J Forensic Sci, 2015

doi: 10.1111/1556-4029.12891
CASE REPORT Available online at: onlinelibrary.wiley.com

PATHOLOGY/BIOLOGY

Alessia Viero,1 M.D.; Giovanni Cecchetto,1 M.D., Ph.D.; Rafael Boscolo-Berto,1 M.D.;
Guido Viel,1 M.D., Ph.D.; and Massimo Montisci,1 M.D., Ph.D.

Suicidal Smothering by Rubber Latex Gloves

and Handkerchief

ABSTRACT: Asphyxial deaths are common in forensic practice, being sustained by a variety of mechanisms that cause an oxygen defi-
ciency to the brain. Several classification models have been proposed in the literature, the most recent one being that of the International Net-
work for Forensic Research Group (INFOR). This report describes an unusual case of suffocation where the obstruction of the airways was
caused by a gag formed of three latex gloves and a handkerchief. The manner of death (differential diagnosis between homicide and suicide)
and the different alternatives of classification are discussed.

KEYWORDS: forensic science, forensic pathology, asphyxia, suffocation, smothering, suicide, differential diagnosis, classification

Asphyxial deaths are common in forensic practice, representing
about 515% of all autopsies (13). In the forensic context,
asphyxia (1) is defined as a situation where the body does not
receive or utilize adequate amounts of oxygen, so that the death (4)
is caused by the failure of the cells to receive or utilize oxygen (par-
ticularly the brain, which uses 20% of the bodys oxygen supply).
Because of the innumerable pathways that lead to asphyxia,
the classification is broad and varied, as discussed in detail else-
where (1,4).
In 2010, an International Network for Forensic Research
Group (INFOR) has been founded with the aim of proposing a
unified and simplified classification model of forensic asphyxia
deaths (5).
This novel classification effort foresees four main categories:
suffocation (which regroups smothering, choking, and confined
spaces/entrapment/vitiated atmosphere), strangulation (which
regroups the subcategories hanging, ligature strangulation and
manual strangulation), mechanical asphyxia (which comprises
also positional and traumatic asphyxia), and drowning.
Herein, we report an unusual case of asphyxia death where the
obstruction of the airways was caused by a gag formed of three
latex gloves and a handkerchief. We discuss the differential diagno-
sis between suicidal and homicidal death, and comment on the dif-
ferent alternatives of classifying this unusual form of suffocation.
Case Report
A 88-year-old bedridden man living in his own house with his
nephew, who was taking care of him, begun to show symptoms
of depression (without explicit suicidal manifestations) 2 days
1
Legal Medicine and Toxicology, Department of Cardiological, Thoracic
and Vascular Sciences, University-Hospital of Padova, Via Falloppio, 50,
35121 Padova, Italy.
Received 6 Oct. 2014; accepted 29 Dec. 2014.
after receiving a diagnosis of lung cancer. Neither previous psy-
chiatric therapies nor previous hospitalizations for psychiatric
diseases were known.
One day the grandson, entering the house, found the corpse of
his grandfather lying on his back on the bed. Rubber latex
gloves protruded from his buccal cavity and his right hand rested
on a box of disposable gloves, localized close to the body and
used by the nephew for personal hygiene.
The forensic autopsy was performed the day after the death.
The external examination showed no injuries on the body (in
particular no defense injuries). Blood toxicology performed fol-
lowing a general unknown screening protocol (6) was negative
for drugs of abuse and psychoactive substances.
The face showed a marked cyanosis, with subconjunctival and
sublingual petechial hemorrhages. From the buccal cavity, three
rubber latex gloves, and a crumpled handkerchief were extracted
by pliers (Fig. 1A, C). The above-mentioned material was recov-
ered above the epiglottis (Fig. 1B).
The autopsy showed congested lungs, pulmonary edema, acute
pulmonary emphysema; a solid circular mass was also found at
the right lung and collected for histology. There were no frac-
tures of the hyoid bone or of the thyroid cartilage.
The neck structures (tonguepharynxlarynxtrachea) were
removed in a single block and fixed in formalin; the section
showed no additional material above or below the epiglottis and
no signs of ulcers, the absence of which was established also at
histology. Histopathological examination confirmed the macro-
scopic framework of asphyxiation and identified the presence of
a right pulmonary adenocarcinoma.
Discussion
Integrating all macroscopic and microscopic autopsy data, the
cause of death was identified in the obstruction of the upper res-
piratory tract (above the epiglottis) by multiple rubber latex
gloves and a crumpled handkerchief.

2015 American Academy of Forensic Sciences 1

2 JOURNAL OF FORENSIC SCIENCES
FIG. 1(A) Buccal cavity of the victim while extracting the foreign mate-
rial; (B) neck structures (larynx and trachea) removed en-block from the
body; (C) gag formed of three rubber latex gloves and a crumpled hand-
kerchief.
In the reported case, it is quite easy to conclude for a violent
asphyxia death, while it is more complicated to reconstruct the
manner of death and, above all, to find the proper classification
for this specific kind of asphyxiation (i.e., suffocation by a for-
eign body inserted into the mouth).
Gagging is a form of asphyxia, which results from pushing a
gag (i.e., rolled up cloth or paper ball) into the mouth (generally
to prevent speaking or crying out), resulting in a block of the
pharynx (7). It is almost always homicidal in manner, involving
incapacitated victims, such as newborns or elderly people,
although rare cases of accidental or suicidal self-gagging have
been reported (8,9). Gagging is a seldom-used classification term
for asphyxias and has not been included in the recent INFOR
scheme.
Smothering and choking have received several different defini-
tions and classifications. For smothering three main alternatives
coexist: (i) obstruction at the level of the nose and mouth; (ii)
obstruction of the external airways; and (iii) obstruction of the
upper airways (1).
Definitions of choking vary even more widely: (i) inhalation
of food regardless of the anatomical localization; (ii) obstruction
at the level of the oropharynx; (iii) obstruction of the internal
airways; and (iv) obstruction of the upper airways (1).
Therefore, in the international literature, there is still a lack of
consensus on how to differentiate smothering from choking
(e.g., anatomical localization of the obstruction? Manner of
asphyxia?).
Following the recent proposal by Sauvageau and Boghossian
(1), smothering is defined as the obstruction of the air passages
above the level of the epiglottis, including the nose, mouth, and
pharynx, whereas choking is defined as the obstruction of the air
passages below the epiglottis. If the obstruction is localized to
areas both above and below the epiglottis, the case should be
ruled as choking (1). The above-mentioned classification is the
first international one that considers an anatomical landmark for
differentiating smothering from choking, being simple, clear, and
easy to use at autopsy.
In our case, the foreign material was recovered above the
epiglottis and there were no macroscopic or histological signs of
ulcers below the above-mentioned landmark, allowing us to
exclude that the latex gloves did pass the epiglottis. Therefore,
ignoring the term gagging, which nowadays is uncommon, and
following the recent proposal by Sauvageau and Boghossian (1),
our case can be classified as a smothering.
Boghossian et al. in their review (10) highlight that smother-
ing is probably more homicidal, rather than suicidal in manner,
when suffocation by plastic bags are excluded (they represent
59% of all smothering forms) (10,11). These data are in keeping
with the Di Maios textbook (4), where the most common form
of suicidal smothering is described as placing a plastic bag over
the head, whereas the most part of the remaining smothering
asphyxias are homicidal in manner.
In light of the above, we could speculate that smothering by
foreign objects inserted into the mouth above the level of the
epiglottis should be more frequently homicidal than suicidal in
manner, probably because the aggressor, in an attempt to kill the
victim who tries to defend her/his own life, is not able to insert
the object in depth.
Conversely, choking (as defined by Sauvageau and Boghos-
sian) should usually be accidental or suicidal in manner because
the subject who wants to kill her/himself, in an attempt to make
an irreversible action, inserts the object in depth, generally
below the level of the epiglottis with the purpose of not being
capable of extracting it. There are indeed many cases reported
in the literature on simple and complex suicidal choking, all
concerning psychiatric subjects, who inserted various means
below the epiglottis, such as talcum powder (12), poison ivy
(13), tissue paper (14,15), newspaper fragments (16), and a
closed pill-bottle (17).
On the other hand, only rare cases of suicidal smothering,
comprising the insertion of foreign material into the mouth
above the epiglottis, have been published (18,19).
Our case belongs to this group, because all circumstantial
(i.e., no signs of breaking; no familiar problems), clinical (i.e.,
recent diagnosis of carcinoma), and autopsy data (lack of exter-
nal injuries on the body, negative results at toxicology) excluded
a homicide or an accident, pointing toward a suicidal manner.
Also the means used for the asphyxiation were in accordance
with the suicidal hypothesis, as the latex gloves were in a box
 VIERO ET AL. . SUICIDAL SMOTHERING BY LATEX GLOVES 3

near the bed of the deceased, easily reachable by the victim just
lengthening his arm.
We believe that the presented case could be of interest for the
readers as for the uncommon means used in the suicide (i.e.,
latex gloves and handkerchief) and their unusual anatomical
localization (i.e., gag positioned above the epiglottis in a
suicide).
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Additional information and reprint requests:
Guido Viel, M.D., Ph.D.
Legal Medicine and Toxicology
Department of Cardiological, Thoracic and Vascular Sciences,
University-Hospital of Padova
Via Falloppio, 50
35121 Padova
Italy
E-mail: guido.viel@unipd.it