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11/30/2005: "Too Many Ways To Die"
One of the inquests today involved the occasional (not common but not rare either) problem that confronts the pathologist - more than one cause of death. Post mortem examinations usually reveal more than one disease process and it is the task (and the skill) of the pathologist to rank them in order of importance. Usually this is not a problem because one disease stands out; thus if one discovers a ruptured abdominal aortic aneurysm, one knows that this was the reason for the body appearing in the mortuary, no matter how bad the ischaemic heart disease or the emphysema. If, however, the deceased had 50% stenosis of the coronary circulation and early bronchopneumonia, it becomes a judgement call as to which one ended the affair, one made leaning heavily on history and experience.
Sometimes, though, there is nothing to give one a clue, as in the case today. In this instance an elderly lady with a long history of depression and suicide attempts decided to take her own life - there was no disagreement that this was her intention as she had fashioned a noose, taken an overdose of sleeping tablets and then jumped into a lake. My problem was that toxicology showed a lethal level of the sleeping tablets and macroscopic and microscopic examination of the lungs showed that she'd drowned (she didn't use the noose).
She did one or the other, but she didn't do both (although the Coroner, rather pragmatically, recorded the cause of death as being due to 'overdose of therapeutic drugs and drowning'). It might be explained by continued absorption and metabolism of the sleeping tablets after death but I find that unsatisfying. Once the circulation stops, there will be little more of either. Another, more appealing hypothesis, is that she had an abnormally high tolerance to the effects of the tablets, so that what would have been lethal for the rest of us was insufficient to kill her.
We'll never know, which is one of the problems with pathology.
Keith McCarthy on Wednesday, November 30th 2005 @ 07:55 PM GMT [link]