Case reportsCase 1: The body of an 85-year-old man was recoveredfrom within a submerged vehicle that he had accidentallydriven into a swimming pool. At autopsy, there was noevidence of decomposition with signs of immersionincluding ‘‘washerwoman’’ hands and feet (Figs. 1, 2),marked pulmonary congestion and edema (Fig. 3) andprominent differential staining of the aortic trunk comparedto the pulmonary outflow tract (Fig. 4). In addition therewas significant atherosclerotic narrowing of the left ante-rior descending coronary artery. No injuries were noted,toxicology was negative, and no other underlying organicdiseases were present which could have caused or con-tributed to death. Death was due to freshwater drowningcomplicating ischemic heart disease.Case 2: A 51-year-old man was observed to drown in ariver while attempting to rescue a model boat. At autopsy,there was no evidence of decomposition with signs ofimmersion including ‘‘washerwoman’’ hands with markedpulmonary congestion and edema and prominent differen-tial staining of the aortic trunk compared to the pulmonaryoutflow tract (Figs. 5, 6). No injuries were noted, toxicol-ogy was negative and no underlying organic diseases werepresent which could have caused or contributed to death.Death was due to freshwater drowning.DiscussionThe reported cases demonstrate differential staining of theintima of the aortic root compared to the pulmonary trunk infresh water drowning. This phenomenon, which has beenreported in the German literature as hemoglobin imbibitionof the intima, has been attributed to a hypo-osmolar effectwithinthebloodduetopassageoffreshwateracrossalveolarmembranes, or so-called hypo-osmolar hemolysis [1–4].AlthoughithasalsobeenmentionedinEnglishforensictexts[5–7],thisislesssoinrecentyears,resultinginitbecomingarelatively overlooked marker for drowning. While the clin-ical significance of the possible hydrostatic and osmoticeffects in fresh water drowning has been argued [8], thedemonstration of reduced levels of sodium in the left ven-tricle in fresh, compared to salt, water drowning would besupportive of the proposed mechanism [9].Hemolytic staining of the vascular intima is a well-recognized phenomenon in forensic practice, encounteredroutinely in association with decomposition and also incases with extensive burns or disseminated sepsis [10]. Inthese situations, however, the effect is usually generalized,involving most vessels. The color change of the intimaresults from breakdown of red blood cells with release oftheir iron-containing pigment hemoglobin which stains theadjacent vessel wall. A similar effect can be observed atpost mortem when vessels are left in contact with bloodthat has been lysed after mixing with water during dis-section [9]. Thus, any circumstance, condition or diseasewhich causes red cell membrane disruption can producethis effect. The striking aspect of this finding in fresh waterdrowning, however, is the geographic, focal nature of thestaining which involves only the aortic root [11]. Anyexplanation for a localized phenomenon such as this mustbe able to evoke a specific focal effect which is not present