This paper reports a rare autopsy case, a 21-years old healthy female worker, who died of acute iatrogenic water intoxication after she had swallowed powder scraped off 17 matches in an apparent suicide attempt. Gastric lavage was performed as she was wrongly considered to have taken poison containing phosphorus. She was given 7.8 1 water within 2 h. The pathological findings and 16 cases from the literature between 1978-1994 are reviewed.