To my colleagues — the forensic medical examiners at the Moscow Forensic-Medical Bureau.

Foreword to the New Edition

It has been over a year since the first edition of my book was published. During that time, I have given many talks in several cities, given media interviews, and even been recognized in the street a few times (I am famous!). I have received over one hundred letters, both emails and handwritten, two of which invited me to join an organization to save the universe, the others simply expressing gratitude. I answered all of them, other than the two from another realm. It is nice when all kinds of people you do not even know like your work. That was a new feeling for me, something I was not used to. Before the first edition came out, I had no idea what kinds of things readers would share with me. I learned that many of them were really interested in finding out more about my specialty, that they were able to look beyond old prejudices, and some were even able to re-evaluate their lives. It would seem that my work was done. After all, the book came out, and people liked it. But, my dear readers, you have rightly pointed out to me that some things were missing from the book. I have tried to include them all here.

In this new edition, I will talk about the many types of tools we use at work. Each of them has a specific purpose. I will also talk about what we do in the lab, about exhumations, motorcycle injuries, dismemberment, and iatrogenesis, and, finally, about some of my favorite students.

Some chapters include case studies and quotes from real criminal cases.

I am always open to hearing from you. And I would be grateful if, after reading my book, you send me a few lines letting me know what you think. Email mossudmed@gmail.com or Instagram @mossudmed.

Introduction

Once upon a time, when I was a boy, I saw the three-volume Atlas of Human Anatomy1 by Raphael Sinelnikov at my parents' friends' house. I got carried away by the book and its realistic drawings and Latin inscriptions. I could not understand a thing, but the words sounded so mysterious and fascinating. I was too young to be thinking about a career in medicine, but I knew that I was deeply interested in the human body, and the way that every single detail has been designed so carefully.

Then I enrolled at the Omsk Medical Institute, which was renamed Omsk State Medical Academy just two years later (today, it is known as Omsk State Medical University). In Omsk (thanks, in part, to the excellent professors of the general anatomy department), I decided to specialize in this particular field of medicine. Even now, at Omsk State Medical University, there is an anatomical preparation[1] of upper extremity blood vessels and nerves in a formalin bath, prepared by me under the watchful eye of the admirable Professor Vladimir Rublev. After Omsk, fate took me to the challenging city of Chelyabinsk, where I completed my studies over the next four years, and where I delved into the most interesting topics, such as topographic anatomy and pathological anatomy. I also began specializing in forensic medicine there. In 1997, the Department of Forensic Medicine was a sad sight, with boring classes and absolutely no scientific community. But we learned Vitaly Kryukov's textbook by heart, and by my fifth year, I knew what I wanted to do. I met Professor Pyotr Novikov, who only strengthened that decision. Then, I could not have imagined that I would one day be lucky enough to work in the same department as Professor Kryukov and so many other wonderful professionals whose books I read in medical school and as an intern. If someone had told me that one day I would rub shoulders with Evgeny Kildyushov, Evgeny Tuchik, Ivan Buromsky, Natalia Kachina, Yuri Solokhin, Natalia Selyutina, and Oleg Kriger, I would have never believed them.

But, as they say, man proposes, but God disposes. In 2006, I landed in Moscow, and I hope that is where I will stay. I work in the best forensic medical bureau in Russia — the Moscow Medical-Forensic Bureau. This bureau is Russia's most advanced forensic institution, with enormous labs, departments, and top professionals.

Over the last decade, so much has happened in my personal and professional life, but the one constant is that I have always studied. I have studied with people, some of whom are no longer with us, and I have studied books. I have a personal library of over one hundred forensic medical books, some of them dating back to the 1800s, and others are recent editions. Some of them have ink or pencil notes in the margins, left by their previous, nameless owners, and others have been restored. I have helped write a couple of them. To me, a book is always so much more than sheets of paper bound together.

And I had never thought that, one day, I would be asked to write a book of my own.

WHO IS THIS BOOK FOR?

It all began in 2011, when I discovered LiveJournal and created my own page, mossudmed.livejournal.com. At the time, I had been working as a medical examiner for about eleven years, and I had formed a set of views on human life, health, bad habits, and human vices.

I had decided that I would share my professional observations on LiveJournal, with occasional illustrations to help explain things. I did not do anything to promote my blog, but over five years, its readership grew, and it is now consistently among the top ten blogs in the Moscow region, and the top twenty blogs in Russia.

The blog's popularity grew to the point that Alpina Publishing House's Deputy Editor-In-Chief, Irina Gusinskaya, approached me with an offer to write a book. Thanks to her incredible enthusiasm and support, my book became a reality.

Medical examiners work between the earthly realm and that which has yet to be. We have a front-row seat to the way people sometimes forget to value their present life or think about the future. Medical examiners get up close and personal with the destruction wrought by nicotine, drugs, and alcohol. Most people have no idea of what those poisons are capable of doing, and as a society, we often turn a blind eye to certain bad habits.

I would like that, after reading my book, people are able to take a step back and see themselves from the outside, and take care to avoid having a hand in reducing the time they have with us in this world. I hope that the information in this book will help my readers preserve their health, and the health of their loved ones.

Though forensic medicine is not secretive, it remains a mystery for most laypeople, rife with all kinds of legends, preconceptions, delusions, and myths. As you read this book, you will understand what it really means to be a forensic examiner, and what our job entails. You will learn how forensic medicine differs from pathology, when and why an autopsy is necessary, what kinds of injuries can kill someone and what they look like, as well as many other aspects of my specialty.

It is not a scientific textbook, and it is intended primarily for people who have little to no background in medicine or, more specifically, forensic medicine. For that reason, I avoid any specialized jargon and dry facts and figures, and have attempted to describe pathological processes as simply as possible.

There is nothing fictional in this book. All of the stories described are actual cases from my own practice or were relayed to me by trusted colleagues.

1. WHAT EXACTLY IS FORENSIC MEDICINE?

The answer to that question lies in the term "forensic medicine" itself. There are many definitions out there in all kinds of textbooks and manuals, but I personally prefer Professor Sapozhnikov's rather short and sweet explanation: forensic medicine is "medicine in law." Unlike in many other countries, in Russia forensic physicians are separate from the police and are not under their control, though they do work very closely together. Despite relatively bare-bones budgeting in forensic science departments (morgues are always funded on leftover scraps), this ensures that we remain independent — after all, that independence is the very foundation of forensic science in the first place.

Forensic science is not a new branch of medicine by any stretch. People everywhere have always wanted to know how their bodies work, how they get injured, and why people die. Written records dating back to antiquity and Mesopotamia mention doctors taking part in court proceedings. I would love nothing more than to have a time machine to go back and watch those trials and listen to what my ancient colleagues had to say.

A bit closer to our own era, we might look at early Germanic law from the fifth through the ninth centuries AD in northern Europe, or the Alemannic laws, which already included the concepts of "damage" and "severity of damage" to determine the amount of compensation to be paid to crime victims. That brings us to the medieval concept of "God's judgment"—trial by ordeal — which took precedence over any secular court, when whatever a doctor had to say was the least of anyone's concerns. Or we might learn how the first autopsy was allowed to take place in the French city of Montpellier during the fourteenth century.

Next came the Constitutio Criminalis Carolina under the Holy Roman Emperor Charles V, which especially recognized cases requiring medical expertise, or the work of Ambroise Paré and many other great thinkers, who laid the foundations for forensic medicine as a science.

In the late eighteenth and early nineteenth centuries, as the Inquisition was abolished, several European countries began holding open trials, which often required an expert physician to publicly substantiate and defend his conclusions. This greatly contributed to the forensic medicine's development as a science.

More specifically, what about Russia? Various elements of forensic medicine go back to the tenth century when courts considered a liability for "beatings," "desecration," and "fornication," among other crimes. By the eleventh and twelfth centuries AD, the legal code of Kievan Rus doled out punishments based on whether any bodily injuries sustained were "light" or "severe." At the same time, people began examining dead bodies, attempting to determine the cause of death. Several specialized institutions were created during the 1500s, including the Apothecary Chancery, which, among other things, was responsible for establishing health and sanitation conditions and examining the body of anyone who appeared to have suffered a sudden or violent death.

Here are two examples of how the Chancery worked.

Going to the doctor was a scary business during the sixteenth and seventeenth centuries, as remedies were often more dangerous than the disease itself. It was not unusual for doctors or other well-meaning but uninformed people to accidentally kill or harm their patients. There was the documented case of a doctor named Mikhail Tuleischik getting drunk and accidentally selling a patient highly toxic mercury chloride instead of medicine. And in 1700, a nobleman named Saltykov was poisoned when a servant named Aleksei Kamen mistakenly bought him the wrong herbs. All of this led to a pair of laws in 1686 and 1700, which would later become part of the Complete Collection of Laws of the Russian Empire, "On punishments for those who do not know medical science and due to their ignorance of medicine, cause their patients to die." These were the first laws that considered any punishments for failed attempts to treat sick people.

And now we have arrived at the era of Peter the Great. Peter reformed just about everything he could possibly reform, and medicine, including forensic medicine, was no exception. His Article on Military and Naval Regulations touched on many aspects related to determining the severity of the injury and the cause of death. For example, the Naval Regulations (1720) included the following paragraphs:

The Naval Regulation included examinations to determine whether someone was faking an illness: "Determine whether they are truly ill, and if there is any false pretense, and issue a certificate."4 By the sixteenth century, forensic medicine was already capable of answering many questions that are still under the scope of a medical examiner's work, even today. Take, for example, this excerpt from the certificate of a forensic autopsy performed in 1731:

Just like anything else in life, people have at times attempted to take advantage of forensic science, twisting it to try to suit their own political goals. During the late nineteenth century, the tsarist government opened the so-called Multan case, in which forensic doctors gave deliberately false conclusions.

With time, forensic medicine has grown and developed. Thanks to new research, today, it includes a vast range of cutting-edge knowledge and technology, and is one of the most engaging fields of medicine. The Moscow Forensic-Medical Bureau boasts a highly developed scientific and practical infrastructure with leading experimentation and research. Medical students and those from other specialties work here, alongside numerous fascinating, creative people, including world-renowned scientists and young, innovative experts. Institutions carrying out their own "independent" examinations is a recent fad in Russia, which often gives people the false impression that these examinations are indeed independent, and that their conclusions are unbiased and objective. Alas, that is often not the case — and this is the reason why the independent status of state medical examiners is confirmed and enshrined in federal laws. State medical examiners' salaries do not depend on the contents of their conclusions, and the positions of either party relative to a court case have no bearing on their work.

2. JUST WHO IS A MEDICAL EXAMINER?

Before writing this section, I asked my blog readers to describe to me what, in their minds, is a medical examiner's appearance. As I expected, most of the responses were heavily influenced by stereotypes they had seen on television and in movies. Movies avoid ever showing medical examiners' offices, and instead prefer the drama of a forensic dissection laboratory — where autopsies are performed on dead bodies. In movies, a medical examiner is almost always an aging man, unshaven, balding, and eccentric, with a sweaty face and a wrinkled white coat. He seems to work exclusively in dimly lit basements, with a messy desk covered in old newspapers and half-eaten food, an ashtray overflowing with cigarette butts, and with mysterious stains on the walls, desk, and his lab coat. The character himself is inevitably strange and constantly making deadpan jokes about his work. Rarely does he leave the laboratory, and when he does, he always manages to be casually chomping on a sandwich or a bag of chips, which he will offer to the investigator, only to be surprised when his offer is rejected. Often, he is portrayed as being a bit tipsy and, in older shows, almost always as a smoker. When the investigator asks for his conclusions, the medical examiner will, without fail, wipe his hands on his coat, whip out his notes, and say, in a weather announcer's voice, "Well, it is just as I suspected…" before once again offering the investigator a chip.

But there is yet a second type of medical examiner character in movies, which is quite the opposite to the first one. He is also invariably a man, middle-aged, intelligent, always well-dressed, and he speaks in confident tones that assure you he knows absolutely everything about everything. He needs to establish the exact time of death — and he will, right down to the second. He needs to assess the damage — and he will do so methodically, as the picture of calm, without the slightest shred of doubt. For some reason, he does his job, as well as that of the criminal profiler, which has nothing to do with his position. Occasionally, this type of fictional medical examiner may be a woman — she will be efficient, with her hair in a messy bun, clicking around in high heels as she zeros in on the next task on her to-do list. Regardless of which type of medical examiner our screenwriters have chosen, they often mistakenly refer to the character as a "pathologist," who also happens to take photos of the body at the crime scene, gathers fingerprints, and bags up pieces of evidence. Even more surprisingly, along with the investigators, the character will report on the investigation results to the police chain of command! This is what my readers had to say. Enjoy some of their submissions below: