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REVIEW
Drowning
R Sarvesvaran DMJ (Lond), MD (For. Med)
Abstract
A body recovered from the water does not necessarily imply that death was due to drowning. The
diagnosis of drowning is discussed together with the significance of the "diatom" and biochemical
tests.
Key words: Cadaveric spasm, "Champignon de mousse", drowning, diatoms, fresh water, sea water.
Address for correspondence andreprrnt requests: Dr. R Sawesvaran, Department of Pathology, Faculty of Medicine, Univers~tyof Malaya. 59100 Kuala
Lumpur, Malays~a.
Malaysian J Pathol December 1992
"Champignon de mousse"
The presence of foam at the mouth and nostrils
is an important sign of drowning. particularly if
the body is freshly recovered from water and has
not undergone putrefaction and other causes of
pulmonary oedema can be excluded (Fig. 2).
Other causes of pulmonary oedema are epileptic
fits, acute left ventricular failure and toxic fumes.
This foam is "fine froth", white or pink in
colour and, when wiped away, more may appear.
Even if not evident externally, it can be seen in
the upper air passages. The production of te-
nacious foam in drowning is essentially a vital
phenomenon. The entry of fluid into the air
passages provokes them to produce mucus. This
substance when mixed with water and possibly
surfactant from the lungs is readily whipped into FIG. 2: "Champignon de mousse" in a recently
a tenacious foam by the violent respiratory ef- recovered body from a river.
forts of the victim." Froth may also appear around
the mouth and nostrils in advanced states of
putrefaction. Under these circumstances the
78
DROWNING
due to cardiac inhibition, and more rapid in holding time runs the risk of losing conscious-
fresh water than in sea water. It is also rapid in ness and drowning follows quickly.
those who are unable to swim, with poor phy- At the end of such effort the arterial PO, is low
sique and when submersion is unexpected. but his deliberately reduced pCO, delays the
onset of respiratory efforts. Peripheral pooling
MECHANISM OF DROWNING of blood occurs when exertion ceases and car-
diac output falls resulting in cerebral hypoxia,
(I) Fresh watet
this accounting for the loss of consciousness and
The inhalation of water results in its absorption death by drowning.
by the circulating blood. This can occur within Water-skiing accidents can also lead to death
a few minutes following total submersion with by drowning, particularly if a severe head, or
coincident haemolysis. The heart muscle sustains skeletal or organ injury is sustained."
"serious biochemical insult,"" there being an
increase in plasma potassium with sodium loss. DIATOMS AND DROWNING
The haemodilution also overloads the circulation.
Diatoms are microscopic unicellular or colonial
This, along with myocardial anoxia, is respon-
algae with distinctive cell walls impregnated
sible for a fall in the systolic blood pressure and
with silica and containing chlorophyll pigment.
fibrillation.
They are universally distributed in fresh and salt
water and comprise over ten thousand species
(ii) Sea water
ranging in size from a few to several hundred
Unlike fresh water drowning where there is micra in diameter.
haemodilution, in salt water drowning there is The "diatom test" is based on the principle
haemoconcentration. There is withdrawal of that diatom species measuring up to 30 micra in
water from the circulating blood into the lungs diameter are said to be able to enter the pul-
whereby massive pulmonary oedema occurs. monary circulation during immersion and are
Electrolyte exchange from sea water into the disseminated widely to sites like liver, brain,
blood occurs with an increase of plasma sodium kidney and marrow.
levels. Ventricular fibrillation is not a feature
but, with the occurrence of myocardial anoxia Method for demonstrating diatoms
and increased blood viscosity, rapid failure of
Several grams of the organ suspected of
the heart occurs.
harbouring the diatoms (liver, kidney or bone
marrow) are digested with fuming nitric acid
DRo WNING (NEAR until all organic material has been destroyed and
DROWNING)
heating is continued until only a small volume
Persons who survive the initial episode of sub- of fluid remains. The solution is centrifuged
mersion may subsequently suffer complications and the supernatant decanted and discarded.
o r even d i e after a period apparent of The residue is washed several times in dis-
wellbeing.'.'? tilled water. After final centrifugation and dis-
The clinical symptoms and signs include posal of the wash water, the residue is poured on
pyrexia, shallow respiration, blood stained frothy a clean slide, covered with a cover slip and
sputum and pain in the chest with cardiac examined under the microscope with subdued
arrythmias. Electrolyte changes are not signifi- light. The diatom skeletons are readily recog-
cant. Coma precedes death. If active treatment nizable as radially or axially symmetrical
is instituted, the prognosis is good in cases of structures. There are other methods available
fresh water submersion but poor in salt water for the demonstration of diatoms?
immersion.
a. Direct microscopic examinnlion: done only
AQUATIC SPORT AND DROWNING in the examination of the lungs. Water is
squeezed from the lungs and centrifuged
Fatalities associated wtih aquatic sport are usu-
and the sediment is examined.
ally directly attibutable to drowning rather than
hyperbaric effects. In the case of the sub-aqua
diver, the acute problem is one of decompression,
,, Incinerarion the organic matter
(brain, liver etc.) is destroyed with heat in
but the skin diver who deliberately overbreathes
an oven. The principle is that diatoms are
to wash out CO, and thereby increase his breath
heat resistant.
DROWNING
Interpretation of the diatom test of electrolytes from sea water to the blood also
has its adverse effects. The haematocrit and
The demonstration of diatoms from the sub-
plasma sodium levels rise steeply.
merging fluid in the body of the victim is of
Ventricular fibrillation is not a feature of sea
value as a confirmatory test of death by drowning.
water drowning, and heart failure is slower,
Examinations of lung juices have limited value,
taking from 5-8 minutes. The cause of death is
although a high diatom content is indicative of
myocardial anoxia and the increased viscosity
drowning. T i m p e ~ n a nfound
'~ that after death
of the blood causes heart failure. There is no
diatoms penetrate only as far as the main bronchi.
haemolysis.
Tamaska" regards the identification of diatoms
Modell"' reviewed the mechanism of
in the bone marrow as the best method in all
drowniilg. He suggested that 10% of drowning
circumstances of drowning, including those
victims do not aspirate water but die of asphyxia
where the body is in an advanced state of pu-
due to laryngospasm. He also demonstrated that
trefaction. This view has been confirmed by
when fresh water was aspirated there was a
RushtonIh who, because of the difficulty of total
decrease in serum sodium, chloride and calcium,
exclusion of contamination, considered the
with an increase of potassium in arterial blood.
finding of diatoms as supportive evidence but
Fresh water drowning was considered to be
not as conclusive evidence. W. V. Spitz, at the
twice as lethal as sea water drowning.
Third International Meeting in Forensic Medi-
cine, London in 1963 showed that diatoms were
CHEMICAL TESTS OF DROWNING
plentiful in the air of Berlin.I7
PeabodyL8has therefore suggested the need GettlerZ0and Fisher21 were of the opinion that
for further research to resolve the controversy comparison between the chloride content of
by establishing with certainty whether non- blood samples taken respectively from the right
drowned subjects do have diatoms in their organs and left sides of the heart would furnish a test of
in significant number, and to what extent results death by drowning. This was on the principle
may be vitiated by contamination of reagents that in fresh water drowning, the blood in the
and glassware. left side of the heart, being diluted by water,
should have a lower chloride content than that in
EXPERIMENTAL EVIDENCE the right, and conversely if drowning occurred
in salt water. TimpermanI4 and Model1 and
Experiments of Swan and Spafford19 produced
D a ~ i considered
s ~ ~ these tests untrustworthy.
results on which the modem view of drowning
Rammer and Gerdin2?compared the osmolarity
is based.
and serum sodium and potassium in the left and
right sides of the heart with that in the cerebro-
a. Fresh water
spinal fluid and were of the opinion that a lower
When dogs were submerged in fresh water, osmolarity and a substantially lower concentra-
large amounts of water were rapidly absorbed. tion of sodium and potassium than that found in
Within three minutes the circulating blood could the cerebro-spinal fluid made a diagnosis of
be diluted by as much as 72% with coincident drowning in fresh water highly probable.
haemolysis. The heart muscle thus sustained a For these biochemical tests to be of value as
"biochemical insult". There was an increase in evidence of drowning, samples must be ob-
plasma potassium with a fall in sodium. In tained within a few hours of submersion.
addition, there was myocardial anoxia. Post mortem biochemistry, particularly of
Haemodilution also overloaded the circulation. the vitreous and cerebro-spinal fluid may not
A rapid and considerable fall in systolic blood only be indicative of sea water drowning, but
pressure occurred and within a few minutes, also provide a means of determining how long a
ventricular fibrillation occurred causing cere- dead body may have been in sea water.
bral anoxia and death. Coutseliuis2~emonstrateda progressive in-
crease in magnesium in the vitreous of
b. Sea water exenterated human eyeballs put in sea water and
was of the opinion that this provides a means of
In sea water the mechanism is different. Swan
determining how long a dead body may have
and Spafford showed that in sea water there is been in the sea. The concentration of magnesium
haemoconcentration; up to 42% withdrawal of in the cerebro-spinal fluid helps in establishing
water from the circulating blood into the lungs, the diagnosis of drowning in sea water whilst
causing massive pulmonary oedema. Exchange
Malaysian J Path01 December 1992