Death in Sauna Associated With a Transdermal Fentanyl Patch.

We present a case of an accidental fatal fentanyl overdose caused by increased uptake of the drug from a transdermal patch while experiencing the heat of a sauna.The transdermal patch administers fentanyl at a relatively constant rate through the skin. However, in the subcutaneous tissue, blood circulation greatly influences the rate of this drug's systemic intake. In the present case, an elderly woman with multiple health conditions was prescribed fentanyl patches but was unaware of the risks associated with external heat sources when one wears the patch. She was found dead in the sauna with a postmortem femoral blood concentration of fentanyl that was elevated (15 µg/L). The cause of death was determined to be fatal poisoning by fentanyl with the contributing factor of external heat from the sauna.Risks associated with transdermal administration of a potent opioid-like fentanyl are widely described in the scientific literature and described in the manufacturer's summary of product characteristics. Physicians and pharmacists should take particular care to ensure that patients understand these risks.

Fatal α-PVP and amphetamine poisoning during a sauna and autoerotic practices.

We describe the sudden death of a middle-aged man while having a sauna under the influence of α-pyrrolidinovalerophenone (α-PVP) (PM blood concentration: 0.8 mg/L), amphetamine (0.34 mg/L), and other drugs (buprenorphine, benzodiazepines), and engaging in solitary sexual activities. The drugs' effects on the cardio-circulatory system and on body thermoregulation combined with the high temperatures are likely to have been central mechanisms leading to death. The high levels of adrenaline triggered by sexual arousal and the respiratory depression caused by buprenorphine, in association with benzodiazepines, may have also contributed to his death. This previously unreported type of accidental autoerotic death illustrates the risk of using amphetamine-like sympathomimetic drugs (e.g. cathinone derivates) in hot environments such as a sauna, and during sexual activities therein.

Sudden Unexpected Death From Unusually Large Primary Cardiac B-cell Lymphoma.

Primary cardiac lymphomas represent approximately 1% to 2% of primary cardiac neoplasms and 5% of malignant cardiac neoplasms. Here we present a case of sudden unexpected death of a middle-aged male resulting from an unusually large cardiac B-cell lymphoma. The neoplasm infiltrated the myocardium of the right atrium and ventricle and, to a lesser extent, the wall of the left atrium and pulmonary trunk. Extensive infiltration of the heart by the primary cardiac lymphoma, combined with the complete lack of symptoms, makes this case unusual.

Physiology Of Drowning: A Review.

Drowning physiology relates to two different events: immersion (upper airway above water) and submersion (upper airway under water). Immersion involves integrated cardiorespiratory responses to skin and deep body temperature, including cold shock, physical incapacitation, and hypovolemia, as precursors of collapse and submersion. The physiology of submersion includes fear of drowning, diving response, autonomic conflict, upper airway reflexes, water aspiration and swallowing, emesis, and electrolyte disorders. Submersion outcome is determined by cardiac, pulmonary, and neurological injury. Knowledge of drowning physiology is scarce. Better understanding may identify methods to improve survival, particularly related to hot-water immersion, cold shock, cold-induced physical incapacitation, and fear of drowning.

Unintentional drowning: Role of medicinal drugs and alcohol.

BACKGROUND: Alcohol is a well-known risk factor in unintentional drownings. Whereas psychotropic drugs, like alcohol, may cause psychomotor impairment and affect cognition, no detailed studies have focused on their association with drowning. Finland provides extensive post-mortem toxicological data for studies on drowning because of its high medico-legal autopsy rates. METHODS: Drowning cases, 2000 through 2009, for which post-mortem toxicological analysis was performed, came from the database of the Toxicological Laboratory, Department of Forensic Medicine, University of Helsinki, using the ICD-10 nature-of-injury code T75.1. The data were narrowed to unintentional drowning, using the ICD-10 external-injury codes V90, V92, and W65-74. Each drowning case had its blood alcohol concentration (BAC) and concentrations of other drugs recorded. Evaluation of the contribution of psychotropic drugs to drowning was based on their blood concentration by means of a 6-grade scale. RESULTS: Among victims ≥15 years old, unintentional drownings numbered 1697, of which, 303 (17.9%) were boating-related and 1394 (82.1%) non-boating-related. Among these, 65.0% of boating-related and 61.8% of non-boating-related victims were alcohol-positive (=BAC ≥ 50 mg/dL). The male-to-female ratio in alcohol-positive drownings was 7.3. At least one psychotropic drug appeared in 453 (26.7%) drowning cases, with some victims' bodies showing up to 7 different drugs. Overall 70 different psychotropic drugs were detectable, with 134 (7.9%) cases both alcohol-negative and psychotropic-drug-positive, of these, 59 (3.5%) were graded 4 to 6, indicating a possible to very probable contribution to drowning. Our findings suggest that psychotropic drugs may play a significant role in drowning, in up to 14.5% of cases, independently or in association with alcohol. CONCLUSIONS: Psychotropic drugs alone or in association with alcohol may be an overlooked risk factor in drowning, due to their effects on psychomotor function and cognition. Future studies should also address other mechanisms-for instance drug-induced long-QT syndrome-by which drugs may contribute to drowning.

Methodological challenges in using the Finnish Hospital Discharge Register for studying fire-related injuries leading to inpatient care.

BACKGROUND: The objective was to examine feasibility of using hospital discharge register data for studying fire-related injuries. METHODS: The Finnish National Hospital Discharge Register (FHDR) was the database used to select relevant hospital discharge data to study usability and data quality issues. Patterns of E-coding were assessed, as well as prominent challenges in defining the incidence of injuries. Additionally, the issue of defining the relevant amount of hospital days accounted for in injury care was considered. RESULTS: Directly after the introduction of the ICD-10 classification system, in 1996, the completeness of E-coding was found to be poor, but to have improved dramatically around 2000 and thereafter. The scale of the challenges to defining the incidence of injuries was found to be manageable. In counting the relevant hospital days, psychiatric and long-term care were found to be the obvious and possible sources of overestimation. CONCLUSIONS: The FHDR was found to be a feasible data source for studying fire-related injuries so long as potential challenges are acknowledged and taken into account. Hospital discharge data can be a unique and powerful means for injury research as issues of representativeness and coverage of traditional probability samples can frequently be completely avoided.

Ethylene glycol poisoning may be associated with elevated post-mortem vitreous glucose level.

Ethylene glycol (EG) is a toxic chemical that is sometimes used as ethanol substitute. Besides the desired intoxicating effects, the intake of EG may often lead to death unless timely treatment measures are provided by medical professionals. We examined 17 fatal EG poisonings between 2016 and March 2022 in Finland in terms of forensic toxicology and biochemistry results and demographic information. Most of the deceased were male and the median (range) age was 47 (20-77) years. Of the cases, 6 were suicides, 5 accidents and in 7 cases the intent remained undetermined. In all cases, vitreous humour (VH) glucose was above the limit of quantitation 0.35 mmol/L (mean: 5.2 mmol/L; range 0.52-19.5 mmol/L). Other markers of the glycaemic balance were within the normal range in all except one case. As EG is not routinely screened for in most laboratories but only analysed in cases where the intake of EG is suspected, some fatal EG poisonings may remain unrecognised in post-mortem (PM) investigations. Although various conditions may induce hyperglycaemia, it is worthwhile keeping in mind that elevated PM VH glucose levels that cannot be otherwise explained may suggest intake of ethanol substitutes.

Autopsy-Based Learning is Essential But Underutilized in Medical Education: A Questionnaire Study.

To this day, autopsies and dissections have been essential in medical education, but declining autopsy numbers have endangered this long-standing tradition. Students' perceptions of these teaching methods should be constantly updated to help educators understand how to achieve their teaching goals. The purpose of this study was to explore the state of autopsy- and dissection-based teaching in two Finnish universities based on the experiences of the students, survey their perceptions of such teaching, and to compare the Finnish situation with students' perceptions in other countries as it emerges from medical literature. A questionnaire went to 859 second-, fourth-, and sixth-year medical students. The questions concerned dissection and autopsy classes these students had attended, the views of the students in regard to the number of classes, and the benefits of and attitudes towards autopsy teaching. An open question of how to improve autopsy teaching was included. The response rate was 19.4%. Most respondents requested more autopsy and dissection classes, especially practical education. They found autopsies most beneficial in learning anatomy and dealing with one's own emotions related to death. Their experiences proved least beneficial for interaction with the relatives of a deceased patient and for people skills. Integrational methods and focusing on the main learning outcomes were suggested as improvements. Overall, students found dissection and autopsy teaching important, but felt concerned about the diminishing autopsy numbers. Focusing on main learning objectives and better integration of autopsies in the teaching of different specialties could help to utilize autopsies to a greater extent.

Land-traffic crash leading to passenger vehicle submersion, drowning and other fatal injuries: A 44-year study based on records from the Finnish Crash Data Institute.

BACKGROUND: Land motor traffic crash (LMTC) -related drownings are an overlooked and preventable cause of injury death. The aim of this study was to analyze the profile of water-related LMTCs involving passenger cars and leading to drowning and fatal injuries in Finland, 1972 through 2015. MATERIALS AND METHODS: The database of the Finnish Crash Data Institute (FCDI) that gathers detailed information on fatal traffic accidents provided records on all LMTCs leading to drowning during the study period and, from 2002 to 2015, on all water-related LMTCs, regardless of the cause of death. For each crash, we considered variables on circumstances, vehicle, and fatality profiles. RESULTS: During the study period, the FCDI investigated 225 water-related LMTCs resulting in 285 fatalities. The majority of crashes involved passenger cars (124), and the cause of death was mostly drowning (167). Only 61 (36.5%) fatalities suffered some-generally mild-injuries. The crashes frequently occurred during fall or summer (63.7%), in a river or ditch (60.5%), and resulted in complete vehicle's submersion (53.7 %). Half of the crashes occurred in adverse weather conditions and in over 40% of the cases, the driver had exceeded the speed limit. Among drivers, 77 (68.8%) tested positive for alcohol (mean BAC 1.8%). CONCLUSION: Multidisciplinary investigations of LMTCs have a much higher potential than do exclusive police and medico-legal investigations. The risk factors of water-related LMTCs are similar to those of other traffic crashes. However, generally the fatal event in water-related LMTC is not the crash itself, but drowning. The paucity of severe physical injuries suggests that victims' functional capacity is usually preserved during vehicle submersion. Practical Applications: In water-related LMTCs, expansion of safety measures is warranted from general traffic-injury prevention to prevention of drowning, including development of safety features for submerged vehicles and simple self-rescue protocols to escape from a sinking vehicle.

Quality of cause-of-death reporting using ICD-10 drowning codes: a descriptive study of 69 countries.

BACKGROUND: The systematic collection of high-quality mortality data is a prerequisite in designing relevant drowning prevention programmes. This descriptive study aimed to assess the quality (i.e., level of specificity) of cause-of-death reporting using ICD-10 drowning codes across 69 countries. METHODS: World Health Organization (WHO) mortality data were extracted for analysis. The proportion of unintentional drowning deaths coded as unspecified at the 3-character level (ICD-10 code W74) and for which the place of occurrence was unspecified at the 4th character (.9) were calculated for each country as indicators of the quality of cause-of-death reporting. RESULTS: In 32 of the 69 countries studied, the percentage of cases of unintentional drowning coded as unspecified at the 3-character level exceeded 50%, and in 19 countries, this percentage exceeded 80%; in contrast, the percentage was lower than 10% in only 10 countries. In 21 of the 56 countries that report 4-character codes, the percentage of unintentional drowning deaths for which the place of occurrence was unspecified at the 4th character exceeded 50%, and in 15 countries, exceeded 90%; in only 14 countries was this percentage lower than 10%. CONCLUSION: Despite the introduction of more specific subcategories for drowning in the ICD-10, many countries were found to be failing to report sufficiently specific codes in drowning mortality data submitted to the WHO.

Land motor vehicle-related fatal drowning in Finland: A nation-wide population-based survey.

OBJECTIVE: WHO mortality statistics overlook land motor-vehicle accident (LMVA)-related drowning. The aim of the study was to provide an overview of the prevalence and trends of fatal LMVA-related drowning in Finland, plus the main crash settings, victims' demographic characteristics, and contributing factors leading to such deaths. METHODS: A descriptive, retrospective, population-based study of drowning deaths associated with LMVA among Finnish residents of all ages, 1971-2013. LMVA-related drownings and applicable variables were extracted from the Statistics Finland (SF) mortality database by cross-analysis of ICD injury- and external cause-of-death codes. RESULTS: During the study period, 538 LMVAs leading to drowning occurred among Finnish residents (2.5/1 000 000/year; 4.9% of all unintentional drownings, 3.7% of all LMVA). Three main settings, ones responsible for over 95% of LMVA-related drownings, were recognized: traffic vehicle accidents involving a passenger car; non-traffic vehicle accident involving a snowmobile; and non-traffic accidents involving agricultural, industrial, or construction vehicles. Alcohol use was a contributing factor for death in > 40% of the victims, whereas severe injuries were reported in less than 6%. CONCLUSION: Because transport safety is crucial to prevent any vehicle entering the water, placing LMVA-related drowning in the category of transport accidents is warranted. Once the vehicle becomes submersed, however, prevention measures to avoid death by drowning remains decisive.

Asbestos fibers in para-aortic and mesenteric lymph nodes.

BACKGROUND: Asbestos fibers are known to accumulate in lung parenchyma and thoracic lymph nodes, but their presence and translocation into the extrapulmonary tissues need clarification. We assessed the presence of asbestos in the para-aortic (PA) and mesenteric (ME) lymph nodes. METHODS: PA and ME lymph nodes and lung tissue from 17 persons who underwent medicolegal autopsy for suspicion of asbestos-related disease and from five controls were analyzed for asbestos fibers using transmission electron microscopy. RESULTS: High concentrations of amphibole asbestos fibers were detected in several lung tissue samples and in the respective PA and ME lymph nodes. The mean concentration for the 10 persons with a lung asbestos content of >/=1 million fibers/g of dry tissue (f/g) was 0.85 (<0.05-4.36) million f/g in the PA lymph nodes and 0.55 (<0.02-2.86) million f/g in the ME lymph nodes. The respective mean values for the 12 persons with a lung asbestos concentration of <1 million f/g were 0.07 for the PA lymph nodes and 0.03 million f/g for the ME nodes. The lung asbestos burden that predicted the detection of asbestos in abdominal lymph nodes was 0.45 million f/g. CONCLUSIONS: In addition to their accumulation in lung tissue, asbestos fibers also collect in the retroperitoneal and the mesenteric lymph nodes. Even low-level occupational exposure results in the presence of crocidolite, amosite, anthophyllite, tremolite, or chrysotile in these abdominal lymph nodes. Our results support the hypothesis of lymph drainage as an important translocation mechanism for asbestos in the human body.

Epidemiology of alcohol-related unintentional drowning: is post-mortem ethanol production a real challenge?

BACKGROUND: Post-mortem (PM) ethanol production may hamper the interpretation of blood alcohol concentration (BAC) in victims of drowning. Different exclusion criteria (e.g. cases with low BAC or with protracted interval between death and toxicological analysis) have been proposed with no factual figures to reduce the potential bias due to PM ethanol production when examining the prevalence rates for alcohol-related drowning. The aim of this study is to verify the extent to which PM alcohol production may affect the accuracy of studies on drowning and alcohol. FINDINGS: Unintentional fatal drowning cases (n = 967) for which a full medico-legal autopsy and toxicological analysis was performed, in Finland, from 2000 to 2013, and relevant variables (demographic data of the victims, month of incident, PM submersion time, blood alcohol concentration, urine alcohol concentration (UAC), vitreous humour alcohol concentration (VAC) were available. Overall, out of 967 unintentional drownings, 623 (64.4%) were positive for alcohol (BAC > 0 mg/dL), 595 (61.5%) had a BAC ≥ 50 mg/dL, and 567 (58.6%) a BAC ≥ 100 mg/dL. Simultaneous measurements, in each victim, of BAC, UAC, and VAC revealed PM ethanol production in only 4 victims (BAC: 25 mg/dL - 48 mg/dL). These false positive cases represented 0.4% of drownings with BAC > 0 mg/dL and 14.3% of drownings with BAC > 0 mg/dL and < 50 mg/dL. CONCLUSIONS: The present study suggests that PM ethanol production has a limited impact on research addressing the prevalence rate for alcohol-related drowning and that the use of too rigorous exclusion criteria, such as those previously recommended, may led to a significant underestimation of actual alcohol-positive drowning cases.

Left cerebral hemisphere hydrophilic polymer embolism associated with endovascular WEB treatment of a ruptured aneurysm of the anterior cerebral artery.

Hydrophilic polymer embolism (HPE) is a rare, likely under-recognized iatrogenic complication, caused by fragmentation of surface materials used on endovascular medical devices. The organs most often involved in HPE are the brain and lungs, resulting in both local and systemic reactions. We present the case of a cerebral HPE associated with WEB treatment of a ruptured aneurysm of the anterior cerebral artery, and involving diffusely the left cerebral hemisphere. The patient developed pneumonia and status epilepticus, and died 24 days after the endovascular procedure, most likely as a result of the sequelae of the aneurysm rupture. The precise role of HPE in the sequence of events leading to death can remain, as in this case, a matter for speculation. However, the potential role of HPE in the events leading to death following diagnostic and therapeutic procedures should be appropriately assessed, especially when recovery does not progress as expected.

How well does a national newspaper reporting system profile drowning?

In Finland, the Finnish Association for Swimming Instruction and Life Saving (SUH) and Statistics Finland (SF) both provide nationwide data on unintentional drowning. The SUH database relies on rapid reporting from a newspaper clipping service and additional local police information, whereas the SF database relies on the later release of the death certificate information, which is based on extensive medico-legal investigation. The aim of the study was to explore the main differences between the SUH and SF databases for drowning and to evaluate the capacity of the former to characterize drowning events in Finland from 1998 to 2000. Computerized files of death certificates tabulated by SF were linked with the SUH database by deterministic methods. SF and SUH databases allowed the identification of 704 and 567 unintentional drownings, respectively, giving an unintentional drowning rate of 4.5 and 3.6/100?000 per year. Of the 704 drownings described by SF, 418 (59.4%) were also found in the SUH database. The SUH database markedly underreported drowning fatalities in certain settings, such as bath, ditch and swimming pool drownings; fall- and land-traffic-related drownings; and drownings occurring in South Finland. The narrative text of SUH drownings contributed limited information to characterize the drowning events. It was concluded that the newspaper-based SUH data provide more timely data on individual drownings but are not representative of all drownings. Conversely, the SF vital statistics data are more accurate but may take up to 2 years to become available. Both SUH and SF data provide little detailed information on drowning events. A multidisciplinary national surveillance system for drowning is necessary to provide more accurate and timely drowning data, analyse risk factors and design follow-up studies for developing and monitoring prevention strategies.

Economic burden of fire-related deaths in Finland, 2000-2010: Indirect costs using a human capital approach.

BACKGROUND: The aim of this study was to examine the indirect economic burden of fire-related deaths in Finland in the period 2000-2010. METHODS: The Human Capital (HC) approach was the main method used to estimate productivity losses due to fire-related deaths. Additionally, Potential Years of Life Lost (PYLL) due to deaths were reported. RESULTS: A total of 1090 fire-related deaths occurred in the period 2000-2010 within a population of some 5.4 million. The majority were male (76% vs 24%), with a mean age of 52 (CI: 51.0-53.2) years for males and 57 (CI: 54.6-59.6) for females; 24% (CI: 21.1-26.2%) of victims were over the retirement age. Most of the victims died of combustion gas poisoning (65%, CI: 61.8-67.6%), followed by burns (33%, CI: 30.6-36.3%). Alcohol was often involved and victims were often socially disadvantaged, with socioeconomic features significantly deviating from those of the general population. Annual PYLL ranged from 2094 (CI: 1861-2326) to 3299 (CI: 3008-3594), with an annual average PYLL of 2763 (CI: 2675-2851). PYLL per death fell in the study period from 34.3 (2000, CI: 31.0-37.7) to 24.6 (2010, CI: 21.8-27.6). The reduction is attributable to a decreasing fraction of young victims and an increase in average ages. CONCLUSIONS: Total productivity loss in the period 2000-2010 was c.a. EUR 342 million (CI: 330-354 million), giving an annual average of EUR 31.1 million (CI: 30.0-32.2 million), with the mean for a victim being EUR 0.315 million (CI: 0.30-0.33 million). The economic burden of deaths is considerable and this study remedies the lack of academic knowledge about the burden of fire-related deaths.

Citalopram-Induced Long QT Syndrome and the Mammalian Dive Reflex.

While SCUBA diving, a 44-year-old Caucasian patient had an abnormal cardiac rhythm, presumably Torsade de Pointes (TdP), during the initial descent to depth. Upon surfacing, she developed ventricular fibrillation and died. The patient had been treated for mild depression for nearly a year with citalopram 60 mg per day, a drug known to cause prolonged QT interval. She had also been treated with two potentially hepatotoxic drugs. Liver impairment causes selective loss of cytochrome P450 (CYP) 2C19 activity, the major pathway for metabolism of citalopram. The post mortem blood level of citalopram was 1300 ng/mL. The patient was found to be an intermediate metabolizer via CYP2D6, the major pathway for metabolism of desmethylcitalopram; the level of which was also abnormally high. It is suggested that drug-induced long QT syndrome (DILQTS), caused by citalopram, combined with the mammalian dive reflex triggered malignant ventricular rhythms resulting in the patient's death. It is further suggested that, in general, the dive reflex increases the risk of fatal cardiac rhythms when the QT interval is prolonged by drugs.

Unintentional drowning in Finland 1970-2000: a population-based study.

BACKGROUND: While standard data on drowning reported by the World Health Organization (WHO) fails to provide a reliable picture of the burden of drowning in Finland, they suggest that the rates are much higher than those of other industrialized countries. AIM: To determine the true burden of drowning in Finland and factors related to its high rates. DESIGN: Descriptive, retrospective, population-based analysis of all deaths by drowning, among residents of all ages. SETTING: Finland, 1970-2000. MATERIAL AND METHODS: Mortality and population data furnished by Statistics Finland (SF) were used to determine age- and sex-specific drowning mortality rates using both nature- and cause-of-injury codes. Individual-level data from the death certificates were analysed and cross-linked to a nationwide postmortem toxicology database. RESULTS: From 1970 to 2000, 9279 unintentional drownings occurred (mean: 299.3/year SD 84.3, rate 6.1/100 000/year; M:F ratio = 8.6:1), accounting for 11.7% of all unintentional injury deaths. Drowning rates overall have decreased from 9.9/100 000/year in 1970-1972, to 4.5 in 1998-2000 (-2.7%/year; 95% CL: -3.0; -2.5). The most frequent activities related to drowning included boating (29.8%), falling (26.1%), swimming (25.0%), and activities on ice (12.4%). In non-boating-related drownings, 74.5% of males and 67.4% of females tested had a blood alcohol concentration (BAC) >/=50 mg/dl, while in boating-related drownings, the respective values were 78.1% and 71.4%. CONCLUSIONS: WHO statistics underestimate the true burden of drowning in Finland by up to 40-50%. Drowning rates and alcohol involvement in drowning are much higher than in other comparable developed countries. Broad-based countermeasures to reduce alcohol use in water activities are needed as part of any strategy to reduce drowning rates.

Undetermined drowning.

Drowning is one of the leading causes of death when the manner of death remains undetermined. In the present study, we examined the epidemiological and medico-legal profile of 276 undetermined deaths (M:F=3.4:1; mean age 41.9+/-16.0 SD) among 1,707 consecutive bodies found in water and autopsied at the Department of Forensic Medicine, University of Helsinki, from 1976 to 2000. We also describe the differences between the police investigator's initial opinion and the forensic pathologist's death certification, and the different approaches among forensic pathologists when determining the cause of death. There was considerable variation among individual pathologists in the percentage of deaths considered undetermined but these differences were not significantly related to their level of training. Medico-legal training should focus on a standardised diagnostic approach to borderline cases, in which essential factors in determining the manner of death are often ambiguous.

Atypical suicides or the first undiagnosed autoerotic deaths in Europe?

Autoerotic accidental deaths (AAD) are increasingly reported deaths occurring during solitary sexual rituals used to enhance sexual excitement. The majority of these fatalities involve hanging or other form of self-inflicted asphyxia. The German medical literature, with the first recognized AAD published in the early 1900s, has antedated by decades the first significant AAD reports (1950-1953) in English. Early contributions in languages other than English and German are mostly overlooked in current AAD reviews, although AAD were recognised in some European countries as early as the 1940s and 1950s. For a variety of reasons, it is likely that, before the description of the first AAD in the medical literature, some asphyxia deaths have been classified as suicides with peculiar features, instead of as accidents resulting from life-threatening sexual practices. In the present study, we review and comment on three such atypical asphyxia deaths investigated in central Europe (Austria, Italy, Switzerland) during the period 1821 to 1927. The retrospective analysis of these cases revealed some circumstantial and individual features which nowadays could be linked to AAD, and disclosed the reluctance of medical examiners to analyse their motivational, and possibly sexual, background. The medico-legal approach to some autopsy findings of these cases also illustrates some controversial diagnostic issues regarding mechanical asphyxia, issues recurrently debated during the 19th century.