Journal of Forensic and Legal Medicine 52 (2017) 1e4

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Journal of Forensic and Legal Medicine

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m

External foam and the post-mortem period in freshwater drowning;

results from a retrospective study in Amsterdam, the Netherlands
G. Reijnen a, *, M.C. Buster b, P.J.E. Vos c, U.J.L. Reijnders d
a
Department of Forensic Medicine, Amsterdam Public Health Service, Rijnstate Hospital Arnhem, The Netherlands
b
Department of Epidemiology & Health Promotion, Amsterdam Public Health Service, The Netherlands
c
Rijnstate Hospital Arnhem, The Netherlands
d
Department of Forensic Medicine, Amsterdam Public Health Service, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Determining the time of death of bodies recovered from water can be difficult. A feature of
Received 14 February 2017 drowning is the presence of external foam. This study describes the presence of external foam in relation
Received in revised form to the post-mortem period.
8 July 2017
Method: The study utilizes a database of death reports dated between January 2011 and July 2016. For
Accepted 24 July 2017
Available online 26 July 2017
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 account for 16.1% of the entire study population. In the population with a post-mortem period of
Keywords:
External foam
less than 24 h, external foam was detected in 27.7% of cases. All 18 incidents with external foam had an
Froth estimated post-mortem period of less than 24 h.
Bodies recovered from water Conclusion: In our study, external foam was only present in freshwater drowning cases with a post-
Time of death mortem period of less than 24 h. Based on this finding, the presence of external foam may be useful
Drowning as an additional indicator when estimating the time of death in freshwater drowning.
© 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.

1. Introduction prevalence of external foam.5,6 Thus it seems that external foam

Drowning is the process of experiencing respiratory impairment
from submersion or immersion in liquid.1 Worldwide, drowning is
a major issue; the World Health Organization estimates that about
388,000 people drown every year.2
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 demon-
strated that, despite thorough autopsy, the circumstances in sub-
mersion 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 Fig. 2.
The literature describes that the longer the period between the
death and the performance of the autopsy, the lower the
* Corresponding author. Department of Forensic Medicine, P.O. Box 2200, 1000
CE Amsterdam, The Netherlands.
E-mail address: greijnen@rijnstate.nl (G. Reijnen).
disappears as time and decomposition progress.
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 cir-
cumstances 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.
2. Methods
2.1. 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 h 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.

http://dx.doi.org/10.1016/j.jflm.2017.07.013
1752-928X/© 2017 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
2 G. Reijnen et al. / Journal of Forensic and Legal Medicine 52 (2017) 1e4
Fig. 1. Flowchart.
Fig. 2. External foam.
2.2. Data collection
The digital register “Formatus” was used for the data collection
in the period from January 2011 through July 2016. All unnatural
deaths in the Amsterdam region, including Amstelland and Zaan-
streek are systematically registered by forensic physicians in “For-
matus”, making it a complete database. A pre-selection of post-
mortem external examination reports (death reports) was pro-
vided, using the search function of the register. The database of
death reports (N ¼ 4905) was searched using the following terms:
“drowning”, “water body”, “external foam”, “float” and “in the
water”.
This pre-selection was then reviewed using the following in-
clusion criteria:
1) Found deceased in public or non-public fresh, outdoor water
(N ¼ 93); or
2) Found in public or non-public fresh, outdoor water and died
within 6 h (N ¼ 27).
In total 120 death reports met the inclusion criteria.
The following exclusion criteria were used:
1) Age below 18; N ¼ 1
2) Organ transplant of heart and/or lungs (donor); N ¼ 1
3) Missing head; N ¼ 2
4) Missing estimate of post-mortem interval; N ¼ 4
Fig. 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.
2.3. External examinations
All external examinations were performed by forensic physi-
cians. 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 ex-
amination 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 were taken by the forensic physician and/or by the
detective force.
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 1 h after a
body was found. This could be achieved thanks to the 24/7 avail-
ability of the forensic physicians.
The estimation of the time of death was based on witness
 G. Reijnen et al. / Journal of Forensic and Legal Medicine 52 (2017) 1e4
statements, circumstances, suicide notes (where relevant) and
post-mortem changes. Post-mortem changes were evaluated by the
forensic physician according to the Dutch guideline “postmortem
external examination” from the Forensic Medical Society (FMG).
Foam was only scored as present when initially visible. No deter-
mination of the amount of foam was made.
All findings were noted in “Formatus” according to a standard-
ized format. Photographs taken by forensic physicians were also
registered in “Formatus”, but, photographs taken by detective force
were registered in police databases and were not available for this
study.
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.
2.4. 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.
Freshwater is defined as water having a sodium chloride content
of less than 9 g per liter. All public outdoor water in the Amsterdam
region has a measured sodium chloride content of less than 9 g per
liter.
2.5. Statistical analysis
Data was presented as an average with a standard deviation or
as a percentage. 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.
3. Results
3.1. 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% were men. The mean age of the entire
group was 48.8 years. Table 1 shows that of the 112 examinations,
foam was described in the report or was shown in the accompa-
nying 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 h (interval 3e20 h). No external foam was seen in the
subjects for whom the post-mortem took place more than 24 h
after death (p ¼ 0.000).
Table 1
Percentage of cases with external foam.
Time of Death Number of cases
<6 h 28
6 > hours, <12 h 17
>12 h, <18 h 14
>18 h, <24 h 6 2
<24 h 65
>24 h 47
Total group 112
3
In the subgroup that was examined less than 6 h after death,
17.9% of the cases had external foam.
External foam was seen in a third of the subjects with a post-
mortem interval between 6 and 24 h.
4. 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 a
combined group of saltwater and freshwater drownings.5,6 The
mechanism for drowning in fresh water theoretically differs 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 intra-
pulmonary shunt and V/Q mismatch the presence of external foam
in freshwater drowning may differ from that in saltwater drowning.
In our study, external foam was only detected in cases involving
a post-mortem period no longer than 24 h. Therefore, if external
foam is detected, it suggests a post-mortem interval between 0 and
24 h. 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 previous study (17.3%).6
4.1. Disappearance of external foam 24 h after death
Our study did not detect external foam in any of the cases that
had a post-mortem period of longer than 24 h (N ¼ 47). There are
several possible explanations. One practical hypothesis is that after
a 24-h 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 h surfactants can no
longer function. This may be because the proteins are partially
consumed or become too decayed, due to the combination of a
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
described.11 Furthermore a previous study demonstrated a poorer
surfactant activity in mammals at 3 Celsius than at 37 Celsius.12
The cooling of a body after death may explain why external foam
is not detected after a longer post-mortem period. Finally, another
possible explanation for the disappearance of external foam after
24 h is the half-life of surfactants, which has been described as
ranging between 6.5 and 28 h.13 Hence, washing away of external
foam, dilution of surfactants, decomposition and cooling of the
body and the half-life of surfactants are possible reasons that
Cases with external foam Percentage of cases with external foam
5 17.9%
6 35.3%
5 35.7%
33.3%
18 27.7%
0 0%
18 16.1%
4 G. Reijnen et al. / Journal of Forensic and Legal Medicine 52 (2017) 1e4
external foam is not seen after 24 h.
The reason why no foam was seen in approximately three-
quarters of the cases with a time of death less than 24 h is not
known.
4.2. Less presence of external foam in the first 6 h after death
We found a lower percentage of external foam in subjects with a
postmortem interval of 6 h or less. In subjects with a postmortem
interval of 3 h or less, we found no external foam at all (N ¼ 17). It
seems that the lower percentage in the 0e6 h after death group is
caused by the fact that no external foam is visible within the first
3 h. 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-mor-
tem process takes several hours. This would mean that at an earlier
stage, foam can be detected internally (trachea, oral cavity and
pharynx) but not externally.
4.3. Current findings compared to those of previous studies
This study relates the prevalence of external foam in freshwater
drowning to the post-mortem period. Two previous studies
investigated the relation between the prevalence of foam and the
post-mortem period. 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 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.
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 period was less than 24 h, which is in
line with the findings of the current study. In 26% of the cases,
external foam was found when the post-mortem period was more
than 24 h. However, this difference could be explained by the fact
that this study contains bodies found in both saltwater and
freshwater.
4.4. Limitations
This retrospective study has some limitations. The determined
times of death are mostly comprised of 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 inter-doctor
variation between the 22 forensic physicians was when esti-
mating post-mortem periods. 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 interval (36 h). Neither of
these cases exhibited external foam.
Photographic material was taken in all cases but only in 72%
(N ¼ 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 photo-
graphs were available (72%, N ¼ 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.
5. Conclusion
This is the first study to describe a relationship between the
presence of external foam and the post-mortem period in fresh-
water drownings. Cases in which external foam was detected
comprise 16.1% of the total study population. In cases with an
estimated post-mortem period of more than 24 h no external foam
was detected. Within the sub-group with an estimated post-
mortem period between 0 and 24 h, external foam was detected
in 27.7% of the cases (p ¼ 0.000). 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 additional indi-
cator 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 24 h and why there is no external foam observed in the cases
with a post-mortem period more than 24 h. 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 period.
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