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15
Drowning can be defined as death caused by submersion in a liquid. It can
occur in an ocean or, in the case of alcoholic stupor, epileptics, or infants, in
water as shallow as 6 in. The mechanism of death in acute drowning is
irreversible cerebral anoxia. The original concept of drowning deaths was
that they were asphyxial in nature, with water occluding the airways. Exper-
iments in the late 1940s and early 1950s suggested that death was caused by
electrolyte disturbances or cardiac arrhythmias produced by large volumes
of water entering the circulation through the lungs.1,2 Present thought, how-
ever, is that the original concept was correct and that the most important
physiological consequence of drowning is asphyxia.3
In drowning, the volume of water inhaled can range from relatively small
to very large. In freshwater drowning especially, large volumes of water can
pass through the alveolar–capillary interface and enter the circulation. Even
when large volumes of water are absorbed, there is no evidence that the
increase in blood volume causes significant electrolyte irregularities or
hemolysis, or that it is beyond the capacity of the heart or kidneys to com-
pensate for the fluid overload.3,4
Some individuals who drown are considered to be victims of “dry drown-
ing.” Here, the lungs do not have the heavy, boggy and edematous appearance
typical of drowning lungs. Rather, the fatal cerebral hypoxia is alleged to be
caused by laryngeal spasm. Dry drowning is said to occur in 10–15% of all
drownings. What is theorized to occur is that when a small amount of water
enters the larynx or trachea, there is a sudden laryngeal spasm mediated as
a vagal reflex. Thick mucous, foam, and froth may develop, producing an
actual physical plug at this point. Thus, water never enters the lungs. The
authors have never seen the “physical plug” said to occur in the larynx and
the “laryngospasm” cannot be demonstrated at autopsy, as death causes
relaxation of the musculature. While the aforementioned explanation for dry
drowning is interesting, it is a hypothesis and not proven. Thus, the authors
do not endorse use of this term or concept. It is probable that dry drowning
is just one end of a spectrum of changes seen in the lung produced by
occlusion of the airways by water, with the other end the heavy, boggy lung
containing a massive amount of edema fluid.
Breath holding
Involuntary inspiration and gasping for air at the breaking point
Loss of consciousness
Death
The type of water that is inhaled, fresh versus salt, probably has very
little influence on whether the individual will survive. In fresh water, as
previously noted, large volumes of water can pass through the alveolar
stomach. There could be dilatation of the right ventricle. When the brain is
examined, it is swollen with flattening of the gyri caused by nonspecific brain
swelling.
Hemorrhage may appear in the petrous or mastoid bones. This, again,
is nonspecific and, if sought, can be found in individuals dying of heart
disease, drug overdose, or other causes of death. Thus, the drug overdose
victim dumped in water and the heart attack victim collapsing into water
can have the washerwoman appearance of the palms and soles, goose flesh,
pulmonary edema, and hemorrhage into the petrous and mastoid bones. The
presence of vegetation and stones such as would be found at the bottom of
the body of water found clutched in the hands indicates that the cause of
death was, in fact, drowning, because they imply that the deceased was alive
when entering the water.
When initially recovered from the water, the body might be in full rigor
mortis, even though only a short time has passed from the time of the drown-
ing. This is caused by violent struggling at the time of drowning, with a decrease
Drownings in Bathtubs
Drownings in bathtubs are relatively uncommon, usually involving young
children left unattended by a parent. Some undoubtedly are homicides.
Adults in the throes of a seizure can drown in a bathtub (Figure 3.8). Less
clear are instances where an individual found in a tub has toxic or lethal drug
levels. Did they pass out and drown, die of the drugs and eventually slide
under water, or were they placed in the tub following an overdose in a futile
attempt to revive them? Similar questions arise in regard to the individual
with severe heart disease found in a bathtub under water. Did they die of a
heart attack and then slip under the water or did they have an incapacitating
heart attack, slip under the water and drown? The presence of pulmonary
edema is of no help, as it might be present in drug overdoses, heart failure
or drowning.
Rarely, a case involving an adult will be homicide. If, while taking a bath,
one’s feet are grasped and one is pulled underwater by them, there can be
an involuntary inhalation of water as the water rushes into the nasopharynx.
This, exacerbated by panic and being in a smooth-walled, wet, slippery con-
tainer, could result in an inability to save oneself, with rapid loss of con-
sciousness and death. Possibly no injuries will be seen at autopsy. Rarely, the
authors have seen well-documented cases where an individual slipped in the
bathtub, struck his head, and drowned.
Scuba Divers
Deaths occurring with use of scuba equipment can be caused by:
Natural disease
As a consequence of being underwater at increased pressure
An environmental hazard
As a result of defective equipment
References
1. Swann HG and Spafford NR, Body salt and water changes during fresh and
sea water drowning. Texas Rep Biol Med 1951; 9:356-382.
2. Swann HG, et al., Fresh- and sea-water drowning: A study of the terminal
cardiac and biochemical events. Texas Rep Biol Med 1947; 5:423-437.
3. Pearn J, Pathophysiology of drowning. Med J Australia 1985; 142:586-588.
4. Modell JH and Davis JH, Electrolyte changes in human drowning victims.
Anesthesiology 1969; 30:414-420.
5. Bolte RG, et al., The use of extracorporeal rewarming in a child submerged
for 66 minutes. JAMA 1988; 260:377-379.
6. Giammona ST and Modell JH, Drowning by total immersion: Effects on
pulmonary surfactant of distilled water, isotonic saline and sea water. Am J
Dis Children 1967; 114:612-616.
7. Ornato JP, The resuscitation of near-drowning victims. JAMA 1986; 256:
75-77.
8. Conn AW and Barker CA: Fresh water drowning and near-drowning — An
update. Can Anaesth Soc, 1984; 31: S38-S44.
9. Reh H, On the early postmortem course of “washerwoman’s skin at the
fingertips.” Z Rechtsmed 1984; 92(31:183-188. (In German).
10. Gonzales TA, Vance M, Helpern M, Legal Medicine and Toxicology. New York,
Appleton-Century Co, 1937.
11. Peabody AJ, Diatoms and drowning – A review, Med Sci Law 1980; 20(4):
254-261.
12. Foged N, Diatoms and drowning — Once more. Forens Sci Int 1983; 21:
153-159.