While human beings can survive in a head-down position for some time, there are rare cases of fatalities from an inverted position. Ten case reports are presented in which an inverted position led to the cause of death. Common features of the cases include finding the victim in a head-down tilted position; significant congestion of the face, scalp, neck, or other dependent parts of the body; evidence of internal congestion with swelling and bleedings at affected areas and edema of the brain and lungs; and a lack of a definite pathoanatomical cause of death. Under most cases, additional pathophysiological considerations are required to determine the cause of death. Based on an analysis of the 10 cases presented here, there is indication that elderly individuals, particularly those with preexisting cardiovascular diseases, are more prone to death in a head-down position than younger persons. As such, final heart failure is more often the cause of death in these cases than cerebral or pulmonary dysfunction. Human and animal experiments confirm this conclusion. Figures, references