JForensicSci, January 2013, Vol. 58, No. S1 doi: 10.1111/j.1556-4029.2012.02302.x CASE REPORT Available online at: onlinelibrary.wiley.com PATHOLOGY AND BIOLOGY

Manoel E. S. Modelli,1 M.D., Ph.D.; Maciel S. Rodrigues,1 M.D.; Bruno Z. M. Castro,2; and Rodrigo S. Corrêa,2

Self-Induced Fatal Air Embolism: Accidental Autoerotic Death or Suicide?

ABSTRACT: Autoeroticism comprises behavior deviations aimed at producing sexual gratification through the manipulation of one’s own body. The use of asphyxia and the induction of pain (masochism) are well-known examples. “Atypical forms” of such behaviors have appeared in the literature as isolated cases. Fatal air embolism is most common in women (causing abortion), being very rare in men (urethral trauma). The authors present a probable case of air embolism associated with signs of autoeroticism, instrumented by the delivery of air through a sys- tem formed by a compressor (typical of those used in refrigerators), a syringe barrel, a segment of latex tubing (tourniquet), and a needle, which was found inserted into the glans penis of an adult male. The hypothesis of accidental death was chosen due to the findings at the scene. The body was decomposing when found, which hampered the conduction of examinations.

KEYWORDS: forensic science, autoeroticism, air embolism, masochism, asphyxia, paraphilias

Paraphilias, formerly called sexual perversions, are attitudes In Germany, there are about 40–80 deaths per year because of that diverge from those commonly accepted by society. People such accidents. Incidence in the Hannover area is 0.49 cases per who practice paraphilias do not have regular sexual activity, that million inhabitants per year. Breitmeier et al. (4) reported 17 is, their “diverted” preference becomes exclusive. People with cases, all relating to men with mean age of 36.8 years; 12 vic- such behavior patterns utilize a large variety of devices and tims were found in their homes, and income levels and types of adopt, among others, the practices of masochism (sexual satisfac- occupation varied widely among victims. Five victims were tion through physical pain) and autoeroticism, which represent completely naked, four were dressed as women, and two were deviant behaviors undertaken in search of sexual gratification dressed but with their genitalia exposed. In addition to women’s through the manipulation of one’s own body. One can include clothes, other objects were found at crime scenes, including asphyxiology, anesthesiophilia, and electrophilia among these ropes, plastic bags, condoms, rubber items, and other erotic arti- practices (1). cles. Blood alcohol levels in these men were between 0.1% and Atypical autoerotic deaths include a variety of mechanisms 2.5%, and toxicology tests revealed chloroform, ketamine, pro- and means to achieve sexual gratification, the most common pane and butane gas, cocaine, and morphine in their bodies. practice of such being asphyxia. The satisfaction mechanism in Causes of death included mainly central nervous system injury this practice would be the deprivation of oxygen flow to the after strangulation (seven cases) and other types of asphyxia central nervous system, which, in turn, leads to rapid distur- (four cases). bance of the central inhibitory mechanisms that control sexual Fatal air embolism is not a rare event, occurring mostly in activity, resulting in heightened senses and hallucinations of women who undergo genital showers to rid themselves of erotic nature (2). unwanted pregnancies. In men, however, the condition is rare. The estimate of autoerotic accidental deaths, based on isolated Cooke (5) reported a case of fatal gas embolism resulting from reports, is of 500–1000 deaths per year (3). In a retrospective study autoinsufflation of the urethra with a Higginson syringe. The of cases from 1985 to 2009, 38 autoerotic deaths were identified right ventricle showed very frothy blood, and the main pulmo- in Alberta, Canada, which corresponds to an incidence of nary artery and the urethra had numerous petechiae. Urethral 0.56 deaths per group of 1,000,000 inhabitants. The most com- injuries caused by repeated passage of urethral probes also can monly practiced methods occur through asphyxia, but there also cause gas embolism (6). are cases of electrocution, overdressing, insertion of foreign bodies, and atypical chest compressions (suspension and immersion) (3). Case Report A 38-year-old man was found dead in his house, already in 1 Institute of Legal Medicine of the DF, Federal District Civil Police, Brasí- decomposition state, with no signs of violence. The body was lia, Brazil. 2Institute of Criminology of the DF, Federal District Civil Police, Brasília, naked, with the exception of slippers. The individual was found Brazil. lying on a sheet of plywood in semi-sitting position, leaning Received 8 Sept. 2011; and in revised form 30 Nov. 2011; accepted 10 back on a mattress supported against the wall. His head was Dec. 2011. bowed and tilted toward the left, resting on a helmet. Under the

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FIG. 2––Detail of the needle inserted into the penis. FIG. 1––Scene where the corpse was found with the system employed. body of the victim, on the floor, the presence of insect eggs cient enough to produce embolism depending on the region (flies) was verified, in addition to a mixture of putrefied liquids reached by needle; (iii) the system described above was not suit- and blood from the corpse. Many magazines and newspapers able for efficiently transmitting electric discharges to the body of also could be seen under the trunk of the body. Close to the sub- the victim; and (iv) the characteristics of the aforementioned sys- ject’s right thigh, a system was found consisting of a compressor tem, the position of the body, and the alignment observed (typical of those used in refrigerators) with its output connected between the mirror and the genital area of the body indicate that to a syringe barrel whose tip was connected to a segment of the victim intentionally introduced the needle on the glans penis. latex tubing (tourniquet). The other extremity of the tourniquet was tied, and the other tip of the syringe was a needle typical of Background those used in the delivery of intravenous medication. Upon arrival on the scene, the compressor was in operation, The victim’s medical history is unknown, and the victim had pumping air, and the bezel and part of the shank of the needle never expressed any suicidal thoughts to his close friends. There had been inserted into the side of the glans penis of the corpse also was no history of sexual disorders or objects that would (Fig. 1). denote sexual perversions at the residence. The items found on the sheet of plywood included, among others, a mirror, aligned with the genital area of the body, male Discussion clothes, and a backpack. A piece of cloth was found on the left hand of the corpse and, next to it, a plastic bottle containing There have been no reports of fatal accidents with autoerotic ethanol. No evidence of female clothing/artifacts was found mechanisms in our services until the present case. Autoerotic anywhere inside the residence. All the belongings of the victim deaths are usually not witnessed because they occur in isolated were lined up and preserved, including personal effects, some environments, as is usually the case because of the secretive nat- amount of cash, a motorcycle, and a car parked in the garage. ure of such activity. These events usually involve young, male The autopsy examination revealed the corpse of a 38-year-old individuals, and death is usually due to failure of the apparatus man, with darkened skin coloration because of the decay process used (2). (gas phase). Brouardel’s posthumous circulation was present on Autoerotic deaths involve a large variety of mechanisms and the trunk and thighs, as well as other factors, including means to achieve sexual gratification. The most common prac- blackened and misshapen face, protruding eyes and tongue, tice is asphyxia, and most victims are young males. Other distension of genitals, putrefactive blistering throughout the modalities include chest compressions, plastic bags covering the body, detachment of epidermic skin flaps, absence of rigor mor- face, use of electric current, inhalation of toxic or chemical tis, and eggs (flies) deposited throughout the entire body. The gases, and partial or total submersion (7). Koops et al. (8) high- subject showed no signs of external injury. The opening of the lighted three of 40 accidental deaths: a firefighter who hanged cranial, chest, and abdomen cavities revealed no fractures or himself from a bridge in a peculiar system; a second case blood collections besides the changes resulting from the putre- involved women’s clothing, on which the victim strangled with faction process. The genitalia showed two types of changes upon an electrical cord; and on the third case, the victim suffered mus- macroscopic examination: alterations derived from the putrefac- cular dystrophy and was incapable of moving. He then led a tion process and also lighter areas, probably caused by the dis- nurse to put plastic bags over his body, close his mouth with semination of air in the tissue (Fig. 2). tape, and put him in a closed container, where he died by suffo- Toxicological investigation on-site did not reveal the presence cation. The police found various diskettes with fantastic sexual of any poisonous substance or drug. The analysis of site imaginations. conditions and the autopsy examination led to the following Among atypical practices in autoeroticism, urethral handling conclusions: (i) the individual died within the place and on a through probes is a rare occurrence, and air embolism resulting location close to that on which he was found; (ii) the system from such practice is even rarer. Chávez et al. (6) reported the found (compressor plugged in, connected to a syringe barrel, first case of gas embolism of the vena cava posturethral trauma. latex tube, and needle partially inserted into the glans) was effi- The traumatic insertion of a Foley catheter resulted in a major, MODELLI ET AL. . SELF-INDUCED FATAL AIR EMBOLISM S263 symptomatic embolism of the vena cava, confirmed using a sexual fantasy, autoerotic behavior, and no prior history of computed tomographic (CT) scan. Most foreign bodies found in suicide. the genital tract are self-inserted into the urethra as a result of erotic impulses and sexual curiosities (9). According to Sauva- Conclusion geau (3), atypical methods of autoerotic activity leading to death accounted for about 10% of cases in the literature. After considering the following facts: there have been no An Italian naturalist, Redi, was the first to describe the death traces of breaking and entering on the access ways of the resi- of animals by injection of air into a neck vein in 1667 (10). dence, there was no indication of acquisition of objects or Presence of air in the neck vein of human male subjects was money from the interior of the house, the keys of the vehicles first reported by Beauchesne during removal of a tumor in 1818 were in visible and easily accessible locations, the furniture was (10). The physiology consists of an obstruction of the right ven- well aligned, the victim had in his left hand a piece of cloth next tricle, thus preventing airflow to the lung. When the air reached to a bottle of alcohol (likely for sepsis), and that the death by the right ventricle, pulmonary arterial pressure increased, and injection of air or other substances in the genital region is not a systemic blood pressure decreased (10). common practice adopted by suicidal individuals, the most likely The main causes of gas embolism in the human body are as hypothesis is that of accidental death by air embolism, secondary follows: decompression syndrome (in cases of deep dives) when to a possible attempt to obtain pleasure from manipulation of sudden pressure differences lead to release of nitrogen, which one’s own body (autoeroticism). dissolves in the body under high pressure; concentration of nitrous oxide (34 times more soluble than air in the blood); sur- geries; accidents; and extracorporeal circulation (11). Han et al. References (12) have reported a case of massive cerebral air embolism in a 1. Janssen W, Koops E, Anders S, Kuhn S, Puschel K. Forensic aspects of man who underwent catheterization of the right internal jugular 40 accidental autoerotic deaths in Northern Germany. Forensic Sci Int – vein and became obnubilated. CT scan revealed acute infarction 2005;147S:S61 4. 2. Solarino B, Leonardi S, Grattagliano I, Tattoli L, Di Vella G. An unusual with multiple blisters on the side of the catheter insertion. Ridick death of a masochist: accident or suicide. Forensic Sci Int 2011;204:e16–9. and Brogdon (13) reported air embolism during kidney dialysis, 3. Sauvageau A. Autoerotic deaths: a 25-year retrospective epidemiological which is rare because of the protective mechanisms present in study. Am J Forensic Med Pathol 2012;33(2):143–6. the unit. 4. Breitmeier D, Mansouri F, Albrecht K, Böhm U, Tröger HD, Kleemann WJ. Accidental autoerotic deaths between 1978 and 1997. Institute of Legal Fundamentally, there are two types of embolism: pulmonary Medicine, Medical School Hannover. Forensic Sci Int 2003;137(1):41–4. or venous and arterial. Arterial embolism is the result of the 5. Cooke RT. Self-induced fatal air embolism in a man. BMJ 1961;4:1197. entry of air on the left side of the heart, either coming from the 6. Chávez AH, Reilly TP, Bird ET. Vena cava air embolism after traumatic pulmonary veins or due to septal defects. Cardiac damage caused Foley catheter placement. Urology 2009;73:748–9. by air bubbles in the coronary and neurological effects of cere- 7. Shields LBE, Hunsaker DM, Hunsaker JC, Wetli CV, Hutchins KD, Holmes RM. Atypical autoerotic death. Part II. Am J Forensic Med bral embolism have both been reported (11). During venous or Pathol 2005;26:53–62. pulmonary embolism, the air comes into a systemic vein and is 8. Koops E, Janssen W, Anders S, Puschel K. Unusual phenomenology of taken to the right side of the heart. Small quantities may be autoerotic fatalities. Forensic Sci Int 2005;147S:S65–7. asymptomatic, whereas larger amounts can cause heart failure 9. Moon SJ, Kim DH, Chung JH, Jo JK, Son YW, Choi HY, et al. Unusual foreign bodies in the urinary bladder and urethra due to autoerotism. Int and death (11). Neurourol J 2010;14:186–9. The current conventional postmortem demonstration of air 10. Gottlieb JD, Ericsson JA, Sweet RB. Venous air embolism: a review. embolism in the heart involves the application of dissection Anesth Analg Curr Res 1965;44:773–9. methods for the demonstration of air into the right ventricle. If 11. Chan KS, Yang W. Survey of literature related to the problems of gas – heart embolism is not suspected, the cardiopulmonary system is embolism in human body. J Biomechanics 1969;2:299 312. 12. Han S, Kim S, Hong H, Lee S, Lee B. Massive paradoxical air embo- not opened under water, which excludes the opportunity to make lism in brain occurring after central venous catheterization: a case report. the diagnosis. Air also may be present in the heart because of J Korean Med Sci 2010;25(10):1536–8. putrefaction. Currently, multislice CT has become the diagnostic 13. Ridick L, Brogdon BG. Fatal air embolism during renal dialysis. Am J modality of choice. It allows one to check the path of air Forensic Med Pathol 2012;33(1):110–2. 14. Saunders S, Kotecha D, Morgan B, Raj V, Rutty G. Demonstrating the through the body (14). origin of cardiac air embolism using post-mortem computed tomography; Analysis of the local scene and autopsy, in the case at hand, an illustrated case. Legal Med 2011;13:79–82. points to accidental death by fatal air embolism. The mechanism 15. Vennemann B, Pollak S. Death by hanging watching violent porno- installed by the victim allowed air to enter the body through the graphic videos on the Internet—suicide or accidental autoerotic death? – cavernous body at great speed, which caused death to occur sud- Int J Legal Med 2006;120:110 4. 16. Hazelwood RR, Dietz PE, Burgess AW. The investigation of autoerotic denly because the dead body remained virtually in the same fatalities. J Police Sci Adm 1981;9:404–11. position as when the device was installed in his genitalia, only with the trunk of the body leaning back. Additional information and reprint requests: In cases of atypical autoerotic death, determining if the death Manoel E.S. Modelli, M.D., Ph.D. was accidental or suicidal is quite challenging for the forensic Federal District Civil Police pathologist. Some authors established criteria for accidental auto- Institute of Legal Medicine erotic death: solitary, accidental, and caused directly by the SQS 210 Bloco D abnormal mechanism aimed at sexual satisfaction (15). Hazel- Apto 604 Brasília Brazil, Brasília 70273-040 wood et al. (16) have described five criteria for designating these Brazil deaths: well-defined self-assistance mechanism, solitary activity, E-mail: [email protected]