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On the evening of 21 November, 1974 explosions occurred almost simultaneously in two crowded public houses in the centre of Birmingham. Of the 21 people who died, 18 were killed outright and 3 died later in hospital. All 21 cases showed the terrible multiple injuries associated with close proximity to a powerful explosion within a confined space. Although all the victims suffered one or more injuries which alone would have been fatal, certain patterns of injury were noted which, if appreciated early in any future similar incident, may help to save the lives of those who are futher removed from the centre of the explosion or exposed to one of lesser force.

The purpose of this paper is to define the criteria for the differential diagnosis of trauma following resuscitation and road accidents. To this end, 311 cases of thoracic and epigastric trauma were selected from the 2893 medico-legal autopsies carried out between 1979 and 1982 at the Institute of Forensic Medicine of the University of Heidelberg. Cardiopulmonary resuscitation had to be considered as the cause of trauma in 140 of these, but 45 of this group were excluded from further evaluation as they had been the victims of blunt trauma and no clear-cut distinction was possible between trauma resulting from an accident and trauma resulting from resuscitation. Thus, we were left with 95 cases of internal injury that presented as emergencies and in whom death followed resuscitation, as a group for comparison with 171 road accident victims who had not received cardiopulmonary resuscitation. Rib fractures, predominantly on the left side, were established in half the cases resuscitated, sternal fractures also being found in one-third of these victims. Bleeding at various sites, including hemato-thorax, was rare, with an incidence of 15%, thus making it highly unlikely that serious traumas caused by resuscitation were a major factor in the cause of death. This paper encompasses an extensive discussion on serious injuries, such as aortic and gastric ruptures, in this connection.

This is a retrospective study of all post-mortem reports made by the Institute of Forensic Medicine at the University of Brno between 1972 and 1981, where a hepatic trauma was present (495 cases). Only 73 patients, suffering from a liver injury mostly in combination with concomitant injuries were admitted in time. All others came to death during transportation or before surgical help could be established. Diagnostically the authors emphasise urgent laparoscopy and in special cases selective arteriography, sonography and CT. Partial resection of the liver segments should be preferred to tamponade of liver wounds which is no longer recommended.

The difficulty in establishing the cause of death of a pregnant woman emphasizes the necessity for the careful gathering of evidence. Especially in the case of motor accidents along lonely stretches of road involving a solitary motorist the possibility of suicide should be taken into consideration. Since a televised suicide had apparently served as model for the method of suicide, mention has been made of the "Werther effect". A literature review reveals that little has been written on the subject-suicide during pregnancy.

A retrospective pilot study of motor vehicle incident fatalities was conducted to determine what relationships exist between injuries received by deceased drivers, passengers, and a control population of pedestrians, and some of the environmental factors existing at the time of the incident. A number of correlations were established between the types and locations of injuries received, seat belt use, position of the injured party, and so forth. A study of this type, if performed on a large enough population, could lead to predictive models for the determination of position of the victims within a motor vehicle at the time of a fatal crash, based on a unique clustering of injuries.

This paper examines the role of neurologic impairment as an indication for CT examination of the abdomen in children after blunt trauma. The clinical information and abdominal CT examinations of 482 consecutive children were reviewed prospectively for indications for abdominal CT and presence and severity of abdominal and chest injury. Children were divided into two groups determined by Glasgow Coma Scale (GCS): GCS less than 8, and greater than or equal to 8. The prevalence and severity of thoracoabdominal injury were higher in the neurologically impaired group. These children had a higher frequency of abdominal injury (GCS less than 8, 25 of 90 patients (27.8%) vs. GCS greater than or equal to 8, 70 of 392 patients (17.8%); p = 0.047 by Chi square test), injury to multiple abdominal organs (16.7% vs. 4.8%; p = 0.0002), chest injury (32.2% vs. 0.09%; p = 0.0001), and combined chest and abdominal injury (18.9% vs. 4.6%; p = 0.0001). In addition, the mortality rate in children with a GCS less than 8 was significantly higher (GCS less than 8, 24% vs. GCS greater than or equal to 8, 0.26%; p = 0.0001). Eleven children had a GCS less than 8 as the only indication for abdominal CT examination. All 11 children had a normal CT of the abdomen. Every child with abdominal injury on CT scan had specific abdominal signs suggestive of underlying injury. Three neurologically impaired children required abdominal surgery (3.3%) vs. 14 of 369 (3.8%) children with a GCS greater than or equal to 8; p = NS). We conclude that children with severe neurologic impairment are at higher risk for intraabdominal injury than those without coma, but that neurologic impairment without abdominal signs is a low-yield indication for abdominal CT examination. Abdominal CT scan should be reserved for children in whom there is a high clinical index of suspicion of significant abdominal trauma based on physical examination and the mechanism of injury.

Nine cases of multiple-shot suicides (suicides involving more than two gunshot wounds) examined in the last 6 years at the Office of the Chief Medical Examiner. State of Maryland, are reported. All victims, with the exception of one, were white: three were women and six were men, with ages ranging from 22 to 81 years. For each case, the results of the scene investigation, the ammunition used, and the autopsy and toxicological findings are described. Each victim suffered 3-5 gunshot wounds. The most common site for the gunshot wounds of entrance was the precordial region, followed by the left chest, the head, and the abdomen. Gunshot wounds were rarely localized exclusively to the head, whereas gunshot wounds scattered on different classic suicide body sites or all confined to the precordial region and the left chest were common. A distinction between instantaneously lethal targets, rapidly lethal targets, and targets of secondary importance is provided, and the guidelines for the proper determination of a multiple-shot suicide are presented.

Two six-shot suicides are reported that occurred in adjoining counties in Ohio eleven-and-one-half weeks apart. There is no indication of any connection between victims, and it is doubtful that the second individual knew of the first death since there was no news media coverage of the first death. The most significant points of commonality between the two cases are the location of the gunshot wounds (anterior chest and upper abdomen) and the responses of disbelief from those outside the medicolegal professions. Knowledge of such cases with a high number of shots and more than one fatal wound can assist death investigators in confronting similar cases.

A case of homicide by dual modality is presented. The intriguing involvement of a hired killer is described. Attention is drawn to the legal implications of the autopsy findings, as well as to the differing emphases placed on them by the defence counsel and the counsel for the prosecution. The forensic significance of the different injuries is discussed.

Placental laceration as a result of blunt maternal trauma has rarely been reported. Herein, we report a case of a 17-year-old, 37-week-pregnant woman who presented after a motor vehicle accident. Initial examination showed no fetal heart sounds or movements. Evaluation included enhanced CT scan of the abdomen. Laparotomy and Caesarian section were precipitated by the development of a coagulopathy, at which time the uterus was found to be filled with blood. Although there were no signs of external uterine injury, examination of the placenta showed a large radial laceration. The fetus had no signs of direct trauma.

The Hydra-Shok bullet is characterized by a hollow-point construction, with a distinctive central post in the base of the hollow. These features allow such missiles to be easily identified during the course of an autopsy examination of a gunshot victim. Higher velocity loadings of the Hydra-Shok may fragment along the wound path, occasionally forming a ring-like fragment that suggests this ammunition, but this feature cannot be considered unique. Although radiographic examination is helpful in bullet localization, the characteristic central post may be identified by X-ray only if sufficient expansion results in its exposure. Three cases of shooting deaths involving Hydra-Shok bullets are presented and discussed; in each case, the entrance wounds were indistinguishable from entrances associated with conventional ammunition, and in no instance did the missiles exit from the body (including head, chest, and abdominal wounds). Familiarity with relatively unusual ammunition types such as the Hydra-Shok allows for quick identification by the pathologist at the time of autopsy.

Stab wounds to the back present a diagnostic problem, since missed occult abdominal injuries can lead to serious morbidity. In a prospective study of 205 patients, the authors evaluated the usefulness of abdominal computed tomography (CT) in assessment of low-velocity penetrating injury to the back. CT results were classified into three groups. Category 1 included injuries limited to superficial subcutaneous tissue (n = 174); category 2, injuries to the retroperitoneal compartment (n = 18); and category 3, injuries within the peritoneal cavity (n = 13). Fifty patients underwent surgery, including 30 with category 1 injuries, nine with category 2 injuries, and eleven with category 3 injuries. CT categorization of injury, compared with surgical findings in these 50 patients, had a sensitivity of 85% and specificity of 93%. The CT interpretation was considered correct if it demonstrated peritoneal penetration or retroperitoneal injury potentially requiring surgery. The remaining 155 patients were managed nonoperatively, and none had late complications. Abdominal CT is a reliable diagnostic tool in the evaluation of penetrating injury to the back.

Blast injury remains an important source of trauma in both civilian and military settings. We have studied a recently developed blast wave generator to evaluate its effectiveness for laboratory study of blast injury. In order to determine the reliability of the device and the pathology of the lesions caused by the short duration (0.5-1.0 msec), and high intensity (60-375 psi) pressure wave, laboratory rats were exposed to the pressure waves generated by the machine. The animals were divided into three groups: the first exposed to midthoracic blasts, the second to abdominal blasts, and a group of controls exposed to a gentle stream of gas. Group I showed gross and microscopic evidence of lung blast injury of "rib imprint" hemorrhages, intra-alveolar hemorrhage, marked increase in lung weight, prolonged apnea, and bradycardia. Group II showed typical blunt abdominal trauma at the closest ranges, but characteristic submucosal hemorrhages up to 4.0 cm from the blast nozzle. In both groups, a protective effect was seen in heavier animals. The blast wave generator permits reproducible blast injury in the laboratory that is safer and faster than current methods. The lung and bowel lesions induced are grossly and microscopically similar to injuries of blast exposure seen in clinical patients.

Intramural haemorrhage of the intestine following blunt trauma to the abdomen has been described in several clinical studies. Though such lesions may have an innocent appearance at primary laparotomy, they lead to delayed intestinal perforation in some cases. In previous experiments with similar lesions produced by penetrating abdominal missile, the histologic appearance and the clinical course were documented in pigs observed under long-term anaesthesia. In the present study anaesthetized pigs were submitted to blunt abdominal trauma in an impact machine, whereby the impact velocity could be regulated. The intra-abdominal pressure and the delivered impulse were recorded and the incidence and histologic appearance of intestinal injuries were observed at laparotomy immediately after the trauma. Intramural haemorrhage was found to occur when the impact velocity exceeded 5 m/s. At impact velocity 20 m/s, intestinal rupture occurred primarily. The observed intramural haemorrhages had the same histologic appearance as those seen after penetrating missile injury. The same clinical course, consequently, could be anticipated after blunt trauma.

The Russian contribution to the new generation of smaller caliber assault rifles is the AK-74, whose 5.61-mm (diameter), 3.4-gm (weight), 2.5-cm (length) aerodynamically shaped bullet has a muzzle velocity of 900 m/s. Our tests show that in living swine soft tissues and gelatin tissue simulant the AK-74's copper-plated steel jacket resists fragmentation or deformation. Since the bullet does not fragment, the tissue disruption surrounding the bullet pathway is limited to the stretching effect of temporary cavitation. We present evidence indicating that the energy used during temporary cavity formation causes limited permanent tissue disruption in the more elastic soft tissues (muscle, bowel wall, lung); the same insult in the relatively nonelastic liver, however, causes multiple fractures and massive permanent disruption. We conclude that the AK-74, despite its rather high velocity and marked tendency to yaw soon after penetration, causes relatively nondramatic wounds due to its nonfragmenting behavior.

Over 720 persons are reported to have died jumping from the Golden Gate Bridge. A review of 100 consecutive autopsies showed that, in the majority of cases, massive pulmonary contusion, pneumothorax, laceration or perforation of the heart, great vessels, or lungs by displaced ribs were the causes of immediate death. Irreparable fractures of the liver or spleen were the most common abdominal injuries. The persons fatally injured appeared to have entered the water in a horizontal position, experiencing maximal deceleration. In contrast, six survivors entered the water feet first with more gradual deceleration. These survivors remained conscious but sustained similar injuries of lesser degree; only one sustained rib fractures. Fifty per cent had fractures of the liver or spleen requiring operative therapy. Fifty per cent sustained lung contusions and subsequent pneumothoraces. Suspicion of underlying injuries to the liver, spleen, and lungs is essential during resuscitation of those who survive impact with water.