Death due to non-traumatic hemoperitoneum in Milan 2002-2016, with focus on two cases of abdominal apoplexy (idiopathic spontaneous hemoperitoneum) and review of the literature.

Abdominal apoplexy, also known as idiopathic spontaneous hemoperitoneum, is a rare event related to sudden death, whose diagnosis and treatment is extremely challenging and whose pathologic mechanisms are still mainly unknown. It is frequently associated with vascular disorders (alterations in the vascular structures) and mainly linked to liver cirrhosis. However, the presence of hemoperitoneum may in such cases pose many challenges to forensic post-mortem examinations since the source of bleeding remains often unknown even after a careful and thorough dissection. The Authors present two cases of sudden death related to massive hemoperitoneum (4,650ml in case 1 and 5,100ml in case 2) occurred in two cirrhotic males aged 49 and 51: no traumatic injuries were detected and the source of bleeding was not identified although a careful dissection of organs and vascular structures was performed. Rare cases have been already described in the literature, only as case reports, and no systematic studies have been performed on this issue. Nevertheless, this event ought to be taken into account asa cause of sudden death in people with advanced liver disease. A general glimpse is provided among the different causal mechanisms and the challenges within forensic pathology.

One Hundred and One Cases of Plastic Bag Suffocation in the Milan Area Between 1993 and 2013-Correlations, Circumstances, Pathological and Forensic Evidences and Literature Review.

Plastic Bag Suffocation is a rare cause of death in developed countries and almost unknown in the rest of the world. This study aims to retrospectively evaluate cases of PBS _asphyxia in Milan's Department of Legal Medicine from 1993 to 2013. Cases were selected from the database of 21,472 autopsies performed in the considered timeframe. One hundred and one cases were considered to be cases of Plastic Bag Suffocation, comprised of 100 suicides, no accidental events and 1 homicide. The most relevant elements pertaining to this type of death were evaluated for both the corpses and the crime scenes. From this study the typical PBS victim is an adult male, aged 52.3 years on average, depressed or afflicted by chronic or terminal diseases, and found at home. In 42.6% of cases, the victims were found with the plastic bag still positioned over their head, fastened by tying. Also common among these cases are drugs, alcohol and chemical abuses. According to the collected data, it is impossible to outline a pathognomonic detrimental background that leads to this cause of death. Crime scene investigation is, therefore, the one and only technical resource for evaluating these cases.

A case report of lethal post-viral lymphocytic myocarditis with exclusive location in the right ventricle.

The inflammatory involvement of vital organs may represent a dangerous and life-threatening situation: in particular, the inflammation of the myocardial tissue of the heart may lead to severe consequences since the clinical history of the disease may be completely asymptomatic, any clinical sign may be lacking, thus preventing correct diagnosis and treatment. This may occur even in the case of myocarditis and may lead to unexpected death whose cause can be assessable only by means of a thorough histopathological examination. The article reports the case of 61-year old female who developed a flu-like syndrome with very few symptoms, followed by sudden death in three weeks. The autopsy and following histopathological investigations identified the cause of death in a post-viral lymphocytic myocarditis, probably related to the previous infectious disease, and alternative causes (as arrhythmic ventricular dysplasia, vasculitis, sarcoidosis and giant cell myocarditis) were excluded. The exclusive location in the right ventricle was a peculiar finding. The case highlights the importance of the myocardium of the right ventricle, a tissue which is often less considered even in histopathological surveys. The exclusive location of myocarditis in the right ventricle is a rare event but in this case fully responsible for death.

The medico-legal observation of an aggressive urogenital fibromatosis with isolated development not related to any traumatic event.

Desmoid tumor is a fibroproliferative neoplasm with an intermediate malignancy and it can be localized in every bodily district: some locations are considered exceptional, like the urogenital localization. The Author point out a rare case of giant idiopathic scrotal fibromatosis that was found during an autopsy. A widower, that lived alone in poor hygienic conditions, was found dead in his house. The Judicial Authority ordered the autopsy, that was performed two days later at the Medico-Legal Section of Milan University. External examinations revealed only the considerable dimension of the scrotum (cm 24 × 41). The cause of death was fixed in a cardiac tamponade due to a natural heart laceration localized in correspondence of a transmural infarction. The toxicological exam resulted negative, while the histopathological and immunohistochemical analysis qualify the scrotal mass as a desmoids tumor. Due to the absence of predisposing conditions and of fibroproliferative infiltration in bladder and retroperitoneal space, the neoplasm was configured as an idiopathic desmoid tumor. The presented case gives the reason for the discussion concerning medico-legal aspects that are typical of rare neoplasms.

Macroscopic and histopathological aspects of chemical damage to human tissues depending on the survival time.

The ingestion of corrosive substances is a widely treated topic in clinical and forensic practice, as an accidental event or as a consequence of voluntary assumption to commit suicide. However, thorough macroscopic and microscopic surveys focused on the correlation between the ingestion of the substance and different survival times have never been performed. Are the ingestion and the metabolism of the substance within the human tissues still recognizable? How could it be related to death? The study concerns a retrospective analysis on ten cases (two accidental, eight suicides) of lethal ingestion of different types of liquid caustic substances, without instant death and survival times ranging from 12 h to 6 months. For each case, a full autopsy and histological examination of the internal organs were performed. The results showed that the early direct effect of the substances is exerted mainly on the gastrointestinal tract, but as survival time increased, the metabolism of the substance exerted its effects in different target organs. When the cause of death was not directly linkable to the ingestion of the substance (i.e., related to cardiac stress, electrolyte disorders, pneumonia) and macroscopic findings were nonspecific, histological analyses allowed for providing crucial elements towards a link between death and assumption of the substance.

Characterisation of the weapon used in a patricide by SEM/EDS analysis of a microscopic trace from the object.

This article presents a case of patricide. The murder was characterised by multiple blunt traumas and asphyxia. A mass of contused wounds was localised to the head and neck, and included the complete avulsion of the left eye (by an unknown tool), which was recovered near the cadaver. This case is of interest due to the possibility of identifying microscopic traces of the object that was used for the homicide by examining the skin margins around the ocular injury. The analysis was conducted using scanning electron microscopy combined with energy dispersive X-ray analysis (SEM/EDX). Analysis of the skin margins allowed microscopic inorganic traces to be detected, which were identified as ceramic material. This result focused the attention of the investigation on a small fish-shaped statue that had been previously found by the police when examining the crime scene. The use of SEM/EDX was therefore essential in determining a match between the microscopic traces detected on the perilesional skin and the composition of the statue. This led to the suspicion that the statue was the murder weapon.

The toll of traffic-related fatalities in a metropolitan Italian area through the experience of the Department of Legal Medicine.

Despite the introduction of new traffic laws in Italy, traffic-related deaths are still a huge burden. The study presents data and medico-legal issues behind traffic deaths in Milan between 2001 and 2012 (1506 traffic-related deaths). Data were collected from the database of the Department of Legal Medicine: 79.4% males and 20.6% females (mean age 44.14). The target group concerned traumatic deaths as a consequence of the accident as well as deaths not directly related to an accident. Although 6.1% were non-traumatic deaths (cause of death unconnected to the accident, i.e. because of a heart attack, or when death occurred after survival and cause of death was not related certainly to the accident), multiple skeletal/visceral injuries were the main cause of death (57.9%), occurring in motorcyclists the most (63.7%). Injuries to the skull and brain were the second cause of death (25.9%). Victims were mostly males (79.4%) and drivers (77.6%). Fifty-five per cent were deaths on-scene, while 45% survived. Other variables were also considered: medications, medical history, and drugs/alcohol/smoke. A downward trend in traffic-related fatalities was evident, but the toll is still high. This study should be a glimpse at the actual situation, since it is indicative of a metropolitan area where autopsies are systematically performed.

Suicide drowning in the non-coastal territory of Milan.

INTRODUCTION: A cadaver in water sets a relevant issue for the forensic pathologist, concerning the differential diagnosis between homicide, suicide, accidental event, and natural death in water. In the present study, the drowning suicides in a non-coastal territory are analyzed, discussing the main diagnostic difficulties, the preventive intervention, and the strategies for outlining the profile of a "mean victim" that is at risk of committing suicide by drowning. METHODS: The cases of drowning suicide were extrapolated by the database of the 21,472 autopsies performed at the Civic Morgue of Milan, in the period between 1993 and 2013. RESULTS: Drowning represents the fifth cause of suicide registered in Milan for the study period, with 139 cases (3.8% of all suicides). Victims were mainly elderly males (61-80 years old) with a history of psychiatric diseases in pharmacological therapy; they committed suicide mainly during summer, in the rivers. The diatoms test was positive in 82 cases (59%) and highlighted typical taxa of fresh water. Alcohol and illicit drugs were not noticed, at high levels. CONCLUSION: Drowning suicide occurs even in a non-coastal territory, far from the sea, if there is an easy access to the water: specifically, many natural and artificial waterways in the Milan district represent a high-risk factor predisposing the drowning suicide.

The case of a prosthetic limb used to cause lethal intravaginal injuries: forensic medical aspects in a case of intimate partner violence.

A common form of violence against women is sexual coercion on the part of their husbands/partners, the uncontrollable effects of which can lead to extreme consequences, as in the case of uxoricide examined in this report. It involved a 59-year-old female alcoholic, under observation on the part of social services as the possible victim of abuse by her husband, an amputee with a transtibial prosthesis. The woman had never admitted to her social workers that her husband was abusing her. One night, she was admitted to hospital in a state of hemorrhagic shock due to massive vaginal bleeding, but despite treatment, she died 20 min after arrival. The anatomical-pathological examination conducted by the hospital revealed serious genital lesions which warranted reporting the case to the Judicial Authorities, who arranged for a forensic autopsy. The cause of death was identified as acute meta-hemorrhagic anemia in a cirrhotic woman, secondary to a large, irregular vaginal lesion involving both the vaginal wall and the soft perivaginal tissues as well as the medium and small urogenital vascular branches. To identify the foreign body used to inflict this injury, a scanning electron microscope and energy dispersive X-ray spectrometer (SEM-EDS) were used. This revealed tiny splinters of wood in the vaginal tissues examined. In addition to the genetic-forensic techniques used, this finding allowed the investigators to identify the husband's prosthetic limb as the instrument of sexual coercion. The report describes a particular case of marital rape that resulted in uxoricide, in which the overall concordance of the investigations carried out played a fundamental role in identifying the offending body and, consequently, the murderer.

Lethal Bochdalek hernia in a three-year-old: pathological findings and medicolegal investigation in accusation of malpractice.

Diaphragmatic hernias can be a pitfall for paediatric diagnostics, especially in the cases of late presentation, which can also have medico-legal ramifications as exposed. A three-year-old boy was taken to a children's hospital after an episode of abdominal pain and vomiting of food. A physical examination proved normal, with mild ketonuria being found and he was discharged. Three months later for the same signs and symptoms, he was taken once more to hospital, where he arrived in a state of cardiac arrest and died. A lawsuit was begun against the doctors who had examined him three months earlier. The autopsy found herniation of the abdominal organs into the left pleural cavity through a defect in the left hemidiaphragm. The cause of death was identified as cardiac tamponade caused by mechanical compression of multiple herniated abdominal organs. The histopathological examination revealed marked atelectasis of the left lung, with non-expansion of 60-90% of the alveoli which suggested an acute mechanism that proved fatal, and the doctors were acquitted. The features of this disease and the possible difficulties in its diagnosis highlight the need for the utmost attention in differential diagnosis, even at an age where the discovery of a diaphragmatic hernia is exceedingly rare.

Analysis of 16 years of homicides and suicides involving the use of weapons recorded at the Milan Medicolegal Bureau.

The criminal use of weapons is a very topical issue in the industrialized countries and worldwide, and a reconsideration of the legislation governing their possession is warranted. We retrospectively analyzed the homicides and suicides involving the use of firearms and piercing and/or cutting weapons recorded at the Medicolegal Bureau in Milan from January 1, 1993, to December 31, 2008. First we considered the clinical histories of the deceased and the circumstantial details of their deaths, then we examined the data relating to the cause of death recorded in the autopsy reports. Our case series consisted of 414 homicides (54.2%) and 350 suicides (45.8%). Firearms were responsible for more deaths (64%) than piercing and/or cutting weapons (36%). The firearms involved were legally licensed in 40% of cases (suicides) and illegal in 22% (homicides). Our findings suggest the need to review the criteria considered for the issue of firearms licenses, in Italy at least.