Philemon and Baucis death: a literature review

Double death, i.e., two bodies at a scene, is relatively rare. The double death from natural causes of two close persons is called Philemon and Baucis death in the medicolegal literature. Despite being mentioned for the first time more than 50 years ago, all detailed case reports on this case constellation are from the last 15 years. A comprehensive review of the literature on this phenomenon has not yet been published. In this article, we review the available literature on Philemon and Baucis death. Pathophysiologically, it can be assumed that this phenomenon is a sub-form of so-called psychogenic death. Therefore, we equally review the literature on sudden cardiac death due to acute psychological stress.

Performance of postmortem CT in the diagnosis of natural death from out-of-hospital cardiac arrest

PURPOSE

Postmortem CT (PMCT) is used widely to identify the cause of death. However, its diagnostic performance in cases of natural death from out-of-hospital cardiac arrest (OHCA) may be unsatisfactory because the cause tends to be cardiogenic and cannot be detected on PMCT images. We retrospectively investigated the diagnostic performance of PMCT in the diagnosis of natural death from OHCA and compared it to that of unnatural death.

MATERIALS AND METHODS

Our series included 450 cases; 336 were natural- and 114 were unnatural death cases. Between 2018 and 2022 all underwent non-contrast PMCT to identify the cause of death. Two radiologists reviewed the PMCT images and categorized them as diagnostic (PMCT alone sufficient to determine the cause of death), suggestive (the cause of death was suggested but additional information was needed), and non-diagnostic (the cause of death could not be determined on PMCT images). The diagnostic performance of PMCT was defined by the percentage of diagnosable and suggestive cases and compared between natural- and unnatural death cases. Interobserver agreement for the cause of death on PMCT images was also assessed with the Cohen kappa coefficient of concordance.

RESULTS

The diagnostic performance of PMCT for the cause of natural- and unnatural deaths from OHCA was 30.3% and 66.6%, respectively (p < 0.01). The interobserver agreement for the cause of natural- and unnatural deaths on PMCT images was very good with kappa value 0.92 and 0.96, respectively.

CONCLUSION

As PMCT identified the cause of natural death by OHCA in only 30% of cases, its diagnostic performance must be improved.

Risk factors for mortality due to natural causes and suicide among people with severe mental illness in western China

Excess mortality in people with severe mental illness (SMI) has been extensively reported. However, little is known about mortality due to natural causes and suicide and their risk factors among people with SMI in western China. The study was conducted to determine the risk factors of natural death and suicide among people with SMI in western China. A totoal of 20,195 SMI patients in western China derived from severe mental illness information system in Sichuan province (January 1, 2006, through July 31, 2018) were included in the cohort study. Mortality rates per 10,000 person-years of natural causes and suicide for patients were calculated with different characteristics. Fine-Gray competing risk model was used to identify risk factors of natural death and suicide. The mortality was 132.8 per 10,000 person-years for natural death and 13.6 per 10,000 person-years for suicide. Males, older age, divorced/widowed, poverty and no anti-psychotic treatment were significantly associated with natural death. Higher education and suicide attempt were strong risk factors of suicide. Risk factors were not shared across natural death and suicide among people with SMI in western China. Risk management and interventions for people with SMI should be tailored for specific causes of death.

What's in a name? A discussion on the definition of natural and unnatural causes of death

When considering the manner of death, two categories can be distinguished, namely natural death and unnatural death. Though most physicians think that the distinction between the two is evident, this is not the case.When comparing the Netherlands, Belgium, England and Germany it is noticed that the terms natural and unnatural might be used in law but are not defined by law. In practice, the term unnatural death is used when there is an external cause of death, but even that turns out to not be sufficient in making an obvious difference between the two terms. Different countries may even label the same death differently. A, at times philosophical and semantic, discussion shows that when it comes to causes of death a very large grey area exists between natural and unnatural causes of death. The Netherlands, Belgium and Germany even have the possibility to label a death as natural (or unnatural) without actually knowing the cause of death.In conclusion, we recommend a new system in which the circumstances surrounding a death are properly investigated. This should lead to a report to an independent legal expert, who is able to decide if and what conclusion can be drawn, from a judicial and a public point of view, thereby, making the distinction and the use of the terms natural and unnatural/nonnatural obsolete.

Recent trends in barbiturate detection in medicolegal deaths

A study was undertaken of 51 cases where barbiturates were detected in post-mortem blood samples from 2000 to 2019 at Forensic Science South Australia, Adelaide, Australia. The cause of death was drug toxicity in only 27 (53%) (M:F = 19:8; age range 19-74yrs, mean 46yrs). In 17 cases, barbiturate toxicity was the primary cause of death, 14 due to pentobarbitone and 3 to phenobarbitone. All were suicides. Barbiturates were obtained by online purchase from overseas sources in 9 cases (33%), and through veterinary practice in 2 cases (7%). Drug toxicity deaths where barbiturates were detected rose from 1 in 2000-2004 to 11 in 2015-2019, and those where deaths were primarily due to barbiturate toxicity rose from 1 in 2000-2004 to 9 in 2015-2019. However, the mere detection of barbiturates in post mortem samples did not equate with illicit use, as 23 of the deaths (45%) were due to natural causes in individuals prescribed barbiturates for epilepsy. The usefulness of examining subset populations separate from accrued national data is also demonstrated in the significantly younger age of decedents in South Australia dying from deliberately administered barbiturates (46 yrs) compared to the national average of 57.9 yrs. The reasons for this difference will require further investigation as this may impact upon local suicide prevention strategies.

The potential of using climate indices as powerful tools to explain mortality anomalies: An application to mainland Spain

Changes in the frequency and magnitude of extreme weather events represent one of the key indicators of climate change and variability. These events can have an important impact on mortality rates, especially in the ageing population. This study assessed the spatial and seasonal distributions of mortality rates in mainland Spain and their association with climatic conditions over the period 1979-2016. The analysis was done on a seasonal and annual basis using 79 climatic indices and regional natural deaths data. Results indicate large spatial variability of natural deaths, which is mostly related to how the share of the elderly in the population varied across the studied regions. Spatially, both the highest mortality rates and the largest percentage of elders were found in the northwest areas of the study domain, where an extreme climate prevails, with very cold winters and hot summers. A strong seasonality effect was observed, winter shows more than 10% of natural deaths compared to the rest of the seasons. Also, results suggest a strong relation between climatic indices and natural deaths, albeit with a high spatial and seasonal variability. Climatic indices and natural deaths show a stronger correlation in winter and summer than in spring and autumn.

Consistent acting, legal knowledge and competence of external postmortem examination in Dutch hospital settings

A crucial role in the external postmortem examination system of the Netherlands is that of the attending physicians, who are either general practitioners or physicians in hospitals. They perform 85% of all external postmortem examinations and must immediately report to forensic physicians all unnatural deaths and deaths that they are not convinced to be natural. These attending physicians need therefore to be properly qualified and need to be competent, by acting consistently and by having knowledge of the appropriate laws surrounding external postmortem examination. The aim of this study is to analyse the competence of the attending physicians in hospital settings. This research studied whether they regard themselves as competent, whether they had knowledge of and acted according to the appropriate laws, and whether they acted consistently in following the procedures around external postmortem examinations. A survey was conducted among clinicians. After discarding 23 questionnaires for various reasons, 326 datasets remained on which the research was based. There was no significant difference between the medical specialists (79%) and the residents and fellows (86%) in their feeling of being competent in undertaking external postmortem examinations. The answers of the respondents showed at least one inconsistency in 54%. Of the respondents 34% were considered as to have knowledge of relevant laws. Of the respondents 21% felt competent, was consistent in all their answers and scored a 100% on legal knowledge. The study showed that though a physician might feel competent, this does not mean he actually is competent in performing an external postmortem examination. Furthermore, the extent of a respondents' ignorance of the appropriate laws and the inconsistency in acts and thoughts is undermining the system of postmortem examination.

Reflections on the Linacre Quarterly Issue on Brain Death

There remain serious doubts that "brain death," or death determined by neurological criteria, is equivalent to true death of the human person. This informal essay offers several distinctions that may help clarify doubts about this issue.

Disparities in mortality by disability: an 11-year follow-up study of 1 million individuals

OBJECTIVES

This longitudinal study examines to what extent the risk of mortality-all-cause, natural death, suicide, and unintentional injury mortality-differs by types and severity of disabilities as well as disability status.

METHODS

Data were the National Sample Cohort of 1,025,340 individuals in South Korea followed from 2002 to 2013. Cox regression with time-variant variables was used to estimate the hazard ratio of mortality by disability.

RESULTS

Individuals with disabilities had a higher risk of mortality compared to those without (HR 1.84, 95% CI 1.80-1.88 for natural death; HR 1.83, 95% CI 1.64-2.03 for suicide; HR 1.54, 95% CI 1.38-1.71 for unintentional injury). All types of disability were associated with an increased risk of natural death. Individuals with mental disability were the highest risk group for suicide (HR 7.14, 95% CI 5.31-9.60). People defined as having severe disability had an elevated risk for all categories of mortality.

CONCLUSIONS

Disabilities are important markers of high risk of mortality. Findings call for actions to reduce mortality risk of people with disabilities, including preventing suicidal behaviors of those with mental disability.

Natural death in the setting of autoerotic practice

Deaths in an autoerotic setting are usually due to accidental asphyxia, in which the individual accidently hangs or strangles themselves while inducing hypoxia for the purpose of heightened arousal. Death occurs when the level of hypoxia causes the individual to lose consciousness and is thus unable to prevent the neck compression from becoming lethal. In some cases there is an "escape" mechanism incorporated into the set-up which may fail. In rare cases, death is not as an immediate result of the autoerotic activity and is as a result of natural causes, which may or may not be related to the process. This case demonstrates the death of a 69 year old male which has occurred in the setting of a complex autoerotic environment, not as a result of asphyxiation, but rather as a result of natural causes which is likely to have been brought about by repeated similar activity. The autopsy revealed pulmonary emboli and lower limb deep vein thrombosis. There was no other natural disease of note and no features considered typical of asphyxiation.

Fatal case of retropharyngeal abscess associated with Pott's disease

Retropharyngeal abscess is a rare, deep seated infection of the neck that usually affects young children. Chronic retropharyngeal abscess is rare and results from tuberculosis of the spine. Such swelling in the neck gradually increases in size and is detected during the routine radiological screening for symptoms like pain, dysphagia, fever, dyspnoea, progressive inspiratory stridor (from laryngeal obstruction), neck hyperextension etc, but rarely leads to sudden death due to airway obstruction. Thus the forensic pathologist rarely comes across such type of cases. Present case concerns obstruction of upper airway by a large retropharyngeal cold abscess leading to death in a 13-year-old female child from a lower socio-economic family. The possible explanation for the progression and fatal outcome of such abscesses associated with the Pott's disease is being discussed in the light of available literature.