Establishing the cause of death in finding a corpse on a flight of stairs

A total of 793 forensic medical conclusions concerning corpses found in vestibules are analyzed. The circumstances of death were unknown in the majority of cases. Causes other than injuries were responsible for the majority (72.4%) of deaths: coronary diseases, hanging, alcohol intoxication, or general hypothermia. Strikes with blunt objects and falling on the staircase or floor rank second among causes of death. Injuries caused by falling from staircase and cases with this cause suspected were responsible for 9.6% deaths. Murders with acute objects and guns were recorded in 6% cases. For facilitating differential diagnosis, a list of signs and injuries occurring as a result of falling from staircase and main causes of death in such injuries, made with consideration for the place where the corpses are found, is offered.     

191例急死死因分析

本文对191例急死法医病理检案资料进行统计分析，结果表明急死年龄以15～59岁为多，共154例（占80．63％）。死因以心血管系统疾病为多，80例（占41．88％），但5岁以下以呼吸系统疾病为多；在191例急风中，以冠状动脉疾病最多，共55例（占28．80％），其次为小叶性肺炎21例（占10．99％）和急性出血性胰腺炎（12例占6．28％）。死亡诱因多为纠纷／或轻微外伤87例（占45．55％），另有51例（占26.70％）死前有轻微临床症状体征，经医生诊治用药后很快死亡，从而引发医疗纠纷。     

Littre hernia--a rare cause of unexpected death in the elderly

A rare case of sudden and unexpected death is reported in an 87-year-old woman who was found dead at her home. At autopsy, the most striking finding was of a right-sided direct inguinal hernia containing a 20 mm infarcted Meckel diverticulum, with proximal small intestinal obstruction. Significant stenosing atherosclerosis was present in all three major epicardial coronary arteries, but with no histological evidence of acute or chronic ischemic myocardial damage. Death was attributed to small intestinal obstruction due to direct inguinal herniation (and infarction) of a Meckel diverticulum (a Littre hernia), complicating ischemic heart disease. Although Littre hernias are not a reported cause of sudden death in the elderly, congenital gastrointestinal anomalies may rarely play a significant role in terminal episodes well beyond childhood years. The autopsy assessment of sudden death at any age involves detailed examination of the entire length of the intestinal tract.     

Schizophrenia as a cause of death

Schizophrenia is a chronic disorder that is associated with increased mortality. Although traumatic deaths account for most of this increase, there is also an increased rate of natural deaths in this population. Altered autonomic physiology in this group might contribute to death. To determine if there are schizophrenics in whom, after a complete autopsy, no recognizable cause of death other than schizophrenia is established, the records of the Office of Chief Medical Examiner of the City of New York were reviewed for deaths associated with schizophrenia and a natural manner of death. Six such decedents were identified, and their histories and autopsy results are described. We believe that schizophrenia per se is a potentially lethal disorder. Autonomic irregularities and their interactions with psychotropic drugs deserve further attention.     

Morbidity and cause of death in homeless persons

The Hamburg Institute of Forensic Medicine analysed 388 deaths of homeless people between 1990 and 1998 considering demographic data, post-mortem results and autopsy findings. The manner of death was either unnatural or unascertained; the autopsy rate amounted to 43.8%. The results confirm the observation discussed in the last few years that homeless people are usually in a poor state of health. In relation to the average age of death, which is 44.5 years, the number of previous diseases is high. Unnatural causes (excluding homicides) account for a high percentage, viz. 62.6%, primarily intoxications. The most frequent natural cause of death is infection (16.8%). Women account for 8.5% of the deaths with their organ findings and causes of deaths being different from those of homeless men in terms of distribution and incidence. The data presented in this report may be helpful for the improvement of the present system of medical help in Hamburg.     

Postmortem serum catecholamine levels in relation to the cause of death

Catecholamines are major humoral factors and neurotransmitters that contribute to various stress responses. However, they have been considered unstable due to agony, terminal medical care and postmortem interference. The present study was a comprehensive investigation of postmortem serum levels of adrenaline (Adr), noradrenaline (Nad) and dopamine (DA) with regard to the cause of death in serial medicolegal autopsy cases (n=542) including fatalities from various traumas and diseases. There was a slight tendency toward postmortem increases of Nad and DA in cardiac blood as well as Adr and Nad in peripheral blood, a slight age-dependent decrease in Adr and DA in right heart blood, and a marked increase in serum DA due to administration during critical medical care. When these factors were taken into consideration, significantly higher cardiac blood levels were observed for Adr and Nad in injury and asphyxiation cases and for Adr in fatal methamphetamine (MA) abuse and other poisoning cases, whereas those levels were lower in fatal hypothermia. Drowning, fire fatality, acute cardiac death and cerebrovascular disease showed intermediate Adr and Nad levels. The DA level was elevated in cases of injury, hyperthermia, MA fatality and other poisoning. Topographical analyses suggested that the major sources of increased serum catecholamines in cases of injury was abdominal viscera including adrenal glands, and that in cases of asphyxiation, drowning, fire fatality, hyperthermia, MA fatality, other poisoning, acute cardiac death and cerebrovascular disease was the extremities in addition to abdominal viscera. However, there was in part a large case-to-case difference in each marker related to individual causes of death. These findings differed markedly from clinical observations and suggest that the postmortem serum catecholamine levels may reflect the magnitude of physical stress responses during the process of death in individual cases.     

Gas embolism as a cause of death

Systemic venous gas embolism other than that due to air is a great rarity. A case is reported and the criteria for the diagnosis are discussed. The clinical similarities between embolism of systemic venous air and that of systemic venous gas are emphasized. The two conditions can be differentiated by laboratory investigation only.     

Hypothermia: a natural cause of death

Deaths due to hypothermia are usually accidental and are the result of exposure to extreme environmental temperatures. Often these individuals are intoxicated, elderly, or exposed to severe cold temperatures. We report the case of a blind, nonambulatory, elderly man who was found alive in his home in an unresponsive state. Core body temperature at hospital was 24 degrees C (75 degrees F). At autopsy, punctate hemorrhages were present in the stomach mucosa. A 4- x 7-cm pituitary adenoma extended from a dilated sella turcica, obliterated the optic chiasm, and compressed the base of the brain in the region of the hypothalamus. Compression in this region of the brain would disrupt the temperature regulatory function of the hypothalamus and create an individual who would be susceptible to minor fluctuations in ambient temperature. The manner of death was designated as natural. This is an unusual presentation of a pituitary adenoma in the current era of advanced imaging techniques in which microadenomas are often detected and treated.     

An unusual cause of sudden child death

Since the rise of HIV/AIDS in Sub-Saharan Africa, there has been a massive promotion of condom use. Unfortunately, this promotion has not always been accompanied with instructions for safe use. In this case report, we describe a small child who aspirated a condom and subsequently died.     

Ascertainment of the cause and tempo of death in forensic medical practice

In order to develop a method of ascertaining a cause of death and of evaluating its tempo the authors undertook a histological study and a study of a dehydration degree in 76 cases of death due to the below reasons: mechanical trauma, mechanical asphyxia, burn shock, and carbon monoxide intoxication. Acute emphysema of lungs, lack of edemas in lungs and brain, desquamation of pulmonary macrophages, hyperemia of renal capillaries, primary urine in some glomerules, prevalence of ischemic changes with karyopyknosis in medulla and hypohydration of brain were typical of fast death. Prevalence of dystelectasis in lungs, emptying of pulmonary capillaries, evident edema of lungs and brain, desquamation of pulmonary macrophages, lack of primary urine in glomerular capsules, acute circulatory disorders of renal hemodynamics with sweating of fibrin and erythrocyte glomerules into cavities, necrotic nephrosis, pigment cylinders in renal tubules, thrombi in vessels, prevalence of chromatolysis, karyolysis and cytolysis in medulla, pronounced glial reaction as well as pronounced edema of brain and its hyperhydration were typical of slow death.     

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.     

Homicide as a cause of the sudden infant death syndrome

The homicidal asphyxiation of a 10 1/2-month-old male infant and the attempted asphyxiation of his 4-month-old sibling, documented by parental confession, is presented as evidence that murder may sometimes be mistaken as sudden infant death syndrome (SIDS). A review of the literature of the relationship between murder and SIDS deaths reveals the suspicions of some physicians but few published cases; this reflects not only the difficulties of making a determination of murder by suffocation, since no injuries may be present, but also a lack of awareness among physicians who must evaluate infant deaths. It is recommended that murder should be considered in the differential diagnosis of sudden, unexpected death in infants and that the autopsy should include full-body x-rays and at least an initial look at the social history of the child.