Proposal for an International Classification of SUDI: A response to Blair, Byard and Fleming

PUBLISHEDBY

Dansk Selskab for RetsmedicinNorsk Rettsmedisinsk Forening

Svensk Rättsmedicinsk Förening

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Editorial:

Deathsceneinvestigationinsuddenunexpecteddeathsin infantsandsmallchildren 3 Timeforachange? 4 Forensicmedicineandthemedia 5 Thebeginningofanewera? 6

Whatisthepotentialsignificanceofinflictedbutnon-lethal injuriesatautopsyininfancy? 7 ProposalforanInternationalClassificationofSUDI: aresponsetoBlair,ByardandFleming 9 CommentaryofBlairetal.ScandJForensSci,2009;15:6-9 12 Isbodypositionrelatedtothemechanismofdeathinfatalepilepsy? 14 FindingsofamphetaminesandecstasyindriversinDenmarkfrom1997to2007 17 Deathsceneinvestigationinsuddendeathininfantandsmallchildren 20

Struckbyalancethroughhisside 24 KaiHolst–Suicideormurder? 28 ’ThemysteriousDeathofPoliticanNilsTraedal:accidentorHomicide? 33 Conspiracyofone.TheassassinationofJohnFitzgeraldKennedy 38 “HowIwish,howIwishyouwerehere” 44 Boganmeldelse 46

Olav Gunnar Ballo resigned from the position as director of the Institute of Forensic Medicine in Oslo after only nine months in office

SCaNdINavIaN JOuRNal OF FORENSIC SCIENCEofficialjournaloftheDanish,theNorwegianandtheSwedishsocietiesforforensicmedicine.Thejournalwillpublishoriginalarticles,reviewarticles,preliminarycommunications,letterstotheeditorandcasereportsinthedifferentdisciplinesofforensicsciences:forensicpathology,clinicalforensicmedicine,forensicgenetics,forensictoxicology,forensicanthropology,forensicodontology,forensicpsychiatryandforensicscience.

Submission of articles

manuscriptspreparedinaccordancewithGuide for authorsshouldbesenttotheeditor-in-chiefortooneofthenationaleditors.

Editor in chief: Torleiv Ole Rognum,oslo [email protected]

Editorial secretary: anne Gunn Winge [email protected] Editorial address: Rettsmedisinskinstitutt, Rikshospitalet,N-0027oslo,Norway

National editor, Denmark: Jørgen lange Thomsen,odense [email protected]

National editor, Norway: Torleiv Ole Rognum,oslo [email protected]

National editor, Sweden: Håkan Sandler,Uppsala [email protected]

Accountant: Sigrid I Kvaal [email protected] Address: Vallegaten17a,N-0454oslo Account: 7874.06.45012

Editorial board

Clinical forensic medicine: Markil Gregersen,Århus [email protected] Kari Ormstad,oslo [email protected] annie vesterby,Århus [email protected]

Forensic anthropology: Per Holck,oslo [email protected]

Forensic genetics: Marie allen,Uppsala [email protected] Bertil lindblom,Linköping [email protected] Niels Morling,Copenhagen [email protected] Bjørnar Olaisen,Lovund [email protected] antti Sajantilla,Helsinki [email protected]

Forensic odontology: Sigrid I Kvaal,oslo [email protected] Sven Richter,Reykjavik [email protected]

Forensic pathology: Thomas Bajanowski,münster [email protected] Roger W Byard,adelaide [email protected] anders Eriksson,Umeå [email protected] Gunnlaugur Geirsson,Reykjavik [email protected] Jorma Hirvonen,oulu Hans Petter Hougen,Copenhagen [email protected] Pekka Karhunen,Tampereen [email protected] Inge Morild,Bergen [email protected] lennart Rammer,Lindköping [email protected] Pekka Saukko,Turku [email protected] Jørn Simonsen,Copenhagen [email protected] Michael Thali,Bern [email protected] Ingemar Thiblin,Uppsala [email protected]

Forensic psychiatry: Peter Kramp,Copenhagen [email protected] Randi Rosenqvist,oslo [email protected]

Forensic science: Bjarni Bogason,Reykjavik [email protected] Frank Jensen,Vanløse [email protected] Reidar Nilsen,oslo [email protected]

Forensic toxicology: Johan ahlner,Linköping [email protected] Jørg Mørland,oslo [email protected] Layout:Holstadgrafisk,oslo-Print:prografia,oslo-ISSN 1503-9552

Scand J of FORENSIC SCIENCE - No 1 - 2010 - Page 1-52 3

EDIToRIaL:

Death scene investigation in sudden unexpected deaths in infants and small children

aLL valid definitions of sudden infant death syndrome (SIDS) requiredeath scene investigation. However, the way the investigation is per-formedvariesfromcountrytocountry.

UnitedKingdomprobablyhasthemostwellorganisedsystemfordeathsceneinvestigation.Itwasintroducedafterachangeinthelegislationin

april2008.ProfessorPeterFlemingandhisco-workershaveestablishedamulti-agencyapproachwhichimpliesthatpaediatriciansandpoliceofficersvisitthedeathsceneandtalktothefamily.IntheU.S.a.deathsceneinvestigationsarepartlydonebymedicalexaminersorcoroners,thepoliceorinsomecasesacombinationofboth.InDenmarkthedeathscenesarevisitedbyordinarypolice.

InNorwaythepolicewaswithdrawnfromthedeathsceneofinfantsandsmallchil-drenin1991.ThiswastheresultoftheSIDSepidemicthatcaused150deathsayear,e.g.almost0.3per1000livebirthsbytheendofthe1980’ties.Unfortunateepisodes,inwhichthepolicewenttothescenewithuniformedcars,interrogatedthefamilyandfinallysentthemaletterinformingthatthecriminalcasewasclosedduetolackofevi-dence,didoccur.

In1991thechiefprosecutorinstructedthepolicetostayawayfromthedeathsceneuntiltheyhadreceivedtheautopsyreport.Theyshouldalsoabstainfromsendingletterstothefamilies.Thedeadinfantsshouldbeadmittedtothenearestpaediatrichospitalandthefamilyshouldbefol-lowedupbythehospitalandbythecommunityhealthsystem.

Itsoonturnedoutthatvaluableinformationwaslostinsomecases.Whenthepolicereceivedtheautopsyreportitwastoolatetolocalizeitemsofinterest.Therefore,aresearchprojectinclud-ingdeathsceneinvestigationbyapoliceexpertandtheforensicpathologistthatperformedtheautopsywascarriedoutinSoutheastNorwayfrom2001to2004.TheresultsfromtheprojectarepresentedinthepresentissueofScandJForensSci(pageXX).BasedontheseresultsandonthereportoftheCentreforCrisisPsychologywhichevaluatedtheimpactonthefamilies,itwasrec-ommendedthatdeathsceneinvestigationbyexpertsshouldbemandatory.

Thespecialistincrisispsychologyconcludedinherreportthatthedeathsceneinvestigationofferedthefamiliesastructuredapproachandqualifiedinformationatanearlystageinthebe-reavementprocess.

afterfiveyears,debatingwhetherthedeathsceneinvestigationshouldbevoluntaryormanda-tory,theNorwegiangovernmenthasdecidedthatdeathsceneinvestigationistobeofferedasavoluntaryhealthservicetofamilieswhoexperiencesuddenunexpecteddeathininfantsandsmallchildren.TheParliamenthoweverisrequiringamandatorydeathsceneinvestigation.Thegov-ernmentallawyersclaimthatamandatoryapproachwouldbeagainsttheNorwegianConstitutionwhichsaysthat“houseinquisition”canonlybeallowedincriminalcases,andthatamandatorydeathsceneinvestigationalso interfereswiththeEuropeanDeclarationofHumanRights.Thegovernmenthasdelegated the responsibilityof thevoluntarydeath scene investigation to theNationalInstituteofPublicHealth,SectionofPsychologicalHealth.This institutionhasthenhiredtheInstituteofForensicmedicinetoperformtheinvestigations.

Thelastmoveoccurredinmarch2010.TheParliamentunanimouslyhasdecidedtochangethelawregulatingcriminalproceduretoallowthepolicetoinvestigatesuddendeathsininfantsandchildrenwithouttherequirementof“reasonablegroundsforsuspicion”.However,untillegislative

4 Scand J of FORENSIC SCIENCE - No 1 - 2010 - Page 1-52

changesaremade,thedeathsceneinvestigationwillbeofferedtothefamiliesasavoluntaryhealthservice.

a service with voluntary death scene investigation including all Norway is planned to startNovember1,2010.TwoexpertswithpolicetrainingandfourmedicaldoctorsfromtheInstituteofForensicmedicine,oslo,aswellasexpertsfromfourotherforensicmedicalcentresofNorwaywilltakepartintheservice.

attheSoriamoriameetingmay19-21,2011wehopetobeabletoshareexperiencesfromdeathscene investigationswithparticipants fromallover theworld (see announcement for theSoriamoriameeting2010onpageXX)

ToR

Time for a change?

ThenewdirectorattheInstituteofForensicmedicinehasresignedafter9monthsinoffice.ThisfactreflectstheorganisationalchallengesinforensicmedicineinNorway.TheinstituteinoslowasoriginallyorganisedundertheFacultyDivisionforLabora-torymedicineattheUniversityHospital.oneyearagothemedicalFacultybecameinchargeandinapril2010thecentralUniversityadministrationtookovertherespon-

sibility.TheyappointedaboardledbyformermanagingdirectorofoneofthebiggestcompaniesinNorway(NorskHydro),Egilmyklebust.

Itisnowtimetolookattheofficialreport(NoU2001:12)Expertknowledgeincriminalpro-ceedingsandtheHareidereportfrom2006,thatbothsuggestanationalbodyresponsibleforallbranchesof forensicmedicine.Suchanindependent instituteorganizingallmedicolegalexpertknowledgewouldhavethesameaimasthedifferentforensicmedicalinstitutions.Todaytheim-pressionmayarisethatsomeoftheresponsibleorganisationsaremoreinterestedinthe“overhead”thaninthequalityoftheservice.

Timemayhavenowcomeforachange!ToR

Forensic medicine and the media

BaCKintheseventieswhenIwasyoungattheinstituteinCopenhagen,contactwiththepresswasabsolutelyprohibited.Nobodyshouldbegivenaccesstothesacredhallsofforensicmedicine.atthetimetherewasonlyoneTV-channel,theappearanceonTVmeantinstantfame.

afewweeksagoabookwaspublishedonthehistoryof“Rapport”latertobeknownas“UgensRapport”,amagazinethatfirstcameoutinthemidseventies.Thebookremindedmeofthefirstdramaticencounterwiththepress.

The deputy state pathologist (Jørgen Voigt) had a view on press contact thatdiffered from that of professor Harald gormsen, state pathologist. So he agreed tocontributetoanarticlein“Rapport”aboutforensicmedicineinCopenhagenHeac-cepted(thehorror,thehorror)photosfromtheautopsyroom.ThiswastheonlytimethatIcanremember,whenHaraldgormsenallowedhimselftoshowvisibleorratheraudiblecriticismofhisnextincommand.Itallhappenedbehindcloseddoors,butwecouldhearhimshout.

IrememberthechillingfeelingwhenIsawaphotoofpageoneofadeathcertificatewithmynameonit.Nobodyattheinstitutereallyknewthenewmagazinebutwe

soonfoundoutthatthemainattractionof“Rapport”werenakedwomen.Sincethenwehaveallacceptedtherightofthemediainademocraticsocietytogainknowledge

ofourprofession.Thereareofcourselimitations,andfirstofallwemustkeepanonymityofthecases.Therearemanyadvantagesconnectedwithastrongprofileinthemedia,anditisimportantto

maintainourpresent,positivestatus.Thereareofcoursealsomanypitfalls,andinmyopinionwehavenothadenoughdiscussions

andteachingonthesubject.Ithereforesuggestthatwetakeitupinthenationalforensicsocietiesandmakeitoneofthe

maintopicsattheNordicmeetingin2012inaarhus.

February2010 Jørgen L.Thomsen

Jørgen L.Thomsen

Iwasrecentlyexposedtothemediaandwantedtotellastorytocastlightonthehistoricaldevelopmentthatshouldnotbeforgotten.

EDIToRIaL:


EDIToRIaL:

aFTER>30yearsinforensicmedicinealthoughinaremotesiteoftheworld(Sweden),thecharacterandpremisesforthejobisreallychang-ing. one of the most important contributing factors, apart from new”brains” within the organisation, is the breakthrough of digital tech-nologiesasacomplement,orinsomeinstances,replacingtheholyau-

topsy.Untilnowtheforensicexpertdoctorhasbeentheundisputedproprietorofhiscase.Thissituationcanbedramaticallychangedupon.arewereadyforthis?Threatoropportunity,orboth?at present our department (Uppsala, Sweden) refers its cases to the Department ofClinicalRadiology,atournearbyuniversityhospital,forCTormRI.Eightyearswiththisarrangementhasgainedsomeexperiences,andraisesmanyquestions:

-TheINDICaTIoNSforradiology?Crimesuspiciononly,anytrauma,paediatric,SIDS,oranycaseadmittedto,andacceptedbytheDepartment?

-FacilityatyourownDepartmentoronaconsultantbasis?Thisissuecontainstoamultitudeofsubunits;eg.Numbers:atasmalldepartmentlikeours,around800-900autopsiesareperformed

annually.optimizedindications,butwiththefacility”inhouse”,wouldsubsequentlyyieldaround400-500digitalizedcases. Is thisenough tobeofpedagogic/educational significance?Expandingindications,sharinginformationint.andext.inascheduledmannercouldhelpoffsettingthis.

Competenceandskill:Thisisanindividualaswellasateamtask.Sharingdigitalinformationiseasierthanever.Interpretationisstillverymuchuptotheindividual,butthebasicprocessofacquiringknowledgecanbemuchfacilitatedbymaintainingagoodrelationtoalimitednumberofclinicalradiologists,co-projects,andscheduledauscultationswithinandafterourspecialisttrainingprogramattheradiologydepartment.Radiologistsmustgetthesameoffer.

ProandContras:aswitheverything,therearetwosidesofthecoin.Willthenumberofperformedautopsiesfurtherdecrease?Paradoxically,thenumbersmayincrease,sincebeingjustadigitalizedimage,the“analogue”

autopsymaystrengthenitsroleas“thegoldenstandard”,intheforensiccommunity.our“custom-ers”willprobablyalsobecomeawareofthecombinedstrengthofbothprocedures.Willtherebe“perceptualcompetition”betweenthetwo,resultinginalossofskillinfinalevaluationofresults?astothedigitalresult,itcanbereevaluatedinamultitudeofways.

Byadoptingthenewtechnologies,ourdisciplinewillprobablybecomemoreattractivefromarecruitingpointofview.alsoitwillbringalotofnewresearchareas,withoffspringsbacktotheclinicaswell.

Håkan SandlernationaleditorSweden

The beginning of a new era?


INTROduCTION

a wide range of inflicted injuries in-volvingmosttissuesandorgansystemsmaybeencounteredatautopsy in in-fants. Non-lethal injuries to the skinandsubcutaneoustissuesincludebruis-es, abrasions and lacerations. Theremay also be single or multiple bonefractures, some having characteristicfeatures such as bucket handle meta-physeal fractures and spiral fracturesof the humerus. Non-lethal injuriesinclude minor subarachnoid hemor-rhage, bruising of the mesentery, andhealedandhealingribfractures.Usu-allynoneoftheseinjurieshavecausedsufficientorgan/tissuedisruptionorhe-morrhagetoresultindeath.

PROBlEMS

In assigning the manner of death ininfantandearlychildhooddeathsitisthepracticeofsomemortalitycommit-tees to classify deaths in infants whohavediedofundeterminedcauses,butwhohavebeenfoundtohaveinflictedbut non-lethal injuries at autopsy, as

homicides.Thisisdonedespitetheab-senceofaplausiblelethalmechanism,becauseitisbelievedthatinfantswhohavebeenabusedhaveagreaterriskofsufferinga lethalasphyxialevent, thefeaturesofwhichmaybeundetectableat autopsy1. although this may makeintuitivesense,theassumptionisoftenbasedonminimalevidenceinindivid-ualcases.

another issue that arises concernsdeterminingthepossiblecontributionthat inflicted but non-lethal injuriesmay have made to the fatal episode.Some pathologists have wonderedwhether it is possible that an infantwithnodefinitecauseofdeathatau-topsy,butwithmultiplefractures,mayhave died from a cardiac arrhythmiaprecipitated by extreme pain. again,while thismayappear tobean intui-tivepossibilitytheevidenceislacking.

Certain difficulties contributing totheseissuesinvolvetheinfantautopsy.Standardautopsieshavevariedconsid-erablyinscopeandquality,withsignif-icantomissionsbeingfoundonreviewofcaseswhenstandardprotocolshavenotbeenfollowed2.Ifcriticalinforma-tionislackingitmaybeimpossibletoform a definite conclusion about thecauseandmannerofdeath.anaddi-tional problem also involves the lackof sensitivity of standard autopsy in-vestigations in detecting certain rareconditionssuchasmetabolicdisordersorcardiacrhythmdisturbancesintheformofprolongedQTsyndrome.

In view of these issues it was de-cidedtoexaminetherangeofinflictedinjuries that may be found in infantsat autopsy, from non-lethal to lethal,andtodefinespecific subcategoriesofcases.

ClaSSIFICaTION

Casesmayfallintothreebroadcatego-rieswheninflictedinjuriesarefoundatautopsy:

A). Infants with inflicted, non-lethal inju-ries that are clearly unrelated to death.Intheseinstancestheinflictedinjuriesare purely coincidental to the lethalmechanisms.Examplesincludeaheal-ingtornfrenulumfromtraumatothemouthinacaseofaninfantdyinginhospital of lethal congenital cardiacmalformation,orcigaretteburnsofthepalmsof an infantwhohasdied in avehicle accident. While a meticulousautopsy examination is required toevaluate the presence or absence ofother injuries, thedeathsarenotdueto inflicted trauma. Police investiga-tions, reliable witness statements andfull autopsy examinations all supportthisconclusion.

B). Infants with inflicted injuries that are clearly the cause of death.Injuries most often result from bluntcraniocerebral or abdominal trauma,butmayalsoincludechesttraumaandburns. Police investigations, reliable

Whatisthepotentialsignificanceofinflictedbutnon-lethalinjuriesatautopsyininfancy?

Roger W Byard1, Torleiv O. Rognum2

DisciplineofPathology,TheUniversityofadelaide&ForensicScienceSa1,adelaide,Southaustralia,australia;InstituteofForensicmedicine,Universityofoslo2,oslo,Norway.

aBSTRaCT determining a precise cause of death is a difficulty that is often encountered in pediatric autopsies because of subtle or non-diag-nostic findings. The issue of classifying a death as being due to sudden infant death syndrome (SIdS) exemplifies this dilemma, as there are no diagnostic pathological or clinical findings. a particular problem arises with the possible significance of inflicted, but non-lethal injuries. Re-view of infant deaths where inflicted injuries were present was undertaken with formulation of three separate categories: cases where injuries were a) coincidental to the cause of death, i.e. clearly unrelated; b) directly involved in terminal lethal processes, i.e. causative; or c) possibly associated with the terminal lethal condition identified at autopsy: i.e. of unknown significance. Cases in categories a) and b) are relatively straightforward. Cases in category c) present the greatest difficulties in trying to relate injuries to plausible lethal mechanisms. Given that the pathological findings in cases with such injuries are more complex than standard SIdS cases, the use of the term SIdS is not recommended. The following could, therefore, be added to standard SIdS definitions: that ‘the autopsy findings should occur in the absence of evidence of inflicted injury’.

Keywords: SIdS, infant death, inflicted injury, abuse, asphyxiation, suffocation

addRESS FOR CORRESPONdENCE:Prof Roger W. Byard,discipline of Pathology,level 3 Medical School North Building,The university of adelaide, Frome Road,adelaide 5005, australiaPhone: (618) 8303 5441Fax: (618) 8303 4408Email: [email protected]


witness statements and full autopsyexaminations all support this conclu-sion.

C). Infants with inflicted, non-lethal in-juries that are possibly but not definitely associated with the terminal lethal condi-tion.These cases include those where thecauseofdeathmaynotbedeterminedat autopsy, even following ancillarymicrobiologic, toxicologic, radiologic,metabolic and genetic testing. Thuswhile there is evidence of inflictedinjuryitcannotbedirectlyassociatedwiththedeath.Whetherthetraumaticlesionsdetectedareamarkerofoccultmoresignificantinflictedinjurysuchassuffocationcannotbedeterminedfromthepathologyfindings.

alsoincludedinthisgrouparecaseswherethecauseofdeathisknown,buttheissueofadequacyofcareisraised.Forexample,ifdeathwasduetoanat-uraldiseasesuchaspneumoniaorcon-genital heart disease, was appropriatemedicalcaresoughtorfollowed?also,could inflicted injuries have predis-posedtonaturaldisease?Forexample,didbacterialpneumoniaresultfromre-ducedrespiratoryexcursionanddimin-ishedairwaysecretionclearanceduetothepainfromfracturedribs?Didlethalaspirationofgastriccontents,withorwithout superimposedpneumonia, re-sult from an altered conscious statefromheadtraumaordrugeffect?Un-fortunately many of these issues mayremainunresolvedevenafterafullin-vestigation.

If an infant with non-lethal in-flicted injuries has died of accidentaltrauma questions may also be raisedastowhetherthismayhavebeendueeithertofailuretoensurethesafetyoftheinfant,ortoarecklessindifferencetotheinfant’swelfare.

Insummary,inflictedinjuriesinin-fantsthatarefoundatautopsymaybe:a. Coincidentaltothecauseofdeath:

i.e.unrelated;b. Directlyinvolvedinterminallethal

processes identified at autopsy: i.e.causative;or

c. Possibly but not definitely associ-ated with the terminal lethal con-dition identified at autopsy: i.e. ofunknownsignificance.

RElaTIONSHIP TO SIdS

oneofthemajordifficultiesininfancyisindeterminingwhetheradeathcanbe attributed to SIDS in the absenceofdiagnosticfeaturesatautopsy3.TheNationalInstituteofHumanDevelop-ment and Child Health (NICHHD)definedSIDSas“thesuddendeathofaninfantunderoneyearofagewhichremainsunexplainedaftera thoroughcase investigation, includingperform-anceofacompleteautopsy,examina-tionofthedeathsceneandreviewoftheclinicalhistory” 4.Thisdefinitionwas refined in 2004 by including anapparentassociationwithsleepandanevaluationoftheentirecircumstancesofdeath,notjustthedeathscene5.

although category Ia in the SanDiegodefinitionspecifiesthatthereis“no evidence of unexplained trauma,abuse,neglectorinflictedinjury”,un-fortunatelynoguidance inmoregen-eral definitionshas beenprovided forcases where inflicted but non-lethalinjuriesare found; i.e.bydefinitionitcould be argued that the death of aninfant with completely negative find-ings except for healed and healingfracturesandmultiplebruisescouldbeattributedtoSIDS,asthesearenon-le-thal(althoughthiswouldnotbeusualpractice).Whileitisquitepossibleforanabused infanttosuccumbtothosemechanismsthatcauseSIDS,thepos-sibility of an increased risk of otherformsofinflictedinjurysuchassmoth-eringhastobeconsidered6.Whileitisunclearwhetherthepresenceofnon-lethal inflicted injuries increases thelikelihood of such occult homicides,perhaps a qualifier to standard SIDSdefinitionsshouldbethattheautopsyfindings occur ‘in the absence of evi-denceofinflictedinjury’.

CONCluSION

Inflictedbutnon-lethalinjuriesatau-topsyininfancyraiseconsiderabledi-agnostic issues. Rather than attempt-ingtoestablishasinglecauseofdeath,itisprobablymoreusefultoindicateinthediagnosisthatinflictedinjuriesarepresent and to provide an additionalcommentonthelikelihoodthatthesecontributedtodeath.

InfantswithinflictedinjuriesshouldnotbeclassifiedasSIDScasesinviewof the presence of more complex pa-thologyandthedifficultythatexistsinexcluding a lethal asphyxial episode.Having these cases as a separate sub-setofSUDI(suddendeathininfancy)will flag them as being different toothercasesofsuddeninfantdeathandwill enable further epidemiologic andpathologicstudiestobeundertaken.

REFERENCES

1. ByardRW,JensenL.Fatalasphyxialepi-sodes in the very young – classificationand diagnostic issues. Forensic Sci medPathol2007;3:177-81.

2. Byard RW. Inaccurate classification ofinfant deaths in australia: a persist-ent and pervasive problem. med J aust2001;175:5-7.

3. ByardRW,KrousHF.Suddeninfantdeathsyndrome–overviewandupdate.PediatrDevelopPathol2003;6:112-27.

4. Willinger m, James LS, Catz C. Defin-ing the sudden infant death syndrome(SIDS):deliberationsofanexpertpanelconvened by the National Institute ofChildHealthandHumanDevelopment.PediatrPathol1991;11:677-84.

5. KrousHF,BeckwithJB,ByardRW,Rog-numTo,BajanowskiT,CoreyT,CutzE,HanzlickR,KeensT,mitchellE.Suddeninfant death syndrome (SIDS) and un-classified sudden infant deaths (USID):a definitional and diagnostic approach.Pediatrics2004;114:234-8.

6. Byard RW, Sawaguchi T. Sudden infantdeath syndrome or murder? Scand J Fo-rensicSci2008;14:14-6.


In 2009, Blair, Byard and Fleming,drawingondiscussionsbetweenSIDS(sudden infant death syndrome) re-searchers and practitioners, proposedan international classification schemeforSUDI(suddenunexpecteddeathininfancy) (Blair et al., 2009). as indi-catedintheirproposal,thetermSUDIincorporatesarangeofcausesofdeath,bothapparentandhidden.WhilsttheproportionofSUDIforwhichacauseisfoundhasrisen,atleast50%remainunexplained in all published studies.Blair,ByardandFlemingpointoutthat,althoughaninternationallyagreeddef-initionofSIDSexists,useofthetermisinconsistent,andbothpractitionersandresearchersoftenresorttoalterna-tivelabelsforthosedeathsthatremainunexplained.Furthermore,approachestotheinvestigationofSUDIvarybothbetween and within countries. Theseinconsistencies complicate researchin the field, and potentially hamperour search for understanding of thesedeaths.Neverthelesstheyarearealitywhichwillnotgoaway.

Blairetal’sproposal is timely. It isessential,asoverallnumbersofunex-pected infant deaths fall, for there tobe collaboration within and betweencountries in continued investigationoftheunderlyingcausesandcontribu-tory factors forthesedeaths.mostre-searchers and practitioners recognisethat SIDS is unlikely to be a singleentity forwhichasimpleexplanationorcurecanbefound,ratheritislikelythatthoseSUDIthatcurrentlyremainunexplained include deaths from un-diagnosedinfections,otherunderlyingmedical conditions, including variousgenetic, cardiac or metabolic condi-tions,andaccidentsornon-accidentaldeathswhichwearecurrentlyunabletoidentify.Theproposedclassificationallows for this, through thecombina-tion of the “avon” grading throughIatoIII,theadditionofcategory0toaccountforincompleteinvestigations,

andthesubgroupsofexplaineddeathswithinthecategoriesofSUDI.

Tobeuseful,anyclassificationsys-tem needs to be simple, yet compre-hensive,andtobeacceptabletobothpractitionersandresearchers.Itneedstoaccommodatedifferencesinpracticebetweenindividualsandonawiderba-sis.TheproposedsystemofBlairetalgoesalongwaytoencompassingtheseelements.ExperienceintheUKhow-everhasshownthattheavonclassifi-cationcanbedifficultforpractitionersto understand and work with, and asimplifiedversionhasnowbeenwidelyadoptedbychilddeathoverviewpan-els and teams responding to unex-pectedchilddeaths(Sidebothametal.,2008).Thisdispenseswiththe(a)and(b)subclassificationandsimplyusesa0– III classification (0– informationnot available; I – no factors or non-contributoryfactorsidentified;II–fac-torspossiblycontributingtodeath;III– fully explained). Individuals usingthis system may choose to subdividecategoriesIandII,butoverallitleadstogreateruniformityandismoreprac-ticalforfront-linepractitioners.

There have previous attempts toclassifySIDSandSUDI,includingtheSan Diego, geSID and ESPID classi-fications (Krous et al., 2004, Kerbl etal.,2003,Findeisenetal.,2004).Theseclassifications acknowledge the varia-tionsinpresentationofSUDIandthedifferencesinapproachestoinvestiga-tion. although they do not directlyconformtothecurrentproposal,thereissufficientoverlaptoproposeamergerof these systems (Table). Itwillprovedifficult to achieve full consensus onany international system of classifica-tion, even amongst researchers, letalone practitioners; nevertheless, thisproposalshouldpromptfurtherdebateintherightdirection.

Thus far, the lack of a generallyaccepted classification system makesit difficult to reliably compare SIDS

orSUDIfiguresworldwide,and thesefiguresusuallycontain incomplete in-formationconcerningautopsyrateandthe incidence of factors potentiallycontributingtodeath in therecordedso-calledSIDScases.astartingpointforallepidemiologicalresearchshouldbe a description of all infant deaths;thenextstagewouldbetodefinewhatis included within any categorisationofSUDI;andfinallyacleardescriptionofthosefinallylabelledasSIDS,con-forming to the internationally agreeddefinitions (Krous et al., 2004, Will-inger et al., 1991), but making clearwhatparametershavebeenusedwithinanyparticularresearchproject.Thisinitselfisnotnecessarilystraightforward,asdifferentareaswillincludedifferentgroupsofdeathswithintheirdefinitionofSUDI.Nevertheless,byincludingallSUDI, within the framework suggest-ed, it ispossibletoseparateoutthosefor which a cause is ultimately foundfrom those that remain unexplained,regardlessofthetermusedtodescribethisgroup.Inordertofullyunderstandthesedeaths,weneedasystemwhichwillallowustogobeyondasimpledi-agnosisof causeofdeath, to incorpo-rate the various shades of grey inher-ent in our approach to investigationandthefindingsthereof.TheproposedsystembyBlairetalgoessomewaytoachieving this, and we believe, withsome modification, could be adoptedbyresearchersandpractitionersalike.

The proposed classification systemcould potentially be a starting pointfor further research and clarification.Thereremaindifficultiesinrelationtowhich deaths should be included: forexample,intheUKandNewZealand,allsuddenunexpecteddeathsininfan-cyarereferredtothecoroner,butthisis not necessarily the case elsewhere,andinmanyplaces,suddendeathsforwhichacauseisimmediatelyapparent,including some accidental deaths, orthosewithanapparentmedicalcause

ProposalforanInternationalClassificationofSUDI:aresponsetoBlair,ByardandFleming

Peter Sidebotham, Thomas Bajanowski, Tom Keens, Thomas Kenner, Reinhold Kerbl, Ronald Kurz, Ed A Mitchell, Rachel Moon, Barry Taylor, Mechtild Vennemann, Jeanine Young, Heinz Zotter


may not be included. It is likely thatwithin the spectrum of SUDI, differ-ent patterns may emerge at differentages, and some sort of developmen-tal trajectory could be developed tofurther explore how different infant

Table: Comparisons of different classification systems for SIdS/SudI

Simplified Blair et al Proposed classification

0

I

II

III

Categories of SudI

Unexplained,incompleteinvestigation.Thiscategorymaybeappliedinconjunctionwithothercategorieswhereanypartoftheinvestigationisincomplete.

Thiscategoryexpandsonotherclassificationsbyincor-poratingcaseswithmissingelementsoftheinvesti-gation,notjustnon-autopsiedcases.

Unexplained;nocon-tributoryfactorsidentified

ThisclassificationdoesnottakeaccountofthepositivefeaturesofaclassicSIDScasesuggestedintheSanDiegoclassification

Unexplained;possiblecon-tributoryfactorsidentified

Explained:RapidinfectionRapidonsetofacute medicalconditionUnrecognisedpre-existing

medicalconditionaccidentaldeathNon-accidentaldeath

San diego Classification

UnclassifiedSuddenInfantDeath:a)deathsthatdonotmeet

thecriteriaforcategoryIorIISIDS,butforwhichalternativediagnosesofnaturalorunnaturalconditionsareequivocal(thesemaybebetterclas-sifiedascategoryIISUDI,withorwithoutacategory0toindicateinadequateinvestigation)

b)casesforwhichautopsieswerenotperformed

CategoryISIDSa)classicfeaturesofSIDS

presentandcompletelydocumented

b)classicfeaturesofSIDSpresentbutincompletelydocumented(thereissomeoverlapbetweenthisclassificationandSUDIcategory0)

TheremaybesomeoverlapbetweencategoryISIDSandSUDIcategoryII,de-pendingonwhichfactorsaredeemedtobepoten-tiallycontributory.

CategoryIISIDSmeetcategoryIcriteria,exceptforsomefeatureswhichraisepossibilitiesofanalternativeexplanation(e.g.outsidethetypicalagerange;closefamilyhistoryofSUDI;possibilityofmechanicalasphyxia;abnormalautopsyfindingsinsufficienttodeter-mineacauseofdeath)

GeSId classification

ThegeSIDclassificationwasbasedonpathologyfindings;beingaresearchbasedclassification,onlycasesinwhichafullautopsyhadbeenperformedwereincluded.

Category1:Withoutpathologicalfindingsfromautopsyandadditionalinvestigations

Category2:Withminorpathologicalfindingsinautopsyandinvestigations

Category3:Severefindings,butnotsufficienttofullyexplainthedeath

Category4:SUDIwithclearcauseofdeathfoundatautopsy.

Excludesknownunnaturaldeaths

ESPId classification

Non-autopsiedSUDI

IncludesanySUDIforwhichanautopsyhasnotbeenperformed;doesnotaccountforothermissingaspectsofaninvestigation

ClassicalSUDI

BorderlineSIDS

ExplainedSUDI

andenvironmental factorsmaybeas-sociatedwithdifferentdevelopmentalstages,anddifferentcategoriesofbothexplainedandunexplainedsuddenin-fantdeaths–anextensionofthewide-ly accepted triple riskmodel ofSIDS

(guntheroth and Spiers, 2002). Fur-therworkwouldbeneededalsototrytoachievesomeconsensusoverwhichassociatedfactorswouldbeincludedincategoryII.Theremay,forexample,bereasonable consensus now to include


prone sleep position, cigarette smok-ing in pregnancy and necropsy find-ings of minor infection; whilst otherfactors,suchastheroleofco-sleepingmayprovemorecontroversial.Finally,thereisacontinuedneedtomoveto-wards greater standardisation of theprocessesbywhichadiagnosisandcat-egorisationofSUDIareachieved.ThecriteriarequiredforadiagnosisofSIDShave previously been agreed withintheinternationalresearchcommunity(Willingeretal.,1991)andincludeacomplete autopsy and review of thecircumstancesofdeathandtheclinicalhistory;whatspecificelementsshouldbeincorporatedwithinthat,andhowthe review should be carried out, forexample through a multi-disciplinarycasereview,remainopentointerpreta-tion,andwillalwaysbedependentonlocal resourcesandworkingpractices,but it ishoped thatover timegreaterconsistency can be achieved, leadinginturntomorerobustdescriptionsofthe causes and circumstances of sud-denunexpecteddeathsininfancy.

REFERENCES

BLaIR, P., BYaRD, R. & FLEmINg, P.(2009)Proposalforaninternationalclas-sificationofSUDI.ScandinavianJournalofForensicScience,15,6-9.

FINDEISEN, m., VENNEmaNN, m.,BRINKmaNN, B., oRTmaNN, C.,RoSE, I.,KoPCKE,W., JoRCH,g.&BaJaNoWSKI,T.(2004)germanstudyonsuddeninfantdeath(geSID):design,epidemiologicalandpathologicalprofile.IntJLegalmed,118,163-9.

gUNTHERoTH, W. g. & SPIERS, P. S.(2002)Thetripleriskhypothesesinsud-den infant death syndrome. Pediatrics,110,e64.

KERBL,R.,ZoTTER,H.,EINSPIELER,C.,RoLL,P.,RaTSCHEK,m.,KoSTL,g.,STRENgER,V.,HoFFmaNN,E.,PER-RogoN,a.,ZoTSCH,W.,SCHoBER,P.,gRaNZ,a.,SaUSENg,W.,BaCH-LER, I., KENNER, T., IPSIRogLU, o.&KURZ,R.(2003)Classificationofsud-deninfantdeath(SID)casesinamulti-disciplinarysetting.TenyearsexperienceinStyria(austria).WienKlinWochen-schr,115,887-93.

KRoUS,H.F.,BECKWITH,J.B.,BYaRD,R.W.,RogNUm,T.o.,BaJaNoWSKI,T.,CoREY,T.,CUTZ,E.,HaNZLICK,R.,KEENS,T.g.&mITCHELL,E.a.(2004) Sudden infant death syndrome

and unclassified sudden infant deaths:a definitional and diagnostic approach.Pediatrics,114,234-8.

SIDEBoTHam,P.,FLEmINg,P.,FoX,J.,HoRWaTH, J., PoWELL, C. & WaL-LaCE, K. (2008) Responding when achilddies.London,DCSF.

WILLINgER,m., JamES,L.&CaTZ,C.(1991)Definingthesuddeninfantdeathsyndrome (SIDS): deliberations of anexpert panel convened by the NationalInstitute of Child Health and HumanDevelopment. Pediatric Pathology, 11,677-684.


First announcement: soria moria meeting 2011may 19-21themes:

● Brain stem research and siDs● genetic risk factors for siDs ● Domestic violence and effect on early brain development● impact of death scene investigation in sudden deaths in infants and small children

contriButors:

●hannah Kinney ●henry F. Krous ●roger W. Byard●Peter Fleming ●Jens grøgaard ● magne raundalen

For more information, please contact: [email protected]

INTROduCTION

Blair et al.1 make an interesting sug-gestion for an International Classifi-cationofSuddenUnexpectedDeathsin Infancy (SUDI). The authors are“SIDSresearchersengagedinidentify-ingdifferentcausesofthissyndrome.”one of the authors previously wrote:“It is also likely that the aetiology ofSIDS is heterogeneous and that thetermSIDSisnotsomuchadiagnosisbutatermcoveringavarietyofmecha-nismswhichresultinacommonlethaloutcome.”2morerecently,KinneyandThachwrote: “If all specificcausesofinfantdeatharedelineated,thedesig-nationofSIDSwillnolongerbeneed-ed.”3 This all implies that SIDS maynothaveasinglecauserequiringonlyasingleInternationalClassificationofDiseases(ICD)rubricandthat it isacompendium of other known causes(diseasesorconditions)currentlyundi-agnosedbythepathologistsanddeathsceneinvestigators.Blairetal.1suggestthatSIDSneedstobe‘parsed’intoitscomponentparts“tobecategorisedforresearchpurposes”toaidthediscoveryofthosemissingcauses.Thisfollowingdiscussionshowsthatrather,SIDSmaybe a single distinct entity unto itselfand that an introspective differentialclassificationsystemmaynotbeneces-saryoruseful.

dISCuSSION

SIDShasacharacteristicandvirtuallyuniqueagedistribution,theexceptionbeinginfantbotulismonset(IB).4TheSIDSagedistributionhasnotchangedsincetheearly1970swhenRaring5firstnotedthatitappearedtobea2-param-eterlognormaldistribution.Forexam-ple,Pollack6hasshownthatthelognor-malformoftheSIDSagedistributionhasnotchanged intheU.S.between1989and1999inspiteoftheshiftofpreferredsleeppositionfromproneto

supine. goldberg et al.7 showed howmost all other ICD classifications ofinfant death have a distinctly differ-entagepatternwithamaximalrateatbirththatdecreaseswithage.Thisbe-havior isopposite toSIDS thathasavirtuallyzerorateatbirthandincreaseswithage.mage8hasshownbyameta-analysis of 15 combined independentSIDSagedistributions that theSIDSage distribution, shown as Figure 1,wasbetterdescribedbya4-parameterlognormal distribution, also knownas the Johnson SB distribution.9 ThistransformtreatsSIDSagexasboundedbetween a minimum age (xmin) and amaximumage(xmax).Thelogarithmofthetransformedage,y=(x-xmin)/(xmax-x),isthenboundedbetween-∞and+∞andisfitwellbyagaussiannormaldistribution.8

LetSIDSbeasummationofsubsetsof undiagnosed independent causesof death, such as neurological pre-maturity (NP), respiratory infection

(RI), positional asphyxiation (Pa),etc. The authors state “Traditionallyall [such] unexplained SUDI deathshave been labeled as sudden infantdeath syndrome (SIDS).”1 Cramér’sTheorem10translatesasfollows:‘ifanyfinite sumof independent real-valuedrandom variables is normal, then thesummandsmustallbenormal.’11IftheSIDS age data set is a summation ofundiagnosedNP,RI,Pa,... independ-entagesubsets(SIDS=NP+RI+Pa+ ...) then all NP, RI, Pa, etc., mustalso be 4-parameter lognormally dis-tributed with same xmax and xmin. Butas vital statistics show,7,12 the neona-tal period (<28 days), and sometimesindeed the very first day of life, areperiodsofmaximalmortality for suchconditions as neurological congenitalanomaliesandothernon-SIDScausesofdeath.This is indirect contrast toSIDS where the above transform (y)ofSIDSage(x)hasagaussianshape,withminimalmortalityatbirth,maxi-

CommentaryofBlairetal.ScandJForensSci,2009;156-9ProposalforanInternationalClassificationofSUDI:IsthisTripNecessary?

David T. Mage, Ph.D.a.I.duPontHospitalforChildren,Wilmington,DE,USa

The 4-parameter lognormal age distribution of 19,949 SIdSfrom 15 Global data Sets Combined

m, month of life

Figure 1. ThecharacteristiclognormalagedistributionofSIDS.8,9Cramér’sTheoremrequiresanyproposedundiagnosedcauseofSIDStohavethesamegaussianlognormaldistributionalform.10,11

SIDS


malmortalitybetween2and4monthsof life, and mortality decreasing to-wardszeroafteroneyear.BecauseagesofdeathforcausessuchasNP,RI,Pa,etc.,allsuggestedtoconstitutesubsetsoffalse-positiveSIDS,arenotlognor-mallydistributed - thatwouldviolateCramér’s Theorem. Therefore all theputative subsets of cause-of-deathclaimed to be now masquerading asSIDS (except IB) cannot possibly betrue subsetsofSIDS.anotherwayoflookingatthisimpossibility,isthatallagedistributionsofeachsupposedun-diagnosedcauseofSIDSwouldhavetobedrawnundertheenvelopeboundedbytheSIDSagedistributionofFigure1sothattheirsummationequaledtheagedistributionofSIDS.

SuMMaRy

SIDS in all developed countries withhighmedicalstandardshasaconsistentlognormalagedistributionandacon-sistent50%maleexcess.8,13giventhatthesecasescomefromdifferentsocie-tieswithdifferentchildcarepracticesandarediagnosedbydifferentpatholo-gistswithdifferentlevelsofexpertise,theconsistencyoftheirglobalfindingsintermsofageandgenderimplythatSIDS is indeed a distinct phenom-enon.ThissuggeststhatwhatarenowdeemedtobepotentialcandidatesforundiscoveredcausesofSIDSaremere-ly risk factors for SIDS and that theappearanceofsubsetsariseswhereoneriskfactorhappenstobemoreintense

than the others. a unifying theoryforSIDSsuggests that itoccurswhena status of a potentially terminal cer-ebralanoxiaoccurs inneuronsof therespiratorycontrolcenterofthebrain-stembyseveralindistinctpathways.14,15Thisstatuscanbereachedbydifferentcombinations of risk factors that arenottobeconfusedwithcauseofdeath(e.g.,pronesleeppositionorlow-graderespiratoryinfection).Whenthatsta-tusisreached,theinfantinpossessionof an X-linked dominant allele thatallows anaerobic oxidation to occurin the anoxic neurons will survive orperhapspresentasanon-fatalappar-entLifeThreateningEpisode(aLTE),buttheinfantwiththecorrespondingnon-protective recessive X-linked al-lelewilldieofSIDS.15ThisX-linkagemechanism predicts the consistent50%maleexcessofSIDS,forwhichnootherexplanationappearsinthemedi-calliterature.16

REFERENCES

1. Blair PS, Byard RW, Fleming PJ. Pro-posal foranInternationalClassificationof SUDI. Scand J Forensic Sciences2009;15:6-9.

2.ByardRW.Suddeninfantdeathsyndrome-a‘diagnosis’insearchofadisease.JClinForensicmed.1995;2:121-8.

3. Kinney HC, Thach BT. The sudden in-fant death syndrome. N Engl J med.2009;361:795-805.

4. arnon SS, Breast-feeding and toxigenicintestinal infections: missing links inSIDS? in Sudden Infant Death Syn-drome. Tildon JT, Roeder Lm, Stein-

schneidera, eds.NewYork,academicPress;1983:539-555.

5. Raring RH. Crib Death: Scourge of In-fants—ShameofSociety.Hicksville,NY:ExpositionPress;1975:93-97.

6. Pollack Ha. Changes in the timing ofSIDSdeathsin1989and1999:indirectevidence of low homicide prevalenceamong reported cases. Paediatr PerinatEpidemiol.2006Jan;20(1):2-13.

7.goldbergJ,HornungR,YamashitaT,We-hrmacherW.ageatdeathandriskfac-tors in sudden infant death syndrome.austPaediatrJ.1986;22Suppl1:21-28.

8.mageDT.aprobabilitymodelfortheagedistribution of SIDS. J. Sudden InfantDeath Syndrome and Infant mortality1996;1:13-31.

9.JohnsonNL.Systemsof frequencycurvesgeneratedbymethodsoftranslation.Bi-ometrika1949;36:297-317.

10.CramérH.ÜbereineEigenschaftdernor-malenVerteilungsfunktion(ingerman).mathematischeZeitschrift1936;41:405–414.doi:10.1007/BF01180430

11. Weisstein EW. “Normal Sum Distribu-tion.” From mathWorld--a WolframWeb Resource. http://mathworld.wolf-ram.com/NormalSumDistribution.html.

12. Centers for Disease Control and Pre-vention, National Center for HealthStatistics. Compressed mortality Files1979-2005. CDC WoNDER on-lineDatabase.accessedathttp://wonder.cdc.gov/,october15,2009.

13.mageDT,DonnerEm.ageneticbasisforthesuddeninfantdeathsyndromesexra-tio.medHypotheses.1997;48:137-142.

14.mageDT,DonnerEm.Thefiftypercentmaleexcessofinfantrespiratorymortal-ity.actaPaediatr.2004;93:1210-1215.

15. mage DT, Donner Em. a Unify-ing Theory for SIDS. Int J Pediatr.2009;2009:368270.

16.Finnströmo.ageneticreasonformaleexcess in infant respiratory mortality?actaPaediatr.2004;93:1154-1155.


INTROduCTION

Itisnowwell-recognizedthatindividu-alswithepilepsyhavehighermortalityratesthanage-matchedcontrols.mor-bidityandmortalitymayberelatedtounderlying conditions that predisposetoepilepsy,suchasalcoholismorheadinjury, or may be associated with ac-cidentalimmersionorburnsoccurringduringaseizure.Deathsmayoccurdur-ingstatusepilepticus,oralternatively,fatalities may occur for reasons thatare ill-understood but that relate tothe intrinsic nature of the condition.There has been a reported 40 timesincreased risk of sudden unexpectedandunexplaineddeathinthosewith,compared to thosewithout, epilepsy1.This increase in mortality has beendocumentedatallages2-4.

Theroleofasphyxia/suffocationintheterminalepisodehasbeendebated,with suggestions that epileptics maydie from asphyxia due to obstructionorcompromiseoftheirairwaysduringa seizure, contrasting with assertionsthat asphyxia is not a significant fac-tor and that the ‘myth of the pillow’should be dispelled5,6. However, we

have observed that individuals whohavediedunexpectedly fromepilepsyareoftenfoundinafacedown,proneposition.Toascertainwhetherthereisa higher rate of prone positioning inthosedyingof epilepsy, and to inves-tigate whether this may relate to themechanism of death, the followingstudywasundertaken.

MaTERIalS aNd METHOdS

Review was undertaken of all deathsattributedtoepilepsyatForensicSci-ence Sa (FSSa) between January1994 and august 2005. FSSa pro-vides autopsy services to the coronerofSouthaustraliaandservesamixedurbanandruralpopulationofapproxi-mately 1.5 million people. all caseshad fullpolice/coronial investigationsandcompleteautopsies.Caseswerein-cludedinthestudyifthevictimswerefounddeadandfulfilledthecriteriaforsudden unexpected and unexplaineddeath in epilepsy (SUDEP)7. Caseswere excluded if the deaths involvedaccidentssuchasdrowningordrugtox-icity.Specificinformationwasgatheredfrombothpoliceandpathologyreportsconcerning the location and positionof thebodywhen found,prior toanydisturbanceof thebodyand scenebyobservers or ambulance personnel.Body locations were recorded as bed,bedroom,homeoroutdoors,andbodyposition was recorded as supine (faceup),prone(facedown),sideorseated.Commenton thefirmness of the sur-faces that the bodies were resting on

was not possible as this informationwas not usually contained in reports.allbrainswereexaminedmacroscopi-callyandhistologically.Noanalysisoftoxicologyresultswasundertaken.

acontrol groupwas selected fromother FSSa coronial cases of naturaldeaths where the deceased had beenfound dead in bed with clear docu-mentationofthepositionofthebody.Statistical analyses were undertakenusingSPSS11formacintoshandChiSquare testing. any association withp<0.01wasconsideredsignificant.

RESulTS

Epileptic group:Eighty-onecaseswerefoundofsuddenunexpected and unexplained deathin epilepsy fulfilling the criteria forSUDEP,consistingof47malesand34females (58% and 42% respectively).Theagerangewasfrom1to79years(mean=37years).Themostcommonpositionof thebodywhen foundwasprone (N=52; 64%) (p<0.001), fol-lowedbysupine(N=17;21%),seated(N=7;8.6%)andside(N=5;6%).The most common locations were inbed(N=43;53%),inthehomeout-sidethebedroom(N=19;23%),thebedroom(N=10;12%)andoutdoors(N=8;10%).ofthe38victimswhowerenotinbed,30wereonafloorand7wereseated.Inonecasethelocationof the body was not stated althoughthe position was documented. of the30 victims found lying on a floor, 19(63%)wereprone.

addRESS FOR CORRESPONdENCE:Prof Roger W. Byard,discipline of Pathology,level 3 Medical School North Building,The university of adelaide, Frome Road,adelaide 5005, australiaPhone: (618) 8303 5441Fax: (618) 8303 4408Email: [email protected]

Isbodypositionrelatedtothemechanismofdeathinfatalepilepsy?

Roger W. Byard1,2, John D Gilbert2, Drew Marshall2

DisciplineofPathology,TheUniversityofadelaide1&ForensicScienceSa2,adelaide,Southaustralia,australia.

aBSTRaCT a retrospective study of 81 epileptic deaths of individuals autopsied at Forensic Science Sa between January 1994 and august 2005 revealed 47 males and 34 females aged from 1 to 79 years (mean = 37 years). The most common position of the body when found was prone (N = 52; 64%), followed by supine (N = 17; 21%), seated (N = 7; 8.6%) and side (N = 5; 6%). The most common locations of the bodies were in bed (N = 43; 53%), in the home outside the bedroom (N = 19; 23%), the bedroom (N = 10; 12%) and outdoors (N = 8; 10%). Of the 38 victims who were not in bed, 30 were on a floor and 7 were seated. (In one case the location of the body was not stated although the position was documented.) Of the 30 victims found lying on a floor, 19 (63%) were prone. a significantly greater number of epileptic individuals were found dead lying in a prone compared to a supine position (p<0.001), contrasting dramatically with 50 controls who had died suddenly in their beds of whom only 2 (4%) were prone (p<0.001). The preponderance of deaths in the prone position with the face down would certainly be in keeping with suffocation/asphyxia playing a role in the terminal episode. as SudEP could result from the integration of a number of mechanisms rather than from the effect of one element in isolation, it is possible that compromise of respiration related to body position might also exacerbate a tendency to lethal cardiac arrhythmia.

Keywords: epilepsy, sudden death, prone, sleep, SudEP


Control groupThe 50 control cases consisted of 35malesand15females(70%and30%,respectively), ranging in age from 12to92years(mean=64years).Causesof death included cardiovascular dis-ease (mostoften ischemic andhyper-tensiveheartdisease)(N=34,68%),respiratorydisease(mostoftenasthmaand chronic obstructive airways dis-ease)(N=8,16%),neurologicaldis-ease (cerebrovascular accidents andtumors)(N=4,8%),gastrointestinaldisease (ruptured esophageal varicesandacuteperitonitis(N=3,6%)anddiabetesmellitus(N=1,2%).

amongthecontrolcases themostcommon position of the body whenfound was supine (N = 30; 60%)(p<0.001), followedby side (N=18;36%)andfinallyprone (N=2;4%).Thepositionsofbodiesinboththeep-ilepticandcontrolgroupsareshowninFigure1demonstratinga significantlygreaternumberofepilepticsfoundinapronepositionwhencomparedtocon-trols(p<0.001).

dISCuSSION

Sudden unexpected and unexplaineddeath in epilepsy (SUDEP) has beendefined as the ‘sudden, unexpected,witnessed or unwitnessed, non-trau-matic, and non-drowning death inpatientswithepilepsy,withorwithoutevidence for a seizure and excludingdocumented status epilepticus wherenecropsyexaminationdoesnotrevealatoxicologicaloranatomicalcausefordeath’7. other epileptic deaths were

attributedtoairwayobstruction,aspi-ration,traumaordrowning,andthosewhere there was significant underly-ing cardiorespiratory disease. Criteriafor SUDEP were further refined toincludethefollowingsixfeatures:thevictimsuffered fromepilepsy(definedasrecurrentunprovokedseizures),thevictim died unexpectedly while in areasonable state of health, the deathoccurred‘suddenly’(inminutes)whenknown,thedeathoccurredduringnor-malactivitiesandbenigncircumstanc-es,anobviousmedicalcauseofdeathwasnotfound,andthedeathwasnotthe direct result of the seizure or sta-tus epilepticus1. While these authorsexcludeddeathsduetoaccidents,theydidnotautomaticallyexcludecasesforconsideration based on circumstancessuch as possible drowning. a classifi-cation of ‘definite SUDEP’, ‘probableSUDEP’, ‘possible SUDEP’ and ‘notSUDEP’ was proposed based on theavailability of information, and thecertainty with which diagnoses couldbemade1.

The cause of death in SUDEP re-mains speculative with sudden deathbeing attributed to suffocation frombedding, asphyxia, pulmonary edemaand cardiac arrhythmia. Specific fatalmechanisms have included sympa-thetic-induced cardiac arrhythmia,parasympathetic-induced bradycardia/asystole, apnea/respiratory failure, acombinationofarrhythmiaandapnea,andneurogenicpulmonaryedemawithcardiacfailure8(Table 1),howeverevi-denceisoftennotstronginsupportofspecificmechanisms.

althoughoneofthestandardthe-ories to explain this kind of suddendeathinvolvesautonomicnervoussys-tem instabilitywithabnormalcardiacrhythms during seizure activity, dataonlethalarrhythmicdeathshavebeencontradictory, with few recordings ofarrhythmiasbeingtakenduringlethalepisodes9-11.Infact,mostreportedclin-icalandexperimentalcasesofarrhyth-mias associated with cerebral eventshave not been fatal12,13. In a study of338monitoredepilepticpatientstherewas no demonstrable increase in car-diacarrhythmiascomparedtothegen-eral population, with only 5% of pa-tientsshowinghigh-riskpatterns14,15.Itis also possible that epilepsy may notbetheprimaryeventbutissecondaryto anunderlyingcardiac abnormality,withseizuresbeingcausedbycerebralhypoxiaarisingfromventriculartachy-cardia.Insupportofthisconcepttherehasbeenanincreasedincidenceofepi-lepsyreportedinpatientswithheredi-taryprolongationoftheQTinterval16.

Determining whether anoxia mayhaveplayedaroleinthelethaleventis also difficult as some authors havesuggestedthatseizuresmaybedirectlyresponsible for delayed respiratory ar-rest17, contrasting with others whohaveasserted that apneaplaysonly asecondaryroleduringthetonicphaseoftheseizure8.giventhatepilepticin-dividualsmaybe inasituationwhereadiminishedconsciousstateprecludesthem from maintaining or protectingtheirairway,itwouldnotseemunrea-sonabletopostulatethatlethalairwaycompromise from suffocation due tosoftbedding,orfrompositionalasphyx-iawithangulationoftheairwaycouldcausedeath6.ascertainingwhetherornot suffocationmayhaveoccurred is,however,oftencomplicatedbyaltera-tionofscenefindingsandbythelackofdiagnosticfindingsatautopsy.

In thecurrent studya significantly

Figure 1:Positionofthebodywhenfoundin74casesofepilepsyandin50controlcasesdyinginbedofothertypesofnaturaldiseases(7casesofepilepsywhowerefoundseatedwerenotincluded)

Table: Possible causes of suddendeathinepilepsy

1. Trauma2. Suffocation3. asphyxia4. Cardiacarrhythmia(sympathetically

mediated)5. Bradycardia/asystole(parasympatheti-

callymediated)6. apnea/respiratoryfailure7. arrhythmia/apnea8. Neurogenicpulmonaryedemawith

cardiacfailure


greater number of epileptic individu-als were found dead lying in a pronecomparedtoa supineposition(prone=52;supine=17;p<0.001).Thiscon-trasteddramaticallywith the50 con-trols who had died suddenly in theirbedsofwhomonly2(4%)wereprone(p<0.001).Itispossiblethatindividu-alswhodiesuddenlyfromnon-epilep-tic conditions may be more likely tobe sleepingon their backs if they arefeeling unwell prior to the terminalepisode.Theymayalsohavecollapsedwhile trying to get out of bed. Thismayexplaintheverylowrateofpronesleepinginthecontrols.

Itisnotedthat40%oftheepilepticsinthecurrentstudyinvolveddeathinbedorinabedroom.Thisisinkeepingwithotherstudieswhereupto79%ofcases of sudden epileptic death havealsobeenfoundinthissituation18,andalsowiththeknownassociationofsud-dendeathinepilepsywithsleepmostlikely related to reduction in seizurethreshold19,20.

There are several possibilities forthe significantly higher rate of proneposition in theepilepticgroup. If thevictimsusuallysleptproneitispossiblethatalethalarrhythmiageneratedbyaseizurecouldresultinrapiddeathbeforethedeceasedcouldrollover.Howeverifthiswasthecaseitmightbeexpectedthatthecontrolcaseswherelethalar-rhythmiascomplicatedischemicheartdiseasewouldalsodie in thepositionof sleepand that there should, there-forebeahighernumberofpronecasesthanhasbeenrecorded.Thefindingof19epileptics(63%)intheproneposi-tionoutofatotalof30lyingonaflooralsosuggeststhatproneissignificantlyassociatedwithsuddenepilepticdeathwhetherinbedornot.Itmaybethatepilepticswhofitinasupinepositionarelesslikelytoobstructtheirairways,and that loss of consciousness in thepronepositioncausessuffocationwhenthefacepushesintoafloorormattress,orthenoseandmouthisobstructedbyapillow.Thesoftnessoftheunderlyingbeddingcouldexplainthehighrateofdeathinbed.

an increased rateof suddendeathassociatedwiththepronepositionhasalso been shown in infants dying ofsuddeninfantdeathsyndrome(SIDS).Whiletheprecisemechanismsrespon-sible for this increase in risk in theface down position are not known,a number of possibilities have beenpostulated including diaphragmaticsplinting/fatigue,rebreathingofcarbon

dioxide, reflex lowering of vasomo-tortonewithtachycardia,bluntingofarousal responses including decreasedcardiac response to auditory stimula-tion,alterationofsleeppatterns,com-promise of cerebral blood flow, upperairway obstruction from distortion ofnasalcartilages,posteriordisplacementofthemandibleandsoftbedding21.Itis possible that similar effects may beexperiencedby anunconsciousproneindividualwhohasjusthadanepilep-ticseizure.

althoughitisprobablethatSUDEPresultsfromtheintegrationofanumberofmechanismsratherthanfromtheef-fectofoneelementinisolation,asinothersituationswherecomplexpatho-physiological processes are acting, wewouldnotdismissthepossiblecontri-bution of suffocation/asphyxia. Thepreponderanceofdeathsinthepronepositionwiththefacedownwouldcer-tainlybe inkeepingwith this.Whilethedeathsmaynotbepurelyasphyxialin nature, compromise of respirationmight also exacerbate a tendency tolethal cardiac arrhythmia, producinganadditiveeffect.Pathologistsshouldthereforealwaysobtainaclearaccountof the circumstances of death in epi-leptics, includinganaccuratedescrip-tionofthepositionofthebodywhenfound, the placing of the nose andmouth,thepresenceofanyobstructivematerialsaroundtheface,thetypeofbedding and the softness/firmness ofthe underlying surface. Fixed ventrallividitywithcongestion,petechiaeandecchymosesandpressureblanchingontheanteriorchestandabdominalwallsmay also be used to provide informa-tiononpositionatthetimeofdeath.

REFERENCES

1, annegersJF,CoanSP.SUDEP:overviewof definitions and review of incidencedata.Seizure1999;8:347-52.

2. Breningstall gN. mortality in pediatricepilepsy.PediatrNeurol2001;25:9-16.

3. CallenbachPm,WestendorpRg,geertsaT,artsWF,PeetersEa,vanDonselaarCa, Peters aC, Stroink H, Brouer oF.mortalityrisk inchildrenwithepilepsy:theDutchstudyofepilepsyinchildhood.Pediatrics2001;107:1259-63.

4. DonnerEJ,SmithCR,SneadoC.Sud-denunexplaineddeathinchildrenwithepilepsy.Neurology2001;57:430-4.

5. Coyle HP, Baker-Brian N, Brown SW.Coroners’ autopsy reporting of suddenunexplaineddeathinepilepsy(SUDEP)intheUK.Seizure1994;3:247-54.

6. NashefL,garnerS,SanderJW,FishDR,ShorvonSD.Circumstancesofdeathinsudden death in epilepsy: interviews of

bereaved relatives. J Neurol NeurosurgPsychiatry1998;64:349-52.

7. NashefL,BrownS.Epilepsyandsuddendeath.Lancet1996;348:1324-5.

8. Leestma J. Forensic Neuropathology.NewYork:RavenPress,1988.

9. DasheiffRm,DickinsonLJ.Suddenun-expected death of epileptic patient duetocardiacarrhythmiaafterseizure.archNeurol1986;43:194-6.

10. LiedholmLJ,gudjonssono.Cardiacar-restduetopartialepilepticseizures.Neu-rology1992;42:824-9.

11. oppenheimer S. Cardiac dysfunctionduringseizuresandthesuddenepilepticdeathsyndrome.JRSocmed1990;134-6.

12. DasheiffRm.Suddenunexpecteddeathinepilepsy:aseriesfromanepilepsysur-geryprogramandspeculationonthere-lationshiptosuddencardiacdeath.JClinNeurophysiol19918:216-22.

13. KiokmC,TerrenceCF,FrommgH,La-vineS.Sinusarrest inepilepsy.Neurol-ogy1986;36:115-6.

14. Keilson mJ, Hauser Wa, magrill JP.Electrocardiographic changes duringelectrographic seizures. arch Neurol1989;46:1169-70.

15. KeilsonmJ,HauserWa,magrillJP,gold-man m. ECg abnormalities in patientswith epilepsy. Neurology 1987;37:1624-6.

16. Bricker JT, garson aJ, gillette PC. afamilyhistoryofseizuresassociatedwithsudden cardiac deaths. am J Dis Child1984;138:866-8.

17. EarnestmP,ThomasgE,EdenRa,Hos-sackKF.Thesuddenunexplaineddeathsyndromeinepilepsy:demographic,clin-ical, and postmortem features. Epilepsia1992;33:310-16.

18. SchwenderLa,TroncosoJC.Evaluationofsuddendeathinepilepsy.amJForen-sicmedPathol1986;7:283-7.

19. DinnerDS.Effectofsleeponepilepsy.JClinNeurophysiol2002;19:504-13.

20. marlow B. Sleep and epilepsy. NeurolClin2005;23:1127-47.

21. Byard RW, Krous HF. Sudden infantdeath syndrome: overview and update.PediatrDevPathol2003;6:12-27.

Table 2:Checklist of infotmation re-quired from the scene in epilepticdeaths

1) Locationofthebody2) Positionofthebody3) Positionofthemouthandnose4) obstructivematerialsaroundface5) Typeofbedding6) Softnessofunderlyingsurface7) Positionoflividity8) other observations e.g. urinary in-

continence,bleedingfromthemouth,typesofmedicationsetc.


INTROduCTION

annually, about 14.000 to 18.000drives are suspected of drunk driv-ing in Denmark, but until year 2000averylimitednumberofdrivershavebeen suspected for driving under theinfluence of drugs other than alcohol(1,2).Since2000,thenumberofcasesofdrivingundertheinfluenceofdrugshas increased. Benzodiazepines andcannabis are some of the most com-monly detected drugs of abuse in theNordic countries, but also cases withamphetamine have increased in thelast years (3,4). Recently, there hasbeena strongpublicaswellaspoliti-cal interest in Denmark in the abuseof ecstasy (mDma). mDma is aring substituted derivative of meth-amphetamineabusedasapsychedelicsubstance.metabolicdemethylationofmDmaproducesmDa,whichisalsopharmacological active. mDma andrelateddrugssuchasmDaandmDEaare listed as prohibited drugs in theDanish law (5). These designer am-phetamines can cause hallucination,paranoid delirium, seizures, psychosis,coma and even death (6-8). The de-tection of designer amphetamines inbiological fluids is therefore of majorconcern in forensic toxicology. This

paperpresentssomedataandstatisticsontheabuseofamphetaminesandde-signeramphetaminesamongdriversinDenmarktogetherwithadiscussionofthedevelopmentinrecentyears.

MaTERIalS aNd METHOdS

Specimens of blood from drivers sus-pected of impaired driving were sub-mittedtotheDepartmentofForensicChemistrybythepolice.From1997to2007atotalof2461samplesweresub-mittedfortoxicologicalanalysis.

abroadroutinetoxicologicalanal-ysis inbloodwasappliedforcommondrugs, narcotics and alcohol. Confir-mationofamphetaminesanddesigneramphetamineswereperformedbyliq-uid-liquid extraction of blood and aderivatizationfollowedbygaschroma-tography-massspectrometry(gC/mS)analysis(9).

RESulTS

The development in positive amphet-amines and designer amphetamines cases

Thedevelopmentoftrafficcasestestedpositiveforamphetaminesanddesign-er amphetamines in Denmark since1997 is shown in Figure 1. annually,the total numbers of traffic cases fortoxicological analysis were between103and345inthisperiod,whileabout14.000 to18.000 blood samples fromDanish drivers were investigated foralcohol annually. From 1997 to 2007at totalof2461sampleswere investi-gatedforcommondrugsandnarcotics.InFigure1,adecreaseinthenumberof positive amphetamine cases is ob-servedfrom1998to2000andasimul-taneous increase of positive designeramphetaminescasesisobserved.From2000 increasesofbothamphetaminesand designer amphetamines cases areobserved. The total number of traf-

FindingsofamphetaminesandecstasyindriversinDenmarkfrom1997to2007Marie Katrine Klose Nielsen and Sys Stybe JohansenSectionofForensicChemistry,DepartmentofForensicmedicine,FacultyofHealthSciences,UniversityofCopenhagen,DK-2100Copenhagen,Denmark.

CORRESPONdING addRESS:Marie Katrine Klose Nielsen Section of Forensic Chemistry,department of Forensic Medicine, Faculty of Health Sciences, university of Co-penhagen, Frederik v’s vej 11, dK-2100 Copenhagen, denmark.E-mail: [email protected]

aBSTRaCT There has been a strong public and political interest in denmark in the abuse of designer amphetamines such as ecstasy (MdMa). In the period from 1997 to 2007, 2461 samples taken from drivers suspected of impaired driving were submitted to the laboratory by the police for toxicological analysis. These investigations have shown a new pattern in drug abuse among drivers and an increase in the number of samples tested positive for designer amphetamines such as MdMa, Mda and MdEa. The first two traffic cases involving designer amphetamines were found in 1997. Four cases were found in 1999. In the last 10 years cases involving designer amphetamine have increased to 13% of all traffic cases requested for toxicological analysis in denmark. In these 114 designer amphetamines cases involving mainly male drivers the dominating compound was MdMa. a few positive cases of MdEa were also observed, but mostly in mixtures with MdMa and/or Mda. The whole blood concentration of MdMa ranged from 0.02 to 3.7 mg/kg with a mean value of 0.47 mg/kg and a median value of 0.34 mg/kg. The concentration varied from low abuse level to high toxic level. In many of the cases, additional drugs were found in the blood such as benzodiazepines, tetrahydrocannabinol and cocaine metabolites.

Keywords designer amphetamines, MdMa, drivers, blood

Figure 1. Thedevelop-ment of traffic casestested positive for am-phetamines (ampheta-mineandmethamphet-amine) and designeramphetamines (mDma, mDa and mDEa) against all trafficcases investigated inDenmarksince1997


ficcases involvingamphetaminesanddesigner amphetamines has increasedfrom 23 cases in 1997 to 69 cases in2007 corresponding to 11 and 20%ofall trafficcases, respectively.Inthewhole period (1997-2007), the totalnumberofcasespositiveforampheta-mines and designer amphetamineswas 436. The designer amphetaminesrepresented less than 13% of all am-phetamines cases until 1999, but in2000 they were found in 43% of allamphetamines cases (Table 1). Since2001,thedesigneramphetamineswerefound in 22 to 48% of all ampheta-mines cases.The totalnumberof de-signeramphetaminecasesinthewholeperiodwas114,in78casesamixtureofbothamphetaminesanddesigneram-phetamineswere found. In thewholeperiod the designer amphetaminesconstituted26%ofthe436cases.

Designer amphetaminesCharacteristicparameterssuchassex,

age and concentrations of designeramphetaminesintrafficcasesinDen-markfrom1997to2007areshowninTable 1. The first two mDma casesamongdriversinDenmarkwerefoundin 1997, which corresponds to 0.9%of all 213 traffic samples investigatedin1997.BothcasesinvolvedmDma,mDEaandmDa.In1999,fourcaseswere positive for mDma (~1.8%),and in the period from 2000 to 2007between 5 and 30 cases a year werefound positive for designer ampheta-mines(4to13%ofalltrafficcases).Ingeneral,thedominatingcompoundwasmDma.ThehighincidenceofmDainmDmacasesandthefactthattheconcentrationofmDawas5-10%ofthemDmaconcentration in98%ofthesecasesconcurwithmDasnatureas a metabolite in mDma consump-tion.mDawasonlydetectedaloneinonecasein2000.afewcasesinvolvedmDEa and always in a mixture withmDa and/or mDma except for one

case.ThedominanceofmDmainthedesigner amphetamines concurs withthe findings in seizures in Denmark.mDmawas themajorcomponent indesigner drugs tablets in the period(10).

The whole blood concentrationofmDmain114 trafficcases rangedfrom 0.02 to 3.7 mg/kg with a meanvalueof0.46mg/kgandamedianval-ueof0.34mg/kg(Table1).Thebloodconcentrations of mDa and mDEaranged from 0.02 to 0.39 mg/kg andfrom0.03to0.17mg/kg,respectively.The mean values were 0.05 and 0.09mg/kg,respectively.ThemDmacon-centrationsrangefromlowabuseleveltohightoxiclevel.

The main part of the cases showninTable1concernedmen.onlythreecases involved females, which corre-sponded to 2.6% of the designer am-phetaminecases in thewholeperiod.Forbothgenders,theagerangedfrom17to32yearsandthemedianwas21years.

year Total Total1 designer2 designer Mda3 MdMa MdEa Sex age Traffic amph. amph. amph. Range Range (mg/kg) Range(mg/kg) Range Cases Cases Cases %oftotal (mg/kg) Mean (Cases) Mean (Cases) Median amph. cases Mean (Cases)

1997 213 23 2 6 0.05 0.23 0.12-0.17 m:2 19-22 (1) 0.23(2) 0.15(2) F:0 21

1998 214 32 32 0 - - - -

1999 222 31 4 13 0.06-0.45 m:4 20-30 0.19(4) F:0 25

2000 235 23 10 43 0.22 0.02-1.1 0.03 m:10 9-30 (1) 0.56(8) (1) F:0 24

2001 103 22 5 23 0.15-0.62 m:5 19-24 0.40(5) F:0 21

2002 123 38 15 39 0.05 0.05-1.4 m:15 17-27 (1) 0.38(15) F:0 21

2003 278 50 11 22 0.03-0.73 m:11 19-32 0.37(11) F:0 21

2004 258 32 9 28 0.04-1.5 m:8 18-30 0.60(9) F:1 23

2005 233 63 30 48 0.03-0.39 0.03-3.7 0.05-0.08 m:29 18-31 0.16(5) 0.54(30) 0.07(2) F:1 20

2006 237 53 13 25 0.03 0.02-1.6 m:12 17-30 (1) 0.46(13) F:1 20

2007 345 69 15 22 0.02 0.09-1.1 m:15 18-31 (1) 0.43(15) F:0 20

Total 2461 436 114 26 0.02-0.39 0.02-3.7 0.03-0.17 m:111 17-32 0.11(10) 0.46(112) 0.09(5) F:3 21

1Includingamphetamine,methamphetamine,mDa,mDmaandmDEa.2IncludingmDa,mDmaandmDEa.3onlycaseswheretheconcen-trationofmDawashigherthan10%oftheconcentrationofmDmaareshown.

Table 1. Characteristicsparametersofdesigneramphetaminesin114positivecasesinDanishdriverssince1997.


In the period from 1997 to 2007,additionaldrugsornarcoticswerede-tected in 83 cases corresponding to73%ofthecases.Themostfrequentlydetected drugs were tetrahydrocan-nabinol (THC), cocaine and/or itsmetabolite benzoylecgonine and ben-zodiazepines,-mainlydiazepam.Bloodalcohol concentration (BaC) wasdeterminedin18casesofalldesignerdrugcases(16%)ofwhichelevencas-esexceededtheDanishtrafficoffencelimit(0.05%).

Amphetamines322 cases were positive for ampheta-mine of which seven cases showedamphetamine as a metabolite frommethamphetamine consumption.methamphetamine was detected in36cases,butonlyinelevencaseswasmethamphetamine detected alone.Thewholebloodconcentrationofam-phetamine ranged between 0.01 and2.0 mg/kg and the mean and medianwere0.25and0.14mg/kg,respectively.The concentration of methampheta-mine ranged from0.01 to0.74mg/kgwithmeanandmedianvaluesof0.13and 0.06 mg/kg, respectively. Bothdrugs ranged from low abuse levelto toxic level. The cases mostly con-cernedmen,whichwerealsoobservedfor the designer amphetamines cases.only eleven cases involved femalescorrespondingto4%of theampheta-mines cases. The age of the driversrangedfrom17to52years(median:24years)formenandfrom17to41years(median:24years)forfemales.

dISCuSSION

The presented data indicates thatabuseofdesigneramphetaminesisoc-curring and increasing in Denmark.Before 1997 designer drugs did notoccur and now they are observed inabout5%ofalltrafficcasesinDK.Theincreasemaybeduetothehighatten-tiononthesedrugsinthepublicorahighawarenessamong thepoliceduetoearlywarningprogramandnewtraf-fic act in late 2007. amphetamine isstillthemostfrequentlyobservedcom-poundof the amphetamines in trafficcases, but designer amphetamines aremore common now. mDma is themostfrequentlyobserveddesigneram-phetamineandmDmaisaverytoxicsubstance that affects the psychomo-

tor skills and impairs driving. StudieshaveshownthattheuseofmDmaisnot consistent with safe driving andthat impairmentofvarious typesmaypersistforaconsiderabletimeafterlastuse (8). The negative effects includemuscletension,pain,increasedsweat-ing, blurred vision, pupillary dilation,ataxia,anxiety,anervousdesiretobein motion, panic attacks etc. (6, 8).all theseproperties indicate that fol-lowing the intake of mDma, a userwouldsuffereffectsthatwouldimpairthe ability to safely operate a motorvehicle. Several cases involved veryhigh concentrations (toxic levels) ofmDma and/or amphetamine thatalso influence the impairment. Fur-thermore,thecombinationofmDmaand alcohol, which was observed in16%oftheinvestigatedcases,induceslonger lasting euphoria and well be-ingthanintakeofmDmaoralcoholalone. mDma reverse the subjectivesedation induced by alcohol withoutreducing the drunkenness feelings.mDmadonotreversetheactionsofalcoholonpsychomotorabilities.Sub-jectsmayfeeleuphoricandlesssedatedand might have the feeling of doingbetter, but actual performance abilitycontinuestobeimpairedbytheeffectofalcohol(11).multipledrugusearetypical in about 60% of the Danishtrafficcasesas shown inother studiesfrom1997to2000(1).Thisindicatesthatincasesinvolvingamphetaminesmultiple drugs use is more frequent(73%). other drugs such as the mostfrequently one THC will also have aseriousnegativeimpact.In future we expect more traffic sam-ples for investigation because of thenewDanishtrafficactincludedinlate2007perselegislationof illegaldrugsinDRUIDcases.Wealsoexpectnewdesigner drugs detected among thetrafficsamplesduetoobservedchangesindesigneramphetaminesamong sei-zures. The confiscated tablets amongseizuresfromthebeginningof2010donotcontainmDmaanymore(12).

CONCluSION

abuse of mixtures of amphetaminesand designer amphetamines are com-monandamphetamineusersareprob-ably using designer amphetaminessuch as mDma as a second step intheirabusepattern.Thesimultaneous

decreaseinamphetaminecasesandin-creaseof designer amphetamine casesuntil2000canverywellbeconnected.In2000,astrongexposureintheme-diamayhaveinfluencedamphetamineusersandotherabuserstoexperimentswith designer amphetamines. Since2001,thetotalnumberofcasesinvolv-ing amphetamines and designer am-phetaminesamongdrivesinDenmarkare increasing (11-31% of all trafficcases),whichindicatesthattheabuseof these substances among drivers inDenmarkarecommonnow.

REFERENCES1. Steentoft a. andre stoffer end alcohol i

trafikkeniDanmark.Nordicconference”an-dre droger an alkohol i trafikken, Norkadt– Nordisk Ratttoksokologisk Kommittee foralkohol,drogerandtrafiksakerhed,Helsinki,2001.

2. Behrensdorff I, Steentoft a. medicinal andillegal drugs among Danish car drivers, ac-cidentanalPrev,2003;35:851-860.

3. Bernhoft Im,Steentofta,JohansenSS,Kl-itgaardNa,LarsenLB,HansenLB,DrugsininjureddriversinDenmark,ForensicSciInt,2005;150:181-189.

4. Christophersen aS, Ceder g, Kristinsson J,LillsundeP,Steentofta.Druggeddrivinginthe Nordic countries - a comparative studybetween five countries. Forensic Sci Int,1999;106:173-190.

5. Bekendtgørelse om klassificering af færd-selssikkerhedsfarlige stoffer. BEK nr 655 af19/06/2007. http://www.hmi.dk/media/Tro-els_Thomsen_Bekendtgrelse_om_klassificer-ing.pdf

6. moore K. amphetamines/sympathomimieticamines.InPrinciplesofForensicToxicology,LevineB, editor,aaCCPress,USa,1999,pp265-285.

7. Baselt RC. Disposition of Toxic Drugs andChemicals in man, 7th ed. Chemical Toxi-cologyInstitute,FosterCity,Ca,2000.

8. Logan BK, Couper FJ. 3,4-methylenedi-oxymethamphetamine(mDma,ecstasy)andDriving Impairment. J Forensic Sci. 2001;46:1426-1433.

9. Johansen SS, Hansen aC, muller IB, Lun-demoseJB,FranzmannmB.ThreeFatalcasesofPmaandPmmapoisoninginDenmark.JanalToxicol.2003;27:253-256.

10. Johansenm,EcstasyiDanmark2007,http://www.sst.dk/publ/Publ2008/CFF/Narkotika/Ecstasyrapport2007.pdf

11. Hernandez-Lopez C, magi F, Roset PN,menoyo E, Pizarri N, ortuno J, Torrens m,Cami J, De la Torre R. 3,4-methylenedi-oxymethamphetamine (ecstasy) and alcoholinteractions in humans: psychomotor per-formance,subjectiveeffects,andpharmacoki-netics.JPharmacolExpTher.2002;300:236-244.

12. SST. Hvad indeholder “ecstasy” pillerne.overvågning af beslaglagte ”ecstasy” pilleri Danmark. Et samarbejdsprojekt mellemSundhedsstyrelsen,Rigspolitietogdetreret-skemiskeafdelingeriKøbenhavn,odenseogÅrhus.1.Kvartal2010.


INTROduCTION

In1991thepolicewasinstructednotto visit death scenes in cases of sud-deninfantdeath.ThereasonwassomeunfortunateepisodesduringtheSIDS“epidemic” when as much as 3‰ ofalllivenewbornsinNorwaydiedfromSIDS(1).

Soon after the withdrawel of thepolicefromthedeathsceneitbecameevident that important informationabout thecircumstancesofdeathwaslost. Therefore the Norwegian SIDSSociety and the Norwegian Founda-tion for Health and Rehabilitationsponsored a research project during aperiod of four years (2,3). The deathscenes in cases of sudden death ininfants and small children in South-eastNorwaywerevisitedbyanexpertteam.Participationintheprojectwasvoluntaryanddependentoninformedconsent from the family. The projectperiod was between 2001 and 2004,andthispaperpresentstheresultsfromtheproject.

METHOd

In all cases of sudden unexpecteddeaths in children between 0 and 3yearsofageinSoutheastNorway(2.5million inhabitants), the family wasofferedavisitbytwoexpertsfromtheInstitute of Forensic medicine, Uni-versityofoslo.Theexpertteamcon-sistedof the forensic pathologistwhohadperformedtheautopsyandaco-or-dinatorwitheducationandexperiencefrom tactical police investigation atThe National Criminal InvestigationService (KRIPoS), oslo. The police

expert was employed by the project,notbythepolice.

In most cases infants and smallchildren found lifeless at home arebroughtwithambulancetothenearestpaediatric hospital. These deaths arecategorisedasunnaturalperdefinitionand the police is informed immedi-ately.Requestof a forensic autopsy iscompulsory.Thepaediatricianondutyinformed the family about the deathscene investigationwhichwasvolun-taryandperformedafterthefamilyhadsignedaninformedconsentform.

ThedeadchildwasbroughttotheInstituteofForensicmedicineforafullautopsy including radiology, microbi-ology, toxicology and genetic investi-gationsandtheautopsywasperformedwithin 24 hours. The diagnostic wasbasedontheNordiccriteriaforSIDS(4).Shortlyaftertheautopsytwoex-pertsvisitedthedeathscene.Thevisitusuallylastedfor2hoursandincludedastructuredinterviewwiththeparentsleadbythepo-lice expert. The forensicpathologist informed theparents about the prelimi-nary resultsof theautopsy(in cases of no criminalnature) and the parentshadtheopportunitytoaskquestions. The room inwhich thebabywas founddead was videotaped. Bymeans of a doll with theappropriatesizeandweight

(Fig 1) the parents took part in thereconstruction showing how they putthebabytosleepandthewaythebabywasfounddead.

Multi-agency case conferenceswereheldapproximately3monthsafterthedeath.Inadditiontothemedicaldoctorsandresearchersinvolvedintheproject,thepaediatricianandnurseondutyonad-missionofthedeadbaby/child,aswellas other experts suchas a radiologist,microbiologist and neuropathologistregularlytookpartinthecaseconfer-ences. In some cases representativesfrom the police also participated. anoverview of the case was summarizedin a power point presentation con-taininghistoryof thedisease,autopsyresults includingessentialhistologicalfeaturesanddeathsceneexamination.Subsequent to a thorough discussionthefinalconclusionsweremade.

DeathsceneinvestigationinsuddendeathininfantandsmallchildrenThe Norwegian experiment

Rognum TO, Wille-Sveum L, Arnestad M, Stray-Pedersen A, Vege Å

Figure 1.Thedollsandthepho-to equipment used in the pro-ject.

aBSTRaCT due to some unfortunate episodes during the SIdS epidemic in the 1980’ies, the police was withdrawn from the death scene. They were not replaced by other professionals. as SIdS rates dropped during the early nineties and other causes of sudden deaths became relatively more important, it became evident that death scene investigation should be reintroduced. In the period 2001-2004 a research project was carried out in Southeast Norway. The most important findings were disclosure of 7 cases of neglect almost not seen in the years before and after. Furthermore the cases with initial suspicion could immediately be dismissed as non-criminal. Evaluation by a crisis psychologist was very favourable for the project.


concerningthebaby’sdeath.The questions contained informa-

tionaboutknownriskfactorsforSIDSandscoresforrisksweregivenaccord-ingtotheanswers.Theriskfactorsandthescoringsystemarepresentedinta-ble1.

RESulTS

DuringthestudyperiodbetweenSep-tember 1, 2001 and march 31, 2004,there were totally 69 deaths, 37 boysand32girls.Forty-nine(71%)ofthedeathsoccurredduringthefirstyearoflife(Fig 2).

In 52 cases death scene investiga-tionwasofferedtothefamily,and46familieswerevisitedafterhavinggiv-en informed consent. Cases in whichcrimeinvestigationhadbeeninitiatedby the police were not visited by thedeathsceneteam..Therewere58caseconferences.

Causes/modes of deathIn27outof69cases(45%)nocauseofdeathwasfound.In18ofthesecasestherewerenopathologicalfindingsatall(pureSIDS).In9casespathologi-calfindingsweredocumented,butnotevaluated sufficient as cause of death(borderline SIDS) (Table 2). In theSIDS/Borderline SIDS group therewere 67 % males and 33 % females.mostdeathsoccurredduringthefirst4monthsafterbirth(Fig 3).

Fromtheremaining43cases22cas-eswereduetoacutedisease,therewere7accidents,7casesofneglectandtheremaining 7 cases were abuse, homi-cide,infanticideandmedicalmaltreat-ment(Table 2).

Risk factors for SIdSTheriskscoresforSIDSbasedontheinformationfromthedeathsceneandtheparentswhohad lost theirbabiesweresignificantlyhigherthanthoseofthecontrols(Fig 4).

Impact of the death scene investigation on the diagnosis In the explained deaths the deathsceneinvestigationcontributedsignifi-cantlytothediagnosisin32%ofthecases(Fig 5).

Home accidentswereseenin7cases.Inonecasean11monthsoldboywassuf-focatedbyfallingbetweenthemother’sbedandhisowncradle(Fig 6).

Figure 2. ageandsexdistribu-tionofallvictimsdur-ing the death sceneinvestigation projectin Southeast-Norway2001-2004 (32 fe-malesand37males)

Figure 3. ageandsexdistribu-tionoftheunexplaineddeaths.Notethatthetypical age peak forSIDS between the2nd and the 4thmonth is not moreevident.

Table 1. Casecontrolstudy:Scoringsystemforriskvariables

Table 2. modes ofdeath in the projectperiod(n=69)

Casecontrolstudy:Scoringsystemforriskvariables

Score Scorevariation

Slipingposition 1-4 1(supine) -4(prone,facedown)Place 1-4 1(ownbed) -4(co-sleepingonsofa)Headcovered 1-2 1(no -2(yes)Layersofclothing 1-4 1(onelayer) -4(>2layers)matress 1-2 1(firm) -2(soft)Duvet 1-2 1(light/none -2(varm/heavy)Roomtemperature 1-2 1(normal) -2(varm>22°C)

Scorerange 7-20

18 SIdS 9 Borderline SIdS

22 disease 7 accidents 7 neglect 1 abuse 2 homicide 3 infanticide 1 medical maltreatment

43 explanable deaths

}

}26 unexplained deaths

A network with contact persons in allpaediatrichospitalsandpolicedistrictshadbeenestablishedbeforetheprojectwithdeathsceneinvestigationstarted.In allhospitals, amidwifepickedoutthree control cases born at the sametimewiththesamesex,andlivinginthesametypeofareaasthedeadbaby.The families of the control cases re-

ceivedaquestionnairecontainingsev-eralof thequestionsthat the familieswho had lost babies were asked, e.g.they were asked how the baby sleptandhowtheenvironmentlookedlikeduring the same night/day as the in-vestigatedbabydied(5).Thebereavedfamilies received identical question-naires, however also with questions


Signs of neglectwereseenin7cases.Inonecasean11montholdfemalebabydied in a sleigh. She was put in thesleighonlywrappedupindownycoats.Thetemperaturewasminus10°C.Shewasfounddeadaftera45minutesskirace during which she had not beenlookedafter.Shewasinpronepositionwiththefacerightdowninthedownycoat. Cause of death was suffocation,combinedwithhypothermia.

Inanothercasea3monthsoldin-fantwasputtosleepwithheavycloth-ingwrappedupinafleececoverwithaduvetontopandawarmwaterbottleplacedinthebed.Theparentshadfor-gottentolookafterthegirlfor18hourswhenshewasfounddead(Fig 7).

Maltreatment and homicide were foundin three cases. Causes of death wereobvious such as scull fractures andknife wounds. There were 3 cases ofinfanticide.

Medical maltreatment was seen in 1case.

Immediate acquittal of suspicionIn14cases(30%)inwhichthepoliceinitially suspecteda criminal act, duetoe.g.aparentoccurringinacriminalregister,thedeathsceneinvestigationledtoimmediateacquittalfromsuspi-cion.

Evaluation by crisis psychologistFiveweeksafterthedeathsceneinves-tigation the 25 first families includedin the study were visited by a crisispsychologistwhoperformedaqualita-tiveinterviewstudy.Thefamilieswereasked to rate their impression of thevisitonascale from1(verygood)to5(verybad).

31answered“verygood”,2answered“good”and1wasneutral.Noneoftheaskedparentswerenegative(6).

dISCuSSION

The most striking result was a rela-tivelyhighnumberofcasesofneglect.Sevencasesofneglectwerefounddur-ingthe3.5yearsproject.Interestinglyinthe4yearsperiodpriortothedeathsceneprojectweonlydisclosed2casesofneglectandinthe5yearsaftertheprojectwasfinished,onlyonecasehasbeen seen (Fig 8). an equally impor-

Figure 4.Distribution of riskscoresforSIDScasesandcontrols

Figure 6.Reconstructionofthemechanismofdeathina9monthsoldboy. a)Howhewasleftbythemother b)Howhewasfoundlifeless

Figure 5.Significane of deathscene investigationfor the diagnosis.Casesofexplainabledeaths,no=28

Figure 7.Threemonthsoldgirlfounddeadafterbeingputtosleepinawarmroom,withtwolayersofclothing,acap,wrappedinafleeceblanket,underaduvetwithahotwaterbottle,andleftwithoutfoodfor18hours.


tantobservationwasthatinitialsuspi-cion against 14 families could be dis-missed immediately after autopsy anddeath scene investigation. We thusthink that the death scene investiga-tionwasimportantforlegalprotectionof the infants and small childrenandtheirfamilies.

Sixfamiliesdecidednottotakepartintheproject.Wedonotknowtherea-sonsinallcases.However,ourimpres-sionisthatthewayinwhichtheywereaskedtotakepart,oftenwasdecisive.Paediatricianswithanegativestandtothe project tended to get more nega-tiveanswersthanthosewithapositiveview.atleastoneofthefamilieswhodid not take part felt sorry about thedecision and in retrospect contactedtheteamtobeinformedaboutthere-sultsoftheautopsy.

Theevaluationperformedbycrisispsychologist was very positive. Thefamilies expressed their thankfulnesstothedeathsceneinvestigationteam;thevisitofferedastructuredfollowup,itgavethefamilieshighlyqualifiedin-formation about cot death in generaland about the findings in their childin special. Lastly, in spite of the factthatthedeathsceneinvestigatorswereexpertsandnottreatingmedicalstaff,the families experienced interest intheirchildandthusasortofcare.

aftertheprojectwasfinishedbytheend of march 2004, the death sceneinvestigation team at the Institute ofForensic medicine was asked by theprosecutorgeneraltoproposeaperma-

nentdeathsceneinvestigationservice.The project report (7) was deliveredby September 1, 2004. The reportconcludes thatdeath scene investiga-tion shouldbemandatory inallcasesofsuddenunexpecteddeathsininfantand small children. It should be per-formedbyexpertsandnotbytreatinghealth personnel. The experts shouldworkonbehalfofthelegalsystemandreporttothepolice.

Inthefollowingyearstheproposalwasdebatedandfinallytheconclusionwas that the Norwegian Institute ofPublic Health was asked to arrange avoluntarydeathsceneinvestigationasahealthservice.However, ifcriminalconditions were disclosed the deathscenevisitorsshouldreporttothepo-lice.

TheNorwegian InstituteofPublicHealthaskedtheInstituteofForensicmedicinetoperformtheinvestigation,and 2 police experts and 2 medicaldoctorswillbeengagedforthetask.

In march 2010 the parliamentunanimously decided that the deathscene investigation shouldbemanda-toryandthenecessaryrevisionoftheregulation of criminal procedure willbemade,sothatthepoliceisallowedto investigate sudden unexpecteddeath in all children independent ofsuspicionofacriminalact.Thevolun-taryhealthserviceprojectwillstartinNovember2010,anditremainstobeseen how soon the mandatory deathscene investigation will be put intopractice.

REFERENCES

1. RognumTo,LierLa.Policeinvestiga-tion and SIDS cases. How can healthpersonnel, forensic pathologists and po-liceco-operate?In:SuddenInfantDeathSyndrome.NewTrendsintheNineties.Ed.ToRognum.ScandinavianUniver-sityPress1995:pp289-292

2. VegeÅ,arnestadm,Sveumm,RognumTo. Barnedødsårsaksprosjektet. Bedreundersøkelsevedplutseliguventetdød ispedbarns-ogbarnealder-enforutsetningfor å bekjempe dødsfallene. NordiskRettsmedisin2001;7:19-22

3. Sveum L, Vege Å, arnestad m, HeltneU, Rognum To. Bedre undersøkelseved plutselig uventet død i spedbarns-og barnealder – en forutsetning for åbekjempe dødsfallene – en oppfølging.NordiskRettsmedisin2002;8:61-63

4. gregersen m, Rajs J, Laursen H, Baan-drupU,FredriksenP,gidlundE,Helweg-Larsen K, HirvonenJ, Isaksen CV, KochK, Lundemose JB, Løberg Em, RognumTo,SkullerudK.PathologiccriteriafortheNordicStudyofSuddenInfantDeathSyndrome.In:SuddenInfantDeathSyn-drome.NewTrendsintheNineties.Ed.To Rognum. Scandinavian UniversityPress1995:pp50-58

5. arnestadm,andesenm,VegeÅ,Rog-numTo.ChangesintheepidemiologicalpatternofSIDSinSouth-EasternNorway1984-1998—implicationsforfuturepre-vention and research. arch Dis Child2001;85:108-115

6. Heltne,Um.Foreldresopplevelseavdel-takelse i frivillig dødsstedsundersøkelse.Rapport. Senter for Krisepsykologi, Ber-gen2003

7. Bedreundersøkelsevedplutseliguventetdødisped-ogsmåbarnsalder.Forskning-sprosjektIhelseregionsørogøst.Rapporttil Riksadvokaten. Rettsmedisinsk insti-tutt,Universitetetioslo,2004

Figure 8.Distributionofcasesofneglect for SoutheastNorway 1997-2009-Note the seven casesduringtheprojectpe-riod.


Politicalassassinationsarenotaneve-rydayoccurrenceinDenmark.anat-tempt on the Danish prime minister(konseilspræsident) J.B.S.Estrup’s lifein 1885 did not succeed because thepistol bullet hit Estrup’s coat button.WehavetogobacktomedievaltimestofindthelastassassinationofaDan-ishpoliticalleader,namelythemurderof King Erik Klippinge that allegedlytook place in a barn in Finnerup inJutland November 22 1286. at thattimesuchmurderswereverycommon.Forty-four percent of the Danish me-dieval kings met a violent death (1).12royalhomicidesin350yearsgiveahomiciderateforkingsofnolessthan3,480per100,000peryear.Thehigh-estpresentdaynationalhomiciderateis 250 per 100.000 per year (Colom-bia).Thispaper concerns themurderofKingCanutetheSaint.

KingCanutetheSaintwasanam-bitious Danish king. He was one ofKingSvendEstridsen’snumeroussons.He was killed in St alban church inodense July 10 1086 after a six-yearreign.

We have had the opportunity toinvestigate the skeletons believed tobelongtoKingCanuteandhisbrotherBenedict, and we would like to com-municate someofourfindings in thispaper, concentrating on the king. Itis the first time these skeletons havebeeninvestigatedbyexpertsinforen-

sicmedicine,anditisalsothefirsttimethat computerized tomography hasbeenusedontheseoldbones.

HISTORICal BaCKGROuNd

KingCanute’sreignwasmarkedbyvig-orousattemptstoincreaseroyalpowerinDenmark,andhewasalsoadevotedchampionof theChurch.Hetried toenforce the collection of tithes, andthesepoliciesledtodiscontentamonghissubjectswhowereunaccustomedto

a king who claimed such powers andwhointerferedintheirdailylives.asthegrandnephewofCanutethegreatheconsideredthecrownofEnglandtoberightfullyhisandregardedWilliamthe conqueror as an usurper. In 1085heplannedaninvasionofEnglandandassembled a fleet at Limfjorden, butit never set sail. Possibly Canute wasafraidof interventionby thegermankingandHolyRomanEmperorHein-richIV.SomeconsiderCanute’sabor-tiveinvasionofEnglandastheendof

CORRESPONdING auTHOR: Peter Mygind leth, e-mail: [email protected]. Mobile +45 60 11 30 03. adress: Institute of Forensic Medicine, J.B.Winsløws vej 17, 5000 Odense C, denmark.

StruckbyalancethroughhissideThe homicide of King Canute the Saint

Peter Mygind Leth and Jesper Lier BoldsenInstituteofForensicmedicine,UniversityofSouthernDenmark

aBSTRaCT The danish King Canute the Saint was killed in St alban church in Odense July 10 1086. according to a legend the king was kneeling in prayers when a lance thrust to his side killed him. Our re-examination of the skeleton presumed to belong to Canute showed a slimly built man with an approximate stature of 165 – 170 cm and an age of 27 – 38 years. There was a peri-mortem lesion on the sacral bone. It was a so-called hinge-fracture that consisted of a horizontal fracture on the ventral surface of the 3rd sacral vertebra, and with a correspond-ing crack on the dorsal surface of the sacral bone. Computerized tomography showed these two fractures to be connected. We suggest that the fracture was caused by a thrust of a sharp instrument through the abdomen with a direction posterior and to the right.

Figure 1:ThemurderofKingCanute theSaint.PaintingbyChristianvonBenzon(1816–1843).


theVikingageasitwasthelasttimeaVikingarmywastoassembleagainstWestern Europe. In reality King Ca-nutewasalsoverymuchamanofthenewageinhisattemptstostrengthenthemonarchyandinhissupportoftheChurch(2).

In 1086 a revolt broke out in Jut-land. a main historical source forthese events stems from the legendwritten by the clergyman Elnoth ofCanterbury20yearsaftertheincident:“Passio gloriosissimi Canuti Regis etmartyris” (3). according to the leg-endtheking,hisbrotherBenedictand17ofhismen sought refuge fromtherebels in the Church of St alban inodense,butthesanctityofthechurchwasnotrespected.TherebelsstormedthechurchandslewCanuteinfrontofthehighalter,asillustratedinthis19thcenturypainting(fig.1).accordingtoElnoththekingdidnottrytodefendhimself. He was kneeling in prayersandwaskilledbyalancethrusttohisside.HisbrotherBenedictandmostofhisentouragewerekilledaswell.

Thislegendisofcoursenotanob-jective accountofwhat actuallyhap-pened.ThecanonizingofKingCanutewas a political act instituted by hisbrotherKingEricI.Elnothsnarrativehad a foregone conclusion, and histask was to make the known facts fitreasonably well with the conclusion:thatthekingwasfittobeasaint.Notaneasytaskconsideringthatthekingwaskilledbycompatriotswhorebelledagainstanoppressiveandbrutalreign.However, the account was writtendownatatimewhensomepeoplestillrememberedthekingsothebasicfacts:that the king was killed by rebels inodensein1086areprobablycorrect.

BuRIEd, ENSHRINEd, WallEd IN aNd FINally dISPlayEd IN a GlaSS CaSE

PartofKingCanute’sstrongassertiontopowerwasbasedonhisdevotedsup-portoftheChurchsoitwasonlynatu-ralthathisbodywasburiedinfrontofthehighalterinthechurchofStal-ban.Hisboneswereexhumedin1095and laid in a stone sarcophagus withanaccountoftheincidentwrittenonacopperplate(Tabulaothiniensis).In1100 he was canonized, and after hiselevation to saint his bones were en-shrined and displayed on the altar of

Figure 2:Photographofthelesionontheventralsurfaceof thesacralbonebelievedto belong to King CanutetheSaint.

Figure 3:3Dmreconstruc-tion of a CT-scanning ofthe lesion on the ventralsurfaceofthesacralbone.

Figure 4:Photographofthelesiononthedorsalsurfaceof thesacralbonebelievedto belong to King CanutetheSaint.

Figure 5: Transversal sec-tionthroughaCT-imageofthesacralbonebelievedtobelongtoKingCanutetheSaint.Theventralanddor-salfracturesareconnected.


thethennewlyerectedstonechurchofStCanutethatwasbuildclosetotheoldchurchofStalban.Thebonesofhishalf-brotherBenedictwerealsoen-shrined.Therearereferencestotheseshrinesfromvariousmedievalsources,butthentheydisappearfromview.In1582 St Canute’s shrine was broughtto light, presumably from a hidingplaceinthechoir.Theshrineheldaninscription denoting it as the shrineofStCanute.Benedict’s shrine isnotmentioned. During the reformationmost relics had been discarded, butthesewereroyalbonesandcouldobvi-ouslynotbetreatedinthisway.atanuncertain time the shrine was walledupagain,andaround1694,whilethechurch was under repair, two shrineswere discovered in a bricked-up cav-ity in the eastern wall. The shrineshadbeenrobbedoftheircostlystones,most of the furnishing had been tornout, one had lost its lid completelyand one had lost part of its lid. Bothshrines were placed on ends, and thebones were partly intermingled. Theshrines were walled up again in 1696andwerebrought to light for the lasttime in 1833. Since then they havebeenonpublicdisplay inthechurch.a scientific committee distributedthebonesbetweenthetwoshrinesin1874-75.mostofthecommitteemem-bersagreedthatStCanute’sshrinewastheonewithoutalid.Thecorrectnessofthedistributionandtheidentityoftheboneshaveoccasionallybeenques-tioned.Formanyyearsitwasdiscussedifthebonesoftheyoungerindividualbelonged to St alban – whose relicshad also been kept in the St albanchurch–orBenedict,butaC-14dat-ingruledStalbanout(3).Theshrinewithout a lid has been dated by den-drochronology.Sincesapwoodwasnotpreserved,itcouldonlybestatedthatthe shrine had been made after 1074and probably before 1100 (3). It hasnotbeenpossibletoobtainDNafromthebones(3).TheskeletonsarenowondisplayinaglasscaseinthecryptofStCanute’sChurchinodense.

THE aNTHROPOlOGICal ExaMINaTION

Theskeletonshavebeendescribedinearlierinvestigations(4,5).ourre-ex-aminationoftheskeletonpresumedtobelong to St Canute showed a slimly

builtmanwithanapproximatestatureof165–170cmandanageof27–38years. The surface of the bones wassmoothwithapalebrowncolourduetopreservationwith Italian resin,ex-cept for the cranial vault, which hadapalegraycolour.arimoflimescaleontheinsideofthecranialvaultmaystemfromtheperiodofburial.Wedidnotfindanyreasontobelievethatthebonesbelonged tomore thanone in-dividual. There was a great similaritybetweentheskeletonsofthetwopre-sumedbrothers.We foundone lesionthat seemed to be peri-mortem. Thislesionwasfoundonthesacralbone.atwhatmoresuitableplacecouldafuturesaintbewounded?Itwasofcoursealsonoticedatthepreviousinvestigations,but the present investigation was thefirst to use computerized tomography.The lesion consisted of a horizontal2.9cmlongand3.1mmbroadinfrac-tionontheventral surfaceof the3rdsacralvertebra (fig. 2).Whenviewedinastereomicroscopeitcouldbeseenthat it was a so-called hinge-fracturewherethefracturedareaofthelaminacompacta was still partially attachedto its original bone so that the sur-facesmetatanunnaturalangle–notunliketheopeningofaletterbox(fig. 3).on thedorsal surface therewas a15mmlongand4mmbroadhorizon-talwedge-shapedcrackinthemediancrestatthe3rddorsalsacralforamen,withfracturelinesrunninginbothdi-rectionstotheseforamina.Totherightandbelowthe3rdsacralforamenwas2mmlongfractureline(fig. 4).TheCT-scanning showed these two fracturestobeconnected(fig. 5).Thefracturesdidnotshowanysignofcallusforma-tion or other bone reaction. Hingingofafracture,suchasseeninthiscase,is considered to indicateperi-mortem

trauma(6).Thesectionofboneisbentaway from the direction of the injur-ing force. Hinging can only occur iftheboneismoistandcontainsorganicmaterial.Drybonewillsnapoffwhenactedonbyaforcesufficienttocauseabreak.

Therealsowasa6.6cmlongverti-cal crack in the left side of the fron-talbone in thecraniumwithno signofbonereaction.Itisuncertainifthisisaperi-mortemorapost-mortemle-sion.Wedidnotfindanyotherlesions.Therewerenodefencelesionsonthelowerarmsorhands,andnolesionsoftheribs.

PROPOSEd INJuRy MECHaNISM

Whatcouldhavecausedthelesiononthesacralbone?Wesuggestthatitwascausedbyathrustofasharpinstrumentthroughtheabdomenwithadirectionposteriorandtotheright(fig. 6).Thisinterpretation is in accordance withtheinterpretationgivenbyTkoczandJensen (4), whereas Rasmussen et al(5)considerthislesiontobetheresultofbluntforcetraumacomingfrombe-hind.Therewerenoothersharplesionsonthepelvis,ascouldhavebeenthecase if the weapon had been a swordenteringthepelviccavitythroughthebelly. The weapon could also havebeena spear,which isa likelyoptionsince the rebels were peasants whowere usually armed with spears. Theabsenceofsharpforcelesionsonotherbonescouldindicatethatthekingwaswearingachainmail.Theforceoftheimpactmusthavebeensubstantial. Itseemsunlikelythatthekingwasstand-ingupwhenhereceivedthislesionasalotoftheenergyinthethrushwouldhave been used to propel him back-

Figure 6: a reconstruc-tionoftheproposedinjurymechanism. The weaponcouldhavebeenaswordoraspear.


ward.Ifheontheotherhandhadbeenpushed over and received the thrustwhilehelayonhisback,moreoftheenergywouldhavebeentransferredtothesacralbonecausingittobreak.Webelievethatmightbepossibletoverifythe theory experimentally, and plantodoso.Theideaistoembedsacralbonesinballisticgelwithathicknessthat corresponds to the soft tissuesoftheabdomenandsubject thesebonestoasharpforceinjuryusingcopiesofcontemporary swords and spears. Wehopeitispossibletodisproveorverifyour theory, and perhaps even get anideaaboutthemurderweapon–spearorsword.

Ifweareright,thistraumamecha-nismismoreorlessinaccordancewiththeaccountgivenontheTabulaoth-iniensis and the narrative by Elnoth,who claims that the king was “struckby a lance through his side”. The le-sionwouldhavebeenlethal,althoughnot immediately lethal. It is howeverlikely that the king received manymore lesions that did not leave anymarksontheskeleton.Forallweknowhisthroatmayhavebeencut.

Theinterestedreaderscanviewtheskeletonsforthemselves.Theyareondisplay in a glass case in the crypt ofStCanute’sChurchinodense,nicelylaidoutsoyoucansethelesions.

REFERENCE lIST

1. LethPm,BoldsenJ:Skeletterneikrypten.In:FynskeÅrbøger2009,HistoriskSam-fundforFyn.

2. Fenger,o:KnuddenHellige.gyldendalog Politikens danmarkshistorie bind 4,“Kirker rejses allevegne”, 2.ed., 1993; p.65-68.

3. NybergT,Bekker-NielsenH,oxenvadN(eds.). Knudsbogen – studier over KnuddenHellige,odensebysmuseer,odense,1986.

4. Tkocz I, JensenKR:antropologiskeun-dersøgelser af skelettet i skrinet med desnoede søjler. In: Knudsbogen – studieroverKnuddenHellige,odensebysmu-seer,odense,1986.

5. RasmussenKL,BennikeP,KjærU,Rah-bekU:Integrityandcharacteristicsofthebones of the Danish King St Knud (II)theHoly.JournalofDanisharchaeologyVol13,1996-97;p.161–170.

6. Byers SN: Perimortem Trauma. In: Fo-rensic anthropology, allyn and Bacon,2002;p.268–270.


INTROduCTION

onthemorningofJune27,1945,the32-year-old Norwegian Kai Holst wasfound dead in an apartment complexatgärdetinStockholm.Thegunshotwoundinhisrighttempleandthepis-tolinhisrighthandindicatedsuicide.The police investigation ended withthatconclusion.Noteveryonewassat-isfiedwiththatverdict,however.Fam-ilymembersofthedeceasedandsever-alofhisfriendswereallconvincedthathehadbeenliquidated.Newlymarriedandamanwithmanyplansforthefu-ture,therewasnojustificationthatheshouldtakehisownlife.anewstudyoftheautopsyreportandareconstruc-tionattheplaceofdeathgivenewin-sight into the case, even though thismysteryfromthedaysofthepostwarisfarfrombeingsolved.

Due to Kai Holst’s background intheNorwegianResistancemovementhis sudden mystic death caused bignewspaper headlines in Sweden andNorway.During1942-43hewasakeyfigurefortheleadersofthesecretmili-tary organization (milorg) that cameintobeinginoccupiedNorwayduringWWII.Theyearsfollowingheworkedas secretary inmilorg’smilitary officeinStockholmthatoperatedunderTheNorwegianLegation.TheorganizationoftheircourierservicetoNorwaywashisprimary taskup to the timewhenhe was found dead. In addition, it is

known that he had an active role intheintelligencecommunity inStock-holm.1

after suicide had been “estab-lished” in thenewspapers, themattersettleddownpubliclyuntiltheSwed-ishjournalistgöranElgemyrproducedaprogramforSwedishRadioin1992.Reactions inNorwaywereexpectant.ThecaseexplodedfirstintheNorwe-gianmediawhenhistorianTorePryserandauthorEspenHaavardsholmwroteeachtheirownbookin1994inwhichtheyquestionedthesupposedsuicide.2TheysuspectedfoulplayandpointedafingeratSweden’ssecretmilitaryintel-ligence agency (C-byrån), possibly incooperationwiththeiramericancol-leagues.othermurdertheoriesthroughtheyearsblamedcommunists,Norwe-gianauthorities,andthegestapo.

KaiHolstdiedinthewakeofape-riodwhentherehadbeenliquidationson a large scale in the Scandinaviancountries. The german occupationalpowerandtheirhenchmancarriedoutliquidations,andinNorwayandDen-markweknowabout, respectively,82andapproximately400,liquidationsofdangerousopponents (Nazis) that areattributable to the Resistance move-ments during the war.3 Conditions inneutralSwedenwere,ofcourse,differ-ent.Evenso,thewarringnationswerewell represented on the intelligencelevel in Stockholm, and the Swedesalsohadawellorganizedandefficientnetworkofsecretintelligenceservices.Thatthereweresuchorganisationsoreven private persons who worked forthemwiththeresourcestostageHolst’ssuicide,isnotunthinkable.

THE CHaIN OF EvENTS

onWednesday,June27,at3:10a.m.,HolstarrivedbytaxiatRindögatan42atgärdetwherehebuzzedaSwedishfriend from the intercom.This friend

latergavevaryingexplanationstothepoliceaboutwhetherheopenedornot,buthemadeitclearthatameetinghadnotbeenarrangedbeforehand.aboutthistimetheclosestneighbortotheat-ticcorridorwasgivingapartythatwasabouttobreakup.Theneighborthenheardabang,whichhebelievedcamefromtheelevatordoor thathadbeenbangedshutwithgreatforce;hecouldnotdefinitelysayifitwasapistolshothehadheard.ashewasgoingtoescorthisguestsout,theelevatorwasstand-ingonthefloorwhereHolst’sSwedishfriend lived. outside the building layarucksackandatravelbagthat,asitturnedout,belongedtoHolst.

THE CORPSE IS dISCOvEREd

at9:15a.m.,thewomanongatedutydiscoveredHolst’sbody.Hewasfoundlyingonthefloorintheatticcorridorwithhishead inapoolofblood.Hisrain coat was hanging over the rail-ing,andinhisrighthandtherewasaloadedsemi-automaticSpanishLlama9mmpistol.His indexfingerwas onthe trigger. In the recordkept by thelocal Stockholm police it was statedthat rigormortiswasnot yet present,thiswasstatedbythepoliceconstablewhoremovedthepistolfromthedeadman’shand.

POSTMORTEM INvESTIGaTION

The autopsy was performed on June30 by forensic pathologist Dr. K. g.Kling. Here follow excerpts from hisreport:“Bodylength178centimeters.… In the right temple just in frontof and somewhat above the right earthereisaroundwound11millimetersindiameter.aroundthewoundtherewasablackburnareasixmillimetersindiameter.Thehairinthevicinitywasnot singed(fig 1a). Inthe left temple

KaiHolst–Suicideormurder?Per Gunnar Egeland, Sonny Björk and Jovan Rajs*

aBSTRaCT active in the Norwegian Resistance Movement during WWII, Kai Holst was found shot to death in Stockholm just seven weeks after the liberation. Had he been liquidated? There were several groups with the resources to stage a suicide. various fractions in the nations at war were well represented on the intelligence level in Stockholm, and Sweden had its own network of secret service agencies.22

*Per Gunnar Egeland, cooperate withgöranElgemyronabookplannedforpublicationin2011.

*Sonny Björk, detective superintend-ent, Department of Crime SceneInvestigation,StockholmPolice.

*Jovan Rajs, professor emeritus, Insti-tuteofForensicmedicine,Karolin-skaInstitutet,Stockholm.



region … a wound approximately 7millimetersindiameter…(fig 1b).Thewounds are connected by a channelthrough the cerebrum. ... The handsdiffuselysoiledwithblackish-redcoag-ulatedblood…Therewereatotalofup to ten penny-sized, reddish-brownscalyscrapesontheskinalongtheleftsideof theneck.…(fig 1b).Nootherinjuries.” No toxicological analyseswere undertaken. Following the au-topsy, the pathologist wrote out KaiHolst’s death certificate:Vulnus sclop-etarium capitis. Suicidium.

Intheautopsyreportwhichhede-livered to the police on July 20, Dr.KlingwrotethatHolstdiedfromgun-shotwoundsfiredfromaweaponaimedat the right templeat relatively closerange,andthatthebulletwasdirectedfrom right to left, slightly upwards, abit backwards. The report stated fur-therthatHolsthadearlierbeenoper-ated for double sided tuberculosis ofthe lungs,butthatnorecentprogres-sion of the disease could be observedandthatthetuberculosis inthelungsat the time of death appeared to behealed. any comments regarding themannerofdeathwerenotmadeinthereportitself.

RECONSTRuCTION OF THE SCENE aT RINdöGaTaN

Theinvestigativereportsincludelittleinformationaboutthesceneofdeath.a local police report refers only to adistinctmarkfromabulletonthedoorto the elevator machine room, about180centimetersabovethefloor.Fromtherethebulletricochetedtotheceil-ing where it made a five centimeterlong gash. Both marks had traces ofblood on them. No photographs orsketches exist, and the criminal po-liceinvestigators,whoarrivedquicklyonthe scene,madenowrittenreportabout their technical investigation.Since the death scene is describedsomewhatdifferentlybythepoliceand

themedia,wewantedtoreinvestigatethesceneofdeath.

Withpermission from theproprie-tor of the building, we were ready todoareconstructionofthedeathsceneon may 18, 2009, nearly 64 years af-ter Holst’s death. an open staircasewindsuptoasmall,semi-darkrectan-gular attic corridor. only light fromthefloorbelowreachesthispartoftheatticwherethereisnoelectricity.Thedoortotheelevatormachineryroomismadeofheavymetal,andexactly186centimetersabove thefloor there isapatchmark.Itwasjusttoscrapeawayfillerandpaintafterasolventhaddoneitsworkforaboutanhour.Hereweun-coveredadrop-shapeddiagonalinden-tation in the direction of the ceiling(fig 1c).acastewasmadebyspreading

1d

Figure 1 a-d: Reconstruction of the event. 1a:Entrancewound. 1b:Exitwound 1c:Hitpointofthebullet afterremovalofthepaint. 1d:Reconstructionwith figurant

1a 1b 1c

Fig. 2: ProfessorJovanRajswhohasthesameheightasHolstinfrontofthehitpoint.

a molding compound (mikrosil) overthe area. The casting that was laterstudiedunderamicroscopeshowsthattheindentation,withoutquestion,wasmadebyabullet.

ThebulletthatkilledHolstisstillinthepolicearchives.Itwasfoundbythewomanongateduty,onJune28,inthestairsonefloorbeneaththeattic.Thebulletispushedinononeside,charac-teristicforabulletthathasricochetedat a low angle. The bullet also has atraceofwhitepaintorplaster,probablyfrom the impact made when strikingthe ceiling. The bullet’s appearanceagrees with observations at Rindöga-tan.Inaddition,theSwedishforensiccrimelaboratorydeterminedalreadyin1945 that the bullet in question hadbeenfiredfromHolst’sweapon.

Thelaboratoryinvestigationofthepistol may disclose some indicationsof the range of the shot. absence ofbloodwithinthebarrel indicatesthatbloodandtissuehavenotbeensuckedintothebarrel.Thisimpliesthatithasnot been a contact wound but rathera distance between muzzle and skinof approximately three centimeters.Backsquirtofbloodfromtheentrancewound has very likely happened andsuch small blood squirts should havebeen left traces on the pistol and onthe hands holding the pistol, thoughnotnecessarilyonthebarrelofthepis-tol.ThatthepistolwasstillinHolst’shand indicates nothing unusual. Thismaybethecaseinapproximatelyoneinfivesuchincidents(SB,ownobser-vation).

Regarding Holst´s position at theshooting,thiscouldbedeterminedonthe basis of the wounds described intheautopsyreport,theautopsyphoto-graphs,andHolst’sheight.Heprobablystoodacoupleofdecimetersoutfromthe wall, with his head or his entirebody turned about 20 degrees towardthe door to the elevator machineryroomatthemomenttheshotwasfired(fig 1d and fig 2).Thus,ourreconstruc-tion confirms that Holst died on thespotwherehewasfound.

BaSIS FOR THE OFFICIal vERSION

The reconstruction also by and largeconfirmsthepolicetheory.animpor-tant testimony apparently had madeitcleartothepolicethatHolstcould

have had a motive for going straightuptotheattictoshoothimself.ThusanacquaintanceofHolstwhoworkedin the Norwegian Legation, the daybeforetheautopsy,hadsuggestedthatHolstcouldhavecommittedsuicideincasehehadreceivednewinformationthathistuberculosishadreturned.

Inouropinion,anoldtuberculosis,whichtheautopsydisclosednottobeactive,wouldnotbeamotiveforcom-mitting suicide, not under the givencircumstances.Holst’swidowtoldthepolice that her husband had gone tohisdoctorsforregularcheck-ups;asre-centlyas inmarchorapril, adoctorinStockholmtoldhimthathis lungswerefine.Ifthedeathwasduetoasui-cide,thenitwasanimpulsiveaction,not premeditated suicide for whichtherewasnoapparentmotive

Evenso,thisinterpretationhasnotstopped others from thinking similarthoughts.In1994,theNorwegianme-diahoped that themilorg leader andformer minister of Defense and min-isterofJusticeJensChr.Haugemightbe able to shed new light on Holst’sdeath.Theyassumedthathewaswellinformed in the matter, not least be-cause Holst had worked closely withHaugeintheperiodbeforehisescapeto Sweden. But Hauge knew littlemorethanwhatwouldbecomepublicknowledge.Hewasmoreopenwithhisbiographer.Hesawnoreasontodoubttheofficialversion.Haugethoughthisoldcolleagueinastateofpsychologi-

calandphysicalexhaustionmayhavebelievedthetuberculosiswasonthere-turnandthat thatwashismotive forsuicide.4

TheNorwegiandriverwhobroughtHolstfromHamar,Norway,toStock-holmonthenightinquestion,painteda rathermorbidpictureofhispassen-ger. Just after crossing the SwedishborderHolst,hesaid,tookoutapistolwhich made the driver uneasy. Dur-ing the entire trip he never behavedlike a normal person; the driver wasconvinced that Holst was close to anervous breakdown. The taxi driverwho drove him further in Stockholmdescribed him as behaving as thoughhewereconfused.Thepossibilityofanimpulsive suicide cannot thereforebeputaside,eventhoughHolstmayhavehadnosymptomsoftuberculosis.ThatmembersoftheResistancemovementlaterhadnervedisorderswasnotun-common.

alTERNaTIvE COuRSE OF EvENTS?

aspointedoutbyPryserandHaavard-sholm,theNorwegiandriverdoesnotappeartotallyreliable.Duringhisfirstpoliceinterrogation,hesaidthatHolstseemed tired, in the second he camewithinformationthatvergedondefa-mationofcharacter,whileduring thethird interrogation with NorwegianpoliceheagaindescribedHolstasbe-ingtired.andtiredhewas.Itappears


thathehadhardlysleptthenightbe-forebecauseofaraidagainstgermancriminalsofwarundertakenbyBritishintelligenceservice.Hiswearinessandlethargicmanner can, therefore,witha little stretchof the imagination, beconstruedassomethingdifferent.and,we might ask, could he have takenoutthepistolbecauseheexperiencedafeelingofthreat?mighttheepisodewiththepistolratherrepresentprepa-rationsforselfdefensethanreflectingthoughtsofsuicide?

The impression is that Holst wasfully aware that someone wanted toput him out of the way. Wladimirmørch Hansson was one of the lead-ersinmilorgwhoworkedcloselywithHolstbothinNorwayandinSweden.He confided to the author Haavard-sholm that Holst had received deaththreatsjustpriortotheliberation.Re-tiredmajorgeneraloleottoPaustookthisastepfurtherwhenhespokewiththesameauthor.PaussaidthatpriortoanintelligencemeetingontheSwed-ish border in the early 1950s, Holst’smurderer was accidentally pointedout to him by a Swedish fiscal agent(chiefconstableandprosecutor).Theidentified man had a common Swed-ish name. However, this does notmean that the fiscal agent’s assertionis necessarily correct. Just as interest-ing iswhether information indicatingpossible murder was ever followed upbySwedishpolice.TheofficerPaus,atanyrate,tooktheinformationseriouslyandreportedittothechiefofthemili-tarystaff, lieutenantgeneraloleBerg(Norway’smilitaryattachétoSwedenin1945andHolst’sclosestbossatthetimeofhisdeath).Theofficerwasthengivensome‘friendlyadvice’toletthematterrest,thatfurtherinvestigationscouldbeverydangerous.others, too,wereadvisedagainstprivateinvestiga-tions,includingfamilymembersofthedeceased.5

apart from the gunshot wounds,the autopsy photos focus only on thescrapesontheleftsideoftheneck(fig 1b). The marks are difficult to inter-pretandDr.Klingdidnot statewhatcausedtheminhisautopsyreport.Norshould we speculate about the omis-sion of toxicology, even though thiscould have disproved the very firstand most fanciful murder theory putforward by an anonymous NorwegiansourcetoAftonbladetonJune29.This

theory implied that the gestapo haddruggedHolstwithsomethingthatputhiminahypnoticstate,andthatitwaswhilehewasinthisstatethatheshothimself.

allthisopensthewayforanalter-nativechainofevents.Inthatcasethefiringpositioncouldnotexcludeanex-ecution.ItissomewhatuncertainwhattookplacefromthetimeHolstenteredthefrontdooruntilhewasfounddeadsix hours later. Neither the criminalpoliceinvestigatorsnorthedoctorwhopronouncedhimdeadleftanywrittenrecordsconcerningthedeadbody.Fur-thermore,itshouldbenotedthatthereisnoforensicevidenceindicatingthatHolsthadshothimself.

SuICIdE vERSuS HOMICIdE

From the medico legal point of viewKaiHolst’scauseofdeathis indisput-able–craniocerebralinjurycausedbyaprojectilefiredfromahandgun.Hismanner of death, that is, whether itwasanaccident, suicideormurder, ismoreproblematic.allforensicpathol-ogists have experienced that a deathinitiallydeterminedtobetheresultofan accident or suicide may later turnouttohavebeenhomicide.orthatamurder may be suspected, without achance of finding positive proof. Theinitial assessment is generally basedon bona fide reports of varying qual-ity and insight, or it may be built onintentionallymisleadingorfalseinfor-mationconcerningthedeceased.Thesamemaybetrueforforensicautopsiesand (in particular) toxicological in-vestigations.Theproblemisnotmade

any simpler when various networks,governmentsecurityservicesandvari-ous criminal groups are brought intothe picture. moreover, most forensicexperts have inadequate knowledgeabout themethods and techniquesofprofessional assassins. Thus, it is justasunwisetorelyunreservedlyon“ob-jective”autopsyfindingsasitistoun-derestimate the knowledge and intel-ligenceofthemurderer.

Holst’sautopsyhasbeenassessedasbeing professional, correct, and welldocumented,althoughthereisnopho-tooftheentrancewoundwithshavedhairinitsvicinity.Whatshouldapa-thologistconcludeaboutamannerofdeathafterfindingagunshotwoundontherighttemplewithabulletchanneldirectedtowardtheleft,backwards,andupwards?andwhenhelearnsthatthedeceasedwasrighthanded,thatapistolwas foundinhisrighthand,andthathisraincoatwasneatlyplacedoverthestairrailingwhenhewasbeingfoundsixfloorsup?Forensicpathologistsdonotnecessarilycarewhetherthereisasuicidenoteornot.Suicide,concludedDr.KlingonKaiHolst’sdeathcertifi-cate,whichhefilledoutassoonashehadcompletedtheautopsy.But threeweeks later, when the investigationswerefinishedandhewrotetheautop-sy report, he left out routine formularegarding the manner of death. Thathe omitted this may indicate that hehad somenewdoubtsor thathemayhavefeltsomedissatisfactionwiththepolice.Hecouldhaverealizedthattheshotinjurywasnotacontactshot,buta“relativelycloserangeshot”asindi-catedbyabsenceofsingedhairandby

Fig. 3: Execution ofa Vietcong prisoner.Therevolverisdirect-edtotherighttemple,left-back-up,typicallyfor suicide. The shotdistance is estimatedto15cm(facsimileofEddie adams’ photofrom 1968: RichardLacayo and georgeRussell “Eyewitness:150 years of photo-journalism”(1995)).


thefactthattheentrancewoundwassmallandquiteround,whichsuggeststheguncouldhavebeenfired fromadistancelongerthanaboutthreecen-timeters.Havinginmindtheabsenceof gunpowderand singedhair in thewound´svicinity,the“blackburnareasixmillimetersindiameter”couldjusthavebeenablackabrasioncollarofanentrance shot wound. also, that thefinding of the pistol in Holst´s righthand could not easily be understoodas a genuine cadaver spasm with afirm grip on the pistol, and that nei-ther thepolicereportnorHolst’shis-tory of illness revealed a motive forsuicide.Quitethecontrarytheclosestofkinadamantly rejectedanymotivefor suicide. Perhaps Kling understoodthat Holst was involved in sensitivemissionsfortheNorwegianResistancemovement.Wheninanintricatecasethe pathologist feels uncertainty, it iswisesttoleavethemannerofdeathoutoftheautopsyreport.Ifthepoliceof-ficerwhoisresponsiblefortheinvesti-gationisnotawareofit,orwillnotdoit,thenthepathologist’shonorisstillsaved.Thesewordsarewrittenbyone(JR),whoatthetimeofwritinghas50year’sexperienceasaforensicpatholo-gist in several countries with varyingpoliticalandlegalsystems.

Butevenifithadbeenamatterofacontactshot,thisisnotdecisiveforbe-ingamatterofsuicide.Itiswellknownthat liquidations, even mass liquida-tionsduringthewartime,tookplaceascontactshots.Thepositionofthegun-shotwoundshouldbeofgreatinterest.Druid(1997)showedthat38percentof thegunshotwounds resulting fromhomicideshad entered thevictims atanatomical regions typical of suicide.Thesameauthorpointedoutthatthedirectionof thebulletpathwasmoreimportant than its location. also,whentheentrancewoundintherighttempleindicatedsuicide,divergentdi-rectionthanthetypicalfront-to-back-directionsuggestedthatthewoundwasmore likely to be homicidal.6 Holst’sbulletholemetthesecriteria,withtheminimaldeviation, if any, that itwaspointedjustabitbackwards.Within-completeorwronginformation,manypathologistswould classify oneof thetwentieth century’s most documentedexecutions as suicide (fig 3). Neitherstatistics, clichés called “forensic ex-perience”orgreatpersonalexperience,canbedeterminativeforthedifferen-tialdiagnosis suicide versus homicide,whenthecircumstancesaboutadeathandotherbackgroundinformationareshroudedindarkness.

CONCluSION

In the case of Kai Holst’s death, weareleftwiththreeprobabilities:inthejudgmentofthepolice,Holstcommit-ted suicide; thedeathmayhavebeenthe result of murder, never disclosedbythepolice;orthepoliceunderstoodrelativelyearlythattheyweredealingwitha fait accompliwithso-calledpo-liticalimplications.

Translated by Harry T. Cleven

REFERENCES1 TorePryser, Svik og gråsoner (2010)2 TorePryser, Fra varm til kald krig (1994) andEspenHaavardsholm,Ikke søkt av sol (1994)3 arnfinn moland, Over grensen? and PeterØvigKnudsen,Etter drapet (Norwegianver-sion2003)4olavNjølstad,Jens Chr. Hauge - Fullt og helt(2008).pp.566-5675EspenHaavardsholm,Taushetens pris. Et es-say til frigjøringsjubileet(1995)p.54ff6H.Druid,”Siteofentrancewoundanddi-rectionofbulletpath infirearmfatalitiesasindicatorsofhomicideversussuicide”(Foren-sic Science International 88-1997)


During the early hours of october12, 1948, the well-known leader ofthe agrarian Party, Nils Traedal, waspronounceddeadatUllevålHospital.Latethepreviouseveninghehadbeenfound unconscious with serious inju-ries in the backyard of his apartmentbuilding at Holtegaten 30 in oslo,whereherentedaroomonthefourthfloor.Toallappearances,hehadfallenout of a stairway window located 6.6metersaboveground.Thateveninghehad attended a board meeting of thenewspaper Nationen. Following themeeting he had dined at a restaurantwiththeparty’ssecretarygeneral,HansHolten. The landlord,alf Killingmo,who had heard some strange soundsfromthestaircaseandbackyard,foundTraedal in a state of unconsciousnesswithbloodflowingfromhishead.Hecalled an ambulance andTraedalwassoon receiving medical treatment atUllevålHospital.Butshortlyafterbe-ing admitted, the well-known politi-ciandiedwithoutregainingconscious-ness. The death certificate issued bytheosloBoardofHealth,senttothemunicipaldoctoratStøren,whereNilsTraedalwasa legal resident, gave thefollowingcauseofdeath:Fraktura Cra-nii, Contusio Cerebralie (Cerebralis)–inotherwords,afracturedskullandbraindamage.(1)

During the decades since, a cloudofmysteryhasshroudedtheeventsofthateveningwhentheclergyman-pol-iticianwasfounddyingatHoltegaten30.alreadyatthefuneralservicesheldinStørenonoctober19,rumorswerecirculating that Traedal might havebeen assassinated. People speculatedaboutmanythings:Therewerethose,for example, who drew a connection

between the death and the evalua-tioninParliamentoftheInvestigativeCommission’s report(2), the so-calledHviteboken (WhiteBook)on the roleplayedbytheParliamentandthegov-ernment during the german occupa-tion of Norway. others believed thatTraedal’sdeathwasrelatedtointernalconflicts in theResistancemovementduring the closing phase of the war,a conflict in which Traedel had alsoplayedapart.Duringthewar,TraedalhadbeenamemberoftheintelligenceorganizationXU.Stillothers stronglybelievedthatTraedel,whosupportedastrongnationaldefenseandNorwegianmembershipinNaTo,hadbeenliqui-datedbyCommunistswhohadreactedstrongly to a confrontation Traedalhad had with NaTo opponents inParliamentduringthespringof1948.Traedalhadprobablyalsocontributedtospeculationsthathisdeathwaspo-liticallymotivated.Whenforeignmin-isterJanmasaryk“fell”fromhisofficewindowinPragueonmarch10,1948,it was Traedal, as acting president oftheParliament,whoheldthememorialspeech.Heleftlittledoubtaboutwhatlaybehindmasaryk’sdeath:“Suchcir-cumstances tell without words morethananythingwhatitsometimescoststofightforyourconvictions!”

From the late 1970s to the end ofthe twentieth century, numerous ar-ticles and interviews appeared whichdescribedthedeathoftheleaderoftheagrarianPartyas“suspicious”and“cu-rious.”

WhenIbeganworkonNilsTraedal’sbiographywithhisfamily’sblessingin2002,mypurposewastwofold.First,Iwantedtodustoffhismemory,becauseIfeelhedeservesagreaterplaceinour

political history. Second, I wantedtotrytofindtheanswertoanaggingquestion: namely, was Traedal’s deaththe result of a political assassinationoranaccident?ItisthelatterquestionthatIwishtofocusoninthisarticle.

There were two things in particu-larthataddedtothemysteryandthatfueledthetheoriesthatTraedal’sdeathwas political: the assertion that thedeathofthepoliticianhadneverbeenproperlyinvestigatedbythepoliceandthe claim that no autopsy had beenperformedonTraedal’scorpse.

Reliable documentation existedthat supported both these assertions.Thekeeperofnationalrecordsinoslohad,onmarch22,1999,respondedasfollowstoaqueryfromhistorianmay-

The Mysterious Death of Politician Nils Traedal:

accidentorHomicide?

By Johan J. Jakobsen, Former MP

On March 10, 1948, The Czechoslovakian foreign minister Jan Masaryk fell from his office window in Prague. acting president Nils Trædal held the memorial speech in the Norwegian Parliament leaving little doubt that Masaryk died for his convictions. Seven months later Trædal who was advocating a strong national defense and Norwegian membership in NaTO, was found seriously injured beneath a window in the apartment building where he lived. For more than sixty years the death of Trædal has been an enigma.

Nils Traedal.


Brith ohman Nielsen: “Neither theaccidentatHoltegatenonoctober11,1948,norNilsTraedal’sdeathwaseverrecordedinthejournaloftheoslopo-licedistrictat that time.”(3) Iwent tothe National archives on November24,2004,tocheckifanyinformationregarding the accident had been re-cordedattheHegdehaugenpolicesta-tion. Several days later I received aninteresting,nottosayastounding,let-terfromtheNationalarchives(4)–andkeepinmindthereplythathadbeenmadetotheaforementionedhistorian.Theletterstates:“TheosloPoliceDis-trictwas,ofcourse,brought intothecase of Traedal’s death in accordancewith regulations concerning cases ofaccidentaldeath.Thedeath,however,wasnotrecordedinthejournal,eithercentrally,inthehomicidedivision,orat Hegdehaugen police station. Norwasitenteredintheordinarybookofpolicerecords,sincethedeathwasnotclassifiedas‘amysteriousdeath.’”

at the same time I was informedthat some investigations had beenmade and several people questioned,andthatallthecasedocuments,twelveinall,includingphotographsfromthe“crimescene,”werestoredintheNa-tional archives. one of these docu-ments turned out to be the autopsyreportfromUllevålHospital!accord-ing to the historian ohman-Nielsen,thereportfromUllevålHospitalstates

that “No medical examinations wereperformedonhim[Traedal]thatcouldclarifywhathadtakenplace.”

Icontactedtheinformationofficerat the oslo Police District, Jørn-Kr.Jørgensen, who advised me to get intouchwithProfessorTorleivoleRog-numattheInstituteofForensicmedi-cine (Rettsmedisinsk institutt). Thatprovedtobegoodadvice.onlyafewdaysafter IhadcontactedRognum, IwasinformedthatanautopsyhadbeencarriedoutonTraedalatUllevålHos-pitalandthus,ofcourse,therewasanautopsyreport.Inthecourseofonlyafewdays Ihadbeen informedby twoseparate sources – the National ar-chivesandUllevålHospital–thatanautopsyhad takenplaceand that theautopsy report was available, both atUllevålHospital and in theNationalarchives.Inaddition,itwasnowclearthat the police had investigated thecase and had questioned certain in-dividuals, and that twelve documentsrelatingtotheseinterviewswereavail-able in theNationalarchives.Thesetwo important sets of records relatedtothedeathhadbeensafelystoredinthese institutions for 56 years. I shallnotgointomoredetailaboutthesig-nificance these facts would have hadonthemystery,thecreationofamyth,and the speculations in the wake ofNilsTraedal’sdeathin1948.

The question now was how the

available material from the Nationalarchives and Ullevål Hospital couldhelptoshed lightonwhathadtakenplaceonthattragiceveningatHolte-gaten30.IshouldmentionthatIhadalso managed to find a living personwhohadresidedinthesamebuildingas Traedal in 1948. The informationthethen17-year-oldRoaldmuggerudhadgiventhepoliceduringtheinter-rogationonthenightofthetragedyin1948, and his conversations with theundersigned in 2005, shed new lightonwhathappenedonthestairwayonthatfatalevening.

Roald muggerud had lived on thethird floor, with his bedroom adjoin-ingthestairway,andsohehadheardTraedalwhenhecameupthestairs.Healso says that it was common knowl-edgetotheresidentswhoseapartmentsopened onto that same stairway thatTraedalhadrespiratoryproblems,andthat halfway up the stairs to his liv-ing quarters he would pause to rest.Thatwasalsothecaseontheeveningin question. Roald heard the familiarfootstepsonthewayuptothe fourthfloor. Traedal stopped, as he usuallydid, and Roald heard the politicianputter with something on the othersideofthewallandheardthewindowmove.Hedidnothear the fall,butafew moments later he heard voicesdowninthebackyard.The17-year-oldwent to thekitchenand, lookingoutthewindow,sawapersonlyingontheasphaltbelow.

according to the reports from theoslopolice,Roald’sfather,olaimug-gerud, called the criminal division at12:30a.m. to report thatamanhadjust fallen from a window at Holte-gaten30,andthattheemergencywardhad been informed. When the policearrived on the scene “the emergencymedicalcrewmemberswereremovingtheinjuredman.”Thecourseofeventswasdescribedthus:“Theinjuredman,asheascendedthestairs,forsomerea-son or another, lost his balance andfell against the window.” It was alsopointed out that the window on theleft-hand side was open and that thestormhookwasnotinplace.

The autopsy report begins witha reference to the patient’s journal,whichstatesthatNilsTraedalfellfromawindowanddiedjustafterbeingad-mittedtoWardIIofUllevålHospital.It also refers to the police report in

Johan J. Jacobsen(author),Bjørn Davan(policesuperintendent),Torleiv O. Rog-num (prof.of forensicmedicine)andRoaldmuggerud&RagnarThorsetwholivedinthebuildingin1948.


stating that “the deceased had fallenoutofthewindowinthestairwaybe-tweenthesecondandthirdstoriesintothe backyard. This was covered withasphalt.”Thereportmakesitperfectlyclearthattheimpactwiththeasphaltinthebackyardwasveryforceful.Theautopsyrevealed“numeroussplinteredfractures on, practically speaking, theentire skull. The fractures are largestonthefrontalareaoftheskull,andontheleftside.”Theleftthighbonewasbrokenaswellastenribs,and,inad-dition,thepelvicbonewasbrokeninfour places. The autopsy report statesthat “death resulted from these inju-ries.Theseinjuriesresulted,inalllike-lihood,fromafallfromagreatheight.”Thereportconcludeswiththefollow-ingsomewhatsurprisingpassage:“Theblood test reveals that the deceasedwasintoxicatedwhentheaccidentoc-curred.”TheautopsyreportwassignedbyDr.JohanHertzbergonoctober20,1948.

The blood sample taken by Dr.Hertzberg at the time of the autopsywas analyzed at the University Phar-macological Institute. The result, ac-cording to a letter sent to the oslopoliceanddatedoctober15,revealed“a content of volatile reducing com-poundscorrespondingto1.79promillealcohol.”TheletterissignedbyJacobmolland,m.D.

IaskedDirectorJørgmørlandattheNationalInstituteofPublicHealthDi-visionofforensictoxicologywhetherthe result of such tests carried out in1948 can be compared directly withtheresultsoftoday’stests.Withregardtothefindingof1.79promillealcohol,mørlandrepliedthatananalysisusingcurrent methods “would most likelyhavegivenaresultsomewherebetween1.6 and 1.9 promille.” But mørlandaddsthatmethodsthenwererelativelyunspecific, and that also substancesother than alcohol could have influ-enced the result, inwholeor inpart.Hefurtherstatesthattheformulationthatappearsinthereport,“volatilere-ducing compounds corresponding to…,”indicatesthatvolatilecompoundsother than alcohol could have led tothe same test result. mørland notesthat acetoneorketonebodies,whichare formed in the bodies of peoplewhohavediabetes,canbeinterpretedas alcohol in an analysis that meas-ures thecontentof“volatile reducing

compounds.” There is,however, no evidencethat Nils Traedal wasdiabetic.

Following the publi-cation of my biographyin theautumnof2005,I was contacted by anacquaintance of mine,Professor Emeritus Dr.TorsteinHovig,whohadread mørland’s evalu-ation of the analyticalmethods employed in1948 as compared withtoday’s methods withinterest and profes-sional insight. Hovig isof theopinion that thetimefactormustalsobetaken into considera-tion–thetime,thatis,whichelapsed fromthemoment of death untilthe takingof thebloodsample. He states thatit is a known fact thata promille level can betoo high if there is alongtimelapsebetweenthe time of death andthe takingof thebloodsample. Even thoughthere are few specificreferencestotimeinthedocuments available inthe National archivesand the oslo PoliceDistrict, there are somegoodclues:theCriminalDivision received thetelephonecallfromolaimuggerud reporting theaccident at 12:30 a.m.as I have pointed out,theeldermuggerudalsoinformed the police atthattimethathehadal-readysummonedanambulance.Whenthe police arrived on the scene, themedicalpeoplewereabout to removetheaccidentvictim.Traedalwastakenintheambulanceand,accordingtoJo-hanHertzberg,diedjustafterbeingad-mittedtoWardIIatUllevålHospital.Dr. Jacob molland of the Pharmaco-logical Institute states thatDr.Hertz-bergtookthebloodsampleinquestionat11:45a.m.onoctober12.onthebasisof this information, amaximumof9to10hourselapsedfromthetime

deathoccurreduntilthebloodsamplewastaken.

Professor Jørg mørland, in a newstatementdatedFebruary5,2010,saysthatthemeasuredlevelofalcoholmayhavebeen somewhathigher than theconcentration of alcohol Traedal hadinhisbloodwhenhefell.mørlandbe-lievestherearetwopossiblereasonsforthis:

“The one is that the fall traumacaused considerable physical damageso that the possibility existed for the

Rognumandtheauthorinspectthewindow.

Thebackyardseenfromthewindow.

TheplacewereTraedalwasfounddying.


transfer of bacteria to the blood to afargreaterdegreethanwouldnormallyoccur, and that therefore, to a muchgreaterdegreethanotherwise,alcoholwas produced from glucose. Thus, amore pronounced postmortem forma-tionofalcoholthanotherwise,whichcanexplain someof themeasuredal-cohol content, even though the timethatwasavailablefortheformationofalcoholwasrelativelyshort.

“Theotheristhathemaypossiblyhave had unabsorbed alcohol in hisstomachaftervisitingtherestaurantarelativelyshorttimeearlier.Thealco-hol in his stomach, a relatively shorttimeafterhisdeath,mayhaveseepedintonearbytissue,andhereaconsid-erable trauma may have affected thismorethanwouldotherwisebethecase.If the blood sample was taken frombloodintheheart(ortheperiphery),itispossiblethattheresultingconcen-trationofalcoholwastoohighduetopostmortemcontamination.

“In conclusion, it should be men-tioned that there is evidence that inextremecasespostmortemalcoholfor-mation,withlevelsofalcoholconcen-trationinthebloodupto1.9promille,andhighermayoccurinpersonswho,apparently, had no alcohol in theirbloodatthetimeofdeath”(5,6).

ItisaknownfactthatNilsTraedalwas not a teetotaller. Secretary gen-eralHoltensaysinhistestimonythatheandTraedalhaddrunk“coffeeandaglassofbeer”attherestaurantbeforecallingitaneveningandthatTraedalhadtakentheBriskebytramhometoHoltegaten.Weshouldkeepinmind,however,thattheexpression“tohavea glass of beer” is also popularly usedtomeanmorethanasingleglass.Itispossiblethatinusingthesingularform,Holten wished to protect his goodfriend.ButitisalsoanestablishedfactthatTraedalwasneverknowntodrinkmuchalcohol.oddBye,aretirededi-tor who knew Traedal well, says thatheneversawhimintoxicated.

Toward the completion of my bi-ographyofTraedal, Ihad thehelpofmany good assistants to whom I owea great debt of gratitude. In the win-ter of 2005 “these good helpers” andtheauthoragreedthattheywouldtryto reconstruct the tragic occurrence.Because the “scene of the crime”–includingthebackyard,stairwayandwindows–hadnotchangedessentially

since1948,TorleivoleRognum sug-gestedthatwecarryoutaninvestiga-tionofthescene.

ItwasasizeablegroupthatgatheredonFebruary15atHoltegaten30todothis: Professor Torleiv ole RognumwastherefromtheInstituteofForen-sicmedicine,aswerethecrimetechni-cianBjørnDavanandtheinformationofficerJørn-Kr.Jørgensen,bothoftheoslo police. In addition, two personswhohadlivedinthesamebuildingin1948, retireesnamedRagnarThorsenand Roald muggerud, the latter ofwhom had been an engineer, joinedthegroup,asdidtheundersigned.

The purpose of the investigation,asProfessorRognumputit,was“tore-constructthechainofeventsinlightofthe autopsy report and investigationscarried out at the scene.” Followingthe inspection of the scene, Rognumwroteafour-pagereport.

Theautopsyhadrevealed that theinjuries Traedal had received weretheresultofthefallfromthewindowbetween the second and third floors.That he ascended the stairs and thathestopped,possibly inordertocatchhisbreath,areconfirmedbothby thelandlord alf Killingmo and Roaldmuggerud.

Those present at the investigationof the scene were in agreement thatthewidewindowsillwouldbeinvitingtoatiredanddizzypersonwhomightwishtositdowninorderto“catchhis

ThewindowframewhereTraedalmayhavesatdowntorest.

Thewindowseenfromthebackyard.

wind.”CrimetechnicianBjørnDavan,who“testsat”thewindowsill,feltthatheacquiredquiteacomfortablesittingpositionwithhislegsplacedonastepapproximately 40 centimeters lowerthanthewindowsill(seephotos).

The window between the secondand third floors was not latched withastormhook.Normally,itwouldhavebeenshut,butThorsenexplainedthatitsometimeswaskeptopeninordertoairoutthestairwell.Inthechurchreg-ister for Støren parish, Nils Traedal’swidow, gunda, wrote the following:“Thestormhookshadapparentlynotbeen fastened, as I often sawwas thecase when I was there on visits.” Itmay also be that Traedal himself hadopenedthewindowinordertobreathefresh air. Professor Rognum writes asfollowsinhiscrimescenereport:“Thewindowwasnormallyclosed,itseems,butitisthinkablethatthestormhookswere unlatched from time to time sothat the window could yield to pres-sureagainstit.Becausehefeltthatheneededair,itisnotinconceivablethatTraedalhimselfcouldhaveopenedthewindow. The temperature that nightwas relatively mild for that time ofyear (7 -8degreesCelsius),and thusitwouldnotbeunnaturaltoopenthewindowinthestairway.”In his report, Rognum writes thatthe autopsy report shows that therewas a severe injury on the left sideof Traedal’s forehead, numerous cra-


nial fractures (also on the left side),afractureontheleftthighbone,sev-eralbrokenribs,andanumberofotherfractures,includingseveralfracturesofthe pelvic bone. Regarding the con-nection between the fall and the in-juries,ProfessorRognumwritesasfol-lows:“IfTraedalsatdowntorest,withhis left sidetowardtheopenwindow,he could very well have fallen out ofthewindoweventhoughtheheightofthewindowisonly120centimeters.acombination of dizziness, shortness ofbreath, and some degree of intoxica-tioncouldhaveresultedinhimlosinghisbalance.IfTraedalfellfromthispo-sitiondownintotheyard,thepointofimpactcouldverywellhavebeentheleft sideofhis forehead/temple, chestand pelvis. The injuries described intheautopsyreportareconsistentwithafallsuchasthatdescribedabove.”

In a report prepared after the in-spectionofthescene,crimetechnicianBjørnDavanwritesthattheplacementofthewindowinrelationtothestairs“increasesthepossibilitythatapersonquite easily could fall out if the win-dowisopenandthepersoneithersitsintheopening,leansagainsttheopen-ing,orfallsagainstitinanunguardedmoment,orloseshisbalance.”

Theinvestigationofthesceneandinput from experts in both forensicscience and crime technology havehelped to clarify the succession ofeventswhichledtothedeathofNilsTraedal at the height of his politicalcareer. a number of allegations andtheorieswhichforcloseto60yearshadfueledrumorsandastoundingconclu-sionshaveproventobeincorrect.Thenew informationand testimonyplacethe”Traedalcase”inanewlightthatcanbesummarizedasfollows:

• Traedal’sdeathwas investigatedbythepolice“inaccordancewiththeprocedures setdown in thecaseofdeathcausedbyaccidents,”toquotetheletterintheNationalarchives

• Thepolicerequestedthatanautop-sybeperformedonTraedal,andanautopsyreportdoesexist

• a new witness, living today, wasabletoassurethepoliceontheverynightthatNilsTraedaldiedthathehadheardTraedalascendthestairs,that Traedal had been alone, andthatduetobreathingdifficultieshehadstoppedtorestbetweenthesec-ondandthirdfloors.Further,therearestatementsfromtwoofTraedal’scolleagues in the Parliament,Elisæus Vatnaland and amund R.Skarholt,testifyingthatTraedalsuf-feredfromdizzyspells

• It must also be taken into consid-eration,onthebasisoftheautopsyreport, thatNilsTraedalhadquiteahighlevelofalcoholinhisblood(1.79promille)

• Professorof forensicmedicineTor-leiv ole Rognum concludes in hisreport that a new look at the evi-dence weakens the theories thatNilsTraedalwasmurdered

Unexplainable deaths may often betheresultofsuicide.ThosewhoknewNilsTraedalwelldismisscategoricallyspeculations about a possible suicide.NotonlybecauseofhisChristiancon-victions,butalsobecausea leap fromaheightof sixtosevenmeterswouldbearatherdubiouswayofcommittingsuicide.

onthebasisofnewevidencethatcame to light through close coopera-tion among persons with broad ex-pertiseincriminaltechnologyandfo-

rensic scienceaswellas throughnewtestimony,myconclusion is thatNilsTraedal,beyonddoubt,diedasthere-sultofatragicaccident.

one of Norway’s leading criminaltechnicians, police superintendentBjørn Davan of the oslo Police Dis-trict,whohasexaminedtheevidenceandwhoparticipatedintheinvestiga-tionofthecrimescene,hasdrawnthesameconclusion.Davan,whohasmorethan20years’experienceasacriminaltechnician,concludeshisreportasfol-lows:“Thereisnoevidenceinthecasewhich, in my opinion, indicates any-thingcriminal.”


NOTES

1) Jakobsen,JohanJ.,maktenogæren(ThePowerandtheglory).BiographyofNilsTrædal,gyldendal,2005.

2) Stortinget (Norwegian Parliament).Regjeringen og hjemmefronten underkrigen(ThegovernmentandResistancemovementDuringtheWar),aschehoug&Co,1948.

3) may-Brith ohman Nielsen, Senterpar-tiets historie 1920-1959 (History of theagrarian Party 1920-1959), Bondekampommarkedsmakt(agrarianStruggleandmarket Power), Det norske samlaget,2001.

4) National archives. Twelve documentsrelated to the death of Nils Traedal, in-cluding the autopsy report from UllevålHospital dated october 20, l948 andmiscellaneous police reports and photo-graphs.

5) Høysetgetal.IntjLegalmed(2000)122:63-66.

6)KugelbergFC,aWJones.ForensicSciInt(2007)165:10-29.

7) Professor Torleiv ole Rognum, Åsteds-befaring i Holtegaten 30 (InvestigatingtheCrimeSceneatHoltegaten30),15/22005.

8) Forensic technician Bjørn Davan, Rap-port / vurdering (Report / Evaluation),april6,2005.


onthe21stand22ndofNovember1963KennedyandhiswifeJacquelinemadeavisittoTexasasapreparationfortheupcoming Presidential Elections thefollowing year. From November 22ndthe Presidential couple stayed over-nightinForthWorth.Beforenoononthe22nd theyweretransportedbythePresidentialairplaneAir Force OnetotheairportinDallas.TheplanelandedatLoveFieldat11:40a.m.c.s.t.

ForthevisitinDallasamotorcaderoutehadbeenplanned from theair-portthroughdowntownDallastoTheTrade mart, where Kennedy was toholdaspeechataluncheonat12.30.The total length of the route was 16kilometres, and the planned time forthe drive was 45 minutes. The routewaspresentedintheDallasTimes-Her-aldonNovember15th,withnewdetailsthe followingday.onNovember19th

theTimes-Heraldafternoonpaperde-tailedthepreciseroute.ThemorningNews reported corresponding detailsonthesamedate.Themotorcadefol-lowedtheroutepresentedbythetwonewspapers,andmadeitpossibleforasniper toplan for anassassinationonthePresidentalongthisroute.(1)

THE MOTORCadE THROuGH dallaS

onarrivalattheairportthePresiden-tialcouplewere,amongothers,metbyVicepresidentLyndonBainesJohnsenand Texas governor John Connallyandtheirwives.

For the motorcade the couplesKennedy and Connally were seatedin the Presidential Limousine, a spe-cially designed Ford Lincoln Conti-nentalwithtwocollapsiblejumpseats

betweenthefrontandrearseats.ThePresidentsatontherightrearseat,andhiswifeintheseattohisleft.ConnallywasplacedinthejumpseatdirectlyinfrontofthePresident,andhiswifeontheleft jumpseat,directly infrontofmrsKennedy.

The car was outfitted with a clearplastic bubbletop. It was neither bul-letproof nor bullet resistant. TherehadbeenrainshowersbeforethePresi-dentarrived,butbecausetheskieshadclearedthebubbletopwasnotmount-edonthecar.ThiscorrespondedwiththewishofthePresidenttobeseenbyasmanyaspossiblewhiletravellinginthemotorcade.(2)

The cars left Love Field shortlyafter 11:50 a.m., and drove at speedsbetween 40 and 50 km/hour in thethinlypopulatedareasontheoutskirtsof Dallas. Following wishes from thePresident, the car stopped twice. Byboth stops Secret Service agents ranup front from running boards on theFollowupcartoprotectKennedyfromany intimidation fromthecrowd,butduringthetwobriefstopsnoincidentsdidoccur.

THE SHOTS

at12:30p.m.thePresi-dent‘s open limousinereached Elm Streetthrough a curve fromHouston Street, passedTheTexasSchoolBookDepository on the cars

right side and was heading towards atripleunderpasswhenshotswerefiredtowardsthemotorcade.

Connally, who was a trained rifleshooter,heardthefirstshot.Inhistes-timonytotheWarrenCommissionhetoldthatheimmediatelythoughtthatwhatheheardwasarifleshot,thatitwasanassassinationattempt,andthattheshotcamefrombehindthePresi-dentiallimousinehewassittingin.Heturnedtohisrighttolookbehindhisshoulder,butwithoutseeingthePresi-dent, he started turning back to theleftwhenhe felt a strongpain inhisback.(3)

Theshotthathithim,had,accord-ingtotheWarrenCommissionReport,atfirsthitKennedyinthebackofhisneck, bruised his right lung, rippedhiswindpipe,andexitedathisthroat,nicking the not of his tie (figure 1).ThenitcontinuedthroughConnallysback,chest,rightwristandleftthigh,werethebulletstoppedrightundertheskin.(4)(Figure 2)

Connally witnessed to the Com-missionthathewassurethefirstshotmissedhim,andthatthesecondshothit him. He did not hear the second

ConspiracyofoneThe assassination of John Fitzgerald Kennedy.

Olav Gunnar Ballo, MDmanagingdirectorInstituteofForensicmedicineoslo,Norway

The 35th President of uSa, John F. Kennedy, was assassinated on 22nd of November 1963 in dallas, Texas. although the murder has been thoroughly examined by american authorities, starting with the investigation of a commission led by the Chief Justice of american High Court; Earl Warren, rumours of a conspiracy with an involvement of many conspirators has lived on for nearly 50 years. does the evidence, including the result of the autopsy, support that view?

Figure 1.Exitwoundobliter-atedbythetracheotomy-in-cision:KennedyonautopsytableatBethesdaHospital.


HISToRICaLREVIEW

shot, which corresponded with histestimony, since a high velocity bul-let travels above the speed of sound,andwillhititstargetbeforethesoundwavefromtheshotwillreachthesametarget.(5)

Jacqueline Kennedy looked to herleft while waving to the crowd whenshe heard what she thought was abackfirefromamotorcycle.Shortlyaf-terwardssheheardanoutcryfromgov-ernorConnally,whichmadeher turntoher right.She then sawaquizzicallookonherhusbandsfaceasheraisedhislefthandtohisthroat.(6)

While looking at her husband sheheardanothershotandsawpartsofthePresident’sskullexplodebytheimpactofthebullet.Fracturesofbone,bloodandbrainmatterwereblown towardsherandstainedherdress.(Figure 3)

WITNESSES TO THE SHOOTING

Thepassengers inthefirstcars inthemotorcadelaterwitnessedtotheWar-ren Commission that the shots camefrom the rear and from the right, thegeneraldirectionofTheTexasSchoolBookDepositoryBuilding.Noneofthepassengers saw the shots being fired.But different other witnesses saw thegunman before, during, and directlyaftertheshooting.

Howard L. Brennan,45 years old, watchedthe motorcade stand-ing on a concrete wallat the southeast cornerof Elm and Houston,with a clear view tothe Depository Build-ing. Before the motor-cade arrived he noticeda man at the southeastcorner window of thesixth floor. Soon afterthe President’s car hadpassed the curve whereBrennanstoodheheardanexplosion.Helookedup,andsawamaninthewindow aiming with agun,andshootingdown

ElmStreettowardstheUnderpass.Hethensawthemandrawthegunbackfromthewindowanddisappear.

amosLeeEuins facedtheDeposi-toryBuildingasthemotorcadeturnedthecorneratElmandHouston.Whenhe heard the first shot he lookedaround,thenup,andsawthegunmanfirehisnextshot.(7)

otherwitnessesmadethe same description,and picked the samewindow as the pointfrom were the shotscame.Basedonthewit-nesses the police couldsendoutadescriptionoftheman.(8)

Two men watchedthe motorcade fromthe fifth floor of thedepository, directly un-derneath the southeastcorner window. Duringtheshooting,theyheardthe shots from directlyabove their heads. af-terwards they describedtothepolicethesoundsof the ejected bullet

shells fallingtothefloorabovethem.(9) The Warren Commission latermadeatestfromthesamestandingpo-sition,whileagunmanfiredariflefromthesixthfloorwindow.Thewitnessesthencouldhearthesamesound,fromthespentshellsfallingtothewoodenfloorabovetheirheads.(10)

PaRKlaNd HOSPITal

Thehospitalhadbeenalarmedthroughradioreportsfromthemotorcade,andtrauma rooms 1 and 2 were preparedbefore thearrival. Connallyhad lostconsciousness during the short trip,butwokeupashewasliftedoutofthecarontoastretcher,describingseverepain.

Kennedy was brought in from thecartoTraumaRoom1onastretcher,transportedonhisback,wherehewasexamined by Dr. Charles J. Carrico,a resident in general surgery. Carricofound that Kennedy was in a deepcoma,withnovitalsignsoflifeotherthanaslowspasmodic,agonalrespira-tionwithoutanycoordinationandnovoluntarymovements,eyesopenwithdilatedpupilswithoutanyreactiontolight,nopalpablepulsation,butafewchestsoundsthoughttobeheartbeats.

Figure 2. Connallys woundsasmarkedonasketchbythedoctors at Parkland Hospi-tal.

Figure 3. Stills from theZapruder film showing theimpactof thebullethittingKennedyinthehead.


Figure 5.TheshotthathitKennedyintheneck.

Figure 6.TheshotthatkilledKennedy.


on the basis of the findings CarricoconcludedthatKennedywasstillalive.(11)

Henotedtwowounds;asmallbul-letwoundinthefrontlowerneck,andan extensive wound in the right partofthePresident‘sheadabovetheear,where a sizeable portion of the skullwasmissing.Insidethewoundmostoftherightpartofthebrainwasmissing.CarricofeltthebackofthePresident‘shead,withoutfindinganysignsoflargewounds at this part of the body. Tosecurefreeairwaysheputanendotra-chealtubedownKennedy’sthroatpastthe neck injury, inflated the cuff andconnectedittoaBennettmachineforassistedrespiration.(12)

Becauseoftheconnectingmedicalequipment and the necessary lifesav-ing treatment, Kennedy was kept onhisbackonthestretcher,andwasnev-er turned around as long as his bodystayedatParklandHospital.(13)

othermembersofthemedicalstaffcameintoTraumaRoom1andstartedassistingDrCarricowithfirstaidtreat-mentofthePresident.Drmalcolmo.Perry,atrainedsurgeon,playedamajorroleinthetreatment.

To achieve free airways Perry per-formed a tracheotomy through thegunshot wound on the front of theneck.Theoperationtook3to5min-utestofulfil.(14)ThedoctorsCarricoand Ronald Jones made incisions inKennedy’s right leg and left arm, af-terwhichbloodtype0RhminusandaRingerlactat infusionweregiven si-multaneously.300mgSoluCortefwasadministrated by Kennedy’s privatephysician george Burkley, who knewthe President had addison’s disease,andthereforenowwasinurgentneedof corticosteroidsas a substitution forlackofadrenalproductionthroughthesuprarenalcapsules.(15)

althoughthetreatmentforashorttimemadeitpossibletofeelaperipheralpulseonthecarotidandradialarteries,themassiveheadwound,inconsistentwith further life, made all lifesavingmeasuresfruitless.afterlastriteswereadministeredtothePresident,JohnF.Kennedywaspronounceddeadatcloseto1o‘clock,underhalfanhouraftertheshotshadbeenfired.(16)

THE HuNT aNd aRREST OF THE PRESuMEd aSSaSSIN

The Dallas Police officer J.D. Tippitstoppedhiscarandwentoutsidetotalktoapersonhehadspottedat1.16p.m.The man then shot several shots to-wardsTippitwitharevolver,andkilledhimonthespot.Hethenranaway,butbrought the pistol with him. (17) atleasttwelvepeoplesawthemanshootorleavetheshootingscene,andgavethepoliceaprecisedescriptionofthegunman.(18)

Shortly afterwards the shoe sales-man Johnny Calvin Brewer heardpolice sirens and then saw a personwhoseemedtocoverhimselffromthepolice, behaving suspiciously. Thisperson then went into Texas Thea-tre without buying a ticket. Brewerhad heard about the assassination ofKennedy and, directly before leavingthe shoe store, also about the killingof Tippit on the radio. By phone healarmed the police, who arrived verysoon afterwards. armed police wentintothecinema.ThereBrewerpickedouttheman,andthepolicetookholdofhim.(19)

The suspect had a revolver, andtried to fire it against one of the po-licemen.Hewasbroughtintocustody,denyingpresentinghisidentitytothepolice. He was identified as Lee Har-vey oswald. (20) During the nightboththeriflefoundatthesixthfloorofTexasSchoolBookDepositoryandtherevolverhecarriedcouldbeidentifiedashisown.(21)Thoughorderedunder

afalsename,photosinhiswife‘spos-session showed oswald with the gun,and his palm print was found on theriflebarrel.(22)(Figure 4)

ThebulletsusedintheTippitslay-ing matched the revolver he carried,and five witnesses identified oswaldasthegunmanoftheTippitmurderinthe same night. (23) oswald was ar-restedonly1hourand15minutesaf-terKennedyandConnallywereshot;at1:45p.m.

THE TRavEl BaCK TO WaSHINGTON

apresidentialassassinationwastobetreatedasalocalcrimein1963(amer-icanlawwaslaterchangedtoconsideritafederalcrime)(24),andthewholeinvestigation, including the autopsy,was to take place through orders oftheDallasPolice.ButSecretService,under support of Lyndon B. Johnson,insisted on the transport of the bodyback to Washington, to have the au-topsyperformedthere.(25)

acoffinwasobtained,andalthoughofficials from Dallas County stronglyopposed, by the help of Secret Serv-icethecoffinwastransportedtoLoveField where it was loaded aboard airForceoneat2.15.p.m.(26)

ThenewPresidentwassworninat2.38p.m.9minuteslatertheairplaneleftforWashington.aboardtheplanewere Jacqueline Kennedy, the newPresidential couple, and members of

Figure 7. The view fromthe sixth floor window oftheTexasSchoolBookDe-positoryasseenthroughthetelescopic sight of oswald’srifle.


staffforthelateandthenewPresident.So was Kennedy’s personal physician,admiralgeorgeBurkley.

WhiletravellingbacktoWashing-ton mrs Kennedy was explained byBurkley that an autopsy was needed.(27)Thewidowwasstillinherblood-edclothes,which she insistedonnottaking off, and all people around herwhere strongly affected by the tragiceventstheyhadlivedthrough.

She was given a choice betweentheNavalmedicalCenteratBethesdaHospital inmarylandandthearmy‘sWalter Reed Hospital in WashingtonDC. Since Kennedy had served thenavyasanofficer,mrsKennedychoseBethesda Hospital for the autopsy.(28)Noneamongthepartymadeanysecondthoughtsaboutthechoice,al-thoughtheautopsiesatBethesdaweremedical autopsies, with the intentionof finding the cause of death to pa-tients dying in the hospital, and notautopsies made for the court in ordertosolvemurdercases.Thisdistinction,althoughimportantforthequalityandresult of the autopsy, seemed to havebeenlosttoallparticipantsinvolvedinthedecision,notthroughevilwill,butthroughabsentanddistressedminds.

THE auTOPSy

The autopsy at Bethesda Naval Hos-pital was led by pathologist James J.Humes,underassistanceofThorntonBoswell and Pierre a. Finck. onlyFinckhadanyexperiencewithgunshotwounds,noneofthethreepathologistswereforensicexperts.(29)Duringtheautopsy both the diseased Presidents´brother; Robert F. Kennedy, and Jac-quelineKennedy,waitedinthehospi-talfortheautopsytofinish.Whiletheywaited RFK repeatedly asked whenitwouldend, so theycouldbring thecorpsetotheWhiteHouseasplanned.Thismadeastressonthedoctorswhoperformedtheautopsy.RFKalsoaskedthemtofindthereasonfordeath,butnottodomorethanwhatwasneededforthesefindings.Suchdemandsmadefurtherrestrictionsforthepathologiststhatweretohaveconsequencesfortheresultoftheautopsy.(30)

By the autopsy a 7 x 4 millimetreoval wound was found on the up-per right posterior thorax just abovethe upper border of the scapula. The

woundwasmeasuredtobe 14 cm from the tipof the right acromionprocess and 14 cm be-low the tip of the rightmastoid process. In thelowanteriorneckatap-proximately the levelof the third and fourthtracheal rings a 6.5 cmtransverse wound withwidely gaping irregularedgeswasfound.(31)

In the night the pa-thologists concludedthat the cause of deathwas a gunshot to thehead from behind andabove,witha small en-trance wound, in thelower, right occipital region, and amassive,gapingexitwoundabovetheright ear, with approximately 70% ofthe right part of the brain missing asa consequence of the gunshot. Sev-eral pieces of the scull were missing,and the exit opening measured appr.13centimetresindiameteratitswid-est,withruggededgesfromloosebonyparts,onlykept togetherbytheover-layingskin.(32)

The tracheotomy incision was de-scribed as such, but the exit woundcausedbythebulletenteringthroughthebackoftheneckwasnotidentifiedduringtheautopsy(figure 5).Thebul-letpaththroughthesofttissuewasnotexplored and thereby not identified.(33)Becausethepathologistscouldnotfindanyexitwoundforthebulletshotinthebackneck,theyspeculatedthatthebulletcouldhave stoppeda shortwayundertheskin,andthenfallenoffon the stretcher, after the Presidentwasplacedonhisback for life savingtreatment.TheyhadheardbeforehandfromParklandHospitalthatatabullethadbeenfoundononeofthestretch-ers, without knowing that it was onConnallys stretcher, not Kennedys,thatthebulletwasfound.(34)

Notes were made, and Dr Humeswrote a first draft for the autopsy re-

portbasedontheassumptionthatoneoftheshotshadnoexitwound.Inthemorning on the 23rd of November,whenHumesspokewiththedoctorsatParkland Hospital, he was told aboutthe exit wound at the front of theneck, obliterated by the tracheotomyincision.Hethenhadtorewritepartsoftheautopsyreport.(35)

DrHumes toldTheWarrenCom-mission that the reason for rewritingthereportwasthatthepaperonwhichthe report was written had got bloodfromthedeadpresidentonit.althoughthismayhavebeentrue,themainrea-son(overseeingtheexitwoundinthefirstreport)wasnotmentionedintheWarrenCommission.(36)ThiscausedalotofspeculationamongscepticstotheCommissionReportandespeciallyamong the growing numbers of con-spiracyseekersintheyearstocome.

although the autopsy report hasbeen strongly criticised for being in-correct, incomplete and inaccurate,the main conclusions have stood theageoftime.Itwassuppliedbytheau-topsyx-rays,whichshowedbulletpar-ticlesalongtheremainingpartof thebraincorrespondingbetweenthesmallwoundinthebackoftheheadandthegapingwoundontheside.(37)

Figure 4. Picture taken bywifemarinaoswaldshowingL.H.oswald’spossessionofmurderweaponsbeforekill-ingofKennedyandTippit.


THE ZaPRudER FIlM

atthesceneofthecrimeamannamedabraham Zapruder filmed the motor-cadewithhiscamera,andthefilmbothshowsKennedyhavingbeenhitintheneck,andshowstheimpactofthebul-lethittingthehead.(Figure 6)

Thefilmmadeitpossibleforthein-vestigatorstomakeanestimatedtimeframe for the shots that were fired,whichmadeittotallyplausible,alsoforanaverageshooter,tofire,reloadandrefiretwiceintheestimatedtimeavail-ablebetweenafirstandathirdshot,onthe assumption that the first shot hitKennedyinthebackoftheneck,thesecond shotmissed, and the thirdhithiminthehead.

BasedonZaprudersfilmsuchatimeframewouldindicate4,8-5,6secondsto shoot, reload, shoot, reload andshoot.(38)Throughlateranalyses,andespeciallythroughthoroughexamina-tionsmadebygeraldPosner,describedin his book Case Closed, it is madeplausiblethatthefirst,andnotthesec-ondshotmissed.Thatwouldmakethetimespanevenlonger,with4,8-5,6secondsnotbetweenallthree,butonlybetweenthetwolastshots.(39)

THE CONSPIRaCy INduSTRy

manyhundredbookshavebeenwrit-tenabout theassassinationof JohnF.Kennedy, and most have their owntheories. Since only one theory canbecorrect,nearlyallof this literaturemakesmythoutofmatters.Somesawsmoke,andevenagunmanonagrassyknoll in frontof thePresident.Somedescribed a gunman shooting fromthe bridge over the triple underpass.Some even thought that people shotfromcarsinthemotorcade.Whenallbooks are put together, there seemedtobegunsalloverDealeyPlazaonthe22ndofNovember,andshotsseemedtocomefromeverywhere,onlynotfromwhereaweaponwas found, and fromwherewitnessessawoswaldshoot.

a strong belief is needed to comeup with explanations excluding hun-dreds of witnesses, pictures and filmsfromtheshootingscene,andpicturesandx-raysfromtheautopsy.Somebe-lieve that USas president was killedin a cover up involving hundreds ofpeople, including their own govern-ment. The Warren Commission may

haveitsflawsandweak-nesses, but comparedto the ever-growing al-ternative literature of apossible conspiracy thereport stands it timeover45yearsafteritwaswritten.

BEST EvIdENCE

What remains as bestevidence, all witnessesaside, are the woundson the corpse of thedead president, and thewounds on Connally,whosurvived.

Thesewounds show-ed that two shots hit, both hit frombehind,andbothfromabove.Theonebullet foundonthestretcheratPark-landinDallascorrespondedwithsmallparticles found in the right underarmofgovernorConnally,whowashit inthe back, sitting directly in front ofpresidentKennedy.Thisnearlypristinebullet, sarcastically called “the magicbullet”bycriticsoftheWarrenReport,may very well have caused both thewounds in the neck of Kennedy, andthe wounds in the thorax, right un-derarmand left thighofConnally, asshowedthroughlatertestshootingun-dersimilarcircumstances.

Thebullet, amannlicherCarcano6.5mm corresponded with the weap-on the accused assassin Lee Harveyoswald knowingly had in his posses-sion prior to the killing, and whichwas found at the Sixth Floor of theTexasSchoolBookdepository shortlythereafter. The distance to the targetwas appr. 60 meters for the shot thathit both Kennedy and Connally, andless than 90 meters for the last shottoKennedy’shead.Throughthetele-scopiclensthetargetwouldlookcloseandsharp,withthecarmovingslowlyalongthebullet’spath(figure 7).

Everysteposwaldmadeduringhislast hour as a free man was that of aguiltypersontryingtoescapethecon-sequences of his own actions. These

actionsweretocausehimhisownlifelessthantwodays later,whenhewasshot at point blank by the nightclubownerJackRuby.Thekillinghadthesameeffecttotheconspiracyrumoursthat petrol has to a fire. But no onecouldcomeupwithanycorrespondingrelations between Ruby and oswaldbefore oswald’s murder, or betweenRubyandanycollaborators.

TOO HaRd TO HaNdlE

The explanation for the never end-ing rumours of a conspiracy connect-ed with the assassination of John F.Kennedy seems tightly connected tothefactthatitisnearlyimpossibletoaccepttheimmenseconsequencestheactionsofasingle,failedhumanbeingmay have on historical events. on ascaleweightoswalddoesnotseemtofitontheonesidewhenyouputJohnF. Kennedy, the Presidency and theamerican Constitution on the other.Itseemshumantotrytomakethetwosides balance, by constructing a con-spiracyinoswald’splace.

Butwhenitcomestotheevidencethereisnootherproofleftthanthosefoundalongoswald’smiserableroute.Kennedy’smisfortunewasthathecametocrossit.


SOuRCES

a) Report of the President‘s Commissionon theassassinationofPresident JohnF.Kennedy.UnitedStatesgovernmentPrinting office, Washington, D.C.,USa,1964

B) William manchester: The Death of aPresident, Harper & Row, New York,USa,1967

C) gerald Posner: Case Closed. RandomHouse,NewYork,USa,1993

D) TexasState Journalofmedicine, Janu-ary1964.

1) a,p.38-39.2) a,p.43-45.3) a,p.49-50.4) a,p.97-109.5) C,p.331-332.6) B,p.155-158.

7) a,p.63-68.8) a,p.143-149.9) a,p.68-70.10) a,p.71.11) a,p.53-54.12) a,p.54.13) C,p.292.14) a,p.54. 15) a,p.183,D,p.61.16) a,p.55.17) a,p.165.18) a,p.166-171.19) a,p.176-180.20) a,p.180.21) a,p.180-181.22) a,p.122-124.23) a,p.143-149.24) B,p.296-305.25) B,p.236-237.26) a,p.58.

27) C,p.299.28) C,p.299.29) C,p.300.30) C,p.303.31) a,p.540.32) a,p.541.33) C,p.304-305.34) a,p.88-89.35) C,p.308.36) a,p.88-89.37) C,p.315-316.38) a,p.117.Because thepresidentialcar

atthattimewaspartlycoveredbyaroadsign the Zapruder film does not showwhen the first bullet hit Kennedy andConnally,whichexplainswhythetimespandiverges.

39) C,p.319,474-479.

Therearemanyquestions,butthefactis that olav gunnar Ballo, who fortwelveyearsheldaseatinParliamentrepresenting the Socialist Left Party(Sosialistisk Venstreparti, SV),tookoveratthe1.ofoctober2009astheinsti-tute’s first executive director. In thepast,therehasbeenanelectedleader,but now everything is changed, andwith many more tasks that often aredifficulttocarryout,anexecutivedi-rector–aprofessionalandadministra-tiveleader–hasbeenhired.Theideais that this will strengthen solidarityandthattheInstituteofForensicmed-icinewillsecureitspositionwithintheUniversity,theNationalHospital,thepolice, and in society at large. Thereisnodoubtthatgrowthandexpansionrequire leadership, and gunnar olavBallohasbeenchosenforthejob.

olav gunnar Ballo is in fact notonlyapoliticianbutamedicaldoctorwhowas the chiefmunicipalmedicalofficerinaltabeforehiselectiontotheStortingin1997.From1994to1997,hewasalsoadvisoryheadphysicianforthe County Health Insurance officein Finnmark. To keep himself profes-sionallyuptodate,hehas,forthepastnineyears,workedasacompanydoc-

torinadditiontoservingasanmP.Hecontinuestoworkonspecificdaysasacompanydoctor inhishomemunici-palityofalta.

as a politician he has proposedmanynewinitiativesandexperiencedboth ups and downs. In his privatelife,twoyearsagoheexperiencedtheworst thing any parent can imagine.HewritesaboutwhathappenedinthebookKaja(2009).HisdaughterofthatnametookherownlifewhilestudyinginNice,France,onthesamedayasshehad,fortheoneandonlytimeinherlife,visitedtheScientologyChurch.Inhisbookhedescribeshis relationshipwithKaja,which,causedbyhereatingdisorder,hadnotalwaysbeenaneasyone.ItisbothenrichingandhelpfultoreadthebookKaja,asitrevealsaspectsof the life of the new director of theInstitute forForensicmedicine.Ballohaswrittenagrippingbookabouthisdaughter’s struggle with a serious ill-ness, about how she got better, andabouthowherdeathcameasashocktothewholefamily.onecanonlyim-aginehowdeeplyherlosshasaffectedBalloandhisfamily.

Ballohasclearlythoughtabouthisnewposition.ItisimportantformethatI createmyown role at the institute,

thatIamaccessibleandthat I am not authori-tarian. Iwanteveryonetohaveasenseofsecu-rityallthewayintothecourtroom with regardtothecaseswithwhichwe are involved, andit is my wish that therelativesofthedeceasedandotheraffectedindi-viduals with whom we

are involved be treated with respect.It is important to remember that inourworkitisqualitythatcounts–andthat the consequences can be fatal ifwemakeanymistakes.

As a physician have you participated in many autopsies?No, only as part of my medical stud-ies. But there have been occasionswhenIhavetakenmoredetailedtestsfromthedeceasedincasesofunnatu-raldeath.Inonecasewehadtohavebloodsugarfromoneofthedeceased.SoItookasyringeandstuckaneedleintotheeyeofthedeceasedandwith-drewtheliquid.Thebloodsugarcountlaterrevealeditselftobecentralintheinvestigationofthecase.

InanothercaseItappedbloodfromthegroinofayoungwomanwhohadbeenkilledinatrafficaccident.Suchcases areno autopsies, but this is theclosest I have come to it, since youraisethequestion.Iamnotanexperton forensic medicine, but a generalpractitioner. Since coming to RmI, Ihaveparticipatedinseveralautopsies,butIhavenoexperienceswithautop-siesas such.So Ihavemuchto learnand at the institute we have world-classexpertsinforensicmedicine.

But Ballo adds: I learned some-thingfrommygrandfatherwhowasatelegraphmanagerandverydown-to-earth, when it came to dealing withpeople: Take your time. give peoplepraise.Bethere,closetoyouremploy-ees.

Ialsothinkaboutthesudden,unex-pecteddeathsofchildren.Icanneverbereconciledtothedeathofchildren.Therealizationthatsmallinfantsandchildren die without any good expla-nationisterrible.Thattheydieisin-comprehensible,andeventhoughonedaywemaymanageto learn fromre-searchwhy ithappenspurelybiologi-cally, physically, and physiologically,

Olav Gunnar Ballo – First Executive Director of the Institute of Forensic Medicine in Oslo

“HowIwish,howIwishyouwerehere”Text and photos: Jørn-Kr. Jørgensen

does it make any sense to appoint a politician as the executive director of the Institute of Forensic Medicine (RMI) in Oslo? Is the question purely rhetorical or does it have a deeper meaning? Who should be responsible for security under the law within the important fields in which RMI is involved – who should make the decisions and who should be responsible for prorities?

olav gunnar Ballo is aguardian of the law as ex-ecutivedirectoroftheInsti-tuteofForensicmedicine.


thefactthatchildrendiewillbejustasincomprehensible as a phenomenon.There is no meaning to it. Therefore–thereforealso– it is importantthatwecontinuetodoresearchaboutit.

What is your leadership philosophy?I don’t know that I have any actualleadership philosophy. It is perhaps abit pretentious to say this after beingin the position of executive directorfor suchashort time,but if Iweretomentiononethingitwouldhavetobe:Bepresent,beattentive, listen, learn,andthenmakedecisions,eventhoughthey may be unpopular. But who hassaidthatitshouldbeeasy?Leadershipisnoteasy.manypeoplehavegreatdif-ficultyinmanagingtheirownlives,sotoleadothersisalwaysdifficult.ButIbelieveitisimportanttolisten.

To listen has also another aspect.I’mnotsureit’swisesttolistentothosewhotalkloudest.Iwilltrytolistentoeveryone, not least to those who aresilent in group gatherings. my expe-rienceisthatthereisa lotofwisdomthere, sowe’ll see…Ihavebeensit-tingbehindthedeskattheinstituteforlessthansixmonths.

Do you have any visions for RMI and your work – you must necessarily have thought through this when you stepped into one of the most important jobs in a society based on law and order?

Yes,Ihavereflectedoverthis–andI’llgiveittoyoupointbypoint.Thisisimportanttome–asitmustbeformycolleaguesonall levels in the in-stitute:

• Wemustbeabletodefendwhatwedoineverycontext

• Everything we do must be profes-sionallyrootedinknowledge

• Whatwedomustbefuture-orient-ed. We have to deal actively withnew developments. For example,we have DNa technology. NextcomesRNa.Wemustbe ready tochange along with society. RmIhas to be top-quality and we mustachieve this in cooperation withother countries and new technol-ogy

• RmImustbeinclusiveandopeninrelation to the client (which, forthemostpart,isthepolice).Peopleshould be able to experience con-tactwithusasapositivething

• We must be open – and what anexpertonforensicmedicinesaysincourtmustbeput incomprehensi-blelanguage

• Weshouldbegratefulwhenpeoplecontactus. In thatwaywecanes-tablishourlegitimacy

• Wemustgivepeopletime–wheth-ertheyarecolleaguesorothers.Nomatterhowbusyoneis,itpaysoffinthelongruntotakethetimeneededtodothejob

I’m sure there is much more that Icouldaddtothelistintime,butthisiswhatIhavereflectedoverandwishtoemphasizeatthebeginning.

What do you think about forensic medi-cine as a separate discipline?It seems reasonable to me that fo-rensic medicine should be a separatediscipline. Even though we have fewforensic medical experts in Norway,thisisnotinitselfanargumentagainstthe identification of forensic pathol-ogyandclinicalforensicmedicineasadistinctdiscipline.Therecognitionofthisareaofexpertiseasadisciplineonits own would probably also contrib-ute to increased recruitment and thestrengtheningofforensicmedicineasadiscipline,whichinmyopinionthereisaneedfor.

olavgunnarBallo speaksquickly,tothepoint,andwithprecision.Inhis

spare timehe is leaderof theNorwe-gianTibetCommittee.HehasmettheDalaiLamaonseveraloccasions.Heisanenthusiasticamateurphotographer.Canheeverstopbeingthepolitician?TwelveyearsasanelectedmemberoftheStortinghave,ofcourse,lefttheirmark. This may explain his enthusi-asm for intense discussions about hisprofession and about administration,aboutfinancesandpriorities.

I have many interests, says Ballo.WhenIwakeup,Ineedtohaveabookwithinreach,andIliketowrite.Ihavedreamedaboutwritingabookwiththetitlemurderasamethod,aboutpoliti-callymotivatedmurdersandassassina-tions of politicians through history. IhavethoughtofstartingwithSocrates,andconcludingwiththeassassinationsof John F. Kennedy, martin LutherKing, Jr.,andRobertKennedy.Thesethree can be taken together, consid-ering the epoch in which they werekilled,aU.S.a.fullofhatred.

What about music, Ballo? Many physi-cians have a strong interest in music.I have been a fan especially of TheBeatles and Pink Floyd – and havebeenworkingonabookprojectaboutPink Floyd under the title “Shine onyoucrazydiamond”.PinkFloydmadesome 120 texts to their songs, and Ihave tried to rewrite these texts inNorwegian. We’ll see if it becomes abook.Thatwasverypopularmusicformanymembersofmygeneration,andthemusicIlistenedtoduringmyyouthisn’tsoeasytoletgoof.

ThereisalinefromPinkFloydthatgoes,‘Soyouthinkyoucantellheavenfrom hell, blue skies from pain. Canyoutellagreenfieldfromacoldsteelrail?’ For me there is something deepinthesewords,somethingthatspeaksaboutmyrelationshiptoKaja.HowIwish,howIwishyouwerehere.


olav gunnar Ballo claims he has much tolearn regarding forensic medicine and will-inglyconsultsJonLundeval’sclassicworkonthe subject. The book was reprinted manytimes and became the forerunner of laterworksbyProfessorTorleivo.Rognum.



Trafikkulykker – eTTerforskning og

granskning

et faglig møte for politi, helsepersonell og andre som er involvert i taktiske, tekniske og medisinske undersøkelser

Dato: 20. oktober 2010

sted: soria Moria, Voksenkollveien 60, oslo

Kursavgift: kr 1.400,- Bindende påmelding til [email protected]

Frist 1. oktober 2010 Arrangør: Norsk Rettsmedisinsk Forening og Gjensidigestiftelsen

Boganmeldelseaf

”biologisk antropologi med human osteologi”

Red.NielsLynnerup,PiaBennikeogElisabethIregren.

Forlaggyldendal2008.

Vihar iNorden længe savneten samletogmodernefremstillingafbiologiskantropologiset fraen skandinavisk synsvinkel.Dennyelærebogibiologiskantropologiopfylderdettebehov.Denerskrevetafførendeforskerefrade skandinaviske lande samt enkelte andre.Bogens opbygning er logisk og overskuelig,og den er sat op med en indbydende grafikog mange interessante illustrationer. Ka-pitlerne er skrevet i et letforståeligt sprog,oger satpædagogiskopmedmangeeksem-pelbokse. Kapitlerne omfatter både baggr-unds kapitler om for eksempel mennesketsevolution og mere praktisk orienterede ka-pitler om for eksempel feltarbejde. Desudenbelyses mere teoretiske emner som statistikogetik.Kapitlerneergenereltletlæseligeoginteressante. Det er lykkedes redaktørerneat fastholde en ensartet stil trods de mangeforskellige forfattere. Det er dejligt at se ennordisklærebogsomindeholderkapitlersomer skrevet i de skandinaviske originalsprog.Bogenvil være til stornytte for studerendefra de mange forskellige faggrupper som be-skæftiger sig med biologisk antropologi.Denkanogsåmed fordel læsesaf færdigud-dannede fagfolk, som ønsker at opfriske ogudvidederesvidenombiologiskantropologi,nok især fra tilgrænsende fagområder somarkæologioglægevidenskab.Iøvrigtviljegvovedenpåstand,atbogenvilkunnelæsesafallenaturvidenskabeligtinteresserede.Deterfornøjelig læsning,somsagtenskankonkur-reremedkriminalromanenpåferierejsen.

Peter Mygind Leth, vicestatsobducent

08.30-09.00 Registrering og kaffe 09.00-09.10 Åpning 09.10-09.30 Politiets arbeid med etterforskning av trafikkulykker - et overordnet perspektiv Jan Guttormsen, Politidirektoratet 09.30-09.50 Hvordan foregår trafikkulykker? Harald Ståle Jansen, Statens Vegvesen UAG, Region ØST 09.50- 10.10 Kan politiet stoppe ”villmannskjøringen” - og redusere trafikkdøden? Roar Skjelbred Larsen, Utrykningspolitiet 10.10-10.30 Kan gjennomgang av alvorlige hendelser forebygge fremtidige dødsulykker? Rolf Mellum, Statens Havarikommisjon. 10.30-10.50 KaFFe 10.50-11.00 Personskader i bilulykker. Bedre sikkerhetsutstyr – færre skader? Arne Stray-Pedersen, Oslo universitetssykehus og Rettsmedisinsk inst 11.00-11.20 Rettsmedisinske undersøkelser. Nye metoder, bl.a. CT/MR – flere svar? Torleiv Ole Rognum, Rettsmedisinsk institutt 11.20-11.40 Kriminaltekniske undersøkelser ved trafikkulykker Trond Sandsbråten, Søndre Buskerud politidistrikt 11.40-12.00 Er dagens biler sikret nok i forhold til utfordringene i trafikken? Om skademekanismer og utvikling av nyere sikkerhetsteknologi Inggard Lereim, NTNU 12.00-13.00 LunsJ 13.00-13.20 Betydning av rusgivende stoffer ved trafikkulykker? Asbjørg Christoffersen, Folkehelseinstituttet 13.20-13.40 Forekomst av rusgivende stoffer/medikamenter i normal veitrafikk Hallvard Gjerde, Folkehelseinstituttet 13.40-13.55 KaFFe 13.55-14.15 Polititaktisk arbeid på skadestedet - Enkle og vanskelige saker Harald Klemetsen, Oslo politidistrikt 14.15-14.30 Tekniske undersøkelser inne i kjøretøyet – har det noen hensikt? Trond Boye Hansen, Oslo universitetssykehus, Ullevål 14.30-14.45 Prosjekt ”Barn i bil”. Hvordan går det med barna ved alvorlige bilkollisjoner? Marianne Skjerven Martinsen, Rettsmedisinsk institutt 14.45-15.00 Dokumentasjon på skadestedet – er vi gode nok? Trine Staff, Oslo universitetssykehus, Ullevål 15.00-16.00 Paneldebatt: Kan bedre samhandling gi bedre etterforskning og bedre forebygging?


Trafikkulykker – eTTerforskning og

granskning

et faglig møte for politi, helsepersonell og andre som er involvert i taktiske, tekniske og medisinske undersøkelser

Dato: 20. oktober 2010

sted: soria Moria, Voksenkollveien 60, oslo

Kursavgift: kr 1.400,- Bindende påmelding til [email protected]

Frist 1. oktober 2010 Arrangør: Norsk Rettsmedisinsk Forening og Gjensidigestiftelsen


themes:

● Brain stem research and siDs● genetic risk factors for siDs ● Domestic violence and effect on early brain development● impact of death scene investigation in sudden deaths in infants and small children

contriButors:

●hannah Kinney ●henry F. Krous ●roger W. Byard●Peter Fleming ●Jens grøgaard ● magne raundalen

For more information, please contact: [email protected]

First announcement: soria moria meeting 2011may 19-21



ScandinavianJournalofForensicSciencesispublishedbytheDanish,theNorwegianandtheSwedishsocietiesforforensicmedicine.Itpublishesoriginalcontributionsandreviewarticlesinthedifferentdisciplinesofforensicsciences:forensicpatho-logy,clinicalforensicmedicine,forensicgenetics, forensicto-xicology, forensic anthropology, forensic odontology, forensicpsychiatry and forensic science. The journal is also open fordebateonissuesconcerninglegalmedicineandfornewsfromthesocieties.

SubmiSSion of manuScriptS

originalarticles,reviewarticles,preliminarycommunications,letterstotheeditorandcasereportsmaybesubmittediftheyarenotbeingconsideredforpublicationelsewhere.

PapersforconsiderationshouldbesubmittedtoTorleiv Ole Rognum(editorinchief),Rettsmedisinskinstitutt,Rikshospitalet,N-0027oslo,Norway.Tel:+4723072718,fax:+4723071331,e-mail:[email protected]@labmed.uio.no

Or to the national editors:Jørgen L Thomsen(Denmark),RetsmedicinskInstitut,Winsløwparken17,DK-5000odenseC,Denmark.Tel:+4565503000,fax+4565916227,e-mail:[email protected]

Håkan Sandler(Sweden),Retsmedicinskaavdelningen,DagHammarskjöldsväg17,S-75237Uppsala,Sweden.Tel:+4618515720fax:+4618559053,e-mail:[email protected]

preparation of manuScriptS manuscripts should preferably be written in English (letterstotheeditorandmattersconcerningthenationalsocietiesofforensicmedicinemaybewritteninScandinavianlanguages).authorswhosenativelanguageisnotEnglisharestronglyad-vised to have their manuscript checked for style, syntax andgrammarpriortosubmission.

articles shouldbe submitted in triplicate,witheachcopybeing complete in all respects as twocopies are sent to refe-rees.

The text shouldbe typed indouble-spacingonconsecuti-velynumberedpagesofuniformsize,preferablya4.Everypageofthemanuscript, includingthetitlepage,references,tables,etcshouldbenumbered.

Manuscripts should be organised in the following order:Title(shouldbeclear,descriptiveandnottoolong)Name(s)ofauthor(s)Completepostaladdress(es)ofaffiliation(s)Telephone and fax numbers and e-mail address of the cor-respondingauthorSummery,whichshouldbeclear,decscriptiveandnot longerthan250wordsKeywords,normally3-6itemsIntroductionmaterialsandmethodsResultsDiscussionReferences

referenceS Referencesshouldbenumberedintheorderinwhichtheyarecited(usingsquarebracketsinthetext)andlistedinnumericalorderonaseparatesheet.ThepresentjournalshouldbecitedasScandJForensSci.Referencestojournalsorbooksshouldaccordwiththefollowingexamples:

1.RollmannD,JarlbækL.minimumlethaldoseofcitalopram.ScandJForensSci2002;8:10-112. Knight B. Forensic pathology. Sec ed. arnold, London,19963.madeaB,HenssgeC.Eyechangesafterdeath.In:KnightB(ed).Theestimationofthetimesincedeathintheearlypost-mortemperiod.Edwardarnold,London,1995

tableS Tables should be typed in double spacing on separate sheets,andnumberedaccordingtotheirsequenceinthetext.Thetextshouldincludereferencestoalltables.

illuStrationS Illustrationsmustbeaccompaniedbysuitablelegendstypedindoublespacingonaseparatesheet.

Illustrationsmustbesubmittedinaformsuitablefordirectreproduction. Photographs should be clear, black and whiteprints onglossypaper.Colourphotographsmaybe accepted.Photographs and figures should, when possible, be submittedasJPg-files.

proofS onesetofproofswillbesenttothecorrespondingauthorasgivenonthetitlepageofthemanuscript.Proofsshouldbere-turnedbyfaxorexpresspostwithin48hoursorreceipt.Cor-rectionsshouldbelimitedtotypographicalerrorsonly.

reprintS Reprintsarenotproduced.aCDwiththearticlewillbeof-feredfreeofchargetothefirstauthor.Thefirstauthormayalsorequire5extracopiesofthejournalfreofcharge.

advertiSing information advertisingscientificmeetingsandcourseswithinthescopeofthejournalisfreeofcharge.

commercial advertiSing and advertiSing of vacant poSitionSCommercialadvertisinghavethefollowingprices:

Backcoverpage,1volume,4numbers,NKR20,000(blackandwhite),Nkr30,000(colour)

Fullpage,insidethejournal,1volume,4numbers,NKR10,000(blackandwhite)

Fullpage,insidethejournal,1number,NKR4,000(blackandwhite)

Halfpage,insidethejournal,1number,NKR2,500(blackandwhite)

guideforauthors

Leica FS C - Motorized Forensic Comparison MacroscopeThe innovative Leica FS C forensic comparison macroscope provides superior optical and motorized performance to forensic scien tists. Offering flexibility, convenience, and user comfort, the Leica FS C is the universal instrument for high-precision firearm and toolmark examinations. The highly stable comparison bridge, the ergononmic design and the highest optical performance combined with versatile illumination options makes this system ideal for the simultaneous observation of evidence during training and consultation.

www.leica-microsystems.com

Living up to Life

Documents

Proposal for an International Classification of SUDI: A response to Blair, Byard and Fleming