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Death in a head-down position
Forensic Science International
F Forensic Science International 61 (1993) I 19-l 32
Death in a head-down position Burkhard Institute
of Forensic
Medicine.
University
of Cologne,
Madea Mrlatengiirtel
(Received 20 January 1993; revision received 2 February
60-62,
D-5000
1993; accepted
K&I
30. Germon,
22 January
1993)
Abstract
Dying in a head-down position is rare and autopsy may reveal no morphological findings which explain the cause of death sufficiently. Functional changes, mainly postural changes of circulation must be considered to explain the cause of death. Two cases of death are reported where death occurred in a head-down position, among them an autoerotic accident with suspension of a man head-down in a sack. Key words: Death; Reverse suspension; Head-down position; Postural changes of circulation; Positional asphyxia
Introduction There are some case reports in the literature on deaths with orthograde (feet down) suspension of the body. The cause of death in these cases was mainly due to hindering of respiratory excursions, in some cases together with orthostatic collapse. All authors reporting on these cases referred to analogies concerning the death on the cross [l-8]. However, there are only a few reports on deaths in a head-down position [9-121 (Table 1). In some of these cases no autopsy was performed (Refs. 10,ll; Fig. 1). Based on the circumstances, the cause of death was thought to be ‘cardiac arrest’ or ‘cardiac death’ (differential diagnosis, diabetic coma), or accident with following ‘orthostatic collapse’. In those cases with a complete postmortem, no clear anatomical cause of death was found [9,12] (and A.K. Mant, pers. commun.) . Marshall [9] mentioned in his paper that during the Second World War, torture had on occassions been inflicted by hanging the victim upside-down by the ankles. Obviously 0379-0738/93/$06.00 0 1993 Elsevier Scientific SSDI 0379-0738(93)01321-H
Publishers
Ireland
Ltd. All rights reserved
[I l]
position or came dying into the head-down position.
window-frame. No autopsy. Differential diagnosic: diabetic coma, cardiac death, accident with orthostatic collapse. It remains unclear whether the woman died in this
position [IO]
[9]
I l-month-old child found dead in a head-down position 4 h after last seen alive. Autopsy revealed no anatomical cause of deth.
Marshall
in the literature
72-year-old man; accidental death during autoerotic practice simulating his own slaughter. The man had simulated a situation comparable to slaughter of a pig. No autopsy. Cause of death was thought to be circulatory arrest in a headdown position.
HilgermanmRichter
on death in a head-down
Elderly woman found dead in a head-down position hanging out of a window with the left foot being fixed between window and
Prokop/Radam
Table I Case reports, [9]
60-year-old man was found dead about 10.5 h after last seen alive suspended by his clothing upside down in a thorn hedge. It seemed that in his intoxicated state he had tripped and fallen head first over the hedge. BAC 230 mg/lOO ml. Autopsy revealed no clear anatomical cause of death
Marshall
[I21
48-year-old man found suspended upside-down from a security fence with the right foot jammed sideways between two adjacent spikes of the fence. Autopsy revealed no clear anatomical cause of death. BAC: 129 mg%.
Purdue
B. Madea / Forensic Sri. ht. 61 (1993)
119-132
Fig I. (a) Accident or sudden natural death? The woman was found in this position hanging out of the window. The left foot was fixed between the window and the frame of the window. No autopsy was performed. The cause of death was thought to be: diabetic coma?, cardiac death?, accident with following orthostatic collapse. From Prokop and Radam [ 1 I]. (b) Death of 72-year-old man in a head-down position. This man simulated his own slaughtering and died in this position. No autopsy was performed. The cause of death was thought to be due to circulatory dysregulation. From Hilgermann and Richter [IO].
such tortures also happen nowadays and forensic pathologists or police medical officers may be asked for their opinion on how long it will be possible to survive in a head-down position (Doney, J., pers. commun.). There seems to be little knowledge available to answer this question. In olden times, death in a head-down position was not rare, when different death penalties are taken into account. For instance (Fig. 2a), an altar painting from Masaccio shows the crucitication of St. Peter in a head-down position and torturing in a head-down position is seen in a drawing by Goya (Fig. 2b). According to old reports, the agonal period after hanging in a head-down position lasts several hours, even a day [13]. In the following two cases, death in a head-down position is briefly reported. Case Reports Case 1
An 85year-old
woman was brought to hospital suffering from vague abdominal
122
B. Madea /Forensic
Sci. hi. 61 (1993)
119-132
pain. The tentative diagnosis was bowel perforation. Diagnostic radiography of the colon by means of barium enema was commerced. After the tube was inserted into the rectum and the barium enema was instilled, the woman was brought in a 30”oblique position with the head down. Circulatory arrest occurred in this position. At autopsy, the main anatomical findings were as follows: calcified aortic stenosis combined with aortic insufficiency; hypertrophy and dilatation of left ventricle and insufficiency of mitral valve; dilatation of left atrium; pulmonary oedema; advanced atherosclerosis; old infarction of right kidney; diverticulosis of descendent colon; but no bowel perforation. The cause of death was given as left heart failure due to severe aortic stenosis. In this case the autopsy revealed a sufficient anatomical cause of death and death occurred accidentally in a head-down position, but it could have occurred due to the severe aortic stenosis in any position. In the second case reported in this paper, no clear anatomic cause of death was found.
Fig. 2. (a) Crucifixion of St. Peter in a head-down position. Painting by Tommaso di Ser Giovanni di Simone Lassai, called Masaccio (1401-1428). Painting Gallery, Berlin ~ Dahlem, Germany. (b) Torturing in a head-down position. Drawing by Francisco de Goya.
B. MLrdea / Forensic Sci. ht. 61 (1993)
123
119-132
Case 2* A 56-year-old man was found in a head-down position, hanging in a sack. The sack was knotted to a board which was laid over a door and cupboard. Tennis balls were wrapped into the free end of the sack and these ‘enveloped’ tennis balls fixed the knots of the rope at the sack so they could not slip. The sack was hanging from the board (Figs. 3a,b). The stitching of the ‘head end’ of the sack was opened for a length of 15 cm and the hands jutted out through this opening. The right hand held a pair of scissors, between the blades of which fibres of the sacking had impacted to prevent further cutting action. *This case was already
published
in German
by Madea
et al. Arch.
Kriminokqir.
IX6
( 1990)
65-74.
124
Fig. 3. (a) Deceased
B. Madea / Forensic Sci. ht. 61 (1993)
at the scene. (b) Board laid over door and cupboard. sack over tennis balls.
The cord is knotted
119-132
with the
B. Madea /Forensic
Sri. ht. 61 (1993)
125
119-132
The body was tightly pressed into the sack, and beside the body were two chairs, one overturned. The man had last been seen 2 days earlier. Autopsy findings
The man was covered only with a blue plastic sack (Fig. 4). There was deep hypostasis of head, face, arms as well as the internal organs of head, neck and thorax. Cuff-like bleeding into the subcutaneous fat of the arms corresponded to the grooves where the arms passed through the sack (Fig. 5a). There was brain and lung oedema, but no anatomical cause of death. Toxicology was completely negative. Histology
The findings were as follows: severe congestion of the organs of the upper part of the body, especially the lungs; vacuolisation of liver cells due to hypoxia; cuff-like
Fig. 4. Deceased
dressed
with a blue plastic
sack (dust-sack)
which was cut up as a woman’s
dress.
126
B. Madea /Forensic
Sci. ht. 61 (1993)
Fig. 5. (a) Cuff like subcutaneous hemorrhages of the forearm. (b) Marked infiltration phonuclear leucocytes within the subcutaneous hemorrhages. (c) Case of Dr O.G. Williams, suspended by legs from ceiling beams.
119-132
of polymorshowing man
B. Madea /Forensic
Sri. ht. 61 (1993)
119-132
127
hemorrhages of the subcutaneous fat of the forearms with marked infiltration of polymorphonuclear leucocytes (Fig. 5b). The whole case was interpreted as an autoerotic accident. Obviously the man - standing on the chairs - covered his body with the sack and used the tennis balls to compress his genitals. One of the chairs must have upset and the man came into a head-down position due to the fact that the turning point was below the center of gravity of the body. Obviously he had taken a scissors into the sack to rescue himself in case of accident, but he was able to cut only the stitching of the head end of the sack. In this attempt at self-rescue, the man had inflicted several sharp cuts to his forehead. According to the morphological findings (emigration of polymorphonuclear leucocytes; signs of general hypoxia) and the circumstances of the case (attempt selfrescue) it was clear that the man had been alive and conscious in the head-down position and died in this position. However, the autopsy revealed no clear morphological cause of death. Whilst preparing this paper, several other similar cases came to my notice through personal communications. Professor Bernard Knight of the Wales Institute of Forensic Medicine has reports of two deaths where men became impacted whilst attempting to climb through a high narrow window, so that they were ‘jack-knifed’ across the hips, with the head, arms and upper body hanging down inside. Both showed only gross facial congestion, cyanosis and some conjuctival petechiae. Two other drunken persons were found having partly fallen from bed, with the head on the floor and the legs still in the bed. Both had gross facial ecchymoses, cyanosis and petechiae. Another case investigated by Dr O.G. Williams (Swansea, Wales) is illustrated in Fig. 5c. A 48-year-old man was found in a derelict house, hanging from beams in the broken ceiling. He had, presumably deliberately, hooked his knees over one beam and secured his feet under the adjacent beam, so that all of his body was hanging vertically downwards, as a means of suicide. Though some post-mortem decom-
128
B. Madea / Forensic Sri. ht. 61 (1993) 119-132
position was present, autopsy revealed no other cause of death, other than the inverted posture. There was a large collection of blood-stained fluid beneath the scalp, due to gravitational movement of blood and tissue fluid. Discussion The following mechanisms of death must be discussed: (i) asphyxia due to fixation of the chest with hindering of thoracic excursions and ventilation on the one hand; and (ii) circulatory failure due to the head-down position on the other hand. (This second factor may be the prevalent one in cases of hanging by the feet in a headdown position - see Fig. la and the cases reported by Purdue [12] and Marshall 191.) The fibres of the sack were already extremely stretched. Thoracic excursions were probably only possible between end expiratory position and expiratory resting position. Compensation of the extremely hindered costal ventilation by abdominal ventilation (diaphragmatic ventilation) was probably only very limited, since the abdominal wall was fixed within the sack. By the fixation of the thorax the elastic resistance of the pulmonary system was raised considerably. Consequently the compliance decreased. The respiratory effort against the elastic resistance increased considerably, over-proportionally to the respiratory effort provided by the energy demand of respiratory muscles [14]. The asphyxia due to increased respiratory resistance is worsened by the extreme oxygen demand of the respiratory muscles. In cases of hard physical work, 20% of the oxygen uptake is used for respiratory work, compared to only 2% in normal respiration [15]. Circulatory failure as a cause of death in a head-down position may be due to the following factors. Investigations on young healthy men revealed that in orthograde (feet down) suspension (body fixed at the arms), after only 12 min orthostatic collapse follows; after 6 min there is a drop of blood pressure from 120 to 70 mmHg and the ECG indicates lack of extracoronary oxygen [3,16]. Reports on the circulatory regulation in a head-down position are almost absent from the literature. Physiology and cardiology have been studied mainly in the circulatory regulation of supine persons, standing persons and the postural change from supine to standing, but in aerospace medicine, physiological investigations on circulatory regulation in a head-down position have been carried out [17- 191. According to a recent paper by Althoff et al. [20] they were warned by clinicians and physiologists not to perform investigations on circulatory regulation in a headdown position, since in a long-lasting head-down position, the hydrostatic pressure in the venous system could increase to 100 mmHg and the danger of micro- or macro-hemorrhages in the central nervous system could not be excluded*.
*(Experimental investigations on ‘afebrile, normotensive hospital patients, convalescent from minor ailments’ were, however, carried out by Wilkins et al. [17] on 42 persons for 2-30 min without development of cerebral hemorrhages.)
B. Madea /Forensic
Sri. Inr. 61 (1993)
129
119-132
E Hydrostatic pressure km H,O)
length of vascular system
Height of blood column A ---_--_--_._
?? 15____
Hydrostatic
ixdifference level
\
+30 45
?? 60 ?? 75
‘L .’
*go
?? 105
I Lb. . +120
f
intravascular pressure (+15cm H,O)
Fig. 6. Hydrostatic right the pressure
indifference level within the human body. In postural changes from horizontal to upand the diameter of venous vessels in the hydrostatic indifference level remains unchanged. Modified according to Busse (211.
From our knowledge of circulatory regulation in supine and standing persons, however, the following hypotheses can be formulated. The hydrostatic indifference level - that is, the horizontal level within the human body where, in postural changes from supine to standing, the pressure within the vessels (and the diameter of the vessels) does not change - in humans is at the height of the liver, 10 cm below the diaphragm. Above this hydrostatic indifference level, the hydrostatic pressure decreases, below it increases (Fig. 6). In a head-down position it is completely reversed: above the hydrostatic indifference level - that means in the thorax, neck and head - the hydrostatic pressure increases, below (in the legs) it decreases. However, it remains unclear whether the
Table 2 Subjective
symptoms
in a head-down
position
Sensation of tumbling head-over-heels Tensing of the body musculature Facial congestion/cranial swelling Congestion of nasal mucosa Perspiration of neck and face Tears from eyes (According
to experimental
observations
from Wilkins et al. 1171.)
blood
position
artery
(According
to experimental
findings
of Wilkins
Irregularity of pulse beats and decrease of pulse rate from 90-100 to 44-68 beats/min
Rise (especially of diastolic pressure) in brachial artery (or no change). This first shift due to passive hydrostatic effects, then decline in pressure of both arteries.
in femoral
pressure
Fall of blood pressure
On arterial
Table 3 Effect of head-down jugular
venous
pressure
et al. 1171.)
Immediate rise of venous pressure (hydrostatic effect) followed by a continous rise of the same amount (drainage of blood from the elevated parts into the dependent chambers).
On internal
output
Increased cardiac output
On cardiac
B. Madea /Forensic
Sci. ht. 61 (1993)
119-132
131
Table 4 Haemodynamic dysregulation in a head-down position Hydrostatic pressure in ‘upper’ body part - ‘shift’ of blood into the intrathoracal blood pools Transmural pressure in the venous part of cerebral circulation Raised static pressure in carotid sinus - drop of arterial blood pressure Decreased venous return of blood to the heart fall away of muscular venous pump fall away of the suction pressure effect of respiration
hydrostatic indifference level in a head-down position is the same as in postural changes from a supine to upright position. As a consequence of the increased hydrostatic pressure in the thorax, head and neck, the pressure in the venous system rises (for instance in the internal jugular vein [17]). This is followed by a blood-volume shift into regions of the body where mechanisms which promote the venous return of blood to the heart are insufficiently developed. It is quite unknown if (and in which direction) the raised transmural pressure in the venous part of cerebral circulation - mainly the rhombencephalic circulatory centers - affects the nervous regulation of circulation. By the addition of the hydrostatic pressure to the arterial blood-pressure in cranial arteries in a head-down position, theoretically (via the carotid sinus) the heart frequency and arterial blood pressure may be decreased. Experimental investigations by Wilkins et al. [17] revealed a rise of blood pressure in the cranial arteries due to hydrostatic effects which were followed by subsequent normalisation (Tables 2 and 3). The hindering of ventilation itself also has consequences for the regulation of circulation. With deep inspirations being impossible, the suction-pressure effect of ventilation decreases falls, away and the venous return of blood to the heart is hindered. Thus in a head-down position, the following haemodynamic effects are to be expected (Table 4): (i) marked depletion of the venous return of blood to the heart; (ii) increase of transmural pressure in the venous part of cerebral circulation; and (iii) probable decrease of systemic (arterial) blood pressure (but here some complex regulatory mechanisms are possible). How long does it take to die in a head-down position? Old reports speak of several hours or even a day, and the marked infiltration of polymorphonuclear phagocytes in the cuff-like haemorrhages of the forearm in the second case indicate a terminal episode of some hours. Conclusion
In deaths in uncommon body postures, autopsy often reveals no clear anatomical cause of death, although it is evident that the deceased has come into this position
B. Madea /Forensic
132
Sci. Int. 61 (1993)
119-132
alive and this position contributed or led to death. Case histories on deaths in a head-down position are rare, but the problem may be of increasing interest again in connection with torture and the forensic pathologist may be asked how long will it take to die in this position. From the limited experience of some recent case histories and the experimental investigations of Wilkins et al. [ 171, it can only be said that in healthy persons it may take some hours. References P. Barbet, Die Passion Jesu Christi in der Sicht des Chirurgen. Badenia, Karlsruhe, 1953. S. Berg and G. Doring, Tod im Kamin. ArchjI Krim. 160 (1972) l-19. S. Berg, R. Rolle and A. Seemann, Des Archiiologe und der Tad. Archiiologie und Gerichtsmedizin. Bucher, Munchen-Luzern 1981, pp. 38-44. H. Patscheider, Die Todesursache beim freihangenden, am Rumpf suspendierten Menschen. Beitr. gerichtl. Med., 21 (1961) 87-93.
8
H. Bankl, Der Tod am Kreuz. ijberlegungen eines Pathologen zu einer ungeklirten Todesart. &err. &ztezt. 38 (1983) 243-246. C. Weglin, Der Tod am Kreuz. Schweiz. Med. Wochenschr., 32 (1960) 857-860. W.D. Edwards, W.J. Gabel and F.E. Hosmer, On the physical death of Jesus Christ. J. Am. Med. Assoc. 255 (1986) 1455-1463. W. Marty, Historisch und forensisch im Dunkeln: Die Exekution durch Kreuzigung. Arch Kriminologie 188 (1991) 129-145.
9
T.K. Marshall, Inverted Suspension, Med. Sci. Law 4, (1968) 49-50. 10 R. Hilgermann and 0. Richter, Einige besondere Fllle aus einem rechtsmedizinischen Obduktionsgut. Beitr. gerichtl. Med. 30 (1973) 163-174. II 0. Prokop and G. Radam, Aflas der gerichtlichen Medizin. 2. iiberarb. Auffl. S. Karger, Base], Miinthen, Paris, London, New York, 1987. 12 B. Purdue, An unusual accidental death from reverse suspension. Am. J. Forensic Med. Pathol., 13(2) (1992) 108-111.
13 G. Radbruch and H. Gwinner, Geschichte des Verbrechens. Versuch einer historischen Kriminologie. Eichborn Verlag, Frankfurt/Main, 1990. 14 A.B. Otis, The work of breathing. In W.O. Fenn, H. Rahn (eds.), Handbook of Physiology, Section 3, Respiration, Vol. I, American Physiol. Sot., Washington, 1964. 15 G. Thews, Lungenatmung. In: R.F. Schmidt and G. Thews, Physiologie des Menschen, Springer, Berlin, Heidelberg, New York, Tokyo, 1985, pp. 500-536. 16 Mijdder H. Die Toclesuracle bei der Krenzigung Stimmer der Zeit 144 (1948) 50-59. 17 R.W. Wilkins, S.E. Bradley and C.K. Friedland, The acute circulatory effects of the head-down position (negative G) in normal man, with a note on some measures designed to relieve cranial congestion in this position. J. Clin. Invesf. 29 (1950) 940-949. 18 O.H. Gauer and J.P. Henry, Negative (-Gz) acceleration in relation to arterial oxygen saturation, subendocarial hemorrhage and venous pressure in the forehead. Aerospace Medicine 35 (1964) 33. 19 O.H. Gauer and M.D. Throp, Postural changes in the circulation. Handbook of Physiology, Sec. 2, Circulation, 3. American Physiological Society, Washington D.C. 1965, pp. 2409-2439. 20 ‘H. Althoff, A. Schafer and R. Lemke, Letale Hamodynamik bei ungewiihnlicher Korperposition. Paper read at the Firsf Spring-Meeting of”rhe German Sociefy of Legal Medicine - North Region, Giessen, May 1992. 21 Busse R. Kreislaufphysiologie, G. Thieme, Stuttgart, 1982.
F Forensic Science International 61 (1993) I 19-l 32
Death in a head-down position Burkhard Institute
of Forensic
Medicine.
University
of Cologne,
Madea Mrlatengiirtel
(Received 20 January 1993; revision received 2 February
60-62,
D-5000
1993; accepted
K&I
30. Germon,
22 January
1993)
Abstract
Dying in a head-down position is rare and autopsy may reveal no morphological findings which explain the cause of death sufficiently. Functional changes, mainly postural changes of circulation must be considered to explain the cause of death. Two cases of death are reported where death occurred in a head-down position, among them an autoerotic accident with suspension of a man head-down in a sack. Key words: Death; Reverse suspension; Head-down position; Postural changes of circulation; Positional asphyxia
Introduction There are some case reports in the literature on deaths with orthograde (feet down) suspension of the body. The cause of death in these cases was mainly due to hindering of respiratory excursions, in some cases together with orthostatic collapse. All authors reporting on these cases referred to analogies concerning the death on the cross [l-8]. However, there are only a few reports on deaths in a head-down position [9-121 (Table 1). In some of these cases no autopsy was performed (Refs. 10,ll; Fig. 1). Based on the circumstances, the cause of death was thought to be ‘cardiac arrest’ or ‘cardiac death’ (differential diagnosis, diabetic coma), or accident with following ‘orthostatic collapse’. In those cases with a complete postmortem, no clear anatomical cause of death was found [9,12] (and A.K. Mant, pers. commun.) . Marshall [9] mentioned in his paper that during the Second World War, torture had on occassions been inflicted by hanging the victim upside-down by the ankles. Obviously 0379-0738/93/$06.00 0 1993 Elsevier Scientific SSDI 0379-0738(93)01321-H
Publishers
Ireland
Ltd. All rights reserved
[I l]
position or came dying into the head-down position.
window-frame. No autopsy. Differential diagnosic: diabetic coma, cardiac death, accident with orthostatic collapse. It remains unclear whether the woman died in this
position [IO]
[9]
I l-month-old child found dead in a head-down position 4 h after last seen alive. Autopsy revealed no anatomical cause of deth.
Marshall
in the literature
72-year-old man; accidental death during autoerotic practice simulating his own slaughter. The man had simulated a situation comparable to slaughter of a pig. No autopsy. Cause of death was thought to be circulatory arrest in a headdown position.
HilgermanmRichter
on death in a head-down
Elderly woman found dead in a head-down position hanging out of a window with the left foot being fixed between window and
Prokop/Radam
Table I Case reports, [9]
60-year-old man was found dead about 10.5 h after last seen alive suspended by his clothing upside down in a thorn hedge. It seemed that in his intoxicated state he had tripped and fallen head first over the hedge. BAC 230 mg/lOO ml. Autopsy revealed no clear anatomical cause of death
Marshall
[I21
48-year-old man found suspended upside-down from a security fence with the right foot jammed sideways between two adjacent spikes of the fence. Autopsy revealed no clear anatomical cause of death. BAC: 129 mg%.
Purdue
B. Madea / Forensic Sri. ht. 61 (1993)
119-132
Fig I. (a) Accident or sudden natural death? The woman was found in this position hanging out of the window. The left foot was fixed between the window and the frame of the window. No autopsy was performed. The cause of death was thought to be: diabetic coma?, cardiac death?, accident with following orthostatic collapse. From Prokop and Radam [ 1 I]. (b) Death of 72-year-old man in a head-down position. This man simulated his own slaughtering and died in this position. No autopsy was performed. The cause of death was thought to be due to circulatory dysregulation. From Hilgermann and Richter [IO].
such tortures also happen nowadays and forensic pathologists or police medical officers may be asked for their opinion on how long it will be possible to survive in a head-down position (Doney, J., pers. commun.). There seems to be little knowledge available to answer this question. In olden times, death in a head-down position was not rare, when different death penalties are taken into account. For instance (Fig. 2a), an altar painting from Masaccio shows the crucitication of St. Peter in a head-down position and torturing in a head-down position is seen in a drawing by Goya (Fig. 2b). According to old reports, the agonal period after hanging in a head-down position lasts several hours, even a day [13]. In the following two cases, death in a head-down position is briefly reported. Case Reports Case 1
An 85year-old
woman was brought to hospital suffering from vague abdominal
122
B. Madea /Forensic
Sci. hi. 61 (1993)
119-132
pain. The tentative diagnosis was bowel perforation. Diagnostic radiography of the colon by means of barium enema was commerced. After the tube was inserted into the rectum and the barium enema was instilled, the woman was brought in a 30”oblique position with the head down. Circulatory arrest occurred in this position. At autopsy, the main anatomical findings were as follows: calcified aortic stenosis combined with aortic insufficiency; hypertrophy and dilatation of left ventricle and insufficiency of mitral valve; dilatation of left atrium; pulmonary oedema; advanced atherosclerosis; old infarction of right kidney; diverticulosis of descendent colon; but no bowel perforation. The cause of death was given as left heart failure due to severe aortic stenosis. In this case the autopsy revealed a sufficient anatomical cause of death and death occurred accidentally in a head-down position, but it could have occurred due to the severe aortic stenosis in any position. In the second case reported in this paper, no clear anatomic cause of death was found.
Fig. 2. (a) Crucifixion of St. Peter in a head-down position. Painting by Tommaso di Ser Giovanni di Simone Lassai, called Masaccio (1401-1428). Painting Gallery, Berlin ~ Dahlem, Germany. (b) Torturing in a head-down position. Drawing by Francisco de Goya.
B. MLrdea / Forensic Sci. ht. 61 (1993)
123
119-132
Case 2* A 56-year-old man was found in a head-down position, hanging in a sack. The sack was knotted to a board which was laid over a door and cupboard. Tennis balls were wrapped into the free end of the sack and these ‘enveloped’ tennis balls fixed the knots of the rope at the sack so they could not slip. The sack was hanging from the board (Figs. 3a,b). The stitching of the ‘head end’ of the sack was opened for a length of 15 cm and the hands jutted out through this opening. The right hand held a pair of scissors, between the blades of which fibres of the sacking had impacted to prevent further cutting action. *This case was already
published
in German
by Madea
et al. Arch.
Kriminokqir.
IX6
( 1990)
65-74.
124
Fig. 3. (a) Deceased
B. Madea / Forensic Sci. ht. 61 (1993)
at the scene. (b) Board laid over door and cupboard. sack over tennis balls.
The cord is knotted
119-132
with the
B. Madea /Forensic
Sri. ht. 61 (1993)
125
119-132
The body was tightly pressed into the sack, and beside the body were two chairs, one overturned. The man had last been seen 2 days earlier. Autopsy findings
The man was covered only with a blue plastic sack (Fig. 4). There was deep hypostasis of head, face, arms as well as the internal organs of head, neck and thorax. Cuff-like bleeding into the subcutaneous fat of the arms corresponded to the grooves where the arms passed through the sack (Fig. 5a). There was brain and lung oedema, but no anatomical cause of death. Toxicology was completely negative. Histology
The findings were as follows: severe congestion of the organs of the upper part of the body, especially the lungs; vacuolisation of liver cells due to hypoxia; cuff-like
Fig. 4. Deceased
dressed
with a blue plastic
sack (dust-sack)
which was cut up as a woman’s
dress.
126
B. Madea /Forensic
Sci. ht. 61 (1993)
Fig. 5. (a) Cuff like subcutaneous hemorrhages of the forearm. (b) Marked infiltration phonuclear leucocytes within the subcutaneous hemorrhages. (c) Case of Dr O.G. Williams, suspended by legs from ceiling beams.
119-132
of polymorshowing man
B. Madea /Forensic
Sri. ht. 61 (1993)
119-132
127
hemorrhages of the subcutaneous fat of the forearms with marked infiltration of polymorphonuclear leucocytes (Fig. 5b). The whole case was interpreted as an autoerotic accident. Obviously the man - standing on the chairs - covered his body with the sack and used the tennis balls to compress his genitals. One of the chairs must have upset and the man came into a head-down position due to the fact that the turning point was below the center of gravity of the body. Obviously he had taken a scissors into the sack to rescue himself in case of accident, but he was able to cut only the stitching of the head end of the sack. In this attempt at self-rescue, the man had inflicted several sharp cuts to his forehead. According to the morphological findings (emigration of polymorphonuclear leucocytes; signs of general hypoxia) and the circumstances of the case (attempt selfrescue) it was clear that the man had been alive and conscious in the head-down position and died in this position. However, the autopsy revealed no clear morphological cause of death. Whilst preparing this paper, several other similar cases came to my notice through personal communications. Professor Bernard Knight of the Wales Institute of Forensic Medicine has reports of two deaths where men became impacted whilst attempting to climb through a high narrow window, so that they were ‘jack-knifed’ across the hips, with the head, arms and upper body hanging down inside. Both showed only gross facial congestion, cyanosis and some conjuctival petechiae. Two other drunken persons were found having partly fallen from bed, with the head on the floor and the legs still in the bed. Both had gross facial ecchymoses, cyanosis and petechiae. Another case investigated by Dr O.G. Williams (Swansea, Wales) is illustrated in Fig. 5c. A 48-year-old man was found in a derelict house, hanging from beams in the broken ceiling. He had, presumably deliberately, hooked his knees over one beam and secured his feet under the adjacent beam, so that all of his body was hanging vertically downwards, as a means of suicide. Though some post-mortem decom-
128
B. Madea / Forensic Sri. ht. 61 (1993) 119-132
position was present, autopsy revealed no other cause of death, other than the inverted posture. There was a large collection of blood-stained fluid beneath the scalp, due to gravitational movement of blood and tissue fluid. Discussion The following mechanisms of death must be discussed: (i) asphyxia due to fixation of the chest with hindering of thoracic excursions and ventilation on the one hand; and (ii) circulatory failure due to the head-down position on the other hand. (This second factor may be the prevalent one in cases of hanging by the feet in a headdown position - see Fig. la and the cases reported by Purdue [12] and Marshall 191.) The fibres of the sack were already extremely stretched. Thoracic excursions were probably only possible between end expiratory position and expiratory resting position. Compensation of the extremely hindered costal ventilation by abdominal ventilation (diaphragmatic ventilation) was probably only very limited, since the abdominal wall was fixed within the sack. By the fixation of the thorax the elastic resistance of the pulmonary system was raised considerably. Consequently the compliance decreased. The respiratory effort against the elastic resistance increased considerably, over-proportionally to the respiratory effort provided by the energy demand of respiratory muscles [14]. The asphyxia due to increased respiratory resistance is worsened by the extreme oxygen demand of the respiratory muscles. In cases of hard physical work, 20% of the oxygen uptake is used for respiratory work, compared to only 2% in normal respiration [15]. Circulatory failure as a cause of death in a head-down position may be due to the following factors. Investigations on young healthy men revealed that in orthograde (feet down) suspension (body fixed at the arms), after only 12 min orthostatic collapse follows; after 6 min there is a drop of blood pressure from 120 to 70 mmHg and the ECG indicates lack of extracoronary oxygen [3,16]. Reports on the circulatory regulation in a head-down position are almost absent from the literature. Physiology and cardiology have been studied mainly in the circulatory regulation of supine persons, standing persons and the postural change from supine to standing, but in aerospace medicine, physiological investigations on circulatory regulation in a head-down position have been carried out [17- 191. According to a recent paper by Althoff et al. [20] they were warned by clinicians and physiologists not to perform investigations on circulatory regulation in a headdown position, since in a long-lasting head-down position, the hydrostatic pressure in the venous system could increase to 100 mmHg and the danger of micro- or macro-hemorrhages in the central nervous system could not be excluded*.
*(Experimental investigations on ‘afebrile, normotensive hospital patients, convalescent from minor ailments’ were, however, carried out by Wilkins et al. [17] on 42 persons for 2-30 min without development of cerebral hemorrhages.)
B. Madea /Forensic
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129
119-132
E Hydrostatic pressure km H,O)
length of vascular system
Height of blood column A ---_--_--_._
?? 15____
Hydrostatic
ixdifference level
\
+30 45
?? 60 ?? 75
‘L .’
*go
?? 105
I Lb. . +120
f
intravascular pressure (+15cm H,O)
Fig. 6. Hydrostatic right the pressure
indifference level within the human body. In postural changes from horizontal to upand the diameter of venous vessels in the hydrostatic indifference level remains unchanged. Modified according to Busse (211.
From our knowledge of circulatory regulation in supine and standing persons, however, the following hypotheses can be formulated. The hydrostatic indifference level - that is, the horizontal level within the human body where, in postural changes from supine to standing, the pressure within the vessels (and the diameter of the vessels) does not change - in humans is at the height of the liver, 10 cm below the diaphragm. Above this hydrostatic indifference level, the hydrostatic pressure decreases, below it increases (Fig. 6). In a head-down position it is completely reversed: above the hydrostatic indifference level - that means in the thorax, neck and head - the hydrostatic pressure increases, below (in the legs) it decreases. However, it remains unclear whether the
Table 2 Subjective
symptoms
in a head-down
position
Sensation of tumbling head-over-heels Tensing of the body musculature Facial congestion/cranial swelling Congestion of nasal mucosa Perspiration of neck and face Tears from eyes (According
to experimental
observations
from Wilkins et al. 1171.)
blood
position
artery
(According
to experimental
findings
of Wilkins
Irregularity of pulse beats and decrease of pulse rate from 90-100 to 44-68 beats/min
Rise (especially of diastolic pressure) in brachial artery (or no change). This first shift due to passive hydrostatic effects, then decline in pressure of both arteries.
in femoral
pressure
Fall of blood pressure
On arterial
Table 3 Effect of head-down jugular
venous
pressure
et al. 1171.)
Immediate rise of venous pressure (hydrostatic effect) followed by a continous rise of the same amount (drainage of blood from the elevated parts into the dependent chambers).
On internal
output
Increased cardiac output
On cardiac
B. Madea /Forensic
Sci. ht. 61 (1993)
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131
Table 4 Haemodynamic dysregulation in a head-down position Hydrostatic pressure in ‘upper’ body part - ‘shift’ of blood into the intrathoracal blood pools Transmural pressure in the venous part of cerebral circulation Raised static pressure in carotid sinus - drop of arterial blood pressure Decreased venous return of blood to the heart fall away of muscular venous pump fall away of the suction pressure effect of respiration
hydrostatic indifference level in a head-down position is the same as in postural changes from a supine to upright position. As a consequence of the increased hydrostatic pressure in the thorax, head and neck, the pressure in the venous system rises (for instance in the internal jugular vein [17]). This is followed by a blood-volume shift into regions of the body where mechanisms which promote the venous return of blood to the heart are insufficiently developed. It is quite unknown if (and in which direction) the raised transmural pressure in the venous part of cerebral circulation - mainly the rhombencephalic circulatory centers - affects the nervous regulation of circulation. By the addition of the hydrostatic pressure to the arterial blood-pressure in cranial arteries in a head-down position, theoretically (via the carotid sinus) the heart frequency and arterial blood pressure may be decreased. Experimental investigations by Wilkins et al. [17] revealed a rise of blood pressure in the cranial arteries due to hydrostatic effects which were followed by subsequent normalisation (Tables 2 and 3). The hindering of ventilation itself also has consequences for the regulation of circulation. With deep inspirations being impossible, the suction-pressure effect of ventilation decreases falls, away and the venous return of blood to the heart is hindered. Thus in a head-down position, the following haemodynamic effects are to be expected (Table 4): (i) marked depletion of the venous return of blood to the heart; (ii) increase of transmural pressure in the venous part of cerebral circulation; and (iii) probable decrease of systemic (arterial) blood pressure (but here some complex regulatory mechanisms are possible). How long does it take to die in a head-down position? Old reports speak of several hours or even a day, and the marked infiltration of polymorphonuclear phagocytes in the cuff-like haemorrhages of the forearm in the second case indicate a terminal episode of some hours. Conclusion
In deaths in uncommon body postures, autopsy often reveals no clear anatomical cause of death, although it is evident that the deceased has come into this position
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alive and this position contributed or led to death. Case histories on deaths in a head-down position are rare, but the problem may be of increasing interest again in connection with torture and the forensic pathologist may be asked how long will it take to die in this position. From the limited experience of some recent case histories and the experimental investigations of Wilkins et al. [ 171, it can only be said that in healthy persons it may take some hours. References P. Barbet, Die Passion Jesu Christi in der Sicht des Chirurgen. Badenia, Karlsruhe, 1953. S. Berg and G. Doring, Tod im Kamin. ArchjI Krim. 160 (1972) l-19. S. Berg, R. Rolle and A. Seemann, Des Archiiologe und der Tad. Archiiologie und Gerichtsmedizin. Bucher, Munchen-Luzern 1981, pp. 38-44. H. Patscheider, Die Todesursache beim freihangenden, am Rumpf suspendierten Menschen. Beitr. gerichtl. Med., 21 (1961) 87-93.
8
H. Bankl, Der Tod am Kreuz. ijberlegungen eines Pathologen zu einer ungeklirten Todesart. &err. &ztezt. 38 (1983) 243-246. C. Weglin, Der Tod am Kreuz. Schweiz. Med. Wochenschr., 32 (1960) 857-860. W.D. Edwards, W.J. Gabel and F.E. Hosmer, On the physical death of Jesus Christ. J. Am. Med. Assoc. 255 (1986) 1455-1463. W. Marty, Historisch und forensisch im Dunkeln: Die Exekution durch Kreuzigung. Arch Kriminologie 188 (1991) 129-145.
9
T.K. Marshall, Inverted Suspension, Med. Sci. Law 4, (1968) 49-50. 10 R. Hilgermann and 0. Richter, Einige besondere Fllle aus einem rechtsmedizinischen Obduktionsgut. Beitr. gerichtl. Med. 30 (1973) 163-174. II 0. Prokop and G. Radam, Aflas der gerichtlichen Medizin. 2. iiberarb. Auffl. S. Karger, Base], Miinthen, Paris, London, New York, 1987. 12 B. Purdue, An unusual accidental death from reverse suspension. Am. J. Forensic Med. Pathol., 13(2) (1992) 108-111.
13 G. Radbruch and H. Gwinner, Geschichte des Verbrechens. Versuch einer historischen Kriminologie. Eichborn Verlag, Frankfurt/Main, 1990. 14 A.B. Otis, The work of breathing. In W.O. Fenn, H. Rahn (eds.), Handbook of Physiology, Section 3, Respiration, Vol. I, American Physiol. Sot., Washington, 1964. 15 G. Thews, Lungenatmung. In: R.F. Schmidt and G. Thews, Physiologie des Menschen, Springer, Berlin, Heidelberg, New York, Tokyo, 1985, pp. 500-536. 16 Mijdder H. Die Toclesuracle bei der Krenzigung Stimmer der Zeit 144 (1948) 50-59. 17 R.W. Wilkins, S.E. Bradley and C.K. Friedland, The acute circulatory effects of the head-down position (negative G) in normal man, with a note on some measures designed to relieve cranial congestion in this position. J. Clin. Invesf. 29 (1950) 940-949. 18 O.H. Gauer and J.P. Henry, Negative (-Gz) acceleration in relation to arterial oxygen saturation, subendocarial hemorrhage and venous pressure in the forehead. Aerospace Medicine 35 (1964) 33. 19 O.H. Gauer and M.D. Throp, Postural changes in the circulation. Handbook of Physiology, Sec. 2, Circulation, 3. American Physiological Society, Washington D.C. 1965, pp. 2409-2439. 20 ‘H. Althoff, A. Schafer and R. Lemke, Letale Hamodynamik bei ungewiihnlicher Korperposition. Paper read at the Firsf Spring-Meeting of”rhe German Sociefy of Legal Medicine - North Region, Giessen, May 1992. 21 Busse R. Kreislaufphysiologie, G. Thieme, Stuttgart, 1982.