J. Sperhake

Intersecting fractures of the skull and gunshot wounds. Case report and literature review

When two fracture lines of a solid surface (ice, glass, eggshell, etc.) intersect, it is always possible to tell which one has been made first. Indeed pre-existing damage of the surface arrests all the fracture lines produced by subsequent impacts. This well-known principle (established by Puppe in 1903) has been largely used in glass fracture analysis, but can be applied also to the examination of skull fractures. It can help sequencing blunt force or gunshot injuries determining the direction of fire and differentiating entrance from exit wounds in the absence of specific distinguishing features (i.e., internal/external beveling of the skull or overlying skin indicators). In this context, we report the case of a 76-year-old man who shot himself in the mouth with a Walther PPK 7.65 handgun and highlight the utility of the application of both Puppe’s Rule and Multislice Computed Tomography (MSCT) in the examination of gunshot wounds to the skull.

Bakterielle Meningitis als Ursache des plötzlichen Todes – Phänomenologie, Histomorphologie und Erregerspektrum

Unter den im Zeitraum von 1992–1999 am Institut für Rechtsmedizin der Universität Hamburg durchgeführten 8305 gerichtlichen und wissenschaftlichen Obduktionen fanden sich 20 Fälle (männliches Geschlecht n = 10, Durchschnittsalter 49,2 Jahre; weiblich n = 10, Durchschnittsalter 53,4 Jahre) erst autoptisch diagnostizierter bakterieller Meningitiden. Dies entspricht einer Häufigkeit von 0,23% im untersuchten Sektionsgut. In 8 Fällen befanden sich die Verstorbenen kurz vor dem Tode wegen unklarer Beschwerden in ärztlicher Behandlung, in 10 Fällen konnte der Verlauf retrospektiv als perakut eingeordnet werden. Erkrankte im Alter < 40 Jahre verstarben weit häufiger im Krankenhaus als Erkrankte des Alters > 60 Jahre, die überwiegend zu Hause verstarben. Erkrankte im Alter zwischen 40 und 60 Jahren zeigten signifikant häufiger Kopfschmerzen und Unwohlsein als initiale Symptome als Erkrankte mit einem Alter von < 40 Jahren und > 60 Jahren. Ein postmortaler Erregernachweis von Abstrichen der Leptomeninx gelang in 12 von 14 diesbezüglich untersuchten Fällen (Streptococcus pneumoniaen = 8; Neisseria meningitidis, Kapseltyp C n = 2; Staphylococcus aureusn = 1; Streptococcus pyogenesn = 1). Häufigste autoptisch festgestellte Begleiterkrankungen waren eitrige Tracheobronchitis, Pneumonie und eitrige Sinusitis, wobei eine definitive Feststellung der Eintrittspforte der Erreger am Autopsiematerial in der Regel nicht möglich ist. Histomorphologisch dominierte der Typ der Haubenmeningitis mit vorwiegend gemischtzelliger Entzündungsreaktion. Bei der forensischen Beurteilung von Meningitistodesfällen kann neben der Verkennung der Erkrankung vor dem Hintergrund evtl. unzureichender ärztlicher Diagnostik insbesondere der Prognose in Abhängigkeit vom Zeitpunkt der korrekten Diagnosestellung unter straf- und zivilrechtlichen Aspekten Bedeutung zukommen. Auch wirft die Anamnese eines vorausgegangenen Schädel-Hirn-Traumas aus rechtsmedizinischer Sicht Fragen hinsichtlich des Kausalzusammenhangs auf.Between 1992 and 1999, 20 cases of a previously undiagnosed meningitis (10 males, mean age 49.2 years; 10 females, mean age 53.4 years) out of a total of 8305 autopsies were identified, corresponding to a frequency of 0.23% in the reviewed autopsy material. In 8 cases, the deceased seeked medical advice shortly before death due to unspecific complaints. In 10 cases, a peracute course of the disease was considered retrospectively. Affected persons under 40 years of age frequently died in hospital whereas persons over 60 years of age died more often in their domestic environment. At the onset of symptoms, persons between 40 and 60 years of age complained of headaches and indisposition significantly more often than persons under 40 years or over 60 years of age. Postmortem swabs of the leptomeninx resulted in cultural growth of pathogenetic germs in 12 out of 14 cases examined (Streptococcus pneumoniaen = 8; Neisseria meningitidis (capsular type C) n = 2; Staphylococcus aureusn = 1; Streptococcus pyogenesn = 1). Most frequent concomitant diseases diagnosed at autopsy were acute tracheobronchitis, pneumonia and purulent sinusitis but in general a definitive identification of the entry site of bacteria is not possible postmortem. Histomorphologically, the predominant type was tegmental meningitis with a mixed polymorphonuclear cell infiltrate. In the forensic elucidation of fatalities due to meningitis, questions concerning medical malpractice can be raised (e. g. misdiagnosis, late diagnosis). In cases with preceding craniocerebral trauma, the forensic expert is confronted with the question of causality between trauma and death.

Sudden death due to cerebrotendinous xanthomatosis confirmed by mutation analysis

Abstract A case of sudden death of a 52-year-old mentally retarded Caucasian male is described where the rectal temperature was 43.4 °C 3 h postmortem. The autopsy revealed cerebrotendinous xanthomatosis (CTX), a rare hereditary metabolic disorder, as the primary disease. The diagnosis was confirmed by postmortem identification of two mutations (compound heterozygosity for R237X and IVS6+1G→A) in the sterol 27-hydroxylase (CYP27) gene. Both mutations have already been described in patients with CTX and can be considered the most likely cause of the disease. The pathomechanism of the excessive hyperthermia could not be completely elucidated.

Autopsy in undergraduate medical education--what do students really learn?

Forensic medicine can provide access to autopsies for students in undergraduate medical education. Previous qualitative studies reported that attending autopsies promotes learning and is helpful in organising information in the context of self-directed learning, covering cognitive, emotional and societal issues. In the present study, learning outcome regarding specific pathophysiological learning objectives of students who attended an autopsy elective (intervention group, n = 32) was estimated in comparison to peer students who signed up for the course but were not selected (control group A, n = 47) and students who had not signed up (control group B, n = 186). Learning outcome (expressed as a percent knowledge gain) was measured by means of comparative self-assessments (CSA). Furthermore, group interviews were conducted to evaluate the attending students’ perceptions and experiences of the course. In the intervention group, the percent knowledge gain for learning objectives reflecting pathophysiological mechanisms was about twice as high than that in the control groups, while all three groups showed comparable knowledge gain for learning objectives covered by mandatory courses that were held during the study period. Results of mandatory post-course assessments showed no statistically significant differences between the intervention and control groups. Therefore, the knowledge gain regarding learning objectives not covered by mandatory courses that was observed in the intervention group reflected the additional benefit of attending the autopsy course. Group interviews with the participants revealed gain of integrated knowledge and understanding of pathophysiological relations as important issues, while negative effects were reported infrequently. Our findings suggest that attendance of a series of autopsies fosters learning and understanding of important issues in medical education and should therefore be part of undergraduate medical curricula wherever possible.

Perimortem fixation of the gastric and duodenal mucosa: a diagnostic indication for oral poisoning

Abstract Two cases of fatal oral poisoning are presented. In the first case, a 40-year-old man died due to a lethal dose of mercury (blood concentration 113.8 μg/ml) and in the second, a 34-year-old man died of chloralhydrate overdose with a lethal blood concentration of trichloroethanol (52 μg/ml), the active metabolite of chloralhydrate. In both cases gross examination and histology showed an unusually well preserved gastrointestinal mucosa in addition to unspecific signs of intoxication. The two cases demonstrate that the phenomenon of perimortal fixation is a useful indication for the forensic pathologist and should direct the suspicion to oral poisoning. The detection of fixation facilitates toxicology screening by indicating that the relevant substance must have the capability to precipitate proteins.

Cao Gio – Kindesmisshandlung oder Heilbehandlung?

ZusammenfassungIn einer Schule fielen bei einem 7-jährigen vietnamesischen Jungen streifige Hautrötungen unklarer Herkunft auf, die den Verdacht zunächst auf eine Kindesmisshandlung lenkten. Die Untersuchung ergab, dass es sich um feine intrakutane Blutungen handelte, die durch eine spezielle asiatische Massage-Form, Cao Gio (vietnamesisch) oder Gua Sha (chinesisch), hervorgerufen wurden. In eigenen Untersuchungen wurde belegt, dass die Methode geeignet ist, gleichartige Hauterscheinungen hervorzurufen. Von einer Kindesmisshandlung war somit nicht auszugehen. Auf die besondere Gefahr der Fehlinterpretation soll hingewiesen werden.AbstractIn an elementary school it was noticed that a 7-year-old boy had reddish streaks on his skin which raised the suspicion of child abuse. Careful examination of the case revealed that the origin of the petechial bleeding was a special Asian massage technique, cao gio (Vietnamese) or gua sha (Chinese). Tests showed that the technique is capable of causing similar skin lesions, therefore there was no cause to suspect child abuse. Health professionals need to be aware of this phenomenon in order to avoid false diagnoses and accusations.

Das Fach Rechtsmedizin und die neue Approbationsordnung für Ärzte

ZusammenfassungDurch die Anforderungen der neuen Approbationsordnung für Ärzte und die damit verbundenen curricularen Reformen haben sich Konsequenzen für die praktische Ausgestaltung des Unterrichts und der Prüfungen im Fach Rechtsmedizin ergeben. Vor dem Hintergrund des in Hamburg gesamtcurricular eingeführten Begriffes der „allgemeinen Arztreife“ sowie den Gegebenheiten und praktischen Anforderungen der alltäglichen ärztlichen Praxis erfolgte eine drastische Reduktion der rechtsmedizinischen Unterrichtsinhalte und der zentralen Lernziele auf die Kernbereiche Leichenschau, Viktimologie und Toxikologie sowie eine methodische Neukonzeption der Unterrichtsveranstaltungen und Prüfungen.AbstractThrough the demands of the new national licence law for physicians and its associated curricular reforms, several consequences have resulted in the practical design of instruction and examinations within the subject of legal medicine. A drastic reduction has taken place regarding the contents of lectures in legal medicine and the main learning goals in the core areas of external examination, victimology and toxicology. A new, methodical concept concerning the lectures and examinations has also been considered. The main learning goals, the practical demands and the conditions in everyday medical practice were taken into consideration when planning the changes within the new curriculum in Hamburg.

Plötzlicher Tod aus endokriner Ursache

ZusammenfassungPlötzliche Todesfälle durch endokrine Krisen sind in der Rechtsmedizin selten. Es wird über zwei Todesfälle von Frauen berichtet, die im jungen bzw. mittleren Lebensalter unerwartet verstorben sind. Durch die histologischen und die immunhistochemischen Untersuchungen konnten die Verdachtsdiagnosen eines Morbus Addison und eines Sheehan-Syndroms mit sekundärer Nebennierenrindeninsuffizienz bestätigt werden.AbstractSudden deaths due to an endocrinological crisis are rare in medico-legal autopsies. In this article two cases of sudden death of a young woman and a middle-aged woman are presented. The assumptions that the deaths were caused by Addison’s disease and Sheehan syndrome, respectively, with secondary insufficiency of the adrenal cortex were confirmed by histological and immunohistochemical investigations.