sign in sign up
<<
Home , Putrefaction

6545 JClin Pathol 1992;45:654-659

Bodies recovered from : a personal

approach and consideration of difficulties J Clin Pathol: first published as 10.1136/jcp.45.8.654 on 1 August 1992. Downloaded from

W Lawler

Introduction It has been reported that about 85-95% of For the pathologist providing a routine nec- those dying from water inhalation present ropsy service to the local , examination features of drowning,59 although in most, not of bodies recovered from water can generate all the typical features are seen9; the remainder the most difficult of interpretational problems, die from vagal inhibition (sometimes, inaccu- and this is probably the prime context where rately, known as "dry drowning", and once appropriate historical and circumstantial evi- designated "hydrocution"), or the post dence is vital to interpretation and overall immersion syndrome; perhaps, rarely, laryn- conclusions,' 2 although such collateral evi- geal spasm may be important. dence should always be available before any At this stage, it is worth remembering that coroner's necropsy is undertaken.3 hypothermia can supervene very quickly in It must be appreciated, at the outset, that individuals swimming or trying to remain not all persons whose bodies are recovered afloat in cold water, and that it may be an from water will have died from its inhalation, important factor contributing to their although they may show features reflecting '0 "; indeed, hypothermia may be the immersion in water. Such bodies should there- main after shipwreck in the fore be particularly carefully examined, both open sea.1 12 externally and internally, to catalogue (and subsequently to explain satisfactorily) all inju- DROWNING ries present, to determine whether death Mechanisms for death from drowning are indeed followed immersion in the water, and to multiple, complex, and, in part, still incom- see whether any natural disease, such as pletely understood. Although drowning is ischaemic disease, cerebrovascular dis- much more than simple asphyxia following ease, and hypertension, may have contributed mechanical airway obstruction by water, this to, precipitated, or even caused death. It is also process probably does at least contribute. important to determine whether the deceased Major factors, however, seem to be osmotic http://jcp.bmj.com/ was under the influence of alcohol or other and perhaps also hydrostatic effects of the drugs at the time of death (although inter- inhaled fluid once it reaches alveolar spaces pretation of laboratory results should be influ- and gains access to semipermeable alveolar enced by the knowledge that, as discussed membranes; here, water and electrolyte below, classic fresh water drowning may exchanges take place, the nature of which is increase the blood volume by as much as influenced by the tonicity ofthe inhaled fluid- 30-35%). Finally, the pathologist has a vital fresh or salt water. on September 26, 2021 by guest. Protected copyright. role in determining, from all pathological and circumstantial evidence available, whether the Fresh water This is hypotonic relative to overall findings are consistent with, or even plasma. Therefore, when present in alveoli, it is point directly towards accident, suicide, or rapidly absorbed into the pulmonary circula- homicide. tion; this causes pronounced haemodilution Unfortunately many bodies recovered from (the blood volume may be increased by up to water will have been there for several days, and 30-35%) which, in turn, soon produces local may have obscured or haemolysis. Although haemodilution will lead destroyed features of drowning; nevertheless, to hyponatraemia, circulatory overload, and, careful examination may elicit sufficient pos- ultimately, high output cardiac failure, hae- itive or negative findings to allow reasonable molysis is probably more important, as it conclusions to be drawn. causes hyperkalaemia and consequent cardiac For the pathologist to interpret accurately arrhythmias, particularly with concomitant the necropsy findings, it is necessary briefly to generalised hypoxia. These changes can consider the mechanisms of death after sub- develop very rapidly-over a few minutes, mersion in water and to appreciate the results supporting the view that drowning in fresh Department of of immersion in water, including artefactual water tends to occur more quickly than in sea Pathological Sciences, injuries. water.5 6 The Medical School, Stopford Building, Oxford Road, Salt water is hypertonic relative to plasma. Manchester M13 9PT Mechanisms of death after submersion Therefore, when present in alveoli, it attracts W Lawler in water water into the airways from the pulmonary Correspondence to: These are well documented in several circulation, causing local haemoconcentration Dr W Lawler of forensic medicine and and severe oedema. Haemocon- Accepted for publication standard textbooks pulmonary 20 December 1991 pathology.48 centration increases blood viscosity and pro- Bodies recovered from water: a personial approach anid cotisideratioon of difficullies 655

duces acute hypernatraemia, while severe Findings and interpretations in pulmonary oedema causes clinically import- after submersion in water ant hypoxia/hypercapnoea; all these factors It is important to distinguish changes directly adversely affect the heart, with bradycardia attributable to death following submersion J Clin Pathol: first published as 10.1136/jcp.45.8.654 on 1 August 1992. Downloaded from and, ultimately, asystole. (discussed here) from those which purely reflect immersion (discussed later). The chan- "VAGAL INHIBITION" ("REFLEX CARDIAC ARREST") ges described here, which are well documented ' This is a well recognised and accepted mech- in standard textbooks4 and review art- anism, particularly since Simpson's widely icles,'8 20 are those encountered in fresh bod- quoted review. '3 Vagus nerve branches may be ies-that is, those removed from the water stimulated in several ways, with a direct and before decomposition becomes established; perhaps almost instantaneously fatal cardiac once a lengthy delay has occurred, positive inhibition. Following submersion, it may be diagnosis may be difficult. initiated by the sudden and unexpected entry of water into the larynx, nose, or naso- DROWNING pharynx4 4 16; concurrent emotional states Externally, although a range of changes may be may act as a contributing sensitising factor.'6 identified, there may be nothing specific to Vagal inhibition seems to be more common drowning. Sometimes, however, firm, tena- when the submersion is total and unantici- cious foam is present at the mouth or nostrils. pated, when the victim is under the influence Typically, it is white or blood tinged, and of alcohol and/or other drugs, when the water reappears after wiping away. It is thought to is cold, and when the individual enters it feet represent an admixture of air, fluid, mucus and first. surfactant, and therefore an ante mortem phenomenon. LARYNGEAL SPASM Internally, the foam, even if not apparent This probably occurs, at least to some extent, externally, is often found in major airways or in most individuals following submersion, as it secondary bronchi and bronchioles. The air- presumably represents a normal reflex to fluid ways may also contain water and such extrinsic entering the larynx.6 15 In most, however, it materials as silt, weeds, or sand. Similar seems to be transient, and a true asphyxial substances (particularly water) may be swal- death from laryngeal spasm, if it occurs at all, lowed and thus identified within the . is probably extremely rare. Gardner reports Pulmonary changes vary according to the having seen only one fatal case-in a boy aged drowning fluid, although they are often not as 8 who sank into water immediately after distinct as suggested by differences in causative jumping in, and whose body showed asphyxial mechanisms and as implied in some text- changes and no features of drowning. '5 This books. mechanism is discussed by Polson, Gee, and Knight,6 who quote Gardner's case but do not Fresh water http://jcp.bmj.com/ offer any of their own; they do, however, state Typically, the are almost twice their that laryngeal spasm is "a rare mode of death normal weight, and present an appearance from submersion." Several reviews9 12 16 do sometimes still designated "emphysema aquo- not mention it at all; some, illogically, link it sum"-they are bulky and overdistended (such with vagal inhibition as a mechanism for that they may well overlap the pericardial sac almost instantaneous death, and do not refer to and meet in the midline), with a very charac- asphyxial features.4 My views, and, I believe, teristic doughy texture which causes them to on September 26, 2021 by guest. Protected copyright. those of many colleagues involved in forensic pit on digital pressure and sometimes to show pathology, are well summarised by Donald, 7 prominent rib markings. Classic petechial who says "previous literature would suggest haemorrhages are uncommon, but larger sub- that a number of human beings are drowned pleural and intrapulmonary haemorrhages may with dry lungs owing to glottic spasm, but little be identified. Section releases frothy, often convincing evidence has been produced". blood tinged fluid. Elsewhere, haemodilution Recently, Knight has stated "another mechan- causes the blood to appear rather "watery"; ism that is often postulated as a cause of non- haemolysis may produce intimal staining of drowning immersion death is 'laryngeal major vessels. spasm', leading to a hypoxic death from closure of the airway.8 The evidence for such a Salt water condition is tenuous, as such closure would Typically, the lungs are slightly, but not always have to operate for a considerable time for significantly, heavier than in fresh water hypoxia to kill, all the time keeping the larynx drowning,2' and although overdistended, clas- closed to prevent entry of water." sic emphysema aquosum is less pronounced; on section, greater quantities of frothy fluid POST IMMERSION SYNDROME (SECONDARY tend to be released. Pleural effusions may also DROWNING) be present. Occasionally, individuals survive the immer- sion and are recovered alive from the water, VAGAL INHIBITION only to die later from delayed effects or other This is really a diagnosis of exclusion based not complications. Such deaths are usually pulmo- only on negative pathological and toxicological nary, reflecting surfactant loss following fluid findings, but also on appropriate circum- inhalation; some represent prolonged, pro- stantial evidence; necropsy shows no foam in found hypoxia.'8"1 the airways, no emphysema aquosum, no 656L66wler

petechial haemorrhages and no clinically rele- diatomologists undertake taxonomic analyses vant natural disease.6 ' and comparisons of test and control samples.26 27 LAYRNGEAL SPASM J Clin Pathol: first published as 10.1136/jcp.45.8.654 on 1 August 1992. Downloaded from Here, presuming the existence of this entity, ELECTROLYTES the features are those of classic mechanical The haemodilution of fresh water drowning or asphyxia, including cyanosis, congestion, and the haemoconcentration ofsalt water drowning widespread petechial haemorrhages; there is may be reflected in different electrolyte (partic- little or no water in the airways (although some ularly chloride ion) concentrations and plasma may be present in the stomach), no or minimal osmolarity or specific gravity between the airway froth, and no emphysema aquosum.' 5 different sides of the heart,28 29 although most Such findings indicate the possibility of an workers find these tests unreliable and quite asphyxial death before entry into the water unhelpful2 8 12 16 30; furthermore, as both are which must be actively and seriously con- invalidated by decomposition, they can only be sidered, as this mechanism for death following of any possible value in bodies recovered soon submersion is extremely rare, if it exists at after death.4 6 22 all.

POST IMMERSION SYNDROME (SECONDARY Effects of immersion in water DROWNING) These, reviewed in standard texts,459 are With short term survival, lungs develop haem- obviously influenced by duration and water orrhagic, desquamative bronchopneumonia, temperature, but other factors, such as with intra-alveolar hyaline membranes; later, whether the water is still or flowing, fresh or abscesses may develop, and granulomatous salt, clean or polluted, are also relevant. reactions to inhaled foreign particles may be Immersion modifies most changes after identified.'8 19 Simultaneously, there may be death. Body cooling will relate directly to the hypoxic damage elsewhere, particularly in cer- water temperature. In the United Kingdom ebrum, brain stem, and renal tubules. cooling in water is roughly twice that in air, and is accelerated in flowing rivers and streams. Onset and duration of are also "Confirmatory" tests for drowning affected by water temperature: in cold water Two are often quoted as providing evidence for onset is delayed and duration prolonged. drowning. In practice, both are difficult to Drowning is a well recognised context in which perform and to interpret, with many false (instantaneous rigor) may be positive and false negative results.2 encountered ("the drowning man clutching at straws"). As most submerged bodies float DIATOMS prone, with arms and legs hanging downwards, This subject has generated much debate and hypostasis (lividity) is usually maximal on face, http://jcp.bmj.com/ controversy, with strong arguments in favour of neck, upper anterior chest, forearms, hands, and against diatom identification as a helpful lower legs and feet. In Caucasians it may be diagnostic test; review articles are avail- appreciably pink, perhaps because immersion able,22 25 26 and the subject has been discussed facilitates oxygenation through the wet skin in standard textbooks.' 5 8 Diatoms (Bacillar- after death,7 9 12 or perhaps merely the result of iophyceae) are unicellular algae with hard silica- cold.8 With fast flowing water, the constant ceous exoskeletons resistant to decomposition, movement may impair, if not inhibit com- on September 26, 2021 by guest. Protected copyright. heat, and acids strong enough to destroy soft pletely, development of hypostasis. tissues. Over 10 000 species and types exist, Decomposition (putrefaction) is also influ- about half in fresh water and half in brackish or enced by water temperature. In the United sea water; unfortunately, they are not found in Kingdom time intervals associated with the substantial numbers all year round, the peaks various standard changes are about twice as being spring and autumn. In theory, drowning long as those in air, but may be prolonged should allow diatoms to enter not only the further in flowing water and reduced in heavy lungs, but also, via the circulation, other pollution. In tropical decomposition organs. Therefore, in the drowned, diatoms may be established by 24 hours, whereas none should be extractable, after tissue digestion in may be apparent after several weeks in water strong acids, from such remote sites as bone constantly below 40°F (5°C). With advancing marrow, , brain and kidneys. Unfortu- decomposition, gas formation increases buoy- nately, two main problems exist: first, there ancy until ultimately (in the United Kingdom may be insufficient or even no diatoms in the after about three to 14 days, depending on the drowning fluid-from seasonal variations as season),9 and providing it is free to do so, the noted above or following pollution by efflu- body will float, often, because of intestinal ent-second, when identified, they may repre- putrefactive gases, belly upwards.4 Inter- sent "contamination", such as during nec- estingly, once a submerged body is exposed to ropsy, from tap water, from reagents, from air after recovery, decomposition often pro- food via the deceased's or ceeds very rapidly, and this may well continue even from the atmosphere. At best, despite despite apparently adequate refrigera- strict, proper techniques and appropriate con- tion.469'2 With prolonged immersion, adipo- trols23 27 the diatom test can only provide cere will form. supportive evidence of drowning.25 Such reser- , the skin change which charac- vations probably apply even when experienced terises immersion, is due to water absorp- Bodies recovered from water: a personal approach and consideration of difficulties 657

tion.6 ' ' It first appears on finger tips, and then deceased's swimming ability-are known by involves the palm followed by the back of the the pathologist before starting the necropsy. hand; similar changes soon affect feet and skin Indeed, most experienced pathologists would elsewhere. The skin becomes whitened, sod- agree that this is one of the few areas where J Clin Pathol: first published as 10.1136/jcp.45.8.654 on 1 August 1992. Downloaded from den, thickened and wrinkled (an appearance collateral evidence can be vital when trying to sometimes designated "washerwoman's skin"). reach the most appropriate conclusions. With time, the epidermis becomes loose and I believe that four groups of questions must peels; finally, nails and hair become detached. be addressed and answered by the patholo- Maceration is accelerated in warm water gist: (where it may appear within minutes), but, in (1) What injuries are present on and within general, it takes about eight to 24 hours for the body? How can each be explained satisfac- early changes to become apparent outdoors in torily? Consideration needs to be given to the temperate climes. By about seven to 10 days, possibility of artefactual injuries as discussed epidermal separation may have started, and by above. The likelihood that some, most, or even about three to four weeks, the skin and nails all the injuries identified were deliberately may be sufficiently loose to allow removal like inflicted by an assailant must always be borne a glove. Clothing, including footwear, delays in mind, and may need appropriate investiga- maceration, perhaps by up to 50%. tion and active exclusion. Following the above observations and com- (2) What natural diseases are present? May ments, it is obvious that considerable variation they have produced sudden collapse and thus exists between the different changes; conse- either caused death or precipitated drowning? quently, it is extremely difficult to estimate the Here, not only obvious structural abnormal- duration of immersion, and great care needs to ities, such as ischaemic heart disease, cerebro- be exercised when trying to draw reasonable vascular disease, and hypertension, but also conclusions.4 functional disorders, the existence of which is only apparent from the deceased's medical history, such as epilepsy, hypoglycaemia and Artefactual injuries during immersion cardiac arrhythmias, should be considered. in water (3) What was the cause of death? Although These are common, and may provide inter- most bodies recovered from water have died pretational difficulties.' 4 7-9 As most sub- from its inhalation, the individual could have merged bodies float prone, with arms and legs fallen into it after collapse and death from hanging downwards, contact with the rough natural causes. The possibility of death from bed of the stream, river, lake or sea will the actions of an assailant followed by immer- produce abrasions maximal over forehead, sion ("dumping") in water as a means of backs of hands, knees and toes. Tides or disposal must always be considered. currents may crush the body against fixed (4) Could the deceased's actions before enter- objects, such as rocks, bridges, quays, weirs, ing the water or once in it have been modified http://jcp.bmj.com/ wharfs and piers or ships; propellers may also by the influence of alcohol or other drugs? inflict considerable damage. Here, the case for requesting routine toxico- Exposed skin may be bitten or chewed by logical analyses is strong-if only to facilitate fish, shellfish, and other marine life including interpretation of circumstances surrounding aquatic mammals, and some creatures are able the death. to gain access to skin below loose clothing. Occasionally, such large marine animals as on September 26, 2021 by guest. Protected copyright. sharks cause extensive lesions. Death certification Although not always artefactual, serious Once the questions considered above have injuries may be sustained either before the been answered satisfactorily by the pathologist, water was reached (on projecting rocks, pier formal death certification is required. This may pilings, bridge supports and quaysides) or be straightforward (Ia drowning; or Ia vagal while entering the water, especially after falling inhibition, due to lb submersion in water; or or jumping from a considerable height. The when death resulted entirely from natural force generated by the latter may be sufficient causes). But when drowning is associated with to rupture internal organs. natural diseases or drugs it may be difficult, and the pathologist needs to appreciate the implications of using the standard death certif- A personal approach to pathological icate format.3' If it is thought that death from conclusions submersion in water was the direct result of As stated earlier, the pathological examination natural disease or intoxication by drugs it of a body recovered from water and the should be so certified (Ia drowning, due to Ib drawing of reasonable and justifiable infer- intracerebral haemorrhage, due to Ic essential ences from the findings can be difficult.2 Each hypertension). But if the pathologist believes case has to be considered on merit, but it is that, given all pathological and circumstantial essential that all circumstances-how and evidence available, death from submersion where the body was found, whether there were occurred regardless of any natural disease or any local factors preventing the deceased intoxication present, then only the mechanism extricating himself from the area involved, the responsible for death should appear on the mental and physical state ofthe deceased when certificate.2 It must be remembered firstly that last seen alive, the deceased's background individuals can die with and not necessarily medical history and even, perhaps, the from diseases and conditions found at post 658 Lawler

mortem examination. Secondly, at present, the Deaths in the bath used in the United Kingdom These may present particular problems, and does not allow for the inclusion of conditions always require adequate explanation.4 1241 43 which have not caused or contributed signifi- Such deaths may, of course, be unrelated to J Clin Pathol: first published as 10.1136/jcp.45.8.654 on 1 August 1992. Downloaded from cantly to death.3' inhalation of bath water-for example from If the pathological findings are negative, natural causes, overdose of drugs or, occasion- ambiguous, or obscured by advanced decom- ally, electrocution. When water inhalation is position certification as "unascertained" (a considered relevant by the pathologist, the term understood and accepted by coroners32) death may, as discussed above, be accidental, may be honest, accurate and entirely appro- suicidal, or homicidal. Precipitation into the priate.3' The qualification "appearances here water by natural disease should always be are entirely consistent with drowning" or considered, as should the influence of poison- "appearances here are entirely consistent with ing, not only by alcohol or drugs, but also by death following immersion in water" may be carbon monoxide from faulty water heaters. helpful and appreciated by the investigating With apparently accidental deaths, many authorities. pathologists would agree with Cameron that "a normal healthy conscious person does not drown accidentally and that the possibility of Circumstances: accident, suicide or such an accident occurring from falling asleep homicide? is a convenient, but virtually unsubstantiated, In practice, almost all deaths after submersion myth." 2 in water are either accidental or suicidal; only a Some authors believe that adult deaths in the few are homicidal. These questions have been bath are most likely to be suicidal4 42; others addressed elsewhere' 47 '9 but are worth con- consider suicide by self immersion to be rare. 12 sidering briefly here. Sometimes the question In infancy and early childhood, although most is more complicated in theory than in practice, deaths are accidental and reflect inadequate as strong collateral evidence may render med- adult supervision, deliberate immersion is well ical data of secondary importance.9 documented, and should always be considered Accidental deaths predominate, and occur and investigated accordingly.44 45 under a wide range of circumstances.4 In a substantial minority, perhaps 20% or even more, particularly among the young adult age 1 Knight B. The Coroner's . A guide to non-criminal for the general pathologist. Edinburgh: Churchill groups, the victim is under the influence of Livingstone, 1983:251-68. drugs, especially alcohol4733 38 ("Bacchus 2 Davis JH. Bodies found in the water. An investigative approach. Am Jf Forens Med Pathol 1986;7:291-7. hath drowned more men than Nepture"35). 3 Lawler W The negative coroner's necropsy: a personal Here, sudden cooling of skin which is warmer approach and consideration of difficulties. J7 Clin Pathol 1990;40:977-80. than normal because of vasodilatation may be 4 Giertsen JC. In: Tedeschi CG, Eckert WG, Tedeschi LG, an important factor in deaths both from eds. Forensic medicine. Philadelphia: WB Saunders Co, http://jcp.bmj.com/ 1977:1317-33. drowning and from vagal inhibition. In many 5 Pullar P. In: Mant AK, ed. Taylor's principles and practice of of the remainder precipitation by clinically medical jurisprudence. 13th ed. Edinburgh: Churchill Livingstone, 1984:292-303. important natural disease may be relevant. 6 Polson CJ, Gee DJ, Knight B. The essentials of forensic Suicidal deaths are probably commoner than is medicine. 4th ed. Oxford: Pergammon Press, 1985: 421-48. appreciated or acknowledged,4 39but returning 7 Gordon I, Shapiro HA, Berson SD. Forensic medicine. A a verdict of suicide in the absence of confirma- guide to principles. 3rd edn. Edinburgh: Churchill Living- stone, 1988:115-25. on September 26, 2021 by guest. Protected copyright. tory or good circumstantial evidence is obvi- 8 Knight B. Forensic pathology. London: Edward Arnold, ously inappropriate and unfair to surviving 1991:360-74. 9 Simpson K. In: Simpson K, ed. Taylor's principles and practice relatives. It is worth remembering that individ- of medical jurisprudence. 12th edn. London: Churchill, uals who commit suicide may first resort to 1965:368-83. 10 Keatinge WR, Prys-Roberts C, Cooper KE, Honour AJ, alcohol or other drugs for "courage" and that Haight J. Sudden failure of swimming in cold water. Br suicides may have substantial natural dis- MedJ7 1969;i:480-3. 11 Keatinge WR. Hypothermia at sea. Med Sci Law 1984; eases. 24:160-2. Homicidal deaths are uncommon40 as it 12 Cameron JM. In: Camps FE, ed. Gradwohl's legal medicine. 3rd edn. Bristol: John Wright, 1976:349-55. requires a considerable physical disparity 13 Simpson K. Deaths from vagal inhibition. Lancet 1949; between the assailant and the victim, or for the i:558-60. 14 Spilsbury B. Some medico-legal aspects of shock. Medico- victim to be incapacitated by disease, drink, or Legal and Criminological Review 1934;2:1-13. drugs, or for the victim to be taken by 15 Gardner E. Mechanism of certain forms of sudden death in medico-legal practice. Medico-Legal and Criminological surprise.6 Nevertheless, the pathologist must Review 1942;10: 120-33. actively consider and positively exclude this 16 Anonymous. Immersion or drowning? [Editorial] Br Med J 1981;282:1340-1. possibility in every body recovered from water; 17 Donald KW. Drowning. Br Med J 1955;ii: 155-60. only then will missed homicides be minimised, 18 Fuller RH. Drowning and the postimmersion syndrome. A clinicopathologic study. Military Med 1963;128:22-36. although without evidence of violence, the 19 Pearn JH. Secondary drowning in children. Br Med J presumption must be that death was accidental 1980;281:1103-5. 20 Gordon I. The anatomical signs in drowning. A critical or suicidal.6 Therefore, it is essential that all evaluation. Forens Sci 1972;1:389-95. injuries on and within the body are docu- 21 Copeland AR. An assessment of weights in drowning cases. The Metro Dade experience from 1978 to 1982. mented and subsequently explained to the Am Jf Forens Med Pathol 1985;6:301-4. complete satisfaction of all parties-patholo- 22 Timperman J. Medico-legal problems in death by drown- ing. Its diagnosis by the diatom method. Jf Forensic Med gists, investigating police officers and Coroner/ 1969;16:45-75. procurator fiscal. When any doubts exist, it is 23 Hendey NI. The diagnostic value of diatoms in drowning. Med Sci Law 1973;13:23-34. wise to engage a specialist forensic pathologist 24 Peabody AJ. Diatoms and drowning-a review. Med Sci Law at an early stage. 1980;20:254-61. Bodies recovered fronm water: a personal approach and consideration of difficulties 659

25 Calder IM. An evaluation of the diatom test in deaths of 35 Plueckhahn VD. Alcohol and accidental submersion from professional divers. Med Sci Law 1984,24:41-6. watercraft and surrounds. Med Sci Law 1977;17: 26 Foged N. Diatoms and drowning-once more. Forens Sci Int 246-50. 1983;21:153-9. 36 Anonymous. Drinking and drowning. [Editorial.] Br MedJ7 27 Hendey NI. Diatoms and drowning-a review. Med Sci Law 1979;i:70- 1. 1980;20:289. 37 Cairns FJ, Koelmeyer TD, Smeeton WMI. Deaths from J Clin Pathol: first published as 10.1136/jcp.45.8.654 on 1 August 1992. Downloaded from 28 Gettler AO. A method for the determination of death by drowning. NZMedJ_ 1984;97:65-7. drowning.3AMA 1921;77:1650-2. 38 Plueckhahn VD. Alcohol and accidental drowning. A 25 29 Fisher IL. Chloride determination of heart blood. Its use for year study. Med 3Aust 1984;141:22-5. the identification of death caused by drowning. Jf Forensic 39 Copeland AR. Suicide by drowning. Am Forens Med Pathol Med 1967;14:108-12. 1987;8:18-22. 30 Modell JH, Davis JH. Electrolyte changes in human 40 Copeland AR. Homicidal drowning. Forens Sci Int 1986; drowning victims. Anesthesiology 1969;30:414-20. 31:247-52. 31 Knight B. The Coroner's autopsy. A guide to non-criminal 41 Gardner E. Death in the bathroom. Medico-legal and autopsies for the general pathologist. Edinburgh: Churchill Criminological Review 1944;12:180-93. Livingstone, 1983:53-60. 42 Geertinger P, Voigt J. Death in the bath. J7 Forensic Med 32 Burton JDK, Chambers DR, Gill PS. ' inquiries-a 1970;17: 136-47. guide to law and practice. Brentford: Kluwer Law Publica- 43 Devos C, Timperman J, Piette M. Deaths in the bath. Med tions, 1985:87. Sci Law 1985;25:189-200. 33 Giertsen JC. Drowning while under the influence of 44 Nixon J, Pearn J. Non-accidental immersion in bath water: alcohol. Med Sci Law 1970;10:216-19. another aspect of child abuse. Br Med I 1977;i:271-2. 34 Plueckhahn VD. The aetiology of 134 deaths due to 45 Pearn JH, Brown J, Wong R, Bart R. Bathtub drownings: "drowning" in Geelong during the years 1957 to 1971. report of seven cases. Pediatrics 1979;64:68-70. Med JAust 1972;ii:1183-7. http://jcp.bmj.com/ on September 26, 2021 by guest. Protected copyright.