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Forensic pathology: Answers
Current Diagnostic Pathology (2001) 7, 150d151 ^ 2001 Harcourt Publishers Ltd doi:10.1054/cdip.2001.0067, available online at http://www.idealibrary.com on
SELF-ASSESSMENT
Forensic pathology Answers Answer 1 The photograph shows ‘pinpoint haemorrhages’ (petechial haemorrhages) in the skin around the eye and in the ‘linings of the eyelids’ (tarsal conjunctivae). These are caused by rupture of superficial vessels within the skin due to raised venous pressure; it has been said that hypoxia of the vessel wall may be a cause but this is unsubstantiated.1 They may be seen in any circumstances where there is obstruction of the return of blood from the head to the heart, for example, pressure on the neck from whatever cause or pressure applied to chest or abdomen (‘traumatic asphyxia’).2 They are seen also in individuals who are found in a ‘head-down’ position (‘positional asphyxia’)1 and after cardio-pulmonary resuscitation3 ethey are, in fact, a ‘non-specific finding’. The finding of petechiae mandates careful inspection of the body with particular attention to the neck and chest and in-situ dissection of the neck structures by the pathologist to allow proper demonstration of possible injury to those structures and to avoid the artefact described by Prinsloo and Gordon.4
Answer 2 The photograph shows what might be described as a ‘scab’ but which raises the possibilityegiven its location in the groin (and the place where the body was found)ethat this represents an ‘injection site’ and may cover a ‘sinus’ to the femoral vein: these appearances raise the suspicion of intravenous drug abuse. Where any puncture wound is found on a body, questions should be directed towards the ‘drug-taking habits’ of the deceased and towards the presence of any ‘drug paraphernalia’ at the scene or in the immediate vicinity of the body. In the context of possible attempted resuscitation, those who attempted the resuscitation should be asked specific questions about their attempts at intravenous access. It is advisable for the general histopathologist to bear in mind that a charge of manslaughter might arise in the circumstances of a ‘drugrelated death’eeven where the deceased injected him or herself:5 if that possibility exists it is appropriate to
request that the post-mortem examination be carried out by an accredited forensic pathologist. Whoever performs the post-mortem examination, that examination should be regarded as a ‘high risk’ procedure and the appropriate protocol6 should be followed. Serious consideration should be given to problems raised by ‘post-mortem testing’ to determine whether there is a risk of ‘serious communicable disease’ ebe they practical problems of test validity7 or ethical problems regarding ‘routine testing’.8 Our personal view is that testing is not necessary: it should be assumed that the risk of infection exists. It should be remembered that there is a duty under Health and Safety legislation to make others who may handle the body aware of the existence of a risk of infection: we feel it is appropriate to give advice on the handling of the body after post-mortem examination9 but not to name the possible infective agent.
Answer 3 The photograph shows the ‘plume of oedema fluid’ which may be seen in deaths associated with opioid use,10 typically heroin-related deaths. Samples of blood should be taken from each external iliac or femoral veineafter ‘tying off’ the vessel to ensure that the sample is of peripheral venous blood11 efor toxicological analysis; samples of urine, vitreous humour, bile, stomach content and terminal small bowel content should be taken also, to allow such questions as route and timing of administration to be addressed.12 The precise explanation for heroin-related deaths remains uncertain: attention has been drawn to the possibility of anaphylaxiseit is appropriate to centrifuge and freeze a serum sample for analysis for mast cell tryptase.13 The interpretation of the significance of the concentration of a drug in a sample of blood taken at post-mortem examination is fraught with difficulties:14 the question of ‘tolerance’ may be approached by toxicological analysis of hair.15 Such hair should be either plucked from the scalp or cut as close to the scalp as possible: whatever the method, whichever is the ‘root end’ must be indicated. Axillary or pubic hair may be sampled if it is not possible to obtain head hair.16
FORENSIC PATHOLOGY
ACKNOWLEDGEMENTS Photographs 1 and 2 are used with permission of the Chief Constables of the respective police forces involved. Photograph 3 was provided by Dr Andrew Davison.
REFERENCES 1. Knight B. Petechial haemorrhages. In: Forensic Pathology. London: Arnold, 1996: 347}349. 2. Fred H L, Chandler F W. Traumatic asphyxia. Am J Med 1960; 29: 508}517. 3. Hood I, Ryan D, Spitz W U. Resuscitation and petechiae. Am J Forensic Med Pathol 1988; 9: 35}37. 4. Prinsloo I, Gordon I. Postmortem dissection artefacts of the neck and their differentiation from antemortem bruises. S Afr Med J 1951; 25: 358}361. 5. R v William Steffan Edwards. [1998] C App Criminal Division 97/7744/Z5. 6. Health Services Advisory Committee. Safety in health service laboratories: safe working and the prevention of infection in the mortuary and the post-mortem room. London: HMSO, 1991. 7. Advisory Committee on the Microbiological Safety of Blood and Tissues for Transplantation. Guidance on the microbiological safety of human organs, tissues and cells used in transplantation. London: Department of Health, 2000. 8. General Medical Council. Serious communicable diseases. London: GMC, 1997.
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9. Healing T D, Hoffman P N, Young S E J. The infection hazards of human cadavers. CDR Review 1995; 5: R61}R65. 10. Siegel H, Helpern M, Ehrenreich T. The diagnosis of death from intravenous narcotism with emphasis on the pathologic aspects. J Forensic Sci 1966; 11: 1}16. 11. Pounder D J, Jones G R. Post-mortem drug redistribution e a toxicological nightmare. Forensic Sci Int 1990; 45: 253}263. 12. Forrest A R. Obtaining samples at post mortem examination for toxicological and biochemical analyses. J Clin Pathol 1993; 46: 292}296. 13. Edston E, van Hage-Hamsten M. Anaphylactoid shockea common cause of death in heroin addicts? Allergy 1997; 52: 950}954. 14. Spiehler V R. Computer-assisted interpretation in forensic toxicology: morphine-involved deaths. J Forensic Sci 1989; 34: 1104}1115. 15. Tagliaro F, de Battisti Z, Smith F P, Marigo M. Death from heroin overdose: findings from hair analysis. Lancet 1998; 351: 1923}1925. 16. Mangin P, Kintz P. Variability of opiates concentrations in human hair according to their anatomical origin: head, axillary and pubic regions. Forensic Sci Int 1993; 63: 77}83.
The self-assessment was compiled by: S. Leadbeatter and D. Cook, Wales Institute of Forensic Medicine, University of Wales College of Medicine, Cardiff CF14 4XN Wales
SELF-ASSESSMENT
Forensic pathology Answers Answer 1 The photograph shows ‘pinpoint haemorrhages’ (petechial haemorrhages) in the skin around the eye and in the ‘linings of the eyelids’ (tarsal conjunctivae). These are caused by rupture of superficial vessels within the skin due to raised venous pressure; it has been said that hypoxia of the vessel wall may be a cause but this is unsubstantiated.1 They may be seen in any circumstances where there is obstruction of the return of blood from the head to the heart, for example, pressure on the neck from whatever cause or pressure applied to chest or abdomen (‘traumatic asphyxia’).2 They are seen also in individuals who are found in a ‘head-down’ position (‘positional asphyxia’)1 and after cardio-pulmonary resuscitation3 ethey are, in fact, a ‘non-specific finding’. The finding of petechiae mandates careful inspection of the body with particular attention to the neck and chest and in-situ dissection of the neck structures by the pathologist to allow proper demonstration of possible injury to those structures and to avoid the artefact described by Prinsloo and Gordon.4
Answer 2 The photograph shows what might be described as a ‘scab’ but which raises the possibilityegiven its location in the groin (and the place where the body was found)ethat this represents an ‘injection site’ and may cover a ‘sinus’ to the femoral vein: these appearances raise the suspicion of intravenous drug abuse. Where any puncture wound is found on a body, questions should be directed towards the ‘drug-taking habits’ of the deceased and towards the presence of any ‘drug paraphernalia’ at the scene or in the immediate vicinity of the body. In the context of possible attempted resuscitation, those who attempted the resuscitation should be asked specific questions about their attempts at intravenous access. It is advisable for the general histopathologist to bear in mind that a charge of manslaughter might arise in the circumstances of a ‘drugrelated death’eeven where the deceased injected him or herself:5 if that possibility exists it is appropriate to
request that the post-mortem examination be carried out by an accredited forensic pathologist. Whoever performs the post-mortem examination, that examination should be regarded as a ‘high risk’ procedure and the appropriate protocol6 should be followed. Serious consideration should be given to problems raised by ‘post-mortem testing’ to determine whether there is a risk of ‘serious communicable disease’ ebe they practical problems of test validity7 or ethical problems regarding ‘routine testing’.8 Our personal view is that testing is not necessary: it should be assumed that the risk of infection exists. It should be remembered that there is a duty under Health and Safety legislation to make others who may handle the body aware of the existence of a risk of infection: we feel it is appropriate to give advice on the handling of the body after post-mortem examination9 but not to name the possible infective agent.
Answer 3 The photograph shows the ‘plume of oedema fluid’ which may be seen in deaths associated with opioid use,10 typically heroin-related deaths. Samples of blood should be taken from each external iliac or femoral veineafter ‘tying off’ the vessel to ensure that the sample is of peripheral venous blood11 efor toxicological analysis; samples of urine, vitreous humour, bile, stomach content and terminal small bowel content should be taken also, to allow such questions as route and timing of administration to be addressed.12 The precise explanation for heroin-related deaths remains uncertain: attention has been drawn to the possibility of anaphylaxiseit is appropriate to centrifuge and freeze a serum sample for analysis for mast cell tryptase.13 The interpretation of the significance of the concentration of a drug in a sample of blood taken at post-mortem examination is fraught with difficulties:14 the question of ‘tolerance’ may be approached by toxicological analysis of hair.15 Such hair should be either plucked from the scalp or cut as close to the scalp as possible: whatever the method, whichever is the ‘root end’ must be indicated. Axillary or pubic hair may be sampled if it is not possible to obtain head hair.16
FORENSIC PATHOLOGY
ACKNOWLEDGEMENTS Photographs 1 and 2 are used with permission of the Chief Constables of the respective police forces involved. Photograph 3 was provided by Dr Andrew Davison.
REFERENCES 1. Knight B. Petechial haemorrhages. In: Forensic Pathology. London: Arnold, 1996: 347}349. 2. Fred H L, Chandler F W. Traumatic asphyxia. Am J Med 1960; 29: 508}517. 3. Hood I, Ryan D, Spitz W U. Resuscitation and petechiae. Am J Forensic Med Pathol 1988; 9: 35}37. 4. Prinsloo I, Gordon I. Postmortem dissection artefacts of the neck and their differentiation from antemortem bruises. S Afr Med J 1951; 25: 358}361. 5. R v William Steffan Edwards. [1998] C App Criminal Division 97/7744/Z5. 6. Health Services Advisory Committee. Safety in health service laboratories: safe working and the prevention of infection in the mortuary and the post-mortem room. London: HMSO, 1991. 7. Advisory Committee on the Microbiological Safety of Blood and Tissues for Transplantation. Guidance on the microbiological safety of human organs, tissues and cells used in transplantation. London: Department of Health, 2000. 8. General Medical Council. Serious communicable diseases. London: GMC, 1997.
151
9. Healing T D, Hoffman P N, Young S E J. The infection hazards of human cadavers. CDR Review 1995; 5: R61}R65. 10. Siegel H, Helpern M, Ehrenreich T. The diagnosis of death from intravenous narcotism with emphasis on the pathologic aspects. J Forensic Sci 1966; 11: 1}16. 11. Pounder D J, Jones G R. Post-mortem drug redistribution e a toxicological nightmare. Forensic Sci Int 1990; 45: 253}263. 12. Forrest A R. Obtaining samples at post mortem examination for toxicological and biochemical analyses. J Clin Pathol 1993; 46: 292}296. 13. Edston E, van Hage-Hamsten M. Anaphylactoid shockea common cause of death in heroin addicts? Allergy 1997; 52: 950}954. 14. Spiehler V R. Computer-assisted interpretation in forensic toxicology: morphine-involved deaths. J Forensic Sci 1989; 34: 1104}1115. 15. Tagliaro F, de Battisti Z, Smith F P, Marigo M. Death from heroin overdose: findings from hair analysis. Lancet 1998; 351: 1923}1925. 16. Mangin P, Kintz P. Variability of opiates concentrations in human hair according to their anatomical origin: head, axillary and pubic regions. Forensic Sci Int 1993; 63: 77}83.
The self-assessment was compiled by: S. Leadbeatter and D. Cook, Wales Institute of Forensic Medicine, University of Wales College of Medicine, Cardiff CF14 4XN Wales