Forensic medicine significance of the fluid content of the sphenoid sinuses

In the forensic literature the opinion is often held that the presence of aqueous liquid in the paranasal sinuses in conjunction with other findings (plume of froth around the mouth and nostrils, emphysema aquosum, Paltauf's spots, increased haemolysis etc.) can be regarded as a sign of drowning. Especially the sphenoid sinus is easily accessible at autopsy; its content can be aspirated from the base of the skull with a cannula. The valency of the liquid content in the sphenoid sinuses was consecutively investigated in 60 deaths by drowning and 157 other deaths. The results showed that in 92% of the deaths by drowning between 1 ml and 4 ml of aqueous fluid could be found in the sphenoid sinuses. However, a positive result was also obtained in 52% of the other cases autopsied, but in the control group the average volume of the aspirate was smaller than in the group of deaths by drowning.     

Organ weight effects of drowning and asphyxiation on the lungs, liver, brain, heart, kidneys, and spleen

An examination of the organ weights associated with victims of drowning, asphyxiation and trauma was undertaken to determine (a) the effects of asphyxiation compared to a trauma group, and in turn, (b) the effects of drowning compared to an asphyxiation group. Included in the study were 217 drowning deaths, 166 pure asphyxiation deaths and 381 trauma deaths. The effects of asphyxiation (compared to trauma) resulted in elevated mean organ weights for the lungs, liver, kidneys and spleen (with mean increases of 17.8, 10.5, 10.3 and 23.4%, respectively). Effects of drowning (compared to asphyxiation) resulted in elevated mean organ weights only with the lungs and kidneys (with mean increases of 30.0 and 4.4%, respectively). Only the mean heart and brain weight remained constant across all experimental groups. A picture of drowning is suggested in which elevated lung and kidney weights are the result of both asphyxiation and the aspiration of water that occurs with drowning, whereas elevated spleen and liver weights in drowning victims are associated with only the effects of asphyxiation. In addition, the common autopsy finding of a small, anemic spleen in drowning, rather than caused by some pathophysiological mechanism of death, is hypothesized to be a postmortem phenomenon.     

Organ weight effects of drowning and asphyxiation on the lungs,liver, brain,heart, kidneys,and spleen

An examination of the organ weights associated with victims of drowning, asphyxiation and trauma was undertaken to determine (a) the effects of asphyxiation compared to a trauma group, and in turn, (b) the effects of drowning compared to an asphyxiation group. Included in the study were 217 drowning deaths, 166 pure asphyxiation deaths and 381 trauma deaths. The effects of asphyxiation (compared to trauma) resulted in elevated mean organ weights for the lungs, liver, kidneys and spleen (with mean increases of 17.8, 10.5, 10.3 and 23.4%, respectively). Effects of drowning (compared to asphyxiation) resulted in elevated mean organ weights only with the lungs and kidneys (with mean increases of 30.0 and 4.4%, respectively). Only the mean heart and brain weight remained constant across all experimental groups. A picture of drowning is suggested in which elevated lung and kidney weights are the result of both asphyxiation and the aspiration of water that occurs with drowning, whereas elevated spleen and liver weights in drowning victims are associated with only the effects of asphyxiation. In addition, the common autopsy finding of a small, anemic spleen in drowning, rather than caused by some pathophysiological mechanism of death, is hypothesized to be a postmortem phenomenon.     

Suicide by drowning: a 20-year review

Drowning as a method of suicide is known to occur, but has primarily been described in environments with readily available access to water, such as coastal regions. In this study, we describe and analyze a series of suicidal drownings occurring in a noncoastal area of Texas. Between 1977 and 1996, 52 cases of suicidal drowning were investigated at the Southwestern Institute of Forensic Sciences in Dallas, Texas. Such deaths accounted for only 0.85% of all suicides and 4% of all drowning deaths. In contrast. suicidal drownings reportedly account for 2.8 to 8.9% of all suicides in regions with easy access to water. As with other studies of suicidal drowning, the victims are usually sober white males over the age of 40 years. Our results also confirm that certain individuals who commit suicide by drowning use weights to facilitate the process. A detailed analysis of the cases is provided. as is a synopsis of several questions that may aid in determining the manner of death in suicidal drowning cases.     

Mortality surveillance: 2004 to 2005 Florida hurricane-related deaths

During 2004 and 2005, Florida was struck by 8 hurricanes, resulting in 213 deaths. The Department of Health and Florida medical examiners monitor hurricane mortality surveillance. This study analyzed hurricane-related deaths reported by the Florida Medical Examiners Commission for 2004 to 2005. The objectives of this study were to (1) describe the Florida hurricane-related mortality for 2004 and 2005, (2) accurately characterize the hurricane-related deaths, and (3) identify strategies to prevent or reduce future hurricane deaths. For 2004, there were 144 total hurricane-related deaths. The majority (59%) occurred in the postimpact phase, with accidents accounting for 76% of deaths. Among these, over half were caused by trauma, followed by drowning, other injury, electrocution, and carbon monoxide poisoning. For 2005, there were 69 hurricane-related deaths. Sixty-one percent of deaths occurred in the postimpact phase, with accidents accounting for 86% of all deaths. Among these, over half were due to trauma, with drowning and carbon monoxide poisoning being the other major contributors. Most hurricane-related deaths are due to unintentional injury and therefore, preventable. Seventy-nine percent of deaths are in those aged 40 and older. Prevention messages should target high-risk, postimpact activities, especially in older adults.     

Fatalities in the bathtub

A retrospective analysis concerning deaths in the bathtub was carried out in the Institute of Legal Medicine in Hamburg. The study includes 245 death cases between 1971 and 1988 (1% of all autopsies). 66 cases proved to be natural deaths, 76 were classified as suicides, 39 as accidents and 13 as homicides; 51 fatalities remained unclear with respect to one of these groups. Among the natural deaths sudden cardiac deaths were dominating (n = 39), among the suicides the intoxications (n = 37) and electrocutions (n = 20), and among the accidents the intoxications by carbon monoxide (n = 17) and electrocutions (n = 12). Out of 13 homicides only 2 were committed directly in the bathtub: One by drowning of a child and one by electric current via a hair dryer; in the other cases the dead body was put into the bathtub post mortem. About 50% of the victims were alcoholized. Signs of drowning were present in about 40% of all cases; the most frequent finding was emphysema aquosum.     

The Impact of Discontinuation of the Medical Examiner System: Cases of Drowning in the Bathtub at Home

The incidence of death by drowning greatly varies among different prefectures in Japan, mainly due to climate difference. However, there could be other factors affecting the incidence of deaths besides climate, for example, differences in regional death investigation systems. Here, we aimed to elucidate other such factors affecting the mortality data of drowning in the bathtub, especially the effects of discontinuing the medical examiner system. Police data in Kyoto and ambulatory care information in Yokohama were used. Data on cases of elderly individuals found dying or dead in the bathtub at home in winter 2014–2015 were obtained. The following data were collected for each case: age, gender, presence/absence of ambulatory transport, performance of autopsy, and cause of death. The autopsy and drowning rates in Kyoto were 0%, whereas both values in Yokohama were significantly higher at 93.1% and 89.4%, respectively (the denominator of each of the rates is the total number of elderly (aged 65 or over) individuals found dying or dead in the bathtub at home in each city during each winter). Despite no significant difference of incidence of total bath-related death, the proportion of drowning-related deaths was overwhelmingly higher in Yokohama than in Kyoto. The difference can be attributed to the difference in autopsy rates between the two cities, mainly caused by the presence/absence of a medical examiner system. Therefore, we should pay careful attention to future changes in autopsy/drowning rates in Yokohama, and ascertain whether the change might be continuously influenced by the abolishment of this system.     

Suicidal drowning in south Florida.

Autopsy protocols at the office of the Chief Medical Examiner were reviewed with respect to suicidal drowning. Between July 1, 1994 and June 30, 1998, there were 267 drownings and 873 people committed suicide in Broward County, Florida. Of those, 25 were suicidal drownings, representing 2.86% of all suicides, and overall the 8th leading cause of suicidal death. When considering suicide in the age group of 65 years and older, (n = 239), which accounts for 19.8% of the population and 27.4%, of all suicides, drowning represents 6.7% of all suicidal deaths, and within females in this group represents the third most common form of suicidal death (13.8%). The presence of alcohol or other drugs is less usual in elderly suicide victims than younger victims. Of the 25 drowning suicides, there was a preference for swimming pools, canals, and lakes as the locations of choice. Additional drowning and suicide related criteria were evaluated including marital status, mental health, clothing worn, previous attempts or threats, suicide notes, and personal effects at the scene; with the intention of establishing a profile for drowning by suicide. Given the relative abundance of water, the suicidal drowning rate appears to be lower than what might otherwise be anticipated.     

2633例机械性窒息法医尸检资料回顾性研究

本文根据湖北省部分地区1957～1986年间尸检记录,收集并分析了2633例机械性窒息死的出现率、案情性质、城市与乡村的差别等问题,为法医学实践提供了可供参考的资料。     

Aquatic fatalities--a systematic retrospective analysis

In a retrospective analysis of the autopsy material (n = 5,767) of the Institute of Legal Medicine of the Hanover Medical School covering the period of 1998-2007, all aquatic fatalities were evaluated, categorized and systematically compared under epidemiological and forensic criteria. The total of 156 cases of death by drowning (2.7 % of all autopsies) included 38 bathtub drownings and 28 deaths in the water for which no pathological anatomical cause of death could be reliably demonstrated. A control group (n = 221) was investigated for the presence of aqueous liquid in the sphenoid sinuses and compared with the findings of the drowning cases without signs of putrefaction. About 16 % of the control cases had fluid in the sphenoid sinuses compared with 57.6 % in the drowning group. Most of the drowning victims were men (60.9 %), whereas in the group of bathtub drownings the majority were women. More than half of the drowning cases (n = 89) could be classified as accidents. The individual groups showed a different incidence of findings associated with drowning.     

Temporal Trends in Rainwater Tank Suicides in Rijeka,Croatia—A 30‐year Study

Although drowning in rainwater tanks is a generally rare phenomenon, this method for suicide has been observed in parts of Croatia. Review of autopsy records at the University of Rijeka, Croatia, was undertaken from 1987 to 2016 to examine this phenomenon. Of 469 drowning deaths, there were 35 suicides in rainwater tanks (7.5%). Overall drowning deaths showed no temporal trends. In contrast, suicidal drownings in rain water tanks showed a marked decline over the years, with 15 cases in 1987–1991, seven in 1992–1996, six in 1997–2001, six in 2002–2006, one in 2007–2011, and none in 2012–2016. Thus, suicidal drowning cases as a percentage of overall drownings dropped from 18% to zero (p<0.001). This study reports a very unusual method of suicide that may have occurred because of the ready availability of large water reservoirs in homes. The recent fall in numbers may relate to less reliance on domestic reservoirs of water.     

Simultaneous Homicide–Suicide: A Case Report of Double Drowning

Homicide–suicide is a tragic phenomenon which typically does not result in a criminal charge or trial. However, correct diagnosis and classification of homicide–suicide cases are important to determine the perpetrators and dynamics of each category properly. The deaths in the homicide–suicide acts can be divided into two categories with respect to the number of involved individuals: dyadic deaths and triple or multiple deaths. These two categories can also be divided into two subgroups according to the chronology of the incidents: simultaneous deaths and consecutive deaths. Herein, a simultaneous homicide–suicide case of a father and daughter where both deaths occurred through drowning which was not found in the selected literature review and where the victim was a child is presented. The article aims to clarify the term discrepancies about multiple death cases in the literature and to discuss the pathological and psychosocial characteristics of the simultaneous dyadic death cases.     

Qualitative diatom analysis as a tool to diagnose drowning.

Since the 1950s, quantitative diatom analysis has been used successfully at the Department of Forensic Medicine at the University of Helsinki as a supportive method for diagnosing deaths by drowning. The reliability of the method was firmly established in 1986 by a study involving 107 probable cases of drowning. Since 1982, the quantitative analysis has been complemented with qualitative diatom analysis. This report presents potential applications of the latter method by describing its use in six cases of drowning.     

Comparison between Temperature Gradient Gel Electrophoresis of Bacterial 16S rDNA and Diatom Test for Diagnosis of Drowning

When a body is discovered in water, it is difficult to conclude whether the cause of death was drowning, even today. Although diatom testing by the digestive method is classical, we hypothesized that aquatic bacteria, as well as diatoms, might be detected in drowned bodies, and conducted temperature gradient gel electrophoresis (TGGE)‐targeting 16S rDNA. DNA was extracted from the site water, and from heart blood and liver samples from 27 bodies concluded as drowning deaths by autopsy and subjected to TGGE after amplification of 16S rDNA by polymerase chain reaction. We observed whether the feature point of each 16S rDNA from the site water and blood or liver samples matched. Considerably higher correspondence was observed in drowned bodies, and the rate was higher than that achieved with the digestive method. Moreover, TGGE is safer than the digestive method. Our study suggests that this method can aid diagnosis of drowning.     

Postmortem stability of lung surfactant phospholipids.

The postmortem stability of the main phospholipids of lung surfactant-phosphatidyl choline (PC), phosphatidyl ethanolamine (PE), phosphatidyl inositol (PI), phosphatidyl serine (PS) and sphingomyelin (S) in three different deaths; one caused by fresh-water drowning, one by salt-water drowning, and one from a sodium-pentobarbital overdose has been studied. The drug overdose was considered the control because there was no surfactant involvement. The results show the stability of these kinds of lipids in the first 24 h, with a progressive decrease from 48 h on until 96 h, with a significant correlation to the time of P less than 0.01 in most cases.     

Deaths during recreational activity

This study of recreational deaths in the "land of sun and fun" has pointed out several useful factors. Firstly, accidental deaths are more common than naturals. Secondly, the most common accidental death is drowning while swimming. The latter is not usually at public facilities, but rather at unsupervised uninstitutionalized surroundings. Finally, a younger population is involved with a frequent number of them with alcohol detected and/or drugs.     

Drug prevalence in drowning deaths in Cuyahoga County, Ohio: a ten-year retrospective study

Previous studies have shown that up to 50% of adult drownings are related to the consumption of alcohol. Little information is available in the literature regarding the possible contribution of ethanol and other drugs to drownings.All records of deaths occurring in Cuyahoga County, Ohio, from 1994-2003, in which drowning was listed as the cause of death, were reviewed. Toxicology analysis was performed on cases where specimens were submitted. Review of the 187 cases showed that the majority (78%) of drowning deaths were ruled as accidents, 26 (14%) as suicide, 5 (3%) as homicide, and 11 (6%) as undetermined.Among the accidental deaths (n=141), 97 (69%) were negative for all drugs, including ethanol, and 30 cases (21%) were positive for ethanol only. Illicit drugs were detected in 4 of the cases (3%). In the suicides (n=26), 16 (62%) were negative for all drugs, including ethanol, and 7 cases (27%) were positive for ethanol only (mean blood alcohol concentration [BAC] 0.03 g/dL). Illicit drugs were detected in 3 of the cases (12%). Two of the 5 homicide cases (40%) were positive for ethanol. There were no cases in which the victim tested positive for illicit drugs.Of the 11 cases ruled as undetermined, 64% (n=7) were negative for all drugs, including ethanol. The remainder of the cases tested positive for ethanol only. There were no cases in which illicit drugs were detected. This study demonstrates that the majority of drowning deaths in Cuyahoga County, Ohio, were not drug related. Deaths in which drugs were detected were typically accidental deaths, with ethanol the most common drug detected.     

Drowning deaths in toddlers and preambulatory children in South Australia

Infants who are preambulatory and toddlers who have only just learned to walk have particular characteristics that give them a unique susceptibility to drowning in certain circumstances. A study of drowning deaths in 32 infants and children <2 years of age in South Australia over a 35-year period from March 1963 to February 1998 was undertaken. The age range was 3 to 24 months (average, 15.4 months), and there was a male:female ratio of 21:11. Drownings occurred in home swimming pools (N = 10); baths (N = 9); waterways (i.e., rivers, irrigation ditches, sea; N = 5); buckets, bins, sinks (N = 4); and fish ponds (N = 3). Details were lacking in one case. Two cases raised questions regarding the manner of death and the possibility of inflicted injury. Specific problems that occur in the assessment of infant drownings include the vulnerability of infants to accidental and nonaccidental drowning, the absence of autopsy findings in inflicted drowning, and the lack of independent witnesses to the fatal episodes. Although the numbers of childhood drownings have declined in recent years, specific situations that remain dangerous for infants include unsupervised bathing and access to swimming pools, fish ponds, and industrial buckets containing water. Complete submersion does not have to occur for drowning to take place.     

Forensic Case Reports Presenting Immersion Pulmonary Edema as a Differential Diagnosis in Fatal Diving Accidents

Immersion Pulmonary Edema (IPE) reduces the transport of gases over the respiratory membrane due to edema in the interstitium and respiratory zones. IPE has previously been described in both swimmers and divers, with a few known fatal cases. We have reviewed 42 SCUBA and snorkeling‐related drowning deaths, and through a thorough analysis of each case, including both diving physiology and forensic pathology, we present IPE as a differential diagnosis to drowning in four cases. Our findings propose that; absence of watery content in the stomach and conducting airways, and liquid filled lungs without hyperexpansion, may be compatible with IPE. We suggest that IPE should be considered in cases where witness testimony reveals; no obvious signs of aspiration and rapid respiratory deterioration despite continuous breathing through an appropriate air source. The diagnosis should be based on the overall impression, including both the autopsy findings and the circumstances regarding the accident.     

Asphyxial deaths: a retrospective study and review of the literature

An increasing death rate as a result of violence constitutes a large group in medicolegal autopsies. Specially, deaths due to asphyxia are one of the most important causes in violence deaths.During the 21-year period from January 1984 to October 2004, there were 134 asphyxial deaths autopsied by the Department of Forensic Medicine, Trakya University, Edirne, Turkey. Asphyxial deaths comprise 15.7% of all forensic autopsies; 20.8% of the cases are aged between 30 and 39 years, and the average age was 41.9 years. Males constitute 79.8% of all the cases.The most frequent method of asphyxiation death is hanging (56 cases, 41.8%), followed by drowning (30.5%) and carbon monoxide poisoning (8.2%). More violent methods, such as ligature or manual strangulations, constitute 2.9% and 2.3% of all asphyxial deaths, respectively. Although it was varying according to the methods of asphyxiation, suicide was found to be the manner of death in the majority of the cases.