Accepted Manuscript

The persistent problem of drowning - A difficult diagnosis with inconclusive tests

Lilli Stephenson, Corinna Van den Heuvel, Roger W. Byard

PII: S1752-928X(19)30054-X
DOI: https://doi.org/10.1016/j.jflm.2019.06.003
Reference: YJFLM 1826

To appear in: Journal of Forensic and Legal Medicine

Received Date: 17 February 2019

Revised Date: 7 June 2019
Accepted Date: 12 June 2019

Please cite this article as: Stephenson L, Van den Heuvel C, Byard RW, The persistent problem of
drowning - A difficult diagnosis with inconclusive tests, Journal of Forensic and Legal Medicine (2019),
doi: https://doi.org/10.1016/j.jflm.2019.06.003.

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Drowning overview 12 02 19

THE PERSISTENT PROBLEM OF DROWNING - A DIFFICULT DIAGNOSIS WITH

INCONCLUSIVE TESTS

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Lilli Stephenson, Corinna Van den Heuvel, Roger W. Byard

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Forensic Science South Australia (FSSA) and the School of Medicine, The University

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of Adelaide, Adelaide, South Australia, 5000, Australia

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Address for Correspondence:

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Professor Roger Byard

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School of Medicine
Level 2 Medical School North Building
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The University of Adelaide

Frome Road
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Adelaide 5005, SA
Australia
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Email: roger.byard@sa.gov.au

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ABSTRACT

Although the diagnosis of drowning may appear straightforward the reality is that it is

sometimes one of the most difficult in forensic pathology. To begin with, there is no

universal agreement on what constitutes drowning with some definitions using the

term in the absence of a lethal outcome. Next are the significant problems that arise

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in finding immersed bodies and in assessing the death scene. Prolonged post

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mortem intervals are associated with artefactual modifications of the body from

putrefaction and post mortem animal predation. Both of these may create and

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disguise injuries. The absence of pathognomonic pathological features at autopsy

and the presence of potentially life threatening underlying organic illnesses

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complicate determination of both the cause and manner of death. There may even
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be no autopsy findings to indicate that immersion had occurred. Finally, the
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unreliability of laboratory tests with significant overlap with control cases where death

had no association with immersion presents further problems. Thus lethal drowning
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remains a complex event that requires the use of a wide variety of information
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sources, not just data gleaned from the dissection table.

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Keywords: drowning; immersion; dry drowning; autopsy features; laboratory tests

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Plus ça change, plus ça reste pareil (the more it changes the more it stays the same)

Jean-Baptiste Alphonse Karr (1808-1890)

“In the case of every unknown body taken out of the water, two questions present

themselves:

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• Was the deceased alive or dead when he fell into the water?

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And has the death occurred by accident, suicide, or the fault of a third party?”

Professor Johann Ludwig Caspar, Berlin, Prussia 18621

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1. Introduction

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Drowning is one of the ten most common causes of death in people under 25 years
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of age, and is most prevalent in low- and middle-income countries2. The investigation
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of suspected drowning deaths is, however, a complex undertaking. In a forensic

context, drowning refers to a lethal incident involving the submersion in, and
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inhalation of, water/liquid3,4. However, as the definition of drowning has been highly
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variable attempts have been made in recent years to improve the consistency of

terminology used in scientific publications5,6.

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The diagnosis of drowning requires the exclusion of other possible causes of

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death, supported by a detailed history, scene findings and a comprehensive autopsy

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examination. If the incident is unwitnessed, however, it may be difficult or impossible

to definitively determine the manner of death7. In suspected drowning deaths,

environmental factors may also complicate determination of the cause and manner

of death. Delayed body retrieval, strong water currents, decomposition and animal

predation associated with aquatic death scenes may hinder and/or complicate the

collection, and compromise the analysis, of physical evidence. Determination of the

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cause of death in a suspected drowning incident may also be made more difficult by

the lack of specific pathological findings8-10.

2. Problems with the pathological assessment

Definitions

The first problem encountered in the diagnostic process is in reaching a consensus

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on the definition of drowning. The general definition of drowning specifies that

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respiratory impairment must occur due to submersion or immersion in a liquid

medium11-13. Or as Caspar stated over 150 years ago: “A man (sic) is said to be

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drowned when the access of the atmospheric air is cut off from the air-passages by

any watery or pultaceous fluid into which his head has fallen and remained”1.

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However, establishing the end point of a drowning incident is where opinions
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diverge. In 2003 it was stipulated that a victim of drowning may live or die after the
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incident, “but whatever the outcome, he or she has been involved in a drowning

incident”11. Given that drowning in a clinical context is not necessarily associated

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with a lethal outcome there is a mismatch between clinical and forensic terminology
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and classifications5.

Van Beeck et al. recommended avoiding terms such as “dry/wet drowning”,

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“secondary drowning”, and “active/passive drowning” to simplify the array of terms

present in the literature12. “Near drowning” describes an event in which the victim
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survives for a period of time after the incident, and although criticized has on

occasion been useful in distinguishing fatal and non-fatal drowning incidents,

assisting in case evaluations and in standardising data5.

A problem also arises in approximately 10-15% of drowning cases where

aspiration of significant amounts of fluid has not occurred. The term “dry drowning”

refers to such an episode in which submersion without aspiration occurs where the
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lethal mechanism is thought to be glottic spasm14,15. While this phenomenon occurs

infrequently the term has been criticised as it brings into question some definitions of

drowning, given that there is no aspiration of fluid; i.e. is it more appropriate to

classify these events as drownings, or are they better categorised as death due to

upper airway obstruction?

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Death Scene

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Underwater death scenes are characterised by a number of obstacles that may

interfere with reaching a definitive diagnosis and this is particularly so in the event of

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a mass disaster16. For example, if a drowning incident is unwitnessed, it is highly

likely that the body will not be discovered for a prolonged period of time unless the

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incident occurred in a public, populated area. Body composition effects the period of
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time the body floats on the surface of the water or is submersed14,17, which may
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influence the likelihood of the body being discovered. The longer the post mortem

interval the more difficult it becomes to determine the time of death, evaluate
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possible injuries and assess pathological changes, as prolonged submersion and

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post mortem intervals exacerbate the effects of decomposition and animal

predation7.
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A piglet study by Di Giancamillo et al. reported significant alterations to tissue

structure after one month of submersion18. In cases of advanced putrefactive change

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(Figure 1), it is critical, therefore, to transport a body for autopsy as quickly as

possible to minimise further tissue and organ damage with resultant loss of

evidence10. Post mortem animal predation can also make it difficult to accurately

assess antemortem injuries as animals tend to focus on wounds and areas where

there has been loss of skin integrity19. The soft tissues of the face are also

particularly vulnerable to predation by crabs, fish and water rats, often producing
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profound facial disfigurement20. Alterations to muscle and subcutaneous tissues may

result in the modification/destruction of existing lesions, complicating the

identification of bruises or other superficial injuries19. Distinguishing ante mortem

from post mortem injuries becomes more difficult with longer submersion times21.

Bodies in sea water are susceptible to predation by marine fauna such as sharks,

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crustaceans and sea lice, compared to bodies in fresh water which may be attacked

by fish, crocodiles, rats, birds and crustaceans19,22.

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Water temperature has also been noted to have a significant effect on the rate

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of decomposition. For example, bodies retrieved from rivers in South Australia tend

to have greater changes of decomposition than those found in the sea due in part to

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the higher temperatures of fresh water. Other factors contributing to this include
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problems finding bodies in flooded rivers, lack of salinity and the presence of

contaminated silt and organic material in river beds19. Conversely, in colder

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temperatures, the production of putrefactive gases may be slowed thus preventing

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the body from resurfacing, which prolongs the period before the body is
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discovered14. Other environmental factors such as water currents, wind, waves and

tides can move a floating body thousands of kilometres from the point of entry in
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quite a short period of time14 thus making it difficult to reconstruct and establish an
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accurate history of events.

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Comorbidities

Although there is a temptation to assume that any person found in water has died by

drowning, it is clear that an individual can die from many other causes while in water,

or on land ending up in water only after death23. Thus, all injuries, organic conditions

and toxicology findings must be fully evaluated and all manners of death considered.

Alcohol intoxication is a particular feature of many drowning deaths8,13,14.

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For example, individuals with epilepsy and ischaemic heart disease may

collapse and drown if a medical episode occurs while they are in water. This is

particularly so with ischaemic heart disease if exertion has occurred. A study of

childhood deaths associated with immersion found that 6/58 (10.3%) of cases were

associated with underlying medical conditions including epilepsy, a bleeding

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intracerebral arteriovenous malformation and a hypoplastic coronary artery24.

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Cardiac channelopathies such as long QT syndrome have a well-recognised

association with 1-2% of drowning deaths25.

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Pathophysiology

The physiology of drowning is complex and involves responses to both immersion

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and submersion13. Immersion in cold water tends to overcome attempts to breath
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hold with so-called “cold shock” and is associated with the development of
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arrhythmias and eventual hypothermia when the deep tissues lose sufficient heat.

Animal experiments have shown that the diving response may be activated by either
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apnoea or facial immersion resulting in both sympathetic and parasympathetic

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responses causing bradycardia and peripheral vasoconstriction. Another mechanism

which may contribute to a fatal outcome is aspiration of fluid into the pulmonary
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alveoli resulting in changes in blood electrolyte levels13,14.

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Deaths while scuba diving may involve depletion of gas, entrapment, or

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nitrogen narcosis, and require very careful evaluation of the equipment that was

being used and evaluation for gas embolism at autopsy 14.

Pathological features

While there may be quite characteristic external and internal features visualised at

autopsy, there are no established diagnostic features of drowning21. Post mortem

changes in aquatic environments are also much less predictable than those
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occurring on land14. External observations often include wrinkling of the hands and

feet with prolonged immersion (so-called “washer woman” hands - sometimes

resulting in sloughing of the epidermis to form a “glove”) (Figures 2 & 3), foam

around the nose, mud and debris in the mouth, and abrasions on the dorsal surface

of the feet, hands and knees from dragging14,26-29. Internally there may be foam in

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the nasal passages and airways, pleural effusions, pulmonary oedema and

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haemorrhage, dilation of the right side of the heart, fluid in the sinuses, middle ear or

mastoid air cell haemorrhage, fluid in the stomach, splenomegaly and soft tissue

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haemorrhage in the neck. The stomach may be filled with water (Wydler’s sign) and

the lungs may be hyperinflated, so-called emphysema aquosum (Figure 4), with

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surface indentations from pressure against the ribs, and Paltauf’s spots26-32.
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However, these features are not always present, nor are they exclusive to

drowning27,31. For example, frothy pulmonary oedema fluid may be observed in

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cases of opiate overdose and following head trauma. Hyperinflated and/or

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oedematous lungs may also occur with heart failure, asthma, bronchopneumonia,
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chronic bronchitis and cystic fibrosis27,33,34. A prominent example of “washerwoman

hands” observed by one of the authors (RWB) involved a homicide victim whose
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body had been found wrapped in wet canvas in a forest many kilometres inland
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away from the sea and rivers.

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Airway foam

While the presence of internal and external foam is sometimes considered a

diagnostic marker of drowning, this may be influenced by environmental factors. The

most characteristic finding is a plume of foam from the nose (Figure 5). However, a

recent study reported that the presence of internal foam was not supportive of

drowning, as it can also be formed by fluid that enters the lungs after death35. Foam
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is also susceptible to environmental degradation, so the longer the post mortem

interval the less likely it is that external foam will be found36,37.

Fluid in the sinuses

Vander Plaetsen et al reported that fluid in the paranasal sinuses, nasal pharynx,

oropharynx and trachea was a common finding in drowning deaths (in 98%, 98%,

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95% and 83% of cases respectively)38. However, fluid in the sinuses is merely a sign

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of immersion and so its presence cannot be used to exclude other causes of

death14,38. For example, fluid in the sinuses and trachea can be a result of

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cardiovascular failure and has also been observed in fatal cases of burning and

poisoning39. Fluid within the sphenoid sinus from drowning has been termed

Svechnikov’s sign32.
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Splenic size
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Changes in splenic morphology related to drowning can be traced back to the 19th

century and are still sporadically used to support or refute a diagnosis of drowning;
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for example, a small, “anaemic” spleen has been thought to be indicative of

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drowning40,41. In a study of 42 cases of freshwater drowning compared to controls,

spleen weights, spleen to body weight ratios and spleen to liver weight ratios were all
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found to be reduced40. However, it is important to note that lower spleen weights are
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not observed in all cases of drowning and it is not a reliable indicator of drowning as

it may be a result of sympathetic stimulation 27,40,42.

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Lung weight

The weight of the lungs is frequently used in the assessment of possible drowning,

but with variable success43,44. An increased lung weight is a common finding in

drowning caused by aspiration of water, pulmonary alveolar damage and cardiac

failure33,45-47. Both Hadley and Fowler and Zhu et al. reported significant differences
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in lung weight between individuals who died by drowning compared with other

causes of death42,48. However, studies have not been able to establish a reliable

relationship between lung weight and submersion time, or to the drowning medium49.

There was also no significant differences in lung weight observed between

freshwater and saltwater drowning37, nor any correlation between lung weight and

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the accumulation of pleural fluid50. With a longer post mortem interval, Kringsholm et

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al. hypothesised that the lung weight would decrease as pleural transudate

increased37. Zhu et al. suggested that a lung-heart weight ratio might be a more

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useful parameter47, which was supported by the study by Tse et al. However, the

overall sensitivity was low and an increased lung weight is not specific to drowning

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as it is observed in a variety of unrelated organic conditions43,44,47. Thus, Lunetta has
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concluded that lung weight is of no diagnostic significance due to the prominent

overlap between cases and control14.

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Drowning index
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Sugimura et al. proposed that a drowning index (ratio of lung to spleen weight) could
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be used to distinguish drowning from other causes of death, rather than using lung

weight or spleen weight in isolation45. However, the usefulness is limited to a post

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mortem interval of 2 weeks, after which time significant tissue/organ changes

prevent any meaningful conclusions to be drawn45.

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Neck Haemorrhage

Interpretation of haemorrhages within the soft tissues of the neck in drowning is

controversial with quite variable results28. For example, while a retrospective study of

99 drowning deaths reported the presence of neck haemorrhage in only 8 cases

(8.1%) cases29, Lunetta had an incidence of greater than 50%14. It is, however,

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important to differentiate this from post mortem haemorrhage on the posterior aspect

of the oesophagus, the Prinsloo Gordon artefact28-30.

While neck haemorrhages may result from violent movements and muscle

contractions associated with the drowning process, they may also indicate injuries

from blunt force trauma or strangulation29. Spitz in fact states that “hemorrhage in the

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anterior neck muscles which are often seen in cases of strangulation do not occur in

drowning and should always raise the suspicion of foul play”30.

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Aortic intimal staining

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Differential staining of the intima of the aortic root compared to the pulmonary trunk

has been suggested as a potential marker for freshwater drowning (Figure 6)51-53.

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First described in the German literature as “hämoglobinimbibiert”54,55 it arises from
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lysed erythrocytes staining the aorta, induced by hypotonic fluid entering the lungs
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during immersion. However, generalised haemolytic staining of the intima is not

specific to drowning and may also be caused by any organic condition that causes
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the degradation of red blood cells (i.e. extensive burn injury or disseminated sepsis);
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differential staining has also recently been reported in a case of pulmonary

thromboembolism56.
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In a retrospective study, differential staining of the aortic root intima was

observed in 5% of freshwater drownings but not in controls57. Zatopkova et al. argue

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for using this type of staining as a marker for freshwater drowning and have

observed haemolytic staining extending into the endocardium of the left cardiac

chambers58.

Computed tomography (CT)

While the use of CT in drowning cases probably has as many limitations as an

autopsy when attempting to distinguish between drowning and non-drowning

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deaths23, and between salt and freshwater drownings59, it has the advantage of

being non-invasive. This is particularly useful in visualising areas such as the

paranasal sinuses which are anatomically quite inaccessible60. However, a more

comprehensive knowledge of the appearance of drowning pathology with CT will be

required to effectively utilise this imaging modality. The lung appearances in

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drowning on CT range from airspace consolidation to a mosaic-like pattern61,62.

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Additionally, The CT appearances have been classified into three major types:

ground-glass opacities with thickened pulmonary interstitium, centrilobular

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distribution of ill-defined nodules along the airways and a combination of both63,64

However these are again not specific for a single cause of death23.

3. Problems with “diagnostic” tests

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The earliest diagnostic markers of drowning deaths which involved analysis of body

temperature and blood viscosity1 are no longer used due to their poor reproducibility.
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Current research is, however, re-evaluating historical methods while investigating

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new techniques to assist diagnosis14.

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Diatoms

Diatoms are a large group of single-celled algae found in fresh and salt water that
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may reach the systemic circulation by diffusing through alveolar capillary membranes
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when water is aspirated. The presence of diatoms in other sites (i.e. bone marrow)

indicates that aspiration of water occurred during life65. The use of diatom testing to
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diagnose drowning has received much criticism since it was first introduced,

however, and has not proven useful in the majority of forensic drowning cases7.

It has been pointed out that the usefulness of diatom testing is negatively

impacted by ante- and post mortem environmental contamination18 which may occur

via ante mortem diatom penetration, during the submersion period through wounds,
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from resuscitation or during the sample preparation process. As such, there are

major discrepancies in the validity and reliability of diatom testing in the diagnosis of

drowning66.

While the conventional methods for diatom testing have proven to be

disappointing, efforts are being made to improve reliability and sensitivity67,68 with

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suggestions of incorporating polymerase chain reaction (PCR) to enhance the

reliability of the testing procedures69-71. While a diagnosis of drowning cannot be

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made on the diatom test alone, it may provide some support for the diagnosis32,67,72.

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Diatom analysis has proven useful in determining the point-of-entry when a body has

drifted from its origin by comparing a post mortem sample with water samples of the

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area73-76. Diatoms sampled from bone marrow were found in the drowning medium in
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90% of cases, supporting the potential use of diatoms in locating the drowning site77.
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Electrolytes

Analysis of vitreous humour electrolyte levels was proposed as a potential test for
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drowning in the early 1900’s78. The Gettler Test, developed in 1921 compared
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chloride levels in the left and right ventricles to diagnose drowning deaths20.

However, the test was subsequently considered unreliable8,79-81. A similar effect was
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proposed for strontium with a difference of greater than 75% in blood strontium
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levels between the right and left sides of the heart in keeping with saltwater
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drowning. Other electrolytes such as magnesium and calcium have had variable

results.

While changes in serum electrolytes have had negligible significance in the

diagnosis of drowning, the analysis of vitreous humour electrolyte changes may be

useful in distinguishing freshwater and saltwater drowning, as vitreous humour fluid

represents a sample site that is less susceptible to the effects of decomposition or

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contamination. Elevated vitreous humour sodium occurs in salt water drowning

cases with reduced levels in freshwater drowning78,82. However, elevated vitreous

sodium levels may be caused by unrelated factors such as dehydration or excess

dietary sodium intake83, or simply by post mortem diffusion; i.e. after a period of

more than one hour, changes to electrolyte levels have been noted due to the effects

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of immersion80,84-87. Thus, electrolyte studies have not proven particularly useful in

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the diagnosis of drowning7.

Other tests

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Although it has been proposed that anthracotic pulmonary macrophages or asbestos

bodies could be found in blood within the left side of the heart following drowning this

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has not proven diagnostically useful. Similarly, changes in pulmonary surfactant
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levels have been of more of experimental than practical interest32.
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4. Conclusion

Inconsistent use of terminology, complex death scenes, non-specific pathology88 and

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lack of definitive diagnostic pathological or laboratory markers make drowning a

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persistently difficult diagnosis.

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FIGURE LEGENDS

Figure 1: Marked putrefactive changes in a drowning victim with loss of

facial features.

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Figure 2: Wrinkling of the hands producing the classic “washerwoman

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changes” of immersion (A). In a more advanced case there has

been shedding of the skin and nails of the hand (B).

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Figure 3: Wrinkling of the sole of the foot (A) which may progress to

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sloughing of the skin and nails of the toes (B).
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Figure 4: Typical emphysema aquosum changes of the lungs in drowning

with hyperinflation causing the lungs to meet in the midline

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covering the heart.

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Figure 5: A characteristic plume of pulmonary oedema fluid emanating

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from the nose.

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Figure 6: Differential intimal staining in fresh water drowning with the

darker lining of the aorta (A) due to red staining from

haemoglobin contrasting with the more usual pale colour of the

pulmonary outflow tract.

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