A case of Munchausen syndrome by proxy with subsequent suicide of the mother.

Munchausen syndrome by proxy is a subtle and difficult to diagnose form of child abuse in which the carer (usually the mother) simulates, manipulates or produces symptoms of illness in the victim. In most cases the detrimental effect is caused by applying foreign substances or by airway obstruction. In the presented case a 20-month-old girl developed a spreading soft-tissue infection resistant to treatment on the left upper arm after vaccination, which required a number of surgical interventions. Repeatedly, microorganisms from the intestinal flora were isolated from the wound secretion. After the girl suffered respiratory and circulatory arrest, which required resuscitation measures, chemical toxicological tests revealed not medically prescribed benzodiazepines in serum and urine. When the mother, a trained nurse, was confronted with the allegation to have manipulated the symptoms of the illness she committed suicide. The forensic autopsy of the suicide produced numerous hints suggesting chronic self-damaging behaviour described as Munchausen syndrome. This case shows a number of manipulation forms with the maintenance of a chronic skin and soft tissue infection belonging to the rarer forms of inflicting damage to the child. It also illustrates that confrontation with the allegation of Munchausen syndrome by proxy creates a very stressful emotional situation that may lead to a suicidal act.

Self-inflicted injuries with negative political overtones.

The report deals with two adolescents (a 17-year-old Turkish boy and a 15-year-old German girl) who simulated right-wing assaults by cutting National Socialist symbols into their own skin. The fact that Nazi symbols were chosen was obviously due to the idea that the alleged commission of the offense by right-wingers would not be doubted due to the negative image of this group. The alleged victims did not inform the police until the family or close friends urged them to report the incident. The rapid elucidation of the facts was possible because medicolegal experts were called in at an early stage of the investigations. The injuries showed typical morphological features of self-infliction (localization in easily accessible parts of the body, multitude of singular lesions with a linear or slightly curved course, equally shallow and non-penetrating cuts, arrangement in groups or over a defined area, lack of defense injuries, no corresponding damage to the clothing).

Detachment of the periosteum and soot staining of its underside in contact shots to the cerebral cranium.

Contact gunshot wounds are usually characterized by a muzzle imprint, a powder cavity ("pocket"), the presence of carboxyhemoglobin and often also stellate tears of the skin radiating from the bullet entrance hole. In shots to the cerebral cranium an additional sign may be observed around the bone defect: the periosteum is detached and reflected with soot on the underside. The frequency and possible causes of these periosteal findings are discussed on the basis of 68 contact gunshot wounds from forensic autopsy material and experimental shots fired against the frontal bone of a slaughtered calf.

Skin tears away from the entrance wound in gunshots to the head.

The present investigation covers 116 contact shots to the head and shots into the mouth from the Freiburg forensic autopsy material including 20 gunshot wounds which showed stretchmark-like tears of the facial skin away from the entrance wound. In these cases the gunshot entrance wounds were localised either in the mouth, the forehead, or the submental region. The stretchmark-like tears were found in the region of the eyes and the nasolabial folds. Radial tears were seen on the lips and in the vicinity of the corners of the mouth, particularly in cases involving shots into the mouth. The stretchmark-like tears essentially followed the skin tension lines and the expression-related lines of the face. They were apparently caused by the subcutaneous or intraoral expansion of the muzzle gases and/or the radial forces of the bullet resulting in ballooning and overextension of the facial soft tissues. The weapons used were not only rifles and shotguns, but also revolvers and pistols.

[Early post-mortem animal bites after suicidal gunshot wound to the head of a police dog handler]. / Frühpostmortaler Tierfrass nach suizidalem Kopfschuss eines polizeilichen Hundeführers.

A 41-year-old police officer committed suicide in his office by firing a contact shot to the left temple. When the body was found 12 hours later, the German shepherd dog the officer had been in charge of had caused considerable damage on the lower half of the face and the adjacent parts of the neck. The clothing of the suicide was undamaged. Blood traces in the shape of paws were found at the place of death. The wound margins of the postmortem animal injury were nicked and jagged by the canine teeth. The entrance and exit wounds were not affected by the soft tissue defect. The findings gathered are discussed in reference to the relevant literature.

[Differential burns of head and pubic hair]. / Zum unterschiedlichen Brandverhalten von Kopf- und Schamhaaren.

A woman, who was hospitalized with extensive burns in the genital and perineal region, accused her husband who lived apart from her to have inflicted the injuries with a lighter and a burning candle out of jealousy. The husband denied the accusations and stated that he wanted to singe off the pubic hair with the lighter during sadomasochist sexual practices performed in mutual agreement. As he did so extensive flames suddenly developed--something he had not expected--thus causing the burns. To check the statement cut off tufts of head and pubic hair were set on fire with a lighter to compare their burning behaviour. Pubic hair was easily inflammable and burnt almost completely within about 10 seconds developing up to 10 cm high flames, whereas straight head hair developed only minor flames and the singed hairs stopped burning spontaneously some seconds later already.

Transfer of biological traces in cases of hanging and ligature strangulation.

In hanging and ligature strangulation, the noose mostly causes a mark or groove which is formed partly by compression of the skin and partly by abrasion with loss of the upper epidermal layers. The horny scales abraded from the neck may be transferred to the strangulation device or to the interposed textiles where they are sometimes visible at stereomicroscopic examination or even to the naked eye as silver-grey particles. The morphologic features of the epidermal transfer due to hanging and ligature strangulation is demonstrated by 14 case examples. The biological traces may be sufficient for comparative DNA typing by means of PCR-based methods. In 9 out of the 14 cases, genomic DNA typing was successful. Analysis of mtDNA succeeded in another two cases, although genomic DNA could not be detected. Beside the accumulation of solid epidermic particles the paper describes deposition of serous and fatty tissue fluid at the ligature (mainly adjacent to skin ridges).

[Using cement-containing powder glue (tile cement) to dispose of a cadaver]. / Verwendung von zementhaltigem Pulverklebstoff (Fliesenkleber) im Rahmen einer Leichenbeseitigung.

A 40 year-old woman was killed by fist and chop blows and buried in a forest area far away from the scene of the homicide. Before covering the body with soil the perpetrator poured 25 kg of tile cement powder over it. When the victim was retrieved 6 weeks later, the cement had hardened covering the body like a plate and encasing it like a sheath. The surface of the tile cement facing towards the body was found to contain two kinds of traces: detailed cast-like reproduction of the textile structures of the victim's clothing and wallpaper-like epidermal adhesions. By means of sequencing the mitochondrial DNA the adherent horny scales could be related to the victim.

[Combined suicide by drinking acetic acid with subsequent hanging]. / Kombinierte Suizide durch Einnahme von Essigsäure mit nachfolgendem Erhängen.

Three late emigrants of German origin from Russia (1 man, 2 women) drank 70- and 86% acetic acid respectively before hanging themselves. In one of the suicides the hanging noose was running across the face. None of the cases presented showed any perioral chemical burns. At autopsy an intense odor of acetic acid was noticeable. The mucosa of the upper digestive tract showed a whitish, grey, brown or black discoloration and was partially detached. In two cases intravascular clotting of blood was discernible in the area affected by the acid; in one case the vessels were imbibed with haemoglobin due to haemolysis. Highly concentrated acetic acid is generally available in the successor states of the former USSR and its use in suicides is thus not uncommon. The legal regulations applying in Germany to the sale of acetic acid and the toxicological data are briefly described.

[Occupation-specific mode of self injury within the scope of a fictitious assault]. / Berufsbezogene Vorgangsweise bei Selbstverletzung im Rahmen eines fingierten Uberfalls.

In typical cases self-inflicted injuries in fictitious offences show a characteristic pattern of findings with multiple, uniform, and mostly superficial skin lesions. If the actors possess special experiences, knowledge or instruments--particularly in the field of medicine--the injuries inflicted by themselves may have an appearance whose autoaggressive origin is less obvious. The case of a 43-year-old nurse is reported who was admitted for surgical treatment with two cuts in the abdomen extending into the subcutis; she pretended to have been attacked by 2 masked men who stabbed her for xenophobic motives. In reality she had inflicted the cuts upon herself after applying a local anaesthetic. The necessary equipment (Scandicain, disposable syringes, stitch cutter) was taken from her place of work. Self-inflicted injuries specific to medical professions, as well as fictitious offences with atypical cut- and stab-wounds and the insinuated motives of the alleged offenders are discussed.

Fractures of the base of the skull in charred bodies--post-mortem heat injuries or signs of mechanical traumatisation?

Based on a recent case, in which an expert opinion had to be prepared, the question was investigated if fractures of the base of the skull can result from the influence of heat on the human skull. Neither the retrospective analysis of autopsy records nor the prospective examination of charred bodies revealed any cases with heat-induced fractures of the base of the skull. Observation of cremations showed that the changes caused by the fire followed certain rules: fractures of the calvaria were seen after approximately 20 min; the base of the skull became exposed after about 45 to 60 min. In none of the 20 cremations watched could any fractures of the base of the skull be detected.

Homicide with a screwdriver and simulation of a similar offence by self-infliction of injuries.

In an underground garage of a department store, a 52-year-old woman was attacked and fatally wounded by several stabs with a screwdriver. The offence happened as the woman was getting into her car. The homicide itself and the subsequent trial were extensively covered in the local media. A few days before the judgement was pronounced, another attack in an underground garage was reported to the police of the town, where the homicide had happened. A 52-year-old woman claimed to have been hurt by an assailant. The wound pattern (several equally shallow cuts arranged in groups), however, suggested self-infliction, which was finally admitted by the informant. The 'victim' used a newly bought kitchen knife to cut herself and left it at the place of the alleged assault. The knife blade was soiled with blood. Referring to the pertinent literature both cases are compared with regard to the injury characteristics and to the damage to the clothing. The morphological features of screwdriver injuries, the criteria differentiating self-infliction and assault as well as the manifestation of copycat offences are discussed.

Excoriations and contusions of the skin as artefacts in fictitious sexual offences.

Some women reporting a sexual offence to the police inflict injuries on themselves, usually with the help of pointed and/or cutting tools, in order to make fictitious assaults more credible. If there is a classical pattern of the findings, such fictitious assaults are easier to identify. However, it is more difficult to distinguish genuine from fictitious injuries, if blunt force is used. This paper reports on 4 such cases, and the characteristics of self-inflicted excoriations and skin contusions are discussed. In the cases described, the excoriations were produced by scratching with the person's own fingernails or by rubbing the skin against a rough surface; contusion bleeding was caused by pinching (lifting and compressing skin folds with the fingers). The pattern of the injuries showed striking parallels to classical patterns: multiple lesions in grouped, parallel and symmetrical arrangement and of evenly minor intensity; preference of body regions within easy reach; no damage of the clothing, or if any, damage inconsistent with the injuries as described.

[Double suicidal gunshots with submental and parietal gunshot sites]. / Zweimalige suizidale Schussabgabe mit submentaler und parietaler Einschusslokalisation.

An 81-year-old suicide killed himself with two contact shots from a Walther PP pistol (cal. 7.65 mm Browning). The first entrance site was located under the chin, the second on the top of the head. The primary submental shot went through the facial part of the skull exclusively, the subsequent parietal shot interspersed central parts of the brain. The sequence of the shots could be identified by means of the different severity of the injuries and its effect on the ability of the person to act on the one hand and the pattern of the blood traces on the other hand. When the body was found, the suicide held the weapon in his right hand, which was stiff from rigor mortis. On the basis of the case presented and the literature available the criminological aspects of suicidal shots on the top of the head and multiple gunshot wounds are discussed.

[Effect of environmental temperature on the course of spontaneous postmortem pupillary changes (studies of the rabbit eye)]. / Zum Einfluss der Umgebungstemperatur auf den Ablauf der spontanen postmortalen Pupillenveränderungen (Untersuchungen am Kaninchenauge).

The diameter of the pupils was measured in the bodies of rabbits under different ambient temperatures (2-4 degrees C, 10-12 degrees C, 18-20 degrees C, 28-30 degrees C). It was found that the pupils changed in three phases: Initial miosis, which set in within minutes after death, was followed by a mydriatic phase, which lasted several hours and was approximately synchronous with the post-mortem rigidity of the skeletal muscles. In the third phase the pupils slowly contracted in the course of several days. The higher the ambient temperature, the more marked was the dilatation of the pupils in the second phase. In contrast to this the reaction of the pupils was characterized by less pronounced changes in size and a longer duration of secondary mydriasis, when temperatures were low.

[Agonal dog bite injuries]. / Agonale Hundebissverletzungen.

A 57-year-old woman, who was unconscious due to apoplectic cerebral haemorrhage, was injured on the right thigh by dog bites while still alive. In addition to a soft-tissue defect of 10 x 9 x 3 cm (gnawing effect) there were numerous small single lesions in the form of slit-shaped skin cuts. The area around the wounds was discoloured by haematomata. The bite wounds were caused by the mongrel dogs living in the same household (2 parent animals and 6 puppies). The pattern of the injuries corresponded well to the anatomy of a dog's set of teeth.

[Analysis of gunshot injuries with a livestock gun]. / Zur Analyse von Bolzenschuss-Stanzverletzungen.

A suicidal injury from a livestock stunner ("humane killer") serves to demonstrate the reconstruction possibilities presented by the morphology of the bolt entrance wound and the imprimata. There are differences to common bullet entrance holes with regard to caliber and soot deposits but also with regard to the wound margin features and the characteristics with shots fired at an oblique angle.