Dr. Thomas Andrew, retired chief medical examiner of New Hampshire and now a forensic consultant, wants to make a point: “We don’t have all of the fictional technology that is seen on television,” he says. “The vast majority of these cases are solved by good old-fashioned digging into the record, digging into the circumstances and comparing them and correlating them with the findings you generate in autopsy.”
Andrew, who began his medical career as a pediatrician, illustrates his point by discussing the murder of a toddler.
“There was a 9-1-1 call for an unresponsive child,” he says. “To everybody’s naked eye, including the first responders—the ambulance, the emergency room—he was just a healthy little fellow.” His investigator did some preliminary research and couldn’t find a reasonable explanation for the child’s death, so he recommended an autopsy.
The toddler was “packaged up,” which means a representative from the medical examiner’s office supervised the handling of the body, ensuring it was kept in the same condition, as nearly as possible, as it was at the scene so that no trace evidence was destroyed and no artifact was introduced.
“Likewise, if there are any apparent fluid stains either on the skin or on the clothing,” Andrew says, “you want to make sure all of that is well preserved by properly getting that body packaged.”
Finally, the corpse was placed in a clean body bag for transport.
At the M.E.’s office, Andrew examined the child’s skin for subtle signs of ligature marks that might indicate the toddler had been strangled. There were none. In fact, there were no suspicious injuries at all.
He then did a series of total body X-rays to look for “red flags” such as healed or partially healed fractures of the ribs, arms or legs that would indicate the child had been abused in the past or had sustained injuries in the past that had not received medical attention.
That, too, was negative. But it didn’t mean abuse hadn’t occurred.
“You can cause horrific injuries internally in infants and children without leaving much in the way of marks on their skin because their skin is so pliable and so elastic,” Andrew explains. “And so are their ribs. Their ribs are very pliable and they may not fracture.”
So it was time for the former pediatrician to make a Y-shaped cut into the toddler’s torso and do the internal-autopsy examination. He admits doing autopsies on children has an effect on him, but this is something he’ll cope with later.
“You’ve got to put the heart stuff aside,” he says. “It’s not to say that it’s not important and you don’t have to deal with it later. But at the time of the autopsy, it’s all brains. You’ve got to be laser-beam focused on what you’re doing.”
Only after the autopsy, when debriefing with the police or at home, talking it over with his spouse, does he get to work through his feelings on the case.
Fortunately for him, he says, his wife is a psychiatrist. “So she gets it.”
Also, the fact that he began as a pediatrician, he believes, lessens the emotional toll. “That’s not to say there isn’t an impact, but the understanding that what I’m doing is a service to that child and to those that child left behind makes it easier for me, rather than harder.”
Andrew never imagined he’d switch from practicing pediatrics to forensic medicine. But in his second year of medical school, he heard a series of lectures by a forensic pathologist that were, he says, “incredible.” In his senior year, he signed up for an elective with the coroner’s office that he found fascinating.
Still, he was committed to pediatrics. But when he got into private practice, he realized seeing a patient every seven minutes didn’t fit his style. “I am more of a deliberative person. I like to look at things from different angles, really try to sort it out,” he says. “And that really is the essence of forensic pathology.”
Andrew reached for his scalpel and made the Y-shaped incision in the front of the toddler’s torso. Systematically, he examined each of the child’s internal organs, searching for any injury or disease that could explain the child’s death. The heart and lungs were normal. There was no abdominal catastrophe. The liver was intact. All of the internal organs of the abdomen looked fine. He still didn’t have a cause of death.
So he began the last part of the autopsy—the examination of the scalp, skull and brain. “And in this particular instance,” he says, “when the scalp was reflected off [peeled back from] the skull, there was a distinctly patterned contusion. It was not visible on the skin, but it was visible in the soft tissue underneath the skin.”
A general rule in pediatric-forensic pathology is that head injuries below the “hat line”—where the brim of the hat goes around a child’s head—are more likely to be the result of an accident, such as a fall. Injuries above the hat line are “a little more suspicious for the possibility of inflicted injury,” he states. But Andrew had no idea what instrument could have possibly caused that patterned contusion.
He took tissue samples of the internal organs for possible clues that could be found under a microscope. And that’s where he found his answer: In the air sacs of the toddler’s lungs there was a large number of cells filled with iron pigment.
Numerous medical reasons could explain that—congestive heart failure, hemosiderosis and Goodpasture syndrome. But the toddler’s heart was normal, his blood vessels were normal, there was no iron pigment his liver, pancreas or heart and his kidneys were normal. However, Andrew explains, iron-filled cells in the breathing sacs could be a sign of “repetitive asphyxia,” where compression of the chest causes the rupture of little blood vessels.
Andrew had an extensive one-on-one conversation with the lead investigator on the case. Together, they created a strategy—guided by the M.E.’s lung findings—for questioning the toddler’s primary caretaker. Then, when the investigator interrogated the caretaker, he learned that whenever the toddler cried or was agitated, the caretaker would squeeze the child until he stopped crying. Sometimes the child even passed out.
The last time, the toddler had been asphyxiated long enough to cause him to stop breathing, permanently.
That led to the caretaker’s indictment for homicide…and a plea deal.
Andrew says they never did discover what instrument caused the internal bruise on the child’s head, which most certainly would have been figured out by what he calls “fictional technology” on one of those crime-drama television shows.
“But seeing that bruise on the inside of the head,” he says, “made the case that much more suspicious and led to a more detailed examination of that tissue, which revealed the ultimate [cause of death]—asphyxiation by compression of the chest.”
It was just good, old fashioned detective work.