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Death by Drowning

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Drowning can be defined as death caused by submersion in a liquid. It can


occur in an ocean or, in the case of alcoholic stupor, epileptics, or infants, in
water as shallow as 6 in. The mechanism of death in acute drowning is
irreversible cerebral anoxia. The original concept of drowning deaths was
that they were asphyxial in nature, with water occluding the airways. Experiments in the late 1940s and early 1950s suggested that death was caused by
electrolyte disturbances or cardiac arrhythmias produced by large volumes
of water entering the circulation through the lungs.1,2 Present thought, however, is that the original concept was correct and that the most important
physiological consequence of drowning is asphyxia.3
In drowning, the volume of water inhaled can range from relatively small
to very large. In freshwater drowning especially, large volumes of water can
pass through the alveolarcapillary interface and enter the circulation. Even
when large volumes of water are absorbed, there is no evidence that the
increase in blood volume causes significant electrolyte irregularities or
hemolysis, or that it is beyond the capacity of the heart or kidneys to compensate for the fluid overload.3,4
Some individuals who drown are considered to be victims of dry drowning. Here, the lungs do not have the heavy, boggy and edematous appearance
typical of drowning lungs. Rather, the fatal cerebral hypoxia is alleged to be
caused by laryngeal spasm. Dry drowning is said to occur in 1015% of all
drownings. What is theorized to occur is that when a small amount of water
enters the larynx or trachea, there is a sudden laryngeal spasm mediated as
a vagal reflex. Thick mucous, foam, and froth may develop, producing an
actual physical plug at this point. Thus, water never enters the lungs. The
authors have never seen the physical plug said to occur in the larynx and
the laryngospasm cannot be demonstrated at autopsy, as death causes
relaxation of the musculature. While the aforementioned explanation for dry
drowning is interesting, it is a hypothesis and not proven. Thus, the authors
do not endorse use of this term or concept. It is probable that dry drowning
is just one end of a spectrum of changes seen in the lung produced by
occlusion of the airways by water, with the other end the heavy, boggy lung
containing a massive amount of edema fluid.

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Physiology of Drowning
When people sink beneath the surface of water, their initial reaction is to
hold their breath. This continues until a breaking point is reached, at which
time the individuals have to take a breath. The breaking point is determined
by a combination of high carbon dioxide levels and low oxygen concentrations. According to Pearn, the breaking point occurs at PC02 levels below 55
mm Hg when there is associated hypoxia, and at PA02 levels below 100 mm
Hg when the PC02 is high.3
Upon reaching the breaking point, the individual involuntarily inhales,
taking in large volumes of water. Some water is also swallowed and will be
found in the stomach. During this interval of submersed breathing, the
patient may also vomit and aspirate some gastric contents. The involuntary
gasping for air under water will continue for several minutes, until respiration
ceases. The developing cerebral hypoxia will continue until it is irreversible
and death occurs.
The point at which cerebral anoxia becomes irreversible is dependent on
both the age of the individual and the temperature of the water. With warm
water, this time is somewhere between 3 and 10 min. 3 Submersion of children
in extremely cold or icy water has resulted in successful resuscitation with
intact neurological outcome for as long as 66 min following drowning. 5 No
matter what the time interval involved, consciousness is usually lost within
3 min of submersion.3
The sequence of events is:
Breath holding
Involuntary inspiration and gasping for air at the breaking point
Loss of consciousness
Death
The sequence can be altered if the individual hyperventilates prior to sinking
under water. Hyperventilation can cause significant decrease in the CO 2
levels. Thus, cerebral hypoxia due to low blood P02, with development of
unconsciousness, might occur before the breaking point is reached. In this
case, the sequence would be:
Voluntary holding of breath
Unconsciousness
Aspiration of water
The type of water that is inhaled, fresh versus salt, probably has very
little influence on whether the individual will survive. In fresh water, as
previously noted, large volumes of water can pass through the alveolar

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capillary membranes. Fresh water alters or denatures pulmonary surfactant,


while seawater dilutes or washes it away. 3,6 The presence of either chlorine
or soap in fresh water apparently has no effect on this property. 3 The
denaturization of surfactant can continue even after a person has been
apparently successfully resuscitated. Loss or inactivation of pulmonary surfactant and alveolar collapse decrease lung compliance, resulting in profound ventilation perfusion mismatch with up to 75% of the blood
perfusing non-ventilated areas.7 When water is inhaled, vagal reflexes cause
increased peripheral airway resistance, with pulmonary vasoconstriction,
development of pulmonary hypertension, decreased lung compliance, and
fall of ventilation perfusion ratios.7 Even in individuals who are successfully
resuscitated and appear healthy, redistribution of blood perfusion takes
several days to return fully to its normal status.
The term near drowning is occasionally encountered. This refers to
a submersion victim who arrives at an emergency facility and survives for
24 h.8 This definition does not take into account whether these individuals
subsequently survive or, if they survive, whether they have any neurological
impairment. It is in the near drowning cases that physicians have been able
to observe electrolyte changes. They have found that the electrolyte disturbances and hemoglobinemia are mild, if present at all, and rarely have any
clinical significance.3,4
As previously mentioned, survival following prolonged underwater
submersion in ice cold water may be for as long as 66 min in the case of
children and infants.5 The traditional explanations for this have been that
immature brains are more resistant to anoxia and that the diving reflex
is still present in children. The diving reflex refers to vasoconstriction in
the vascular beds (except for the heart and brain), shunting of blood to
the brain and heart and bradycardia, all triggered by immersion of the face
in cold water. There is, however, some question as to whether the diving
reflex exists in humans exactly as it does in animals. 8 Bradycardia does
occur, but there has been no proof of the vasoconstriction in the vascular
beds with shunting of blood to the heart and brain. Many people feel that
these children survive because of the rapid development of hypothermia. 58
Because of the relatively large surface area and lack of adequate insulation
in children, the body cools very rapidly. This is especially true in conjunction with the swallowing and aspiration of large quantities of cold fluid.
There is rapid cooling of the body caused by immersion in cold water and
aspiration of cold water with absorption of this water into the circulation.
Thus, while in warm water, a submersion time of 310 min is thought to
represent the maximum time prior to irreversible neurological injury, in
ice water, submersion times as long as 66 min have been reported with
neurological recovery.5

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Autopsy Findings
At autopsy, there are no pathognomonic findings to indicate the diagnosis
of drowning. The diagnosis is based on the circumstances of the death, plus
a variety of nonspecific anatomical findings. Chemical tests put forth to make
the diagnosis are nonspecific and essentially unreliable. A diagnosis of drowning cannot be made without a complete autopsy, especially a complete toxicological screen, because this is a diagnosis of exclusion. If individuals are
found in water and all other causes of death have been excluded, they are
presumed to have drowned. It must be remembered, however, that people
have fatal heart attacks and fall into water, and that victims of a fatal drug
overdose are occasionally dumped into a body of water. Attachments of
heavy weights to a body to keep it under water is consistent with both
homicidal and suicidal drownings, as is disposal of the body of an individual
who has died from some other cause than drowning.
When a person drowns, the body sinks, assuming a position of head
down, buttocks up, and extremities dangling downward. Unless there are
strong currents, the body will not move very far from its initial position. In
relatively shallow water, the extremities or face may bump or drag against
the bottom of the body of water, often causing postmortem injuries to the
face, back of the hands, knees, and toes. The crown of the head and the
buttocks can be seen at water level. In deeper water, the body stays below the
surface until decomposition begins and gas forms; the body then gradually
rises to the surface. In very cold water, the body might stay submerged for
months before decomposition creates enough gas to bring it to the surface.
Depending on how long a body has been in the water, there might be evidence
of animal activity, for example, fish, turtles, crabs, or shrimp. The authors
have seen bodies that appear relatively intact but, when opened up, reveal
complete absence of the thoracic and abdominal viscera. Examination of the
exterior of the body will reveal a defect(s) in the trunk that communicates
with the chest or abdominal cavity, through which water denizens have eaten
their way inside, where they consume the internal viscera.
The hands and soles typically have a washerwoman appearance if the
deceased has been in the water for more than 12 h (Figure 15.1). Experiments have shown that if you place the hands of a corpse in water whose
temperature ranges between 10 and 18C, initial formation of washerwomans skin appears at the fingertips in 2030 min (maximum of 100 min),
with the whole finger involved at 5060 min (maximum of 150 min). 9 This
appearance of the hands and feet does not indicate that the deceased
drowned, as it will develop whether they were alive or dead when they entered
the water. The same is true for goose flesh (cutis anserina). This is a spasm
of the erector pilae muscles caused by rigor mortis and, again, does not
indicate whether the person was alive or dead when entering the water.

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B
Figure 15. 1 (A and B) Washerwoman palms caused by prolonged immersion
in water.

In the classic wet drowning, white or hemorrhagic edema fluid is present


in the nostrils, mouth, and airways. Compression of the chest can cause it
to flow out. Pulmonary edema is, however, nonspecific. An individual dying
of a drug overdose and disposed of in water can also have pulmonary edema.
The lungs of the typical wet drowning victim are large and bulky, completely
occupying their respective pleural cavities. On cut section, they usually have
a brick-red appearance, with large quantities of edema fluid flowing from
the cut surfaces (Figure 15.2). A white or hemorrhagic foam is commonly
found in the trachea and bronchi. Water may be found in the lumen of the

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Figure 15.2 Hemorrhagic pulmonary edema.

stomach. There could be dilatation of the right ventricle. When the brain is
examined, it is swollen with flattening of the gyri caused by nonspecific brain
swelling.
Hemorrhage may appear in the petrous or mastoid bones. This, again,
is nonspecific and, if sought, can be found in individuals dying of heart
disease, drug overdose, or other causes of death. Thus, the drug overdose
victim dumped in water and the heart attack victim collapsing into water
can have the washerwoman appearance of the palms and soles, goose flesh,
pulmonary edema, and hemorrhage into the petrous and mastoid bones. The
presence of vegetation and stones such as would be found at the bottom of
the body of water found clutched in the hands indicates that the cause of
death was, in fact, drowning, because they imply that the deceased was alive
when entering the water.
When initially recovered from the water, the body might be in full rigor
mortis, even though only a short time has passed from the time of the drowning. This is caused by violent struggling at the time of drowning, with a decrease

2001 by CRC Press LLC

in ATP and rapid development of rigor mortis. Bodies cool much more rapidly
in water than air. Thus, decomposition of bodies in water takes longer.
Immersion of a body in water for several hours may cause leaching out
of the blood from antemortern wounds. Thus, an individual might be found
with a number of what appear to be bloodless postmortem wounds that are,
in actual fact, antemortem and the cause of death. This can cause problems
when a body is pulled out of the water exhibiting propellor cuts. There may
be no bleeding around these injuries, initially leading to the conclusion that
these were postmortem injuries when, in fact, they were antemortem, the
blood having been leached out by the action of the water. The authors have
seen leaching out of blood as early as 34 h following immersion.
Tests for Drowning
A number of tests have been developed over the years to determine whether
a person has drowned. The most famous is the Gettler chloride test, 10 in which
blood was analyzed from the right and left sides of the heart. If the chloride
level was less on the right than on the left, the person was assumed to have
drowned in saltwater. If it was elevated on the right side of the heart over the
left, then one was thought to be dealing with a freshwater drowning. Tests
have also been done for other elements in the blood, as well as comparing the
specific gravity of blood in the right versus the left atria. All of the aforementioned tests are unreliable and of no help in diagnosing drowning.
A more exotic, though controversial, test involves the identification of
diatoms in the tissue of drowning victims. Diatoms are microscopic unicellular algae varying in size from 5 to more than 500 m. These organisms
have a silica skeleton in the shape of two valves. They are found everywhere
in all types of water (fresh, brackish, and saltwater), on moist soil, and in
the atmosphere. Some authors contend that the identification of diatoms in
human organs is clear proof of drowning, while others say that it is not
possible to come to this conclusion because of the widespread distribution
of these organisms throughout the environment.11,12 The whole question
revolves around whether diatoms are normally present in human organs,
their density if present, and what types are present. Lung, liver, kidney, and
bone marrow have been analyzed for diatoms and conclusions have been
reached based on the presence or absence of these organisms. Some medical
professionals have found diatoms in the organs of non-drownings, while
others have not.
If diatoms are present in a body, there are three possible ways they could
have gotten there. First is by inhalation of airborne diatoms, second is by
ingestion of material containing diatoms, and third is by aspiration of water
containing diatoms, with subsequent circulation of these throughout the
body. Complicating all this is the fact that diatoms are so ubiquitous that

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some of the analyses may have been contaminated by the glassware and
reagents used.
Today, people who use diatom analysis tend to deal with closed organ
systems, such as femoral bone marrow or an encapsulated kidney from a
non-decomposed body. Contact of the sample with water is limited to triple
distilled water. The instruments are specially cleaned to prevent contamination with diatoms. The material, such as bone marrow, is digested in concentrated acid. The deposit is examined with a standard microscope for the
presence of the diatoms. The water in which the individual has allegedly
drowned is sampled to see what type of diatoms are present and a comparison
is made between those in the water and those found in the body. While a
positive comparison is helpful, a negative result does not rule out drowning.
Drownings in Bathtubs
Drownings in bathtubs are relatively uncommon, usually involving young
children left unattended by a parent. Some undoubtedly are homicides.
Adults in the throes of a seizure can drown in a bathtub (Figure 3.8). Less
clear are instances where an individual found in a tub has toxic or lethal drug
levels. Did they pass out and drown, die of the drugs and eventually slide
under water, or were they placed in the tub following an overdose in a futile
attempt to revive them? Similar questions arise in regard to the individual
with severe heart disease found in a bathtub under water. Did they die of a
heart attack and then slip under the water or did they have an incapacitating
heart attack, slip under the water and drown? The presence of pulmonary
edema is of no help, as it might be present in drug overdoses, heart failure
or drowning.
Rarely, a case involving an adult will be homicide. If, while taking a bath,
ones feet are grasped and one is pulled underwater by them, there can be
an involuntary inhalation of water as the water rushes into the nasopharynx.
This, exacerbated by panic and being in a smooth-walled, wet, slippery container, could result in an inability to save oneself, with rapid loss of consciousness and death. Possibly no injuries will be seen at autopsy. Rarely, the
authors have seen well-documented cases where an individual slipped in the
bathtub, struck his head, and drowned.
Scuba Divers
Deaths occurring with use of scuba equipment can be caused by:
Natural disease
As a consequence of being underwater at increased pressure
An environmental hazard
As a result of defective equipment

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Too rapid an ascent to the surface can cause air embolism, pneumothorax, or interstitial emphysema. Divers occasionally get trapped by underwater
debris or in caves. Equipment can be the cause of death if it is defective or
if there is contamination of the contained air by a substance such as carbon
monoxide. Severe rusting of the interior of the tank could result in a tank
atmosphere depleted of oxygen due to formation of iron oxide. In any scuba
death, the authors suggest examination of the equipment by a person knowledgeable in this field, analysis of the residual atmosphere in the tank, and
consultation with someone in your area experienced in scuba diving.

References
1. Swann HG and Spafford NR, Body salt and water changes during fresh and
sea water drowning. Texas Rep Biol Med 1951; 9:356-382.
2. Swann HG, et al., Fresh- and sea-water drowning: A study of the terminal
cardiac and biochemical events. Texas Rep Biol Med 1947; 5:423-437.
3. Pearn J, Pathophysiology of drowning. Med J Australia 1985; 142:586-588.
4. Modell JH and Davis JH, Electrolyte changes in human drowning victims.
Anesthesiology 1969; 30:414-420.
5. Bolte RG, et al., The use of extracorporeal rewarming in a child submerged
for 66 minutes. JAMA 1988; 260:377-379.
6. Giammona ST and Modell JH, Drowning by total immersion: Effects on
pulmonary surfactant of distilled water, isotonic saline and sea water. Am J
Dis Children 1967; 114:612-616.
7. Ornato JP, The resuscitation of near-drowning victims. JAMA 1986; 256:
75-77.
8. Conn AW and Barker CA: Fresh water drowning and near-drowning An
update. Can Anaesth Soc, 1984; 31: S38-S44.
9. Reh H, On the early postmortem course of washerwomans skin at the
fingertips. Z Rechtsmed 1984; 92(31:183-188. (In German).
10. Gonzales TA, Vance M, Helpern M, Legal Medicine and Toxicology. New York,
Appleton-Century Co, 1937.
11. Peabody AJ, Diatoms and drowning A review, Med Sci Law 1980; 20(4):
254-261.
12. Foged N, Diatoms and drowning Once more. Forens Sci Int 1983; 21:
153-159.

2001 by CRC Press LLC