D

DROWNING
 Drowning
Drowning is a form of asphyxial death
due to aspiration of fluid into the air
passages by submersion of the body in
water or fluid medium.

Complete submersion not necessary ,

submersion of nose and mouth is
enough.
Types of Drowning
Typical Drowning-
The term typical drowning indicates
obstruction of air passage and lungs by
fluid. It is also known as wet drowning.
A. Fresh Water Drowning
B. Sea Water Drowning
Types of Drowning
Atypical Drowning-
Indicates condition in which there is very
little or no inhalation of water in air
passage and includes
Dry drowning,
Immersion syndrome,
Submersion of an unconscious and
Secondary drowning.
Mechanism of drowning
Pathophysiology

Inhalation of fluid in lung causes number of

changes.
Reflex vasoconstriction pulmonary

hypertension broncoconstriction increased

airway resistance denaturation of lung
surfactant lung compliance falls
decrease lung tissue for ventilation
abnormal ventilation/perfusion ratio
hypoxia hypercapnia respiratory acidosis
asphyxia.
 Fresh water drowning (0.5% Nacl)

water rapidly moves across the alveolar septum & capillary w

Hemodilutio Dilution of
n plasma
Volume of Blood Rupture of
RBCs
Overloads heart Release of
K+
Ventricular Hyperkalamia

fibrillation
Heart failure

Death
Sea Water Drowning (3.5%
Nacl)

Hemoconcent Pulmonary
ration edema

Hypovolemi Circulatory shock

a

Heart failure/
asystole

DEATH
 Difference between
fresh & sea water drowning

Features Fresh water Sea water

Water Hypotonic Hypertonic
Changes Hemodilution Hemoconcentra
in blood Hyponatremia tion
Hyperkalemia Hypernatremia
Hypocalcaemia Increase
Decrease in Cl magnesium
Time for death 4-5 minute 8-12 minute
Changes -Retains shape -Do not retain
in lung after removal shape
-edematous, -Marked edema,
voluminous, soft, jelly like
 2.Dry drowning
Water does not enter lungs
but death results owing to
laryngeal spasm due to
inrush of water into
nasopharynx or larynx .
It occurs in 15 to 20 % of cases
of drowning .
the lungs remain dry or water-
free.
 Shallow Water Drowning
In this condition, drowning occurs in small
puddle of
water when depth of water is only few
inches but suf
cient to submerge the mouth and nostrils
Immersion Syndrome

Also called Hydrocution.

The classical signs of drowning is, as a
rule, absent
Secondary
Drowning
Cause of Death
1. Asphyxia
2. Vagal inhibition-
3.Laryngeal spasm
4.Head injury
5.Septic aspiration pnemonia
6.Sudden bursting of aneurysm
 Diagnosis of death by
15 drowning

(i) External signs of drowning

(ii) Internal signs of drowning

(iii) Biochemical and biophysical

tests
(iv) Analysis of Diatoms
External signs of
drowning
The clothes are wet
Face- pale,
pupil dilated and conjunctivae are
congested .
Rigor mortis appear & passes early due to
exhaustion / violent struggle for life.
 Eye

Petechial
hemorrhages

17
PM
Lividity
Froth

Fine, tenacious, copious white froth

oozing from nostrils.
Characteristic of Drowning
20
Due to violent churning, froth is formed
Other condition in which froth is
seen-

Strangulation
Putrefaction
epileptic fit
Electric shock
Acute pulmonary edema
Poisoning-Cocaine, OP, Morphine,
Barbiturate
Cutis Anserina - or Goose skin It is
puckered and granular appearance with hair
standing on end due to contraction of
erector pilorum muscle.
Occasionally grass & leaves may be found
firmly grasped in hands due to cadaveric
spasm . It is diagnostic of death from drowning
because it shows struggle of victim for life .
Washermans hands

The skin in sodden, thickened , wrinkled and

white is called washerwomans hands.
 Internal signs of drowning

LUNGS
voluminous, bulky,
water logged,
overinflated,
filling the chest
cavity &
overlapping the
heart.
On c/s blood
stained froth oozes
out.
(LUNGS) Fresh Vs Sea

Fresh Sea
Lungs- light
Colour-Pinkish
Consistency- Heavy
Purplish/ Bluish
Emphysematous

Shape-Retained,do
not collapse
On cut section-
Soft,jelly like
Not retained,tend to flatten out
No crepitus,copious fluid & froth

Crepitus is heard,little
froth & no fluid
Emphysema aquosum On section,an
edematous condition due to the presence of a
large amount of watery , frothy blood
stained fluid is seen. Drowning fluid
penetrates alveolar walls to enter the
tissues and blood vessels . This is known as
emphysema aquosum . It is presumptive
evidence of death from drowning
Edema aquosum:- this condition develops
when person is passively immersed with no
violent effort of respiration in water / person
is unconcious.
It is a mere flooding of lungs with water with
no formation of column of froth
The stomach contains water of same
characteristics as that in which body was found
immersed and contain mud , sands and algae.
Water is not found in stomach if person died from shock,
syncope & was already dead .
Brain, Liver, Spleen & Kidney Congested
Middle ear- Water & haemorrhage
The heart presents appearance usually in death
from asphyxia, left sides is empty and right is full
of blood.
 Antemortem Vs
Postmortem
Antemortem Post mortem

Froth- Fine,lathery, spontaneous

Cadaveric spasm in hand Absent/ not spontaneous
Lungs- Ballooned, bulky Not
Stomach- mud & algae Collapsed, Decomposed
Diatom & Gittler tests- +ve Absent
Water in middle Ear- Present Negative
Never present
Laboratory Findings
Microscopy
Lung: Pulmonary alveoli are distended &
contain fluid with foreign material such as
aquatic vegetation.
The alveolar septal wall appears stretched and
thinned with compression of capillaries along
with some ruptured alveoli
 Laboratory Findings
Microscopy Blood:
Fresh water drowning- shows low RBC count
with hemolysis.
In seawater drowning- relative increase in RBC
count with RBCs appear crenated and shrunken

A: Fresh water drowning showing lysis of RBCs with low count.

B: Salt water drowning with RBCs appear crenated and
shrunken and relative increase in count
 Biochemical Tests
35

Gettlers Test
Normally chloride content of left and right
side of heart is same
In fresh water drowning chloride content
of left side of heart is lower by 25% than
the right side
In sea water drowning, the reverse occurs
Strontium test: Difference of 75 g/L of
strontium concentration between right and
left side of heart is considered as significant
in seawater drowning.
Diatoms
Diatoms are unicellular algae found
whenever there is water and sufcient
sunlight for photosynthesis
Principle of Diatom Test
The diatom test is based on principle that

when a living person is drowned in water

containing diatoms, many diatoms will
penetrate the alveolar wall and be carried
to distant organs such as brain, kidney,
liver, bone marrow
Diatoms
Procedure of Diatoms Demonstration-2 to 5 gm of tissue or
bone marrow is taken in a flask and concentrated nitric acid is
added.
The preparation is heated for 15 to 20 minutes.
This yields a transparent yellow fluid.
The fluid is centrifuged and the centrifuged deposit is examined
by placing a cover slip.
Diatoms

Importance of Diatoms
Demonstration of significant quantities

of diatoms indicate:
Death was due to drowning
Person was alive when he was
submerged in water
Site of drowning can be known by
comparing diatom species in body and
the source/site where body was found.
Diatoms

Advantage
Diatoms resist decomposition and can be
demonstrated even in highly decomposed body.
Drawback
Caution should be exercised while interpreting

result solely on basis of positive diatom test since

diatoms are ubiquitous and present in soil, water,
laboratory apparatus etc.
so contamination may occur.

Similarly diatoms can be demonstrated even in

nondrowning deaths
Medico- legal importance
1.Accidental drowning Most
commonly seen in children
,fisherman ,drunkenness and
epileptics.
2.Suicidal drowning It is commonly
seen in female.
3. Homicidal drowning It is not very
common, though may be seen in
cases of infanticide.
DROWNING
90. Diatom test may be useful as an
investigational aid in deaths due to:

A.Hanging
B.Strangulation
C. Drowning
D. All asphyxial deaths
ANSWER: C, Drowning.
91. The average specific gravity of
human body is about:

A.0.89
B.1.08
C. 1.23
D. 1.65
ANSWER: B, 1.08.
92. All are seen in drowning
except:

A.Miosis
B.Wet heavy lungs
C. Water and weeds in
stomach and lungs
D. Froth from nose and mouth
ANSWER: A, Miosis.
93. Most common consistent feature
in a child who has died from drowning
in a pond is:

A.Water in the alveoli of lungs

B. Petechial hemorrhages in
the lungs
C. Washer womans hands
D. Cyanosis
ANSWER: A, Water in the alveoli of lungs.
94. Most common type of
drowning is:

A.Suicidal
B.Accidental
C. Homicidal
D. Immersion syndrome
ANSWER: B, Accidental.
95. Which of the following signs
would indicate that the death was
ante mortem?

A.Cutis anserine
B.Washer womans hands
C. Weed and grass in the hands

D. Cyanosis
ANSWER: C, Weed and grass in the hands .
96. Which one of the following is a
definite sign of death due drowning?

A.Sand and mud in the mouth

and nostrils
B. Fine lathery froth in the
mouth and nostrils
C. Washerwomans hands and
feet
D. Diatoms in the bone marrow
ANSWER: B, Fine lathery froth in the
mouth and nostrils.
97. Gettlers test is done in:

A.Hanging
B.Strangulation
C. Drowning
D. Throttling
ANSWER: C, Drowning.
98. The term near drowning refers to:

A. A person who was about to

drown but just saved himself
from drowning
B. A person, who drowned but
was brought out and he
survived for at least 24 hours
C. A person, who survived
drowning for 1 week
D. Dry drowning
ANSWER: B, A person, who drowned but
was brought out and he
survived for at least 24 hours .
99. Dry drowning is defined as:

A. Drowning in sea water

B. Falling in a deep well which
has dried
C. Drowning in very cold water
with death occurring due to
cardiac arrest
D. Drowning where death is due
to laryngospasm
ANSWER: D, Drowning where death is due
to laryngospasm
100. Dry drowning is said to occur in
% of all drowning:

A.1-2 %
B.10-15 %
C. 25 %
D. 30-30 %
ANSWER: B, 10-15 %.
101. Paltaufs hemorrhages are seen in:

A.Drowning
B.Firearm injury
C. Hanging
D. Strangulation
ANSWER: A, Drowning.
102. Bleaching of the cuticle becomes
quite evident after ... hours of
immersion:

A.2
B.12
C. 24
D. 48
ANSWER: B, 12.
103. Floatation of the body in our
country in summers occurs in:

A.12 hours
B.24 hours
C. 3 days
D. 6 days
ANSWER: B, 24 hours.
104. Besides drowning froth at the
mouth may be seen in a few other
conditions. Identify that condition
below:

A.Opium poisoning
B.Sulphuric acid poisoning
C. Head injury
D. Tetanus
ANSWER: A, Opium poisoning.
105. How many species of diatoms
are there?

A.About 100
B.Between 500-1000
C. Between 2000-5000
D. About 15,000
ANSWER: D, About 15,000.
107. Diatom test may be negative in
a case of:

A.Freshwater drowning
B.Seawater drowning
C. Drowned body but
decomposed
D. Dry drowning
ANSWER: D, Dry drowning.
108. For diatom test, the best site
for taking samples is:

A.Lungs
B.Bone marrow in ulna
C. Bone marrow in femur
D. A large and fleshy muscle
ANSWER: C, Bone marrow in femur.
109. Emphysema aquosum is seen
in:

A.Wet drowning
B.Dry drowning
C. Secondary drowning
D. Immersion syndrome
ANSWER: A, Wet drowning.
110.Hyperventilation before
underwater swimming:

A.Causes dry drowning

B. Causes immersion
syndrome
C. Can result in unintentional
drowning
D. Is a surefire method to
prevent drowning
ANSWER: C, Can result in unintentional
drowning
111. The term hydrocution refers to

A.Electrocution in water
B. Drowning in cold water
C. Immersion in boiling water
D. Postmortem submersion
ANSWER: B, Drowning in cold water .
113. Froth at the mouth and nostrils in a
dead body is seen in all of the
following cases, EXCEPT

A.Snake bite
B. Organophosphate poisoning
C. Drowning
D. Burns
ANSWER: D, Burns .
114. Post mortem lividity may not
develop at all in a case of

A.Hanging
B. Strangulation
C. Smothering
D. Drowning
ANSWER: D, Drowning.
115. The colour of post mortem lividity in
a case of drowning is

A.Bright pink
B. Purple
C. Scarlet
D. Cherry red
ANSWER: A, Bright pink.
116. Floater is the term applied to

A.An expert swimmer

B. A device used by non-
swimmer to keep afloat
C. A life boat
D. Floating dead body of a
drowned victim
ANSWER: D, Floating dead body of a
drowned victim .
117. One of the following statements is TRUE
regarding the utility of diatoms in drowning

A. Demonstration of diatoms in tissues

is conclusive evidence of
antemortem drowning
B. Diatoms cannot be demonstrated in
a case of dry drowning
C. A negative diatom test rules out
antemortem drowning
D. Diatoms are not seen in sea water
ANSWER: B, Diatoms cannot be demonstrated in
a case of dry drowning .
118. Diatoms are a variety of

A.Bacteria
B. Plant
C. Sea weed
D. Algae
ANSWER: D, Algae.
119. One of the following is NOT an
antemortem sign of drowning

A.Water in the middle ear

B. Firmly clenched mud or
weeds in hand
C. Fine, tenacious, persistent
froth
D. Cutis anserina
ANSWER: D, Cutis anserina.
120. The cause of death in hydrocution
(immersion syndrome) is

A.Vagal inhibition
B. Asphyxia
C. Ventricular fibrillation
D. Pulmonary oedema
ANSWER: A, Vagal inhibition.
121. Post mortem staining is usually
found on the face, upper part of the
chest and hands and feet in death
due to

A.Choking
B. Strangulation
C. Drowning
D. Traumatic asphyxia
ANSWER: C, Drowning.
122. In most characteristic internal
finding in drowning is

A.Emphysema aquosum
B. Froth in the trachea
C. Right chambers of heart
full
D. Diatoms in the lungs
ANSWER: A, Emphysema aquosum.
123. In fresh water drowning the lungs are

A.Ballooned but light in

weight
B. Ballooned and heavy
C. The shape of the sectioned
portion is not retained
D. Copious amount of fluid
pour out of the cut section
ANSWER: A, Ballooned but light in
weight.
124. In salt water drowning the lungs are

A.Ballooned and heavy

B. Ballooned but light in
weight
C. Pale pink in colour
D. Copious amount of fluid
pour out of the cut sections
ANSWER: A, Ballooned and heavy.
125.Which of the following is true about
drowning

A.Water can be absent in stomach

in sudden death due to vagal
inhibition
B. Water in small intestine is
important proof of antemortem
drowning
C. Acid digestion technique is used
for demonstration of diatoms
D. All of above
ANSWER: D, All of above.
126. Temporal bone haemorrhages are
found in

A.Throttling
B. Drowning
C. Cyanide poisoning
D. Arsenic poisoning
ANSWER: B, Drowning.
128. Increase in magnesium content of left
ventricle even by 1 mg/100 ml
suggests

A.Fresh water drowning

B. Salt water drowning
C. Both A & B
D. None of above
ANSWER: B, Salt water drowning.
129. Floatation of dead in water is due to

A.Flesh being eaten away by

fishes
B. Presence of gases
C. Water logging of body
D. All of above
ANSWER: B, Presence of gases.
130. The most fatal complication which
can occur to divers (Under high
atmospheric pressure) is

A.Pulmonary oedema
B. Air embolism
C. Vagal inhibition
D. Suffocation
ANSWER: B, Air embolism.
131.Exchange of water in drowning at
alveolar level will depend upon

A.Osmotic gradient between

blood and water
B. Quantity of water inhaled
C. Diatoms in water
D. Thickness of the alveolar
septa
ANSWER: A, Osmotic gradient between
blood and water.
132.In sea water drowning, there is

A.Fall of haemoglobin level

B. Increase in haemoglobin
level
C. No effect in haemoglobin
level
D. Variable change in
haemoglobin level
ANSWER:B, Increase in haemoglobin
level.
133. In sea water drowning, there is

A.Steep fall in Na and Mg level

B. Steep rise in Na and Mg level
C. Steep rise Mg level
D. Steep rise Na level
ANSWER: B, Steep rise in Na and Mg level.
134. Antemortem drowning is best
demonstrated by

A.Cyanosis
B. Water in stomach and lungs
C. Froth at nose and mouth
D. Washer womans feet and
hands
ANSWER: B, Water in stomach and lungs.