[Complex suicides--a review of the literature]

The term "complex suicide" stands for suicides committed by using more than one method. A distinction can be made between planned and unplanned complex suicides (primary/secondary combinations). In planned complex suicides 2 or more methods are applied simultaneously in order to make sure that death will occur even if one method fails. In unplanned complex suicides the mode of performance is changed after the first method chosen failed or was working too slow or proved to be too painful. In planned complex suicides typically two of the generally common methods of suicide (e.g. ingestion of medicines, hanging, use of firearms, drowning, fall from a height) are combined. But also unusual combinations have been described such as the simultaneous firing of two guns, self-immolation in combination with other suicide methods or shooting oneself while driving a car. In unplanned complex suicides self-inflicted injuries by sharp force, especially cuts of the wrists, are often found as the primary act of suicide. In some cases the suicide switches from cuts to stabs (mostly to the heart region). Other methods often used after the first phase of suicide are hanging and jump from a height. In the literature the use of up to 5 suicidal methods applied one after the other have been described.

Prognostic factors in hanging injuries

The objectives of this study were to review variable factors influencing outcomes in hanging and to identify prognostic factors related to outcomes. Forty-seven patients presented to our department. Eleven patients survived and 36 died. A significant difference in mean hanging time was observed between survivor (11.8 +/- 8.37 minutes) and nonsurvivor (50.81 +/- 61.9). In survivors, heartbeat was recognized in 63.6% at the scene and in 90.9% on arrival. Conversely, cardiopulmonary arrest (CPA) was recognized in all nonsurvivors and heartbeat was recognized on arrival in only 5.6%. Thirty-nine (83%) had a Glasgow Coma Score (GCS) of 3 on arrival. Three (7.7%) of theses 39 patients survived. In survivors, eight patients had a GCS greater than 3. A significant difference in outcome existed between patients with a GCS of 3 and those with a GCS greater than 3. Hanging time, presence of CPA at the scene and on arrival, and GCS on arrival represented prognostic factors of outcome in hanging.

A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest

BACKGROUND

When efforts to resuscitate a child after cardiac arrest are unsuccessful despite the administration of an initial dose of epinephrine, it is unclear whether the next dose of epinephrine (i.e., the rescue dose) should be the same (standard) dose or a higher dose.

METHODS

We performed a prospective, randomized, double-blind trial to compare high-dose epinephrine (0.1 mg per kilogram of body weight) with standard-dose epinephrine (0.01 mg per kilogram) as rescue therapy for in-hospital cardiac arrest in children after failure of an initial, standard dose of epinephrine. The trial included 68 children, and Utstein-style reporting guidelines were used. The primary outcome measure was survival 24 hours after the arrest.

RESULTS

The rate of survival at 24 hours was lower in the group assigned to a high dose of epinephrine as rescue therapy than in the group assigned to a standard dose: 1 of the 34 patients in the high-dose group survived for 24 hours, as compared with 7 of the 34 patients in the standard-dose group (unadjusted odds ratio for death with the high dose, 8.6; 97.5 percent confidence interval, 1.0 to 397.0; P=0.05). After adjustment by multiple logistic-regression analysis for differences in the groups at the time of arrest, the high-dose group tended to have a lower 24-hour survival rate (odds ratio for death, 7.9; 97.5 percent confidence interval, 0.9 to 72.5; P=0.08). The two treatment groups did not differ significantly in terms of the rate of return of spontaneous circulation (which occurred in 20 patients in the high-dose group and 21 of those in the standard-dose group; odds ratio, 1.1; 97.5 percent confidence interval, 0.4 to 3.0). None of the patients in the high-dose group, as compared with four of those in the standard-dose group, survived to hospital discharge. Among the 30 patients whose cardiac arrest was precipitated by asphyxia, none of the 12 who were assigned to high-dose epinephrine were alive at 24 hours, as compared with 7 of the 18 who were assigned to a standard dose (P=0.02).

CONCLUSIONS

We did not find any benefit of high-dose epinephrine rescue therapy for in-hospital cardiac arrest in children after failure of an initial standard dose of epinephrine. The data suggest that high-dose therapy may be worse than standard-dose therapy.

[Death due to unusual position of the body--an explanationfor the consequence of reduced venous reflux to the heart]

The article describes the case of a 29-year-old woman who was found dead in her apartment on a bar stool with the body being maximally retroflected in the lumbar region, the head hanging down and the feet and hands barely touching the floor. On external inspection of the body the cuff-like distribution of hypostasis on the forearms and lower legs was consistent with the position in which the body was found. There were no signs of foreign intervention. At autopsy massive congestion was found in the internal organs as well as pulmonary and cerebral edema. In the ventral region of the lumbar intervertebral discs superficial hemorrhages were detected. The alcohol content was 3.40 per thousand in the blood and 4.43 per thousand in the urine. As the essential pathogenetic mechanisms responsible for death reduced venous reflux to the heart in combination with postural asphyxia and the influence of alcohol are discussed.

Trends in hanging and firearm suicide rates in Australia: substitution of method?

This study examined the increase in the rate of suicide by hanging and an apparently simultaneous decrease in the rate of suicide by firearm as hypothetical evidence that Australian males have substituted one method of suicide for another. Trends in hanging and firearm suicide rates were examined from 1975 to 1998 for all Australian males and from 1971 to 1998 for a subset of Australian male youth, as well as a group of Australian males aged over 64 years at the time of their death. When the firearm suicide rate for Australian males declined the hanging rate increased simultaneously, with no statistical difference in the rate of change of the two methods. A similar pattern of simultaneous divergence in hanging and firearm suicide rates of a 15- to 24-year-old subgroup occurred at a not dissimilar rate over a longer time period. Rates of suicide by hanging were found to have begun increasing prior to the decline in firearm suicide. The declining rate of firearm suicide in the 15- to 24-year-old subgroup coincided with an increase in the overall suicide rate. Relationships between trends in hanging and firearm suicide differed between states and between urban and non-urban areas within Queensland, with the firearm suicide rate falling more rapidly in urban areas, especially following the introductions of restrictions to weapon purchases. Individual suicide method choice may be related to independent changes in the social acceptability of each method, as well as to an increasing prevalence of suicide in younger males, who are more likely to use the hanging method. The functioning and effect of social acceptability remains unclear, however. Intervention and prevention strategies should focus on challenging the social acceptability of hanging, especially among males aged 15 to 24 years.

[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.

Are seasonalities in suicide dependent on suicide methods? A reappraisal

In general, suicide frequencies peak in spring and early summer and depict a low in autumn and winter months. Suicide seasonality is a ubiquitous phenomenon; however, recent studies have indicated that it is related particularly to violent suicide methods. We investigated differences in suicide seasonalities by suicide methods using Swiss mortality data. The suicide data were extracted from the Swiss cause of death statistics and cover the period 1969-1994. In this period 37,518 suicides (ICD-8 codes 950-959) were registered in the mortality statistics. The data were analysed by the Edwards' method, which examines unimodal sinusoidal patterns in aggregated monthly data, and by spectral analysis with disaggregated monthly data. Overall, Swiss suicide data in 1969-1994 depict the expected pattern with a peak in May and June and a low in December. However, analyses by suicide methods show that there is no common pattern. Suicide seasonalities are absent or weak in some violent as well as non-violent methods (firearms, cutting, crashing, poisoning). Even if clearly present (hanging, drowning, jumping from high places, unspecified/other), the seasonalities show distinct patterns and cycles. Apart from sinusoidal patterns, there are also outliers: in overall data as well as in most method-specific data, the December frequencies fall more than 10% below the neighbouring months. The decrease of the frequencies culminates at Christmas/New Year and then returns to average levels. Hence, the seasonality of the overall Swiss suicide frequencies is but a compound seasonality. It largely depends on specific suicide methods and different cyclical dynamics.

Hypothermia for 24 hours after asphyxic cardiac arrest in piglets provides striatal neuroprotection that is sustained 10 days after rewarming

The neuroprotective effect of hypothermia instituted after resuscitation from asphyxic cardiac arrest has not been studied in immature brain, particularly in a large animal model with recovery periods greater than 4 d. Moreover, protection from severe hypoxia seen with 3 h of hypothermia was reported to be lost when hypothermic duration was extended to 24 h in unsedated piglets, in contrast to the neuroprotection reported by 72 h of intrauterine head cooling in fetal sheep. Piglets (5-7 postnatal days) were subjected to asphyxic cardiac arrest followed by 24 h of either hypothermia (34 degrees C) or normothermia (38.5-39 degrees C). Comparisons were made with normothermic and hypothermic surgical sham animals without asphyxia. All of these groups were sedated, paralyzed, and mechanically ventilated for the first 24 h to prevent shivering and possible depletion of glucose stores. Hypothermia per se did not cause remarkable structural abnormalities. Ischemic damage was evaluated in putamen at 1 d of recovery without rewarming and at 11 d (10 d +/- SD after rewarming). Ischemic cytopathology affected 60 +/- 12% of neurons in putamen of normothermic animals compared with 9 +/- 6% in hypothermic animals at 1 d of recovery without rewarming. At 11 d of recovery from hypoxia-ischemia, the density of viable neurons (neuron profiles/mm2) in putamen was markedly reduced in normothermic animals (81 +/- 40) compared with hypothermic animals (287 +/- 22), which was the same as in sham normothermic (271 +/- 21), sham hypothermic (288 +/- 46) and naïve animals (307 +/- 51). These data demonstrate that 24 h of hypothermia at 34 degrees C with sedation and muscle relaxation after asphyxic cardiac arrest prevents necrotic striatal neuronal cell death in immature brain before rewarming, and that the effect is sustained at 11 d after injury without deleterious side effects.

Differential ranking of causes of fatal versus non-fatal injuries among US children

OBJECTIVE

Leading causes of fatal and non-fatal injury among US children aged <15 years were compared.

METHOD

A descriptive study was conducted using nationally representative data on injury related deaths (National Vital Statistics System) and on non-fatal injury related emergency department visits (IEDV; National Electronic Injury Surveillance System-All Injury Program). Data were accessed using a publicly available web based system.

RESULTS

Annually, an estimated 7100000 pediatric IEDV and 7400 injury deaths occurred. The overall non-fatal to fatal ratio (NF:F) was 966 IEDV:1 death. Among deaths, the leading causes were motor vehicle traffic occupants (n = 1700; NF:F = 150:1), suffocations (n = 1037; NF:F = 14:1), and drownings (n = 971, NF:F = 6:1). Among non-fatal injuries, falls (estimated 2400000) and struck by/against (estimated 1800000) were the most common causes, but substantially less lethal (NF:F = 19000:1 and 15000:1, respectively).

CONCLUSIONS

The leading causes of pediatric fatal and non-fatal injuries differed substantially. This study indicates the need for consideration of common causes of non-fatal injury, especially falls.

Adverse effects associated with physical restraint

OBJECTIVE

Restraint use is not monitored in the US, and only institutions that choose to do so collect statistics. In 1999, investigative journalists reported lethal consequences proximal to restraint use, making it a life-and-death matter that demands attention from professionals. This paper reviews the literature concerning actual and potential causes of deaths proximal to the use of physical restraint.

METHOD

Searching the electronic databases Medline, Cinahl, and PsycINFO, we reviewed the areas of forensics and pathology, nursing, cardiology, immunology, psychology, neurosciences, psychiatry, emergency medicine, and sports medicine.

CONCLUSIONS

Research is needed to provide clinicians with data on the risk factors and adverse effects associated with restraint use, as well as data on procedures that will lead to reduced use. Research is needed to determine what individual risk factors and combinations thereof contribute to injury and death.

Fatal unintentional traumatic asphyxia in childhood

OBJECTIVE

The present study was undertaken to examine specific features of unintentional traumatic asphyxial deaths in childhood.

METHODS

Coronial files and records at the Forensic Science Centre in Adelaide, South Australia, were examined over a 35-year period from 1966 to 2000 for all cases of traumatic asphyxial death occurring in children under the age of 17 years.

RESULTS

Six cases of unintentional fatal traumatic asphyxia were identified. All of the victims were boys with an age range of 2-15 years (mean 6.8 years) and all were found dead at the scene. Fatal traumatic asphyxia resulted from entrapment beneath a chest of drawers, beneath a table tennis table, between a pile of wooden pallets and a metal fence, between a conveyor belt and its frame, and under a motor vehicle (in two cases).

CONCLUSIONS

Fatal traumatic asphyxia in childhood is a rare event, with younger children commonly being trapped by furniture or by industrial equipment while playing, and older children being trapped under motor vehicles in similar circumstances to adult traumatic asphyxial deaths. Unsupervised play of young children around heavy and potentially unstable pieces of furniture may be dangerous, particularly if more than one child is present. Unsupervised play of young children in industrial yards should be avoided.

Contributing Factors to Engulfments in On-Farm Grain Storage Bins

Since 1978 Purdue University has maintained a national database of agriculture-related engulfment cases that have occurred in loose agricultural material in both commercial and on-farm facilities. The database presently contains 502 documented cases of fatal and non-fatal engulfments from the U.S. and Canada. A review of the more recent on-farm fatal and non-fatal engulfment cases, those occurring in 1980 through 2001, was conducted in order to characterize engulfments and identify contributing factors that would be relevant to future intervention strategy development including the implementation of design standards for on-farm structures. From 1980 through 2001, 197 cases were identified that occurred in on-farm grain bins, 156 of which were fatal and 41 were non-fatal. A rate of approximately seven fatal and two non-fatal cases per year were identified from 1980 through 2001. The magnitude of the engulfment problem is continuing, based on six and seven fatal cases reported in the years 2000 and 2001, respectively. Sixteen percent of fatal and six percent of non-fatal victims were children and adolescents under the age of 16. Fifty percent of the survivors were 60 years of age or older. Engulfments were generally reported more often in the top corn-producing states and involved corn in 76% of the fatal cases when product was known. Seventy-seven percent of the fatal victims were unloading the bin at the time of engulfment in cases where activity at the time of engulfment was known. Forty-one percent of the fatality cases involved corn that was out-of-condition where the condition of the grain was known. In survival cases where information about the presence of co-workers at the time of engulfment was known, it was found that a co-worker was present at the time of engulfment in 86% of the cases. In four cases, a survivor was rescued from a bin after being completely engulfed in grain. In all four cases, a co-worker was present at the time of engulfment and out-of-condition grain was involved. Findings are being used to design new injury prevention strategies, including educational materials and recommendations for engineering controls that focus on primary causative factors.

Mining disasters in South Africa: the Rovic Diamond Mine disaster and the criminal liability of the mine authorities

The South African economy depends heavily on the mining industry. Deep level mining--which is a very common occurrence in the South African Mining Industry, is fraught with dangers. It is therefore inevitable that these dangers will be a constant source of medico-legal involvement. At the end of November 1996, a mining disaster occurred at the Rovic Diamond Mine between Boshof and Dealsville. At about 1000 metres underground, a mudslide occurred and trapped 20 miners. Rescue workers could only retrieve four bodies. Due to the dangers of additional mudslides and collapse of the entire slope, the rescue workers were withdrawn. The 16 miners were later declared dead by a Court Order after a full investigation into the disaster was completed. In this discussion focus will be placed on the Rovic Mine Disaster Investigation, the post mortem examination of the four victims, the legal declaration of death of the other victims not found and the legal accountability of the mine authority.

Submersion and asphyxial injury

Drowning and other asphyxial injuries are important causes of childhood morbidity and mortality. In this review, the epidemiology, pathophysiology, and treatments applied to near-drowning victims are discussed, with an emphasis on the difficulties encountered attempting to predict outcome using current methods.

Toxic inhalation fatalities of US construction workers, 1990 to 1999

Construction workers account for a disproportionately large number of occupational fatalities. A small percentage of these deaths is attributable to poisoning. Risk factors for such deaths using national data have not been reported previously. Construction poisoning fatalities from 1990 to 1999 in the Occupational Safety and Health Administration Integrated Management and Information System data set were analyzed. Risk and risk factors were determined using Bureau of Labor Statistics and census data. Eighty-seven poisoning deaths of construction workers are characterized, all attributable to toxic inhalation. Cellular and simple asphyxiants accounted for the largest numbers of fatalities. The majority of these deaths occurred in confined spaces. Water, sewer, and utility line workers are at increased risk for poisoning fatality. Toxic inhalation fatalities in the construction industry are preventable. Extending the Occupational Safety and Health Administration's confined space standard could save lives, particularly among water, sewer, and utility line industry workers.

The lethal paraphiliac syndrome: accidental autoerotic deaths in four women and a review of the literature

Four previously unpublished cases of female asphyxiophilia are presented. All women were found immobilised by obviously self-tied ropes, string or handcuffs. The women, who were alone at the time of death, died of a lethal paraphilia. The autopsies revealed asphyxiation as the cause of death, caused in two cases by suffocation as a result of hanging and strangulation and in the other two cases by plastic bags placed over the individuals head. In one case there was additional evidence at the scene that the deceased had inhaled ether. In none of the four cases was there any indication that the asphyxiation was due to homicide or suicide. Thus they can be described as accidental autoerotic deaths (AAD). The four cases closely mirror findings from scenes of male AADs, although autoerotic practices are generally believed to be rarer among females than in males.

Deaths between bedrails and air pressure mattresses

OBJECTIVES

To describe how patients die by becoming trapped between therapeutic air pressure mattresses and bed rails.

DESIGN

A retrospective review of all voluntary reports deaths in beds with air mattresses that can be found in the Food and Drug Administration's on-line databases of adverse medical events that cover 1994 to 2001.

SETTING

Death reports come from manufacturers, medical staff, and coroners and describe deaths in hospitals, nursing homes, and home care, although type of care site is often not given.

MEASUREMENTS

Event descriptions were reviewed to determine how the person became entrapped in the rail and how responsibility for the event was allocated.

RESULTS

There were 35 deaths involving many product lines. Twenty-one deaths involved overlay air mattresses placed on top of a regular mattress. Thirteen patients died in beds with built-in air mattresses. Compression of the mattress allowed an off-center person to slide against the rail where reexpansion of the mattress kept the person compressed against the rail. Two patterns were seen. In one, the mattress bunched up behind a person who was lying on the side of the bed, pushing the neck against a bedrail. In the second type, a patient died after sliding off the bed and having the neck or chest compressed between the rail and bed. Manufacturers attributed the deaths to poor clinical decision-making or inadequate monitoring.

CONCLUSIONS

Lethal asphyxiation in beds with air pressure mattresses is a variant of bedrail-mattress entrapment that requires redesign by bed manufacturers and risk awareness by clinicians.

Considering suffocatory abuse and Munchausen by proxy in the evaluation of children experiencing apparent life-threatening events and sudden infant death syndrome

This study describes 138 young children admitted to the hospital over a 23 year period for recurrent apparent life threatening events (ALTEs), unexplained deaths, or with Sudden Infant Death Syndrome (SIDS)-related diagnoses. In examining the potential for suffocatory abuse in living children, we utilized characteristics in the literature that distinguish SIDS or ALTEs due to natural disease states from abuse. Findings demonstrate a co-occurrence of risk factors that raise suspicions of suffocatory abuse or Munchausen by Proxy. Of the 35 children who died, SIDS was the presumed clinical diagnosis at the time of death in 71 % of the cases. Comprehensive chart review and autopsy findings revealed a non-SIDS diagnosis in 54% and confirmed or suspicious child abuse in 37% of these deaths. Reports to Child Protective Services were made in 6% of cases. Recommendations for assessment of children including attention to risk indicators, involvement of child protection teams, mandatory autopsies, and eath scene investigations are offered.

Vasopressin and epinephrine are equally effective for CPR in a rat asphyxia model

Epinephrine has been administered as a drug essential for cardiopulmonary resuscitation (CPR). Recently, vasopressin has been reported to be more effective than epinephrine for CPR in a ventricular fibrillation (VF) model. As a different myocardial pathology is speculated to exist between the VF model and the asphyxia model, we investigated whether vasopressin is also effective in a rat asphyxia model. Twenty-one Sprague-Dawley male rats were divided into three groups: vasopressin 0.8 U/kg (Vaso-Gr), epinephrine 0.05 mg/kg (Epi-Gr), and saline same volume as the other two drugs (Sal-Gr). Five minutes after suffocation induced by obstruction of the tracheal tube, CPR was performed using each drug. Although only one animal survived (17%) in the Sal-Gr, 6/7 (85%) survived in both Vaso-Gr and Epi-Gr (P<0.01). Vasopressin is as effective as epinephrine for CPR in asphyxia-induced rats.

Avalanche trauma and closed head injury: adding insult to injury

OBJECTIVE

The incidence of fatal closed head injury (CHI) and nonfatal CHI causing an altered level of consciousness in avalanche victims is unknown. The purpose of this study was to assess the incidence and potential significance of CHI in avalanche-related deaths.

METHODS

The records of the state medical examiner and hospital records of all victims killed in avalanches in the state of Utah from October 1, 1992 through April 30, 1999 were reviewed for a cause of death and for the presence of CHI. Closed head injury was described as "present" or "severe," depending on whether the degree of CHI was sufficient to have caused or directly contributed to death, as determined by the medical examiner.

RESULTS

In this review, 28 avalanche-related deaths were identified, of which 22 (79%) were due to asphyxia. Seventeen victims (61%) had evidence of some degree of CHI. Six victims (21%) had evidence of severe CHI. One of 7 snowmobile riders sustained a severe CHI, whereas 4 of 16 skiers or snowboarders sustained a severe CHI (P = not significant).

CONCLUSION

Although asphyxiation was the cause of death in most avalanche victims, evidence of CHI was present in 61% of the cases studied. While avalanche-associated CHI may not be sufficient to cause death in many cases, a depressed level of consciousness might render a victim incapable of self-rescue and predispose to asphyxia. Helmet use may help prevent avalanche-associated CHI and thus be a useful safety adjunct.

Specific dangers associated with infants sleeping on sofas

AIM

A study was undertaken to examine specific circumstances that may lead to accidental asphyxial deaths in infants on sofas.

METHODS

Coronial files in South Australia (Australia) from 1989 to 1998, and files at the Office of the Medical Examiner in San Diego County (USA) from 1991 to 1998 were searched for all cases of infant deaths occurring on sofas.

RESULTS

A total of 10 cases with complete death scene descriptions were found. Four deaths were attributed to sudden infant death syndrome and six deaths to accidental asphyxia, of which four involved shared sleeping with an adult. Lethal circumstances involved infants being overlayed by an adult (n = 2), wedged between an adult and the back of a sofa (n = 1), sleeping with an intoxicated/sedated adult (n = 2), wedged between pillows and the back of a sofa (n = 1), and wedged into the back of a sofa (n = 1).

CONCLUSIONS

Although shared sleeping of an adult with an infant on a sofa may result in accidental asphyxia, there is also the potential for wedging and accidental asphyxia of infants sleeping alone on a sofa. For this reason the use of sofas for both shared and solitary infant sleeping is discouraged.

Self strangulation by hanging from cloth towel dispensers in Canadian schools

OBJECTIVE

To investigate a local "epidemic" of incidents of strangulation by hanging from continuous cloth towels in dispensers.

METHOD

The coroner's office in all provinces and territories were contacted. Five cases of hanging from continuous cloth towels in Canadian schools were identified and reviewed.

RESULTS

There were four deaths, and one near-death, all males age 7 to 12. Two cases were attributed to a "choking game" that provides a sensation (impending loss of consciousness) described as "cool". In three cases, the child was alone at the time. All deaths were due to strangulation from hanging and all occurred in school washrooms. One child (playing with two friends) recovered after admission to an intensive care unit. Towel dispensers were removed from the two index schools. In one province the Ministry of Education encouraged removal of towel dispensers from all schools and education of students of the dangers of "choking games".

CONCLUSIONS

Thrill seeking from partial asphyxiation appears to underlie these incidents. Awareness of such cases should prompt appropriate education strategies to highlight the serious consequences of this form of risk taking behavior in young males. In Canada, these incidents have resulted in changes in the design of, and legislation regarding, cloth towel dispensers.

Intranuclear ubiquitin immunoreactivity of the pigmented neurons of the substantia nigra in fatal acute mechanical asphyxiation and drowning

To evaluate the significance of immunohistochemical staining of ubiquitin (heat shock protein) in the midbrain for the medico-legal diagnosis of fatal asphyxiation and drowning, we investigated forensic autopsy cases of fatal mechanical asphyxia (n = 18), manual/ligature strangulation (n = 9), hanging (n = 4), aspiration/choking (n = 5) and drowning (n = 16). These were compared to control groups (n = 30) consisting of fatalities from brainstem injury (n = 12) and acute myocardial infarction (n = 18). Ubiquitin was clearly demonstrated in the nuclei of pigmented substantia nigra neurons, showing two intranuclear staining patterns: a type of inclusion (possibly Marinesco bodies) and a diffuse staining. The diffuse staining was significantly more frequently observed in cases of drowning. The percentage of total ubiquitin positive neurons was frequently higher in strangulation (5.1-28.4%, mean 17.0%), aspiration/choking (5.3-32.0%, mean 17.6%) and drowning (7.0-34.1%, mean 19.8%), but relatively low in hanging (5.1-12.7%, mean 8.6%), brainstem injury (0-10.4%, mean 5.0%) and acute myocardial infarction (1.5-16.9%, mean 8.3%). These observations suggest that intranuclear ubiquitin immunoreactivity of the pigmented substantia nigra neurons in the midbrain was induced by a fatal severe stress on the central nervous system in asphyxiation and drowning.