Undetermined Manner of Death: An Autopsy Series

A manner of death may be ruled undetermined by the forensic pathologist when there is insufficient information about the circumstances surrounding the death to make a ruling. The aim of our study was to retrospectively analyze a series of autopsy cases that were classified as undetermined manner of death after complete investigations. In all, 48 cases were examined. In 23 cases (48%), the cause of death was determined. The most frequent cause of death was toxic death (n = 11). More than one manner of death was deemed conceivable for most cases (n = 39). The most frequent and the most probable manner of death was accident (n = 37). Homicide was not excluded in about 23% of the cases. Our study showed that the manner of death may remain undetermined despite an established cause of death, and even when two or more conceivable causes of death are considered. Our study pointed out that undetermined manner of death covers a wide range of situations and that homicide may be underestimated.     

Screening of milk aspiration in 105 infant death cases by immunostaining with anti-human alpha-lactalbumin antibody.

To determine the frequency and degree of milk aspiration in infant death cases, immunohistochemical examinations were performed on lung sections from 41 sudden death cases and 64 in-hospital death cases using anti-human alpha-lactalbumin antibody. Milk aspiration to some degree was detected in more than half of the sudden death cases and in about one-third of the in-hospital death cases. A semi-quantitative examination of the amount of aspirated milk was subsequently performed in the positive cases. The amount of aspirated milk in the sudden death cases was significantly higher than that in the in-hospital death cases. The frequency distribution of the amount of aspirated milk was similar in shape in both groups. In most cases, a very small amount of aspirated milk was detected. The aspirated milk was assumed to be a result of occasional gastroesophageal reflux or cardiopulmonary resuscitation. However, in five cases, much larger amounts of aspirated milk were found. In these cases, milk aspiration may have been an important part of the cause of death. We concluded that slight milk aspiration is not rare in infant death cases, and that in a few cases, the aspiration is lethal. An immunohistochemical screening test is available to perform a postmortem diagnosis in these cases.     

Postmortem behavior of the rheobase

Own investigations on the postmortem rise of muscular threshold were conducted on 20 bodies with exactly known time of death. Muscular contraction was objectified using a sensitive force transducer. The muscle was excitated using rectangular impulses of 1 second duration of a current intensity which produces a force of muscular contraction of 2.5 mN. These excitations were continued over the postmortem interval until a current intensity of 80 mN doesn't cause a contraction of 2.5 mN any more. Investigations were mainly performed at the thenar muscles. There is a linear relationship between ln of muscular threshold (current intensity) and the time since death (r = 0.965). For any case the linear regression line between ln of muscular threshold and time since death was calculated. With mean values for slope and intercept the time of death was calculated for each measured threshold. Extrapolation of the time since death with mean values also for the slope reveals a much more precise estimation of the time since death than an extrapolation with an individual slope as proposed by Joachim and Feldmann (1980). The method was proved on a random sample of 8 practical cases. The real time since death was always within the 95%-limits of confidence of the extrapolated time since death.     

Validation of diagnoses on death certificates for male alcoholics in Stockholm

The mortality and the causes of death have been studied in a cohort consisting of 1548 male alcoholics in Stockholm. During the period 1969-1981 there were 542 cases of death in this population. The mortality rates were triple those for males in Stockholm generally. Using the official causes of death there was a highly significant excess mortality in the following diagnostic groups: Cancer in the upper digestive region, primary hepatic cancer, cirrhosis in the liver, pancreatitis, pneumonia, alcoholism and alcoholic poisoning, suicides and other causes of violent death as well as ischemic heart disease. The underlying and contributing causes of death on the death certificates were reclassified according to ICD-rules using clinical records and autopsy protocols. It was found that the underlying cause of death was incorrect in 21.8% of the cases. Important information was withheld in further 19.8%. After validation there was no longer any excess mortality in ischemic heart disease. The number of alcohol-related diagnoses, i.e. alcoholic cardiomyopathy, cirrhosis and fatty liver with alcoholism and alcoholic intoxication, was much greater. It is concluded that there is a underreporting of alcohol-related diseases and injuries which has a great influence on the reliability of death statistics.     

Accuracy of cause of death determination without forensic autopsy examination

Medical examiners and coroners commonly determine cause and manner of death without an autopsy examination. Some death certificates generated in this way may not state the correct cause and manner of death. From the case files of the Department of Forensic Medicine in Sydney, Australia, the authors retrospectively reviewed investigative information of all cases in a 6-month period that were initially considered natural deaths (429). The authors, blinded to autopsy results, accepted 261 cases as appropriate for certification without autopsy and assigned a cause of death to each. Per standard local practice, all cases had been autopsied. The actual causes of death as determined by autopsy were then revealed and compared with the presumed causes of death. Most presumed and actual causes of death were cardiovascular (94% and 80%, respectively). The majority of presumed causes of death were listed as ASCVD as the cases lacked features of a more specific cardiovascular process. A large majority of cases had a presumed cause of death of ischemic heart disease based on individual case details. The actual causes of death demonstrated a large breadth of cardiovascular and noncardiovascular disease processes, even though ischemic heart disease accounted for 62% of deaths. The presumed cause of death was completely wrong in 28% of cases. A nonnatural manner of death was present in 3% of cases. This study demonstrates that experienced forensic pathologists may generate erroneous death certificates for cases that are not autopsied.     

Pesticide poisoning initially suspected as a natural death

A pesticide poisoning victim suspected initially as having died a natural death was autopsied. The victim was a 47-year-old male. Macroscopically, signs of acute death and, in particular, general erosion in the mucosa of the airways and esophagus were observed. In the gastric contents, which had a pungent smell and a greenish-brown color, 5.00 g/L of propanil, 1.27 g/L of carbaryl, 0.38 g/L of ethylbenzene, and 0.32 g/L of xylene were detected. In the blood (serum), 21.6 mg/L of propanil, 8.1 mg/L of carbaryl, 1.7 mg/L of ethylbenzene, and 4.0 mg/L of xylene were identified. Postmortem methemoglobinemia (45%) was recognized. The cause of death was considered to have been pesticide poisoning; propanil was probably most responsible for his death. The police considered the case to be "death with illness as the suspected cause." By performing an autopsy, however, we were able to clarify that the cause of death was pesticide poisoning.     

The value of the hospital autopsy. A study of causes and modes of death estimated before and after autopsy

Among 312 consecutive deaths in a Danish Central Hospital autopsy was performed in the pathology department on 266 cases, i.e. 85%. Retrospectively, the underlying causes of death were estimated from the clinical information alone by an experienced clinician and subsequently compared with the autopsy report. The definite cause of death was determined jointly by the clinician and the pathologist. The clinician's diagnosis was thereby confirmed as incorrect in 18% of the cases if small differences in site and type of malignant tumours were not considered. This is less than in many other investigations, but it is stressed that this could partly be because formal errors in completing the death certificate were avoided. The main causes of death were ischaemic heart disease and neoplasia. Clinical diagnosis of malignant diseases was never found to be erroneous. There was a slight tendency to clinically overestimate ischaemic heart disease, but in general the different errors outweighed each other, so that the total number of different causes of death before and after autopsy was nearly the same. The original death certificate was investigated in 12 accidental cases. Hereby it was found that the mode of death was originally stated erroneously as natural in 7 cases, i.e. 4.5%. It is concluded that hospital autopsy is still needed for the control and correction of causes of death, and it is stressed that clinicians as well as pathologists should be more aware of cases with a trauma in the history to avoid errors in the mode of death. Such errors can imply legal as well as insurance problems.     

The use of mental status in death certification of suicide

A 5-year study (1982-1986) illustrates the use of mental status in death certification of suicide in 182 consecutive cases from Marion County, Oregon, U.S.A. The presence of specific mental illness was documented in Part II of the filed death certificate whenever sufficient data supported such a diagnosis. This study represents, so far as we are aware, the first use of mental illness in the routine death certification of suicide. The study subjects were described in terms of sex; age group; the presence or absence of a suicide note; the anatomical cause of death (Part I of the death certificate); and the presence of mental illness, severe physical illness, or alcohol abuse (Part II of the death certificate) as contributive to the death. About half (97 of 182 = 53.30%) of the study group was diagnosed as suffering from a major affective disorder. Another portion (18 of 182 = 9.89%) was classified as schizophrenic. A subgroup of 18 men, all of whom were residents of state mental or correctional institutions at the time of death, was also briefly described.     

Death penalty attitudes and the tendency to convict or acquit

Three studies examined whether attitudes toward the death penalty were related to conviction or acquittal proneness. They were not, even in a case where it was clear that the prosecution was asking for death. Two questions asked whether attitudes toward the death penalty were related to changes in the threshold of guilt or in the amount of evidence required to find guilt when death as compared to life imprisonment was the potential sentence. They were so related, but answers to such questions were unrelated to verdicts in a death case. In one study, strong opponents of the death penalty were no different from others in attitudes toward attorneys and witnesses, in recollection of the facts of a trial, or in their subjective impressions about the trial. The basis of any attitude-behavior relation in this area is questioned.     

The murderer is the bed: an unusual case of death by traumatic asphyxia in a hotel folding bunk bed

This paper presents the first referenced case on a death by traumatic asphyxia in a folding bunk bed. A middle-aged man was found dead in a hotel room trapped into a lower folding bunk bed where he had been sleeping after a party. The autopsy showed signs of asphyxia and excluded signs of struggle and sexual intercourse. Toxicological analyses revealed alcohol intoxication. A differential diagnosis of the manner of death including a technical study of the bed which contributed to understand the circumstances of death was made. The medico-legal investigation of the case strongly supported the hypothesis of an accidental death by traumatic asphyxia.     

Suicide on death row

The suicide rate on death row for the period 1976 through 1999 was found to be high (113 per 100,000 per year), some five times higher than the suicide rate for the male population of the United States. The death row suicide rate was predicted by features of the death row population (negatively with the population on death row) and by social indicators of the society as a whole (negatively with birth and divorce rates and positively with marriage rates).     

Sudden death resulting from lesions of the cardiac conduction system

Sudden unexpected deaths in young persons with noncontributory histories, autopsy results, and drug screen results are a common problem in forensic pathology. As part of the evaluation of such cases, the cardiac conduction system (CCS) should be studied. To determine the type and incidence of lethal CCS lesions, the authors reviewed their files of sudden unexpected cardiac deaths with particular attention to cases with causes of death in the conduction system. Cases of sudden cardiac death in patients aged < or=40 years during a 10-year period (Michigan) and a 4 year-period (Spain) were selected from the files. From this group, cases were identified in which the cause of death was a lethal change in the CCS. The portions of the heart containing the CCS were excised, and at least one hematoxylin and eosin slide and at least one trichrome or elastic trichrome slide per block were studied. In the two centers, 381 cases of sudden cardiac death were identified. The most common causes of sudden cardiac death were arteriosclerotic narrowing of the coronary arteries, cardiomyopathy, and myocarditis. In 82 cases, there was no identifiable cause of death even after complete gross and microscopic autopsy was performed, a medical history was obtained, and a drug screen was performed. In 11 cases, the CCS contained lesions that were considered lethal: narrowing of the atrioventricular node artery by fibromuscular hyperplasia (7 cases) and atrioventricular node tumors (4 cases). The 11 cases accounted for 2.9% of the 381 cases of sudden cardiac death and 11.8% of the indeterminable cases. It was concluded that examination of the CCS in deaths in which the gross and microscopic autopsy, history, and drug screen fail to provide a cause of death can yield a cause of death in a significant percentage of cases. If heart block was not documented during life and no explanatory lesions were found during routine cardiac examination, examination of the CCS can yield valuable information.     

How Strong Is Public Support for the Death Penalty in Singapore?

Singapore is well known internationally for its uncompromising stance towards law and order and its use of the death penalty in particular for murder and drug trafficking. Until 2012, it was one of the few countries in the world where the death penalty was mandatory for persons convicted of these two crimes. The law was amended in 2012 to give a judge the choice to impose the death penalty or life imprisonment (with caning) for non-intentional murder and drug trafficking in some situations. What do Singaporeans think of the use of the death penalty in their own country? This article reports on some findings of a survey conducted in 2016 on 1500 Singaporeans to assess their knowledge and support of the death penalty.     

Why We Need Postmortem Analysis of Cardiac Implantable Electronic Devices

The prevalence of cardiac implantable electronic devices (CIEDs), pacemakers and implantable cardioverter defibrillators (ICDs) is increasing. However, postmortem analysis of CIEDs is not performed routinely. Fourteen consecutive CIEDs were analyzed. The indication for and date of implantation, technical data, CIED reprogramming, heart rhythm disturbances, patient demographics and medical consultations were investigated. Death during the first year after implantation was seen in 54%, whereof 71% consulted a physician within 10 days before death. The time of death was attributed to a particular day in 29%. There was a relationship between CIEDs and cause/manner of death in 50%. Although limited by a small sample size, this study advocates the routine postmortem CIED analysis for forensic and clinical purposes in selected cases. Patients with CIEDs seem to show an increased risk of death during the first year after implantation. The analysis of CIEDs can be helpful in evaluating the time/cause/manner of death.     

Analysis of gastrocnemius compound muscle action potential in rat after death: significance for the estimation of early postmortem interval

The estimation of postmortem interval is of great importance in forensic medicine. Changes in the properties of excitable tissue provide another possible means by which the time of death can be estimated. This paper reports the monitorization of the compound action potentials recorded from gastrocnemius muscle by means of sciatic nerve stimulation in rats before and after death. The sciatic nerve was stimulated using rectangular impulses of 0.1ms duration and intensities ranged between 1 and 100mA while the rat was alive. Subsequently, the rat was killed by cervical dislocation. The similar measurement procedure was performed at the moment of death and every 5min after sequentially. There was a progressive decline in amplitude values that began 10min after death. The decrease in the amplitude of the compound muscle action potentials (CMAP) was most prominent especially when elicited with lower stimulus intensities. The mean area of the CMAPs also began to decrease beginning from 15min after death. Fifteen minutes after death, the motor latencies began to prolong. Thirty-five minutes after death, the decline in amplitude and area of mean CMAP was most prominent as the mean motor latency. At the 40th minute, most of the CMAPs were unelicitable. During the early postmortem interval, these amplitude, area and motor latency alterations decrease in the amplitude and area, prolongation of motor latency seems to be well correlated with each other and this was statistically significant. These findings are discussed as possible basis of a forensic method for postmortem interval estimation.     

类胰蛋白酶和IgE测定在过敏性猝死诊断中的应用研究

目的探讨过敏性猝死法医学鉴定的诊断方法和指标。方法采取10例正常人、9例过敏性猝死和19例其他死因（排除过敏反应、冠心病）尸体的静脉血，采用荧光酶联免疫法（Pharmacia UniCAP100过敏原定量分析仪）和酶联免疫吸附试验ELISA法分别测定血清肥大细胞类胰蛋白酶和]gE含量，采用免疫组化方法观察过敏性猝死和其他死因的肺组织中的肥大细胞类胰蛋白酶免疫组化染色。结果过敏性猝死者的血清类胰蛋白酶和IgE含量升高，与其他死因之间的差异具有显著性意义（P〈0．01），其他死因和正常人之间的差异无统计学意义（P〉0．05）；与其它死因相比，过敏性猝死肺组织中的肥大细胞类胰蛋白酶免疫组化阳性染色增强（P〈0．01）。结论过敏性猝死者血清IgE和肥大细胞类胰蛋白酶含量显著升高；过敏性猝死者肺组织中肥大细胞类胰蛋白酶染色增强。     

Cardiac Inhibitory Reflex as a Cause/Mechanism of Death

The role of cardiac inhibitory reflex as a potential cause of death is still a matter of debate. This study reports two cases of death under unusual circumstances. Case 1 corresponds to a man found hanging where the role of ligature compression of the carotid sinus became relevant as a possible explanation of death. In Case 2, the participation of a vasovagal syncope was clearly triggered by the laryngoscopic procedure. It is proposed that cardiac inhibitory reflex should be taken into account in those cases of unexpected death, which fulfills the following three criteria: (i) The investigation of the circumstances of the death is consistent with a hypothesis of cardiac arrest. (ii) A typical triggering peripheral stimulus is present. (iii) The performance of a complete autopsy cannot rule out the participation of a cardiac inhibitory reflex in the cause of death.     

Sudden death in a 35-year-old man with occult malformation of the brain and aseptic meningitis

A 35-year-old man was found dead by his wife. He was reported to have had symptoms of a common cold the week preceding his death. The medicolegal autopsy yielded signs of central dysregulation (ectasia of the urinary bladder and rectum, dystelectasis of the lungs) together with marked brain edema and fresh bite marks on the tongue. The cause of death was presumed to be lethal epileptic seizure. Neuropathologic examination revealed neuronal nodular heterotopia as well as discrete lymphocytic meningitis (aseptic meningitis). The death was most probably caused by the combination of the meningitis with the occult malformation, leading to a lowered seizure threshold and subsequent lethal seizure. The morphologic findings of this case are presented, and the probable mechanisms of death are discussed.     

Cardiac rhabdomyoma presenting as sudden infant death syndrome

A case of cardiac rhabdomyoma presenting as sudden infant death in a four-and-one-half month-old infant is reported. The child was the product of an essentially uncomplicated pregnancy and enjoyed good health before his unexpected, sudden death. Autopsy examination revealed the presence of multiple cardiac lesions which histologically were diagnosed as rhabdomyomas. Death was attributed to fatal cardiac arrhythmia caused by the tumor. To the authors' knowledge this represents the first reported case in the forensic science literature of death as a result of cardiac rhabdomyoma presenting as sudden infant death syndrome (SIDS).