Spitz and Fisher’s

MEDICOLEGAL INVESTIGATION
OF DEATH
"The search for truth is the essence of forensic pathology. This truth forms an essential link between the
enforcement of law and the protection of the public in administration of justice." This illustration
shows a sculpture by Una Hanbury, located in the lobby of Maryland's Medical Examiner's Building
in Baltimore. The guardian figure on the left represents law. Next to it the doctor holds up the lamp of
knowledge towards the symbolic figure of justice. Justice is interpreted in its aspect of love. The general
public is suggested by the group of figures on the right. An inscription underneath the sculpture reads,
"Wherever the art of medicine is practiced is there is also a love of humanity." (Hippocrates)
 Spitz and Fisher’s

MEDICOLEGAL INVESTIGATION
OF DEATH
Guidelines for the Application
of Pathology to Crime Investigation
FiFth Edition

Edited by

WERNER U. SPITZ, M.D.

Consultant, Forensic Pathology and Toxicology

St. Clair Shores, Michigan
Chief Medical Examiner
Wayne and Macomb Counties, Michigan (Retired)
Professor of Pathology
Wayne State University School of Medicine, Detroit, Michigan
Adjunct Professor of Chemistry (Former)
University of Windsor
Windsor, Ontario, Canada (Former)

Co-edited by

FRANCISCO J. DIAZ, M.D.

Deputy Chief and Medical Director

Office of the Chief Medical Examiner
Washington, DC
Clinical Assistant Professor
George Washington School of Medicine
Former Assistant Medical Examiner of Wayne County, Michigan
Faculty at University of Michigan School of Medicine

With a Foreword by

RAMSEY CLARK
Former Attorney General of the United States

C H A R L E S C T H O M A S • P U B L I S H E R • LT D.
Springfield • Illinois • U.S.A.
 Published and Distributed Throughout the World by

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Springfield, Illinois 62704

This book is protected by copyright. No part of

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© 2020 by CHARLES C THOMAS • PUBLISHER, LTD.

ISBN 978-0-398-09312-9 (cloth)

ISBN 978-0-398-09313-6 (ebook)

First Edition, 1973

Second Edition, 1980
Third Edition, 1993
Fourth Edition, 2006
Fifth Edition, 2020

Library of Congress Catalog Card Number: 2019038286

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and design. It is the Publisher’s desire to present books that are satisfactory as to their
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Library of Congress Cataloging-in-Publication Data

Names: Spitz, Werner U., 1926- editor. | Diaz, Francisco J. (Medical examiner), editor. | Fisher,
Russell S., 1916-1984 past editor.
Title: Spitz and Fisher's medicolegal investigation of death: guidelines for the application of
pathology to crime investigation/ edited by Werner U. Spitz, M.D., Consultant, Forensic
Pathology and Toxicology, St. Clair Shores, Michigan, Chief Medical Examiner, Wayne
and Macomb Counties, Michigan (Retired), Professor of Pathology, Wayne State University
School of Medicine, Detroit, Michigan, Adjunct Professor of Chemistry (Former),
University of Windsor, Windsor, Ontario, Canada (Former), co-edited by Francisco J. Diaz,
M.D., Deputy Chief and Medical Director, Office of the Chief Medical Examiner,
Washington, DC, Clinical Assistant Professor, George Washington School of Medicine,
Former Assistant Medical Examiner of Wayne County, Michigan, Faculty at University of
Michigan School of Medicine; with a foreword by Ramsey Clark, Former Attorney General
of the United States.
Other titles: Medicolegal investigation of death
Description: Fifth edition. | Springfield, Illinois : Charles C Thomas, Publisher, Ltd., 2020. |
Revised edition of: Spitz and Fisher's medicolegal investigation of death/ edited by Werner
U. Spitz, co-edited by Fisher, Russell S., 4th ed. c2006. | Includes bibliographical references
and index.
Identifiers: LCCN 2019038286 (print) | LCCN 2019038287 (ebook) | ISBN 9780398093129
(cloth) | ISBN 9780398093136 (ebook)
Subjects: LCSH: Forensic pathology. | Death--Causes.
Classification: LCC RA1063.4 .S63 2020 (print) | LCC RA1063.4 (ebook) | DDC 614/.1--dc23
LC record available at https://lccn.loc.gov/2019038286
LC ebook record available at https://lccn.loc.gov/2019038287
 To my father
Siegfried Spitz, M.D.
my first and foremost teacher
and to
my mother
Anna Spitz, M.D.
who relentlessly showed me the way.

W.U.S.

To my parents
Luz Domingo de Diaz and Francisco Diaz-Morales
for their sacrifice and for showing me and my siblings
that education is our most valuable asset.
To
Javier
in hopes that this work inspires him in his life’s journey
and to
Angalena
for making a reality of what seemed impossible

F.D.
 CONTRIBUTORS

MICHAEL M. BADEN, M.D.

Former Director, Medicolegal Investigations Unit
New York State Police, Albany, New York
Former Chief Medical Examiner, City of New York

WILLIAM MARVIN BASS, III, PH.D.

Professor Emeritus
Forensic Anthropology Center, University of Tennessee
Knoxville, Tennessee

B. G. BROGDON, M.D. (DECEASED)

University Distinguished Professor Emeritus of Radiology
University of South Alabama, College of Medicine
Consultant in Forensic Radiology
Office of the Medical Examiner, State of Alabama
Mobile, Alabama

FRANCISCO J. DIAZ, M.D.

Deputy Chief and Medical Director, Office of the Chief Medical Examiner
Washington, DC
Clinical Assistant Professor, George Washington School of Medicine
Former Assistant Medical Examiner of Wayne County, Michigan
Former Faculty at University of Michigan School of Medicine

NEAL H. HASKELL, PH.D.

Forensic Science and Biology Professor
Saint Joseph’s College, Rensselaer, Indiana
Consultant, Forensic Entomology
Rensselaer, Indiana

vii
viii Medicolegal Investigation of Death

JAN E. LEESTMA, M.D., MBA

Consultant, Forensic Neuropathology Brainworks, LLC
Former, Associate Professor of Pathology and Neurology
Northwestern University, Feinberg School of Medicine
Former, Professor of Pathology and Associate Dean
University of Chicago, Division of Biological Sciences and
the Pritzker School of Medicine
Associate Medical Director and Neuropathologist
Chicago Institute of Neurosurgery and Neuroresearch, Columbus Hospital,
Chicago, Illinois
Assistant Medical Examiner and consultant in Neuropathology
Cook County Medical Examiner’s Office, Chicago, Illinois

JOSHUA A. PERPER, M.D., LL.B., M.S.C.

Chief Medical Examiner and Director of Broward County Medical Examiner
and Trauma Services Clinical Professor of Pathology, Epidemiology and
Public Health University of Miami (Retired)
Clinical Professor of Epidemiology, Nova Southeastern University (Retired)

WERNER U. SPITZ, M.D.

Consultant, Forensic Pathology and Toxicology
St. Clair Shores, Michigan
Chief Medical Examiner Wayne and Macomb Counties, Michigan (Retired)
Professor of Pathology, Wayne State University School of Medicine,
Detroit, Michigan
Adjunct Professor of Chemistry, University of Windsor, Windsor,
Ontario, Canada (Former)
 FOREWORD

“M ordre Wol Out,” Chaucer’s Prioress tells us. But those who work in
homicide investigation, forensic pathology, and criminal law know
better. The true manner of death which may have been murder is not deter-
mined in tens of thousands of cases annually in our violent land. The cost to
the nation in truth, justice, health, and safety is enormous.
Had Hamlet put aside indecision, sentimentality, emotion, the wan grief
spent on the skull of the jester of his youth—“Alas, poor Yorick! I knew him,
Horatio”—and obtained an autopsy on his dead father, the King of Denmark,
Shakespeare’s play might have turned from tragical to historical. Surely, we
now see how our failures can affect history itself. The violent death of a Presi-
dent will always cause the deepest fears and suspicions. There will always be
the allegation of gunfire from a grassy knoll.
We can determine the truth, and medical science must play a major role.
The coeditor of this important volume was one of four professionals I called on
as Attorney General to review the autopsy photos and x-rays of our beloved
President who looked “forward to the day when America would no longer be
afraid of grace and beauty.” In a time of profound doubt and international
concern, with the highest integrity, self-discipline, and professional skill, Dr.
Fisher contributed to those most reassuring phenomena, facts linked together
pointing to truth.
How many men in America can qualify for such a task? That this is the
first volume in twenty-five years dealing directly and effectively with the sub-
ject of medicolegal investigation of death tells us that our neglect here is
enormous. The deaths of John F. Kennedy, Medgar Evers, Malcolm X, Martin
Luther King, Jr., Robert Kennedy, and Whitney Young, Jr., show how our in-
adequacy can alter our destiny.
About 4:45 a.m., on December 4, 1969, two young Black Panthers, Fred
Hampton and Mark Clark, were killed by gunfire in the city of Chicago. The
shooting occurred during the course of a police raid on Panther headquar-
ters. There followed an official inquest, a protest inquest, three autopsies, and
three grand jury investigations. Each of the autopsies was performed under con-
ditions in a manner or reported in a way that added to speculation over the
real cause of death.
A community has been left in profound doubt as to the identity of the
guns from which the bullets causing death were fired, even the direction of
entry and number of shots. Were the deaths accidental? Were police justified
in this use of deadly force? Were the dead murdered by the police? Was Fred
Hampton drugged at the time of death? That over five thousand people at-
tended his funeral indicates the impact of our failure to establish the truth.
The resulting division in the community will affect the quality of life there
and, through those who live there, elsewhere, for a generation or more.

ix
x Medicolegal Investigation of Death

Perhaps many pathologists avoid medicolegal investigation of death because

its contribution to life is not clear and the happy side of the docket is with the
life savers. A study of such chapters as “Investigation of Deaths from Drug
Abuse,” “Forensic Aspects of Alcohol,” and “Aircraft Crash Investigation”
immediately demonstrates the great importance of this field in life saving and
social problem solving. Indeed, few in the medical profession will be more
involved in the action and passion of our times than those who seek to find
and demonstrate these medical facts. We can foresee the risks of willful de-
struction of crowded airplanes and the meaning to mass urban technological
society.
With a hundred new dangerous drugs to be created by chemical science
in the next five years, with a youth culture in an age of anxiety approaching
incoherence, with grossly inadequate preventive research, it often will be the
autopsy that tells us of the new synthetic chemicals threatening life. With this
knowledge, society can endeavor to cope with one of its most difficult
problems.
There are few crueler injustices directly inflicted on an individual by gov-
ernment than conviction of a crime one did not commit. Important chapters
such as “Sudden and Unexpected Death from Natural Causes in Adults,”
“Trauma and Disease,” and “Injury by Gunfire” show us how easy it is to mis-
judge the cause of death where circumstances are suspicious. It is of the utmost
importance to the individual, to society, to truth, justice, and safety that we find
the facts concerning death.
Because of its pathos, we too often ignore the truths disclosed in Chapter
XVIII, “Investigations of Death in Childhood—The Battered Child.” How
many of our most violent criminals were the subject of physical abuse as
children? Forensic pathology can give us some indication. It is important that
we know. The national attitude toward violent crime could be dramatically
changed by this truth.
Few professions create greater despondency about the goodness of man
and the worth of life than the practice of criminal law. Not many human
documents are more pessimistic than Clarence Darrow’s autobiography. Few
activities tend to diminish an appreciation of life more than forensic patholo-
gy as generally practiced. Neither should be. The criminal lawyer seeks jus-
tice—the forensic pathologist, truth. Noble causes. If both will abandon
rhetoric, ancient dogma and fictive contentions in favor of finding and pre-
senting fact, which is the teaching of this text, their proper purposes will be
justified. Practitioners will then enjoy the satisfaction of helping people.
We must have the courage, indeed the ardent desire, to know the causes of
death. We cannot let the corpus delicti diminish our capacity for joy. We should
not faint at the photos here. They are true, and while all truth may not seem
beauty, all truth can strengthen our humanity. Then, however irresolute, we
will find the compassion like Hamlet to hold in our hands the skull of a
beloved friend, look on it and say, “Here hung those lips that I have kissed I
know not how oft.” The great and constant need of those who investigate
 Foreword xi

homicide and practice forensic pathology or criminal law is a warm human-

ism. A people who will not face death cannot revere life.
But these are mere musings. Study this work.

RAMSEY CLARK
Former Attorney General
of the United States
Washington, D.C.
14 July 1972
 PREFACE TO THE FIFTH EDITION

T his is not just a new edition but a different book emphasizing trauma and
wound analysis. We have eliminated a number of chapters that are no
longer applicable or that are adequately covered in other publications. The
addition of a new co-editor, Dr. Francisco J. Diaz, has brought new ideas to
this fifth edition. We are proud to include a chapter by Doctor Jan Leetsma,
world-renowned neuropathologist. Doctor Leetsma’s vast experience in fo-
rensic neuropathology will certainly enhance this book.
Over time, in the past 48 years since this book was first published, Medico-
legal Investigation of Death has been dubbed the “Bible of Forensic Pathology.”
We hope that it will continue to be known as such.
The fifth edition includes over 600 case reports and hundreds of color photo-
graphs. The cases are from files we have handled. Many times we have found
that analysis of small wounds will lead to understanding of a giant case—like
the case in Hawaii, where a body was found under a full-size van with a
thread mark on the cheek consistent with the victim’s having been hit with a
black pipe used for gas lines that were found in a bucket in the rear of the
van. As it turned out, this was a murder, not an accident. The book is full of
such cases.
Medicolegal Investigation of Death now embraces not just basic forensic
pathology, but also includes death during restraint, including conscious pain
and suffering, and new concepts related to the interpretation of injuries by
detailed wound analysis.
I remember spending hours into the night with Doctor Karplus teaching
me the details of injuries, to understand how a person was injured and how
he or she died. Injuries that you would never believe significant would sud-
denly shed a new light on the case—like the small rectangular (dice) imprint
on the back of a bald head which indicated that the shot that killed the driver
was fired from outside the vehicle through the rear window of the car, and
was not fired by the passenger sitting next to him.
We have again included the foreword by Ramsey Clark, former Attorney
General of the United States. His words could not have been more appropriate
when he said, “Study this work.”
We wish to thank Michael Thomas of Charles C Thomas, the publisher of
this tome, for all the help, advice, and patience that he and his staff have given
us in the preparation and printing of the fifth edition.
Last but not least, we acknowledge with gratitude the contributions of
Diane Lucke for preparing this manuscript.

     W.U.S.
     F.J.D.

xiii
 PREFACE TO THE FOURTH EDITION

I t is with great pleasure that I present this fourth edition of Medicolegal Inves-
tigation of Death and introduce my son Daniel as Coeditor. I am thrilled
that he decided to follow in my footsteps. After working several years in
Florida at the Dade and Hillsborough Counties Medical Examiner’s Offices,
Dan has now joined me in Michigan. His relocation enables us to exchange
ideas, discuss cases, and work together.
This book was first published in 1972 with Russell Fisher, then Chief Med-
ical Examiner of Maryland. Russ was a pioneer who early on recognized the
importance of teaching, research, and publication in forensic pathology, if
this discipline was to withstand the challenges of time. Russ died in 1987, but
left an indelible mark in these pages. This is the reason why his name is and
will be on the cover.
Medicolegal Investigation of Death has been applauded since its inception,
primarily because of its simple style, avoidance of technical terminology, and
the numerous illustrations it contains. The book was meant for pathologists,
pathology residents, coroners, and all those who have an interest in the rec-
ognition and interpretation of wound patterns, and mechanisms of injury, in-
cluding prosecuting and criminal defense attorneys, attorneys engaged in
civil litigation, detectives, investigators, forensic nurses, and others.
Medicolegal Investigation of Death is a textbook in forensic pathology. It has
become a tradition that this book is rewritten, updated, and expanded every
10 years or so. The present version has been completely redone. Eleven new
chapters and sections, an overall updated and expanded text, hundreds of
new illustrations, and many new contributors make this a totally new book. I
want to acknowledge my profound gratitude to all contributors and welcome
the new authors.
The illustrations are still in black and white and not only to reduce cost.
Color evokes emotions. Black and white is more neutral. For an astute observer,
the lack of color will not be significant.
The popularity of shows depicting medical legal death investigation, such
as Quincy in the 1980s, and recently CSI, Crossing Jordan, and Court TV, to
name but a few, has brought the world of forensic science into everyone’s
living room. These shows have caused the general public to become aware
and intrigued, while raising expectations of what may be derived from a post-
mortem examination.
Every piece of the puzzle plays a role, from the observations recorded by
the police officer at the scene, EMS workers, nurses, and physicians in the
ER, to the forensic pathologist in the autopsy room. It is therefore important
that each understand their role and the significance of their notes when re-
constructing an event.
Such manpower must realize that their notes in patients records may well
become evidence in later legal proceedings. Thus, what were once mere words

xv
xvi Medicolegal Investigation of Death

lost in reams of paper are now subject to scrutiny and cross-examination.

Diagnoses are no longer buried with the patient’s demise, and clinical forensic
medicine where physicians are called upon as experts to testify in courts of
law has grown and prospered far beyond training in the field.
This book hopes to fill the void and its text has been adapted to a broader
readership.

W.U.S.
 PREFACE TO THE THIRD EDITION

M edicolegal Investigation of Death has recently celebrated its twentieth year

of publication. When Russ Fisher and I were compiling the first edition
back in 1970, we were aware of a need for such a book. Ten years later, wide-
spread demand required a second, expanded edition. Since that time, fre-
quent queries and concerns of attorneys, investigators, pathologists, and
others interested in medicolegal investigation, coupled with recent develop-
ments, prompted a third edition, not only to keep abreast of the present
state of the art, but perhaps, more importantly, to deal with areas not ad-
dressed in previous editions. Some of these areas are not new, but their ab-
sence in the text was obviously significant.
To those who have stimulated me by their inquiries and prompted this
third, expanded edition of this book, I wish to extend my heartfelt gratitude
for keeping the fire alive.
The present text is profusely illustrated, with many new photographs and
added diagrams and sketches to show mechanisms of injury. Most of the old
pictures have been retained because it was considered senseless to replace
classic illustrations only for the purpose of novelty.
The book has largely kept its simplistic and practical approach, avoiding
technical terminology where possible, in compliance with its aim of address-
ing not only physicians but all those who are engaged in the study of injury
patterns and the practice of pathology as it relates to the law.
Unfortunately, since the last edition of this book, three prominent contrib-
utors, leaders in the field of forensic pathology and friends, are no longer
with us, Doctor James T. Weston, Doctor Russell S. Fisher, and Doctor Rich-
ard Lindenberg. Their spirits live on in these pages.
A number of new contributors bring fresh ideas and expertise to this volume,
and I wish to extend my sincere thanks to them for their indispensable effort.
Lastly, I wish to indicate my debt of gratitude to Diane Lucke for her tire-
less efforts in compiling and coordinating this entire manuscript. Without
such help this book could not have been completed.

W.U.S.

xvii
 PREFACE TO THE SECOND EDITION

W hen the first edition of this text was published in 1973, we intended
that it would fill an existing void for an up-to-date account of the cur-
rent state of knowledge of death investigation. The need for a second printing
three years later supported our original belief that such a publication did
indeed meet a demand. Rather than continue with a third printing, we felt
that it would be appropriate at this time to undertake a complete revision of
the text and to include new developments, including primarily a considerable
volume of material that had been previously omitted.
Consequently, many additions and alterations were made to nearly all of
the chapters. New sections on sudden infant death syndrome and chemical
considerations associated with postmortem changes were included. A new
chapter dealing with methodology and interpretation of toxicological pro-
cedures was added. Furthermore, a shortcoming of the previous edition was
corrected by devoting space to preparation of a medicolegal autopsy report
and formulation of a medicolegal opinion, as have been found to be advanta-
geous in the author’s own experience.
Significantly more space was allotted to illustrations. We were almost
tempted to include color, but in the interest of lower cost, photographs were
again limited to black and white, although the emphasis on quality was
continued.
In conformity with the first edition, an attempt was made to maintain the
practical character of the book, and where possible, technical terminology
was avoided in the interest of easier understanding for a wider spectrum of
readers.
It is the editors’ pleasure to acknowledge the assistance received from so
many colleagues, pathologists, police officers, and attorneys, who contributed
by their questions and suggestions. As previously, a great debt of gratitude is
owed to Mrs. Hannelore Russell-Wood (Schmidt-Orndorff) for assistance with
the editorial work, preparation of the index, and collating of the entire manu-
script. Elaine Sacra, research assistant at the Wayne County Medical Exam-
iner’s Office, helped transform a raw manuscript into a coordinated text, and
Nancy Whayne prepared additional drawings. Special thanks are due to our
photographers, Lester Walter and Anna Faulkner, for hours of expert labor
spent in providing illustrations for the new material in this edition.

W.U.S.
R.S.F.

xix
 PREFACE TO THE FIRST EDITION

W henever a new textbook is to be written three basic questions should

be answered by the authors: Why, who needs it? Is it needed now?
Why should the authors in question, rather than others, undertake the work?
In the last thirty years there has been increasing sophistication in the train-
ing of police officers assigned to homicide investigation. To a significant
degree this has been due to the philosophy developed at the Harvard Medi-
cal School in the late 1940s of teaching homicide investigators the nature of
the medical aspects of injuries. This has led to the development of a sizeable
corps of highly expert individuals in this field. The need for this type of infor-
mation has also been greatly emphasized by the fact that throughout a large
part of the United States the medical investigation of death at the scene is
woefully inadequate, conducted by untrained and unskilled coroners who are
frequently nonphysicians. No new textbook oriented to the homicide investi-
gator or the novice forensic pathologist has appeared in the last two and one-
half decades. It is our aim to meet the need by presenting, in readable style,
an authoritative text embracing all aspects of the pathology of trauma as it
is witnessed daily by law enforcement officers, interpreted by pathologists
of varying experience in forensic pathology, and finally used by attorneys
involved in the prosecution and defense in criminal cases, as well as by those
engaged in civil litigation.
Since the text is addressed to a wide range of professional disciplines,
some of the chapters are inevitably directed more towards readers with medi-
cal backgrounds, whereas others are suited for general understanding. Never-
the- less, the large number of illustrations and diagrams will, we hope, render
the text comprehensible to all who are interested in the interpretation of fo-
rensic pathologic findings.
As it has been noted above, no up-to-date textbook covering the material
contained herein is currently available. While working in the Maryland
Medical Examiner’s Office and its partner in teaching and research, the
Maryland Medical-Legal Foundation, we have accumulated a large volume
of material upon which to base the text. This material and experience also
serve to answer the question: Why us? We have been concerned not only
with the day-to-day investigation of sudden and violent deaths in a statewide
medical examiner’s system but also with teaching in medical and law schools
in Baltimore and elsewhere throughout the country as well as with training
of young pathologists who wish to become expert in the field. Furthermore,
we have been conducting the Frances G. Lee Seminars in Homicide Investigation
for state and other police officers for many years. It is our hope that our
experience and those of our coauthors will make a significant contribution
to the improvement of the investigation of sudden and violent death, the

xxi
xxii Medicolegal Investigation of Death

prosecution and defense of those related to such events, and the protection
of the public welfare.

W.U.S.
R.S.F.
 ACKNOWLEDGMENTS TO THE FIFTH EDITION

Let it be Known

Now that we have completed the fifth edition, we miss Bill Loechel more
than ever. Bill made all the drawings, sketches, and diagrams that appeared in
all five editions of Medicolegal Investigation of Death since 1972, when the first
book appeared in print. He prepared the drawings while I talked to him and
told him what I needed. He was amazing; he was a perfectionist, a master at
his job. I wish he was still here.
William Edgar Loechel was born and raised in Baltimore, where I first met
Bill. He was the first medical illustrator for the NIH. Bill died on September
7, 2011, at the age of 88. As amazing as he was, he was humble, always pa-
tient, meticulous and perfect.
We wish to acknowledge and thank Javier Diaz for spending hours on end
to help locate pictures, which was not an easy task, and help in preparation
of the manuscript. Javier just started college and intends to continue a career
in orthopedic medicine. We wish him good luck.
Our sincere gratitude to Diane Lucke for her devotion and dedication to
preparing this manuscript for print and compiling the index. Only her per-
severance and tireless effort made it possible to accomplish this task. Without
Diane’s meticulous efforts in the third, fourth, and present fifth editions, this
book would have never been published.
Lastly, we wish to acknowledge our gratitude to Philip Pokorski, Ph.D., for
the days he spent doing library research in connection with the publication
of this book.

W.U.S.

xxiii
 ACKNOWLEDGMENTS TO THE FOURTH EDITION

M y sincere gratitude, as editor of this book, goes to Diane Lucke, my

assistant and office manager, who has been with me 32 years. Her tire-
less perseverance in preparing the manuscript, often providing valuable
advice, sorting the illustrations, compiling the index, proofreading, and much
of the work usually done by the editor, deserve special recognition. Without
Diane’s help, this book would not have seen the light of day.
David Woodford, Forensic Manager of the Michigan State Police Crime
Laboratory in Sterling Heights merits more than just thanks for his expertise,
availability to consult at all times and obtaining and confirming information
on so many different topics. Indeed, Dave is not only a colleague but a dear
friend. Unfortunately on March 9, 2005, while this book was in print, we lost
him.
Many of the drawings and sketches were prepared by William Loechel,
retired director of Medical Illustrations at Wayne State University, School of
Medicine. Bill made work fun. His keen knowledge of anatomy resulted in
renditions with a perfection that only Bill could have achieved. For this, my
utmost gratitude to Bill.
A special thanks also to one of the leading Evidence Photographers in the
Detroit area, Edward Gostomski of the Robert J. Anderson Company, for
preparing a large number of the photographs in this book and his expert
advice in regards to the photography chapters.
Cameron L. Marshall, Charleston, South Carolina, formerly Solicitor of
the Ninth Judicial Circuit, now in private practice, provided case information
and numerous hours of stimulating and delightful discussion.
Last, but not least, I am deeply moved by all those unnamed individuals
who provided case material, advice, and encouragement in the course of
preparation of the manuscript. Many thanks to them as well.

W.U.S.

xxv
 ACKNOWLEDGMENTS TO THE FIRST EDITION

T he idea of compiling a book such as this was not new to us. We had been
toying with this thought many times in the past. However, by insisting on
the need for such a book and by impulsively establishing contact with the
publishers, Col. James T. McGuire, Superintendent of the Illinois State Police,
gave us the necessary impetus to go ahead with our plan. To him goes our
appreciation for his insight and understanding of the need for dissemination
of experience in the pathology of trauma among law enforcement personnel
to help ensure a better administration of justice.
Our thanks to all those who have contributed to this book with their knowl-
edge and experience, and who have thereby helped us make this endeavor
possible.
Finally, our sincere gratitude to Hannelore Schmidt-Orndorff for her able
assistance with the editorial work. Her continuous drive and suggestions have
helped immensely in the task of preparing the manuscript from its inception.
The editors also wish to acknowledge the cooperation of the photographers
of the Medical Examiner’s Office in Baltimore—Walter C. Carden and M.
Gibson Porter—for the preparation of the illustrations of the chapters contrib-
uted by the editors as well as Chapters IV, XVII, and XXI.

W.U.S.
R.S.F.

xxvii
 CONTENTS

Page
Foreword—Ramsey Clark . . . . . . . . . . . . . . . . . . . . . . . . ix
Preface to the Fifth Edition . . . . . . . . . . . . . . . . . . . . . . . xiii
Preface to the Fourth Edition . . . . . . . . . . . . . . . . . . . . . . . xv
Preface to the Third Edition . . . . . . . . . . . . . . . . . . . . . . . xvii
Preface to the Second Edition . . . . . . . . . . . . . . . . . . . . . . . xix
Preface to the First Edition . . . . . . . . . . . . . . . . . . . . . . . xxi

Chapter
I. Time of Death and Postmortem Changes . . . . . . . . . . . 3
II. Forensic Aspects of Anthropology . . . . . . . . . . . . . . . 43
III. Blunt Force Injury . . . . . . . . . . . . . . . . . . . . . . . 57
IV. Forensic Aspects of Radiology . . . . . . . . . . . . . . . . . 107
V. Death in Childhood . . . . . . . . . . . . . . . . . . . . . . 125
VI. The Road Traffic Victim . . . . . . . . . . . . . . . . . . . . 189
VII. Sharp Force Injury . . . . . . . . . . . . . . . . . . . . . . . 243
VIII. Injury by Gunfire . . . . . . . . . . . . . . . . . . . . . . . 313
IX. Asphyxia . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
X. Drowning and Injury in Water . . . . . . . . . . . . . . . . . 467
XI. Electrical and Lightning Injuries . . . . . . . . . . . . . . . . 499
XII. Fire and Scalding Injuries . . . . . . . . . . . . . . . . . . . 519
XIII. Trauma of the Nervous System . . . . . . . . . . . . . . . . 549
XIV. Forensic Aspects of Alcohol and Marijuana . . . . . . . . . . 609
XV. The Forensic Autopsy and Medical Legal Reporting . . . . . . 625
XVI. Selected Procedures at Autopsy . . . . . . . . . . . . . . . . 653

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685

xxix
“In fine, nothing is said now
That has not been said before.”

TERENCE (185–159 b.c.)

 Spitz and Fisher’s
MEDICOLEGAL INVESTIGATION
OF DEATH
Open your mind to the wonders of forensic science.
 Chapter I

TIME OF DEATH AND POSTMORTEM CHANGES

W hen did he/she die? That is probably the

most common question that the forensic
pathologist is asked by family members, law
time of death remains elusive because of the
multiple and varied factors that are involved in
the postmortem process.
enforcement, and attorneys; and nowadays, it We are going discuss those factors that are
is a question that is expected to be answered. needed to estimate the time of death.
Despite scientific advances, the determination of

DEFINITION OF DEATH

A consensus in the definition of death is as organs to ischemia/anoxia is variable, with the

elusive as trying to determine the time of death. central nervous system displaying a particu-
In 2014, the Uniform Law Commission (ULC) larly high sensitivity. The classic literature in-
published a summary on determination of dicates that a four- to six-minute period of
death.1 In that summary it is postulated that cerebral anoxia from a delay in effective resus-
“advances in medical techniques and equipment citation will commonly result in irreversible
have made it necessary to re-evaluate traditional and extensive brain damage. Exceptions have
legal standards for declaring a human being been reported where the reversible interval
dead.” was longer.2
Until the 1960s, the cessation of circulation and Young children and hypothermic individuals
respiration was the unchallenged definition of are known to resist cerebral hypoxia for thirty
death. Even today in most deaths, particularly in minutes or longer with no ill effects. In the
those which occur outside hospitals, or are un- well-known case reported by Kvittingen and
witnessed, the criteria used are still the cessation Naess,3 a five-year-old boy fell into a partly
of circulation and respiration. frozen river and recovered fully, following a
However, the classical definition of death has presumed submersion time of twenty-two
been challenged in recent times by medical ad- minutes.
vances, such as resuscitation techniques and The development of life-sustaining equip-
advanced life sustaining equipment capable of ment has also changed the definition of death
maintaining blood pressure, circulation and by permitting dissociation between a severely
respiration in individuals with severe brain hypoxic or dead brain (incapable of sustaining
injury. spontaneous respiration and circulation) and
These developments necessitated, in many the peripheral organs, which can be kept alive
cases, the obvious revision of the definition of artificially. Therefore, the definition of death in
death from just cessation to irreversible cessation a person with severe and irreversible brain
of respiratory and heart activity following injury, incapable of sustaining spontaneous res-
modern resuscitation attempts. The reversibil- piration and/or circulation, had to be revised to
ity of the death process is dependent on the include what is now defined as brain death.4–5
capability of tissues to recover from the effects According to Bernat,6 physicians now may
of ischemia/anoxia occurring between the lawfully determine death using brain criteria in
advent of clinical death to the initiation of ef- every state of the United States, all Canadian
fective resuscitation. The resistance of various provinces, and 80 countries around the world.

3
4 Medicolegal Investigation of Death

POSTMORTEM CHANGES AND ESTIMATION OF THE TIME OF DEATH

Following death, numerous physicochemical death is longer, the estimate of time of death be-
changes occur, which ultimately lead to the lique- comes more inaccurate.
faction of all soft tissues. The medicolegal impor- A young, thin, adult female was found on her bed, un-
tance of these postmortem changes is related covered, nude, with over 100 stab wounds on the limbs and
primarily to their sequential nature which can be torso. Due to a ceiling fan operating over the body, she was
utilized in the determination of the time of death not decomposed, despite the room temperature being in
and the related destructive and/or artefactual the mid-80s (°F), with high humidity and time of death esti-
mate of 12-15 hours.
changes which may simulate premortem injuries
or modify toxicological findings. Because of inherent inaccuracies in the timing
The determination of the time of death is of individual postmortem changes, the following
generally based on the principle of using sequen- approach is usually effective. An initial determi-
tial changes as a postmortem clock. Physicochemi- nation of a wide window of death is made, which
cal changes are evident upon direct examination is then subsequently narrowed and refined by
of the body, such as changes in body tempera- using variable parameters. The window of death is
ture, livor, rigor, and decomposition. These defined as the time interval prior to which one
changes are routinely reported in protocols may assert with confidence, that the individual
and are most commonly used in postmortem was alive. The window of death should be estab-
timing. lished according to the most reliable testimony
Injuries to the decedent are also often useful or evidence as to when the individual was last
in determining the time of death. The survival known to be alive (witnesses, verified signed doc-
time after injuries, particularly when the time of uments, last time newspapers were brought into
infliction is known, can be estimated. Qualities the house, last time of withdrawal on bank ac-
to look for include the nature, extent, and sever- counts, use of credit cards, use of phone and
ity of injuries, the quantitation of associated social media, etc.).
complications, amount of bleeding, and early
tissue reaction to injuries. In addition, any ade- Postmortem Cooling (Algor Mortis)
quate autopsy will record the amount, composi-
tion, and appearance of gastric contents. Postmortem body temperature declines pro-
The major problem encountered in the esti- gressively until it reaches ambient temperature.
mation of the time of death is the variation in Under average conditions, the body cools at a
the environmental and individual factors that rate of 2.0°F to 2.5°F per hour during the first
impact the magnitude and kinetics of postmor- few hours and slower thereafter, with an average
tem phenomena. The physicochemical changes loss of 1.5°F to 2°F during the first twelve hours
following death are greatly dependent on envi- and 1°F for the next twelve to eighteen hours.
ronmental conditions and the metabolic status The final slowing of the rate of cooling is attrib-
of the individual prior to death. Therefore, the uted to the reduced gradient between body tem-
deceased must be considered in view of envi- perature and ambient temperature. Careful
ronmental factors (temperature, ventilation, hu- studies under controlled conditions have shown
midity) and his or her characteristics (body that the decrease in the postmortem body tem-
build, premortem exercise, state of health). Due perature is not rectilinear but sigmoid in shape
to the significant variation in the kinetics of with a plateau at the beginning and at the end of
postmortem phenomena, the time of death the cooling process.7
cannot be pinpointed exactly; the time of death The initial plateau, which rarely lasts more than
is rather estimated within a range of time. The three to four hours, is generally explained on the
time range is wider when the interval since the basis of heat generated by the residual metabolic
actual death is longer. As the actual time of process of dying tissues and by the metabolic
 Time of Death and Postmortem Changes 5

activity of intestinal bacteria. A study by TABLE I-1

Hutchins8 reports elevations of the temperature, BODY COOLING:
rather than a plateau, within the first hours fol- IMPORTANT FACTORS
lowing death, with a return to base line within Clothing
four hours. Whereas the average postmortem State of nutrition
temperature increment in Hutchins’ series is Environmental temperature and wind
Relative humidity
minimal, it is significant that during the first few Contact of body with hot and cold objects
hours following death, the temperature did not Temperature of body at death
decline, as would have been expected under the
above rule of thumb. It is also significant that all
of Hutchins’ cases were patients in a hospital set- Postmortem cooling of the human body at the
ting who had died from natural causes with a skin surface (loss of heat to the environment)
possibility of an acute occult infection in prog- takes place by three major mechanisms:
ress. (Comment: Also to be considered is the tem- 1. Conduction: transfer of heat by direct contact
perature regulation stops with death and the to another object.
patient is then exposed and takes on the tem- 2. Radiation: transfer of heat to the surround-
perature of the environment in the bed.) ing air by infrared rays.
The skin, as the closest organ to the environ- 3. Convection: transfer of heat through moving
mental air, cools quite rapidly and is not useful for air currents adjacent to the body.
sequential temperature measurements. Tempera- Internal organs cool primarily by conduction. It
ture changes of the core are preferred, because follows that factors which affect these mechanisms
the decline is slower and more regular.9 Many are bound to affect the rate of cooling as well.
sites have been tried for taking body tempera- For example, body insulators such as clothing
tures. The most convenient and commonly used and increased body fat will decrease the rate of
procedure involves hourly measurements of the heat loss, therefore decreasing the rate of cooling.
deep rectal temperature (8" depth). Some prefer Active air currents increase heat loss by convec-
the liver as a more representative site of core tion, which accelerates the rate of cooling. Simi-
temperature larly, immersion in cold water will increase the
The postmortem rate of cooling may be used heat loss by conduction and accelerate the rate
for estimating the time interval since death. As a of cooling.
matter of fact, literature surveys indicate that The rate of body cooling in water, such as in a
more than 150 years ago, postmortem cooling warm swimming pool at air temperature, may be
was used for this purpose in medicolegal cases. double the temperature lost on dry land. Under
Since then, numerous studies by forensic scien- these circumstances, it would be possible to esti-
tists have attempted to refine the use of the cool- mate the time since death in a body recovered
ing rate as a reliable postmortem clock. A from a pool.
thorough historical review of various methods of A larger body surface ratio to body mass, such
estimating the time of death from body tempera- as in children, will increase relative heat loss and
ture by Bernard Knight10 concluded that in spite therefore increase the rate of cooling. Further-
of the extensive application of physical theory and a more, the rate of cooling is dependent on the tem-
great deal of direct experimentation, the level of accu- perature gradient between the body and the
racy remains low, even in the artificial venue of a con- environment. Its calculation assumes that the en-
trolled experiment. This does not mean that vironment is cooler than the body temperature;
measurements of postmortem temperatures are the higher the gradient, the faster the loss of heat.
worthless in determining the postmortem inter- However, if the environment is warmer than
val, but that the data should be cautiously inter- the body temperature, the postmortem body tem-
preted in view of variables affecting postmortem perature will be increased. In calculating back to
cooling (Table I-1). the time of death, one should not necessarily
6 Medicolegal Investigation of Death

assume that the body temperature at the time of

death was normal (36.5°C to 37°C, or 98.6°F).
People may die with hyperthermia at much
higher than normal body temperature because of
a variety of conditions, including sepsis, hyper-
thyroidism, physical exercise, heat stroke, seizures,
or drugs (cocaine, amphetamines, anticholinergic
drugs, phencyclidine, synthetic stimulants).
Head injury, with damage of the hypothalamic
area of the brain, may cause a terminal body tem-
perature of 105°F or higher. Obviously, postmor- Figure I-1. Tâche noire is a black discoloration between
tem cooling would be significantly affected in the lids caused by drying. The portion of the eye covered by
such cases. On the other hand, individuals may the lid retains moisture.
die in a state of hypothermia caused by shock,
environmental exposure or drugs (alcohol, seda-
tive hypnotics, opiates, phenothiazine). Myosis (constriction), often referred to as pin-
point pupils, may persist in some opiate deaths,
Early Postmortem Ocular Changes while it may disappear in others. Similarly, dif-
ferences in the shape of the pupil are equally
The eyes often exhibit some of the earliest post- variable and unreliable. Postmortem changes
mortem changes. An immediate sign of death in may affect the shape of the iris and create arte-
the fundi of the eyes is the arrest of capillary circu- factual irregularities.
lation, with settling of red blood cells in a rou-
leaux or boxcar pattern. Postmortem Lividity (Livor Mortis)
When the eyes remain open, a thin film may
be observed within minutes on the corneal sur- Postmortem lividity (livor mortis), or postmortem
face, and within two to three hours, corneal cloud- hypostasis, is a purplish blue discoloration due
iness sets in. If the eyes are closed, the appearance to the settling of blood by gravitational forces
of the corneal film may be delayed by hours and within dilated, toneless capillaries of the body.
that of corneal cloudiness by 24 hours or longer. Accordingly, livor is seen in the dependent
If the eyes are partly open in a dry environ- areas, such as on the back if the body was in a
ment, the exposed areas between the lids may supine position and on the face and front if the
develop a blackish brown discoloration known as body remained prone. A body which remained
tache noire (black spot) (Fig. I-1). This phenome- hanging for several hours in an upright position
non has been mistakenly interpreted as bruising. will have livor mortis from the elbows to the fin-
Denting of the cornea and absence of intraocular gertips and from the mid-abdominal level down
fluid suggest a time of death of several days. to the toes. Within the circumscribed sites of
Postmortem changes of the pupils consist of livor, one may see pale areas where the skin was
dilatation of the pupils and central positioning, pressed against a hard surface or object prevent-
resulting from relaxation of the iris muscle. The ing postmortem sedimentation (Fig. I-2). Post-
iris muscle, like all muscles in the body, abides mortem lividity may be evident as early as 20
by the rules governing rigor mortis. minutes after death or may become apparent
In life, constricted pupils occur as a result of cer- after several hours. The development of lividity is
tain drugs, such as heroin and morphine, and differ- a gradual process which progressively becomes
ences in the size of the pupils may have neurological more pronounced. However, even after a number
significance, such as stroke or brain tumor. Howev- of hours, postmortem lividity may be difficult to
er, postmortem differences in pupillary size are discern in cases of severe anemia or following
variable and unreliable for such determination. extensive blood loss. In a case of a ruptured aortic
 Time of Death and Postmortem Changes 7

Figure I-2. Livor mortis. The pale area is due to pressure of

the head against the floor on which he was lying. Death was Figure I-3. Pressure in areas of livor causes blanching, in
due to heart disease. The abrasions on the forehead, locat- this case 7 hours after death.
ed in protuberant areas of the underlying skull, were sus-
tained when he collapsed.

aneurysm or aortic tear, postmortem lividity may

be so faint as to be practically indiscernible. At all
times, evaluation of the presence of livor mortis
requires good lighting conditions; daylight is best.
In individuals with dark skin pigmentation, livid-
ity in the skin can go unnoticed. At autopsy, find-
ing congestion of internal organs may assist in
determining the presence of lividity.
In the early stages, livor can be blanched by
compression (Fig. I-3) and may shift if the position
of the body is changed. Livor mortis is also seen
in the fingernail beds. The fingernail beds are a Figure I-4. Multiple pinpoint hemorrhages (Tardieu spots)
good location for evaluation of livor in individuals on the skin in a case of early decomposition.
of dark complexion and for determination of
whether livor is fixed or is still blanchable by ap-
plication of pressure. Depending on temperature,
but usually after eight to twelve hours, the blood
congeals in the capillaries or diffuses into the ex-
travascular tissues and does not usually permit
blanching or displacement. In advanced stages of
livor, skin capillaries in dependent areas often
burst and cause pinpoint hemorrhages known as
Tardieu spots (Figs. I-4 to I-6b).
Unusual discoloration of postmortem lividity
may serve as a diagnostic clue regarding the cause
of death. The pathological mechanism responsi-
ble for the abnormal discoloration is usually the
presence of an abnormal hemoglobin compound Figure I-5. Tardieu spots in a case of early decomposition.
(carboxyhemoglobin, methemoglobin). In some Woman lying in bed her arm hanging over the side, blood
instances, cherry-red discoloration may be caused settling in the skin out of the vessels, by gravity.