Suicide by drowning

A study of suicidal drownings was performed by using the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida, U.S.A., during 1980-1984. A total of 70 cases were collected and analyzed as to the age, race, sex, and cause of death of the victim, along with blood alcohol content, the drugs detected at postmortem examination, the geographic location of the terminal incident, the scene circumstances, the presence or absence of a suicide note, and the reason for the suicide. Essentially, one deals with an older white male population, although all age groups can be affected. Members of the population studied frequently died from drowning alone, rather than from additional contributory causes. Most were sober and frequently without drugs detected. Most incidents occurred at home or in a canal, with the victim just "found floating". A note was absent approximately half the time. The reason for the act was depression concerning poor health, death of a loved one, financial problems, chronic pain, or being "tired of life". A discussion ensues about the approach a forensic scientist should have concerning such cases.     

Asthmatic deaths in the medical examiner's population

A study of people who die from asthma was performed. The case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida, U.S.A., were examined during the 5-year period 1979-1983, and all autopsied cases in which bronchial asthma was the primary or contributory cause of death were collected. These 39 cases were then analyzed as to the age, race, sex, and cause of death of the victim. Additionally, the medication list of the victim, the location of the terminal incident, the scene circumstances, the presence of hospitalization at the terminal incident, and the histopathology of the lungs at autopsy were additionally observed. Essentially, the asthma victim the medical examiner sees at autopsy is an adult white male commonly dying in an acute asthmatic attack. Ninety percent (90%) of the deaths had medications noted with 20% having three or more medicines, one of which was a steroid. The terminal incident occurred at home most frequently with an acute attack or being found dead noted. Most victims received some form of terminal hospitalization. Histopathologically, classical "asthma findings" were noted approximately one half of the time.     

Homicide by fire

A study of homicide perpetrated by fire was performed on the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida, during the years from 1977 until 1984. A total of 26 cases were collected and analyzed as to age, race, sex, and the cause of death of the victim along with the blood alcohol content, the drugs detected at autopsy, and the blood carboxyhemoglobin level. Additionally noted were the geographic location of the terminal incident, the scene circumstances, how the fire started, who started the fire, and the reason for the fire. The most common victim was a 31-50-year-old white man who died from smoke inhalation while sober. Commonly, drugs detected were negative, and the carboxyhemoglobin levels were elevated. The fire occurred at "home" while the victim was sleeping. Usually, a flammable liquid was poured and ignited by a drifter who was a brief acquaintance and earlier involved in an argument with the victim.     

Suicidal fire deaths revisited

A study of self-immolation or suicidal fire deaths was performed on the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida, during the 8-year period from 1977 to 1984. A total of 24 cases, representing 0.96% of the suicides that occurred during this period, were collected and analyzed as to age, race, sex cause of death of the victim along with the blood alcohol content at autopsy, drugs detected at autopsy, and the terminal carboxyhemoglobin. Additionally, the scene circumstances, geographic location of the terminal incident, the reason for the suicide, whether or not there was a past suicide attempt, a past psychiatric history, how the fire was started, presence or absence of an outside example, time of occurrence, presence of hospitalization, and presence of a suicide note were also noted. Most of the victims were white women of over 50 years of age who died of thermal injuries. Half of the time the blood alcohol content was negative at autopsy, 1/3 of the time the drug screen was negative, and 1/3 of the time a small amount of carboxyhemoglobin was noted. Most fires originated at home, although motor vehicles were also common. Reasons for the suicide were varied. Of the cases 1/3 had a precious suicide attempt and approximately 1/2 of the cases had a psychiatric history. Commonly, the fire is started by pouring a flammable liquid on one-self as isopropyl (rubbing) alcohol or gasoline and igniting it. No outside media examples were noted. These events occurred more frequently in the afternoon or evening.(ABSTRACT TRUNCATED AT 250 WORDS)     

Non-commercial, accidental water transport (boating) fatalities

A study of non-commercial accidental water transport (boating) fatalities was performed on the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Fla., during the years 1980-1984. A total of 23 cases were collected and analyzed as to the age, race, sex, and the cause of death of the victim along with the blood alcohol content and the Urine EMIT drug screen at autopsy. Furthermore, the type of boat involved, the geographic locale, the time of the incident, the reason or risk factor for the incident, and the scene circumstances were also noted. Commonly, one is dealing with a male population below the age of 30 years who die of drowning. In approximately half of the cases alcohol is detected. The scenario involves "small" boats or canoes in the Atlantic Ocean or in canals in the afternoon or evening. Inexperience in boating/or stupidity plays a key role. A discussion ensues concerning recommendations designed to avoid such tragedies.     

The pathomorphology of chronic alcohol-associated myocardial changes

Forensic cases of sudden cardiac death were reviewed from the point of view of a history of alcohol consumption. A group of known cases of chronic alcoholism and another group of cases known to have been normal social drinkers without evidence of chronic alcoholism were selected. Cases with evidence of hypertension, ischemic or coronary heart disease, as well as cases with positive toxicological findings, were excluded. Applying the same criteria, cases of sudden death from other causes without a known history of alcohol consumption were selected to form a control group. With particular reference to histological myocardial changes, which are often documented in association with alcohol consumption, no noteworthy differences were found between the two major groups despite the significantly much lower frequency in the control group.     

Hyperthermia deaths in Finland in 1970-86

All cases in which hyperthermia had been determined as the basic cause of death during the period 1970-86 were collected from the records of the Central Statistical Office of Finland. Of the total of 230 cases, 228 were included in the present study; the two remaining victims died abroad, and no autopsy was performed in Finland. Most of the hyperthermia deaths occurred while the decedent was taking a sauna bath; most decedents were men aged 42-62 years. An increase in the total number of hyperthermia deaths, and of male victims, was noted from the beginning of the 1970s onward; the number of female victims remained at a relatively steady level throughout, with the exception of a slight rise in 1986. Acute alcohol consumption was detected in most of the victims; in some cases there was also a reference to chronic alcoholism or recent long-term heavy drinking. The findings suggest that in addition to the acute hazardous effect of ethanol on thermoregulatory mechanisms, the long-term consumption of alcohol may have promoted fatal hyperthermia in these subjects.     

Sudden epilepsy deaths and the forensic pathologist

Sudden unexpected deaths in epileptic persons are not rare events, most commonly encountered by the forensic pathologist rather than the clinician. Such deaths may represent 1-1.5% of all "natural" deaths certified by the medical examiner or coroner. The typical victim is a black male about 30 years of age who tends to abuse alcohol, with a history of generalized epilepsy for more than 1 year and likely for more than 10 years. There are a lack of obvious anatomic causes for the death at autopsy, but 60-70% of cases will have a lesion in the brain (most commonly old trauma) to explain the epilepsy. Most victims have no blood levels of anticonvulsant medications at the time of death. We have evolved a form for use by medical examiner/coroner's investigators at the scene to collect relevant information which will be of assistance to the pathologist in interpreting the case. Estimated prevalence of sudden epilepsy death, mechanisms, and other features of such cases are reviewed briefly.     

Suicide by jumping from buildings

A study of 82 suicides during 1982-1986 that were committed by jumping from buildings was performed using the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, Florida, U.S.A. The analysis involved the age, race, and sex of the victim along with the results of toxicologic studies and the cause of death. Additionally, the decedent's place of residence, location of the suicide, height of the building, and the reason for the suicide were investigated. Whether or not a note was left by the decedent was also ascertained. The suicidal "jumper" most commonly was a white man who was greater than 60 years of age who died from the resultant multiple injuries. The victim commonly was sober and drug free at the time of the incident. In approximately two-thirds of the cases, the location of the suicide was the victim's residence, which frequently was an apartment or condominium-type dwelling that was seven floors or higher from the ground. The victim often had experienced depression prior to the incident and did not usually leave a suicide note. This article compares the Dade County cases with others that have been studied and discusses the reasons why jumping from a building may have been chosen as the suicidal mechanism.     

One Hundred and One Cases of Plastic Bag Suffocation in the Milan Area Between 1993 and 2013—Correlations,Circumstances, Pathological and Forensic Evidences and Literature Review

Plastic Bag Suffocation is a rare cause of death in developed countries and almost unknown in the rest of the world. This study aims to retrospectively evaluate cases of PBS _asphyxia in Milan's Department of Legal Medicine from 1993 to 2013. Cases were selected from the database of 21,472 autopsies performed in the considered timeframe. One hundred and one cases were considered to be cases of Plastic Bag Suffocation, comprised of 100 suicides, no accidental events and 1 homicide. The most relevant elements pertaining to this type of death were evaluated for both the corpses and the crime scenes. From this study the typical PBS victim is an adult male, aged 52.3 years on average, depressed or afflicted by chronic or terminal diseases, and found at home. In 42.6% of cases, the victims were found with the plastic bag still positioned over their head, fastened by tying. Also common among these cases are drugs, alcohol and chemical abuses. According to the collected data, it is impossible to outline a pathognomonic detrimental background that leads to this cause of death. Crime scene investigation is, therefore, the one and only technical resource for evaluating these cases.     

Causes of death in hospitalized intravenous drug abusers

The authors reviewed at autopsy the causes of death of 274 patients with evidence of intravenous drug abuse who had been admitted to a large public hospital. There were 127 who died from diseases unrelated to intravenous drug abuse, and in 41% of these, chronic alcoholism was implicated. Deaths from overdose syndromes and drug-related organ pathology comprised only 11% of all cases. The mean age at death was 39 years. There was a male/female ratio of 3.6:1. Half of all patients died from infection--72 from acquired immunodeficiency syndrome (AIDS) alone. These findings indicate that persons hospitalized with a history of intravenous drug abuse usually die from causes other than overdose and that AIDS and chronic alcoholism are significant problems. Emphasis should be placed upon detecting "hidden" intravenous drug deaths to provide more accurate statistical information.     

Accidental non-commercial aircraft fatalities: the 7-year Metro-Dade County experience from 1977-1983

A study of accidental non-commercial aircraft fatalities was performed on the case files of the Office of the Medical Examiner of Metropolitan Dade County in Miami, FL, U.S.A., between the years 1977 through 1983. A total of 57 cases were collected and analyzed as to the age of the victim, the race and sex of the victim, the cause of death, the blood alcohol content at autopsy, the drugs detected at autopsy, the type of aircraft, the occupant role, the risk factor responsible for the crash, the time of the fatality, and the nature of usage of the aircraft. Essentially, these 57 cases comprised 1.2% of the non-vehicular accidental fatalities during the period. The age of distribution is relatively evenly distributed from age 16 to 65 years with white males predominating. Multiple injuries were the most common cause of death although conflagration injuries (e.g., smoke inhalation, burns) were frequent. The victims were sober and free of drugs in the majority of cases. Most fatalities occurred in a single engine plane with the victim, the pilot, flying for private reasons in the afternoon or evening hours. The most common identifiable risk factor was human error (e.g., judgement), rather than mechanical or plane failure.     

The association of alcohol-induced blackouts and grayouts to blood alcohol concentrations

The primary aim of this study was to investigate the association between measured blood alcohol concentration (BAC) and the presence and degree of amnesia (no amnesia, grayout, or blackout) in actively drinking subjects. A secondary aim was to determine potential factors other than BAC that contribute to the alcohol-induced memory loss. An interview questionnaire was administered to subjects regarding a recent alcohol associated arrest with a documented BAC greater than 0.08 g/dL for either public intoxication, driving under the influence, or under age drinking was administered. Demographic variables collected included drinking history, family history of alcoholism, presence of previous alcohol-related memory loss during a drinking episode, and drinking behavior during the episode. Memory of the drinking episode was evaluated to determine if either an alcohol-induced grayout (partial anterograde amnesia) or blackout (complete anterograde amnesia) occurred. Differences in (1) mean total number of drinks ingested before arrest, (2) gulping of drinks, and (3) BAC at arrest were found for those having blackouts compared with no amnesia; while differences in drinking more than planned were found between the no amnesia and grayout groups. A strong linear relationship between BAC and predicted probability of memory loss, particularly for blackouts was obvious. This finding clinically concludes that subjects with BAC of 310 g/dL or greater have a 0.50 or greater probability of having an alcoholic blackout.     

The microscopic pathology of the liver in fatal cocaine intoxication

The microscopic pathology of the liver in fatal cocaine intoxication was studied. Data from cases of cocaine intoxication during the years 1981-1986 were collected and analysed. Thirty cases with a negative past history for intravenous drug abuse, and in which the terminal drug testing revealed solely cocaine or its metabolites, were compared with a control group of nineteen people who had died in motor vehicle accidents, with a terminal negative blood alcohol, negative drug screen and no history of drug abuse. A comparison of liver histology was made along with gross anatomical liver weight. These findings are compared to other studies of hepatotoxicity in drug abuse.     

Mallory-Weiss syndrome as the cause of sudden, unexpected death

The Mallory-Weiss-syndrome is an upper gastrointestinal haemorrhage due to longitudinal mucosal lacerations in the oesophagogastric junction. The mucosal lacerations occur as a sequel of vomiting or any other increase in intraabdominal pressure and account for up to 15% of all upper gastrointestinal bleedings. If death is due to a bleeding Mallory-Weiss-tear, however, massive blood stains on the corpse and around it frequently give rise to the suspicion of an unnatural cause of death. For this reason, autopsy is usually indispensable to elucidate the circumstances in which death occurred. The authors carried out a retrospective analysis of 5958 autopsies performed between 1997 and 2001 at the Institute of Legal Medicine, University of Hamburg, in order to identify all cases of Mallory-Weiss-syndrome as cause of sudden, unexpected death. The results (9 cases, amounting to 0.15% of all autopsies) suggest that Mallory-Weiss-syndrome is probably much more common as a cause of sudden death than previously described. Regarding epidemiological aspects, men clearly predominate; the average age was 48 years. It should also be stressed that in 8 of the 9 cases there was a previous history of chronic alcohol abuse.     

A decade of pediatric homicide: a retrospective study at the Medical University of South Carolina.

More than 3 million children are abused and/or neglected each year in the United States. Unfortunately, a significant percentage of these cases result in homicide by child abuse or child neglect. Causes of death range from blunt force trauma and shaking to asphyxia to immolation. We retrospectively reviewed all pediatric forensic cases referred to the Medical University of South Carolina Forensic Pathology Section over the past 10 years, from January 1986 to December 1995. Of these, we looked only at children < or =5 years of age. The majority (342 cases, 69%) of these deaths were classified as natural, 96 (19%) as accident, and 60 (12%) as homicide. Of the homicides, we examined the cause of death; age, gender, and race of the victim; relationship to the perpetrator; time interval between injury and death; and the initial history given as to the cause of the injury. The cause of death fell into nine categories, the number one category being head trauma. Forty-five percent of the homicides were by head trauma, 12% by abdominal or body trauma, 25% by asphyxia (with half of these due to drowning), 10% by carbon monoxide poisoning or thermal injury, and the remaining 8% involving cases of neglect, stabbing, and poisoning. The majority of the homicide victims were male (67%) and black (67%). Forty-six percent were < or =1 year of age. Approximately 25% of the homicide cases were designated as shaken baby syndrome (SBS). In 97% of the cases, the assailant was known to the victim and was a family relative in 77%. Sixty-three percent of the assailants were female and 45% of the assailants were male; in 12%, the assailants were both parents, and in 1 case, the assailant remains unknown. Of the asphyxia deaths, 87% of the assailants were female. The time interval between injury and death ranged from minutes to hours in most cases to months in cases of repeated abuse and chronic injury and sequelae. The time interval between injury and the onset of symptoms remains unknown in most cases due to inconsistencies in the history and lack of credibility of the caretaker. The most common initial history given was "a fall" (20%). We report our findings of a decade of pediatric homicides to increase awareness of the common scenarios and case histories, demographics of the victims, causes of death, and perpetrators of pediatric homicide.     

Homicides committed by youth assailants: a retrospective study

The pediatric population has received considerable attention in the forensic community; the youth assailant of homicide, however, is understudied. The authors retrospectively reviewed all cases referred to the Forensic Pathology Section of the Medical University of South Carolina between January 1991 and May 2006. Cases included in the study were homicides in which 1 or more assailants were 19 years of age or younger. The cases were examined as to the cause and manner of death, victim age, gender, race, incident location, weapon used, assailant-victim relationship, assailant age, gender, race, motive, and postmortem toxicology results. Assailant information was obtained from forensic records at Medical University of South Carolina, police department records, and online search engines of South Carolina State newspaper archives confirmed by law enforcement reports. The youth assailants were predominantly black men, 15 to 19 years of age (range, 4-19 years). Most victims were black male acquaintances, and the motive was most often an argument. The most common cause of death was cerebral laceration because of a gunshot wound. The incident occurred in the home in 41% of cases, followed by the street in 31%. Victim toxicology was frequently positive for cocaine, marijuana, and alcohol.     

Unexpected natural death secondary to intra-abdominal bleeding: report of one idiopathic spontaneous intraperitoneal hemorrhage case

A 39-year-old woman was found dead at home. She was single, foreign national, chronic alcoholic, and had given shelter to a compatriot for three days. This man found the deceased in her bed, after a night of heavy drinking. The emergency medical team observed numerous recent blue ecchymoses of the upper limbs. Because of the unclear circumstances, a medicolegal autopsy was ordered by the public prosecutor. Massive hemoperitoneum was diagnosed with no visible internal traumatic injury. Autopsy revealed hepatic and pancreatic abnormalities secondary to chronic alcoholism, which were confirmed by pathological study. The source of the hemoperitoneum was not identified despite careful visceral and vascular examination. The authors concluded that death was secondary to idiopathic spontaneous hemoperitoneum or abdominal apoplexy. The forensic literature on unexpected death due to massive nontraumatic intra-abdominal hemorrhage in association with liver cirrhosis is sparse, with only five cases reported, including the present case.     

Urine/blood ratios of ethanol in deaths attributed to acute alcohol poisoning and chronic alcoholism

The concentrations of ethanol were determined in femoral venous blood (BAC) and urine (UAC) and the UAC/BAC ratios were evaluated for a large case series of forensic autopsies in which the primary cause of death was either acute alcohol poisoning (N=628) or chronic alcoholism (N=647). In alcohol poisoning deaths both UAC and BAC were higher by about 2g/l compared with chronic alcoholism deaths. In acute alcohol poisoning deaths the minimum BAC was 0.74 g/l and the distribution of UAC/BAC ratios agreed well with the shape of a Gaussian curve with mean+/-standard deviation (S.D.) and median (2.5th and 97.5th centiles) of 1.18+/-0.182 and 1.18 (0.87 and 1.53), respectively. In alcoholism deaths, when the BAC was above 0.74 g/l (N=457) the mean+/-S.D. and median (2.5th and 97.5th centiles) UAC/BAC ratios were 1.30+/-0.29 and 1.26 (0.87 and 2.1), respectively. When the BAC was below 0.74 g/l (N=190), the mean and median UAC/BAC ratios were considerably higher, being 2.24 and 1.58, respectively. BAC and UAC were highly correlated in acute alcohol poisoning deaths (r=0.84, residual S.D.=0.47 g/l) and in chronic alcoholism deaths (r=0.95, residual S.D.=0.41 g/l). For both causes of death (N=1275), the correlation between BAC and UAC was r=0.95 and the residual S.D. was 0.46 g/l. The lower UAC/BAC ratio observed in acute alcohol poisoning deaths (mean and median 1.18:1) suggests that these individuals died before absorption and distribution of ethanol in all body fluids were complete. The higher UAC/BAC ratio in chronic alcoholism (median 1.30:1) is closer to the value expected for complete absorption and distribution of ethanol in all body fluids.     

Post mortem markers of chronic alcoholism

We compared the post mortem diagnostic value of γ-glutamyltransferase (GGT), carbohydrate-deficient transferrin (CDT), alcoholic liver disease (ALD), blood alcohol concentration (BAC), the presence of multiple bruises and poor hygiene of the feet as markers of chronic alcoholism (heavy continuous drinking) in 32 alcoholics with 32 age-sex matched controls drawn from a forensic autopsy population. Alcoholics and controls were selected on the basis of positive and negative medical history but controls were excluded if BAC exceeded 70 mg%. Femoral venous blood, urine and vitreous humour alcohol concentrations were determined by headspace gas chromatography (GC). BAC was positive in 19 alcoholics (mean 234 mg%, range 2–570 mg%) and six controls (mean 32 mg%, range 2–52 mg%). Serum GGT was measured by a kinetic photometric method, and CDT by both isoelectric focusing/laser densitometry and by a commercial radioimmunoassay kit (CDTect^™). Features of alcoholic liver disease were graded histologically using two weighted scoring systems. Eleven alcoholics tested positive for GGT, CDTq and ALD, nine were positive for two tests, five for one test and three were negative for all three tests. No controls were positive for all three tests but six were positive for two tests and nine for only one test; 17 were negative for all three tests. Using the normal clinical cut-off values GGT, CDTq and CDTect^™ gave poor specificity which was improved at moderate cost to sensitivity by raising cut off values for each test. Comparison of receiver operating characteristic curves, likelihood ratios and post-test odds showed CDT to be the best individual test, followed by ALD and GGT. Quantitation of CDT by IEF/laser densitometry performed slightly better than MAEC/RIA by CDTect^™. CDT shows considerable promise as a post mortem marker of chronic alcoholism.