Accepted Manuscript

External foam and the post-mortem period in freshwater drowning; results from a
retrospective study in Amsterdam, the Netherlands

G. Reijnen, M. Buster, P.J.E. Vos, U.J.L. Reijnders

PII: S1752-928X(17)30102-6
DOI: 10.1016/j.jflm.2017.07.013
Reference: YJFLM 1522

To appear in: Journal of Forensic and Legal Medicine

Received Date: 14 February 2017

Revised Date: 8 July 2017
Accepted Date: 24 July 2017

Please cite this article as: Reijnen G, Buster M, Vos PJE, Reijnders UJL, External foam and the
post-mortem period in freshwater drowning; results from a retrospective study in Amsterdam, the
Netherlands, Journal of Forensic and Legal Medicine (2017), doi: 10.1016/j.jflm.2017.07.013.

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External foam and the post-mortem period in freshwater drowning; results
from a retrospective study in Amsterdam, the Netherlands

G. Reijnen1, M. Buster2, P.J.E. Vos3, U.J.L. Reijnders4

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MSc, Forensic physician and resident pulmonology. Department of Forensic Medicine, Amsterdam

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Public Health Service and Rijnstate Hospital Arnhem
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PhD, Researcher, Department of Epidemiology & Health Promotion, Amsterdam Public Health
Service

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PhD, Pulmonologist, Rijnstate Hospital Arnhem
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PhD, Forensic physician, Department of Forensic Medicine, Amsterdam Public Health Service

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Corresponding author:

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Guido Reijnen
Forensic physician and PhD candidate
Department of Forensic Medicine
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P.O. Box 2200

1000 CE Amsterdam
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The Netherlands
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Phone: ++31 (0)68400293

E-mail: guido_reijnen@hotmail.com
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External foam and the post-mortem period in freshwater

drowning; results from a retrospective study in Amsterdam,
the Netherlands

Abstract

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Introduction Determining the time of death of bodies recovered from water can be difficult. A feature of

drowning is the presence of external foam. This study describes the presence of external foam in relation to

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the post-mortem period.

Method The study utilizes a database of death reports dated between January 2011 and July 2016. For

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bodies recovered from fresh water, the presence or absence of external foam was noted.

Results In this study, 112 death reports are included. Of these reports, 18 mentioned external foam, which

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account for 16.1% of the entire study population. In the population with a post-mortem period of less than
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24 hours, external foam was detected in 27.7% of cases. All 18 incidents with external foam had an

estimated post-mortem period of less than 24 hours.

Conclusion In our study, external foam was only present in freshwater drowning cases with a post-mortem
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period of less than 24 hours. Based on this finding, the presence of external foam may be useful as an

additional indicator when estimating the time of death in freshwater drowning.

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Keywords:

External foam; froth; bodies recovered from water; time of death; drowning.
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Introduction Drowning is the process of experiencing respiratory impairment from submersion or

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immersion in liquid.1 Worldwide, drowning is a major issue; the World Health Organization estimates that

about 388,000 people drown every year.2

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The circumstances relating to bodies recovered from water vary and an autopsy should be performed to

determine the exact cause of death.3 However, an American study of 123 subjects demonstrated that,

despite thorough autopsy, the circumstances in submersion deaths (suicidal, accidental or homicidal)

remained unclear in 41% of cases.4'In drowning cases , external foam can be present as a distinctive

characteristic. External foam is defined as snow-white, fine-meshed foam, located around the mouth and/or

nose of the deceased person as seen in picture 1.

The literature describes that the longer the period between the death and the performance of the autopsy,

the lower the prevalence of external foam.5,6 Thus it seems that external foam disappears as time and

decomposition progress.
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To determine the time of death it will be helpful to know how much time must pass after death before

external foam can no longer be detected. The time of death can help to clarify the circumstances in which

people are recovered from water. This study describes the post-mortem period in which external foam is

visible in post-mortem external examinations of freshwater drowning cases.

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Methods

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Study design This study retrospectively evaluates data of the post-mortem external examinations of bodies

recovered from fresh water as well as subjects who were found still alive in fresh water, and died within 6

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hours of being found. This study involves bodies recovered from, or found in, the canals of Amsterdam, as

well as from lakes, meres and ditches in the Amsterdam region (the Netherlands), between January 2011

and July 2016.

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Data collection The digital register “Formatus” was used for the data collection in the period from January
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2011 through July 2016. All unnatural deaths in the Amsterdam region, including Amstelland and

Zaanstreek are systematically registered by forensic physicians in “Formatus”, making it a complete

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database. A pre-selection of post-mortem external examination reports (death reports) was provided, using

the search function of the register. The database of death reports (N=4905) was searched using the
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following terms: “drowning”, “water body”, “external foam”, “float” and “in the water”.
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This pre-selection was then reviewed using the following inclusion criteria:

1) Found deceased in public or non-public fresh, outdoor water (N=93); or

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2) Found in public or non-public fresh, outdoor water and died within 6 hours (N=27).

In total 120 death reports met the inclusion criteria.

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The following exclusion criteria were used:

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1) Age below 18; N=1

2) Organ transplant of heart and/or lungs (donor); N=1

3) Missing head; N=2

4) Missing estimate of post-mortem interval; N=4

Figure 1 shows an overview of the inclusion of cases.

The death reports that met the inclusion and exclusion criteria were entered into the database. For each of

these death reports, the full text and any accompanying photographs were studied for the presence or

absence of external foam.

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External examinations

All external examinations were performed by forensic physicians. A total of 22 forensic physicians were

involved in collecting the data. All of them had completed the post-academic training for forensic physicians

and work according to an established protocol. An external examination involves a complete inspection and

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examination of the undressed body, toxicological urine and blood analyses, an exploration of the medical

history and an investigation of the circumstances together with the detectives at the scene. Photographs

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were taken by the forensic physician and/or by the detective force.

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The external examination was performed at the place where the body was recovered from the water or at

the mortuary if the place of recovery was not suitable or safe. When a person died in hospital, the external

examination was carried out there by a forensic physician. All external examinations took place within one

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hour after a body was found. This could be achieved thanks to the 24/7 availability of the forensic
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physicians.
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The estimation of the time of death was based on witness statements, circumstances, suicide notes (where

relevant) and post-mortem changes. Post-mortem changes were evaluated by the forensic physician
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according to the Dutch guideline “postmortem external examination” from the Forensic Medical Society
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(FMG). Foam was only scored as present when initially visible. No determination of the amount of foam was

made.
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All findings were noted in “Formatus” according to a standardized format. Photographs taken by forensic

physicians were also registered in “Formatus”, but, photographs taken by detective force were registered in
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police databases and were not available for this study.

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A forensic autopsy is not the standard procedure in the Netherlands after a body is recovered from water.

One is only performed when there is a suspicion of a crime after external examination.This was conducted

among the two cases without a head. Both of these cases however, were excluded from this study.

Definitions In this study, a post-mortem external examination is defined as a thorough, exterior

assessment of a deceased person. Unlike an internal autopsy, post-mortem external examinations do not

involve opening a body.

In the Netherlands a forensic physician is defined as a doctor involved in post-mortem external

examinations, who is specialized in the recognition and interpretation of external findings.

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Freshwater is defined as water having a sodium chloride content of less than 9 grams per liter. All public

outdoor water in the Amsterdam region has a measured sodium chloride content of less than 9 grams per

litre.

Statistical analysis Data was presented as an average with a standard deviation or as a percentage.

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During the analysis, the different groups were compared using the Chi-square test (Pearson Chi-Square).

For all statistical analyses, SPSS version 23 was used.

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Results

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Prevalence of external foam in relation to time of death

All 4905 post-mortem external examinations reports in the period from January 2011 through July 2016 in

the Amsterdam region were screened. A total of 112 reports met the inclusion criteria. Of these cases, 82%

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were men. The mean age of the entire group was 48.8 years. Table 1 shows that of the 112 examinations,
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foam was described in the report or was shown in the accompanying photographs in 18 cases (16.1%). All

of these 18 cases were found in the sub-groups with an estimated time of death between 0 and 24 hours
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(interval 3 -20 hours). No external foam was seen in the subjects for whom the post-mortem took place

more than 24 hours after death (p= .000).

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In the subgroup that was examined less than 6 hours after death, 17.9% of the cases had external foam.
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External foam was seen in a third of the subjects with a post-mortem interval between 6 and 24 hours.
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Discussion

This is the first study in which the presence of external foam on bodies found in fresh water has been

related to the post-mortem interval. Previous studies examined saltwater drowning, or an combined group
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of saltwater and freshwater drownings.5,6 The mechanism for drowning in fresh water theoretically differs
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from the mechanism for drowning in salt water. Fresh water is hypotonic and is absorbed in the lungs via

osmosis. In this process pulmonary surfactant becomes less effective, resulting in an increased surface

tension and collapse of the alveoli,7 leading to an intrapulmonary shunt and V/Q mismatch. Saltwater is

hypertonic and by way of osmosis draws fluid from the blood circulation into the lungs, resulting in fluid-

filled alveoli.8 Just like with freshwater drowning, this leads to an intrapulmonary shunt and V/Q mismatch.

But because of the different mechanisms that lead to an intrapulmonary shunt and V/Q mismatch

the presence of external foam in freshwater drowning may differ from that in saltwater drowning.
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In our study, external foam was only detected in cases involving a post-mortem period no longer than 24

hours. Therefore, if external foam is detected, it suggests a post-mortem interval between 0 and 24 hours.

The prevalence of external foam found in 112 death reports of freshwater drowning in the current study

(16.1%) corresponds with the prevalence of external foam in saltwater and freshwater drowning found in a

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previous study (17.3%).6

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Disappearance of external foam 24 hours after death

Our study did not detect external foam in any of the cases that had a post-mortem period of longer than 24

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hours (N=47). There are several possible explanations. One practical hypothesis is that after a 24-hour

period, external foam is washed away or becomes so diluted with water that there is insufficient surfactant

to produce external foam.9 Another hypothesis is that after 24 hours surfactants can no longer function. This

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may be because the proteins are partially consumed or become too decayed, due to the combination of a
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warm and moist environment that bodies in water provide for the growth of micro-organisms.10 More

specifically, the breakdown of surfactants by Pseudomonas aeruginosa through elastase has been
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described.11 Furthermore a previous study demonstrated a poorer surfactant activity in mammals at 3

degrees Celsius than at 37 degrees Celsius.12 The cooling of a body after death may explain why external
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foam is not detected after a longer post-mortem interval. Finally, another possible explanation for the
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disappearance of external foam after 24 hours is the half-life of surfactants, which has been described as

ranging between 6.5 and 28 hours.13 Hence, washing away of external foam, dilution of surfactants,
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decomposition and cooling of the body and the half-life of surfactants are possible reasons that external

foam is not seen after 24 hours.

The reason why no foam was seen in approximately three-quarters of the cases with a time of death less
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than 24 hours is not known.

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Less presence of external foam in the first 6 hours after death.

We found a lower percentage of external foam in subjects with a postmortem interval of 6 hours or less. In

subjects with a postmortem interval of 3 hours or less, we found no external foam at all (N=17). It seems

that the lower percentage in the 0-6 hours after death group is caused by the fact that no external foam is

visible within the first 3 hours. Perhaps this is because aspirated water must first enter the alveoli, and mix

with already-present surfactants, before it can start to form a fine-meshed foam. Once formed, the foam

must traverse the bronchial tree by way of passive transfer to the oral cavity and pharynx. It is

hypothesized that the above-mentioned post-mortem process takes several hours. This would mean that at
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an earlier stage, foam can be detected internally (trachea, oral cavity and pharynx) but not externally.

Current findings compared to those of previous studies This study relates the prevalence of external

foam in freshwater drowning to the post-mortem interval. Two previous studies investigated the relation

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between the prevalence of foam and the post-mortem interval. The first study in saltwater subjects, found

that foam (including foam in the airways) is only detected in bodies that have not yet decomposed.5 Our

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results are in line with the findings of this previous study, since none of the subjects on whom external foam

was detected could be categorized as decomposed based on the decomposition criteria noted in that paper.

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The second study described the detection of external foam on 1590 bodies found in saltwater and

freshwater.6 In this study, external foam was found on 275 (17.3%) of the bodies. In 74% of those cases,

the post-mortem interval was less than 24 hours, which is in line with the findings of the current study. In

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26% of the cases, external foam was found when the post-mortem interval was more than 24 hours.
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However, this difference could be explained by the fact that this study contains bodies found in both

saltwater and freshwater.

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Limitations
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This retrospective study has some limitations. The determined times of death are mostly comprised of
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estimates based on data collected during forensic practice. These estimates were made as accurately as

possible based on the features of the body, as well as witness accounts, but it is not known how great the
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inter-doctor variation between the 22 forensic physicians was when estimating post-mortem intervals. When

an interval was reported, the middle of the range was taken as the time of death during analysis. In two

cases the range of the interval was about 1 day to two days. For the analysis we used the middle of the
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interval (36 hours). Neither of these cases exhibited external foam.

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Photographic material was taken in all cases but only in 72% (N=80) of cases was it recorded in “Formatus”.

The photographs from the remaining 32 cases were stored in the police database and were not available for

analysis. For death reports where photographs were available (72%, N=80), there was only one incidence of

external foam being visible on photographs that was not mentioned in the death report (1.3%). All forensic

physicians were instructed to report external foam (if visible) in the death report.

Although there were no clues in our cases, it is possible some bodies ended up in the water after death. The

literature is unclear on whether or not external foam can also occur on these bodies.

Conclusion
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This is the first study to describe a relationship between the presence of external foam and the post-mortem

period in freshwater drownings. Cases in which external foam was detected comprise 16.1% of the total

study population. In cases with an estimated post-mortem interval of more than 24 hours no external foam

was detected. Within the sub-group with an estimated post-mortem period between 0 and 24 hours,

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external foam was detected in 27.7% of the cases (p = .000). The reason why no foam was seen in the

other cases is unknown. The presence of external foam during external examinations may be used as an

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additional indicator when estimating the post-mortem period. Further research is needed to determine why

no external foam is observed in the majority (72.3%) of the cases with a post-mortem period of less than

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24 hours and why there is no external foam observed in the cases with an post-mortem interval more than

24 hours. Furthermore the relationship between the presence or absence of external foam and internal foam

in drowning cases has to be investigated, especially in relation to the postmortem interval.

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deaths. Int J Clin Pract. 2010 Jan;64(1):75-83. Feb 16.

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nondecomposed bodies retrieved from water: a comparative approach. Med Sci Law. 2013

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[7] Modell JH, Moya F, Newby EJ et al. The effects of fluid volume in sea water drowning. Ann Intern Med

1967 67:68-80

[8] Giammona ST, Modell JH. Drowning by total immersion; effects on pulmonary surfactant of distilled

water, isotonic saline and seawater. Am J Dis Child 1967 114:612-616

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[9] Henssge C1, Althaus L, Bolt J, Freislederer A, Haffner HT, Henssge CA, Hoppe B, Schneider V.

Experiences with a compound method for estimating the time since death. II. Integration of non

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surfactant proteins A and D. Am J Respir Cell Mol Biol. 2003

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[12] McCaig L, Picardi MV, Ospina OL, Veldhuizen RA, Staples JF, Possmayer F, Yao LJ, Perez-Gil J, Orgeig S.

Suri LN1 Adaptation to low body temperature influences pulmonary surfactant composition thereby

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Time of Death Number of cases Cases with external Percentage of cases

foam with external foam

< 6 hours 28 5 17.9%

6> hours, <12 hours 17 6 35.3%

>12 hours, <18 hours 14 5 35.7%

>18 hours, <24 hours 6 2 33.3%

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<24 hours 65 18 27.7%

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>24 hours 47 0 0%

Total group 112 18 16.1%

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Table 1: Percentage of cases with external foam

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Figure 1: flowchart
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Picture 1: external foam

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Highlights

Determining the time of death of bodies recovered from water can be difficult

The presence of external foam is an essential feature of bodies recoverd from water

External foam is only present in bodies recovered from freshwater with a post-mortem interval of
less than 24 hours

External foam is an additional indicator for estimating the time of death in freshwater drowning

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It is unexplained why external foam is not seen after 24 hours

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