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A case of deferred death from drowning of a man found dead in bed at home
Journal of Clinical Forensic Medicine (1996)3, 105-107 © APS/PearsonProfessionalLtd 1996
CASE REPORT
A case of deferred death from drowning of a man found dead in bed at home Y. Sato, T. Kondo, T. Ohshima Department of Legal Medicine, Kanazawa University Faculty of Medicine, Kanazawa, Japan SUMMARY. An autopsy case of deferred death from drowning is reported. A 63-year-old man was found dead wearing wet clothing in his bed at home. At a medico-legal autopsy, mud was observed in the air passages as well as in the stomach, and a total of 210 g pleural effusion was also noted in the thoracic cavity (left 70 g, right 140 g). The left and right lungs were expanded and weighed 800 g and 950 g, respectively. Histological examination revealed the pathological finding of pneumonia with the exudation of numerous leucocytes into the alveoli as well as some postmortem changes. Diatoms were detected in the liver and both lungs by the disorganization method. In addition, scene investigation disclosed that he had fallen into a ditch in front of his house and had inhaled muddy water in the ditch, and had then managed to reach his bed and survive for a while, but dying eventually from aspiration pneumonia as a result of inhalation of exogenous water. The cause of his death was, therefore, given as deferred death from drowning rather than aspiration pneumonia. Journal of Clinical Forensic Medicine (1996) 3, 105-107 INTRODUCTION
CASE HISTORY
The accurate diagnosis of death by drowning is not always accessible to forensic pathologists, since not only the autopsy findings but also such data as the scene investigation findings and other reliable sources of information as to the circumstances must be considered. Among them, the detection of diatoms in the major organs is the most important evidence in establishing the diagnosis of death by drowning, even in the case of a corpse with advanced putrefaction. Although drowning is commonly regarded as a form of asphyxia, it is possible for a person who survives after the immersion to die from the delayed effects of the fluid inhalation. These clinicopathological findings in immersed victims have been discussed by Fuller. 1 However, in the medico-legal field, deferred death from drowning is rarely reported in spite of the high incidence of death by drowning even in Japan. In this article, the authors report an unusual autopsy case of deferred death from drowning in which the deceased was found dead in his bed at home.
On a cold winter morning, a 63-year-old male was found dead in a prone position in his bed at home (Fig. 1). This male had last been seen alive 2 weeks before the discovery. His clothing was wet and his trousers had been removed whilst in the room. There was muddy water in the rubber boots that were found at the entrance to his house, thus suggesting that he had fallen into a ditch full of muddy water in front of his house. The heater had not been switched on, and the room temperature was 4.5 °C.
Yasunori Sato MD, Toshikazu Kondo MD, Tohru Ohshima PhD, MD, Department o f Legal Medicine, Kanazawa University Faculty of Medicine, 13-1 Takara-machi, Kanazawa 920, Japan Correspondence to: Y. Sato
Fig. 1 The scene where the m a n was found dead with wet clothing 105
106
Journal of Clinical Forensic Medicine
AUTOPSY F I N D I N G S
DISCUSSION
The deceased was 170 cm tall and weighed 57 kg. Postmortem rigidity was no longer present. Postmortem hypostasis was evident and, additionally, dark greenish putrefactive discoloration was observed on the abdominal surface. The rectal temperature was 3.5 °C and the postmortem interval was estimated at approximately 2 weeks. Abrasions were observed on the surface of the left cheek and the left ear, and subcutaneous hemorrhages were noted on the right side of the chest and abdomen. The skin of the right hand showed waterlogged appearance ('washerwoman's hand'). Internally, every organ was moderately congested. The left and right lungs were expanded and weighed 800 g and 950 g, respectively. There was a total of 210 g pleural effusion in the thoracic cavity (left 70 g, right 140 g). Mud was observed in the air passages as well as in the stomach. The dark red intracardiac blood contained blood clots. The brain was edematous (weight 1520 g) and showed no pathological lesion. Histological examination revealed definite evidence of pneumonia with the exudation of numerous leukocytes into the alveoli of every lobe of both lungs as well as some postmortem changes (Fig. 2). No other natural disease or major traumatic lesion could be found. Ethanol was not detected in the blood and urine by the pulse heating-gas chromatograph method, nor was any drug detected in the blood or urine by the TOXI-LAB ® screening system. Diatoms were detected in the liver and both lungs by repeated examinations with disorganization method (Fig. 3).
The victims who survive after immersion are generally hospitalized, and may recover completely owing to the recent progress in intensive management. The outcome in some patients, however, is unfortunately fatal even after the admission. Survival after immersion depends on the interaction of many factors such as the victim's age, water temperature, type of inhaled fluid, duration of immersion, and so on. Gee has mentioned that the volume of inhaled fluid itself determines the prognosis in drowning cases. 2 Inhalation of fluid causes considerable changes in the serum electrolytic level, hemoglobin level, blood volume and cardiovascular function, 3,4 and in most of the fatal cases there is a close association with such pathological lesions as pulmonary edema or pneumonia due to the delayed effect of inhaled fluid. 5,6 Ischaemic or anoxic brain damage and respiratory distress syndrome are possibly other delayed effects of drowning. Although the presence of froth in the mouth is known as a positive external sign of drowning, autopsy findings are essential to confirm for the diagnosis of death by drowning. In a survey of several hundred drowning autopsies, Fuller demonstrated that foreign materials other than water were present in the lungs in 70% of these cases. 1 In our case, the presence of mud in the air passages as well as of expanded lungs and pleural effusion indicates the inhalation of muddy water. As clear evidence of inhalation of exogenous fluid in death by drowning, forensic pathologists commonly cite the detection of diatoms, which are present in most water in the natural environment, in the
Fig. 2 Exudation of numerousleucocytesinto the alveolias a result of inhalation of water (H.E. stain, x 100)
Fig. 3 One of the diatoms that were detectedin the liverspecimen
A case of deferred death from drowning of a man found dead in bed at home major organs. The detection of diatoms in our case, especially in the liver, reflects a vital reaction showing the transport of inhaled fluid into the blood stream. Histologically, the acute dilation of the alveoli is a sign of rapid entry of fluid and one of the important findings in drowning cases. 7 The inhaled fluid also produces an inflammatory reaction in the alveolar capillary membrane, occasionally with hyaline membrane formation, even in the immersion victims with short survival. 1 Therefore, we regard the exudation of numerous leucocytes into alveoli observed in our case as a result of the inhalation of muddy water, and this inflammatory reaction as nothing other than a vital reaction, indicating that the man was alive when he presumably fell into the muddy water. In short, this man inhaled muddy water in the ditch and, afterwards, he managed to reach his bed and survive for a while, but aspiration pneumonia, as a vital reaction, eventually led to his death. As for the actual cause of death, however, the authors are of the opinion that 'deferred death from drowning', which has a close relation with the entry of exogenous fluid, rather than 'aspiration pneumonia', more clearly reflects the true circumstances, since the inhaled fluid was neither the gastric contents nor his own blood but the exogenous muddy water; this form of death, with defective blood oxygenation in the lungs due to the exogenous fluid entering the air passages, is more appropriately defined as drowning. 8
107
In addition, it seems odd that this man was found dead with his trousers off, despite the low room temperature. We note that the body temperature occasionally is reduced during the first few hours after the immersion, ~ and if this holds true in our case, this man probably suffered secondary hypothermia after his immersion. It is known that some cold-exposed persons are found dead with their clothing off, a phenomenon known as 'paradoxical undressing'. 9 Therefore, paradoxical undressing due to secondary hypothermia is one possible explanation for his removal of his trousers. REFERENCES
1. Fuller R H. The clinical pathology of human near-drowning. Proc R Soc Med 1963; 56:33 38 2. Gee D J. Drowning. In: Polson C J, Gee D J, Knight B (eds.) The Essentials of Forensic Medicine. 4th ed. Oxford: Pergamon Press 1985:421-448 3. Modell J H. Biology of drowning. Ann Rev Med 1978; 29:1 8 4. Modell J H, Graves S A, Ketover A. Clinical course of 91 consecutive near-drowning victims. Chest 1976; 70:231-238 5. Oakes D D, Sherck J P, Maloney J R, Charters A C. Prognosis and management of victims of near-drowning. J Trauma 1982; 22:544-549 6. Barr A M, Taylor M. A case of drowning. Anaesthesia 1976; 31:651 657 7. Janssen W. Forensic Histopathology. Berlin: Springer-Verlag 1984:224-233 8. Gordon I. The anatomical signs in drowning. A critical evaluation. Forens Sci 1972; 1:38%395 9. Wedin B, Vanggaard L, Hirvonen J.'Paradoxical undressing' in fatal hypothermia. J For Sci 1979; 24:543-553
CASE REPORT
A case of deferred death from drowning of a man found dead in bed at home Y. Sato, T. Kondo, T. Ohshima Department of Legal Medicine, Kanazawa University Faculty of Medicine, Kanazawa, Japan SUMMARY. An autopsy case of deferred death from drowning is reported. A 63-year-old man was found dead wearing wet clothing in his bed at home. At a medico-legal autopsy, mud was observed in the air passages as well as in the stomach, and a total of 210 g pleural effusion was also noted in the thoracic cavity (left 70 g, right 140 g). The left and right lungs were expanded and weighed 800 g and 950 g, respectively. Histological examination revealed the pathological finding of pneumonia with the exudation of numerous leucocytes into the alveoli as well as some postmortem changes. Diatoms were detected in the liver and both lungs by the disorganization method. In addition, scene investigation disclosed that he had fallen into a ditch in front of his house and had inhaled muddy water in the ditch, and had then managed to reach his bed and survive for a while, but dying eventually from aspiration pneumonia as a result of inhalation of exogenous water. The cause of his death was, therefore, given as deferred death from drowning rather than aspiration pneumonia. Journal of Clinical Forensic Medicine (1996) 3, 105-107 INTRODUCTION
CASE HISTORY
The accurate diagnosis of death by drowning is not always accessible to forensic pathologists, since not only the autopsy findings but also such data as the scene investigation findings and other reliable sources of information as to the circumstances must be considered. Among them, the detection of diatoms in the major organs is the most important evidence in establishing the diagnosis of death by drowning, even in the case of a corpse with advanced putrefaction. Although drowning is commonly regarded as a form of asphyxia, it is possible for a person who survives after the immersion to die from the delayed effects of the fluid inhalation. These clinicopathological findings in immersed victims have been discussed by Fuller. 1 However, in the medico-legal field, deferred death from drowning is rarely reported in spite of the high incidence of death by drowning even in Japan. In this article, the authors report an unusual autopsy case of deferred death from drowning in which the deceased was found dead in his bed at home.
On a cold winter morning, a 63-year-old male was found dead in a prone position in his bed at home (Fig. 1). This male had last been seen alive 2 weeks before the discovery. His clothing was wet and his trousers had been removed whilst in the room. There was muddy water in the rubber boots that were found at the entrance to his house, thus suggesting that he had fallen into a ditch full of muddy water in front of his house. The heater had not been switched on, and the room temperature was 4.5 °C.
Yasunori Sato MD, Toshikazu Kondo MD, Tohru Ohshima PhD, MD, Department o f Legal Medicine, Kanazawa University Faculty of Medicine, 13-1 Takara-machi, Kanazawa 920, Japan Correspondence to: Y. Sato
Fig. 1 The scene where the m a n was found dead with wet clothing 105
106
Journal of Clinical Forensic Medicine
AUTOPSY F I N D I N G S
DISCUSSION
The deceased was 170 cm tall and weighed 57 kg. Postmortem rigidity was no longer present. Postmortem hypostasis was evident and, additionally, dark greenish putrefactive discoloration was observed on the abdominal surface. The rectal temperature was 3.5 °C and the postmortem interval was estimated at approximately 2 weeks. Abrasions were observed on the surface of the left cheek and the left ear, and subcutaneous hemorrhages were noted on the right side of the chest and abdomen. The skin of the right hand showed waterlogged appearance ('washerwoman's hand'). Internally, every organ was moderately congested. The left and right lungs were expanded and weighed 800 g and 950 g, respectively. There was a total of 210 g pleural effusion in the thoracic cavity (left 70 g, right 140 g). Mud was observed in the air passages as well as in the stomach. The dark red intracardiac blood contained blood clots. The brain was edematous (weight 1520 g) and showed no pathological lesion. Histological examination revealed definite evidence of pneumonia with the exudation of numerous leukocytes into the alveoli of every lobe of both lungs as well as some postmortem changes (Fig. 2). No other natural disease or major traumatic lesion could be found. Ethanol was not detected in the blood and urine by the pulse heating-gas chromatograph method, nor was any drug detected in the blood or urine by the TOXI-LAB ® screening system. Diatoms were detected in the liver and both lungs by repeated examinations with disorganization method (Fig. 3).
The victims who survive after immersion are generally hospitalized, and may recover completely owing to the recent progress in intensive management. The outcome in some patients, however, is unfortunately fatal even after the admission. Survival after immersion depends on the interaction of many factors such as the victim's age, water temperature, type of inhaled fluid, duration of immersion, and so on. Gee has mentioned that the volume of inhaled fluid itself determines the prognosis in drowning cases. 2 Inhalation of fluid causes considerable changes in the serum electrolytic level, hemoglobin level, blood volume and cardiovascular function, 3,4 and in most of the fatal cases there is a close association with such pathological lesions as pulmonary edema or pneumonia due to the delayed effect of inhaled fluid. 5,6 Ischaemic or anoxic brain damage and respiratory distress syndrome are possibly other delayed effects of drowning. Although the presence of froth in the mouth is known as a positive external sign of drowning, autopsy findings are essential to confirm for the diagnosis of death by drowning. In a survey of several hundred drowning autopsies, Fuller demonstrated that foreign materials other than water were present in the lungs in 70% of these cases. 1 In our case, the presence of mud in the air passages as well as of expanded lungs and pleural effusion indicates the inhalation of muddy water. As clear evidence of inhalation of exogenous fluid in death by drowning, forensic pathologists commonly cite the detection of diatoms, which are present in most water in the natural environment, in the
Fig. 2 Exudation of numerousleucocytesinto the alveolias a result of inhalation of water (H.E. stain, x 100)
Fig. 3 One of the diatoms that were detectedin the liverspecimen
A case of deferred death from drowning of a man found dead in bed at home major organs. The detection of diatoms in our case, especially in the liver, reflects a vital reaction showing the transport of inhaled fluid into the blood stream. Histologically, the acute dilation of the alveoli is a sign of rapid entry of fluid and one of the important findings in drowning cases. 7 The inhaled fluid also produces an inflammatory reaction in the alveolar capillary membrane, occasionally with hyaline membrane formation, even in the immersion victims with short survival. 1 Therefore, we regard the exudation of numerous leucocytes into alveoli observed in our case as a result of the inhalation of muddy water, and this inflammatory reaction as nothing other than a vital reaction, indicating that the man was alive when he presumably fell into the muddy water. In short, this man inhaled muddy water in the ditch and, afterwards, he managed to reach his bed and survive for a while, but aspiration pneumonia, as a vital reaction, eventually led to his death. As for the actual cause of death, however, the authors are of the opinion that 'deferred death from drowning', which has a close relation with the entry of exogenous fluid, rather than 'aspiration pneumonia', more clearly reflects the true circumstances, since the inhaled fluid was neither the gastric contents nor his own blood but the exogenous muddy water; this form of death, with defective blood oxygenation in the lungs due to the exogenous fluid entering the air passages, is more appropriately defined as drowning. 8
107
In addition, it seems odd that this man was found dead with his trousers off, despite the low room temperature. We note that the body temperature occasionally is reduced during the first few hours after the immersion, ~ and if this holds true in our case, this man probably suffered secondary hypothermia after his immersion. It is known that some cold-exposed persons are found dead with their clothing off, a phenomenon known as 'paradoxical undressing'. 9 Therefore, paradoxical undressing due to secondary hypothermia is one possible explanation for his removal of his trousers. REFERENCES
1. Fuller R H. The clinical pathology of human near-drowning. Proc R Soc Med 1963; 56:33 38 2. Gee D J. Drowning. In: Polson C J, Gee D J, Knight B (eds.) The Essentials of Forensic Medicine. 4th ed. Oxford: Pergamon Press 1985:421-448 3. Modell J H. Biology of drowning. Ann Rev Med 1978; 29:1 8 4. Modell J H, Graves S A, Ketover A. Clinical course of 91 consecutive near-drowning victims. Chest 1976; 70:231-238 5. Oakes D D, Sherck J P, Maloney J R, Charters A C. Prognosis and management of victims of near-drowning. J Trauma 1982; 22:544-549 6. Barr A M, Taylor M. A case of drowning. Anaesthesia 1976; 31:651 657 7. Janssen W. Forensic Histopathology. Berlin: Springer-Verlag 1984:224-233 8. Gordon I. The anatomical signs in drowning. A critical evaluation. Forens Sci 1972; 1:38%395 9. Wedin B, Vanggaard L, Hirvonen J.'Paradoxical undressing' in fatal hypothermia. J For Sci 1979; 24:543-553