Forensic Pathological Considerations of a Unique Case of “Complicated Suicide”*,†

In the forensic literature, peculiar and uncommon cases of suicides defined as “complicated” are reported. In these circumstances, the suicide method chosen by the victim fails, and death occurs due to a subsequent unforeseen accidental event defined as secondary trauma. Through retrospective examination of 25,512 autopsies in 27 years (1993–2019) at the Bureau of Legal Medicine of Milan, a unique case of complicated suicide was identified from a total of 4497 suicides. It concerns an elderly man who, after killing his wife by inflicting incised wounds to her neck, tried to hang himself by tying a rope to a heater and jumping from the window located over the heater itself. However, the rope suddenly snapped and the man fells to the ground causing fatal traumatic injuries. Death occurred because of an accidental event caused by the failure of the hanging mechanism. Therefore, a peculiar yet characteristic case of complicated suicide is described.     

Further observations on the speed of death in hanging

Given that most fatal hangings are suicidal and occur in locations that have been selected to conceal this activity (thus maximizing the chances of a lethal outcome), there has been very little corroboration of the speed with which unconsciousness and death may occur. A 35-year-old male is reported who committed suicide by hanging immediately after talking to his spouse. Police investigations confirmed her reliability as a witness indicating that lethal anoxia in this case had occurred within a very short time (most likely in less than 1 min) of suspension. The speed with which death may result from hanging not only gives an insight into fatal pathophysiological mechanisms, but also provides useful information for situations where a lethal outcome is to be avoided, or is not intended. For example, individuals at risk of suicide who are being monitored in institutional facilities need to be constantly under direct visual surveillance as significant hypoxia can be rapidly induced, parents and caregivers with infants and children in potentially unsafe sleeping environments need to realize how swiftly death or irreversible anoxic brain damage may occur from neck compression, and those who engage in recreational asphyxia should be informed just how quickly a fatal outcome may ensue.     

A Case of Insect Colonization Before the Death

Forensic entomology is a branch of forensic science in which insects are used as evidence in legal investigations relating to humans, domestic animals and wildlife. One of the theoretical pillars on which the discipline is based concerns the fact that flies colonize a body after death. However in cases of myiasis, maggots are present before death, with consequences in the correct estimation of the minimum postmortem interval (mPMI). We report here the case of a woman, largely colonized by fly larvae, who has lain alive in her garden for four days prior to being rescued. Larvae were found on the conjunctivae, the bronchi, the rectum and vagina. The woman's death, two months later, was caused by tetanus. The consequences of myiasis on mPMI estimation are here discussed. In fact, despite she was still alive larvae, indicated and estimated age of 1.5–2.5 days, based on environmental and body temperature.     

Suicidal hanging on high-voltage line pylon

Hanging is one of the most frequent methods for suicides among young males. This report presents two cases of suicide by hanging on pylons carrying high-voltage power lines. The male victims suffered electrocution while committing suicide. Electrocution was the cause of death in both cases, however in one case blunt force injuries from hanging contributed to death. In these two cases hanging was the intentional method of suicide and it was followed by electrocution. The cases demonstrate that scene investigation, a detailed autopsy with histology, and amamnestic data are essential in the evaluation of suicides by hanging and that the determination of the cause of death remains a challenge in investigating such cases.     

Complex autoerotic death with full body wrapping in a plastic body bag

Autoerotic deaths are normally classified as accidental deaths occurring during individual, and usually solitary, sexual activity in which a device, apparatus, or prop used to enhance sexual stimulation of the deceased somehow causes unintended death. The most common methods of autoerotic practices are asphyxia by hanging, ligature, plastic bag, chemical substances, or a mixture of these. However, atypical methods such as overdressing/body wrapping have also been reported. In fact, overdressing/body wrapping is so rare that it is implicated in only 1.5% of published cases. Although plastic bags are often implicated in autoerotic deaths, there has been only one previous case that involved a plastic covering the victim's body from head to toe. We here report the case of a 34-year-old man who died due to asphyxia, secondary to body wrapping in the largest and most complex plastic bag ever involved in a published case of autoerotic death.     

Planned Complex Occupation‐related Suicide by Captive‐bolt Gunshot and Hanging*

Abstract: Planned complex suicides are committed by using two or more previously planned methods simultaneously to make sure that death will occur even if one method fails. Herein, we presented a case of occupation‐related planned complex suicide, committed by captive‐bolt gunshot and hanging. A 29‐year‐old man, who worked as a butcher, was found dead in the stable, hanging by the neck with a captive‐bolt gun embedded in the forehead region of his head. The hanging was complete. Along the bolt canal were bone fragments, and at the end of the path was the punched‐out fragment of the skin and soft tissue. There were no fractures of the hyoid bone and laryngeal cartilages, and a superficial hemorrhage was present in the right sternocleidomastoid muscle. Our case underlines the utility of forensic autopsy and death scene investigation in reconstructing the mechanism of death, as well as the dynamics of the event.     

A Unique Fatal Moose Attack Mimicking Homicide

Fatalities caused by animal attacks are rare, but have the potential to mimic homicide. We present a case in which a moose attacked and killed a woman who was walking her dog in a forest. Autopsy showed widespread blunt trauma with a large laceration on one leg in which blades of grass were embedded. Flail chest was the cause of death. The case was initially conceived as homicide by means of a riding lawn mower. A review of the case by moose experts and analyses of biological trace material that proved to originate from moose, established the true source of injury. The dog probably provoked a moose, which, in response, stomped and gored the victim to death. The injuries resembled those previously reported from attacks by cattle and water buffalo. Fatal moose attacks constitute an extremely rare threat in boreal areas, but can be considered in traumatic deaths of unknown cause.     

Hands Tied with Bag Full of Books in Suicidal Hanging

Hanging deaths associated with binding of limbs, masking of a face, and gagging are always suspicious. In suicidal hanging, the victim uses these added techniques to prevent him from backing out of his decision and to ensure death. However, binding of limbs and adding extra weight to the suspension in hanging are not reported. Herein, we report a case where the victim tied a bag containing books weighing 7 kg (15.4 lbs) to both his hands during hanging. The forensic specialist must be aware of the unusual presentation of suicidal hanging which may suggest foul play. The manner of death must be established after detailed analysis of circumstantial evidence, information obtained from the witnesses, complete autopsy, and toxicological examination.     

Autoerotic deaths in the literature from 1954 to 2004: a review

Autoerotic death by hanging or ligature is a method of autoeroticism well known by forensic pathologists. In order to analyze autoerotic deaths of nonclassic hanging or ligature type, this paper reviews all published cases of autoerotic deaths from 1954 to 2004, with the exclusion of homicide cases or cases in which the autoerotic activity was not solitary. These articles were obtained through a systematic Medline database search. A total of 408 cases of such deaths has been reported in 57 articles. For each case, the following characteristics are presented here: sex, age, race, method of autoerotic activity, cause of death, and location where the body was found. Autoerotic death practioners were predominantly Caucasian males. Victims were aged from 9 to 77 years and were mainly found in various indoor locations. Most cases were asphyxia by hanging, ligature, plastic bags, chemical substances, or a mixture of these. Still, atypical methods of autoerotic activity leading to death accounted for about 10.3% of cases in the literature and are classified here into five broad categories: electrocution (3.7%), overdressing/body wrapping (1.5%), foreign body insertion (1.2%), atypical asphyxia method (2.9%), and miscellaneous (1.0%). All these atypical methods are further discussed individually.     

Sudden Unexpected Death Due to Graves' Disease During Physical Altercation

We report a case of a 30‐year‐old woman who suddenly collapsed after having a physical altercation with her husband. Despite immediate resuscitation, she died on arrival at the hospital. The victim's parents requested an autopsy because they believed that their daughter was killed by her husband. Postmortem examination revealed that the victim had a diffusely enlarged thyroid gland and cardiomegaly with left ventricular hypertrophy. There was no evidence of significant trauma on the body. Further postmortem thyroid function tests and review of her medical history indicated that her death was due to Graves' disease. To the best of our knowledge, this is the first case reported of sudden death due to cardiac arrhythmia from Graves' disease induced by physical and emotional stress associated with the criminal activity of another person. The autopsy findings are described. In addition, the literature is reviewed and the significance of postmortem evaluation of thyroid hormones in the cases of sudden death is discussed.     

Observed Characteristics of Suicidal Hangings: An 11-year Retrospective Review

Many studies have been published regarding suicidal hanging deaths, and most forensic pathologists and coroners are very familiar with such causes of death. Forensic pathologists are challenged over their rulings regarding manner of death in part because the general public has a limited scope of knowledge. One such challenge centers on the question of whether a hanging can be a suicide if the individual is not fully suspended. The authors designed a retrospective study to review suspension in hangings and to analyze other criteria used to help in deciding manner of death. We examined 229 suicidal hanging deaths over an 11-year period (1997 through early 2009) using the data from two separate jurisdictions in Ohio. In conclusion, we found that the vast majority (83.4%) of people who hanged themselves were found partially suspended. Among other criteria analyzed, only the presence of petechial hemorrhages and acute neck injury was statistically significant.     

Complex Suicide by Self‐stabbing and Drowning: A Case Report and a Review of Literature

Sharp force injuries and drowning are methods exceptionally combined in complex suicides. We report a challenging case of complex suicide by self‐stabbing and drowning that illustrates the difficulty in discriminating between homicide and suicide in such circumstances of death. The corpse of a young man was found submerged in a river, stabbed nine times with two wounds that had penetrated the thorax and had caused lung injuries and a hemopneumothorax. The postmortem and histological examinations were consistent with a death caused by drowning, but the manner of death still remained undetermined. Police investigation finally concluded to a suicide, although no suicide note had been left and the victim had no underlying diagnosed mental disorder. The parameters that may help distinguish suicide from homicide at the autopsy should be interpreted in light of a thorough forensic investigation to determine the exact manner of death in such a case.     

Sudden unexpected death due to a previously undiagnosed plasma cell dyscrasia

The plasma cell dyscrasias are a diverse group of disorders characterized by the production of a clonal paraprotein. Sudden death is a recognized complication of the plasma cell dyscrasias, most commonly in individuals with cardiac involvement by amyloidosis. However, the current forensic literature has no reported cases in which sudden death resulted from complications of a plasma cell dyscrasia that was first diagnosed by postmortem histologic examination. We present the case of a woman whose sudden and unexpected death resulted from a seizure. Postmortem examination revealed no evidence of trauma or a grossly identifiable natural disease process that would have accounted for her death. However, microscopic and immunohistologic studies revealed a previously undiagnosed plasma cell dyscrasia, the clonality of which was determined by immunohistochemical studies for immunoglobulin light chains, that was not associated with amyloid deposition. This case elucidates a previously unrecognized cause of sudden unexpected death and illustrates the importance of microscopic studies in selected cases examined in medical examiner/coroner offices.     

Autopsy Identification of Viable Mycobacterium Tuberculosis in the Lungs of a Markedly Decomposed Body

Various infectious diseases, including COVID-19, MERS, and tuberculosis, are global public health issues. Tuberculosis, which is caused by Mycobacterium tuberculosis (MTB), is highly contagious and can be transmitted through inhalation of the bacteria. However, it has been assumed that the infectiousness of bacteria and viruses in dead bodies weakens as the time from death increases. In particular, there is little awareness of infection control measures concerning decomposed bodies or even the need for such measures. The deceased, in whom we discovered MTB 3 months following her death, was a woman in her 80s who died at home. We performed judicial autopsy, because police suspected homicide when her husband hanged himself. Obtained organs were used for microscopic examination by hematoxylin–eosin staining and Ziehl–Neelsen staining. In addition, real-time PCR and mycobacterial culture testing using Ogawa's medium were performed for the detection of MTB. We found that the MTB in the decomposed body remained viable and potentially infectious. To identify the bacterial strain further, we performed DNA-DNA hybridization and identified the strain as MTB complex. Potentially infectious live MTB survived in the dead body far longer than had been previously reported. Pathologists should consider microbial culture tests for all autopsied cases in which the decedent's medical history or macro-examination suggests possible infection, even when a long duration of time has passed since death. Pathologists and specialists who perform autopsies should recognize that all dead bodies are potentially infectious, including those in which long periods have elapsed since death.     

Fatal Spontaneous Retropharyngeal Hematoma with Airway Obstruction in the Setting of Treatment with Dipyridamole

We report a fatal case of airway obstruction caused by spontaneous retropharyngeal hematoma (RH) in the setting of treatment with dipyridamole. A 90-year-old woman presented with cervical swelling, neck and chest ecchymoses, and complaints of dyspnea. She suffered cardiopulmonary arrest in the ambulance, and her death was confirmed after transportation to the hospital. The major finding of postmortem computed tomography (PMCT) prior to autopsy was widening of the prevertebral soft tissue. The results of the autopsy indicated that the cause of death was mechanical asphyxia, secondary to pharyngeal and laryngeal compression caused by the RH. There were no evident injuries, medical interventions, or particular diseases, suggesting the spontaneous cause of the RH. To the best of our knowledge, this is the first report of a fatal case secondary to spontaneous RH that was revealed through PMCT imaging.     

Agonal Sequences in Four Filmed Hangings: Analysis of Respiratory and Movement Responses to Asphyxia by Hanging*

Abstract: The human pathophysiology of asphyxia by hanging is still poorly understood, despite great advances in forensic science. In that context, filmed hangings may hold the key to answer questions regarding the sequence of events leading to death in human asphyxia. Four filmed hangings were analyzed. Rapid loss of consciousness was observed between 13 sec and 18 sec after onset of hanging, closely followed by convulsions (at 14–19 sec). A complex pattern of decerebration rigidity (19–21 sec in most cases), followed by a quick phase of decortication rigidity (1 min 00 sec–1 min 08 sec in most cases), an extended phase of decortication rigidity (1 min 04 sec–1 min 32 sec) and loss of muscle tone (1 min 38 sec–2 min 47 sec) was revealed. Very deep respiratory attempts started between 20 and 22 sec, the last respiratory attempt being detected between 2 min 00 sec and 2 min 04 sec. Despite differences in the types of hanging, this unique study reveals similarities that are further discussed.     

Aqua-eroticum: an unusual autoerotic fatality in a lake involving a home-made diving apparatus

The term Aqua-eroticum was first introduced in 1984 by Sivaloganathan to describe the unusual autoerotic death of a man using submersion as an asphyxia method. This was the first case of that kind, and since then, no other case of autoerotic submersion has been reported, nor other autoerotic fatality in open water. Here we report the case of a 25-year-old man, nude under a home-made plastic body suit, overdressed for the season with winter clothes and restrained by complex bondage. He was submersed, tied underwater to a boat and was using a home-made diving apparatus for air supply. Death was ruled as accidental autoerotic asphyxia from rebreathing, caused by the faulty air-supply device.     

Accidental Hanging Deaths in Children in Konya,Turkey Between 1998 and 2007*

Abstract: In general, hanging cases are the result of suicide, and accidental and homicidal hanging cases are rarely seen. This study retrospectively investigated 4571 death examinations and autopsies that were performed at The Konya Branch of the Forensic Medicine Council (Turkey) between 1998 and 2007; hanging was involved in 201 (6.5%) of the cases. There were a total of 13 accidental hanging cases, where 12 of these involved children. In seven of the cases, the accidental hanging involved a scarf that wraps around swing‐like cradles and is intended to prevent infants from falling down. It was concluded that accidental hanging deaths can be reduced by replacing swing‐like cradles with cribs that are designed for children, removing ropes in and around the house, and preventing children from reaching and/or playing with rope‐like objects.     

Sudden Death by Occult Metastatic Carcinoma

A 33-year-old female collapsed and died suddenly after presenting with acute dyspnea and increasing cough over the preceding several months. Autopsy revealed poorly differentiated linitis plastica adenocarcinoma of the stomach. Microscopic examination of the lungs showed features consistent with pulmonary tumor thrombotic microangiopathy (PTTM). PTTM is a well-described complication in patients with adenocarcinoma. The typical presentation involves acute pulmonary hypertension, right-sided heart failure, and sudden death, often before the adenocarcinoma is discovered. The pathophysiology of PTTM remains elusive; it has been suggested that carcinoma cells may produce substances that influence pulmonary vasculature. Our patient had classic clinical and histologic features of PTTM in addition to prominent extravascular compression by intralymphatic tumor cells. These features undoubtedly caused her precipitous decline and lethal pulmonary hypertension, induced by underlying adenocarcinoma. This case demonstrates that sudden death can occur from pulmonary hypertension induced by metastatic carcinoma with remarkably little prior symptomatology.