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.     

Analysis of accidental deaths in mountain tourism and sport according to statistics from the Republic of Kabardino-Balkariia

Lethal cases in mountain tourism and sports in the Republic of Kabardino-Balkaria were studied for 1978-1995. A total of 152 accidental deaths were analysed. Most of the victims were males under 30 years of age. The greatest number of the accidents took place on Monday, in July and August. Many amateur visitors from abroad were among the victims. The main cause of death in the mountains of Kabardino-Balkaria for the 18 years studied was multitrauma of the body (69.7%). Hypothermia and obturation asphyxia with snow and compression asphyxia due to snowbreak account for 11.8 and 13.2% deaths, respectively; lightning killed 4%. Combination of high mountain hypoxia with exacerbated chronic somatic disease or hypothermia caused death in 1% victims. The authors propose how to improve forensic-medical expert examination of accidental death and safety in the mountains.     

Autoerotic asphyxia: part I

Fatal autoerotic asphyxia refers to death during solitary sexual activity with self-induced asphyxiation meant to be brief and reversible. However, an unexpected fatality results from a failure of a release mechanism apparatus. The large majority of victims of autoerotic death are Caucasian males between the second and fourth decade. While autoerotic death may encompass a myriad of other means of achieving sexual gratification, which includes asphyxia by plastic bag or inhalation of noxious chemicals, the most common method is by ligature about the neck. This study presents a 9-year retrospective review of deaths due to autoerotic asphyxia, specifically ligature asphyxia, in Kentucky between 1993 and 2001. Of the sixteen victims, all were Caucasian males between the ages of 14 and 59 years, with a mean age of 38.3 years. Cross-dressing was a feature in 4 cases. A thorough review of the decedent's background, meticulous scene investigation, and complete postmortem examination may shed light on the mechanism and psychosocial predisposition associated with autoerotic asphyxia.     

Metal Railing Fences and Accidental Death

Two cases of accidental deaths caused by the sharp ends of fence or gate posts are reported. Case 1: A 47‐year‐old man was found hanging by his ankle in an inverted position on fencing. He had attempted a shortcut to a railway platform by climbing over a metal rail fence. He had slipped and been impaled through his ankle by the sharp end of the fence post, resulting in death from positional asphyxia. Case 2: An 18‐year‐old male slipped while climbing over a gate and died after being impaled on a spear tip finial, which had lacerated his external iliac vein. Death was due to exsanguination. These cases demonstrate two rare examples of accidental deaths from impalement by the ends of sharp fence posts. Mechanisms of death in such circumstances involve suspension with positional asphyxia and vascular injury with exsanguination.     

Homicidal asphyxia

Homicides due to asphyxia are relatively uncommon. To better understand the presentation of such cases, the files of the Bexar County Medical Examiner's Office were reviewed from January 1, 1985, through December 31, 1998, for all such homicides. A total of 133 cases were found. The largest category was ligature strangulation with 48 deaths (21 male, 27 female). Petechiae were present in the conjunctivae and/or sclerae in 86% of the cases; fractures of the hyoid and/or thyroid cartilage were present in 12.5%. There were a total of 41 deaths from manual strangulation (27 female, 14 male). Petechiae were present in 89% of the cases. In cases of manual strangulation, fractures of the hyoid, thyroid, or cricoid cartilage were found in all the male victims and slightly more than one half of the female victims. Twenty-six cases of suffocation were found; 20 of the victims were < or =2 years of age. Only 1 of these children had petechiae and/or scleral hemorrhage. Five deaths were due to choking. Three of the deaths involved adults who were gagged; 2 deaths involved infants with foreign material pushed into the mouth. Other categories of asphyxia were as follows: 9 deaths due to more than one form of asphyxia; 1 death due to hanging, and 3 deaths due to drowning. Rape was the motive in 66% of the female victims of ligature strangulation and 52% of those due to manual strangulation.     

Death of an 89-year-old man during autosexual activity

Autoerotic fatalities are accidental deaths occurring as a direct result of autosexual activities, mostly involving men in the 2nd to 8th decade of life. Death most often occurs in the domestic environment due to strangulation or asphyxia. However, fatalities related to autosexual activity in a wider sense may also be caused by an accident or sudden death from an internal cause. We report the case of an aged man who died while engaged in outdoor autosexual activities due to a combination of a pre-existing internal disease and an accident (drowning).     

Atypical autoerotic death: part II

Autoerotic fatalities encompass a wide array of means and mechanisms used to attain sexual gratification. The most commonly encountered autoerotic practice, specifically, autoerotic asphyxia, denotes death resulting from failure of a release mechanism of the apparatus designed to attain cerebral hypoxia for heightened arousal. Historically, the majority of victims of autoerotic death are Caucasian males under the age of 30. While autoerotic death is most often associated with a constrictive cervical ligature tied to either other parts of the victim's body or to an inanimate object such as a door, several other methods have been reported. These modalities include ligature around the thorax or abdomen, plastic bags covering the face, electrical current, inhalation of a toxic gas or chemicals, or partial or total submersion, known as aquaerotic asphyxiation. This study highlights 11 cases of atypical autoerotic death, including asphyxia with a plastic bag, electrocution, and inhalation of butane and nitrous oxide (N2O). Whereas the manner of death in the majority of autoerotic death cases is deemed accidental, we present and analyze unique and equivocal cases representing 4 different manners of death: accident, natural, suicide, and homicide. The 11 victims were all Caucasian and between the ages of 17 and 55. Ten decedents were males, 1 female. A comprehensive investigation incorporating a thorough scene analysis, gathering of the victim's history, and complete postmortem examination is necessary to elucidate both the cause and manner of death in these atypical cases.     

Asphyxial games in children and adolescents

Asphyxial games, as played by young adolescents, and going by various names, are not new phenomena. What seems to be different at present is an increase in lethality introduced by the increasing use of ligatures and "playing" the game alone. The authors present a properly certified but insufficiently appreciated case followed 2 years later by 2 closely spaced but unrelated deaths in young adolescent males that made known this practice in New Hampshire youth. Other cases presented to the author from other jurisdictions are reviewed in aggregate. Presented are characteristics of victims of this practice that may help distinguish these deaths from suicidal asphyxia. A relative paucity of literature regarding asphyxial games outside the realm of autoerotic asphyxia gives rise to certification difficulties given the high prevalence of youth suicide.     

Investigation of sudden infant deaths in the State of Maryland (1990-2000)

The Office of the Chief Medical Examiner (OCME) has recorded a significant decline in the deaths of sudden infant death syndrome (SIDS) in the state of Maryland since 1994. However, infants who died of accidental or non-accidental injuries remained consistent during the same time period. This report focuses on the epidemiological characteristics and scene investigation findings of infant victims who died suddenly and unexpectedly in Maryland between 1990 and 2000. A retrospective study of OCME cases between 1990 and 2000 yielded a total of 1619 infant fatalities. 802 infant deaths were determined to be SIDS, which represented 50% of the total infant deaths in our study population. Five hundred and twenty-three (31.8%) deaths were due to natural diseases, 128 (7.9%) deaths were accidents, and 74 (4.6%) were homicides. The manner of death could not be determined after a thorough scene investigation, review of history and a complete postmortem examination in 92 (5.7%) infants. SIDS deaths most often involved infants who were male and black. The peak incidence of SIDS was between 2 and 4 months of age. The majority of SIDS infants (60%) were found unresponsive on their stomach. Among SIDS infants, 269 (33.4%) were found in bed with another person or persons (bed sharing). Of the bed-sharing SIDS cases, 182 (68%) were African-American. In the past 11 years, 52 infants died of asphyxia due to unsafe sleeping environment, such as defective cribs, ill-fitting mattresses, inappropriate bedding materials. Of the 74 homicide victims, 53 (70%) involved infants less than 6 months of age. Twenty (27%) exhibited the classical abuse syndrome characterized by repeated acts of trauma to the infants.     

The cocaine "body stuffer" syndrome: a fatal case

Body stuffer, sometimes called "mini packer", is the definition of someone who admits to or is strongly suspected of ingesting illegal drugs in order to escape detection by authorities, and not for recreational purposes or to transport the drug across borders. Cocaine is the drug most commonly involved in the body stuffer syndrome. Reported cases of body stuffer deaths are rare, however a fatality related to the ingestion of a plastic bag containing cocaine is described regarding a 17-year-old dealer. The authors describe how the cocaine body stuffer syndrome differs from the usual body packer. Histological and toxicological findings are examined and discussed for a better definition of this unique syndrome.     

Cocaine- and methamphetamine-related deaths in San Diego County (1987): homicides and accidental overdoses

Cocaine- and methamphetamine-related homicides and fatal accidental overdoses in San Diego County were studied retrospectively for the 1987 calendar year. Cocaine was involved in 66 cases (39 homicides, 27 accidental overdoses), methamphetamine in 32 cases (23 homicides, 9 accidental overdoses), and a combination of cocaine and methamphetamine in 10 cases (4 homicides, 6 accidental overdoses). The composite for cocaine-related deaths was a 30-year-old black man in whom was also found at least 1 other drug, usually ethanol or morphine. The composite for methamphetamine-related deaths was a 32-year-old Caucasian man who used methamphetamine with at least 1 other drug (usually ethanol). For cases involving both cocaine and methamphetamine, the composite was a 36-year-old Caucasian man in whom was also found at least 1 other drug, usually ethanol, codeine, or morphine. Mean tissue concentrations of cocaine and benzoylecgonine were significantly higher in accidental overdoses than in homicides except for cocaine concentrations in liver, which did not differ significantly between the two groups. For methamphetamine-related deaths there was no significant difference between mean tissue concentrations in accidental overdoses and in homicides. Cocaine or methamphetamine or both were involved in approximately one third of homicides in San Diego County in 1987, and when fatal accidental overdoses were included, cocaine was involved in twice as many cases as methamphetamine.     

2633例机械性窒息法医尸检资料回顾性研究

本文根据湖北省部分地区1957～1986年间尸检记录,收集并分析了2633例机械性窒息死的出现率、案情性质、城市与乡村的差别等问题,为法医学实践提供了可供参考的资料。     

Accidental sharp force injury fatalities.

The authors review all accidental sharp force injury deaths investigated at the Southwestern Institute of Forensic Sciences from 1990 to 1999. Twenty-two cases of accidental sharp force injury were identified, accounting for 0.29% of all accidental deaths (9,562) during the 10-year study period. Included in this series are 5 incised wounds, 11 stab wounds, 4 chop wounds, and 2 deaths caused by dog attacks. About half of the cases involved some type of motorized machinery. The victims' ages ranged from 2 years to 71 years, with most deaths occurring in older teenagers and younger adults. Male subjects (17) were involved much more frequently than female subjects (5). In 50% of the cases, ethanol or other drug use was a possible underlying contributing factor in the accident. The cases are briefly reviewed, and the importance of detailed investigation in manner-of-death certification is emphasized.     

Deaths during recreational activity

This study of recreational deaths in the "land of sun and fun" has pointed out several useful factors. Firstly, accidental deaths are more common than naturals. Secondly, the most common accidental death is drowning while swimming. The latter is not usually at public facilities, but rather at unsupervised uninstitutionalized surroundings. Finally, a younger population is involved with a frequent number of them with alcohol detected and/or drugs.     

Forensic medical specificity of death in atypical sexual behavior: asphyxiophilia, autoerotism

The diagnosis of death of autoerotic asphyxia has not been virtually stated by Russian forensic medical expert. All such cases were interpreted as mechanical asphyxia entailing suicide, and "accidental" or "fatal" death. The authors observed, during the recent 5 years, 10 lethal cases in different-type autoerotic practice. Strangulation asphyxia was the death cause in 7 cases. Compression asphyxia, inhaling of glue vapor and electric shock caused death, each in one case. Death of asphyxia seizes to be exceptional; it is rather a regular phenomenon in the present-day life, which needs a proper research from 2 standpoints--etiopathogenesis, and forensic medical diagnosis.     

Positional asphyxiation in adults. A series of 30 cases from the Dade and Broward County Florida Medical Examiner Offices from 1982 to 1990.

Over a 9-year period, 30 cases of positional (or postural) asphyxia were identified in the Dade and Broward County (Florida) Medical Examiner Offices. The victims had an average age of 50.6 years with no significant sex or racial differences as compared with the general medical examiner population. Chronic alcoholism or acute alcohol intoxication was a significant risk factor in 75% of cases and these had an average postmortem ethanol concentration of 0.24 g%. Signs of mechanical asphyxiation (petechiae and/or combined lung weights greater than 900 g) were present in 93% of cases. Victims were commonly (43%) found in a restrictive position producing hyperflexion of the head and neck. Two deaths involved restraint vests ("poseys") in elderly, demented, wheel-chair-confined victims. Scene photographs of the undisturbed decedent are extremely helpful in confirming a suspicion of postional asphyxia.     

Household furniture tip-over deaths of young children

The potential for the injury or death of a child resulting from the tip-over of a piece of household furniture or a domestic appliance has not been previously well recognized. We reviewed nine accidental deaths of young children that resulted from avoidable residential hazards and/or lapses in supervision of the children by their caregivers. The offending household items included televisions, bedroom dressers, a kitchen stove, and a lounge chair. The causes of death were mechanical asphyxia, blunt trauma, and combined blunt head trauma and asphyxia. All of the deaths could have been prevented by appropriate anchoring of the piece of furniture and/or closer supervision of the child. A thorough multidisciplinary investigation is essential in establishing the cause and manner of death in such cases and in identifying risk factors that may aid in the prevention of future childhood deaths.     

"Permanent discharge": deaths of people under 50 years of age in residential aged care in Victoria

In June 2007 there were 210 people under 50 years of age living in residential aged care in Victoria, Australia, most of whom had acquired brain injuries. There are an average of 21 deaths per year in this group yet very little is known about the causes of such deaths. While the Coroners Act 2008 (Vic) requires mandatory reporting of "unexpected" and "accidental" deaths, anecdotal evidence and data from the Coroner's Office suggest that most deaths of people under 50 years of age in residential aged care are not reported. This research presents the cases of three "preventable" deaths, none of which was reported to the coroner and all of which have implications for systemic reform. It concludes that cross-sectoral solutions to meet the complex needs of people under 50 years of age with disabilities in residential aged care are urgently needed as well as monitoring to help us to understand better the needs of young people in residential aged care.     

Pulmonary siderophages and unexpected infant death

It has been proposed that the presence of siderophages in the lungs of infants who die unexpectedly should be considered a marker of a previous hypoxic event, which may preclude a diagnosis of sudden infant death syndrome. The authors retrospectively reviewed all infant deaths (<1 year old) going to autopsy at the Denver Office of the Medical Examiner from January 1999 to January 2001. Lung sections were stained with Prussian blue, and siderophages were counted in 20 high-power fields per lobe sampled. Cell counts were performed by two independent pathologists who were blinded to history and cause of death, with good reproducibility. Iron stain results were then categorized by average number of siderophages per 20 high-power field (category 1 = <5, category 2 = 5-100, category 3A = 100-500, category 3B = >100 in a single lobe, category 4 = >500). The results were subsequently correlated to case history, autopsy findings, and cause/manner of death. Forty-three cases were reviewed. The causes of death included sudden infant death syndrome (16), asphyxia (5), undetermined (6), and other (16). Those deaths were categorized by the above criteria as follows: category 1. (32), category 2. (6), category 3. (4), and category 4. (1). All sudden infant death syndrome deaths were in category 1. Categories 1 and 2 also included deaths in which hypoxia might have been present before death because of such factors as pneumonia and congenital heart disease. Categories 3 and 4 included a known homicidal asphyxia in which repeated episodes of intentional smothering were documented, 2 probable asphyxias, 1 nonaccidental trauma, and 1 undetermined. All 5 cases had questionable circumstances surrounding the death of the infant. Pulmonary siderophages were described in only 1 of the 43 autopsy reports. It was concluded that pulmonary siderophages can be markedly increased in cases of repeated asphyxia. Siderophages may also be increased in cases where hypoxia may have been present for another reason, but not to the same degree. Siderophages are not increased in sudden infant death syndrome. Because iron-laden macrophages often are not recognized on routine examination with hematoxylin and eosin staining, iron stains may be helpful in the evaluation of infant deaths. If siderophages are present in increased amounts without an obvious explanation, further investigation is warranted.     

The "mini-packer" syndrome. Fatal ingestion of drug containers in Baltimore, Maryland

We report seven fatalities resulting from the ingestion of illicit drugs packaged in condoms, rubber balloons, or plastic bags which were observed in the last 4 years at the Office of the Chief Medical Examiner, State of Maryland. All the victims, with the exception of one, were men ranging in age from 19 to 37 years. There was no racial predominance. No drug paraphernalia was found at any scene. In two cases, seizure-like activity was documented. One victim had recently returned from Nigeria; therefore, Lassa fever was initially suspected. Two of the victims were "body packer" contrabanders who had just arrived from Africa. They used body cavities to hide large amounts of heroin to avoid U.S. Customs. The other five cases were "mini-packers," small-time illicit drug dealers who had swallowed a single bag of cocaine to avoid police detection. The possible mechanism of leaking or rupture of the latex container is discussed.