Journal of Forensic and Legal Medicine 66 (2019) 79–85

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Journal of Forensic and Legal Medicine

journal homepage: www.elsevier.com/locate/yjflm

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

tests
Lilli Stephenson, Corinna Van den Heuvel, Roger W. Byard∗
Forensic Science South Australia (FSSA) and the School of Medicine, The University of Adelaide, Adelaide, South Australia, 5000, Australia

A R T I C LE I N FO A B S T R A C T

Keywords: Although the diagnosis of drowning may appear straightforward the reality is that it is sometimes one of the
Drowning most difficult in forensic pathology. To begin with, there is no universal agreement on what constitutes drowning
Immersion with some definitions using the term in the absence of a lethal outcome. Next are the significant problems that
dry drowning arise in finding immersed bodies and in assessing the death scene. Prolonged post mortem intervals are asso-
Autopsy features
ciated with artefactual modifications of the body from putrefaction and post mortem animal predation. Both of
Laboratory tests
these may create and disguise injuries. The absence of pathognomonic pathological features at autopsy and the
presence of potentially life threatening underlying organic illnesses complicate determination of both the cause
and manner of death. There may even be no autopsy findings to indicate that immersion had occurred. Finally,
the unreliability of laboratory tests with significant overlap with control cases where death had no association
with immersion presents further problems. Thus lethal drowning remains a complex event that requires the use
of a wide variety of information sources, not just data gleaned from the dissection table.

Plus ça change, plus ça reste pareil (the more it changes the more it stays causes of death, supported by a detailed history, scene findings and a
the same) comprehensive autopsy examination. If the incident is unwitnessed,
however, it may be difficult or impossible to definitively determine the
Jean-Baptiste Alphonse Karr (1808–1890)
manner of death.7 In suspected drowning deaths, environmental factors
“In the case of every unknown body taken out of the water, two questions may also complicate determination of the cause and manner of death.
present themselves: Delayed body retrieval, strong water currents, decomposition and an-

• Was the deceased alive or dead when he fell into the water?
imal predation associated with aquatic death scenes may hinder and/or

• And has the death occurred by accident, suicide, or the fault of a third
complicate the collection, and compromise the analysis, of physical
evidence. Determination of the cause of death in a suspected drowning
party?”
incident may also be made more difficult by the lack of specific pa-
thological findings.8–10
Professor Johann Ludwig Caspar, Berlin, Prussia 18621
2. Problems with the pathological assessment
1. Introduction
2.1. Definitions
Drowning is one of the ten most common causes of death in people
under 25 years of age, and is most prevalent in low- and middle-income
The first problem encountered in the diagnostic process is in
countries.2 The investigation of suspected drowning deaths is, however,
reaching a consensus on the definition of drowning. The general defi-
a complex undertaking. In a forensic context, drowning refers to a lethal
nition of drowning specifies that respiratory impairment must occur
incident involving the submersion in, and inhalation of, water/liquid.3,4
due to submersion or immersion in a liquid medium.11–13 Or as Caspar
However, as the definition of drowning has been highly variable at-
stated over 150 years ago: “A man (sic) is said to be drowned when the
tempts have been made in recent years to improve the consistency of
access of the atmospheric air is cut off from the air-passages by any
terminology used in scientific publications.5,6
watery or pultaceous fluid into which his head has fallen and
The diagnosis of drowning requires the exclusion of other possible

∗
Corresponding author. School of Medicine, Level 2 Medical School North Building, The University of Adelaide, Frome Road, Adelaide, 5005, SA, Australia.
E-mail address: roger.byard@sa.gov.au (R.W. Byard).

https://doi.org/10.1016/j.jflm.2019.06.003
Received 17 February 2019; Received in revised form 7 June 2019; Accepted 12 June 2019
Available online 13 June 2019
1752-928X/ © 2019 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
L. Stephenson, et al. Journal of Forensic and Legal Medicine 66 (2019) 79–85

remained”.1 However, establishing the end point of a drowning incident

is where opinions diverge. In 2003 it was stipulated that a victim of
drowning may live or die after the 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 with a lethal
outcome there is a mismatch between clinical and forensic terminology
and classifications.5
Van Beeck et al. recommended avoiding terms such as “dry/wet
drowning”, “secondary drowning”, and “active/passive drowning” to
simplify the array of terms present in the literature.12 “Near drowning”
describes an event in which the victim 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 data.5
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 lethal mechanism is thought to be
glottic spasm.14,15 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 ap-
propriate to classify these events as drownings, or are they better ca-
tegorised as death due to upper airway obstruction?

2.2. Death scene

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 a mass disaster.16 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 incident
occurred in a public, populated area. Body composition effects the
period of time the body floats on the surface of the water or is sub-
mersed,14,17 which may 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 possible injuries and
assess pathological changes, as prolonged submersion and post mortem
intervals exacerbate the effects of decomposition and animal preda-
tion.7
A piglet study by Di Giancamillo et al. reported significant altera-
tions to tissue structure after one month of submersion.18 In cases of
advanced putrefactive change (Fig. 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 evidence.10 Post mortem
animal predation can also make it difficult to accurately assess ante-
mortem injuries as animals tend to focus on wounds and areas where
there has been loss of skin integrity.19 The soft tissues of the face are
also particularly vulnerable to predation by crabs, fish and water rats,
often producing profound facial disfigurement.20 Alterations to muscle
and subcutaneous tissues may result in the modification/destruction of
existing lesions, complicating the identification of bruises or other su-
perficial injuries.19 Distinguishing ante mortem from post mortem in-
juries becomes more difficult with longer submersion times.21 Bodies in
sea water are susceptible to predation by marine fauna such as sharks,
crustaceans and sea lice, compared to bodies in fresh water which may
be attacked by fish, crocodiles, rats, birds and crustaceans.19,22
Water temperature has also been noted to have a significant effect
on the rate 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 the higher temperatures of fresh
water. Other factors contributing to this include problems finding
bodies in flooded rivers, lack of salinity and the presence of con-
taminated silt and organic material in river beds.19 Conversely, in
colder temperatures, the production of putrefactive gases may be
slowed thus preventing the body from resurfacing, which prolongs the
period before the body is discovered.14 Other environmental factors
Fig. 1. Marked putrefactive changes in a drowning victim with loss of facial
features.
such as water currents, wind, waves and tides can move a floating body
thousands of kilometres from the point of entry in quite a short period
of time14 thus making it difficult to reconstruct and establish an accu-
rate history of events.
2.3. 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 death.23 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
deaths.8,13,14
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 intracerebral arter-
iovenous malformation and a hypoplastic coronary artery.24 Cardiac
channelopathies such as long QT syndrome have a well-recognised as-
sociation with 1–2% of drowning deaths.25
2.4. Pathophysiology
The physiology of drowning is complex and involves responses to
both immersion and submersion.13 Immersion in cold water tends to
overcome attempts to breath hold with so-called “cold shock” and is
associated with the development of arrhythmias and eventual hy-
pothermia when the deep tissues lose sufficient heat. Animal experi-
ments have shown that the diving response may be activated by either
apnoea or facial immersion resulting in both sympathetic and para-
sympathetic responses causing bradycardia and peripheral vasocon-
striction. Another mechanism which may contribute to a fatal outcome
is aspiration of fluid into the pulmonary alveoli resulting in changes in
blood electrolyte levels.13,14
Deaths while scuba diving may involve depletion of gas,

80
L. Stephenson, et al. Journal of Forensic and Legal Medicine 66 (2019) 79–85

Fig. 2. Wrinkling of the hands producing the classic “washerwoman changes” of immersion (A). In a more advanced case there has been shedding of the skin and
nails of the hand (B).

entrapment, or nitrogen narcosis, and require very careful evaluation of

the equipment that was being used and evaluation for gas embolism at
autopsy.14

2.5. Pathological features

While there may be quite characteristic external and internal fea-

tures visualised at autopsy, there are no established diagnostic features
of drowning.21 Post mortem changes in aquatic environments are also
much less predictable than those occurring on land.14 External ob-
servations 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”) (Figs. 2 and 3), foam
around the nose, mud and debris in the mouth, and abrasions on the
dorsal surface of the feet, hands and knees from dragging.14,26–29 In-
ternally there may be foam in the nasal passages and airways, pleural
effusions, pulmonary oedema and 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 hae-
morrhage in the neck. The stomach may be filled with water (Wydler's Fig. 4. Typical emphysema aquosum changes of the lungs in drowning with
hyperinflation causing the lungs to meet in the midline covering the heart.
sign) and the lungs may be hyperinflated, so-called emphysema
aquosum (Fig. 4), with surface indentations from pressure against the
ribs, and Paltauf's spots.26–32 However, these features are not always
present, nor are they exclusive to drowning.27,31 For example, frothy

Fig. 3. Wrinkling of the sole of the foot (A) which may progress to sloughing of the skin and nails of the toes (B).

81
L. Stephenson, et al.
Fig. 5. A characteristic plume of pulmonary oedema fluid emanating from the
nose.
pulmonary oedema fluid may be observed in cases of opiate overdose
and following head trauma. Hyperinflated and/or oedematous lungs
may also occur with heart failure, asthma, bronchopneumonia, chronic
bronchitis and cystic fibrosis.27,33,34 A prominent example of “washer-
woman hands” observed by one of the authors (RWB) involved a ho-
micide victim whose body had been found wrapped in wet canvas in a
forest many kilometres inland away from the sea and rivers.
2.5.1. 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 (Fig. 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 death.35 Foam is also
susceptible to environmental degradation, so the longer the post
mortem interval the less likely it is that external foam will be
found.36,37
2.5.2. 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%, 95% and 83% of cases respectively).38
However, fluid in the sinuses is merely a sign of immersion and so its
presence cannot be used to exclude other causes of death.14,38 For ex-
ample, fluid in the sinuses and trachea can be a result of cardiovascular
failure and has also been observed in fatal cases of burning and poi-
soning.39 Fluid within the sphenoid sinus from drowning has been
termed Svechnikov's sign.32
2.5.3. Splenic size
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; for example, a small, “anaemic” spleen
has been thought to be indicative of drowning.40,41 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
found to be reduced.40 However, it is important to note that lower
spleen weights are 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
2.5.4. Lung weight
The weight of the lungs is frequently used in the assessment of
possible drowning, but with variable success.43,44 An increased lung
weight is a common finding in drowning caused by aspiration of water,
pulmonary alveolar damage and cardiac failure.33,45–47 Both Hadley
and Fowler and Zhu et al. reported significant differences in lung
weight between individuals who died by drowning compared with
82
Journal of Forensic and Legal Medicine 66 (2019) 79–85
other causes of death.42,48 However, studies have not been able to es-
tablish a reliable relationship between lung weight and submersion
time, or to the drowning medium.49 There was also no significant dif-
ferences in lung weight observed between freshwater and saltwater
drowning,37 nor any correlation between lung weight and the accu-
mulation of pleural fluid.50 With a longer post mortem interval,
Kringsholm et al. hypothesised that the lung weight would decrease as
pleural transudate increased.37 Zhu et al. suggested that a lung-heart
weight ratio might be a more useful parameter,47 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 as it is observed in
a variety of unrelated organic conditions.43,44,47 Thus, Lunetta has
concluded that lung weight is of no diagnostic significance due to the
prominent overlap between cases and control.14
2.5.5. Drowning index
Sugimura et al. proposed that a drowning index (ratio of lung to
spleen weight) could be used to distinguish drowning from other causes
of death, rather than using lung weight or spleen weight in isolation.45
However, the usefulness is limited to a post mortem interval of 2 weeks,
after which time significant tissue/organ changes prevent any mean-
ingful conclusions to be drawn.45
2.5.6. Neck haemorrhage
Interpretation of haemorrhages within the soft tissues of the neck in
drowning is controversial with quite variable results.28 For example,
while a retrospective study of 99 drowning deaths reported the pre-
sence of neck haemorrhage in only 8 cases (8.1%) cases,29 Lunetta had
an incidence of greater than 50%.14 It is, however, important to dif-
ferentiate this from post mortem haemorrhage on the posterior aspect
of the oesophagus, the Prinsloo Gordon artefact.28–30
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 strangulation.29 Spitz
in fact states that “haemorrhage in the 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
2.5.7. Aortic intimal staining
Differential staining of the intima of the aortic root compared to the
pulmonary trunk has been suggested as a potential marker for fresh-
water drowning (Fig. 6).51–53 First described in the German literature as
“hämoglobinimbibiert”54,55 it arises from lysed erythrocytes staining
the aorta, induced by hypotonic fluid entering the lungs during im-
mersion. However, generalised haemolytic staining of the intima is not
specific to drowning and may also be caused by any organic condition
that causes the degradation of red blood cells (i.e. extensive burn injury
or disseminated sepsis); differential staining has also recently been re-
ported in a case of pulmonary thromboembolism.56
Fig. 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.
L. Stephenson, et al.
In a retrospective study, differential staining of the aortic root in-
tima was observed in 5% of freshwater drownings but not in controls.57
Zatopkova et al. argue 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 chambers.58
2.5.8. Computed tomography (CT)
While the use of CT in drowning cases probably has as many lim-
itations as an autopsy when attempting to distinguish between
drowning and non-drowning deaths,23 and between salt and freshwater
drownings,59 it has the advantage of being non-invasive. This is parti-
cularly useful in visualising areas such as the paranasal sinuses which
are anatomically quite inaccessible.60 However, a more comprehensive
knowledge of the appearance of drowning pathology with CT will be
required to effectively utilise this imaging modality. The lung appear-
ances in drowning on CT range from airspace consolidation to a mosaic-
like pattern.61,62 Additionally, The CT appearances have been classified
into three major types: ground-glass opacities with thickened pul-
monary interstitium, centrilobular 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 death.23
3. Problems with “diagnostic” tests
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. Current research is, however, re-
evaluating historical methods while investigating new techniques to
assist diagnosis.14
3.1. Diatoms
Diatoms are a large group of single-celled algae found in fresh and
salt water that may reach the systemic circulation by diffusing through
alveolar capillary membranes when water is aspirated. The presence of
diatoms in other sites (i.e. bone marrow) indicates that aspiration of
water occurred during life.65 The use of diatom testing to diagnose
drowning has received much criticism since it was first introduced,
however, and has not proven useful in the majority of forensic
drowning cases.7
It has been pointed out that the usefulness of diatom testing is ne-
gatively impacted by ante- and post mortem environmental con-
tamination18 which may occur via ante mortem diatom penetration,
during the submersion period through wounds, from resuscitation or
during the sample preparation process. As such, there are major dis-
crepancies in the validity and reliability of diatom testing in the diag-
nosis of drowning.66
While the conventional methods for diatom testing have proven to
be disappointing, efforts are being made to improve reliability and
sensitivity67,68 with suggestions of incorporating polymerase chain re-
action (PCR) to enhance the reliability of the testing procedures.69–71
While a diagnosis of drowning cannot be made on the diatom test alone,
it may provide some support for the diagnosis.32,67,72 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 area.73–76 Diatoms sampled from bone marrow were
found in the drowning medium in 90% of cases, supporting the po-
tential use of diatoms in locating the drowning site.77
3.2. Electrolytes
Analysis of vitreous humour electrolyte levels was proposed as a
potential test for drowning in the early 1900's.78 The Gettler Test, de-
veloped in 1921 compared chloride levels in the left and right ventricles
to diagnose drowning deaths.20 However, the test was subsequently
considered unreliable.8,79–81 A similar effect was proposed for
83
Journal of Forensic and Legal Medicine 66 (2019) 79–85
strontium with a difference of greater than 75% in blood strontium
levels between the right and left sides of the heart in keeping with
saltwater drowning. Other electrolytes such as magnesium and calcium
have had variable results.
While changes in serum electrolytes have had negligible sig-
nificance 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 contamination.
Elevated vitreous humour sodium occurs in salt water drowning cases
with reduced levels in freshwater drowning.78,82 However, elevated
vitreous sodium levels may be caused by unrelated factors such as de-
hydration or excess dietary sodium intake,83 or simply by post mortem
diffusion; i.e. after a period of more than 1 h, changes to electrolyte
levels have been noted due to the effects of immersion.80,84–87 Thus,
electrolyte studies have not proven particularly useful in the diagnosis
of drowning7.
3.3. Other tests
Although it has been proposed that anthracotic pulmonary macro-
phages or asbestos bodies could be found in blood within the left side of
the heart following drowning this has not proven diagnostically useful.
Similarly, changes in pulmonary surfactant levels have been of more of
experimental than practical interest.32
4. Conclusion
Inconsistent use of terminology, complex death scenes, non-specific
pathology88 and lack of definitive diagnostic pathological or laboratory
markers make drowning a persistently difficult diagnosis.
Conflicts of interest
None.
Sources of funding
None.
Ethical approval
N/A - A review with no case information.
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