Blunt head trauma or extensive tension pneumothorax

Case reportThe emergency medical squad and police found a 60-year-old alcoholic dead in his unlocked apartment. On firstinspection at the death scene, lividity of the supine bodywas pronounced in the head and neck area (Fig. 1), theeyelids (within the livid area) were discolored blue andmarkedly swollen, and bloody purge trickled from the nose(Fig. 2). Ostensibly subacute, partially scabbed skin lesionson the arms, hands and kneecaps were identified, and abrownish, scabbed, 1 cm-long wound was present on theback of the head, which was suggestive of a possiblephysical argument and battery. Despite the absence of otherinjuries or indications of a struggle at the death scene,investigators postulated that fatal blunt head trauma due toa physical attack had occurred. The man had been last seen4 days earlier when he fell down while intoxicated withoutobvious injury.At forensic external examination, a generalized parch-ment-like, crepitant cutaneous emphysema invested theentire body, notably including a prominently distendedpneumatoscrotum. Autopsy revealed the cause of death tobe an extensive tension pneumothorax, which was charac-terized by the following: (a) collapsed lungs; (b) depressionof the diaphragm; (c) pneumomediastinum; and (d) pneu-mopericardium, which was attributed to (e) a fractured 7thrib in the right posterior axillary line; the sharp-edged bone