Bodies found in the water. An investigative approach

The determination of the cause of death of a person whose body is found in the water requires careful investigative work on the part of both police and pathologists. Opinions as to cause and manner of death should not be derived from the autopsy alone but must result from a logical correlation of data regarding victim identity, circumstances, autopsy, and laboratory findings.     

Mountaineering fatalities on Mount Rainier, Washington, 1977-1997: autopsy and investigative findings.

Mountain climbing is a popular recreational activity with a growing number of participants and associated fatalities. To define the characteristics of these fatal incidents and the typical autopsy findings in the victims, we reviewed the autopsy and investigative findings of all fatalities that occurred on Mount Rainier from 1977 through 1997. A total of 50 deaths occurred in 29 separate incidents. Fifty-eight percent of accident victims died as the result of a fall; another 34% died as a result of an avalanche. The incidents leading to death occurred at an average altitude of 3652 m (11,977 feet); range, 2073 to 4389 m (6800-14,400 feet). The average age of the victims was 31.2 years (range, 17-55 years), and 47 of the 50 were men (94%). Bodies were not recovered in 13 cases (26%). Autopsies were performed in 30 of the remaining 37 cases. At autopsy, the cause of death was ascribed to multiple injuries in 12 cases (40%), isolated head and neck injuries in 7 cases (23%), and chest injuries in 1 case (3%). Asphyxia and hypothermia were the cause of death in 8 cases (27%) and 2 cases (7%), respectively. The frequency of specific injuries is presented by anatomic region. The unique autopsy and investigative features of mountaineering deaths are discussed.     

Septo-optic dysplasia and unexpected adult death--an autopsy approach.

A 20-year-old woman who suffered from septo-optic dysplasia died unexpectedly following a presumed viral gastroenteritis. Autopsy and neuropathological examination confirmed optic nerve hypoplasia with absence of the septum pellucidum. Marked adrenal gland hypoplasia reflected hypothalamic hypopituitarism. The small and large intestines were dilated and filled with liquid fecal material. This case demonstrates that individuals with septo-optic dysplasia may be at risk of unexpected death at all ages. The complexity of mechanisms of death in rare dysmorphic conditions may be overlooked if relevant clinical information is not available at the time of autopsy and unless specific steps are taken to clearly delineate the underlying features of the condition.     

Natural death in the forensic setting: a study and approach to the autopsy

Although unexpected natural deaths comprise a large proportion of the cases seen in the forensic setting, the investigation of these cases remains a unique challenge. Some cases are straightforward; however, others require special examination and dissections, as well as the use of special dissections and ancillary studies. For the forensic investigator to accurately assign a cause and manner of death, one must be aware of the differential diagnoses, common scenarios, and typical victim. The authors reviewed all forensic cases referred to the Forensic Section of the Medical University of South Carolina over a 15-year period from January 1989-December 2003. The number of natural deaths occurring in adults (age 18 years and older) was 6932, compared with the overall number of 13,227 cases. The natural deaths were then analyzed as to autopsy findings, cause of death, cardiac versus noncardiac, age, race, and gender. Current techniques, special dissections, and ancillary studies that can assist in the classification of these deaths in the forensic setting are reviewed.     

Narrative approach to ethics education for students without clinical experience

Niigata University School of Medicine has provided three courses in which medical ethics (ME) is taught to students who have little or no clinical experience. To evoke student's imagination, we have developed a "narrative approach" to learn ME using cases. Prior to a case analysis, students are required to exchange their own life history regarding the core issues in the case. A case is presented not only in the traditional form of vignette, but also in the form of narrative. In the narrative, the case is a story composed of personal narratives, collected and edited from diaries, letters, interviews of persons involved. Our experience suggests that the principle-based reasoning using simple vignettes is often hardly accomplished by students. However, the narrative approach was found to be useful since students can: (1) gain more accurate and wide comprehension of medical and psycho-social aspects of the case; (2) grasp the nature and the history of the conflicting views among persons in the case; (3) find more easily any method for dealing with and settling problems; and (4) exchange viewpoints with patients and their family.     

An approach to dissecting the congenitally malformed heart in the forensic autopsy: the value of sequential segmental analysis.

The demonstration of congenital heart disease at autopsy necessitates the careful preservation and examination of the heart, the vessels, and their connections. Techniques preserving these connections and using a reproducible and systematic approach are preferred. The Rokitansky method of organ block dissection, in combination with a system of heart examination termed sequential segmental analysis, provides such an approach. This study is based on the examination of heart specimens accessioned into the Frank E. Sherman, M.D., and Cora C. Lenox, M.D., Heart Museum (containing approximately 2400 specimens) of the Pathology Department, Children's Hospital of Pittsburgh. Specimens received in consultation during a 25-year period from hospitals and coroners'/medical examiners' offices were examined, and the corresponding reports were reviewed. Of 46 total heart specimens examined (1975-1999), 29 (63%) were dissected properly or left intact for dissection at Children's Hospital of Pittsburgh, and 17 (37%) were incorrectly dissected for the demonstration of congenital heart disease. Of these 17 cases, 11 (24%) displayed dissection errors, which did not hinder a complete diagnosis, 3 cases (6.5%) had errors that enabled only an incomplete diagnosis, and in 3 cases (6.5%), no diagnosis of congenital heart disease could be made. Dissection mistakes and means of avoiding them are discussed. Review of medical and family history, external and internal examination, and a reproducible and sequential method of examining the heart and its connections enables documentation of even the most complex cardiovascular anomalies.     

Iatrogenic deaths following treatment for hypertrophic obstructive cardiomyopathy: case reports and an approach to the autopsy and death certification

Hypertrophic cardiomyopathy (HCM) is a disease process which results in a large, heavy heart, with hypertrophy of the interventricular septum (IVS) and left ventricle. HCM accounts for a significant number of cases of sudden cardiac death each year, most infamously in young athletes. The prevalence of the disease has increased over the past several years due to advances in clinical diagnosis and molecular genetic studies. Over this same period, new forms of treatment also have emerged. One such treatment is alcohol septal ablation (ASA). ASA is a procedure performed by a cardiologist, via cardiac catheterization, by injecting pure ethanol into selected arteries which supply the IVS, resulting in a targeted myocardial infarction. This infarct then retracts and forms a scar, decreasing the outflow obstruction and improving the patient's clinical symptoms.The authors report 2 cases of death following ASA treatment of HCM. The first, a 56-year-old male, had his ASA procedure 10 days prior to death. The second decedent, a 76-year-old female, had her procedure only 30 hours before death. These case reports are followed by a discussion about HCM, including pathology, treatments, and treatment-related pathology, before closing with a discussion about death certification in the cases presented and therapy-related deaths in general.     

An autopsy case of infant death due to heat stroke.

We report an autopsy case of infant death due to heat stroke. On a winter day, a 52-day-old female baby was placed under a Japanese electric foot warmer with a coverlet (kotatsu) on an electric carpet warmer in a heated room at home. After about 5 h, the mother noticed that the baby was unconscious and took her to a hospital. Spontaneous respiration, however, was already absent, and the pupils were dilated. The trunk was hot; body temperature was 41.3 degrees C. The skin of the whole body was dry. Autopsy revealed second-degree burn injuries on the left side of the face and the dorsum of the left hand. Numerous marked petechiae and ecchymoses were found in the thymus (capsule and parenchyma), pleurae (visceral and parietal), pericardial cavity (internal and external surfaces), epicardium, and beneath the serosa at the origin of the aorta. In addition, there was congestion in various organs, edema in the brain and lungs, and hemorrhage in the lungs. Histopathologically, macrophages without hemosiderin granules were present in the alveoli. When the heating conditions at the accident were reproduced experimentally, the temperature in the electric kotatsu warmer rose to 50-60 degrees C. Thus, we concluded that misuse of the electric kotatsu caused heat stroke in this infant.     

The value of the hospital autopsy. A study of causes and modes of death estimated before and after autopsy

Among 312 consecutive deaths in a Danish Central Hospital autopsy was performed in the pathology department on 266 cases, i.e. 85%. Retrospectively, the underlying causes of death were estimated from the clinical information alone by an experienced clinician and subsequently compared with the autopsy report. The definite cause of death was determined jointly by the clinician and the pathologist. The clinician's diagnosis was thereby confirmed as incorrect in 18% of the cases if small differences in site and type of malignant tumours were not considered. This is less than in many other investigations, but it is stressed that this could partly be because formal errors in completing the death certificate were avoided. The main causes of death were ischaemic heart disease and neoplasia. Clinical diagnosis of malignant diseases was never found to be erroneous. There was a slight tendency to clinically overestimate ischaemic heart disease, but in general the different errors outweighed each other, so that the total number of different causes of death before and after autopsy was nearly the same. The original death certificate was investigated in 12 accidental cases. Hereby it was found that the mode of death was originally stated erroneously as natural in 7 cases, i.e. 4.5%. It is concluded that hospital autopsy is still needed for the control and correction of causes of death, and it is stressed that clinicians as well as pathologists should be more aware of cases with a trauma in the history to avoid errors in the mode of death. Such errors can imply legal as well as insurance problems.