- Email: [email protected]
Uncertainty of determining mode of death in medicolegal material without autopsy — A systematic autopsy study
3
Forensic Science International, 15 (1980) 3 - 17 0 Elsevier Sequoia S.A., Lausanne - Printed in the Netherlands
UNCERTAINTY OF DETERMINING MODE OF DEATH IN MEDICOLEGAL MATERIAL WITHOUT AUTOPSY - A SYSTEMATIC AUTOPSY STUDY
S. ASNAES and F. PAASKE University Institute hagen (Denmark)
of Forensic
(Received May 21,1979;
Medicine,
Frederik
den
Femtes
Vej 11, DK-2100
Copen-
accepted June 25,1979)
Summary Systematic autopsy was performed in 807 medicolegal deaths where the police had not requested autopsy. In all cases both the cause of death and the mode of death had been reported at the medicolegal external examination. The autopsy revealed differences in the mode of death in about 4% of all cases. This was due in particular to the problems associated with distinguishing presumed natural deaths from accidents and suicide. The cases of “concealed” suicide were found in particular among the higher age groups. However, no characteristic relationship was found between the proportion of differing modes of death and the age groups. All cases of homicide were recognized at the medicolegal external examination. Malignant disease that had not been diagnosed previously was found in about 4% of the cases, the reason being the large proportion of elderly subjects in the material. Syphilitic aortitis that had not been previously diagnosed was demonstrated in about 1% of all cases, and pulmonary tuberculosis that had not been previously diagnosed was demonstrated in 0.7% of the cases. The conclusion is that the results provide no support for replacing the medicolegal autopsy by medicolegal external examination alone, but rather suggest that the proportion of medicolegal autopsies should be increased.
Introduction The annual number of deaths in Denmark during the last years has been about 50 000. Among these, the figure for medicolegal deaths (homicide, suicide, accident, found dead) has also been relatively constant, around 12%. Of these approximately 6000 medicolegal deaths, an average of about 20% came to autopsy, although this figure varies considerably from one region to another. All the autopsies were performed at the request of the police in accordance with the law. In Copenhagen the autopsy rate has been relatively constant around 25% for several years. 4 number of retrospective studies [ 1 - 81 have shown that the cause and mode of death as reported without autopsy would have been in error in about 25% and lo%, respectively, of the cases. However, these studies were all made on deaths which under normal circumstances would have come to autopsy. Such studies, therefore, cannot provide reliable
4
figures for the proportion of deaths not coming to autopsy. In a preliminary study from the municipality of Copenhagen, systematic autopsy carried out in such cases has shown modes of death reported in error in about 3-4s of the cases [ 91. As far as we are aware, no other systematic autopsy studies of this kind have been made, i.e. systematic autopsy of a group of medicolegal deaths normally not coming to autopsy. Both from a legal and a statistical point of view it must be regarded as important to obtain detailed information of those changes in mode (and cause) of death occurring when deaths not normally autopsied are systematically subjected to autopsy. The aim of the present study was to elucidate this problem, as well as to throw light on some other information obtained from autopsy.
Material and methods Of 127vonsecutive medicolegal deaths in the municipality of Copenhagen during one year, the police requested an autopsy in 436 cases. In all other cases the death certificate was issued on the basis of the medicolegal external examination alone, at which both the cause and mode of death were determined. All medicolegal external examinations were carried out by experienced pathologists at the Institute of Forensic Medicine. Following the medicolegal external examination, systematic autopsy was carried out in 836 of these deaths, provided the relatives had not objected. In all cases, however, an analysis was made for alcohol, barbituric acid and meprobamate. The autopsy procedure, the quantitation of the autopsy findings, the demonstration of the presence of active tuberculosis and syphilis, and the microscopic investigations were all carried out as previously described [lo] . The basic principle in the study is the comparison between modes of death recorded at the medicolegal external examination and the findings subsequently demonstrated at autopsy.
Results Females There were 325 women (39%); 319 underwent autopsy (98%). Among 6 cases not autopsied (all over the age of 50 years) there was one suicide by barbiturate poisoning. The age distribution into lo-year age groups for those coming to autopsy is shown in Table 1. The total represented 7.4% of all women who died in the municipality of Copenhagen during the same period. In the age groups 20 - 29 years and 30 - 39 years the percentages were 28.0% and 19.6% respectively, while the age groups 0 - 9 years and over 80 years had lower representation, 3.0% and 4.1%, respectively. The proportion of the other age groups was about 10%; 88% were aged 50 years and over. Sixty-two per cent
5 TABLE 1 Women coming to systematic autopsy, by age in decades
Age
Number
0 -9
10 -19
20 -29
30-39
40 -49
50 -59
60 -69
70 -79
80-
Total
3
2
7
10
16
45
72
107
57
319
0.6
2.1
14.1
22.5
17.8
100
Percentage 0.9
3.1
of the deaths among single women women took place at home.
5.0
and 21% of the deaths
33.9
among married
Differences in mode of death The mode of death differed between medicolegal external examination and autopsy in 13 cases, i.e. 4.1% (Table 2). If the case is included where autopsy was not performed, there were 14 cases (4.3%). Most of the cases were among presumed natural death, There was no characteristic relationship between differences in mode of death and age group. Alterations in the classification: mode of death -natural
(1.2) (1.3)
Accident (1.2). In 4 cases natural death had been presumed. The first case was that of a 62-year-old widow who had been admitted to hospital on several occasions for cerebral haemorrhage. She was found dead in bed. It was assumed that the cause of death was a spontaneous cerebral haemorrhage. Autopsy showed no external signs of violence to face or cranium. In the occipital region, a small haematoma was found in the scalp. Subdurally there was a fresh haematoma measuring 250 ml. The brain tissue showed no contusions and no vascular malformations. In the other 3 cases, the cause of death had been recorded as coronary sclerosis. The second case was that of a 7%yearold pensioner with heart disease, who was found dead at home. At autopsy a small contusion wound was found on the scalp which had also been observed at the medicolegal external examination. Subdurally there was a fresh haematoma measuring 150 ml, and below this a small subarachnoid haemorrhage. The third case was that of a 93-year-old woman with heart disease who was found dead at home. At autopsy no sign of violence to face or cranium was found. In the occipital region there was a fresh subdural haematoma, measuring 100 ml. The brain was normal. The fourth case was that of a 76-year-old woman who had had pronounced arteriosclerosis. She was found dead at home. At autopsy a large bolus of jam was found blocking the entrance to the larynx with total occlusion of the air passage. There was neither alcohol nor drugs in the blood. It was characteristic of all 4 cases that the deceased were of an age at which the first thought was of natural death, even when death occurred suddenly and unexpectedly. As detailed information was also available of any diseases there was no doubt at the medicolegal external examination that these were cases of natural death. Suicide (1.3). Among the presumed natural deaths 7 suicides were found. In 5 of these cases heart disease was reported in detail, in one case severe renal disease, and in one case a bronchogenic carcinoma was reported. Six of these 7 cases showed lethal concentrations of barbiturate in the blood, while in the last case everything pointed to drug poisoning, although the drug employed could not be demonstrated by the standard investigations used (there were numerous remains
6 TABLE 2 Women coming to systematic autopsy, classified by mode of death as found at medicolegal external examination and at autopsy Medicolegal external examination
Autopsy
1. Natural
-223
1. Natural
2. Accidental
Total 2. Accidental
3. Suicide
4. Homicide
5. Unknown
4
7
234
17
2
19
3. Suicide
-65
4. Homicide
65 -1
1
1
319
5. Unknown Total
223
21
74
of tablets in the stomach). In none of the cases did the medicolegal external examination reveal any pressure marks. In most of the cases there were tablet remains in the stomach. A common feature was that nothing suggesting suicide was found at the police investigation, nor were any supplementary investigations requested at the time of the medicolegal external examination.
Alteration in the classification: mode of death accident (2.3) Suicide (2.3). In 2 cases where accident was presumed, autopsy showed suicide. The one case concerned a 71-year-old woman who was found lying dead on the floor of her bedroom. One gas tap was open in the kitchen, but no pots had been put on the stove. No attempts had been made to seal windows and doors, and there was no farewell letter. The gas tap was an older model with a wing-screw without a safety arrangement. The death was recorded as carbon monoxide poisoning due to accident. After autopsy, a high but not lethal concentration of barbiturate was found in the blood, and the carbon monoxide concentration was 54%. The other case was that of a 79-year-old woman, always in good health, who was found dead in an armchair in her home. Both gas taps in the kitchen were open. There was no farewell letter and no efforts to seal doors and windows. A kettle of water stood over one gas burner, but this was not lit. It was stated that the deceased had previously opened the gas taps and forgotten to light them. The death was recorded as carbon monoxide poisoning as the result of an accident. Autopsy revealed the remains of tablets in the stomach and a high concentration of barbiturate in the blood. The carbon monoxide saturation was 56%. Both were cases of elderly women without actual disease. Nothing was reported about depressive illness. Both were found under circumstances where everything pointed to accident. The barbiturate concentrations found, however, were regarded as resulting from deliberate intake of tablets with the aim of suicide.
No differences in mode of death (2.2) (3.3) (4.4) (1 .l) Accident (2.2). In 17 cases of accident there was full agreement between the result at medicolegal external examination and at autopsy (Table 2). In all cases the information regarding the circumstances of the death was clear. The autopsies revealed no findings which went against this assumption. Cases of carbon monoxide poisoning predominated; 11 out of 12 cases had occurred
7
under circumstances where a gas tap had not been properly closed, while one case was the result of burning to death due to carelessness with fire. In all cases the carbon monoxide concentration had been measured at the medicolegal external examination. The other causes of death were drowning, falls and strangulation in cot-belts. Suicide (3.3). In 65 cases obvious suicide was found at both medicolegal external examination and autopsy. The majority of cases were found in the higher age groups, corresponding to the age distribution of the material. The number of correctly reported suicides amounted to a total of 20.4% of the systematically autopsied women. In 40 of the 65 cases information was available that the deceased had been suffering from depression or mental disease. In many of the cases the forensic chemistry investigations had already been carried out at the time of the medicolegal external examination. In most of the cases of drug poisoning the remains of tablets were found. Pressure marks were recorded in only 6 cases and exclusively in the group with barbiturate poisoning (23 cases) or carbon monoxide poisoning (21 cases). Where suicide was due to hanging (8 cases) there was fracture of the larynx in 3 cases. The other methods of committing suicide were taking hydrochloric acid (1 case), poisoning with Doriden (1 case), leaping from a height (5 cases), drowning (2 cases), throwing themselves in front of a train (2 cases), shooting themselves through the head (1 case). Homicide (4.4). One homicide, a mother who had taken her child with her into death (drug poisoning), was correctly recorded at the medicolegal external examination. Natural death (1 .l). The 223 cases of natural death were confirmed at autopsy (Table 2). This group will be reported in detail in a separate paper
[Ill * Males There were 511 males (61%), 488 came to autopsy (95.5%). Among the 23 cases not autopsied 20 (87%) were over the age of 50 years. Among them 2 suicides from barbiturate poisoning were found. The age distribution into lo-year age groups is shown in Table 3. The total represented 10.6% of all male deaths in the municipality of Copenhagen during the same period. In the age groups 20 - 29 years, 30 - 39 years and 40 - 49 years, the proportion of men coming to systematic autopsy was particularly high (25.5, 19.2 and 22.9%, respectively), while the age groups 0 - 9 years and over 80 years had a lower representation (1.8% and 7.3%, respectively). The proportion of the other age groups is about 12%; 83.4% were aged 50 years or over. Of the deaths among single men 52.1% took place at home, but only 16.3% of the deaths among married men.
8 TABLE 3 Men coming to systematic autopsy, by age in decades
Number Percentage
O-9
lo-19
20-29
30-39
40-49
50-59
60-69
70-79
80-
Total
3
2
13
14
49
95
142
105
65
488
10.0
19.5
13.3
100
0.6
0.4
2.7
2.9
29.1
21.5
Differences in mode of death The mode of death differed between medicolegal external examination and autopsy in 14 cases, i.e. 2.9% (Table 4). If the 2 cases of suicide by barbiturate poisoning among those not autopsied are included, there were 16 cases where mode of death differed (3.1%). Most of these cases were among those where a natural mode of death had been presumed. Most of the cases were in the higher age groups, but there was no characteristic relationship between differences in mode of death and age group. Alterations in the classification: mode of death -natural
(1.2) (1.3)
Accident (1.2). In 4 cases a natural death had been presumed (Table 4). The first case was that of a 79-year-old man who was found dead in his bath dressed in an undervest, with no water in the bath. It appeared that he had probably been wasbing clothes. He was found face down in the bottom of the bath as if he had fallen forward while working. At the medicolegal external examination death was presumed to have occurred from heart disease. At autopsy a rupture of the intervertebral disc was found between cervical vertebrae 3 and 4, with pulmonary changes associated with drowning. The second case was a 76-year-old man found dead lying on the kitchen floor with his head up against a shelf. The situation suggested that the deceased had been washing himself. It is reported that he had a heart condition, At the medicolegal external examination it was assumed that death was due to heart disease. Autopsy revealed a subdural haematoma measuring 200 ml of fresh blood above and at the back of the left hemisphere. There was moderate coronary sclerosis. The third case was an 81-year-old man who was found lying lifeless on a stair landing. Under his face there was a small pool of blood and a small amount of vomit. The deceased’s upper denture lay beside him. At autopsy a traumatic wound was found on the brow. Obstructive masses of stomach contents were found in the trachea. There was severe coronary sclerosis and a not quite fresh thrombus a few mm in size was found in the ramus descendens which in no way occluded the lumen. At the medicolegal external examination it was assumed that the cause of death was heart disease. After the autopsy it was concluded that this was a case of accident with aspiration after a fall on the stairs. The fourth case was that of a 62-year-old man with known liver cirrhosis and heart disease, who was found dead in bed at home. The cause of death was assumed to be cirrhosis of the liver. Autopsy showed a traumatic wound at the nape of the neck and a fresh subdural haematoma, 150 ml in size, together with contusions of the brain. The traumatic wound had not been observed at the medicolegal external examination. After the autopsy, the mode of death had to be regarded as accidental, and the cause of death the subdural haematoma. The case shows that there is need for care in accepting even small lesions as only insignificant fall lesions. It was also characteristic that all four cases
9
TABLE
4
Men coming to systematic autopsy, classified by mode of death as found at medicolegal external examination and at autopsy Total
Medicolegal external examination
Autopsy
1. Natural
322
4
8
334
1
-24
1
26
126
126
2. Accidental
1. Natural
2. Accidental
3. Suicide
3. Suicide
4. Homicide
4. Homicide
5. Unknown
-2
2
5. Unknown Total
323
28
135
2
488
were of an age where the first obvious thought is of natural death, even when death occurs suddenly and unexpectedly. Suicide (1.3). Among the presumed natural deaths, there were 8 cases where the mode of death had to be altered to suicide, following autopsy and associated investigations. In all cases there was detailed information of heart disease, and this cause of death was reported at the medicolegal external examination. Autopsy showed lethal doses of drugs (7 cases of barbiturate poisoning and 1 case of meprobamate poisoning). None of the cases showed pressure marks. In 5 cases the stomach contained the remains of tablets. In all cases the deceased were of an age at which natural death is not at first sight unexpected. No special somatic disease was found. The group as a whole provides no indications or evidence for detecting hidden suicide at a medicolegal external examination alone. In all these cases, however, the autopsy had not been necessary to clarify the cause of death, which was elucidated in all of them as a result of the chemical analysis.
Alteration in the classification: mode of death accident (2.3) (2.1) Suicide (2.3). One case of presumed accident was a 38-year-old divorced windowdresser with fatty degeneration of the liver and “varicosities in the oesophagus”. The day before his death he was seen intoxicated at his address. The next day he was found dead on the floor. Three empty tubes of tablets (allypropymal) were found on a shelf. It was concluded at the medicolegal external examination that this was probably an accident, the result of a combined poisoning from alcohol and barbituric acid, but no forensic chemistry studies were made. Autopsy revealed the remains of tablets in the stomach and 0.14%0 alcohol in the urine. The blood contained 112 mg of barbituric acid per litre. It was concluded that death was due to barbituric acid poisoning in combination with alcohol, but the massive ingestion of tablets was interpreted as due to suicidal intent. Natural death (2.1). A 66-year-old unmarried old-age pensioner, who avoided other people and was addicted to alcohol, was found lying dead on his back on the floor. Beside him were 24 empty beer bottles and 6 empty wine bottles. At the medicolegal external examination plentiful amounts of vomit were found in both nostrils and on the face. It was assumed that there had been aspiration of the contents of the stomach to the respiratory tract in connection with alcoholic intoxication, and the mode of death was characterized as accidental. At autopsy a fresh thrombosis was found in the left coronary
10 artery and a completely fresh infarction in the anterior wall. There was 0.73%0 alcohol in the blood and no aspiration.
No differences in mode of death (2.2) (3.3) (4.4) (1.1) The following cases showed full agreement between legal external examination and autopsy.
results at medico-
Accident (2.2). There were 24 cases of accident: carbon monoxide poisoning 10 cases, falls from heights 4 cases, explosion accidents 3 cases, run-over in traffic, crush lesions and falls 6 cases, alcoholic poisoning 1 case. At the medicolegal external examination there was no doubt as to cause and mode of death in any of the cases. The cases of carbon monoxide poisoning were due either to defective gas apparatus or to boiling-over of pots. The falls from heights were in particular accidents at work. In 3 cases the subjects were run over by a train. In one case of death due to alcohol poisoning the level of alcohol in the urine was 4X%0. Fifty per cent of the accidents had taken place at work. Suicide (3.3). The proportion of suicides is high (126), the reason being that it is relatively uncommon for obvious cases of suicide to come to legal autopsy. The majority of cases were in the higher age groups, corresponding to the age distribution of the material, but it also included a number of younger subjects. There were 54 cases of carbon monoxide poisoning, 31 cases of barbituric acid poisoning, 23 cases of hanging, 4 cases of leaping from a height, 4 cases of drowning, 4 cases of shooting, 3 other forms of poisoning, 1 case of external asphyxiation and 1 case of severing the ulnar artery. The well-characterized cases of suicide amounted to 25.8% of the systematically autopsied deaths among the men. In 73 cases there was a report of depression. In many cases chemistry studies had been carried out at the medicolegal external examination. In the majority of cases of poisoning by drugs, remains of tablets were found in the stomach, but pressure marks were only recorded in 3 cases. Where the method of suicide was hanging, there was fracture of the larynx in 12 cases. In 43 cases there was a report of alcoholism, and 28 of these showed a positive alcohol reaction in the blood. A total of 59 cases showed a positive alcohol reaction in the blood or urine. Homicide (4.4). Two homicides, mothers them into death (drug poisoning), presented record at the medicolegal external examination
who took their children with no grounds for altering the to that at autopsy.
Natural death (1 .l ). In 322 cases there was clear evidence at the medicolegal external examination that the mode of death was natural. This group will be reported in detail in a separate paper [ 1 l] .
11
Histological
investigations
Histological investigations were made in the case of 204 autopsies, i.e. 28.2%. An average of 3 tissue specimens were taken at each autopsy. In 81 of the autopsies the results of the histological investigations were mainly a confirmation of the macroscopic findings, compatible with the fact that the tissue specimens were often taken as a stage in an objective control of the autopsy findings. In the remaining autopsies the histological studies were made primarily with a view to a more detailed characterization of the various organ changes. Only in one case did the histological investigation have any direct significance for determining the cause of death (pulmonary tuberculosis). However, cultures were also made. Syphilis There was a total of 6 cases of syphilitic aortitis in women (1.9%) and 10 in males (2.0%). Of these, 4 cases (1.3%) and 5 cases (1.0%) respectively, had not been diagnosed previously. Of these 9 cases, 4 had a positive WR. Of the 7 cases which had been diagnosed previously only one had a positive WR. Among the cases of syphilis which had not been diagnosed previously, syphilis was the cause of death in 3 cases (spontaneous aortic rupture and stenosis of a coronary ostium). The age of these cases with syphilitic aortitis varied between 69 and 87 years. Tuberculosis No active tuberculosis was demonstrated among the women who came to systematic autopsy. Among the men a total of 8 cases had active tuberculosis, demonstrated by the presence of acid-fast rods as well as by culture. In 2 cases information was available that the deceased had previously had tuberculosis, and in one case the tuberculosis was also the cause of death, correctly recorded at the medicolegal external examination. Six cases (i.e. 1.2%) had not been diagnosed previously. In one of these cases the tuberculosis was the cause of death. A total of 13 tissue samples from the lungs were submitted to culture of tuberculosis. None of the patients with negative findings had been registered previously in the Danish Tuberculosis Index. The mean age for cases with active tuberculosis was 57 years (41- 82). Malignant
disease
Malignant disease was demonstrated in 50 cases (i.e. 6.9%); 16 malignant tumours had been diagnosed previously (mammae, stomach, prostate gland, Hodgkin’s disease, body of the uterus, lymphatic leukaemia, colon, lungs). In all cases there was information that the deceased had a malignant disease.
12
In one case, however, it was stated that the primary tumour could not be demonstrated, even after many hospitalizations. Autopsy revealed a mammary tumour and metastases to many organs. In 5 out of the 16 cases death was due to other than natural causes, 2 deaths were due to a different natural cause, while in 9 cases death had resulted from the malignant disease. A total of 34 cases (13 females and 21 males) of malignant tumour had not been diagnosed previously, i.e. 4.1% and 4.3%, respectively (see Tables 5 and 6). In none of these cases was there any information at the medicolegal external examination as to the presence of malignant disease, and none of the cases were recorded in the Cancer Register. A total of 11 had died TABLE 5 Distribution of 13 cases of malignant tumours not previously diagnosed, in 319 women according to woman’s age and histological type of tumour
Age
Number
Histological type
Number
(years) 60 - 69 70 - 79 80 -
Total
1 7 5
Adenocarcinoma ventriculi Hypernephroma Carcinoma planocellulare portionis uteri Carcinoma transitiocellulare vesicae urinariae Hepatoma Adenocarcinoma mammae Carcinoma folliculare glandulae thyroideae Adenocarcinoma pulmonis Adenocarcinoma coli Carcinoma planocellulare cutis
13
2 2 2 1 1 1 1 1 1 1 13
TABLE 6 Distribution of 21 cases of malignant tumours not previously diagnosed, in 488 men according to man’s age and histological type of tumour Age (years) 40 -49
50 60 70 80
- 59 - 69 - 79 -
Total
Number
1 3 3 5 9
21
Histological type
Number
Hypernephroma Bronchogenic carcinoma Pancreatic cardinoma Adenocarcinoma ventriculi Adenocarcinoma recti Prostatic carcinoma Hepatoma Pulmonary hemangiopericytoma 21
13
from the malignant natural causes. Cardiovascular
disease, 3 had committed
suicide and 20 died from other
changes
It was considered of interest, in those cases where death was due to ischaemic heart disease, to compare the changes in the coronary arteries and myocardium with the changes found where death was due to other natural causes or was violent. Purely valvular diseases are thereby excluded from the deaths due to cardiac ischaemia. Unknown causes are excluded from other natural deaths. Violent deaths where the heart was too damaged were also excluded together with all cases of severe decomposition. As a basis for the comparison, it was considered important to record the healed infarctions as both a characteristic and easily identified lesion. Tables 7 and 8 show that there was a far greater proportion of severe coronary sclerosis and healed infarctions among those who died from ischaemic heart disease than among the other groups. However, if only cases of severe coronary sclerosis are compared, the incidence of healed infarctions appears to be the same, suggesting that if coronary sclerosis had developed to a certain degree, there is no significant difference in the proportion of healed infarctions between the various modes of death. In those few cases where deaths from heart disease showed only slight coronary sclerosis, coronary thrombosis was present. However, in a certain number of deaths due to causes other than natural, or due to other natural causes, the changes in the heart and coronary arteries were so considerable that if some other cause of death had not been obvious these changes might well have been accepted as the cause of death. The majority of cases of “cardiac deaths” occurred among men in the age group 60 - 69 years, while the largest figure among women was in age group 70 - 79 years.
Discussion During the period of the investigation, the medicolegal deaths amounted to 14.3% of the total number of deaths in the municipality of Copenhagen. The number of cases undergoing systematic autopsy amounted to 9.4% of all deaths, so that the police requested autopsy in less than half of the number of medicolegal deaths. The autopsy index (medicolegal autopsies in relation to all deaths) in Copenhagen during the period in question was 4.9%. The average age of those who underwent systematic autopsy was greater than in those for whom the police requested autopsy [lo], in good agreement with the observation that autopsy is often requested by the police when it is a case of death in a young subject, while there is a tendency to regard death as natural in a subject reaching a high age, which is why autopsies are rarely requested in such cases. The systematic autopsies showed that
14 TABLE
7
Degree of coronary sclerosis in 140 female deaths from ischaemic with 73 deaths from other natural causes and 76 violent deaths Degree of severity of coronary sclerosis
Natural deaths Heart disease
Other natural causes
Coronary sclerosis
Coronary sclerosis
’ None Slight Moderate Severe
9 49 82
Total
TABLE
140
Healed infsrction
heart disease compared
Deaths other than natural
Healed infarction
Coronary sclerosis
1 17 58
1 28 33 11
4 5 3
4 47 22 3
76
73
12
76
Total
Healed infarction
Coronary sclerosis
Healed infarction
2 2
5 a4 104 96
5 24 63
4
289
92
8
Degree of coronary sclerosis in 224 male deaths from ischaemic with 97 deaths from other natural causes and 121 violent deaths Degree of severity of coronary sclerosis
Natural deaths Heart disease
Other natural causes
Coronary sclerosis
Coronary sclerosis
Healed infarction
Healed infarction
heart
Deaths other than natural
Coronary sclerosis
disease
compared
Total
Healed infarction
Coronary sclerosis
Healed infraction
None Slight Moderate Severe
1 11 88 124
2 56 101
5 39 40 13
3 10 6
17 59 37 8
1 12 6
23 109 165 145
6 78 113
Total
224
159
97
19
121
19
442
197
death was due to natural causes in 70.0% of the women and 66.2% of the men. Suicide was the cause of death in 23.2% of the women and 27.7% of the men. It thus appears that both natural death and suicide have a higher representation among the cases coming to systematic autopsy than among corresponding medicolegal autopsies [lo] . In no case was the mode of death unclarified following autopsy. In no case was the mode of death reported as unknown at the medicolegal external examination. Nevertheless, differences in mode of death were found in 4.3% of the women and in 3.1% of the men. This was influenced in
15
particular by the difficulties in distinguishing presumed natural death from cases of accident and suicide. There were no cases of undetected homicide. It was characteristic of these cases where the mode of death differed that at the medicolegal external examination there had been no uncertainty in the report of the mode of death. All cases of “concealed” suicide appeared as natural death. These were often elderly subjects for whom there was adequate information regarding previous disease. No characteristic relationship was found between the proportion of differing modes of death and age groups. While nearly all cases of “concealed” suicide would have been recognized if systematic chemistry investigations had been carried out at the medicolegal external examination, autopsy was absolutely essential to establish cases of accident. In by far the greater number of cases, however, the mode of death was correctly reported. Among the suicides and accidents correctly recorded at the medicolegal external examination no differences in cause of death were found. This was in contrast to the findings among the medicolegally autopsied [lo] . The over-all reason for that is that no late sequelae after accidents were included in those systematically autopsied. In such cases the police automatically request autopsy. Among the cases of well-diagnosed homicide, the cause of death was also recognized at the medicolegal external examination. Syphilitic aortitis which had not been previously diagnosed was found in 1.3% of the women and 1.0% of the men. This is ten times more than the figures for the corresponding medicolegal autopsy material [lo] . Tuberculosis was not demonstrated in the women, while active pulmonary tuberculosis which had not been previously diagnosed was found in 1.2% of the men. Cases of pulmonary tuberculosis which had not been previously diagnosed were thus found altogether in 0.7% of the cases. This corresponds to the findings in hospital autopsy series [ 12, 131, but is more than ten times greater than the figure demonstrated in medicolegal autopsy material from Denmark [ 141. This may be because the systematically autopsied subjects were all older than is usually found in medicolegal autopsy series, and because the higher age, and in consequence a possibly greater morbidity, might have contributed to autopsy not having been performed in the first instance. On the other hand, our own corresponding medicolegal autopsy material showed an incidence of previously undiagnosed pulmonary tuberculosis which was of the same extent as in the present material studied. The accuracy of the system of registration may also be of significance. Malignant tumours which had not been previously diagnosed were found in 4.1% of the women and 4.3% of the men. The cases were almost exclusively in the higher age groups. If an age correction is made, so that the proportion of previously undiagnosed malignant tumours in each age group is adjusted to the age distribution for the corresponding cases coming to medicolegal autopsy [lo] , the expected frequency is 2.4% for the women and 2.0% for the men. These values correspond more or less to what others have found in medicolegal autopsy series [15]. The greater proportion of
16
previously undiagnosed malignant tumours is thus due to the fact that more of the deaths are in the older age groups. Bronchogenic carcinoma and hypernephroma in particular are undiagnosed. No brain tumours were found, which is in agreement with the results obtained by Huntington and Bakerfield [ 16, 171. This could be interpreted as signifying that the bizarre symptomatology of this type of tumour will often result in a demand for medicolegal autopsy. Comparing the degree of coronary sclerosis between the two sexes, it was found that provided the coronary sclerosis was severe there was no difference in the proportion of healed infarctions in men and women for all age groups and’ all modes of death. A greater incidence of healed infarctions was found among cases of cardiac death than among the other natural deaths. If a comparison is made between cases with moderate coronary sclerosis exclusively, more healed infarctions were found among men than among women, in agreement with the results in other studies [18]. For example, Morris and Crawford [18] found an increased incidence of healed infarctions in subjects engaging in hard physical work, which may in fact be assumed to take place among men. The highest proportion of cardiac deaths among women was found in the age group 70 - 79 years, while most cardiac deaths among men were found in the age group 60 - 69 years. However, among the non-cardiac deaths, there was in many cases a considerable degree of coronary sclerosis. This might well in itself have explained the death, if another cause of death had not been obvious. This demonstrates the importance of a careful autopsy investigation, with a view to excluding all forms of death from violent causes, even in cases where the cardiac changes are pronounced. The results of the study provide no support for replacing medicolegal autopsy by medicolegal external examination alone, but indicate that the proportion of autopsies should be increased.
Acknowledgement Many thanks to Professor
P. C. Matthiessen
for statistical
advice.
References 1 H. 0. Swartout and R. G. Webster, To what degree are mortality statistics dependable? Am. J. Public Health, 30 (1940) 811. 2 I. Wallgren, Obduktionsfyndet och de kliniska diagnoserna. Nord. Med., 26 (1945) 1311. 3 N. Schulz and W. Schaarschmidt, Zur Relation zwischen klinischen und pathologischanatomischen Diagnosen in der Todesursachenstatistik. Zentralbl. Gesamte Hyg., 16 (1970) 928.
17 4 A. Otterland and E. Pihl, Klinisk, patologisk-anatomisk och officiell dodsorsaksdiagnostik med utgangspunkt fran 321 obduktionsfall. Ltikartidningen, 61 (1968) 68. 5 W. Munck, Autopsy finding and clinical diagnosis. A comparative study of 1000 cases. Acta Med. Stand. Suppl., 226 (1952) 775. 6 L. Justin-Besancon, J. Chretien and P. Dalavierre. Communication. Bilan de 1000 confrontations anatomo-cliniques recentes. Bull. Acad. Natl. Med. (Paris), 147 (1963) 330. 7 M. A. Heasman, Accuracy of death certification. Proc. R. Sot. Med., 8 M. Virrkunen, A Penttila, M. Tenhu, V. M. Huittinen, H. Lehti,
9
10 11 12 13
14 15 16 17
18
55 (1962)
733.
V. Rissanen and U. Uotila, Comparative studies on the underlying cause and mode of death established prior to and after medicolegal autopsy. Forensic Sci., 5 (1977) 73. F. Paaske, Medicolegal principles in the examination of dead bodies in Denmark and their value to the rule of law. Paper presented at the Fifth International Meeting of Forensic Sciences, Toronto, 1969. S. Asnaes and F. Paaske, The significance of medicolegal autopsy for determining mode and cause of death. Forensic Sci. Znt., 14 (1979) 23. S. Asnaes and F. Paaske, Uncertainty of determining cause of death in medicolegal material without autopsy. In preparation. F. Line11 and G. Ostberg, Tuberculosis in an autopsy material. Stand. J. Respir. Dis., 47 (1966) 200. T. Helms, H. C. Engbaek, W. Kiaer, B. Vergmann and E. Vibaek, Tuberculosis in a autopsy material. Ugeskr. Laeg., 129 (1967) 1673. A. Juul, Unrecognized active tuberculosis in a medicolegal autopsy material. Ugeskr. Laeg., 139 (1977) 940. G. K. Murphy, Cancer and the coroner. J. Am. Med. Assoc., 237 (1977) 786. R. W. Huntington and M. D. Bakersfield, Primary intracranial neoplasma in a medicolegal autopsy service. J. Forensic Sci., 2 (1957) 457. R. W. Huntington, K. L. Cummings, T. I. Moe, H. V. O’Connell and R. Wybel, Discovery of fatal primary intracranial neoplasma at medicolegal autopsies. Cancer, 18 (1965) 117. J. N. Morris and M. D. Crawford, Coronary heart disease and physical activity of work. Br. Med. J., II (1958) 1485.
Forensic Science International, 15 (1980) 3 - 17 0 Elsevier Sequoia S.A., Lausanne - Printed in the Netherlands
UNCERTAINTY OF DETERMINING MODE OF DEATH IN MEDICOLEGAL MATERIAL WITHOUT AUTOPSY - A SYSTEMATIC AUTOPSY STUDY
S. ASNAES and F. PAASKE University Institute hagen (Denmark)
of Forensic
(Received May 21,1979;
Medicine,
Frederik
den
Femtes
Vej 11, DK-2100
Copen-
accepted June 25,1979)
Summary Systematic autopsy was performed in 807 medicolegal deaths where the police had not requested autopsy. In all cases both the cause of death and the mode of death had been reported at the medicolegal external examination. The autopsy revealed differences in the mode of death in about 4% of all cases. This was due in particular to the problems associated with distinguishing presumed natural deaths from accidents and suicide. The cases of “concealed” suicide were found in particular among the higher age groups. However, no characteristic relationship was found between the proportion of differing modes of death and the age groups. All cases of homicide were recognized at the medicolegal external examination. Malignant disease that had not been diagnosed previously was found in about 4% of the cases, the reason being the large proportion of elderly subjects in the material. Syphilitic aortitis that had not been previously diagnosed was demonstrated in about 1% of all cases, and pulmonary tuberculosis that had not been previously diagnosed was demonstrated in 0.7% of the cases. The conclusion is that the results provide no support for replacing the medicolegal autopsy by medicolegal external examination alone, but rather suggest that the proportion of medicolegal autopsies should be increased.
Introduction The annual number of deaths in Denmark during the last years has been about 50 000. Among these, the figure for medicolegal deaths (homicide, suicide, accident, found dead) has also been relatively constant, around 12%. Of these approximately 6000 medicolegal deaths, an average of about 20% came to autopsy, although this figure varies considerably from one region to another. All the autopsies were performed at the request of the police in accordance with the law. In Copenhagen the autopsy rate has been relatively constant around 25% for several years. 4 number of retrospective studies [ 1 - 81 have shown that the cause and mode of death as reported without autopsy would have been in error in about 25% and lo%, respectively, of the cases. However, these studies were all made on deaths which under normal circumstances would have come to autopsy. Such studies, therefore, cannot provide reliable
4
figures for the proportion of deaths not coming to autopsy. In a preliminary study from the municipality of Copenhagen, systematic autopsy carried out in such cases has shown modes of death reported in error in about 3-4s of the cases [ 91. As far as we are aware, no other systematic autopsy studies of this kind have been made, i.e. systematic autopsy of a group of medicolegal deaths normally not coming to autopsy. Both from a legal and a statistical point of view it must be regarded as important to obtain detailed information of those changes in mode (and cause) of death occurring when deaths not normally autopsied are systematically subjected to autopsy. The aim of the present study was to elucidate this problem, as well as to throw light on some other information obtained from autopsy.
Material and methods Of 127vonsecutive medicolegal deaths in the municipality of Copenhagen during one year, the police requested an autopsy in 436 cases. In all other cases the death certificate was issued on the basis of the medicolegal external examination alone, at which both the cause and mode of death were determined. All medicolegal external examinations were carried out by experienced pathologists at the Institute of Forensic Medicine. Following the medicolegal external examination, systematic autopsy was carried out in 836 of these deaths, provided the relatives had not objected. In all cases, however, an analysis was made for alcohol, barbituric acid and meprobamate. The autopsy procedure, the quantitation of the autopsy findings, the demonstration of the presence of active tuberculosis and syphilis, and the microscopic investigations were all carried out as previously described [lo] . The basic principle in the study is the comparison between modes of death recorded at the medicolegal external examination and the findings subsequently demonstrated at autopsy.
Results Females There were 325 women (39%); 319 underwent autopsy (98%). Among 6 cases not autopsied (all over the age of 50 years) there was one suicide by barbiturate poisoning. The age distribution into lo-year age groups for those coming to autopsy is shown in Table 1. The total represented 7.4% of all women who died in the municipality of Copenhagen during the same period. In the age groups 20 - 29 years and 30 - 39 years the percentages were 28.0% and 19.6% respectively, while the age groups 0 - 9 years and over 80 years had lower representation, 3.0% and 4.1%, respectively. The proportion of the other age groups was about 10%; 88% were aged 50 years and over. Sixty-two per cent
5 TABLE 1 Women coming to systematic autopsy, by age in decades
Age
Number
0 -9
10 -19
20 -29
30-39
40 -49
50 -59
60 -69
70 -79
80-
Total
3
2
7
10
16
45
72
107
57
319
0.6
2.1
14.1
22.5
17.8
100
Percentage 0.9
3.1
of the deaths among single women women took place at home.
5.0
and 21% of the deaths
33.9
among married
Differences in mode of death The mode of death differed between medicolegal external examination and autopsy in 13 cases, i.e. 4.1% (Table 2). If the case is included where autopsy was not performed, there were 14 cases (4.3%). Most of the cases were among presumed natural death, There was no characteristic relationship between differences in mode of death and age group. Alterations in the classification: mode of death -natural
(1.2) (1.3)
Accident (1.2). In 4 cases natural death had been presumed. The first case was that of a 62-year-old widow who had been admitted to hospital on several occasions for cerebral haemorrhage. She was found dead in bed. It was assumed that the cause of death was a spontaneous cerebral haemorrhage. Autopsy showed no external signs of violence to face or cranium. In the occipital region, a small haematoma was found in the scalp. Subdurally there was a fresh haematoma measuring 250 ml. The brain tissue showed no contusions and no vascular malformations. In the other 3 cases, the cause of death had been recorded as coronary sclerosis. The second case was that of a 7%yearold pensioner with heart disease, who was found dead at home. At autopsy a small contusion wound was found on the scalp which had also been observed at the medicolegal external examination. Subdurally there was a fresh haematoma measuring 150 ml, and below this a small subarachnoid haemorrhage. The third case was that of a 93-year-old woman with heart disease who was found dead at home. At autopsy no sign of violence to face or cranium was found. In the occipital region there was a fresh subdural haematoma, measuring 100 ml. The brain was normal. The fourth case was that of a 76-year-old woman who had had pronounced arteriosclerosis. She was found dead at home. At autopsy a large bolus of jam was found blocking the entrance to the larynx with total occlusion of the air passage. There was neither alcohol nor drugs in the blood. It was characteristic of all 4 cases that the deceased were of an age at which the first thought was of natural death, even when death occurred suddenly and unexpectedly. As detailed information was also available of any diseases there was no doubt at the medicolegal external examination that these were cases of natural death. Suicide (1.3). Among the presumed natural deaths 7 suicides were found. In 5 of these cases heart disease was reported in detail, in one case severe renal disease, and in one case a bronchogenic carcinoma was reported. Six of these 7 cases showed lethal concentrations of barbiturate in the blood, while in the last case everything pointed to drug poisoning, although the drug employed could not be demonstrated by the standard investigations used (there were numerous remains
6 TABLE 2 Women coming to systematic autopsy, classified by mode of death as found at medicolegal external examination and at autopsy Medicolegal external examination
Autopsy
1. Natural
-223
1. Natural
2. Accidental
Total 2. Accidental
3. Suicide
4. Homicide
5. Unknown
4
7
234
17
2
19
3. Suicide
-65
4. Homicide
65 -1
1
1
319
5. Unknown Total
223
21
74
of tablets in the stomach). In none of the cases did the medicolegal external examination reveal any pressure marks. In most of the cases there were tablet remains in the stomach. A common feature was that nothing suggesting suicide was found at the police investigation, nor were any supplementary investigations requested at the time of the medicolegal external examination.
Alteration in the classification: mode of death accident (2.3) Suicide (2.3). In 2 cases where accident was presumed, autopsy showed suicide. The one case concerned a 71-year-old woman who was found lying dead on the floor of her bedroom. One gas tap was open in the kitchen, but no pots had been put on the stove. No attempts had been made to seal windows and doors, and there was no farewell letter. The gas tap was an older model with a wing-screw without a safety arrangement. The death was recorded as carbon monoxide poisoning due to accident. After autopsy, a high but not lethal concentration of barbiturate was found in the blood, and the carbon monoxide concentration was 54%. The other case was that of a 79-year-old woman, always in good health, who was found dead in an armchair in her home. Both gas taps in the kitchen were open. There was no farewell letter and no efforts to seal doors and windows. A kettle of water stood over one gas burner, but this was not lit. It was stated that the deceased had previously opened the gas taps and forgotten to light them. The death was recorded as carbon monoxide poisoning as the result of an accident. Autopsy revealed the remains of tablets in the stomach and a high concentration of barbiturate in the blood. The carbon monoxide saturation was 56%. Both were cases of elderly women without actual disease. Nothing was reported about depressive illness. Both were found under circumstances where everything pointed to accident. The barbiturate concentrations found, however, were regarded as resulting from deliberate intake of tablets with the aim of suicide.
No differences in mode of death (2.2) (3.3) (4.4) (1 .l) Accident (2.2). In 17 cases of accident there was full agreement between the result at medicolegal external examination and at autopsy (Table 2). In all cases the information regarding the circumstances of the death was clear. The autopsies revealed no findings which went against this assumption. Cases of carbon monoxide poisoning predominated; 11 out of 12 cases had occurred
7
under circumstances where a gas tap had not been properly closed, while one case was the result of burning to death due to carelessness with fire. In all cases the carbon monoxide concentration had been measured at the medicolegal external examination. The other causes of death were drowning, falls and strangulation in cot-belts. Suicide (3.3). In 65 cases obvious suicide was found at both medicolegal external examination and autopsy. The majority of cases were found in the higher age groups, corresponding to the age distribution of the material. The number of correctly reported suicides amounted to a total of 20.4% of the systematically autopsied women. In 40 of the 65 cases information was available that the deceased had been suffering from depression or mental disease. In many of the cases the forensic chemistry investigations had already been carried out at the time of the medicolegal external examination. In most of the cases of drug poisoning the remains of tablets were found. Pressure marks were recorded in only 6 cases and exclusively in the group with barbiturate poisoning (23 cases) or carbon monoxide poisoning (21 cases). Where suicide was due to hanging (8 cases) there was fracture of the larynx in 3 cases. The other methods of committing suicide were taking hydrochloric acid (1 case), poisoning with Doriden (1 case), leaping from a height (5 cases), drowning (2 cases), throwing themselves in front of a train (2 cases), shooting themselves through the head (1 case). Homicide (4.4). One homicide, a mother who had taken her child with her into death (drug poisoning), was correctly recorded at the medicolegal external examination. Natural death (1 .l). The 223 cases of natural death were confirmed at autopsy (Table 2). This group will be reported in detail in a separate paper
[Ill * Males There were 511 males (61%), 488 came to autopsy (95.5%). Among the 23 cases not autopsied 20 (87%) were over the age of 50 years. Among them 2 suicides from barbiturate poisoning were found. The age distribution into lo-year age groups is shown in Table 3. The total represented 10.6% of all male deaths in the municipality of Copenhagen during the same period. In the age groups 20 - 29 years, 30 - 39 years and 40 - 49 years, the proportion of men coming to systematic autopsy was particularly high (25.5, 19.2 and 22.9%, respectively), while the age groups 0 - 9 years and over 80 years had a lower representation (1.8% and 7.3%, respectively). The proportion of the other age groups is about 12%; 83.4% were aged 50 years or over. Of the deaths among single men 52.1% took place at home, but only 16.3% of the deaths among married men.
8 TABLE 3 Men coming to systematic autopsy, by age in decades
Number Percentage
O-9
lo-19
20-29
30-39
40-49
50-59
60-69
70-79
80-
Total
3
2
13
14
49
95
142
105
65
488
10.0
19.5
13.3
100
0.6
0.4
2.7
2.9
29.1
21.5
Differences in mode of death The mode of death differed between medicolegal external examination and autopsy in 14 cases, i.e. 2.9% (Table 4). If the 2 cases of suicide by barbiturate poisoning among those not autopsied are included, there were 16 cases where mode of death differed (3.1%). Most of these cases were among those where a natural mode of death had been presumed. Most of the cases were in the higher age groups, but there was no characteristic relationship between differences in mode of death and age group. Alterations in the classification: mode of death -natural
(1.2) (1.3)
Accident (1.2). In 4 cases a natural death had been presumed (Table 4). The first case was that of a 79-year-old man who was found dead in his bath dressed in an undervest, with no water in the bath. It appeared that he had probably been wasbing clothes. He was found face down in the bottom of the bath as if he had fallen forward while working. At the medicolegal external examination death was presumed to have occurred from heart disease. At autopsy a rupture of the intervertebral disc was found between cervical vertebrae 3 and 4, with pulmonary changes associated with drowning. The second case was a 76-year-old man found dead lying on the kitchen floor with his head up against a shelf. The situation suggested that the deceased had been washing himself. It is reported that he had a heart condition, At the medicolegal external examination it was assumed that death was due to heart disease. Autopsy revealed a subdural haematoma measuring 200 ml of fresh blood above and at the back of the left hemisphere. There was moderate coronary sclerosis. The third case was an 81-year-old man who was found lying lifeless on a stair landing. Under his face there was a small pool of blood and a small amount of vomit. The deceased’s upper denture lay beside him. At autopsy a traumatic wound was found on the brow. Obstructive masses of stomach contents were found in the trachea. There was severe coronary sclerosis and a not quite fresh thrombus a few mm in size was found in the ramus descendens which in no way occluded the lumen. At the medicolegal external examination it was assumed that the cause of death was heart disease. After the autopsy it was concluded that this was a case of accident with aspiration after a fall on the stairs. The fourth case was that of a 62-year-old man with known liver cirrhosis and heart disease, who was found dead in bed at home. The cause of death was assumed to be cirrhosis of the liver. Autopsy showed a traumatic wound at the nape of the neck and a fresh subdural haematoma, 150 ml in size, together with contusions of the brain. The traumatic wound had not been observed at the medicolegal external examination. After the autopsy, the mode of death had to be regarded as accidental, and the cause of death the subdural haematoma. The case shows that there is need for care in accepting even small lesions as only insignificant fall lesions. It was also characteristic that all four cases
9
TABLE
4
Men coming to systematic autopsy, classified by mode of death as found at medicolegal external examination and at autopsy Total
Medicolegal external examination
Autopsy
1. Natural
322
4
8
334
1
-24
1
26
126
126
2. Accidental
1. Natural
2. Accidental
3. Suicide
3. Suicide
4. Homicide
4. Homicide
5. Unknown
-2
2
5. Unknown Total
323
28
135
2
488
were of an age where the first obvious thought is of natural death, even when death occurs suddenly and unexpectedly. Suicide (1.3). Among the presumed natural deaths, there were 8 cases where the mode of death had to be altered to suicide, following autopsy and associated investigations. In all cases there was detailed information of heart disease, and this cause of death was reported at the medicolegal external examination. Autopsy showed lethal doses of drugs (7 cases of barbiturate poisoning and 1 case of meprobamate poisoning). None of the cases showed pressure marks. In 5 cases the stomach contained the remains of tablets. In all cases the deceased were of an age at which natural death is not at first sight unexpected. No special somatic disease was found. The group as a whole provides no indications or evidence for detecting hidden suicide at a medicolegal external examination alone. In all these cases, however, the autopsy had not been necessary to clarify the cause of death, which was elucidated in all of them as a result of the chemical analysis.
Alteration in the classification: mode of death accident (2.3) (2.1) Suicide (2.3). One case of presumed accident was a 38-year-old divorced windowdresser with fatty degeneration of the liver and “varicosities in the oesophagus”. The day before his death he was seen intoxicated at his address. The next day he was found dead on the floor. Three empty tubes of tablets (allypropymal) were found on a shelf. It was concluded at the medicolegal external examination that this was probably an accident, the result of a combined poisoning from alcohol and barbituric acid, but no forensic chemistry studies were made. Autopsy revealed the remains of tablets in the stomach and 0.14%0 alcohol in the urine. The blood contained 112 mg of barbituric acid per litre. It was concluded that death was due to barbituric acid poisoning in combination with alcohol, but the massive ingestion of tablets was interpreted as due to suicidal intent. Natural death (2.1). A 66-year-old unmarried old-age pensioner, who avoided other people and was addicted to alcohol, was found lying dead on his back on the floor. Beside him were 24 empty beer bottles and 6 empty wine bottles. At the medicolegal external examination plentiful amounts of vomit were found in both nostrils and on the face. It was assumed that there had been aspiration of the contents of the stomach to the respiratory tract in connection with alcoholic intoxication, and the mode of death was characterized as accidental. At autopsy a fresh thrombosis was found in the left coronary
10 artery and a completely fresh infarction in the anterior wall. There was 0.73%0 alcohol in the blood and no aspiration.
No differences in mode of death (2.2) (3.3) (4.4) (1.1) The following cases showed full agreement between legal external examination and autopsy.
results at medico-
Accident (2.2). There were 24 cases of accident: carbon monoxide poisoning 10 cases, falls from heights 4 cases, explosion accidents 3 cases, run-over in traffic, crush lesions and falls 6 cases, alcoholic poisoning 1 case. At the medicolegal external examination there was no doubt as to cause and mode of death in any of the cases. The cases of carbon monoxide poisoning were due either to defective gas apparatus or to boiling-over of pots. The falls from heights were in particular accidents at work. In 3 cases the subjects were run over by a train. In one case of death due to alcohol poisoning the level of alcohol in the urine was 4X%0. Fifty per cent of the accidents had taken place at work. Suicide (3.3). The proportion of suicides is high (126), the reason being that it is relatively uncommon for obvious cases of suicide to come to legal autopsy. The majority of cases were in the higher age groups, corresponding to the age distribution of the material, but it also included a number of younger subjects. There were 54 cases of carbon monoxide poisoning, 31 cases of barbituric acid poisoning, 23 cases of hanging, 4 cases of leaping from a height, 4 cases of drowning, 4 cases of shooting, 3 other forms of poisoning, 1 case of external asphyxiation and 1 case of severing the ulnar artery. The well-characterized cases of suicide amounted to 25.8% of the systematically autopsied deaths among the men. In 73 cases there was a report of depression. In many cases chemistry studies had been carried out at the medicolegal external examination. In the majority of cases of poisoning by drugs, remains of tablets were found in the stomach, but pressure marks were only recorded in 3 cases. Where the method of suicide was hanging, there was fracture of the larynx in 12 cases. In 43 cases there was a report of alcoholism, and 28 of these showed a positive alcohol reaction in the blood. A total of 59 cases showed a positive alcohol reaction in the blood or urine. Homicide (4.4). Two homicides, mothers them into death (drug poisoning), presented record at the medicolegal external examination
who took their children with no grounds for altering the to that at autopsy.
Natural death (1 .l ). In 322 cases there was clear evidence at the medicolegal external examination that the mode of death was natural. This group will be reported in detail in a separate paper [ 1 l] .
11
Histological
investigations
Histological investigations were made in the case of 204 autopsies, i.e. 28.2%. An average of 3 tissue specimens were taken at each autopsy. In 81 of the autopsies the results of the histological investigations were mainly a confirmation of the macroscopic findings, compatible with the fact that the tissue specimens were often taken as a stage in an objective control of the autopsy findings. In the remaining autopsies the histological studies were made primarily with a view to a more detailed characterization of the various organ changes. Only in one case did the histological investigation have any direct significance for determining the cause of death (pulmonary tuberculosis). However, cultures were also made. Syphilis There was a total of 6 cases of syphilitic aortitis in women (1.9%) and 10 in males (2.0%). Of these, 4 cases (1.3%) and 5 cases (1.0%) respectively, had not been diagnosed previously. Of these 9 cases, 4 had a positive WR. Of the 7 cases which had been diagnosed previously only one had a positive WR. Among the cases of syphilis which had not been diagnosed previously, syphilis was the cause of death in 3 cases (spontaneous aortic rupture and stenosis of a coronary ostium). The age of these cases with syphilitic aortitis varied between 69 and 87 years. Tuberculosis No active tuberculosis was demonstrated among the women who came to systematic autopsy. Among the men a total of 8 cases had active tuberculosis, demonstrated by the presence of acid-fast rods as well as by culture. In 2 cases information was available that the deceased had previously had tuberculosis, and in one case the tuberculosis was also the cause of death, correctly recorded at the medicolegal external examination. Six cases (i.e. 1.2%) had not been diagnosed previously. In one of these cases the tuberculosis was the cause of death. A total of 13 tissue samples from the lungs were submitted to culture of tuberculosis. None of the patients with negative findings had been registered previously in the Danish Tuberculosis Index. The mean age for cases with active tuberculosis was 57 years (41- 82). Malignant
disease
Malignant disease was demonstrated in 50 cases (i.e. 6.9%); 16 malignant tumours had been diagnosed previously (mammae, stomach, prostate gland, Hodgkin’s disease, body of the uterus, lymphatic leukaemia, colon, lungs). In all cases there was information that the deceased had a malignant disease.
12
In one case, however, it was stated that the primary tumour could not be demonstrated, even after many hospitalizations. Autopsy revealed a mammary tumour and metastases to many organs. In 5 out of the 16 cases death was due to other than natural causes, 2 deaths were due to a different natural cause, while in 9 cases death had resulted from the malignant disease. A total of 34 cases (13 females and 21 males) of malignant tumour had not been diagnosed previously, i.e. 4.1% and 4.3%, respectively (see Tables 5 and 6). In none of these cases was there any information at the medicolegal external examination as to the presence of malignant disease, and none of the cases were recorded in the Cancer Register. A total of 11 had died TABLE 5 Distribution of 13 cases of malignant tumours not previously diagnosed, in 319 women according to woman’s age and histological type of tumour
Age
Number
Histological type
Number
(years) 60 - 69 70 - 79 80 -
Total
1 7 5
Adenocarcinoma ventriculi Hypernephroma Carcinoma planocellulare portionis uteri Carcinoma transitiocellulare vesicae urinariae Hepatoma Adenocarcinoma mammae Carcinoma folliculare glandulae thyroideae Adenocarcinoma pulmonis Adenocarcinoma coli Carcinoma planocellulare cutis
13
2 2 2 1 1 1 1 1 1 1 13
TABLE 6 Distribution of 21 cases of malignant tumours not previously diagnosed, in 488 men according to man’s age and histological type of tumour Age (years) 40 -49
50 60 70 80
- 59 - 69 - 79 -
Total
Number
1 3 3 5 9
21
Histological type
Number
Hypernephroma Bronchogenic carcinoma Pancreatic cardinoma Adenocarcinoma ventriculi Adenocarcinoma recti Prostatic carcinoma Hepatoma Pulmonary hemangiopericytoma 21
13
from the malignant natural causes. Cardiovascular
disease, 3 had committed
suicide and 20 died from other
changes
It was considered of interest, in those cases where death was due to ischaemic heart disease, to compare the changes in the coronary arteries and myocardium with the changes found where death was due to other natural causes or was violent. Purely valvular diseases are thereby excluded from the deaths due to cardiac ischaemia. Unknown causes are excluded from other natural deaths. Violent deaths where the heart was too damaged were also excluded together with all cases of severe decomposition. As a basis for the comparison, it was considered important to record the healed infarctions as both a characteristic and easily identified lesion. Tables 7 and 8 show that there was a far greater proportion of severe coronary sclerosis and healed infarctions among those who died from ischaemic heart disease than among the other groups. However, if only cases of severe coronary sclerosis are compared, the incidence of healed infarctions appears to be the same, suggesting that if coronary sclerosis had developed to a certain degree, there is no significant difference in the proportion of healed infarctions between the various modes of death. In those few cases where deaths from heart disease showed only slight coronary sclerosis, coronary thrombosis was present. However, in a certain number of deaths due to causes other than natural, or due to other natural causes, the changes in the heart and coronary arteries were so considerable that if some other cause of death had not been obvious these changes might well have been accepted as the cause of death. The majority of cases of “cardiac deaths” occurred among men in the age group 60 - 69 years, while the largest figure among women was in age group 70 - 79 years.
Discussion During the period of the investigation, the medicolegal deaths amounted to 14.3% of the total number of deaths in the municipality of Copenhagen. The number of cases undergoing systematic autopsy amounted to 9.4% of all deaths, so that the police requested autopsy in less than half of the number of medicolegal deaths. The autopsy index (medicolegal autopsies in relation to all deaths) in Copenhagen during the period in question was 4.9%. The average age of those who underwent systematic autopsy was greater than in those for whom the police requested autopsy [lo], in good agreement with the observation that autopsy is often requested by the police when it is a case of death in a young subject, while there is a tendency to regard death as natural in a subject reaching a high age, which is why autopsies are rarely requested in such cases. The systematic autopsies showed that
14 TABLE
7
Degree of coronary sclerosis in 140 female deaths from ischaemic with 73 deaths from other natural causes and 76 violent deaths Degree of severity of coronary sclerosis
Natural deaths Heart disease
Other natural causes
Coronary sclerosis
Coronary sclerosis
’ None Slight Moderate Severe
9 49 82
Total
TABLE
140
Healed infsrction
heart disease compared
Deaths other than natural
Healed infarction
Coronary sclerosis
1 17 58
1 28 33 11
4 5 3
4 47 22 3
76
73
12
76
Total
Healed infarction
Coronary sclerosis
Healed infarction
2 2
5 a4 104 96
5 24 63
4
289
92
8
Degree of coronary sclerosis in 224 male deaths from ischaemic with 97 deaths from other natural causes and 121 violent deaths Degree of severity of coronary sclerosis
Natural deaths Heart disease
Other natural causes
Coronary sclerosis
Coronary sclerosis
Healed infarction
Healed infarction
heart
Deaths other than natural
Coronary sclerosis
disease
compared
Total
Healed infarction
Coronary sclerosis
Healed infraction
None Slight Moderate Severe
1 11 88 124
2 56 101
5 39 40 13
3 10 6
17 59 37 8
1 12 6
23 109 165 145
6 78 113
Total
224
159
97
19
121
19
442
197
death was due to natural causes in 70.0% of the women and 66.2% of the men. Suicide was the cause of death in 23.2% of the women and 27.7% of the men. It thus appears that both natural death and suicide have a higher representation among the cases coming to systematic autopsy than among corresponding medicolegal autopsies [lo] . In no case was the mode of death unclarified following autopsy. In no case was the mode of death reported as unknown at the medicolegal external examination. Nevertheless, differences in mode of death were found in 4.3% of the women and in 3.1% of the men. This was influenced in
15
particular by the difficulties in distinguishing presumed natural death from cases of accident and suicide. There were no cases of undetected homicide. It was characteristic of these cases where the mode of death differed that at the medicolegal external examination there had been no uncertainty in the report of the mode of death. All cases of “concealed” suicide appeared as natural death. These were often elderly subjects for whom there was adequate information regarding previous disease. No characteristic relationship was found between the proportion of differing modes of death and age groups. While nearly all cases of “concealed” suicide would have been recognized if systematic chemistry investigations had been carried out at the medicolegal external examination, autopsy was absolutely essential to establish cases of accident. In by far the greater number of cases, however, the mode of death was correctly reported. Among the suicides and accidents correctly recorded at the medicolegal external examination no differences in cause of death were found. This was in contrast to the findings among the medicolegally autopsied [lo] . The over-all reason for that is that no late sequelae after accidents were included in those systematically autopsied. In such cases the police automatically request autopsy. Among the cases of well-diagnosed homicide, the cause of death was also recognized at the medicolegal external examination. Syphilitic aortitis which had not been previously diagnosed was found in 1.3% of the women and 1.0% of the men. This is ten times more than the figures for the corresponding medicolegal autopsy material [lo] . Tuberculosis was not demonstrated in the women, while active pulmonary tuberculosis which had not been previously diagnosed was found in 1.2% of the men. Cases of pulmonary tuberculosis which had not been previously diagnosed were thus found altogether in 0.7% of the cases. This corresponds to the findings in hospital autopsy series [ 12, 131, but is more than ten times greater than the figure demonstrated in medicolegal autopsy material from Denmark [ 141. This may be because the systematically autopsied subjects were all older than is usually found in medicolegal autopsy series, and because the higher age, and in consequence a possibly greater morbidity, might have contributed to autopsy not having been performed in the first instance. On the other hand, our own corresponding medicolegal autopsy material showed an incidence of previously undiagnosed pulmonary tuberculosis which was of the same extent as in the present material studied. The accuracy of the system of registration may also be of significance. Malignant tumours which had not been previously diagnosed were found in 4.1% of the women and 4.3% of the men. The cases were almost exclusively in the higher age groups. If an age correction is made, so that the proportion of previously undiagnosed malignant tumours in each age group is adjusted to the age distribution for the corresponding cases coming to medicolegal autopsy [lo] , the expected frequency is 2.4% for the women and 2.0% for the men. These values correspond more or less to what others have found in medicolegal autopsy series [15]. The greater proportion of
16
previously undiagnosed malignant tumours is thus due to the fact that more of the deaths are in the older age groups. Bronchogenic carcinoma and hypernephroma in particular are undiagnosed. No brain tumours were found, which is in agreement with the results obtained by Huntington and Bakerfield [ 16, 171. This could be interpreted as signifying that the bizarre symptomatology of this type of tumour will often result in a demand for medicolegal autopsy. Comparing the degree of coronary sclerosis between the two sexes, it was found that provided the coronary sclerosis was severe there was no difference in the proportion of healed infarctions in men and women for all age groups and’ all modes of death. A greater incidence of healed infarctions was found among cases of cardiac death than among the other natural deaths. If a comparison is made between cases with moderate coronary sclerosis exclusively, more healed infarctions were found among men than among women, in agreement with the results in other studies [18]. For example, Morris and Crawford [18] found an increased incidence of healed infarctions in subjects engaging in hard physical work, which may in fact be assumed to take place among men. The highest proportion of cardiac deaths among women was found in the age group 70 - 79 years, while most cardiac deaths among men were found in the age group 60 - 69 years. However, among the non-cardiac deaths, there was in many cases a considerable degree of coronary sclerosis. This might well in itself have explained the death, if another cause of death had not been obvious. This demonstrates the importance of a careful autopsy investigation, with a view to excluding all forms of death from violent causes, even in cases where the cardiac changes are pronounced. The results of the study provide no support for replacing medicolegal autopsy by medicolegal external examination alone, but indicate that the proportion of autopsies should be increased.
Acknowledgement Many thanks to Professor
P. C. Matthiessen
for statistical
advice.
References 1 H. 0. Swartout and R. G. Webster, To what degree are mortality statistics dependable? Am. J. Public Health, 30 (1940) 811. 2 I. Wallgren, Obduktionsfyndet och de kliniska diagnoserna. Nord. Med., 26 (1945) 1311. 3 N. Schulz and W. Schaarschmidt, Zur Relation zwischen klinischen und pathologischanatomischen Diagnosen in der Todesursachenstatistik. Zentralbl. Gesamte Hyg., 16 (1970) 928.
17 4 A. Otterland and E. Pihl, Klinisk, patologisk-anatomisk och officiell dodsorsaksdiagnostik med utgangspunkt fran 321 obduktionsfall. Ltikartidningen, 61 (1968) 68. 5 W. Munck, Autopsy finding and clinical diagnosis. A comparative study of 1000 cases. Acta Med. Stand. Suppl., 226 (1952) 775. 6 L. Justin-Besancon, J. Chretien and P. Dalavierre. Communication. Bilan de 1000 confrontations anatomo-cliniques recentes. Bull. Acad. Natl. Med. (Paris), 147 (1963) 330. 7 M. A. Heasman, Accuracy of death certification. Proc. R. Sot. Med., 8 M. Virrkunen, A Penttila, M. Tenhu, V. M. Huittinen, H. Lehti,
9
10 11 12 13
14 15 16 17
18
55 (1962)
733.
V. Rissanen and U. Uotila, Comparative studies on the underlying cause and mode of death established prior to and after medicolegal autopsy. Forensic Sci., 5 (1977) 73. F. Paaske, Medicolegal principles in the examination of dead bodies in Denmark and their value to the rule of law. Paper presented at the Fifth International Meeting of Forensic Sciences, Toronto, 1969. S. Asnaes and F. Paaske, The significance of medicolegal autopsy for determining mode and cause of death. Forensic Sci. Znt., 14 (1979) 23. S. Asnaes and F. Paaske, Uncertainty of determining cause of death in medicolegal material without autopsy. In preparation. F. Line11 and G. Ostberg, Tuberculosis in an autopsy material. Stand. J. Respir. Dis., 47 (1966) 200. T. Helms, H. C. Engbaek, W. Kiaer, B. Vergmann and E. Vibaek, Tuberculosis in a autopsy material. Ugeskr. Laeg., 129 (1967) 1673. A. Juul, Unrecognized active tuberculosis in a medicolegal autopsy material. Ugeskr. Laeg., 139 (1977) 940. G. K. Murphy, Cancer and the coroner. J. Am. Med. Assoc., 237 (1977) 786. R. W. Huntington and M. D. Bakersfield, Primary intracranial neoplasma in a medicolegal autopsy service. J. Forensic Sci., 2 (1957) 457. R. W. Huntington, K. L. Cummings, T. I. Moe, H. V. O’Connell and R. Wybel, Discovery of fatal primary intracranial neoplasma at medicolegal autopsies. Cancer, 18 (1965) 117. J. N. Morris and M. D. Crawford, Coronary heart disease and physical activity of work. Br. Med. J., II (1958) 1485.