[Autopsies at the boundary between pathology and forensic medicine : Suggestions for interdisciplinary cooperation]. / Obduktionen im Grenzbereich zwischen Pathologie und Rechtsmedizin : Vorschläge zur interdisziplinären Kooperation.

There are many differences between forensic medicine and pathology but also many similarities, as they share a common basis. In this article the characteristics of the forensic autopsy and it's legal foundations are presented. Furthermore, possibilities are discussed for a cooperation between forensic medicine and pathology to increase the rate of autopsies. This could contribute to the legal certainty, to the quality assurance and to the training of physicians.

[Forensic medicine and the overlap with pathology]. / Zur Rechtsmedizin und ihren Berührungspunkten mit der Pathologie.

Forensic medicine incorporates research, teaching and professional service. In the routine practice this encompasses interdisciplinary cooperation with physicians, natural scientists and the legal profession. Lectures in forensic medicine include the correct performance of an external examination of corpses, which every physician must be capable of, just as medical questions and the evidential documentation of injuries. Clinical forensic medicine encompasses the examination and documentation of living victims of physical and/or sexual violence. For further training to become a specialist for forensic medicine it is mandatory to undertake a 6-month training period in pathology. Fatalities with an unclear or unnatural manner of death must be registered with the police. On suspicion of third party involvement the public prosecutor will request a legal autopsy, which is carried out and documented by two physicians in accordance with the penal code. Imaging procedures are standard for an autopsy. Extensive samples are taken for additional testing, such as toxicological and molecular biological investigations.

Criteria for age estimation in living individuals.

This paper presents updated recommendations of the Study Group on Forensic Age Diagnostics for age estimations in living individuals in criminal proceedings. In order to increase the diagnostic accuracy and to improve the identification of age-relevant developmental disorders, a physical examination, an X-ray examination of the left hand, as well as a dental examination including the determination of the dental status and an X-ray of the dentition should be performed in each case. If the skeletal development of the hand is completed, an additional radiological examination of the clavicles should be carried out. Minimum requirements for reference studies are defined and recommendable studies are listed. Instructions for the examination and the preparation of expert reports are presented. The committee of the study group organizes annual proficiency tests for quality assurance.

[Value of postmortem computed tomography in comparison to autopsy]. / Prospektive Untersuchung zur Wertigkeit der postmortalen Computertomographie im Vergleich zur Autopsie.

PURPOSE: To assess the diagnostic value of postmortem computed tomography (CT) in comparison to autopsy. MATERIALS AND METHODS: Twenty-seven cadavers were examined by sequential cranial CT and helical CT through the neck, thorax and abdomen and subsequently underwent an autopsy with histomorphologic examination of the pathologic specimens. The findings of CT, autopsy and histology were registered and compared by three radiologists and one specialist for forensic medicine, using a data entry form. RESULTS: In 19 of 27 cases, the findings explaining the cause of death were concordant for CT and autopsy. Intracranial, intraspinal and intracardiac gas accumulations (n = 12) were registered by CT alone. The detection of skull fractures was equal for both methods (n = 3). CT showed diagnostic problems in the assessment of pneumonic infiltrations (n = 16) and pulmonary edema (n = 21). CONCLUSION: CT is a useful and complementary method to autopsy.

[Postmortem roentgen diagnosis of the skull]. / Zur postmortalen Röntgendiagnostik des Schädels.

In this prospective study, skulls of 164 dead bodies were x-rayed in two different planes. The findings were assessed independent to the results of the subsequent autopsy, however afterwards compared with the autopsy findings. In 86 cases (53.4%) x-ray findings were significant. Dislocated calvarium fractures were clearly visible on the x-rays, however non-dislocated calvarium fractures as well as fractures of the visceral cranium and skull base were difficult to detect. Gas and foreign bodies could easily be observed. Similar to the clinical assessment the indication for a post-mortem x-ray of the skull must consider the case history and the respective condition of the corpse (for example putrefaction, charred body).

[Fatal outcome during physiotherapy (Vojta's method) in a 3-month old infant. Case report and comments on manual therapy in children]. / Uber einen Todesfall während der Physiotherapie nach Vojta bei einem 3 Monate alten Säugling. Fallbeschreibung und Bemerkungen zur Manualtherapie bei Kindern.

Detailed clinical and neuropathological report on a fatal incident during the first manual therapy according to Vojta conducted in a 3 months old baby: during forced active rotation and head retraction the baby suffered from a bleeding into the adventitia of both her vertebral arteries at the level of C1 prompting ischemia of the caudal brainstem with subarachnoid haemorrhage around. It has to be suggested that similar cases already have occurred but have not been reported yet. There might be a time lag between the performance of physiotherapy and the beginning of neurologic symptoms. The risks of manual therapy in children will be discussed.

Identification of unknown dead bodies by X-ray image comparison of the skull using the X-ray simulation program FoXSIS.

The aim of the study was to improve the objectivity of X-ray image comparison for the identification of unknown dead individuals. CT-data were collected for 30 macerated skulls. An already presented computer program which uses CT data to establish virtual X-ray images was used to obtain X-rays with different beam angulations simulating rotation, dorsal flexion, and ventral flexion. Specific parameters were measured on the simulated images. The frontal sinus reveals the highest variability not only between the individual skulls but also within an individual skull in different positions. The most consistent parameters with respect to different positions were the skull breadth, the biorbital breadth and the bizygomatic breadth. In a blind study, three out of 24 skulls could clearly be identified just by measured distances although the positions were different and unknown to the investigator. The dimensions of the frontal sinus do not correlate with the other skull parameters (analysis of covariance). Based on the presented results, we propose a method that will calculate the probability of identity. The presented results demonstrate that the comparison of X-ray images can be undertaken in an objective way by quantifying the probability of identity even when the comparative images were made under different conditions.

[Delayed aortic rupture following a fall from an examination couch. Clinical and forensic aspects]. / Zweizeitige Aortenruptur nach Sturz von Untersuchungsliege. Klinische und forensische Aspekte.

BACKGROUND: Physicians frequently have to face an investigation of their work from a judicial point of view. Due to these proceedings the number of cases when they are reproached with malpractice is increasing. CASE REPORT: We report the rare case of a 76-year-old female patient who fell from a 68 cm high couch after a sedative was applied during gastroscopical examination. She died 24 hours after the incident. Forensic necropsy revealed a delayed aortic rupture as the cause of death. The preliminary proceedings against the physician involved for culpable homicide by criminal negligence were suspended after he paid a fine. The possible legal consequences under German law for physicians involved in such cases are discussed as well as strategies to avoid them. CONCLUSION: Physicians who are under investigation for malpractice should act carefully. They are advised to seek professional help at an early stage of preliminary proceedings. A public trial should be avoided if possible.

[Self-injury or attempted murder--analysis of an unusual case]. / Selbstbeschädigung oder versuchtes Tötungsdelikt--Analyse eines ungewöhnlichen Falles.

An unusual case of self-injury involving several, partly deep penetrating stab wounds is described. A young emotionally disturbed consulting-room assistant accused her husband of having inflicted the injuries upon her in the course of an argument over custody of the children. An analysis of the injury pattern showed clear indications of self-injury and willfully transferred blood from punctures in the woman's fingertips to the clothes of the accused. The case demonstrates that in cases involving members of a medical profession and individuals with psychiatric disorders, the possibility of highly unusual types of self-injury should not be excluded. It further emphasizes the importance of a physical examination performed by a medico-legal specialist.

Bone age determination based on the study of the medial extremity of the clavicle.

The development of the medial clavicular epiphysis and its fusion with the clavicular shaft have been a subject of medical research since the second decade of this century. Computed tomography provides the imaging modality of choice in analyzing the maturation process of the sternal end of the clavicle. In a retrospective study, we analyzed normal development in 380 individuals under the age of 30 years. The appearance of an epiphyseal ossification center occurred between ages 11 and 22 years. Partial union was found from age 16 until age 26 years. Complete union was first noted at age 22 years and in 100 % of the sample at age 27 years. Based on these data, age-related standardized age distributions and 95 % reference intervals were calculated. Compared to the experience recorded in the relevant literature, there are several landmarks that show no significant change between different ethnic groups and different periods of publication; these are the onset of ossification, the time span of partial union, and the appearance of complete union. Despite the relatively long time spans of the maturation stages, bone age estimation based on the study of the development of the medial clavicular epiphysis may be a useful tool in forensic age identification in living individuals, especially if the age of the subject is about the end of the second or the beginning of the third decade of life (e. g. in determining the applicability of adult or juvenile penal systems). Another possible use is in identifying human remains whose age is estimated at under 30 years.

Metal pins fired from unmodified blank cartridge guns and very small calibre weapons--technical and wound ballistic aspects.

Blank cartridge guns are generally regarded as being harmless and are not considered to be firearms in most countries. A comparison of the legal situations in Germany and Austria concerning weapons is given. There have been several reports of serious injuries and even fatalities due to these weapons. Ballistic experiments show that even unmodified blank cartridge guns and very small calibre weapons can fire wire nails and can inflict potentially fatal injuries even at distances of 50 cm. Two serious injuries inflicted by metal pins fired from a blank cartridge gun and a very small calibre weapon are reported. These cases suggest that such weapons should also be considered handguns in the legal sense.

[Computerized tomography of the epiphyseal union of the medial clavicle: an auxiliary method of age determination during adolescence and the 3d decade of life?]. / Die computertomographisch bestimmte Ausreifung der medialen Klavikulaepiphyse--eine additive Methode zur Altersbestimmung im Adoleszentenalter und in der dritten Lebensdekade?

PURPOSE: To establish a reference population for the stages of epiphyseal union of the medical clavicle determined by CT. MATERIAL AND METHODS: Retrospectively, the thoracic CTs of patients under 30 years of age were reevaluated. Basic conditions were the lack of a bone development disorder and a sufficient assessment of the medial clavicle in a bone window setting. The stages of epiphyseal union were categorized as follows: Stage 1 refers to nonunion without ossification of the epiphysis, Stage 2 to nonunion with a separate and ossified epiphysis, Stage 3 to partial, and Stage 4 to complete union. RESULTS: Up to now, 279 individuals could be included in the study. Stage 1 was observed till age 16, Stage 2 occurred from ages 13 through 22, Stage 3 was found from ages 16 through 26. Stage 4 was first noted at age 22, and in 100% of the sample at age 27. CONCLUSIONS: CT is well suitable to determine the stages of epiphyseal union of the medial clavicle. It may become a generally accepted method of age identification during adolescence and the 3rd decade of life. The presented data serve as a reference population at least for white Europeans.

[Identification of unknown cadavers in forensic medicine practice]. / Zur Identifizierung unbekannter Leichen in der rechtsmedizinischen Praxis.

50 unknown dead were identified at the Institute of Forensic Medicine in Mainz (Germany) in the years between 1985 and 1993, most of them by dental records, x-ray comparison and morphological findings. This is equivalent to an overall success rate of 94.3%. In most cases unnatural causes of death were established (suicide, accident, and homicide). The male to female rate was more than 2:1. The increase of the number of unknown corpses since 1985 from 5% to nearly 10% of the total number of autopsies may be caused by increasing mobility and anonymity of the population.

Estimation of sex on the basis of radiographs of the calcaneus.

Lateral and anteroposterior radiographs of the ankles of 800 Central Europeans aged 20 to 79 were analyzed with regard to sexual dimorphism. All the distances, but not the angles, of the calcaneus were much larger in males than in females. Approximately 80% of the study sample could be sexed correctly by classifying all specimens greater than 86.0 mm in length as male and those less than 86.0 mm as female. The prevalence of os tibiale externum was 8.0 and 2.6% and the prevalence of plantar heel spur was 16.3 and 6.5% (increasing with age) for males and females, respectively, being significantly more frequent in females. On the other hand, the bone island frequencies were 9.1% in males and 4.8% in females. Our study suggests that radiographs of the ankle are a convenient, rapid, cheap and non-invasive means for estimating sex.