just before it closed and was therefore not served any drinks. He got angry about this and returned to his pharmacy (within walking distance) to fetch three disposable syringes which he filled with phosphoric acid (85%). Through the open pub window, he splattered the acid from the syringes on two guests and the host, who were hit on the upper part of their bodies and the arms. All the victims developed dermal alterations such as focal erythema and small blisters (pemphigus-like efflorescences, as already described by Weyrich). At first, the pharmacist denied the use of phosphoric acid and claimed to have used a mixture of urine and water. Examinations of spots on the still unwashed clothes revealed very low pH-values (ca. 2.0; pH-Indicator-Stripes, Merck; Medi-Test, Machery & Nagel). Tests for substances typical of urine produced completely negative results. However, very high phosphate concentrations were found on the spots in question. Thus, the probability that the pharmacist had used phosphoric acid to commit the offence was very high. The pharmacist was sentenced to one year and two months' imprisonment for dangerous bodily harm according to Section 224 German Criminal Code. In accordance with the law, phosphoric acid was classified as "poison", for which application on the skin is sufficient.

Malrotation syndrome resulting in fatal ileus in children.

BACKGROUND: This report deals with two deaths of children involving intestinal volvulus, i. e. a pathological knotting and twisting of the mesenterial root on the basis of congenital malrotation followed by obstruction and extensive ischaenia. CASE REPORTS: (1) A 10-year-old girl (premature, 25th week) with severe disability, amaurosis and epilepsy was admitted to hospital due to general agitation and a bloated abdomen without peristaltic sounds, but died some hours later. Autopsy revealed a volvulus of 2/3 of the small intestine based on congenital malrotation with additional clamping of the intestine underneath adhesions (previous appendectomy). The abdominal cavity showed beginning peritonitis as the cause of death. (2) A 2-month-old premature male baby (surviving twin, 29th week) with a persisting ductus arteriosus was hospitalised for four weeks after failed vascular surgery due to acute general deterioration. Radiological diagnostics using a contrast medium revealed a vascular anomaly (right-sided aortic arch). Around 10 hours later, the infant developed an acute abdomen with ileus symptoms. Emergency surgery showed infarction of the entire small intestine due to an anti-clockwise 180°-volvulus, with death occurring 24h later. Further examination showed a malrotation as anomaly. Apparently, the volvulus had been caused by extensive use of contrast medium resulting in increased intestinal mobility.

Lethal hypothermia after firing a suicidal shot to the head in a car.

In suicide cases involving an automobile, the car is mostly used as a tool/instrument for the suicide (intoxication by exhaust fumes, crash against solid objects such as a pylon). However, a car is uncommonly also used only as the location for a suicide. In the present case, a 70-year-old man had been found dead on the passenger seat of his car. According to witnesses, the car had not been parked there at the same time of the previous day. During that period, the weather had been dry, with temperatures ranging from -1° C at night to +5° C during the day. The man had shot himself with a small-caliber revolver (so-called bulldog-revolver) almost horizontally in the left temple (transtemporal shot through the frontal lobes). Obviously, the suicide had retained the capability to act at least for a short time, as the revolver was found under his left bottom. As morphological signs of prolonged agony some findings of hypothermia were observed (e. g. Wischnewski spots of the stomach).

Interrupted (self -)medication with pancuronium(bromide) and fatal outcome.

Pancuronium(bromide) is used because of its relaxing effect on striated muscles and usually requires artificial respiration. A 52-year-old woman suffered from long-standing "generalized dystonia", which had become resistant to conventional therapy. Therefore, an anesthetist established a permanent medication scheme with pancuronium using a PCA pump. This pump had been controlled by the patient herself ensuring an acceptable quality of life with broad personal autonomy. Finally, the woman was found dead in her flat by a member of a home nursing service. The infusion hose showed a fixed knot and further blocking by a clamp. The autopsy findings were non-specific, except for the presence of opioid tablets in the colon. Toxicological analyses showed 72ng/ml pancuronium and 21 ng/ml oxycodone (therapeutic) in the femoral venous blood. The range of published pancuronium levels varies from approx. 80 to 2,000 ng/ml. Thus it had to be assumed that the pancuronium level was too low (72 ng/ml) so that symptoms of dystonia recurred. Based on extensive literature research, the described case can be qualified as unique. The therapy concept had been innovative, sufficient and effective for more than 10 years. It allowed the patient to enjoy a maximum of autonomy. Ultimately, death was due to the blocked pancuronium infusion. The relatively low pancuronium level had provoked the dystonia to return with generalized spasms also involving the respiratory muscles resulting in respiratory arrest. During the police investigations, two previous suicide attempts came to light.

[Sepsis due to fusobacteria in a young adult]. / Fusobakterien-Sepsis bei einem jungen Erwachsenen.

Fusobacteria belong to the normal population of the pharyngeal mucosa as well as the mucosa of the upper airways and the gastrointestinal tract. Infections are comparatively rare. The most common causative organism is Fusobacterium necrophorum. A well-known infection caused by this germ is Lemierre's syndrome. In the presented case, a 19-year-old man (123 kg body weight, 186 cm body length) was found dead in his bed in the morning after having complained of muscular fatigue and vomiting the previous day. Autopsy was carried out only two days after death. At that time, the body showed marked putrefaction with partial greenish discoloration and marbling of the skin although it had been stored in a refrigerator at +2 degrees C in the meantime. While the autopsy itself revealed no cause of death, microbiological examination of a smear from the left lower pulmonary lobe demonstrated Staphylococcus aureus and Fusobacterium necrophorum. Toxicological investigations produced negative results throughout. The cause of death was defined as sepsis caused by Fusobacterium necrophorum.

,,Aorta angust'' - a possible cause of sudden death?.

Over one year, 7 autopsy cases with narrow diameters of the descending aorta were seen in the Institute of Forensic Medicine at the University of Bonn. The autopsy results were supplemented by chemical-toxicological, alcohol and histological examinations. In all cases middle-aged men (24-38 years) died suddenly and predominantly in a domestic environment. To some extent the inner aortic diameters ranged significantly below the expected values in relation to body surfaces or were lower than the 5th percentile related to men aged 45 years. In four cases, potentially lethal concentrations of alcohol or intoxications, e.g. with heroin, were noted. In one case, the blood sugar level was significantly elevated. In the other two cases, all further investigations were unremarkable.

[Suicidal fall from height after restraint or accident?]. / Suizidaler Sturz aus der Höhe nach Fixierung oder Unfallgeschehen?

Restraining patients is common practice in psychiatric hospitals and is permitted by section 1906 BGB (German Civil Code) if there is a risk of suicide or serious self-damage because of a mental disease or mental disability. Permanent monitoring and supervision during restraints should be obligatory not only in psychiatric hospitals. Nevertheless a number of deaths have occurred during restraints, usually due to strangulation. Reports of cases with suicidal actions after self-release from restraint are rare in the literature. We report on the case of a 45-year-old woman who had suffered from schizophrenia for more than 20 years. After admission to a hospital, she had to be restrained since she became more and more aggressive. When the monitor showed no vital signs any more, nurses checked the patient's room and found an empty bed. The woman was detected lying on the ground in a pool of blood under an open window of the hospital. The cause of death was a polytrauma with leading cranio-cerebral injuries. Obviously the woman had freed herself from the restraining device and committed suicide by jumping out of the window on the third floor.

[Suicide in childhood or accidental hanging? A case report]. / Suizid im Kindesalter oder unfallbedingtes Erhängen? Eine Fallvorstellung.

Suicides of children, adolescents and young adults are a rare manner of death. Hanging is the dominant suicide method in all age groups. Risk factors for suicide at a young age are mental diseases, use of illicit drugs, antisocial behaviour and problems within the family. A 10-year-old boy was found to have hanged himself with a scarf at the handrail of a staircase. He had had school problems and was often sent home earlier as he tended to disturb classes. In the week prior to his death the headmaster of his school had told him that he should better attend another type of school. The deceased's elder brother had recorded a video with his mobile phone some years before showing his sister in a simulated hanging situation. Apart from the macroscopic and microscopic findings of the reported case, the frequency and special characteristics of suicides in childhood and adolescence are discussed.

Driving under the influence of synthetic cannabinoids ("Spice"): a case series.

Recreational use of synthetic cannabinoid receptor agonists-so-called "Spice" products-became very popular during the last few years. Several reports on clinical symptoms and poisonings were published. Unfortunately, most of these reports do not contain any analytical data on synthetic cannabinoids in body fluids, and no or only a limited number of cases were reported concerning driving under the influence (DUI) of this kind of drugs. In this article, several cases of DUI of synthetic cannabinoids (AM-2201, JWH-018, JWH-019, JWH-122, JWH-210, JWH-307, MAM-2201 (JWH-122 5-fluoropentyl derivative), and UR-144) are presented, focusing on analytical results and signs of impairment documented by the police or the physicians who had taken the blood sample from the suspects. Consumption of synthetic cannabinoids can lead to impairment similar to typical performance deficits caused by cannabis use which are not compatible with safe driving. These deficits include centrally sedating effects and impairment of fine motor skills necessary for keeping the vehicle on track. Police as well as forensic toxicologists and other groups should become familiar with the effects of synthetic cannabinoid use, and be aware of the fact that drug users may shift to these "legal" alternatives due to their nondetectability by commonly used drug screening tests based on antibodies. Sophisticated screening procedures covering the complete range of available compounds or their metabolites have to be developed for both blood/serum and urine testing.

[Morphology and phenomenology of crossbow injuries with a review of the literature]. / Zur Morphologie und Phänomenologie von Armbrust-Schussverletzungen--zwei Fallbeispiele mit einer Literaturübersicht.

This paper presents two cases of survived and fatal injuries caused by broad-head arrows. Case no. 1 is characterised by repeated assaults resulting in severe injuries to the legs of the victim. The lesions showed characteristic patterns due to the arrow-heads with four cross-shaped blades. Case no. 2 represented a suicide with the crossbow arrow entering the upper mouth region at close range, penetrating the base of the skull, the pons and the inter-hemispheric space, with the tip of the arrow being lodged in the skullcap. Morphology of the wounds, ballistic features and technical characteristics are discussed and the available literature is reviewed.

Experimental fracture investigations concerning the hyoid bone fracture.

INTRODUCTION: Extensive literature exists concerning the etiology and morphology of fractures of the hyoid bone (h.b.) in cases of fatal strangulation. There is an agreement to the effect that fractures are mostly located within the distal third of the cornua majora (c.m.). Although several predictors have been described very accurately, the fracture analysis has neither been based on the osseous construction nor on the stress distribution of the c.m. under strangulation resulting from the configuration and its details. This especially applies to the apex of the distal ends of the big horns, the bulbi. The objective of the experimental break tests that were performed was to contribute to elucidating the biomechanics of the horizontal and vertical fractures and to fractures of the bulbi. MATERIALS AND METHODS: Break tests in the a.p. direction line were carried out on 28 unfixed h.b. of adults on a specially constructed test bench by continuously increasing the tension until a fracture/dislocation occurred. The test arrangement followed the constellation of typical-symmetrical hanging. The selection criteria were the symmetry of the h.b. and the gender. Before and after the experiments, a radiological depiction (DIMA system 20 kV, 10 sec; Institute for Diagnostic Radiology, University-Hospital Goettingen) was carried out, followed by a preparative depiction under magnifying glass control. The h.b. configuration was classified according to the following types: hyperbole-, parabola-, and horseshoe-type. Following this classification, the results were related to the findings achieved by the photo-elastic model experiments. By this, the results of the experimental fracture tests could be specifically compared to the tension distribution within the model. RESULTS: A total of 70 % of the experimentally-produced fractures were located within the distal third of the c.m. This matches with the frequency distribution in real typical symmetrical hanging. Following the radiological and preparative investigations that were carried out, the c.m. have to be viewed as tubular bones. The transition regions of different osseous strength/elasticity are thus to be considered as areas of increased vulnerability. For the distal third of the c.m., it is the level at which the dense spongiosa/compacta of the shaft part turn into wide-meshed spongiosa and tender compacta of the bulbi. Additionally, the bulbi themselves represent a locus of reduced strength in which the fractures were located basally and/or apically in the transition. It was not only in the whole c.m. that the direction in which the fragment was snapped off or fractured was not random, as all fractures were located on the broad side of the horn, following the applied force. CONCLUSIONS: The experimental fracture tests explained the known accumulation of fractures in the distal third of the c.m. in cases of hanging with the knot of the rope located against the neck. It could be demonstrated radiologically and preparatively that, anatomically, the big horn of the h.b. is a tubular bone. From this, a new approach to the forensic reconstruction of trauma can be derived. The transitional area from the shaft into the bulbus represents a locus minoris resistentiae. In case of pressing the h.b. towards the cervical spine under ventral application of force, one could expect a point load of the bulbi. Two different types of bulbus fractures showed that this load is diagnostically relevant. The fracture direction is also of diagnostic value. It depends on the angle that is formed by the c.m. with their broad side towards the horizontal. This angle may even change for about 90° for the c.m. in the course from proximal to distal movement. By adjustment of the alignment of the broad side with the stress distribution within the different types of the h.b., a mechanically justified answer can be given to the question of why a horizontal fracture appears in the one case and a vertical fracture in the other.

The potential use of the eye temperature decrease in determining the time of death in the early postmortem period: studies in pigs.

The experiment was performed in pigs during which the postmortem body temperature was continuously measured. The study was focused on a period of time starting 0.5 hours after the animals' termination and consisted in computer recording of the cooling process of the eyeball (vitreous humor), orbit soft tissues, muscles, and the rectum. The experiment revealed the absence of a plateau phase of temperature decrease in eyeball and orbit soft tissues contrary to muscles and rectum, what demonstrates that temperature measurements in the eye could become an alternative method of determining the time of death during the initial phase of postmortem cooling. During this early postmortem period determination of the time of death based on measurements of the rectum or muscles temperatures due to existing plateau is not possible.

A preliminary study for identifying olfactory markers of fear in the rat.

In stressful situations, many animals release alarm pheromones to warn conspecifics of impending danger. The authors sought to establish experimental conditions for a larger study aimed at identifying alarm pheromones emitted by the rat. They placed rats in a specially designed chamber and exposed them to aversive tactile, visual and acoustic stimuli over the course of a few days. The researchers observed rats' behavior and analyzed air samples taken from their immediate environment under the following conditions: (i) when rats were unstressed; (ii) immediately after rats were exposed to aversive stimuli; and (iii) when rats were left alone in the chamber after being conditioned to fear imminent aversive stimuli. Stressed rats emitted several substances that are known to function as alarm pheromones in insects. When previously unstressed control rats were exposed to these same substances, they had a distinct behavioral fear response.

Strangulation--Suicide at the wheel.

In cases of suicide at the wheel mostly velocity is used to cause death by a single occupant vehicle crash against a fixed roadside object or collision with other vehicles. A further well known mode of death is e.g. carbon monoxide poisoning. In the recent years several cases of vehicle assisted ligature strangulation resulting even in decapitation have been reported. However, cars are also used in rare cases just as places for a suicide by hanging or ligature strangulation. Not only forensic pathologists but also police officers have to be aware of this rare type of suicide to avoid unnecessary investigations.

The evidence of carbohydrate metabolism disturbances in traffic delinquents.

Hypoglycaemia may have forensic importance concerning the ability of running a car and possible imputability. This study is based on an analysis of anamneses and clinical symptoms of traffic delinquents. Furthermore were estimated biochemical parameters such as glucose and lactic acid (additionally ethanol and toxicological screening). There is proposed a sum value (glucose+lactate) on blood samples taken, on behalf of the police, to be a reliable equivalent of the actual state of glucose metabolism.

Fatal outcome of varicella in children.

Varicella or chicken-pox are one of the most frequent diseases in childhood. Severe or even lethal complications are rare (in about 0.03 per thousand ). Our paper presents two cases of varicella infections leading to sudden deaths (3- and 7-year-old children). In one of these cases, the paediatrician in charge was accused of an impaired medical treatment. Both of the children showed multiple typical efflorescences in different stages. Furthermore were observed affections of the respiratory tracts and serious involvements of the hearts, the lungs, and the livers. In one case an immunological identification could be made of an acute varicella infection. Based on autoptical, histological, bacteriological, virological, and neuropathological findings is given an analysis of such uncommon and severe courses of chicken-pox in children being identified as haemorrhagic form and massive abscess-forming varicella pneumonia.

Olfactory and tissue markers of fear in mammals including humans.

Pheromones are a mysterious world of chemical signals involved in conspecific communication. They play a number of key functions important for preservation of life of individual organisms, for their defence, survival of offspring and preservation of species. The best-known groups of pheromones include: trail pheromones, territorial pheromones, sex pheromones, aggregation pheromones, dispersion pheromones, repellent pheromones, social pheromones and alarm pheromones. Alarm pheromones are pheromones that are emitted by animals in threatening situations and inform members of the same species of danger. The identified alarm pheromones are synthesised by insects and aquatic organisms. Also humans are able to emit and perceive pheromones. Although alarm pheromones have not been isolated and identified in man so far, there is presumably evidence for their presence in humans. Pinpointing human alarm pheromones, determinants of experienced stress and inductors of provoked fear could have widespread consequences. Their identification could also be of significant importance for the practical utilisation of results by institutions responsible for safety and defence as well as law enforcement/crime detection and antiterrorist activities.