Table Of ContentPRINCIPLES OF FORENSIC PATHOLOGY
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PRINCIPLES OF
FORENSIC
PATHOLOGY
FROM INVESTIGATION TO
CERTIFICATION
Edited by
Susan F. Ely
James R. Gill
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Dr.CharlesS.Hirsch
In honor of the immeasurable value of timeless mentorship and in loving memory of Dr. Charles S. Hirsch.
We also dedicate this book to each of our spouses, Scott and Raffaella, and to our families, for their tireless
support and encouragement, not to mention their endless patience in enduring many late nights and cancelled
dinners throughout this long, but ultimately very rewarding process.
SFE and JRG
April, 2022
Watercolor byDr.Cricket Coleman
v
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Contents
List of contributors xi 3. The pathophysiology of death and death
In memoriam xiii certification
Biography xv
Biography xvii SUSANF.ELYANDJAMESR.GILL
Foreword xix
The pathophysiologyof death 31
Preface xxi
Death certification 36
Acknowledgments xxiii
Other death certificate fields andmiscellaneous
1. Forensic pathology: overview issues 55
Key death certification tips 60
SUSANF.ELYANDJAMESR.GILL
References 61
Introduction:who we are andourunique roleas
4. The scene investigation, postmortem
physicians 1
changes, and time of death
Historical perspective 2
Coroner versus medical examiner systems in the SUSANF.ELY,KELLYKEYES,ANDJAMESR.GILL
United States and abroad 3
The written narrative 65
What constitutes “medical examiner/coroner
Postmortem changesand establishing the basis for
jurisdiction”? 4
postmortemintervalestimates 81
The forensic autopsy 5
Timeofdeathversustimeofpronouncement:reports
Death certification 6
and testimony 86
Planningforacareerinforensic pathology:adviceto
The trauma scene 87
future trainees 7
Crime scenes and deaths inpublic view 88
References 8
Fieldchallengesintherecognitionandidentification
ofhuman skeletal remains 88
2. Thinking forensically: planning,
Attemptsat postmortemconcealment ofbodies in
anticipating, observing, documenting,
homicides (dismemberment, incineration,and
inquiring, synthesizing, opining, and
burial) 90
communicating, in that order
Mass fatality incidents(MFI) 91
SUSANF.ELYANDJAMESR.GILL Avoidingthe top10 investigative oversights 93
References 93
The importanceofcontext 11
Theroleofinference:releasingthegriponexclusively 5. The forensic autopsy
anatomic findings 12
SUSANF.ELYANDJAMESR.GILL
Objectivity, neutrality,and observational acumen:
being autoptic 13 The big picture 103
Anticipating, planning,observing, documenting, The forensicautopsy: general tips 104
inquiring, synthesizing, opining, and communi- Photography 104
cating, in that order 14 Radiography 105
Preautopsyanalysis and planning 15 Radiologictasksand tips 105
Anticipating questions andfuture issues 16 Evidence 106
Postautopsy analysis and planning 16 The standard external autopsy examination 108
Observing and documenting 17 The standard internal autopsy examination 108
Inquiring 20 Cardiovascular pathology 108
Interpreting andsynthesizing 21 Neuropathology 109
Opining 24 Forensic anthropology 110
Communicating 27 Toxicological sampling 110
References 28 Histology 111
vii
viii
Contents
Microbiology 111 Conclusion 155
Approach to the trauma autopsy 112 References 156
Special techniquesand examinations 113
7. Approach to natural deaths (adult)
The negative autopsy: the importance of whatwe
exclude 117 SUSANF.ELYANDJAMESR.GILL
Organ and tissue donation 118
Dissections and the funeral home 118 The sudden and unexpected death 166
Religiousobjections to autopsy 119 Specificforensic issues insudden cardiac death 172
Theforensicteam:investigators,technicians,clerical Pulmonary thromboembolism 174
staff 120 Seizure-related deathsand epilepsy 177
Quality assurance 121 Anaphylaxis 180
Safety inthe autopsy environment 121 Alcohol use disorder(formerly known as chronic
References 123 alcoholism) andchronicsubstance use disorder 181
Pancreatitis 184
6. Approach to forensic perinatal and Gastrointestinalhemorrhage (GIH) 184
pediatric pathology Bronchial asthma 186
Dementia and oldage 187
SUSANF.ELY,KRISTENLANDI,ANDJAMESR.GILL
Diabetes mellitus 188
Initialinvestigation 127 Obesity as a cause ofdeath 189
Primaryscene 128 Bronchopneumonia 189
Reenactment 129 Sudden death andchronic renal disease 189
Medical history 129 Sudden death from endocrine disorders 190
Radiology 129 Sudden death andpsychiatric disease 190
Photography 130 Sickle cell disease andtrait 191
The pediatric autopsy 130 Human immunodeficiency virus 191
External examination 130 References 192
Postmortem changesand artifacts 131
Evidenceof therapeutic intervention 132 8. Approach to medical intervention-
Clothing 132 related deaths
Injuries 132
SUSANF.ELYANDJAMESR.GILL
Internal examination 132
Histology 134 Therapeutic complications 203
Neuropathology 135 Deaths related tocosmetic, weight loss,and dental
Toxicology 135 procedures 207
Metabolic studies 135 Accidents and homicides inmedical settings 210
Microbiologic studies 135 References 211
Molecular genetics 136
Forensic odontology 136 9. Approach to firearms deaths
Forensic biology 136
SUSANF.ELYANDJAMESR.GILL
Forensic anthropology 136
Pediatric trauma 136 Deaths dueto trauma 215
Fatalchild abuse syndrome(aka, batteredchild Firearminjury 215
syndrome)andabusive head trauma 139 Graze and tangential gunshot wounds 218
Patterns ofinflictedinjury: infants versustoddlers/ Retractorartifact 219
preschoolers 142 Bullet “bookkeeping” 219
Asphyxia 143 Range offire 223
Bathtub drownings 143 Penetrating gunshot wounds 227
Thermal injuries 144 Mechanisms ofdeath infirearmsfatalities 228
Neglect 145 Mannersofdeath infirearmsfatalities:
Consultations 146 homicides, suicides, andaccidents 229
Child fatality review boards 146 Gunshotresidue testing (GSR) 230
Mandatory reporting 147 Rifles (rifled long guns) 230
Home births: stillbirth versus live birth 147 Shotguns 230
Approachtothelivebornversusstillborninfant/fetus Ballistics 231
and possible neonaticide 148 Conclusion 235
What is SUID, SIDS, SUDC,and SUDP? 151 References 235
ix
Contents
10. Approach to blunt, sharp, and Drug packers (“Mules”) 354
transportation deaths Suicide versus accident 354
The apparent drug intoxication death with negative
SUSANF.ELYANDJAMESR.GILL
toxicologyand no anatomic cause 357
Blunt injury 239 Legal implications ofmixed drug intoxications and
Sharp injury 258 other special toxicologic considerations 357
Chop injury 268 Miscellaneous toxicological issues 359
Transportation injury 270 Toxicological considerations in pediatric deaths 362
References 273 References 362
15. Special topics: in-custody deaths,
11. Approach to asphyxial deaths
physical altercations, neglect (adult),
SUSANF.ELYANDJAMESR.GILL approach to unexpected hemorrhage,
and delayed and concealed homicides
Asphyxia 279
Approach to potentialchokingdeaths 279 SUSANF.ELYANDJAMESR.GILL
Approach to lack ofenvironmental
Deaths in detention centers/correctional facilities/
oxygen 282
Approach to final exit (and similar) deaths 283 police custody 375
Approach to hangings 285 Deaths in the setting ofpolice restraint 376
Approach to potentialpositional asphyxia Hyperactive delirium (so-called “excited delirium”) 377
deaths 289 Suicidal behaviorin law enforcement encounters 380
Approach to asphyxia: homicides 290 The investigation 381
Police investigations and the medical examiner/
References 301
coroner 381
Physicalstruggles:contact,altercations,andthedeath
12. Approach to burns, blast, and radiation
certificate 382
injury
Abuse and/or neglect in the debilitated adult orteen 384
SUSANF.ELYANDJAMESR.GILL Approach tohemorrhage ofunclear origin
(unexpected hemorrhage found at autopsy) 386
Thermal andinhalational injury 307
Delayeddeathsdue toremote injury: issues and
Blast/radiation injury 314
concepts 394
Animal attacks, domestic and inthe wild 315
Approachtodismemberedremainsandotherformsof
References 316
postmortemconcealment 395
References 401
13. Approach to environmental deaths
16. Communication
SUSANF.ELYANDJAMESR.GILL
SUSANF.ELY,JAMESR.GILL,JONATHANHAYES,AND
Drowning 319 JONATHANLUCAS
Electricity 325
Environmental exposure: hyperthermia 328 Overview 413
Environmental exposure: hypothermia 329 Verbal: one-on-one communication 415
References 331 Testifying inlegal forums 422
High-profiledeaths,mediainquiries,andpressoffices 433
14. Approach to toxicological deaths Public speaking: case presentations,lectures, and
teaching 436
THOMASGILSON,DAVIDDOLINAK,SUSANF.ELY,AND
Writtencommunication 438
JAMESR.GILL
References 442
History andscene investigation 339
17. The forensic pathologist’s public
Autopsy examination 340
health role
Toxicology testing 344
Death certification 346 ERING.BROOKS
Examplesof drug intoxications 348
Natural disease inthe presence ofintoxicants 351 Introduction 445
Toxicology testing and trauma deaths 352 Passive surveillance 446
Toxicology testing followinghospitalization 353 Activesurveillance 447
Interpretingtoxicologytestresultsinthedecomposed Death review teams 448
body 353 Identification ofmissing and unidentifiedpersons 448
