J Forensic Sci, 2014 doi: 10.1111/1556-4029.12496 Available online at: onlinelibrary.wiley.com
TECHNICAL NOTE PHYSICAL ANTHROPOLOGY Ann W. Bunch,1 Ph.D.
National Academy of Sciences “Standardization”: On What Terms?
ABSTRACT: The frequently cited 2009 National Academy of Sciences Report entitled “Strengthening Forensic Science in the United States: A Path Forward” has become a focal point of forensic science practitioners’ discussions and research since its publication. One of its recommendations is “Standardized Terminology and Reporting”. Little has been published to date on this topic, although conversations and dialogs on the subject are ongoing. The upshot of this communication is to draw attention to the problem of one term in particular, perimortem, which may be only the proverbial “tip of the iceberg” in the lexicon-related concerns of forensic scientists. Even if it is an isolated issue, it is one that reflects the need for a consensus on term use and definitions by interdisciplinary practitioners who are currently using the term haphazardly, to the confusion of colleagues and potentially finders-of-fact in the courts.
KEYWORDS: forensic science, perimortem, forensic anthropology, forensic pathology, National Academy of Sciences report The National Academy of Sciences Report on “. . .A Way Forward” for forensic science in the United States has emphasized, among many other concerns, a need for the “standardization” of terminology and reporting (1). The report cites examples such as the terms “match,” “consistent with,” and “identical” (p. 21). The authors bemoan the fact that the “use of . . .recommended language is not standard practice among forensic science practitioners” even when such vocabulary and scales are proposed (p. 21). In addition, they warn that “[t]he use of such terms can and does have a profound effect on how the trier of fact in a criminal or civil matter perceives and evaluates scientific evidence” (p. 21). Four years later, this guidance has apparently been largely ignored, at least in peer-reviewed literature. A paper by Sauvageu and Boghassian (2) is a rare example of a published discussion and remedy for the varied and confusing use of the term “asphyxiation” in medical investigations and reports. Outside the peer-reviewed literature, informal discussions are undoubtedly taking place within and between forensic specialties in an attempt to address terms that require attention given their vagueness or use (misuse?) across disciplines. One such conversation has been ongoing between forensic anthropologists and medical examiners, because one particularly vague term in need of clarification has (1) emerged: perimortem. Current Definitions and Use of Perimortem in Medicine At first glance into the standard English dictionary (Webster’s, Funk and Wagnall’s, etc.), one will not find the term perimortem. This amalgam of Greek (peri) and Latin (mortem) root
1 Department of Criminal Justice, College at Brockport, State University of New York, 160 Albert W. Brown Building, Brockport, NY 14420. Received 30 July 2012; and in revised form 30 May 2013; accepted 15 June 2013.
© 2014 American Academy of Forensic Sciences
words translates to “all around, about, near, enclosing, surrounding” [peri] and “death” [mortem]. Online dictionaries and Google searches provide a less cumbersome—yet less reliable in an academic sense—definition that typically reads “at or near the time of death” (e.g., www.anthropology.si.edu, www.definition-of.net, en.wiktionary.org). In published volumes in pathology and medical death investigations, the definition given is “at the time of death” (3) but more often there is complete absence of the term from the lexicon of the volume (4–14). Applications (“apps”) for smart devices (i-phones, tablets, etc.) such as Medwords and Taber’s Cyclopedic Medical Dictionary also lack the term perimortem. The term seems generally to be avoided in the medical/clinical literature. The relative absence of this word may be related to the questions surrounding the term “death” itself in medicine. In the past, death would be relatively easy to pinpoint in time, that is, when the body organs cease to function on a gross level (heart stops beating, breathing ceases). Yet with technological advances of the 20th century, the ability to sustain life and organ function has altered the concept of death so that it is broken down into somatic and molecular levels (12). Even without considering medical technology, the medical examiner or coroner must determine immediate and intervening causes of death on the standard US death certificate (4). Thus, the implication that death can be an extended process and that the length of time depends on the cause of death. Among death investigators, who work closely with pathologists, the Special Working Group of Medicolegal Death Investigators (SWGMDI) has as one of its listed committee foci “Terminology” yet detailed guidelines or a lexicon from this committee do not appear online as of this writing (June 2012). In the Handbook for Death Scene Investigators (15) and Death Investigation: System and Procedures (16), the term perimortem does not appear in the Medical Terminology Appendix/ Index. 1
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To put the medical use of the term into a historical perspective, the medical field appears to have used the term perimortem in a clinical context, specifically in reference to birth practices. In order for a dying mother to give birth, the rendering of medical assistance may be required. According to Whitten and Irvine (17), the label “perimortem” to this procedure began . . . in the 1985–1987 triennium, when the Confidential Enquiry introduced a new term, perimortem caesarean section, for cases where the patient was moribund or in extremis, or was on cardiopulmonary resuscitation before the caesarean section and showed no signs of recovery afterwards. The medical literature thereafter reports on perimortem births, that is, those that occur at or during the time of death of the mother, across time and space (17,18). The writings on this type of surgery (abbreviated as PRMCS) indicate that it stems from the practice of the earlier postmortem cesarean section (PMCS) (18). Religious sacred books discuss PMCS, as it dates back to ancient times; it is said to have been practiced by “all cultures” (18), although no evidence of this is given. In this context, clearly the term perimortem refers to the birth event taking place within minutes of the mother’s death. As the practice continued among physicians, it became known that a child could be born using PRMCS more than 40 min after the mother’s death (18). Lopez-Zeno et al. (19) report intact fetal survival with delivery 47 min after fatal maternal injury by gunshot wound. In a text that bridges that gap between medicine and forensic anthropology, Rich et al. (20) indicate that the pathologist’s definition of perimortem is related to a relatively narrow time frame when the “person breathed his or her last or thought his or her last thought” (p. 257). A diagrammatic depiction shows “death” equal to “perimortem” as an abrupt cut-off point on the line of “life of the individual.” These authors contrast this use of the term to that of the forensic anthropologist who applies the term perimortem to “the time when the bone was first able to show skeletal signs of healing or lost the resiliency of living moist tissue” (p. 256) (emphasis mine). These signs may take “up to 2 weeks to appear after injury” (p. 256); the diagrammatic representation of the “perimortem period” (emphasis mine) for bone is one that demonstrates a segmented line, divided into thirds, “antemortem,” “perimortem,” and “postmortem” all relatively equal in length. It is clear that modern day medical practitioners in the literature avoid the term perimortem. If the term is used, it appears to imply a relatively narrow time period (3,17–20). Medical examiners who deal often with traumatic deaths may frequently use the term much the same way as obstetricians/clinicians, describing wounds, injuries and physical events that occur(ed) in very close temporal proximity to (within minutes of) the death event [“at the time of death”]. Yet, as immediate cause and intervening causes of death may be separated by lapse(s) of time, the perimortem “moment” may become a “period” of time in some cases (disease, infection, etc.). It is also evident with Rich, Dean and Powers’ work that when using the term perimortem, medical doctors are referring to the “person” (body), whereas the forensic anthropologist is referring to bone. This distinction is at the heart of discrepancy in term use and will be returned to later.
Current Definitions and Use of Perimortem in Forensic Anthropology If one turns directly to writings of practitioners in forensic anthropology, the waters begin to muddy considerably. The Special Working Group for Anthropology (SWGANTH), in its drive to delineate best practices, has run into this hard-to-define word within the special area of trauma analysis. The latest published use of the term perimortem that appears on the SWGANTH website (Trauma Analysis section dated 5/27/2011) as of this writing (December 2012) reads as follows: Perimortem trauma refers to an injury occurring at or around the time of death. Because of the properties of bone, the timing of injury is less precise when evaluating bone than when evaluating soft tissue. Within the anthropological realm, perimortem is determined on the basis of evidence of the biomechanical fracture characteristics of fresh bone. Perimortem trauma is a category in which remains lack evidence of healing and lack diagnostic taphonomic evidence of postmortem damage. . .[emphasis mine]. The document goes on to warn about use of the term perimortem: . . .When trauma is classified as perimortem, consideration should be given to: *Cautious use of the term perimortem, since it is used with varied temporal precisions within the forensic community; thus an explanation of the term should be provided with clear reasons for a perimortem classification. . .[emphasis mine]. The term perimortem itself is not defined by the SWGANTH; the difficulty in applying a clear and concise meaning to this term is apparent. Caution is wisely advised to those using the term. The contrast of analyzing the “bone” versus “soft tissue” is discussed—again, revealing the root of the timing discrepancy. Some recent anthropological publications demonstrate the dissatisfaction with the term perimortem and its differential use among medical versus anthropological practitioners (21–25). Mann and Hunt (21) also contrast the difference in meaning of perimortem in reference to soft tissue versus dry bone (p. 230); they explain (as did Rich et al. [20]) that one of the confusing factors in applying this term to bone is that it (bone) may retain its visco-elastic qualities until the collagen component deteriorates after death, which may take “weeks or months” (p. 230). The authors advise caution and judgment when linking cause of death to any case where bone is being analyzed without soft tissue (p. 230). Komar and Buikstra (22) acknowledge that discrepancies exist between how those in the medical community and anthropologists differentiate ante-, peri- and postmortem periods (p. 27). Since, according to these authors, the perimortem period encompasses the events surrounding death, this period could be brief (as with a fatal gunshot wound) or prolonged (as with toxic chemical exposure in industry) (p. 26). Komar and Buikstra do not the terms intervening and immediate cause of death, however. As mentioned earlier, these terms assist the medical doctor to clarify temporal distinctions for medico-legal purposes. The problem of duration of time is one that is found primarily in the forensic anthropologists’ bailiwick, as the focal point of our investigations is the bone, not the body. Komar and Buikstra
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indicate that they do not attempt to terminate “the debate” [on the term perimortem] yet desire to “highlight. . .the ambiguities present in current thinking.” They conclude that “clearer definitions and a more widely accepted understanding is crucial. Clearly, additional consideration and consensus is urgently needed” (p. 27). Nawrocki (23) also addresses the broadness of the anthropologists’ “perimortem” period and the lack of connection with the physiological death event or any “fixed unit measure of time.” (p. 287). He advises “extreme caution” when interpreting skeletal trauma and touches on the ethics of anthropologists venturing into the realm of cause and manner of death at all. Nawrocki perceives and highlights this apparent disconnect between the anthropologists’ data set (bone) and terminology (relating to death, time of death, cause of death). Some authors move beyond describing the situation and urging vigilance to recommending a course of action. Symes et al. (24) suggest clarification of “discipline specific terminology in. . .report[s]” (p. 349), whereas Passalaqua and Fenton (25) allude to the use of new descriptive terminology, such as “fresh bone fracture” (p. 402). The former may be merely a continuation of the current lack of standardization that the NAS report decries (1). The latter addresses the problem head-on. “Fresh bone fracture” however may result in confusion, because “fresh” implies recent —thus “fresh” equals postmortem or “fresh” equals perimortem? In other forensic anthropological writings, the term has been presented with less caution (26,27). A widely used forensic anthropology textbook (26) definition of the term perimortem reads “Perimortem trauma refers to injuries that occurred around the time of death. . .” (p. 289). The phrasing changes slightly in a subsequent discussion, thus “Injuries that occur close to the time of death will not exhibit the signs of healing seen in antemortem trauma” (26,28). The author goes on to detail “five characteristics of fractures [that] indicate perimortem trauma” (26). Yet if one accepts the premise aforementioned that perimortem injuries occur “close to the time of death” [and not “at” the time of death], then all of the “five characteristics” probably should be taken with the proverbial grain of salt. The discrepancy between the caution advised by some (20–25) and the textbook’s lack thereof should be a warning to practitioners that there is no standardization in our understanding of what anthropologists mean when we use the term, how we should use it, and how we should promote its use to students (future practitioners). Loe (27) also uses the term without any advisory words on its vagueness, citing Roberts (28). Byers cites Sauer (29) in his discussion of trauma. In a review of Sauer’s (28) introductory definition of perimortem, a close resemblance to pathologists’ use is seen: “Any injury directly associated with manner of death is considered a perimortem injury” (p. 321). Yet when Sauer delves into the anthropological realm specifically, he acknowledges the challenging nature of working with skeletal remains alone: Distinguishing between perimortem and postmortem injuries (and identifying antemortem injuries that occurred close enough to death that the healing process was not recorded on the skeleton) is less straightforward than identifying ante-mortem trauma. If there is no evidence for an osteogenic reaction, the pattern of the injury becomes a paramount concern (pp. 322–323). Here, we see implied that the indicator used to inform forensic anthropologists of perimortem trauma is lack of something (oste-
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ogenic reaction, i.e., healing). Yet we also see that even antemortem injuries that occur close to the death event will lack that same thing. The reader finds little certainty in the determination of timing of injuries here (28). In a closing summary, Sauer (28) opens with “[A]ssociating trauma to bone with the death event is a critical issue in a forensic investigation of decomposed human remains” (p. 329). And concludes this section with “[W] hile evidence of vital reactions are rarely preserved in bone, skeletal material often holds the key to the determination of the timing of injuries with respect to death” (p. 330). It is not convincing that forensic anthropology offers a reliable way to do this, however, given the variables Sauer mentions that may have an effect on bone (28). Conveying the lack of precision that belies this undertaking in forensic anthropology is preferable as it relates the reality of the situation and gives no false pretense of what forensic anthropologists can do. Original Amalgamation and Use of the Term So how did the term perimortem come to take on different applications, and, in a sense, different temporal spans, one narrow (“at the time of death”) and one relatively broad (“at or around the time of death”) or even, a third definition, more vague still, disconnected with the actual physiological death event? Or perhaps the question is, how did this seemingly medical term find its way into the forensic anthropological lexicon, where its application seems much more tenuous? It appears to have been amalgamated in the early 1980s in a rather roundabout way. The word makes its appearance not in forensic anthropological writings but in another “realm” of anthropology —bioarchaeology. Reports of archeological analyses of possible cannibalism by Turner (30,31) refer to perimortem trauma observed on some of the human remains. Turner later states that he “coined the term” (32,33) and mentions that other scholars (“faunal analysts”) have adopted the term, citing Morlan (34) and Malville (35). He goes on to state that the term has been used instead of “perthotaxic” or “greenstick fracture,” which has a special medical connotation (32: 188). Given the timing of the term’s appearance in medicine in the late 1980s (17), it appears that Turner did in fact “coin” the term. In his bioarcheological studies (30–32), he describes “bone damage signatures that can provide a kind of historic record of events that happened at or near the time of death. In many instances they might represent the actual cause of death” (30) (emphasis mine). Turner published a list of indicators, or “bone signatures” that could be seen on prehistoric human bone that, considered together, comprised a “cannibalism signature.” One such trait was “few signs of bone weathering or animal gnawing (indicating that bone damage and the covering of remains occurred at or around the time of death)” (30). It is apparent with this application of the term perimortem to prehistoric human skeletal remains that its meaning has been applied in a rather casual way. The concurrence of the death event to the injury/insult implied and required by the medical examiner/physician has been ignored. In terms of ancient skeletal remains that exhibit “few signs of . . .weathering or animal gnawing. . .” we must be talking about a much longer expanse of time—weeks, months, or even years? Turner (30) in reference to the same ancient skeletal remains states that he takes a “forensic anthropology and odontology approach. . .” to the analysis of prehistoric mass burials in the Southwest United States (p. 221). The goal was to “reconstruct the conditions under which burial
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occurred, the causes of death, demographic information, and what happened to the remains after death” (p. 221) {ibid} (emphasis mine). Turner goes on to say that he and his colleagues “established beyond a reasonable doubt that most of the bone damage had resulted from human activity” (p. 225) (emphasis mine). In addition, Turner finds that the signatures he observes on the human remains are “obviously products of human intent” (p. 233) (emphasis mine). It is interesting that no forensic anthropological or odontological works are cited in the references of this 1983 archeological work. Speaking about individuals who died hundreds of years in the past in such terms is remarkable, yet there are no legal implications nor ramifications in so doing. However, for an expert in a court of law to state his or her opinion in such a way clearly does have serious implications, far beyond his/her career as an expert or practitioner. If one reviews what actual forensic anthropologists write at about the same time as Turner’s analyses are ongoing, we see much more reticence and caution being promoted in the analysis of trauma. In regard to “Cause of Death”, Stewart (36) writes: When a forensic anthropologist has finished his examination of a skeleton he is likely to be asked: “Did you learn the cause of death?” Seldom can this question be answered in the affirmative with any assurance. Individuals can survive massive bone damage and then die or be put to death in some way that leaves no sign on the skeleton. For this reason a forensic anthropologist should simply describe any evidence of bone damage, point out its location in relation to vital centers, explain the possibility of its having been sustained at the time of death or otherwise, and discuss the likely types of objects that produced the damage. After all, someone has died and the reason for the investigation is to learn whether or not a crime was committed, whatever the cause of death (p. 76). Stewart does not use the term perimortem in his entire, chapter-long discussion of judging trauma and cause of death. He also warns the reader more than once that anthropological analyses of blows (caused by bullets or blunt objects) have limitations and that some details are simply “not the province of the forensic anthropologist” (p. 77). He adds that “simple breaks in the bones do not always have . . .lethal connotations. This is true especially when the bones in question have been exposed on the ground for some time. A heavy animal can break a bone by stepping on it” (p. 79). Still earlier, one of the founding fathers of forensic anthropology in the United States, Krogman (37) bluntly states “I don’t think the physical anthropologist should tackle cause of death. This sort of thing . . . is ably handled in any good text in pathology or in forensic medicine” (p. 7). Nonetheless, forensic anthropologists apparently borrowed the term along with the “faunal analysts” cited by Turner (32). Soon after Turner’s original cannibalism research (30), Maples (38) uses the term perimortem in reference to skeletal trauma. Yet, upon introducing the term, Maples remarks on the “elasticity” of the term and its potential vagueness (p. 221). As mentioned earlier, medical doctors adopted the term somewhere between 1985–1987 (17) and used it in a more precise way. Regardless of these pre-eminent forensic anthropologists’ cautious guidance and open acknowledgement of their interpretive limitations, an online search of the keyword/title use of perimortem in the Journal of Forensic Sciences (2006 until July 2012)
reveals that the term is used much more frequently by authors of physical anthropological subject matter (43/56 or 77%) than those in other specialties (path/bio 7/56 or 13%; odont 5/56 or 9%; other DNA 1/56 or 1%). Discussion The foregoing has been an attempt to continue a conversation on one problematic term that is used across disciplines in forensic science and general medicine. It is not presumed to be an exhaustive work but merely a probe and demonstration into the lack of clarity surrounding a frequently used but clearly misunderstood term. Certainly, the use (and misuse) of a term cannot be remedied without consensus from practitioners who use the term. So far, forensic anthropologists, informally or in book chapters, have suggested complete abandonment of the term within forensic anthropology (letting it be used by those who use it more precisely, in the medical realm); replacement of the term with more descriptive, specific verbiage, or the provision of a personal or discipline-specific definition of the term in each and every report that is submitted in a questioned death case. Clearly, the authors of the NAS report would prefer the former two options and are advocating against the latter, that is, a continuation of a plethora of definitions existing to the confusion of judges, advocates, and jurors. Anthropologists acknowledge in numerous publications (20– 22,28) that their use of perimortem refers to bone response versus physiological death of a person. Thus, it appears that Turner, in his coining of this term in the 1980s, has led us into an oxymoronic conundrum. Forensic anthropologists analyze bone and use a Latin term for death (mortem) in referring to something that, by itself, cannot live. (As Nawrocki states, there is a “lack of connection with the physiological death event. . .” (23: 287). The bone belongs to the larger body system, which is the purview (in court) of the medical examiner/medical doctor. When we write “perimortem” in a report, we are referring to the physiological death of a person, are we not? Surely, we are not discussing “bone death.” Ultimately we are attempting to tie what we see in bone back to the body of the decedent. Yet, we are de facto entering into realms of expertise that are not ours, with the words that we use. Our forebears wisely warned against this (36,37). To stay within the bounds of our expertise and furthermore to resolve this vexing terminological issue, perhaps our observations of skeletal trauma can be clarified using words that describe the bone, for example, de os vivum (of fresh bone) (similar to the current use of perimortem) or de os siccum (of dry bone) (similar to the current use of postmortem). Or, a more extreme position might be the complete abandonment of the term perimortem from the anthropological lexicon, relying on description of what is observed (no healing response would indicate that the injury may have occurred near the time of death). The later interpretation of what is observed may require new terms or additional words (e.g., “no healing response was observed, indicating the injury may have occurred near the time of death”), yet the accuracy and precision of the anthropological meaning are conveyed. (In addition, as an important side note, separating the opinion from the description of evidence is strongly advised in report writing: thus, the interpretation of the skeletal fractures is a very different thing than the description of such. The interpretation may in fact not be written in the report and rather may be proffered in open court upon questioning.)
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In forensic science, where multidisciplinary members work together frequently, the lack of shared training in theory and bodies of the literature can be a detriment when it comes to borrowing terms. For the sake of the integrity of the expert and for the jury attempting to comprehend complex scientific testimony, practitioners of particular forensic specialties should maintain constant oversight and quality control on frequently used terms that have important implications on forensic case reports. Acknowledgments The author would like to extend her appreciation to Dr. Robert Stoppacher, Chief Medical Examiner of the Onondaga County Medical Examiner’s Office for his insights and to members of the SWGANTH Trauma Analysis guidelines committee for their acknowledgment of and desire to address this problem. References 1. Committee on Identifying the Needs of the Forensic Sciences Community, National Research Council. Strengthening forensic science in the United States: a path forward. Washington, DC: National Academy of Sciences, 2009. 2. Sauvageu M, Boghassian T. Classification of asphyxia: the need for standardization. J Forensic Sci 2010;55(5):1259–67. 3. Quigley C. Death dictionary. Jefferson, NC: McFarland and Company Inc, 1994. 4. Finkbeiner W, Ursell P, Davis R. Autopsy and pathology: a manual and atlas, 2nd edn. Philadelphia, PA: Saunders, 2009. 5. DiMaio V, DiMaio D. Forensic pathology, 2nd rev. edn. Boca Raton, FL: CRC Press, 2001. 6. Spitz W, editor. Spitz and Fisher’s medicolegal investigation of death, 4th rev. edn. Springfield, IL: Charles C. Thomas Publishers, 2006. 7. Koehler S, Wecht C. Postmortem. Buffalo, NY: Firefly Books, 2006. 8. Camps F, editor. Gradwohl’s legal medicine. Bristol, UK: John Wright and Sons, Ltd, 1976. 9. Mosby M. Mosby’s medical dictionary, 9th edn. Philadelphia, PA: Elsevier Publishers, 2013. 10. Watson A. Forensic medicine—a handbook for professionals. Aldershot, U.K.: Gower, 1989. 11. Mason J. Forensic medicine for lawyers, 2nd edn. London, U.K.: Butterworths, 1983. 12. Polson C, Gee D, Knight B. The essentials of forensic medicine, 4th edn. Oxford, U.K.: Pergamon Press, 1985. 13. Simpson K, Knight B. Forensic medicine, 9th edn. London, U.K.: Edward Arnold, 1985. 14. Mant AK, editor. Taylor’s principles and practice of medical jurisprudence. Edinburgh, UK: Churchill Livingstone, 1984. 15. Dix J. Handbook for death scene investigators. Boca Raton, FL: CRC Press, 1999. 16. Hanzlick R. Death investigations: systems and procedures. Boca Raton, FL: CRC Press, 2007. 17. Whitten M, Irvine L. Postmortem or perimortem caesarean section: what are the indications? J R Soc Med 2000;93:6–9. 18. Fadel H. Postmortem and perimortem cesarean section: historical, religious, and ethical considerations. J IMA 2011;43(3):194–200. 19. Lopez-Zeno J, Carlo W, O’Grady J, Fanaroff A. Infant survival following delayed postmortem cesarean delivery. Obstet Gynecol 1990;76:991–2. 20. Rich J, Dean D, Powers R, editors. Forensic medicine of the lower extremity: human identification and trauma analysis of the thigh, leg, and foot. Totowa, NJ: Humana Press, 2010.
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21. Mann R, Hunt D. Photographic regional atlas of bone disease. Springfield, IL: Charles C. Thomas, 2005. 22. Komar D, Buikstra J. Forensic anthropology: contemporary theory and practice. New York, NY: Oxford University Press, 2008. 23. Nawrocki S. Forensic taphonomy in handbook of forensic anthropology and archaeology. In: Blau S, Ubelaker D, editors. Handbook of forensic anthropology and archaeology. Walnut Creek, CA: Left Coast Press, 2009;284–94. 24. Symes S, L’Abbe E, Chapman E, Wolff I, Dirkmaat D. Interpreting traumatic injury to bone in medicolegal investigations. In: Dirkmaat D, editor. A companion to forensic anthropology. Chichester, West Sussex, U.K.: Wiley-Blackwell, 2012;340–89. 25. Passalaqua N, Fenton T. Developments in skeletal trauma: blunt force trauma. In: Dirkmaat D, editor. A companion to forensic anthropology. Chichester, West Sussex, U.K.: Wiley-Blackwell, 2012;400–11. 26. Byers S. Introduction to forensic anthropology, 4th rev. edn. Boston, MA: Pearson, 2010. 27. Loe L. Perimortem trauma. In: Ubelaker D, Blau S, editors. Handbook of forensic anthropology and archaeology. Walnut Creek, CA: Left Coast Press, 2009;263–83. 28. Roberts C. Forensic anthropology 2: positive identification of the individual: cause and manner of death. In: Hunter J, Roberts C, Martin A, editors. Studies in crime: an introduction to forensic archaeology. London, U.K.: Berttler and Turner, 1996;122–7. 29. Sauer N. The timing of injuries and manner of death: distinguishing among antemortem, perimortem, and postmortem trauma. In: Reichs K, editor. Forensic osteology: advances in the identification of human remains, 2nd rev. edn. Springfield, IL: Charles C. Thomas, 1998. 30. Turner C. Taphonomic reconstruction of human violence and cannibalism based on mass burials in the American southwest. In: LeMoine GM, MacEachern AS, editors. Carnivores, human scavengers, and predators: a question of bone technology. Proceedings of the Fifteenth Annual Conference of the Archaeological Association of the University of Calgary. Calgary, AB, Canada: University of Calgary Archaeological Association, 1983. 31. Turner C, Turner J. The first claim for cannibalism in the southwest: Walter Hough’s 1901 discovery at Canyon Butte Ruin 3, Northeastern Arizona. Am Antiq 1992;57(4):661–82. 32. Turner C, Turner J. Perimortem damage to human skeletal remains from Wupatki National Monument, Northern Arizona. Kiva 1990;55(3):187– 212. 33. Arizona State University (ASU). Research Bulletin, Summer 2003. Phoenix, AZ: Arizona State University, 2003. 34. Morlan R. Archaeology as paleobiology. Transactions of the Royal Society of Canada, Series V/Vol II. Ottawa, Canada: The Royal Society of Canada, 1987;117–24. 35. Malville N. Two mass interments from Yellow Jacket, Southwestern Colorado. Kiva 1990;55(1):3–22. 36. Stewart TD. Essentials in forensic anthropology. Springfield, IL: Charles C. Thomas Publishers, 1979. 37. Krogman W. The human skeleton in forensic medicine. Springfield, IL: Charles C. Thomas, 1962. 38. Maples W. Trauma analysis by the forensic anthropologist in forensic osteology. In: Reichs K, editor. Forensic osteology. Springfield, IL: Charles C. Thomas, 1986;218–28. Additional information and reprint requests: Ann Webster Bunch, Ph.D. Department of Criminal Justice College at Brockport, SUNY 160 Albert West Brown Building 350 New Campus Drive Brockport, NY 14420 E-mail: [email protected]
TECHNICAL NOTE PHYSICAL ANTHROPOLOGY Ann W. Bunch,1 Ph.D.
National Academy of Sciences “Standardization”: On What Terms?
ABSTRACT: The frequently cited 2009 National Academy of Sciences Report entitled “Strengthening Forensic Science in the United States: A Path Forward” has become a focal point of forensic science practitioners’ discussions and research since its publication. One of its recommendations is “Standardized Terminology and Reporting”. Little has been published to date on this topic, although conversations and dialogs on the subject are ongoing. The upshot of this communication is to draw attention to the problem of one term in particular, perimortem, which may be only the proverbial “tip of the iceberg” in the lexicon-related concerns of forensic scientists. Even if it is an isolated issue, it is one that reflects the need for a consensus on term use and definitions by interdisciplinary practitioners who are currently using the term haphazardly, to the confusion of colleagues and potentially finders-of-fact in the courts.
KEYWORDS: forensic science, perimortem, forensic anthropology, forensic pathology, National Academy of Sciences report The National Academy of Sciences Report on “. . .A Way Forward” for forensic science in the United States has emphasized, among many other concerns, a need for the “standardization” of terminology and reporting (1). The report cites examples such as the terms “match,” “consistent with,” and “identical” (p. 21). The authors bemoan the fact that the “use of . . .recommended language is not standard practice among forensic science practitioners” even when such vocabulary and scales are proposed (p. 21). In addition, they warn that “[t]he use of such terms can and does have a profound effect on how the trier of fact in a criminal or civil matter perceives and evaluates scientific evidence” (p. 21). Four years later, this guidance has apparently been largely ignored, at least in peer-reviewed literature. A paper by Sauvageu and Boghassian (2) is a rare example of a published discussion and remedy for the varied and confusing use of the term “asphyxiation” in medical investigations and reports. Outside the peer-reviewed literature, informal discussions are undoubtedly taking place within and between forensic specialties in an attempt to address terms that require attention given their vagueness or use (misuse?) across disciplines. One such conversation has been ongoing between forensic anthropologists and medical examiners, because one particularly vague term in need of clarification has (1) emerged: perimortem. Current Definitions and Use of Perimortem in Medicine At first glance into the standard English dictionary (Webster’s, Funk and Wagnall’s, etc.), one will not find the term perimortem. This amalgam of Greek (peri) and Latin (mortem) root
1 Department of Criminal Justice, College at Brockport, State University of New York, 160 Albert W. Brown Building, Brockport, NY 14420. Received 30 July 2012; and in revised form 30 May 2013; accepted 15 June 2013.
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words translates to “all around, about, near, enclosing, surrounding” [peri] and “death” [mortem]. Online dictionaries and Google searches provide a less cumbersome—yet less reliable in an academic sense—definition that typically reads “at or near the time of death” (e.g., www.anthropology.si.edu, www.definition-of.net, en.wiktionary.org). In published volumes in pathology and medical death investigations, the definition given is “at the time of death” (3) but more often there is complete absence of the term from the lexicon of the volume (4–14). Applications (“apps”) for smart devices (i-phones, tablets, etc.) such as Medwords and Taber’s Cyclopedic Medical Dictionary also lack the term perimortem. The term seems generally to be avoided in the medical/clinical literature. The relative absence of this word may be related to the questions surrounding the term “death” itself in medicine. In the past, death would be relatively easy to pinpoint in time, that is, when the body organs cease to function on a gross level (heart stops beating, breathing ceases). Yet with technological advances of the 20th century, the ability to sustain life and organ function has altered the concept of death so that it is broken down into somatic and molecular levels (12). Even without considering medical technology, the medical examiner or coroner must determine immediate and intervening causes of death on the standard US death certificate (4). Thus, the implication that death can be an extended process and that the length of time depends on the cause of death. Among death investigators, who work closely with pathologists, the Special Working Group of Medicolegal Death Investigators (SWGMDI) has as one of its listed committee foci “Terminology” yet detailed guidelines or a lexicon from this committee do not appear online as of this writing (June 2012). In the Handbook for Death Scene Investigators (15) and Death Investigation: System and Procedures (16), the term perimortem does not appear in the Medical Terminology Appendix/ Index. 1
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To put the medical use of the term into a historical perspective, the medical field appears to have used the term perimortem in a clinical context, specifically in reference to birth practices. In order for a dying mother to give birth, the rendering of medical assistance may be required. According to Whitten and Irvine (17), the label “perimortem” to this procedure began . . . in the 1985–1987 triennium, when the Confidential Enquiry introduced a new term, perimortem caesarean section, for cases where the patient was moribund or in extremis, or was on cardiopulmonary resuscitation before the caesarean section and showed no signs of recovery afterwards. The medical literature thereafter reports on perimortem births, that is, those that occur at or during the time of death of the mother, across time and space (17,18). The writings on this type of surgery (abbreviated as PRMCS) indicate that it stems from the practice of the earlier postmortem cesarean section (PMCS) (18). Religious sacred books discuss PMCS, as it dates back to ancient times; it is said to have been practiced by “all cultures” (18), although no evidence of this is given. In this context, clearly the term perimortem refers to the birth event taking place within minutes of the mother’s death. As the practice continued among physicians, it became known that a child could be born using PRMCS more than 40 min after the mother’s death (18). Lopez-Zeno et al. (19) report intact fetal survival with delivery 47 min after fatal maternal injury by gunshot wound. In a text that bridges that gap between medicine and forensic anthropology, Rich et al. (20) indicate that the pathologist’s definition of perimortem is related to a relatively narrow time frame when the “person breathed his or her last or thought his or her last thought” (p. 257). A diagrammatic depiction shows “death” equal to “perimortem” as an abrupt cut-off point on the line of “life of the individual.” These authors contrast this use of the term to that of the forensic anthropologist who applies the term perimortem to “the time when the bone was first able to show skeletal signs of healing or lost the resiliency of living moist tissue” (p. 256) (emphasis mine). These signs may take “up to 2 weeks to appear after injury” (p. 256); the diagrammatic representation of the “perimortem period” (emphasis mine) for bone is one that demonstrates a segmented line, divided into thirds, “antemortem,” “perimortem,” and “postmortem” all relatively equal in length. It is clear that modern day medical practitioners in the literature avoid the term perimortem. If the term is used, it appears to imply a relatively narrow time period (3,17–20). Medical examiners who deal often with traumatic deaths may frequently use the term much the same way as obstetricians/clinicians, describing wounds, injuries and physical events that occur(ed) in very close temporal proximity to (within minutes of) the death event [“at the time of death”]. Yet, as immediate cause and intervening causes of death may be separated by lapse(s) of time, the perimortem “moment” may become a “period” of time in some cases (disease, infection, etc.). It is also evident with Rich, Dean and Powers’ work that when using the term perimortem, medical doctors are referring to the “person” (body), whereas the forensic anthropologist is referring to bone. This distinction is at the heart of discrepancy in term use and will be returned to later.
Current Definitions and Use of Perimortem in Forensic Anthropology If one turns directly to writings of practitioners in forensic anthropology, the waters begin to muddy considerably. The Special Working Group for Anthropology (SWGANTH), in its drive to delineate best practices, has run into this hard-to-define word within the special area of trauma analysis. The latest published use of the term perimortem that appears on the SWGANTH website (Trauma Analysis section dated 5/27/2011) as of this writing (December 2012) reads as follows: Perimortem trauma refers to an injury occurring at or around the time of death. Because of the properties of bone, the timing of injury is less precise when evaluating bone than when evaluating soft tissue. Within the anthropological realm, perimortem is determined on the basis of evidence of the biomechanical fracture characteristics of fresh bone. Perimortem trauma is a category in which remains lack evidence of healing and lack diagnostic taphonomic evidence of postmortem damage. . .[emphasis mine]. The document goes on to warn about use of the term perimortem: . . .When trauma is classified as perimortem, consideration should be given to: *Cautious use of the term perimortem, since it is used with varied temporal precisions within the forensic community; thus an explanation of the term should be provided with clear reasons for a perimortem classification. . .[emphasis mine]. The term perimortem itself is not defined by the SWGANTH; the difficulty in applying a clear and concise meaning to this term is apparent. Caution is wisely advised to those using the term. The contrast of analyzing the “bone” versus “soft tissue” is discussed—again, revealing the root of the timing discrepancy. Some recent anthropological publications demonstrate the dissatisfaction with the term perimortem and its differential use among medical versus anthropological practitioners (21–25). Mann and Hunt (21) also contrast the difference in meaning of perimortem in reference to soft tissue versus dry bone (p. 230); they explain (as did Rich et al. [20]) that one of the confusing factors in applying this term to bone is that it (bone) may retain its visco-elastic qualities until the collagen component deteriorates after death, which may take “weeks or months” (p. 230). The authors advise caution and judgment when linking cause of death to any case where bone is being analyzed without soft tissue (p. 230). Komar and Buikstra (22) acknowledge that discrepancies exist between how those in the medical community and anthropologists differentiate ante-, peri- and postmortem periods (p. 27). Since, according to these authors, the perimortem period encompasses the events surrounding death, this period could be brief (as with a fatal gunshot wound) or prolonged (as with toxic chemical exposure in industry) (p. 26). Komar and Buikstra do not the terms intervening and immediate cause of death, however. As mentioned earlier, these terms assist the medical doctor to clarify temporal distinctions for medico-legal purposes. The problem of duration of time is one that is found primarily in the forensic anthropologists’ bailiwick, as the focal point of our investigations is the bone, not the body. Komar and Buikstra
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indicate that they do not attempt to terminate “the debate” [on the term perimortem] yet desire to “highlight. . .the ambiguities present in current thinking.” They conclude that “clearer definitions and a more widely accepted understanding is crucial. Clearly, additional consideration and consensus is urgently needed” (p. 27). Nawrocki (23) also addresses the broadness of the anthropologists’ “perimortem” period and the lack of connection with the physiological death event or any “fixed unit measure of time.” (p. 287). He advises “extreme caution” when interpreting skeletal trauma and touches on the ethics of anthropologists venturing into the realm of cause and manner of death at all. Nawrocki perceives and highlights this apparent disconnect between the anthropologists’ data set (bone) and terminology (relating to death, time of death, cause of death). Some authors move beyond describing the situation and urging vigilance to recommending a course of action. Symes et al. (24) suggest clarification of “discipline specific terminology in. . .report[s]” (p. 349), whereas Passalaqua and Fenton (25) allude to the use of new descriptive terminology, such as “fresh bone fracture” (p. 402). The former may be merely a continuation of the current lack of standardization that the NAS report decries (1). The latter addresses the problem head-on. “Fresh bone fracture” however may result in confusion, because “fresh” implies recent —thus “fresh” equals postmortem or “fresh” equals perimortem? In other forensic anthropological writings, the term has been presented with less caution (26,27). A widely used forensic anthropology textbook (26) definition of the term perimortem reads “Perimortem trauma refers to injuries that occurred around the time of death. . .” (p. 289). The phrasing changes slightly in a subsequent discussion, thus “Injuries that occur close to the time of death will not exhibit the signs of healing seen in antemortem trauma” (26,28). The author goes on to detail “five characteristics of fractures [that] indicate perimortem trauma” (26). Yet if one accepts the premise aforementioned that perimortem injuries occur “close to the time of death” [and not “at” the time of death], then all of the “five characteristics” probably should be taken with the proverbial grain of salt. The discrepancy between the caution advised by some (20–25) and the textbook’s lack thereof should be a warning to practitioners that there is no standardization in our understanding of what anthropologists mean when we use the term, how we should use it, and how we should promote its use to students (future practitioners). Loe (27) also uses the term without any advisory words on its vagueness, citing Roberts (28). Byers cites Sauer (29) in his discussion of trauma. In a review of Sauer’s (28) introductory definition of perimortem, a close resemblance to pathologists’ use is seen: “Any injury directly associated with manner of death is considered a perimortem injury” (p. 321). Yet when Sauer delves into the anthropological realm specifically, he acknowledges the challenging nature of working with skeletal remains alone: Distinguishing between perimortem and postmortem injuries (and identifying antemortem injuries that occurred close enough to death that the healing process was not recorded on the skeleton) is less straightforward than identifying ante-mortem trauma. If there is no evidence for an osteogenic reaction, the pattern of the injury becomes a paramount concern (pp. 322–323). Here, we see implied that the indicator used to inform forensic anthropologists of perimortem trauma is lack of something (oste-
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ogenic reaction, i.e., healing). Yet we also see that even antemortem injuries that occur close to the death event will lack that same thing. The reader finds little certainty in the determination of timing of injuries here (28). In a closing summary, Sauer (28) opens with “[A]ssociating trauma to bone with the death event is a critical issue in a forensic investigation of decomposed human remains” (p. 329). And concludes this section with “[W] hile evidence of vital reactions are rarely preserved in bone, skeletal material often holds the key to the determination of the timing of injuries with respect to death” (p. 330). It is not convincing that forensic anthropology offers a reliable way to do this, however, given the variables Sauer mentions that may have an effect on bone (28). Conveying the lack of precision that belies this undertaking in forensic anthropology is preferable as it relates the reality of the situation and gives no false pretense of what forensic anthropologists can do. Original Amalgamation and Use of the Term So how did the term perimortem come to take on different applications, and, in a sense, different temporal spans, one narrow (“at the time of death”) and one relatively broad (“at or around the time of death”) or even, a third definition, more vague still, disconnected with the actual physiological death event? Or perhaps the question is, how did this seemingly medical term find its way into the forensic anthropological lexicon, where its application seems much more tenuous? It appears to have been amalgamated in the early 1980s in a rather roundabout way. The word makes its appearance not in forensic anthropological writings but in another “realm” of anthropology —bioarchaeology. Reports of archeological analyses of possible cannibalism by Turner (30,31) refer to perimortem trauma observed on some of the human remains. Turner later states that he “coined the term” (32,33) and mentions that other scholars (“faunal analysts”) have adopted the term, citing Morlan (34) and Malville (35). He goes on to state that the term has been used instead of “perthotaxic” or “greenstick fracture,” which has a special medical connotation (32: 188). Given the timing of the term’s appearance in medicine in the late 1980s (17), it appears that Turner did in fact “coin” the term. In his bioarcheological studies (30–32), he describes “bone damage signatures that can provide a kind of historic record of events that happened at or near the time of death. In many instances they might represent the actual cause of death” (30) (emphasis mine). Turner published a list of indicators, or “bone signatures” that could be seen on prehistoric human bone that, considered together, comprised a “cannibalism signature.” One such trait was “few signs of bone weathering or animal gnawing (indicating that bone damage and the covering of remains occurred at or around the time of death)” (30). It is apparent with this application of the term perimortem to prehistoric human skeletal remains that its meaning has been applied in a rather casual way. The concurrence of the death event to the injury/insult implied and required by the medical examiner/physician has been ignored. In terms of ancient skeletal remains that exhibit “few signs of . . .weathering or animal gnawing. . .” we must be talking about a much longer expanse of time—weeks, months, or even years? Turner (30) in reference to the same ancient skeletal remains states that he takes a “forensic anthropology and odontology approach. . .” to the analysis of prehistoric mass burials in the Southwest United States (p. 221). The goal was to “reconstruct the conditions under which burial
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occurred, the causes of death, demographic information, and what happened to the remains after death” (p. 221) {ibid} (emphasis mine). Turner goes on to say that he and his colleagues “established beyond a reasonable doubt that most of the bone damage had resulted from human activity” (p. 225) (emphasis mine). In addition, Turner finds that the signatures he observes on the human remains are “obviously products of human intent” (p. 233) (emphasis mine). It is interesting that no forensic anthropological or odontological works are cited in the references of this 1983 archeological work. Speaking about individuals who died hundreds of years in the past in such terms is remarkable, yet there are no legal implications nor ramifications in so doing. However, for an expert in a court of law to state his or her opinion in such a way clearly does have serious implications, far beyond his/her career as an expert or practitioner. If one reviews what actual forensic anthropologists write at about the same time as Turner’s analyses are ongoing, we see much more reticence and caution being promoted in the analysis of trauma. In regard to “Cause of Death”, Stewart (36) writes: When a forensic anthropologist has finished his examination of a skeleton he is likely to be asked: “Did you learn the cause of death?” Seldom can this question be answered in the affirmative with any assurance. Individuals can survive massive bone damage and then die or be put to death in some way that leaves no sign on the skeleton. For this reason a forensic anthropologist should simply describe any evidence of bone damage, point out its location in relation to vital centers, explain the possibility of its having been sustained at the time of death or otherwise, and discuss the likely types of objects that produced the damage. After all, someone has died and the reason for the investigation is to learn whether or not a crime was committed, whatever the cause of death (p. 76). Stewart does not use the term perimortem in his entire, chapter-long discussion of judging trauma and cause of death. He also warns the reader more than once that anthropological analyses of blows (caused by bullets or blunt objects) have limitations and that some details are simply “not the province of the forensic anthropologist” (p. 77). He adds that “simple breaks in the bones do not always have . . .lethal connotations. This is true especially when the bones in question have been exposed on the ground for some time. A heavy animal can break a bone by stepping on it” (p. 79). Still earlier, one of the founding fathers of forensic anthropology in the United States, Krogman (37) bluntly states “I don’t think the physical anthropologist should tackle cause of death. This sort of thing . . . is ably handled in any good text in pathology or in forensic medicine” (p. 7). Nonetheless, forensic anthropologists apparently borrowed the term along with the “faunal analysts” cited by Turner (32). Soon after Turner’s original cannibalism research (30), Maples (38) uses the term perimortem in reference to skeletal trauma. Yet, upon introducing the term, Maples remarks on the “elasticity” of the term and its potential vagueness (p. 221). As mentioned earlier, medical doctors adopted the term somewhere between 1985–1987 (17) and used it in a more precise way. Regardless of these pre-eminent forensic anthropologists’ cautious guidance and open acknowledgement of their interpretive limitations, an online search of the keyword/title use of perimortem in the Journal of Forensic Sciences (2006 until July 2012)
reveals that the term is used much more frequently by authors of physical anthropological subject matter (43/56 or 77%) than those in other specialties (path/bio 7/56 or 13%; odont 5/56 or 9%; other DNA 1/56 or 1%). Discussion The foregoing has been an attempt to continue a conversation on one problematic term that is used across disciplines in forensic science and general medicine. It is not presumed to be an exhaustive work but merely a probe and demonstration into the lack of clarity surrounding a frequently used but clearly misunderstood term. Certainly, the use (and misuse) of a term cannot be remedied without consensus from practitioners who use the term. So far, forensic anthropologists, informally or in book chapters, have suggested complete abandonment of the term within forensic anthropology (letting it be used by those who use it more precisely, in the medical realm); replacement of the term with more descriptive, specific verbiage, or the provision of a personal or discipline-specific definition of the term in each and every report that is submitted in a questioned death case. Clearly, the authors of the NAS report would prefer the former two options and are advocating against the latter, that is, a continuation of a plethora of definitions existing to the confusion of judges, advocates, and jurors. Anthropologists acknowledge in numerous publications (20– 22,28) that their use of perimortem refers to bone response versus physiological death of a person. Thus, it appears that Turner, in his coining of this term in the 1980s, has led us into an oxymoronic conundrum. Forensic anthropologists analyze bone and use a Latin term for death (mortem) in referring to something that, by itself, cannot live. (As Nawrocki states, there is a “lack of connection with the physiological death event. . .” (23: 287). The bone belongs to the larger body system, which is the purview (in court) of the medical examiner/medical doctor. When we write “perimortem” in a report, we are referring to the physiological death of a person, are we not? Surely, we are not discussing “bone death.” Ultimately we are attempting to tie what we see in bone back to the body of the decedent. Yet, we are de facto entering into realms of expertise that are not ours, with the words that we use. Our forebears wisely warned against this (36,37). To stay within the bounds of our expertise and furthermore to resolve this vexing terminological issue, perhaps our observations of skeletal trauma can be clarified using words that describe the bone, for example, de os vivum (of fresh bone) (similar to the current use of perimortem) or de os siccum (of dry bone) (similar to the current use of postmortem). Or, a more extreme position might be the complete abandonment of the term perimortem from the anthropological lexicon, relying on description of what is observed (no healing response would indicate that the injury may have occurred near the time of death). The later interpretation of what is observed may require new terms or additional words (e.g., “no healing response was observed, indicating the injury may have occurred near the time of death”), yet the accuracy and precision of the anthropological meaning are conveyed. (In addition, as an important side note, separating the opinion from the description of evidence is strongly advised in report writing: thus, the interpretation of the skeletal fractures is a very different thing than the description of such. The interpretation may in fact not be written in the report and rather may be proffered in open court upon questioning.)
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In forensic science, where multidisciplinary members work together frequently, the lack of shared training in theory and bodies of the literature can be a detriment when it comes to borrowing terms. For the sake of the integrity of the expert and for the jury attempting to comprehend complex scientific testimony, practitioners of particular forensic specialties should maintain constant oversight and quality control on frequently used terms that have important implications on forensic case reports. Acknowledgments The author would like to extend her appreciation to Dr. Robert Stoppacher, Chief Medical Examiner of the Onondaga County Medical Examiner’s Office for his insights and to members of the SWGANTH Trauma Analysis guidelines committee for their acknowledgment of and desire to address this problem. References 1. Committee on Identifying the Needs of the Forensic Sciences Community, National Research Council. Strengthening forensic science in the United States: a path forward. Washington, DC: National Academy of Sciences, 2009. 2. Sauvageu M, Boghassian T. Classification of asphyxia: the need for standardization. J Forensic Sci 2010;55(5):1259–67. 3. Quigley C. Death dictionary. Jefferson, NC: McFarland and Company Inc, 1994. 4. Finkbeiner W, Ursell P, Davis R. Autopsy and pathology: a manual and atlas, 2nd edn. Philadelphia, PA: Saunders, 2009. 5. DiMaio V, DiMaio D. Forensic pathology, 2nd rev. edn. Boca Raton, FL: CRC Press, 2001. 6. Spitz W, editor. Spitz and Fisher’s medicolegal investigation of death, 4th rev. edn. Springfield, IL: Charles C. Thomas Publishers, 2006. 7. Koehler S, Wecht C. Postmortem. Buffalo, NY: Firefly Books, 2006. 8. Camps F, editor. Gradwohl’s legal medicine. Bristol, UK: John Wright and Sons, Ltd, 1976. 9. Mosby M. Mosby’s medical dictionary, 9th edn. Philadelphia, PA: Elsevier Publishers, 2013. 10. Watson A. Forensic medicine—a handbook for professionals. Aldershot, U.K.: Gower, 1989. 11. Mason J. Forensic medicine for lawyers, 2nd edn. London, U.K.: Butterworths, 1983. 12. Polson C, Gee D, Knight B. The essentials of forensic medicine, 4th edn. Oxford, U.K.: Pergamon Press, 1985. 13. Simpson K, Knight B. Forensic medicine, 9th edn. London, U.K.: Edward Arnold, 1985. 14. Mant AK, editor. Taylor’s principles and practice of medical jurisprudence. Edinburgh, UK: Churchill Livingstone, 1984. 15. Dix J. Handbook for death scene investigators. Boca Raton, FL: CRC Press, 1999. 16. Hanzlick R. Death investigations: systems and procedures. Boca Raton, FL: CRC Press, 2007. 17. Whitten M, Irvine L. Postmortem or perimortem caesarean section: what are the indications? J R Soc Med 2000;93:6–9. 18. Fadel H. Postmortem and perimortem cesarean section: historical, religious, and ethical considerations. J IMA 2011;43(3):194–200. 19. Lopez-Zeno J, Carlo W, O’Grady J, Fanaroff A. Infant survival following delayed postmortem cesarean delivery. Obstet Gynecol 1990;76:991–2. 20. Rich J, Dean D, Powers R, editors. Forensic medicine of the lower extremity: human identification and trauma analysis of the thigh, leg, and foot. Totowa, NJ: Humana Press, 2010.
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21. Mann R, Hunt D. Photographic regional atlas of bone disease. Springfield, IL: Charles C. Thomas, 2005. 22. Komar D, Buikstra J. Forensic anthropology: contemporary theory and practice. New York, NY: Oxford University Press, 2008. 23. Nawrocki S. Forensic taphonomy in handbook of forensic anthropology and archaeology. In: Blau S, Ubelaker D, editors. Handbook of forensic anthropology and archaeology. Walnut Creek, CA: Left Coast Press, 2009;284–94. 24. Symes S, L’Abbe E, Chapman E, Wolff I, Dirkmaat D. Interpreting traumatic injury to bone in medicolegal investigations. In: Dirkmaat D, editor. A companion to forensic anthropology. Chichester, West Sussex, U.K.: Wiley-Blackwell, 2012;340–89. 25. Passalaqua N, Fenton T. Developments in skeletal trauma: blunt force trauma. In: Dirkmaat D, editor. A companion to forensic anthropology. Chichester, West Sussex, U.K.: Wiley-Blackwell, 2012;400–11. 26. Byers S. Introduction to forensic anthropology, 4th rev. edn. Boston, MA: Pearson, 2010. 27. Loe L. Perimortem trauma. In: Ubelaker D, Blau S, editors. Handbook of forensic anthropology and archaeology. Walnut Creek, CA: Left Coast Press, 2009;263–83. 28. Roberts C. Forensic anthropology 2: positive identification of the individual: cause and manner of death. In: Hunter J, Roberts C, Martin A, editors. Studies in crime: an introduction to forensic archaeology. London, U.K.: Berttler and Turner, 1996;122–7. 29. Sauer N. The timing of injuries and manner of death: distinguishing among antemortem, perimortem, and postmortem trauma. In: Reichs K, editor. Forensic osteology: advances in the identification of human remains, 2nd rev. edn. Springfield, IL: Charles C. Thomas, 1998. 30. Turner C. Taphonomic reconstruction of human violence and cannibalism based on mass burials in the American southwest. In: LeMoine GM, MacEachern AS, editors. Carnivores, human scavengers, and predators: a question of bone technology. Proceedings of the Fifteenth Annual Conference of the Archaeological Association of the University of Calgary. Calgary, AB, Canada: University of Calgary Archaeological Association, 1983. 31. Turner C, Turner J. The first claim for cannibalism in the southwest: Walter Hough’s 1901 discovery at Canyon Butte Ruin 3, Northeastern Arizona. Am Antiq 1992;57(4):661–82. 32. Turner C, Turner J. Perimortem damage to human skeletal remains from Wupatki National Monument, Northern Arizona. Kiva 1990;55(3):187– 212. 33. Arizona State University (ASU). Research Bulletin, Summer 2003. Phoenix, AZ: Arizona State University, 2003. 34. Morlan R. Archaeology as paleobiology. Transactions of the Royal Society of Canada, Series V/Vol II. Ottawa, Canada: The Royal Society of Canada, 1987;117–24. 35. Malville N. Two mass interments from Yellow Jacket, Southwestern Colorado. Kiva 1990;55(1):3–22. 36. Stewart TD. Essentials in forensic anthropology. Springfield, IL: Charles C. Thomas Publishers, 1979. 37. Krogman W. The human skeleton in forensic medicine. Springfield, IL: Charles C. Thomas, 1962. 38. Maples W. Trauma analysis by the forensic anthropologist in forensic osteology. In: Reichs K, editor. Forensic osteology. Springfield, IL: Charles C. Thomas, 1986;218–28. Additional information and reprint requests: Ann Webster Bunch, Ph.D. Department of Criminal Justice College at Brockport, SUNY 160 Albert West Brown Building 350 New Campus Drive Brockport, NY 14420 E-mail: [email protected]
