[Autoptical display of the nasopharyngeal space in cases of suspected SARS-Co2 infection]. / Autoptische Darstellung des Nasen-Rachen-Raumes bei Verdacht auf SARS-CoV2-Infektion.

This paper deals with a dissection technique in order to display the nasopharyngeal space. It consists of a parafrontal saw cut through the base of the skull at the level of the sella turcica. In this way the ventral part of the nasopharyngeal space can be separated from the cervical spine and the posterior base of the skull within an anatomically preformed border region. Apart from a comprehensive overview of the nasopharyngeal space, this technique also enables samples to be correctly taken. The time required takes approximately 2-3 min, the external appearance of the deceased is not affected and the preparation of the body is not complicated.

[Erratum to: Histopathological findings following SARS-CoV-2 infection with and without treatment-Report of three autopsies]. / Erratum zu: Histopathologische Befunde bei therapierter und nichttherapierter SARS-CoV-2-Infektion ­ Bericht über 3 Autopsien.

[This corrects the article DOI: 10.1007/s00194-020-00408-x.].

[Histopathological findings following SARS-CoV-2 infection with and without treatment-Report of three autopsies]. / Histopathologische Befunde bei therapierter und nichttherapierter SARS-CoV-2-Infektion ­ Bericht über 3 Autopsien.

According to the current state of knowledge, several internal organs are usually involved in cases of SARS-CoV­2 infections with a fatal course. Pathological changes are primarily found in lung tissues but there are also reports concerning direct or indirect (histo)pathological changes due to SARS-CoV­2 infections in samples from the kidneys, liver and myocardium. Comparing three fatal cases associated with SARS-CoV­2 infections in men using conventional histological staining, there were partly identical findings that enabled interpretations with respect to the chronology and pathophysiology of the disease. Of the men two were invasively ventilated in the intensive care unit and one man died after 8 days in domestic quarantine without treatment. A wide spectrum of findings potentially associated with SARS-CoV­2 must be taken into account.

Death due to diabetic ketoacidosis: Induction by the consumption of synthetic cannabinoids?

We present a case study on a man who suffered from diabetic ketoacidosis, probably following consumption of synthetic cannabinoids. In blood from a femoral vein AB-CHMINACA, AB-FUBINACA, AM-2201, 5F-AMB, 5F-APINACA, EAM-2201, JWH-018, JWH-122, MAM-2201, STS135 and THJ 2201 could be detected by LC-MS/MS. Diagnosis of ketoacidosis as cause of death was carried out using biochemical measurements of glucose and lactate concentrations in vitreous humour (sum formula: 463 mg/dl) and cerebrospinal fluid (sum formula: 506 mg/dl), of acetone (163 mg/l in femoral venous blood) and of HbA1c (98 mmol/mol). Death due to hyperglycaemia could have been induced by skipping of insulin doses due to his intoxicated state or by the cannabinoids which were described to be able to produce hyperglycaemia themselves.

Traumatology of the superior thyroid horns in suicidal hanging--an injury analysis.

It appears still questionable whether fractures to the superior thyroid horns can be used for forensic reconstruction purposes regarding the functional mechanism causing compression of the neck soft tissues. Localisations and types of such fractures were documented in 118 cases of superior thyroid horn fractures caused by suicidal hanging. The placement of the ligature was above the larynx in 109 cases and in the remaining nine cases across the thyroid cartilage. As a secondary parameter the degree of ossification of thyroid cartilages and superior horns was used. Bone densities of typical cases (equidensities) were measured radiologically. Additionally, dummy tests were performed focused on two extreme shapes of superior thyroid horns to assess stress peaks using resin dummies and polarised light. Such peaks were located in the lower thirds of the horns close to their bases. With the larynx still cartilaginous, the base appears a typical location for fractures caused by suicidal hanging. An ossification pattern defined as "type 1" showed broad and osseous superior thyroid horns. If ossification was homogenous, fractures were located at the sites of maximum mechanical stress. In case of inhomogenous ossification, being the more common mode, the horn bases were more resistant to pressure and bending so that no fractures occurred. They were instead located at the sites of the greatest differences in density and distributed in an apparent random pattern. Narrow and deep insertions of the superior thyroid horns at the back surface of the upper thirds of the thyroid cartilages (posterior aspects) were classified as "type 2" ossification. Upon flexion, the long horns came into contact with the upper edges of the dorsal aspect creating a torque. Further flexion from an increasing impact by the ligature extended the long lever arm causing the base of the upper thyroid horn being broadly torn out of the dorsal aspect. The results suggest that localisations of fractures to the superior thyroid horns in connection with ossification patterns may be helpful for the reconstruction in suicidal hanging regarding the mechanics of the ligature in relation to its position around the neck.

The evidential value of intra-alveolar haemosiderin-macrophages in cases of sudden infant death syndrome (SIDS).

Intra-alveolar deposits of haemosiderin have repeatedly been brought into connection with some diagnostic value, such as markers for previous imposed suffocation, smothering due to Munchausen syndrome by proxy or sudden infant death syndrome (SIDS). This study is based on 104 SIDS cases and 14 controls (causes of death, e.g. inflammatory changes, internal haemorrhages, asphyxia, blunt force trauma or acute toxicity). The SIDS group comprised 44 females (aged 7 days to 12 months) and 60 males (aged 12 days to 16 months 8 days) with the ages of the controls ranging from 2 months 3 days to 47 months. Routine histology samples from the lungs were stained with Prussian blue and haemosiderin foci were counted in 20 hpf for each lung lobe by a pathologist blinded to the cause of death. Results were assigned to one of five categories for haemosiderin positivity. Data were analysed by the Levene-test revealing identical variances in both groups and with a two-sample t-test showing the mean values for haemosiderin counts not being significantly different between SIDS and control groups. Although the sizes of both samples differed considerably it is our opinion that the haemosiderin counts did not show sufficient diagnostic value. This outcome supports the latest results of other comparable investigations. Furthermore, it highlights the necessity to assess carefully positive haemosiderin findings to avoid false suspicion.

Kinking of a coronary artery as a rare complication in mitral valve replacement.

We present the case of a 70-year old woman who had elective mitral and aortic valve surgery. She underwent surgery without complications for about 4h until 4 pm. Approx. 3h after surgery her condition deteriorated. 1500ml of blood were collected in the chest drainage until 11 pm. An emergency thoracotomy in the patient's bed showed a ventricular rupture. Death occurred around 11:30 pm. At autopsy, the implants of the biological mitral and aortic valves were found to be sewn tightly. There was no vascular injury and no unusual bleedings to the mediastinum. In the left ventricular wall, a rupture of 1cm and a surrounding fresh myocardial infarction area of 10cm×6cm was noted. Preparation of the coronary arteries showed moderate coronary atherossclerosis without stenosis or clots. The left circumflex coronary artery (LCX) showed a sharp, obviously stenosing kink which had been caused by the mitral valve surgery. Exsanguination due to ventricular rupture following myocardial infarction caused by implant-related "kinking" of a coronary artery, was found to be the cause of death.

The mobile Condylus tertius occipitalis and fractures of the hypochordal clasp.

The Condylus tertius is defined as a small bony hunch on the anterior surface of the clivus. Its presence means an enormous functional impairment of the upper head joint, looking at the 3-point-contact between the skull base and the upper cervical vertebrae. In 10 of the 2000 forensic examined bodies, analyses of neck vertebra + skull base revealed this feature. The origin of these findings is discussed, as stated in the literature of embryology, to be a suboccipital hypochordal plate. So in one of the cases the condylus was found at the hypochordal plate itself whereas the so-called socket was lying at the margin of the clivus. In three cases there was found a free body between the apex of the Dens and the Clivus forming a mobile Condylus tertius. In our opinion its position varies over the anterior arch of the atlas and the apex of the dens as a result of rotatory forces between the atlas and axis and physiological strain. Examples are given to elucidate this. There is a difference in the differentiation of the deposited material according to functional demand. A pressure bed (i.e. a Condylus tertius) is formed when a bony structure is deposited on the clivus. This functional prospect relativises the hypothesis of a purely constitutional genesis of the Condylus tertius. A fracture of the hypochordal clasp being joined with a bony connection to the anterior atlantic arch is described for the first time.

Care of relatives following sudden infant death.

This paper deals with 301 families who have been offered a consultation for managing bereavement following sudden infant death. Eighty-eight percent of the parents (269 families) accepted and 36 more families out with Lower Saxony wished to be cared for. Without a previous autopsy 1.172 contacts happened from 1989 to 2003 comprising primary crisis intervention and long-term care, the latter including saying farewell before and after autopsy. One main aim was a close linking with the international self-help organization of parents (GEPS). Single cases conferences were carried out for more than five years according to the Sheffield model. There is given the methodical basis and many details of the care project.

Some medicolegally important aspects of symphyseal injuries due to trauma.

A total of 58 cases of fatal trauma (forensic autopsies) were investigated for lesions of the pelvic girdle, the pubic symphysis, and for injuries distant from the pelvis. Traumata of the pubic symphysis were present in 30% (n = 17) of the cases. The symphyses were examined by x-ray and macroscopically related to the main violence (Abbreviated Injury Scale [AIS]). A correlation between the latter and the severity of the resulting injuries could be deducted. Characteristic patterns of symphyseal injuries included small hemorrhages, partial and complete ruptures, and also ruptures of the ligamentary insertions, which have not yet been described. The kind and severity of these lesions related to the intensity/direction of the violence are demonstrated and discussed.

Fatal aviation accidents in Lower Saxony from 1979 to 1996.

So far no national or regional studies have been published in Germany regarding the number of fatal aviation accidents and results of autopsy findings. Therefore, we evaluated all fatal aviation accidents occurring in Lower Saxony from 1979 to 1996. A total of 96 aviation accidents occurred in this period involving 73 aeroplanes. The crashes resulted in the death of 154 people ranging in age from 19 to 68 years. The greatest number of victims in a single crash of an aircraft was (n=7). Other types of fatal accidents were crashes of aircraft and helicopter while on the ground (n=5), hot-air balloons (n=2), parachutes (n=10), hang glider accidents (n=5) and the striking of a bystander by a model airplane. Autopsies were performed on 68 of the 154 victims (44.2%), including 39 of the 73 pilots (53.4%). Some of the autopsies yielded findings relevant to the cause of the accident: gunshot wounds, the presence of alcohol or drugs in blood and preexisting diseases. Our findings emphasize the need for autopsy on all aviation accident victims, especially pilots, as this is the only reliable method to uncover all factors contributing to an accident.

On the diagnosis of hypoglycemia in car drivers--including a review of the literature.

Hypoglycemia may reach forensic relevance concerning the psychophysical ability of running a car and with respect to a possible imputability. Our retrospective study included anamnesis and clinical symptoms observed in drivers with impaired performance to point out correlations between biochemical parameters and the actual course of the disease and its sequelae on roadworthiness. Clinical-biochemical estimations were performed on glucose, lactic acid and ethanol including a toxicological screening. It is proposed to utilize the estimation of glucose and lactic acid (the so-called combined value) in blood samples taken on behalf of the police as an important hint to the actual state of glucose metabolism. The anamnesis and the symptomatology may complete the biochemical analyses.

The shaking trauma in infants - kinetic chains.

The findings in three children who died as a consequence of shaking and those in another child who survived are presented. In the three fatal cases, a combination of anatomical lesions were identified at autopsy which appear to indicate the sites where kinetic energy related to the shaking episodes had been applied thus enabling the sequence of events resulting in the fatal head injury to be elucidated. Such patterns of injuries involved the upper limb, the shoulder, the brachial nerve plexus and the muscles close to the scapula; hemorrhages were present at the insertions of the sternocleidomastoid muscles due to hyperextension trauma (the so-called periosteal sign) and in the transition zone between the cervical and thoracic spine and extradural hematomas. Characteristic lesions due to traction were also found in the legs. All three children with lethal shaking trauma died from a subdural hematoma only a few hours after the event. The surviving child had persistant hypoxic damage of the brain following on massive cerebral edema. All the children showed a discrepancy between the lack of identifiable external lesions and severe internal ones.

On the contamination of ambient air by preparations carried out with a band-saw.

The aim was to evaluate contamination by bone-dust and formaldehyde when using a band-saw for preparations of the base of the skull and the cervical vertebral spine (stationary band-saw, 1400 upm, saw blade with 160 saw teeth/m; distances 19-26 cm, time intervals 55-90 s). The asservation of bone particles was done with adhesive microscopic slides and calcium-specific staining by alizarin-red. The quantification of air contamination was carried out with micrometry and a particle-counter. Dräger-tubes 0.2/9 were utilized for estimation of formaldehyde. The band-saw did not produce high amounts of bone-dust with suspension power. Nevertheless, 75% of the particles ranged below 5 microns in size and were respirable. Contamination decreased with an increasing height above the floor. A massive flow of particles was observed during the first minutes of sawing. The bone-dust spread some metres away. The formaldehyde levels ranged throughout between 0.5 and also over 5 ppm (MAK = 0.5 ppm). This fact makes clear an intensive contamination of the air. Therefore, a ventilation directed to the floor is necessary when a band-saw is used, as well as breathing masks and safety-goggles.

[Phenomenology of ether administration. With a review of the literature]. / Zur Phänomenologie bei Etherapplikation. Mit einer Literaturübersicht.

A 45-year-old man was found dead lying on a sofa in his house. He had pulled a plastic bag over his head, the bag containing a pad of cotton-wool soaked with diethylether. Different aspects are discussed in this paper including a review of the literature: anamnesis, scene of death, utensils used for inhalation and autopsy findings. There are especially pointed out the results of chemical-toxicological analyses in many body compartments. Furthermore are interpreted the manners and the relations of the distribution of ether as well as possible effects on the consciousness. In consideration of other published cases, the analytical results concerning ether are discussed with regard to the presumed cause of death (e.g. asphyxia) and other potential competitive mechanisms.

[Sawdust in autopsies: production, spreading, and contamination]. / Knochenstäube bei der Autopsie. Entstehung, Ausbreitung, Kontamination.

Airborne infections are well known in clinical medicine (transport of bacteria by aerosols). During autopsies floating, respirable kinds of bone dust are produced, depending on the type of saw. Experiments were carried out with oscillating saws (without/with exhauster) and manual saws (autopsy of cranial cavity). The intention was to characterize and quantify the sawdust produced by the different saws. Furthermore, we wanted to find out whether bacteria are transported by these aerosols. Bone dust was collected with adhesive microscopic slides. Alizarin red was used for solid histochemistry of bone particles. Quantification was carried out by an eyepiece micrometer. Airborne particles and bacteria were identified macroscopically per unit of time. The oscillating saw without exhauster produced sawdust in large quantities. This dust was respirable and had suspension power for hours. There was a remarkable reduction of sawdust by an integrated exhauster. Spreading of particles carrying bacteria/saccharomycetes was seen over 6-8 m. There is a very low risk of an airborne infection when utilizing a manual saw (production of particles similar to chippings, absence of suspended sawdust). It is necessary to take every precaution against airborne infections by wearing breathing masks and safety goggles when using an oscillating saw.

Clinical and morphological aspects of death due to liquid nitrogen.

A 24-year-old student died while filling flasks with liquid nitrogen. The arms, legs and back were frozen and the face, ears and neck showed a dark red and livid colour with horizontal lines of demarcation. In the electrocardiogram, the heart showed asystolia followed by wide ventricular complexes. The patient was intubated orally as the situs of the larynx and pharynx showed no pathology findings. Cardiopulmonary resuscitation was carried out and terminated after 90 min. Unfortunately, the body temperature was not measured. The gas analysis of venous blood showed metabolic acidosis and oxygen deficiency. The student had worked alone with nitrogen, without opening the windows and without a working ventilation system. While filling the third flask he lost consciousness. As nitrogen does not cause characteristic prodromal signs he laid on the floor and was unable to help himself. The liquid nitrogen which was still escaping spread over the floor and vaporized. The student died from asphyxia due to oxygen deficiency in an atmosphere of nitrogen.

[Heavy metal incorporation as an unusual self-injury]. / Schwermetall-Inkorporation als ungewöhnliche Selbst(be)schädigung.

A 19-year-old man was admitted to hospital because of uncharacteristic neurologic symptoms. During the first examination morphologic alterations due to an injection of mercury into the left arm and the left side of the trunk were found. The dose and the manner of application were doubtful and suspected to be a case of self-infliction. The man informed the police only 7 months later because his relatives had finally persuaded him to do so. The description of the infliction by unknown perpetrators was full of contradictions. Initially the patient gave only an indistinct description. But later on, the number of details increased. At the same time there was a change in the characteristics of the perpetrator(s). Other differences existed concerning a loss of consciousness which should have been caused by a single stroke on an arm. Furthermore, the patient told about a swelling as big as an egg, provoked by an injection of liquid mercury. It could be shown by experiments that mercury can be injected into soft-tissue very simply and that it spreaded widely. Arguments for a self-injection were e.g. the technical possibility, the topography of the injection marks, and an easy handling of the syringe. A psychiatric examination furthermore revealed, that the patient had had periods of restriction of thinking, sometimes combined with a lack of appreciation.

On the phenomenology of lethal applications of insulin.

This study deals with the postmortem findings in cases of lethal hypoglycaemia due to injections of insulin. In 12 cases (four female; eight male; mean age 42 years) the following aspects were evaluated retrospectively: circumstances of life, scene of death, pathomorphological findings and postmortem biochemistry on cerebrospinal fluid, vitreous humour, blood, and urine (levels of glucose, lactate, hemoglobin A1C and insulin). Furthermore, analyses of ethanol in blood and urine as well as toxicological and histological examinations were performed. Unexpectedly, the dead persons rarely represented diabetics, relatives of diabetics, or medical personnel. It is concluded, that the diagnosis of fatal hypoglycaemia can only be established by a synopsis of postmortem biochemistry, pathomorphological alterations and anamnesis. Besides, this diagnosis must always be made "per exclusionem".