Forensic Science, 10 (1977) 141 - 145 @ Elsevier Sequoia S.A., Lausanne -Printed
SUICIDE BY INJECTION
BERNARD
141 in the Netherlands
OF SNAKE VENOM
KNIGHT
Welsh National School of Medicine, Cardiff (Gt. Britain) ANDREW BARCLAY
and ROGER MANN
Home Office Forensic Science Laboratory,
Birmingham
(Gt. Britain)
(Received November 30, 1976; accepted in revised form June 6, 1977)
SUMMARY An unusual suicide is described where the deceased, a schizophrenic young man in perfect physical health, deliberately injected himself subcutaneously with snake venom, by means of a syringe. The circumstances, autopsy findings and laboratory investigations are recorded.
INTRODUCTION
Though deaths from snake bites are common in tropical and subtropical countries (30,000 - 40,000 per annum [ 11) deaths from the effects of snake venom are extremely rare in Britain. Deaths from deliberate self-injection of snake venom has hitherto been unrecorded, to the knowledge of the authors. A case is described in which this bizarre method was used to accomplish suicide.
CIRCUMSTANCES
OF THE DEATH
The person involved was a physically healthy man of 26 years of age. He lived at home with his parents. The family circumstances were excellent, the father being an Anglican priest, a brother a lawyer and a sister a senior hospital nurse. The deceased had been exceptionally intelligent as a child but at the age of 14 years, whilst away at public school, his mental state deteriorated so much that he had to be brought home. From then until the time of death, the typical symptoms of schizophrenia developed, lately of a particularly paranoid nature. Over these latter years, he was treated as an outpatient at various mental hospitals, but never admitted until shortly before death. There were two previous attempts at suicide. At the age of 15 years an overdose of drugs were taken, though the danger to life was not serious. At the age of 23 years he took an overdose of Mogadon (nitrazepam). Even as far back as his school days, he had declared that he would commit suicide.
142
In the months prior to his death, he became more and more paranoid, becoming extremely antagonistic to his father. In the few days before death, he began to behave even more strangely, molesting a woman in the belief that she was a policewoman spying upon him. Owing to this deterioration in his mental state and the possible development of aggressive tendencies, arrangements were made to admit him to a mental hospital as a voluntary patient. However, he immediately discharged himself and returned home the same day. The father persuaded him to return to hospital and took him back in the evening. On return to the mental hospital he was said to have been slightly drowsy but otherwise normal. He had allegedly “had a drink” but there were no other abnormal findings in his physical state. Later that evening the psychiatric registrar was called to see the patient as he was agitated and in a collapsed state. The blood pressure was raised and there was a fast pulse. He complained of a severe thirst. He began talking about having injected himself with insulin. Then, however, he whispered into the doctor’s ear “It is snake venom, not insulin”. Due to rapid deterioration in his physical condition, he was transferred from the mental hospital to a nearby general hospital where he was treated as a suspected case of snake venom poisoning. A polyvalent anti-serum to European snakes was given but he lapsed into coma and died early the next morning, within twelve hours of first being taken ill. The home was searched but no notes or toxic substances were found. However, a search of the garden revealed a makeshift syringe hidden in a hedge. This consisted of the distal part of a plastic syringe with a needle glued on, but no plunger. No other materials were found at this time or any time subsequently. In spite of intensive enquiries, no evidence of the purchase of commercial snake venom could be traced, though the family reported that a year or two prior to the death, they had intercepted correspondence between the deceased and a snake farm, indicating that the son had been attempting to buy snakes. Though no formal suicide note was found, a membership card to a political party was discovered, with additions indicating that his property should be left to them and that he did not wish his parents to see his body after death. There was no indication of how long before the death this annotation was made.
POST-MORTEM
FINDINGS
At autopsy, the body was found to be that of a very well built young man 6 ft (180 cm) in height, the estimated weight being about 13 stone (82 kg). The main external finding was the presence of a well demarcated red flare upon the skin of the flexor surface of the left forearm. This was slightly indurated, being about 2.5 X 1.5 inches (6.5 X 4 cm) with a central needle puncture mark. The skin of all the rest of the forearm was very congested and showed numerous petechial haemorrhages, some of them large. These
143
extended up to a sharply demarcated line just above the elbow, where some constriction had prevented skin haemorrhages beyond. There were two other injection marks which were due to medical treatment. There were no other external signs of significance. Internally the main finding was that all the blood in organs and body cavities was completely fluid, there being no trace of any blood clot within the heart or vessels. The blood was also extremely dark and appeared to be somewhat haemolysed as well as being completely unclotted. The lungs were very congested and there were extensive haemorrhages into the substance of the lung though there were no subpleural petechial haemorrhages. There were no haemorrhages anywhere else in the body. The injection mark on the left forearm appeared to have penetrated muscle and subcutaneous tissue but not directly entered a vein. The stomach and intestines contained dark red blood-stained fluid but there were no mucosal haemorrhages. The kidneys were extremely congested with almost black coloration of the medulla but there were no haemorrhages. The rest of the body showed no significant abnormal findings to the naked eye. Samples of blood, stomach contents, kidneys, liver and brain as well as the injection site on the skin and some underlying muscle were retained for analysis. These were submitted to the Home Office Forensic Science Laboratory, Birmingham, for further investigation and other samples of tissue were taken for conventional histological examination. Microscopy showed no specific changes, apart from confirmation of the haemorrhages and haemorrhagic oedema in the lungs, small haemorrhages in the skin and intense congestion of the vessels of the renal medulla, though no actual haemorrhages were present. Special stains for fibrin revealed no intravascular deposition of fibrin, which is sometimes a cause of the haemorrhagic manifestations due to the defibrillation syndrome.
LABORATORY
INVESTIGATIONS
Introduction Snake venoms are complex mixtures of proteins including enzymes and polypeptides. They possess neurotoxic, cardiotoxic, haemolytic and necrotic properties, each venom having these properties in varying degree. It is possible to generalise, however, and classify snakes by the main effects of their poisons. Thus the Crotahdae (pit vipers such as the North American rattlesnake) possess haemolytic venom causing death within 1 - 2 days, with a severe necrotic effect at the injection site: the Elapidae (cobras, coral snakes) have neurotoxic effects causing death from within a few minutes to several hours, with little proteolytic activity: and the Viperidae (true vipers, such as the Central African Puff Adder, Gaboon viper) have venoms with both neurotoxic and haemolytic properties. Further information is to be found in the works of Jiminez-Porras [ 21 and Trewithie [ 31.
144
On receipt at the laboratory 74 hours after death 10 ml of fluid had drained from the injection site tissue submitted and a large haematoma was noted between the subcutaneous tissue and the fascia overlying the muscle blocks. In view of this and the history of a haemorrhagic illness, it was decided to start an immediate analysis of this specimen for snake venom. Routine analysis of the stomach contents, liver, blood and urine for common organic drugs including anticoagulants and ethanol proved negative. In view of the relatively rapid death without overwhelming haemorrhagic symptoms it was felt that some neurotoxic venom might be present in addition to that producing the haemolytic symptoms. Control venoms of Gaboon viper and North American rattlesnake were obtained from a local zoo, together with polyvalent anti-sera against Crotalids, Central African snakes and Elapids, as well as the standard polyvalent anti-serum against European snakes with which the deceased had been treated, and Russel Viper venom from a local hospital.
Examination Counter current electrophoresis was performed on the standards and case material after the method of Culliford [4] . Electrolyte : water barbital buffer (l:l), pH 8.6, Medium : 1% Agar in Barbital, 7.5 cm plates, 12 V/cm. Serial dilutions of each venom or extract from 1 to l/2048 were run against each of the antisera. Crotalid and Gaboon viper venom both reacted with all ant&era down to l/128 and injection site fluid reacted to l/2 with all anti-sera. Rattlesnake venom reacted down to l/2048 with crotalid anti-serum and Central African anti-serum. The European anti-serum did not react with either venom, nor did it react with Russel Viper venom. An extract of the syringe mentioned above reacted with Central African and Indian (Elapid) antisera only, while case and normal human sera did not react with any. A further extract of haematoma reacted weakly with all antisera and an extract of connective tissue overlying the haematoma along the needle track reacted down to l/2 with all. These results indicated that venom was present in the injection site tissue and in the hope that the proteins had not degraded sufficiently to prevent species identification, immunodiffusion plates were prepared [ 51. These Ouchterlony plates using the medium as before and run overnight showed partial identity between connective tissue extract and Crotalid venom, i.e. they possessed closely related venom proteins, whilst the syringe extract showed a line of partial identity to Central African anti-serum only.
Conclusions Since adequate fresh venoms were not available, estimate of the titre of the anti-sera could not be made, but subjectively the tissue reacted most
145
strongly with crotalid anti-serum and least well with the Indian. The venom from the connective tissue possessed elements not present in Gaboon viper venom and showed clear partial identity with North American rattlesnake venom. However, the lines of partial identity to Central African anti-serum were not those between Crotalid venom and this anti-serum. In view of these findings and the clinical picture of a relatively rapid death without overwhelming haemorrhagic symptoms, it seems possible that the deceased injected either a mixture of haemotoxic and neurotoxic venoms or a venom containing both, such as the Central African Puff Adder. The position is, of course, complicated by the effect of time and storage on the proteins and polyeptides involved.
REFERENCES E. C. Faust, Animal Agents and Vectors of Human Disease, Lea and Febiger, Philadelphia, 1955,400 pp. J. M. Jimenez-Porras, Biochemistry of snake venoms, Clin. Toxicol., 3( 3) (1970) 389 431. E. R. Trewithie, Detection of snake venom in tissues, Clin. Toxicol., 3(3) (1970) 445p 455. B. J. Culliford, The examination and typing of bloodstains in the criminal laboratory, U.S. Dept. of Justice P.R. 71-7, (1971) p. 62. 0. Ouchterlony, Acta Pathol. Microbial. Stand., 25 (1948) 186. Gradwohl’s Legal Medicine, 2nd edn, John Wright, Bristol, 1968, 664 pp.
SUICIDE BY INJECTION
BERNARD
141 in the Netherlands
OF SNAKE VENOM
KNIGHT
Welsh National School of Medicine, Cardiff (Gt. Britain) ANDREW BARCLAY
and ROGER MANN
Home Office Forensic Science Laboratory,
Birmingham
(Gt. Britain)
(Received November 30, 1976; accepted in revised form June 6, 1977)
SUMMARY An unusual suicide is described where the deceased, a schizophrenic young man in perfect physical health, deliberately injected himself subcutaneously with snake venom, by means of a syringe. The circumstances, autopsy findings and laboratory investigations are recorded.
INTRODUCTION
Though deaths from snake bites are common in tropical and subtropical countries (30,000 - 40,000 per annum [ 11) deaths from the effects of snake venom are extremely rare in Britain. Deaths from deliberate self-injection of snake venom has hitherto been unrecorded, to the knowledge of the authors. A case is described in which this bizarre method was used to accomplish suicide.
CIRCUMSTANCES
OF THE DEATH
The person involved was a physically healthy man of 26 years of age. He lived at home with his parents. The family circumstances were excellent, the father being an Anglican priest, a brother a lawyer and a sister a senior hospital nurse. The deceased had been exceptionally intelligent as a child but at the age of 14 years, whilst away at public school, his mental state deteriorated so much that he had to be brought home. From then until the time of death, the typical symptoms of schizophrenia developed, lately of a particularly paranoid nature. Over these latter years, he was treated as an outpatient at various mental hospitals, but never admitted until shortly before death. There were two previous attempts at suicide. At the age of 15 years an overdose of drugs were taken, though the danger to life was not serious. At the age of 23 years he took an overdose of Mogadon (nitrazepam). Even as far back as his school days, he had declared that he would commit suicide.
142
In the months prior to his death, he became more and more paranoid, becoming extremely antagonistic to his father. In the few days before death, he began to behave even more strangely, molesting a woman in the belief that she was a policewoman spying upon him. Owing to this deterioration in his mental state and the possible development of aggressive tendencies, arrangements were made to admit him to a mental hospital as a voluntary patient. However, he immediately discharged himself and returned home the same day. The father persuaded him to return to hospital and took him back in the evening. On return to the mental hospital he was said to have been slightly drowsy but otherwise normal. He had allegedly “had a drink” but there were no other abnormal findings in his physical state. Later that evening the psychiatric registrar was called to see the patient as he was agitated and in a collapsed state. The blood pressure was raised and there was a fast pulse. He complained of a severe thirst. He began talking about having injected himself with insulin. Then, however, he whispered into the doctor’s ear “It is snake venom, not insulin”. Due to rapid deterioration in his physical condition, he was transferred from the mental hospital to a nearby general hospital where he was treated as a suspected case of snake venom poisoning. A polyvalent anti-serum to European snakes was given but he lapsed into coma and died early the next morning, within twelve hours of first being taken ill. The home was searched but no notes or toxic substances were found. However, a search of the garden revealed a makeshift syringe hidden in a hedge. This consisted of the distal part of a plastic syringe with a needle glued on, but no plunger. No other materials were found at this time or any time subsequently. In spite of intensive enquiries, no evidence of the purchase of commercial snake venom could be traced, though the family reported that a year or two prior to the death, they had intercepted correspondence between the deceased and a snake farm, indicating that the son had been attempting to buy snakes. Though no formal suicide note was found, a membership card to a political party was discovered, with additions indicating that his property should be left to them and that he did not wish his parents to see his body after death. There was no indication of how long before the death this annotation was made.
POST-MORTEM
FINDINGS
At autopsy, the body was found to be that of a very well built young man 6 ft (180 cm) in height, the estimated weight being about 13 stone (82 kg). The main external finding was the presence of a well demarcated red flare upon the skin of the flexor surface of the left forearm. This was slightly indurated, being about 2.5 X 1.5 inches (6.5 X 4 cm) with a central needle puncture mark. The skin of all the rest of the forearm was very congested and showed numerous petechial haemorrhages, some of them large. These
143
extended up to a sharply demarcated line just above the elbow, where some constriction had prevented skin haemorrhages beyond. There were two other injection marks which were due to medical treatment. There were no other external signs of significance. Internally the main finding was that all the blood in organs and body cavities was completely fluid, there being no trace of any blood clot within the heart or vessels. The blood was also extremely dark and appeared to be somewhat haemolysed as well as being completely unclotted. The lungs were very congested and there were extensive haemorrhages into the substance of the lung though there were no subpleural petechial haemorrhages. There were no haemorrhages anywhere else in the body. The injection mark on the left forearm appeared to have penetrated muscle and subcutaneous tissue but not directly entered a vein. The stomach and intestines contained dark red blood-stained fluid but there were no mucosal haemorrhages. The kidneys were extremely congested with almost black coloration of the medulla but there were no haemorrhages. The rest of the body showed no significant abnormal findings to the naked eye. Samples of blood, stomach contents, kidneys, liver and brain as well as the injection site on the skin and some underlying muscle were retained for analysis. These were submitted to the Home Office Forensic Science Laboratory, Birmingham, for further investigation and other samples of tissue were taken for conventional histological examination. Microscopy showed no specific changes, apart from confirmation of the haemorrhages and haemorrhagic oedema in the lungs, small haemorrhages in the skin and intense congestion of the vessels of the renal medulla, though no actual haemorrhages were present. Special stains for fibrin revealed no intravascular deposition of fibrin, which is sometimes a cause of the haemorrhagic manifestations due to the defibrillation syndrome.
LABORATORY
INVESTIGATIONS
Introduction Snake venoms are complex mixtures of proteins including enzymes and polypeptides. They possess neurotoxic, cardiotoxic, haemolytic and necrotic properties, each venom having these properties in varying degree. It is possible to generalise, however, and classify snakes by the main effects of their poisons. Thus the Crotahdae (pit vipers such as the North American rattlesnake) possess haemolytic venom causing death within 1 - 2 days, with a severe necrotic effect at the injection site: the Elapidae (cobras, coral snakes) have neurotoxic effects causing death from within a few minutes to several hours, with little proteolytic activity: and the Viperidae (true vipers, such as the Central African Puff Adder, Gaboon viper) have venoms with both neurotoxic and haemolytic properties. Further information is to be found in the works of Jiminez-Porras [ 21 and Trewithie [ 31.
144
On receipt at the laboratory 74 hours after death 10 ml of fluid had drained from the injection site tissue submitted and a large haematoma was noted between the subcutaneous tissue and the fascia overlying the muscle blocks. In view of this and the history of a haemorrhagic illness, it was decided to start an immediate analysis of this specimen for snake venom. Routine analysis of the stomach contents, liver, blood and urine for common organic drugs including anticoagulants and ethanol proved negative. In view of the relatively rapid death without overwhelming haemorrhagic symptoms it was felt that some neurotoxic venom might be present in addition to that producing the haemolytic symptoms. Control venoms of Gaboon viper and North American rattlesnake were obtained from a local zoo, together with polyvalent anti-sera against Crotalids, Central African snakes and Elapids, as well as the standard polyvalent anti-serum against European snakes with which the deceased had been treated, and Russel Viper venom from a local hospital.
Examination Counter current electrophoresis was performed on the standards and case material after the method of Culliford [4] . Electrolyte : water barbital buffer (l:l), pH 8.6, Medium : 1% Agar in Barbital, 7.5 cm plates, 12 V/cm. Serial dilutions of each venom or extract from 1 to l/2048 were run against each of the antisera. Crotalid and Gaboon viper venom both reacted with all ant&era down to l/128 and injection site fluid reacted to l/2 with all anti-sera. Rattlesnake venom reacted down to l/2048 with crotalid anti-serum and Central African anti-serum. The European anti-serum did not react with either venom, nor did it react with Russel Viper venom. An extract of the syringe mentioned above reacted with Central African and Indian (Elapid) antisera only, while case and normal human sera did not react with any. A further extract of haematoma reacted weakly with all antisera and an extract of connective tissue overlying the haematoma along the needle track reacted down to l/2 with all. These results indicated that venom was present in the injection site tissue and in the hope that the proteins had not degraded sufficiently to prevent species identification, immunodiffusion plates were prepared [ 51. These Ouchterlony plates using the medium as before and run overnight showed partial identity between connective tissue extract and Crotalid venom, i.e. they possessed closely related venom proteins, whilst the syringe extract showed a line of partial identity to Central African anti-serum only.
Conclusions Since adequate fresh venoms were not available, estimate of the titre of the anti-sera could not be made, but subjectively the tissue reacted most
145
strongly with crotalid anti-serum and least well with the Indian. The venom from the connective tissue possessed elements not present in Gaboon viper venom and showed clear partial identity with North American rattlesnake venom. However, the lines of partial identity to Central African anti-serum were not those between Crotalid venom and this anti-serum. In view of these findings and the clinical picture of a relatively rapid death without overwhelming haemorrhagic symptoms, it seems possible that the deceased injected either a mixture of haemotoxic and neurotoxic venoms or a venom containing both, such as the Central African Puff Adder. The position is, of course, complicated by the effect of time and storage on the proteins and polyeptides involved.
REFERENCES E. C. Faust, Animal Agents and Vectors of Human Disease, Lea and Febiger, Philadelphia, 1955,400 pp. J. M. Jimenez-Porras, Biochemistry of snake venoms, Clin. Toxicol., 3( 3) (1970) 389 431. E. R. Trewithie, Detection of snake venom in tissues, Clin. Toxicol., 3(3) (1970) 445p 455. B. J. Culliford, The examination and typing of bloodstains in the criminal laboratory, U.S. Dept. of Justice P.R. 71-7, (1971) p. 62. 0. Ouchterlony, Acta Pathol. Microbial. Stand., 25 (1948) 186. Gradwohl’s Legal Medicine, 2nd edn, John Wright, Bristol, 1968, 664 pp.
