Asphyxial Games

Introduction

The asphyxial games have been referred to as the “good kid’s drug” [1]. In India while parents worry that their children may consume alcohol or get addicted to drugs, they remain oblivious to the existence of this “safe high”. The ways these games are played are many: having a friend use his hands to squeeze the neck of the “player”, press his hands on the player’s chest, press the player’s neck in the crook of his arm (sleeper hold), or “bear hugging” him. The child makes this game more deadly when he plays it alone. He may attempt to asphyxiate himself by squatting down, breathing rapidly for a few seconds, then quickly standing up and holding his breath, using his own hands to tightly squeeze the neck; placing heavy objects on the chest; placing a plastic bag over the head; or applying a ligature (belt, rope, tie, etc.) around the neck. The resulting restricted blood supply to the player’s brain often leads to pleasurable or euphoric feeling just before losing consciousness and then again when the oxygen deprived brain gets a sudden rush of blood once pressure is released [2, 3, 4]. When these games result in death they are misclassified as suicides. The following five cases bring forth the fatal outcome of what appeared to be a “child’s play”.

Case 1

A 12 year old female was playing in her house with her chunni and some dolls. After a few hours, she was found hanging from the window grill by her mother with the same chunni encircled around the neck. She was immediately brought to Safdarjung Hospital where she was declared brought dead. In the MLC report a query of sexual abuse was raised due to the apparent presence of bite mark present on chin. On post mortem examination the following significant findings were noted: Congestion of face and conjunctiva, tongue was bitten and fingers, lips and gums showed bluish discoloration. Two crescentric nail mark abrasion, were placed vertically, lying end to end, one below the other, of length 0.5 cm each, 03 cm below chin, 1.5 cm left to midline, 3.2 cm above upper border of ligature mark. The ligature mark was present over neck above the thyroid cartilage, oblique, incomplete, total length being 12 cm, and average width being 1.0 cm.

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On reflection of the skin of neck, undersurface of ligature mark appears faint, bloodless, white, glistening. Neck muscles, vessels, hyoid bone, thyroid cartilage, cricoid cartilage, trachea, esophagus, vertebra and spinal column did not show any abnormality. Both lungs were congested. Multiple petechiael hemorrhages was present in interlobar fissure of both lungs. Multiple diffuse petechiael hemorrhages was present over surface of heart. External & internal genitalia, anal orifice and anal canal did not show any gross evidence of sexual abuse. The cause of death was attributed to suicidal hanging.

Case 2

A 11 year old female was found hanging from the ceiling fan hook, using a stool, following which she was brought to Safdarjung Hospital where she was declared dead. The mother accused her neighbor of sexually assaulting the child due to personal enimity. Deceased was 58 inches tall (4 ft 11 inches). Ceiling fan hook to ground distance was 99 inches. Hook to a cemented rack on the side of the room from where the deceased climbed to reach the hook (inclined length) was 64 inches, (straight length) 52 inches, & (horizontal length) 60 inches. On recreating the crime scene, it was deduced that it was not possible for the deceased to have set up the ligature material alone, looping it through the hook, raising question of homicidal intent.

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The neighbor on whom the allegation was made had suffered from knee ligament tear a week ago and was incapable of climbing the stairs to the fourth floor where the victim was found hanging.

Deceased was playing with other children and was reported to have said that since her dad had scolded her she is going to hang herself. All the other children (4 in number) were aged about 11-12 years. They were the last to see the deceased. The role of these children was not investigated due to the statements given by the mother. On autopsy, face and conjunctiva was congested. Fingers, lips and gums showed bluish discoloration. Ligature material was a multi colored stoal with a single fixed knot present in situ. Ligature mark was present over the neck, above the thyroid cartilage, oblique, going symmetrically upwards on both sides of neck to occipital region, incomplete, total length of ligature mark being 11 cm, and average width being 1.5 cm. No other external injury/ scuffle mark seen over body. Neck structures did not show any abnormality. Both lungs were congested. Multiple petechiael hemorrhages was present in interlobar fissure of both lungs. External & internal genitalia, anal orifice and anal canal did not show any injury. Hymen was intact .No other external injuries was present, thus grossly no evidence of sexual assault was present and cause of death was given as suicidal hanging. All relevant specimen and swabs were handed over to investigating officer after autopsy.

Case 3

An 11 yr old male was found hanging by a chunni. He used the chunni as a swing at home. His neck was found on the swing and he was found kneeling on the floor. No knot was present. His mother found him hanging and according to her statement, both she and her son were alone in the house at the time of incident, and the house was locked from inside. He was brought to our hospital where he died while undergoing treatment after a few hours. Investigating officer in the inquest papers gave manner of death as suicide in this case.

Ligature mark was present over neck over the thyroid cartilage, faint brown colored pressure abrasion, incomplete, present over front of neck and on either side of neck, almost horizontal, total length of ligature mark being 17 cm, and average width being 1.0 cm. No other external injury/ scuffle mark seen over body. The neck structures were intact and did not show any hemorrhage or fracture. Both lungs were congested. Multiple petechiael hemorrhages present in both lungs. Cause of death was concluded as accidental hanging.

Case 4

A nine year old male child was found dead, tightly wrapped in a curtain which was suspended from the overhead rod, by his parents. He was apparently in the habit of wrapping his head while playing, with the curtain or some other cloth material like bed sheet. On the fateful day, his mother couldn’t find him anywhere in the house and then she found him dead entangled in the curtain. Lungs were congested edematous and having petechiae hemorrhages. Cause and manner of death was determined as accidental smothering.

Case 5

A 14 year old boy was found dead in his hostel room by the police. The room was locked from inside and the deceased was alone. A polythene bag with glue was present covering the face. On investigation it was found that the child was in the habit of glue sniffing and bagging and even used to persuade his friends to try it. He even had “dared” his friend to do the same and time the duration of being able to hold the breath under the polythene bag. On examination, eyes were congested. Lungs were congested and edematous, having petechial hemorrhages. The viscera and nasal swabs were sent for chemical analysis. The cause of death was given as accidental suffocation. The investigating officer labeled the case as suicide in the inquest papers.

Discussion

Asphyxial games are known by many names like Black Hole, Black Out, Flatlining, Funky Chicken, Gasp, Knock Out, Rising Sun, Space Cowboy, Space Monkey, Suffocation Roulette, Tingling, and American Dream Game. But there exists only sparse literature regarding recreational asphyxial behaviour even as, autoerotic asphyxia is detailed in literature as is, accidental hanging [5, 6, 7, 8, 9, 10]. Anecdotally, fatal and nonfatal cases have been reported in the United States, Canada, Australia, Israel, France, England, and Ireland. However, there is virtually no published statistics regarding how many children are aware of the game, have played the game, or are regular practitioners. Self-strangulation by hanging from cloth towel dispensers in Canadian schools was reported by Le and Macnab in 2001 [11]. And a case in the French literature documents the ophthalmologic complications of what is called in France, “the scarf game” [12]. The key generational differences observed was more solo play and the use of ligatures such as dog leashes, belts, bungee cords, and the like to induce asphyxia. The typical age range is between 9 and 15 years with a male: female ratio of approximately 2:1. (In our case series, 9-14 years, male: female 3:2) [13]. This behaviour was considered safe simply because of the absence of alcohol or drugs [9]. Although limited access to such agents sometimes becomes the very reason to turn to this kind of behaviour as a substitute [13]. Cooke, et al. in an article in 1995, on hanging deaths, revealed “Childhood hangings are usually certified as accidental, based on a presumed lack of fatal intent as a result of immaturity, and a humanitarian wish to comfort the family (an accidental finding being perceived to be more helpful to a bereaved family than one of suicide)” [14]. There is gross misclassification of such cases. In India, manner of deaths in children is majorly categorized as accidental or homicidal, while in a case of a female child, further more an angle of sexual abuse comes into play. While what has been observed is, an overwhelming influence of media on children, which seeks to highlight celebrity cases of hanging, further glorifying and encouraging risk taking behavior. This coupled with lack of parental supervision and knowledge results in death by playing such games.

Conclusion

The investigating officer must ask the right questions to the right people to evaluate the possibility of such games in hanging deaths, without preconceived notions. Crime scenes must be diligently scrutinised to discover the unintentional nature of the outcome of asphyxial activity. The medico legal experts, paediatric societies, NGO and media should be educated regarding asphyxial games that can coalition raise public awareness, thus preventing the next catastrophic game from happening.