The following case reports of stingray injuries are not attributable to any particular stingray species, but demonstrate the range of adverse affects following a sting, which are potentially applicable to any species of stingray. This does not imply that any given species of stingray can cause any or all of the adverse effects described in these case reports. However, they do indicate the important non-envenoming effects, particularly mechanical injury and infection, and the potential compounding effect of these with any venom-induced local tissue damage or necrosis.

Cook M.D., Matteucci M.J., Lall R. and Ly B.T (2006) Stingray envenomation. The Journal of Emergency Medicine, Vol. 30(3), pp 345-347.

A 37-year-old male was wading in shallow ocean waters off the Southern Californian coast when he felt a sudden sharp pain in his right foot. After exiting the water he noticed a small pointed object embedded in his foot surrounded by mottled skin. He immediately experienced throbbing pain in the foot to the point of near-syncope. He immediately returned home and placed his foot in hot water, which greatly reduced the pain. After several hours of soaking his foot in hot water he could tolerate the pain out of the water with oral analgesics and was nearly pain-free by the next day. Over the next week he developed a tender painful swelling in the right groin from which he recovered uneventfully.

Comment: The effectiveness of hot water immersion for stingray injury pain is demonstrated in this case. It also illustrates that even when significant pain is present, local necrosis is not inevitable.

Forrester, M. B. (2005) Pattern of stingray injuries reported to Texas poison centers from 1998 to 2004.  Human and Experimental Toxicology, Vol. 24(12), pp 639-642.

A study of stingray injury reports across the state of Texas USA between the years 1998-2004 revealed 153 cases were reported during this period. 2% of injuries were to patients under 6 years of age, 25% to 6-19 years and 73% to above 19 years. In 54% of cases injuries occurred in public places and 61% of cases patients were referred to a health care facility for treatment. No cases reported a lack of clinical effects and 53% reported minor effects to patients. The highest occurrence of stingray injuries was recorded during the summer months particularly in August and 60% of all cases were reported from coastal counties.

Comment: Stingray injury is more common in the summer months in coastal counties of the state of Texas presumably reflecting a higher proportion of aquatically active public during this time.

Riggs CM, Carrick JB, O'Hagan BJ, Rayner S, Pascoe RR, Fischer AB. (2003) Stingray injury to a horse in coastal waters off eastern Australia. Vet Rec, Vol. 152(5), Pp 144-145.

A group of horses were being exercised in shallow water of a beach in south-eats Queensland Australia during the afternoon of the 11th of April 2001. One horse suddenly became distressed and appeared lame on its right foreleg. Upon reaching the shore the horse continued to show distress and it was found to have sustained a small wound in the palmaromedial aspect of the distal metacarpal immediately proximal to the fetlock. The horse was attended too by a veterinary surgeon, broad-spectrum antibiotics was administered along with non-steroidal anti-inflammatory medication. The wound was also sutured and bandaged and the horse referred to a veterinary hospital for further investigation and treatment.

On admission to hospital the horse was bright and alert however it favoured its foreleg at rest and was mildly lame upon walking. Close examination of the foreleg revealed diffuse oedematous swelling of the palmar metacarpal and fetlock regions. An associated 10 mm penetrating wound in the plamaromedial aspect of the distal metacarpal region was also noted. A sharp object was palpated, protruding 2-3 mm through the skin on the lateral aspect of the limb in the middle third of the metacarpal region. A series of radiographs were taken to determine the nature of the object. These revealed a tapering, sword like radiopaque structure with serrated edges running obliquely across the palmar aspect of the metacarpal region in a distomedial to proximolateral direction. A second radiopaque body was lying next to the first body on the palmaromedial aspect of the metacarpal region. This was confirmed through ultrasonic examination.

The horse was anaesthetised and a tourniquet applied to the proximal metacarpal region. The wound was enlarged revealing a small cavity in the underlying soft tissues. The smaller of the two foreign bodies was identified by physical exploration and removed with ease. The base of the second body could be palpated deep within the wound. To remove the object a small incision was made adjacent its tip and the object gently pushed outwards in a medial to lateral direction. Close examination of the object confirmed it was the spine from the tail of a stingray. Examination revealed the spine had penetrated the metoacarpophalangeal joint. The area was debrided and flushing with Hartmann’s solution. The surgical incision sutured and the wound left open to drain.

Post-surgically the horse was treated with 7.5 g procaine penicillin (i.m) twice daily and 3 g gentamicin (i.v) once daily for seven days followed by 10 g sulphadimidine with 2 g trimethroprim orally twice daily. For a further seven days. The horse was also given 2 g of phenylbutazone (i.v) once daily for five days. There was an initial serious discharge from the wound, which stopped after three days. The horse showed little lameness after surgery and the oedematous swelling subsided steadily over a two-week period. The horse showed no signs of lameness upon re-examination after 14 weeks.

Comment: Surgically removing the stingray spine by drawing it through the penetration site prevented further tissue damage in the local area. The need for aggressive debridement of tissues surrounding the wound tract was again highlighted in this case involving a horse that sustained a penetrating injury from a stingray spine.

Groen R J, Kafiluddin E A, Hamburger H L, Veldhuizen E J. (2002) Spinal cord injury with a stingray spine, Acta Neurochir (Wien), Vol. 144, pp 507-508.

A 17-year-old man was stabbed with a bilaterally retro-serrated stingray spine. He was hit below the shoulders and the spine was projecting out his back. He experienced electric sensations along his spine and legs, and at the same time lost control of both legs. A neurological examination confirmed the paralysis of the right leg and decreased vital and gnostic sensibility on the right side. However sensor motor functions on the left side were unaffected. CT scans showed that the stingray spine has crossed the thoracic spinal canal. The stingray spine could not be removed under local anesthesia. Due to the absence of a neurological expert the stingray spine was not removed and the outer part was trimmed. Motor function returned after a few days but servere pain in the back and right leg remained. A cutaneous fistula developed at the site of the wound. Staph. aureus was found in wound cultures, but meningitis did not present. He was presented for neurological treatment after 4 weeks. The pre-operative MRI showed penetration of the spinal cord by the stingray spine. There was swelling and induration of the spinal cord and surrounding tissue. The stingray spine was removed microsurgically. The wound healed uneventfully. The pain and the paresthesias in the back and leg disappeared. 7 months post-operatively only discrete hypertonia and mild hypaesthesia of the right leg remained.

Comment: This case demonstrates yet another area at risk from stingray injury. Despite delayed removal of the spine, necrosis did not occur.

Enad J G, Espiritu J M, Fisher D. (2001) Stingray injury of the hand review of management. Trop. Doct, Vol. 31, pp 174-175.

A 35-year-old man in Cuba presented to an emergency department with a stingray injury to the palm of his right hand. He experienced the sting about 30 min before while swimming and suffered from severe pain that radiated through 4 fingers.  The laceration was 8 mm overlaying the transverse carpal ligament. The area was swollen and pale with minimal sanguineous drainage. Erythematous streaking the proximal forearm was noted. An electrograph showed no dysrhythmia and radiograph showed no foreign material.

The patient was given 0.5 cmcubic of tetanus toxoid. The hand was soaked in hot water and a formal irrigation and debridement was performed. Under regional anesthesia no foreign material was found and the carpal ligament was not penetrated. The swelling reduced and the wound was closed. The wound healed uneventfully within 2 weeks.

Rocca A F, Moran E A, Lippert FG. (2001) Hyperbaric oxygen therapy in the treatment of soft tissue necrosis resulting from a stingray puncture. Foot Ankle Int (United States), Vol. 22, pp 318 - 323.

A 46-year-old female presented eleven days after being stung by a stingray over the dorsum of the left third toe. She described how initially she had responded to warm water soaks and had felt better over the course of 2 days and had returned to her usual activities including running. After an additional 3-4 days a vesicle developed and some material drained with the area becoming increasingly erythematous, edematous and painful. She was started on Augmentin (500 mg po q8h) with no improvement and 3 days later Doxycycline (100 mg po BID) was added for possible Vibrio species with superimposed Staphylococcal and/or Streptococcal cellulitis. The condition of her foot worsened with intense pain over the dorsum of the toe and the foot which radiated proximally and prevented full weight-bearing on the foot. On examination the patient was afebrile with normal vital signs. Her left foot had a 10 x 14 cm area of erythema and warmth over the mid-dorsum which extended proximally to the ankle. Additionally the skin over the central area was necrotic and a punctate lesion on the dorsum of the third toe was noted. There were no areas of fluctuance or drainage and the patient had no palpable lymphadenopathy. A neurological exam was normal and she had no pain with passive stretch of her toes and X-rays of her foot showed no presence of foreign bodies. A tentative diagnosis of Vibrio infection with a superimposed Staphylococcus or Streptococcus cellulitis was made and i.v antibiotics given.

Upon debridement an incision was made directly over the dorsum of the third toe along the third metatarsal to the area of necrosis. Necrotic fat and muscle was noted with a prominent green discoloration of the extensor tendon and sheath with about ¾ of the extensor tendon having been destroyed. No purulent material was found, the wound was left open to allow repeat washout in 48 hrs. After a second debridement, hydrotherapy and wet to dry dressings were initiated. On day four the patient had a dramatic increase in pain, the area of erythema was increasing and petechiae were noticed on the dorsum of the foot to the ankle. The patient was returned to surgery where grossly necrotic and liquidfied tissue was noted necessitating a more comprehensive debridement of the extensor brevis and dorsal interossei. Despite continuing hydrotherapy, treating the wound with REGRANEX and continued IV antibiotic coverage, the wound required serial debridements (24-48 hrs) over the next three weeks. During these obviously nonviable skin edges were removed through scraping with a curette. Despite this the wound continued to expand and hoping to prevent further loss of tissue on the dorsum of the foot hyperbaric oxygen therapy was initiated. Upon commencement the wound measured 5 x 7 cm and was centered on the dorsum of the foot. Extensor tendons of the third and forth toes had been removed and the patient had no peripheral leukocytosis or fever and no inguinal lymphadenopathy was present.

Hyperbaric treatment incorporated in total 72 hours of twice daily 90 minutes at 2.4 ata followed by a final debridement and subsequent split thickness skin grafting from a left thigh donor site to the granulating bed on the dorsum. After the grafting the patient underwent a further four days at once daily hyberbaric treatment at 2.0 ata.

In this case multiple debridements confirmed haemorrhagic necrosis in the deep dermal layers as well as in muscle and tendons. All cultures were negative and tissue stains revealed no organisms or foreign material. Follow up care was uneventful and after six months the skin graft had healed completely and she had returned to full activity.

Comment: It is unclear what the relative roles of secondary infection and primary venom-induced necrosis played in this case. Hyperbaric oxygen therapy may possibly have speeded healing.

Weiss B.F., Wolfenden H.D. (2001) Survivor of a stingray injury to the heart. Med. J. Aust, Vol. 175, pp 33 - 34.

A 33-year-old man was rescued by lifeguards while snorkeling at Coogee Beach near Sydney Australia. He was unconscious and not breathing and had an increased heart rate of 150 beats/min when recovered from the water. After a short period of expired air resuscitation he regained consciousness and commented that he had been struck by the tail of a stingray. He complained of difficulty breathing and severe pain in the left side of his chest where the tail of the stingray had struck.

Upon arrival of paramedics he was cyanosed with a systolic blood pressure of 75 mmHg and sinus tachycardia (150 beats/min), but had a normal level of consciousness. He was given 500 ml of Haemaccel while in transit to hospital with no improvement in haemodynamics.

On arrival at hospital he remained in cardiac shock with a systolic blood pressure of 70 mmHg, sinus tachycardia (140 beats/min), hypothermia (31 degrees Celsius), poor peripheral perfusion and central cyanosis and a Glasgow coma score of 10. Initial blood gas results on oxygen 14 L/min were pH, 7.15, PaO2 74 mmHg, PaCO2 61 mmHg. The patient was administered 1 L of Haemaccel with little haemodynamic effect and was intubated. He had a 2 cm laceration in the lower left parasternal region and distended neck veins. A central line was also inserted and his central venous pressure measured 20 mmHg. After administration of 1 mg of adrenalin i.v systolic blood pressure increased to 150 mmHg, but his peripheral perfusion remained poor and his heart rate remained raised at 130 beats/min.

Transthoracic echocardiography revealed a moderate pericardial effusion with diastolic collapse of the right atrium and right ventricle, consistent with tamponade, and what appeared to be stranded foreign material in the pericardial space. An echocardiography-guided pericardiocentesis was performed draining 150 ml of dark blood which resulted in prompt restoration of blood pressure (170/80 mmHg) and reduction in heart rate (100 beats/min) and central venous pressure of 11 mmHg.

The patient underwent surgery to explore for foreign material in the pericardial space and the left pleural cavity was examined. A puncture wound was observed in the right marginal branch of the right coronary artery that had appeared to have spontaneously sealed over. There was no injury to the right ventricular muscle and no foreign material, only strands of fibrin and no barb remnants were found. There was a moderate ecchymosis of the left extrapericardial and extrapleural tissues but no breach of the left pleural space. The pericardial space and extrapericardial tissues were irrigated thoroughly to remove all potential venom, as was the barb entry site into the chest that was additionally debrided. Post-surgery the patient was given cefotaxime (1 g three times/day) and metronidazole (500 mg three times/day) i.v for five days. His recovery was unremarkable and he was discharged after 6 days and was well when consulted for a two-month follow up.

Comment: In this case the patient was fortunate to have only sustained an injury to a coronary artery rather than to the myocardium. The artery, through bleeding, may have immediately washed away any venom. Alternatively myocardium injury may be difficult to debride and carries a risk of delayed necrosis and perforation.

Vijayasekran V.S. (2001) Stingray envenomation or iatrogenic thermal burn. Australian and New Zealand Journal of Surgery, Vol. 71, pp 323 - 325.

A 55-year-old female tourist was walking in shallow water along the coast approximately 100 km from Perth, Western Australia. She described stepping on an object after which she experienced sudden intense pain in her left ankle. She was of the belief she stepped on a stingray of unknown identity. Upon arrival at a hospital her foot was immersed in hot water that partially relieved the pain. Examination revealed a 2 cm laceration below the lateral malleolus with surrounding oedema. She retained regular movement in her ankle and had a low-grade temperature. A local anaesthetic nerve block was administered and the patient was discharged and continued hot water immersion at home for several hours.

Approximately 24 hours after the injury she re-presented to hospital with haemorrhagic blisters, swelling and erythema over the lateral aspect of her ankle. She had a temperature of 37.2 degrees Celsius and a diagnosis of an infected thermal burn as a result of hot water immersion was made. The wound was dressed with silver sulfur diazide, tetanus toxoid was administered and the patient referred to a plastic surgery unit. Upon initial inspection the wound had the appearance of a partial thickness thermal burn, however, the blisters had a haemorrhagic component and there was significant erythema and oedema of the surrounding tissues. A few small haemorrhagic blisters on the dorsum of her toes separate from her ankle were also noted. The distribution of the burn was not consistent with an immersion type burn. The patient was admitted with a diagnosis of an infected wound with possible envenomation or thermal aetiology. She was given i.v antibiotics and the wound dressed twice daily. The patient underwent surgery 48 hrs after admission. A penetrating wound 5 cm deep in the centre of the necrotic area was observed posterior to her lateral malleolus. The wound was debrided and the defect grafted with a thin split-thickness skin graft. The patient was discharged 3 days later with a healed wound.

Comment: The potential dangers of hot water immersion, especially if combined with local analgesia, a practice which should be strenuously avoided, are evident in this case, though the nature and extent of necrosis suggests envenoming might have made a substantial contribution.

Germain M., Smith K.J., Skelton H. (2000) The cutaneous cellular infiltrate to stingray envenomation contains increased TIA+ cells.  Br. J. Derm, Vol. 143 pp 1074 - 1077.

A 44-year-old women was walking barefoot through shallow water on a Florida Beach when she suddenly saw a stingray move out from under her left foot and felt pain on the dorsum of the proximal third toe of her left foot. When she reached shore she noted a small puncture mark proximal to the toes on the dorsum of her foot. She did not seek medical attention until 72 hrs had elapsed even though the pain in the foot was moderate to severe, but did start tetracycline, which she had from a prior prescription.

After 72 hrs she sought medical attention due to oedema and an expanding area of ulceration of the skin proximal to the puncture site. Tetanus prophylaxis was administered, cultures performed and the wound soaked in hot water (40 degrees Celsius) for 90 min with care to avoid thermal damage. The wound was then re-irrigated and examined for visible pieces of sheath or spine. The patient underwent surgery approximately 96 hrs after envenomation. Extensive underlying tissue necrosis was found and the necrotic tissue including a narrow strip of viable tissue was excised down to the tendon that appeared normal. Post-surgery the patient was started on trimethoprim-sulpamethoxazole as prophylaxis for secondary infection. At approximately 1 week post-surgery there was evidence of granulation tissue. The wound was left open for secondary healing. After a period of three weeks there was only early granulation of the wound despite no evidence of secondary infection. At this point the patient was began on hyperbaric oxygen therapy and showed complete healing with no loss of function after approximately 2 months.

Histological examination reported a central area of necrosis within the epidermis. The subjacent dermis showed an expanded area of necrosis with a central area of haemorrhagic necrosis that extended into the subcutaneous fat layer. The surrounding viable skin and subcutaneous tissue showed a perivascular and interstitial mononuclear infiltrate with numerous eosinophils and rare neutrophils.

Immunohistochemical stains (CD3, CD8, CD20, TIA, L-26, KP-1) revealed most mononuclear cells (60-80%) showed positive staining for CD3. 10-20 % of cells showed positive staining for L-26, 10-20 % for KP-1, 50-60 % CD4 and 10-20 % for CD8. TiA+ cells appeared to correspond to the CD4 + cells and represented 30-50 % of the mononuclear cells.

Comment: It is unclear if hyperbaric oxygen therapy contributed significantly to the healing process in this case.

Van Offel J.F and Stevens W.J (2000) A stingray injury in a devotee of aquarium fishes. Acta Clinica Belgica, Vol. 55, pp 174-175.

A 37 year-old male presented three months after he was stung by a small stingray he was feeding in his home aquarium. He was treated when initially stung with intravenous amoxicillin and clavulanic acid for a period of five days. Upon representing he complained of residual itching and pain on the ulna side of the right hand where the initial sting had occurred. Clinical examination revealed a small scar in the right hypothenar region with focal anaesthesia surrounded by an area of pain on local pressure. The patient also located the itching in a zone surrounding the painful area, but there was no sign of cellulitis. Ultrasonography and X-ray of the hand excluded the presence of a foreign body. No further therapeutic measures were taken and the patient recovered completely several months after his revisit.

Barber G.R., Swygert J.S. (2000) Necrotizing Fasciitis Due to Phytobacterium damsela in a Man Lashed by a Stingray. The New England Journal of Medicine, Vol. 342, pp 824.

A 43-year-old man presented with necrotizing fasciitis after being lacerated by stepping on a stingray in Tampa Bay, Florida. Upon presentation to hospital at the time of the injury the patient had a wound on his right tibialis anterior muscle. This would was irrigated and sutured approximately six hours after admission, however antimicrobial therapy was not prescribed before the patient was released. Three days later fever developed and erythema appeared along the wound margins, followed within the next 24 hours by the appearance of a 2.5 cm-wide fluctuant lesion. At this time the patient re-presented to hospital with a temperature of 39 degrees Celsius, a WBC of 15,500 per cubic millimeter, with a septic appearance. There appeared to be necrotizing fasciitis in his right tibialis anterior muscle. Doxycycline (400 md/d), cefazolin (3 mg/d) and tobramycin (6.5 mg/kg/body weight/day) i.v was begun and continued for a period of seven days. Deep surgical debridement was performed on an emergency basis and again under surgical conditions the following morning. Wound cultures yielded P. damsela which were sensitive to antibiotics used for gram-negative organisms with the exception of amikacin to which it only showed an intermediate sensitivity. As an outpatient he received oral doxycycline and cephalexin for a period of two weeks and subsequently he required physical therapy and a split-thickness graft for wound closure.

Comment: Clinicians should be aware of P. damsela and other vibrio species, particularly in the care of wounds exposed to salt or brackish water or wounds inflicted by marine animals living in such environments as in this case with a wound inflicted by a stingray.

Baldinger P J. (1999) Treatment of stingray injury with topical becaplermin gel. J. Am. Podiatr. Med. Assoc. (US), Vol. 89, pp 531 - 533.

A 64-year-old male in Florida presented to hospital with a 3.5-inch stingray spine embedded in the dorsal part of his left foot. A general surgeon excised the spine and he was advised to wash the affected area with hypochlorite and dilute liquid detergent solution and to soak the foot periodically with Epsom salts.

One month later the patient presented with a large ulceration (1.0 x 0.5 x 1.0 cm) across the dorsum of the foot at the level of the first and second metatarsophalangeal joints. There was localized edema but no acute infection. The wound was debrided and flushed with dilute povidone-iodine solution. The patient was advised to continue the soaking with Epsom salts and to cover the wound with dilute iodine solution and a moist saline dressing. One week later deep ulceration was still present and there was slight serous drainage. Topical growth factor treatment with becaplermin gel was started and applied every 12 hrs. In addition chlorazene hydrotherapy was also started. The wound started to heal and Ciprofloxacin 500 mg twice a day was prescribed. Localized cellulitis developed and culture results showed Pseudomonas aeruginosa infection. One week later the healing improved. Some edema and rubor persisted. The treatment continued with becaplermin gel and chlorazene hydrotherapy and began application of silver sulfadiazine cream. 10 days later the wound was manually debrided to promote rapid healing. The treatment continued and 2 months later the wound was completely healed.

Ho P.L., Tang W-M., Lo K.S., Yuen K.Y.(1998) Necrotizing fasciitis due to Vibrio alginolyticus following an injury inflicted by a stingray. Scand J Infect Dis, Vol. 30, pp 192-193.

A single case report from China, of a 31 yr old man stung on the calf by an unidentified stingray, who presented 20hrs later with apparent cellulitis. Initially treated with penicillin G & cloxacillin, within 48hrs he had deteriorated, with increasing local pain, numbness, then development of haemorrhagic bullae, superficial vein thrombosis and skin necrosis. Emergency surgical exploration revealed necrotizing fasciitis, involving several muscle groups. Antibiotics were changed to IV ciprofloxacin & amoxicillin-clavulanate. A further 4 surgical debridements were required before control was established, 7 days later. Antibiotics were continued for 21 days and recovery, but with tissue deficit requiring grafting, occurred. Vibrio alginolyticus was recovered from the wound twice, but not from blood cultures. The patient was also found to have cirrhosis secondary to hepatitis B infection.

Comment: This organism is rarely associated with human infection, then nearly always in immunocompromised hosts, and may cause bacteraemia or local necrosis, with a high mortality rate. It is unclear in this case what contribution venom-induced local tissue injury may have played in development of infection and necrosis. Aggressive surgical debridement and antibiosis were required to secure a favourable outcome.

Whiting S D, Guinea M L (1998) Treating stingray wounds with onions. Med. J. Aust, Vol. 168,  pp 584.

In December 1997 a man was wounded by a blue spotted stingray in the Northern territory. The barb penetrated wetsuit, boot and 2 cm in to the instep of the right foot. He experienced intense pain, which spread to through the entire leg. Other effects were profuse bleeding, swelling, numbness, and muscle twitching. The pain continued for 45 min until a local fishing family. They immersed the foot in hot water, but the pain returned when the foot was taken out of the hot water. Then half a bulb of an onion was bandaged on to the wound. After 30 min the pain reduced and after 1 hr he was able to walk on it with joint stiffness. One dose of antiseptic cream was applied and the wound did not get necrotic or infected and healed without complications.

Polack F.P., Coluccio M., Ruttiman R., Gaivironsky R.A., Polack N.R. (1998) Infected stingray injury. Pediatr. Infect. Dis. J, Vol. 17, pp 349 - 360.

An 11-year-old boy was swimming in a river on the outskirts of Buenos Aires when he stepped on a stingray. He immediately experienced intense pain and noticed upon retreating from the water a 3 cm-long bleeding laceration on the dorsal aspect of his foot. Upon presenting to hospital the patient's wound was sutured and he was started on a course of amoxicillin/clavulanic acid.

He returned to the hospital the following day with a temperature of 38.5 degrees Celsius and generalized malaise. The wound showed serosanguinous discharge with an erythematous border. The wound was reopened and cleaned through forceful irrigation. 18 hrs after admission the patient had a fever of 39.2 degrees Celsius, was vomiting and complained of decreased energy. His left foot was edematous, with impressive tenderness, mild crepitation and a purple surface discoloration but had good distal pulses. The wound showed necrotic borders and was draining a fishy smelling purulent fluid, however the rest of a physical examination proved unremarkable. The patient recorded a WBC of 19,300 cells/microlitre, with 25 % band neutrophil forms and 55 % polymorphonuclear cells and hematocrit 39 % and platelets 455,000 per microlitre. Treatment included aggressive debridement of necrotic fascia and subcutaneous fat under surgical conditions. No evidence of myonecrosis was observed.

Comment: Because of the potential for both secondary infection and primary venom-induced necrosis, it is generally inadvisable to suture stingray wounds.

Evans R J, Davies R S. (1996) Stingray injury. J. Accid. Emerg. Med, Vol. 13 pp 224-225.

In July 1994, off the coast of Wales, some fishermen caught a 40-pound stingray. One person accidentally kicked the stingray and it thrust its tail into a fishermen’s leg. The spine cut through the boots and trousers and lacerated his lower left leg. The patient complained of sharp pain at the wound and later it spread down to his ankle. He was taken to a local emergency unit, where the wound was immersed in hot water, irrigated and debrided. The edges were excised under general anesthesia. The wound was packed and antibiotics were prescribed. He was discharged the following day and followed up by his GP. Later the leg became swollen and erythematous. His wound healed completely by secondary intention over a 2 months period.

Fenner P J. (1995) Stingray envenomation: a suggested new treatment. Med. J. Aust, Vol. 163, pp 655.

In April 1995 a person suffered a stingray sting to the lower limb. 10 mm round and 10 mm deep area was excised and packed with an alginate based wick and Ciproflaxacin 500 mg twice daily was prescribed. The alginate dressing was changed in 6 days and the wound was clean and healing. A transparent waterproof dressing was applied over a thin layer of Kaltostat. 14 days after the sting the wound was completely healed.  

Burk M P, Richter P A. (1990) Stingray injuries of the foot. Two case reports. J. Am. Podiatr. Med, Vol. 80, pp 260-262.

31-year-old man presented for treatment in August 1986 after stepping on a dead decomposing stingray. The spine penetrated the plantar region of the right heel, but broke off at the entry site with about 1 mm protruding out. Pain was limited to the site of the puncture, which was about 0.75 cm in diameter. The patient had received tetanus toxoid 9 months before. The spine was removed under local anesthesia. A wet to dry dressing was applied and antibiotic therapy was commenced, consisting of Augmentin 250 mg twice a day.  

In July 1988 a 14-year-old male stepped on something sharp in a shallow bay. He was wearing tennis shoes, but the sharp object went through its sole and punctured the plantar aspect of the left foot causing a painful wound. The boy returned to the shore with the painful and bleeding wound. He was taken to an emergency walk-in clinic. At the clinic he was given a tetanus toxoid booster injection and the left foot was x-rayed. The radiograph showed foreign material at the level of the third metatarsophalangeal joint and this looked similar to a stingray spine. The spine could not be removed at the walk-in clinic and he was advised to go to a podiatrist. On the next day the wound measured to be 0.75 x 0.50 cm with marked edema, induration, ecchymosis and erythema. The patient complained of pain radiating through his leg. The foreign object was removed under local anesthesia. The tip and the serrated edges of the spine were intact. Gauze drain was placed in the wound and the patient was started on oral antibiotics consisting of Augmentin 250 mg twice a day. The wound healed without any complications.

Comment: These cases demonstrate a risk even from a dead stingray, by stepping on it. In the second case, if a serrated spine had not been found, the differential would have been stepping on a spiny venomous fish.

Hiemenz JW, Kennedy B, Kwon-Chung KJ. (1990) Invasive fusariosis associated with an injury by a stingray barb. J. Med. Vet. Mycol, Vol. 28(3), pp 209-213.

A previously healthy 34-year-old male, suffered a wound to the dorsal ulnar aspect of his right hand, just distal of the wrist while fishing off the East coast of Florida. In an attempt to free itself while hooked, the stingray embedded its barb in the fisherman’s hand; the barb broke off and disappeared beneath the skin. X-rays taken immediately after the injury revealed the tip of the barb deep in the tissue of the hand, with a smaller superficial piece close by. The smaller of the foreign bodies was removed through a 1cm incision. Five hours after the injury this incision was expanded to 3 cm and a 1.5 cm long terminal stingray barb was removed. The wound copiously irrigated with antibiotic solution containing cefazolin in sterile normal saline. The patient was also treated perioperatively with 1 g cefazolin (i.v) every 8 hr. No cultures were obtained at the time of surgery and the patient was discharged 24 hrs later and given an oral antibiotic therapy of cephradine 500 mg/day for 1 week.

Initial healing of the wound was observed however on day 14 the patient complained of increasing erythema around the wound. Oral trimethoprim/sulfa (one double strength tablet per day) was administered. Due to development of progressive induration, skin sloughing and erythema the patient was readmitted on day 17 for further evaluation and treatment.

On admission the wound was surrounded by a 4 cm area of erythema and induration from which a small amount of straw-coloured fluid was discharged. His hand still displayed a good range of movement and neurovascular function was intact. X-Ray of the wrist revealed no retained foreign body or bone erosions but there was some soft tissue swelling. Specimens were taken from the wound for culture. Ticarcillin/clavulanic acid (i.v) 3.1 g every 6 hr was given in addition to the oral trimethoprim/sulfa. Following a further three days the wound was unchanged.

Cultures revealed no gram negative or acid-fast bacilli but fungal culture rapidly grew a species of Fuscarium (F solani). This result was initially disregarded as contaminant. Debridement was performed and fragments of hyalinized fibrous debridement were stained with Gomori methenamine silver and showed extensive invasion by septate and branching hyphae. The following day an elliptical incision 4.5 cm in circumference was made with the original 2.5 cm x 1.4 cm wound in the centre. Pathology revealed fungus in the deep-dermal margin of the ulcerated zone but not present in the peripheral margin of the excised skin. All cultures taken grew the same fungus that was previously identified from the wound drainage.

The patient was given ketoconazole (200 mg/week) for the first week. This was later increased to 600 mg/week for a second week and he was discharged 30 days post-injury. The patient stopped taking the ketoconazole 1 week after discharge and was readmitted and found to have a granulating wound 4 cm in circumference with a partially exposed extensor carpi ulnaris tendon. Debridement of the wound and split thickness skin crafting was performed. Cultures revealed no bacteria of fungi were present and ketoconazole was discontinued. This skin craft did not mature sufficiently and the patient was again readmitted some 2-3 months later. A staged-groin flap reconstruction of the soft tissue defect on the hand was performed; cultures again were negative for fungi. Healing of the groin-flap craft progressed without incident and the patient showed no functional impairment of the hand and no evidence of recurrent infection over a two year follow up period.

Comment: This case highlights the need for careful consideration of both bacterial and fungal infection of wounds caused by stingray barbs. It also indicates the importance of conducting appropriate cultures to identify potential sources of secondary infection allowing early treatment.

Fenner P. J., Williamson J.A., Skinner R.A. (1989) Fatal and non-fatal stingray envenomation, Med J Aust. Vol. 151, pp 621-625.

Case report 1.

In April 1988 in north Queensland, a 56-year-old man was stung by a stingray on his right ankle. He experienced severe pain and a GP gave him 10 mg of morphine and 10 mg of metoclopramide. The pain reduced and the wound was covered with a non-stick dressing. A week later the surrounding area of the wound became red, hot and painful. An intramuscular injection of lincomycin (300 mg) and a tetanus toxoid booster was given. Clindamycin (300 mg) three times a day was prescribed. Clitobacter freundii was cultured from the wound. Over the next seven months the wound became infected a several times, causing complications. 4 months later a small amount of glass like material was found extruding from the skin just below the wound. More similar fragments were found near the sole of the foot. This material was identified to be parts of a stingray barb. 18 months after envenomation the wound finally healed.  However the ankle becomes painful and swollen after being active for some time.

Case report 2.

In November 1988, a 26-year-old man was walking through shallow water when he was stung by a stingray on the left foot just above the ankle. He experienced severe pain and when he left the water he saw a small deep gash. He went to the local hospital after several hours. The wound was cleaned and a butterfly dressing was used. Tetanus toxoid was administered intramuscularly. Metronidazole (400 mg three times a day orally) and erythromycin succinate (400 mg twice a day orally) was prescribed. 3 days later he presented with a swollen, bruised and painful left ankle. The area was infiltrated with 2% lignocaine with adrenaline and the butterfly closure was removed. A cut of about 1 cm was exposed which penetrated to the ligaments below. Any foreign material was removed and the wound was cleaned. A gauze wick soaked in saline was inserted. The patient was advised to continue antibiotic therapy. The wound healed within 2 weeks. 6 weeks later a 3 cm area around the wound was excised and was left open to granulate. The excised tissue contained small parts of material that were identified to be parts of stingray integumentary sheath. The wound healed completely over the next two months.      

Case report 3.

In October 1988 in Mackay a stingray in shallow water stung a 26-year-old man. He felt a sharp pain and saw a 75 mm stingray barb stuck on the 4th toes of his right foot. He presented to hospital and the area was infiltrated with 2% lignocaine. The barb and a small area of tissue around it were excised. The wound was cleaned with hexachlorophene in 70% alcohol. The wound was sutured and trimethoprim (80 mg) and sulphamethoxazole (400 mg twice a day orally) was prescribed. Prophylactic injection of adult diphtheria and tetanus toxoid was administered. No infection developed and the sutures were removed a week later.

Case report 4.

In 1988 in north Queensland a stingray leapt out of the water in front of a fast moving boat and glanced against all 3 passengers and fell back in to the sea. A 12-year-old boy and his father suffered no stings. The other 12-year-old boy was hit by the ray and immediately experienced chest pain and had trouble breathing. He had a barb wound on his left nipple and another wound on his knee. He was taken to a general surgery within 30 min. where he was breathing, with chest pains, pale, sweating and drowsy. He was in considerable pain, his heart sounds were normal and lung fields were clear. There was a 2 cm curved laceration under his left nipple and 2 lacerations on the lateral side of the left knee; one laceration still contained part of the barb.

Hot packs were applied to both wounds and 1% lignocaine was injected. The barb was removed and he was transferred to a hospital. Plain erect chest x-ray showed no penetrating wound. The track between the wounds in the knee was cleaned with chlorhexidine gluconate in 70% alcohol. The chest wound was explored carefully was cleaned with chlorhexidine gluconate in 70% alcohol. A small vessel bleeding persistently beneath the nipple was tied off and the wound was left open to granulate.

The boy was discharged and was recovering until 6 days later he collapsed and had trouble breathing. The ambulance medical personnel and the medical personnel at the hospital could not revive him. Post mortem showed the cause of death to be cardiac tamponade as a result of chemical myocardial necrosis from a penetrating stingray injury. 

Comment: The last case demonstrates the major risk from any stingray injury penetrating to major organs, including the danger of delayed effects as the result of necrosis, which may be venom-induced.

McCall J, Sugrue W. (1986) An unusual diving injury. N Z Med. Journal, Vol. 99, pp 205.

A 26-year-old woman was diving in murky water 10-15 m away from the shore when she felt a sudden pain in the right flank.  She presented at the hospital 2 hr later. She had a systolic BP of 100 mmHg and slightly cool peripheries. The wound was 2 cm above the right iliac crest and it was 2 cm long. She was given fluids and antibiotics. At surgical exploration the wound was found to extend across the retroperitoneum towards the alar of the sacrum, abrading in its path the iliolumbar ligament. A large haematoma lay behind the caecum and ascending colon while the peritoneal cavity was not affected. The wound was cleaned and closed with a drain inserted. It took about 7 days for her temperature to return to normal levels; otherwise she had an uneventful postoperative recovery. As the victim or her friends did not see anything in the murky water there is no proof, but it was assumed to be a stingray that was disturbed.

Dormon F M (1985) Local Nerve Block After Stingray Injury. The Lancet, Vol. 2, pp 1131 - 1132.

In the coastal waters of Sri Lanka a man stepped on a stingray and was stung on the left foot between the second and third toes. He experienced severe pain. He had some medications with him and took dihydrocodeine and chlorpheniramine, but the pain was back again in 15 min. The pain became severe and caused whole leg muscle spasms. With the aid of the general practitioner who was with him they tried to block the deep peroneal nerve at the ankle with 1% plain lignocanine. The victim experienced immediate relief and the block lasted for 80 min and was repeated. The pain was less severe and victim had an uneventful recovery.

Funayama M., Aoki Y., Hayasaka K., Sagisaka K. and Ohno Y (1985) A case of fatal loss of blood caused by a stab with the venomous spine of a stingray. Research and Practice in Forensic Medicine, Vol. 28, pp 145-148.

A 47-year-old fisherman working on a tuna long line fishing vessel in the Southern Pacific Ocean was pierced with the venomous spine of a stingray that had been flung away by a colleague. The man died after approximately half a day. Autopsy revealed that the well developed hard-spine of the stingray had cut the left femoral artery upon puncture resulting in a fatal loss of blood.

Comment: It is not clear why the haemorrhage was not controlled, given the delay between sting and death. It does illustrate the capacity for major trauma to large vessels from stingray spines, though in this case the spine was not embedded by the stingray.

Cross T B (1976) An unusual stingray injury - the skindiver at risk. Med. J. Aust, Vol. 2, pp 947 - 948.

A 16-year-old Polynesian male was stung by one of two stingrays he disturbed while fishing. He sustained wounds on the right thigh and lower part of the abdomen and immediately experienced severe pain. Upon reaching shore the boy was given chlorpheniramine (10 mg) and pethidine hydrochloride (100 mg i.m) for pain relief and clean dressings were applied to wounds. He was admitted to hospital 2 hours after the injury.

The patient was lucid and had good colour with no evidence of shock. A 0.75 cm wound on the abdomen was noted in the left iliac fossa surrounded by a tender oedematous area with diameter 4 cm. There was no discharge from the wound and there was no rebound tenderness. A similar wound was also noted on the anterior surface of the upper third of the thigh. Treatment consisted of giving fluids i.v,, nasogastric suction and the administration of antibiotics (penicillin and streptomycin) and tetanus toxoid. Under surgical conditions the abdomen was explored through a left paramedian incision. Approximately 250 ml of blood was found in the peritoneal cavity and four puncture wounds in the bowel where the lumen of the upper part of the ileum had been transversed. A small tear with a severed blood vessel was also present in the omentum of the small bowel. Bowel wounds were over sewn in two layers, the severed vessel was ligated, the mesentery was repaired and a peritoneal toilet was carried out and the incision closed allowing peritoneal drainage through the cleansed wound. Similarly the lesion in the thigh was explored, cleansed and left to drain and the drain removed on the second postoperative day. The patient was released after 10 days and experienced unremarkable convalescence.

Comment: In this case, risk to life was from the injury inflicted by the stingray’s barb striking a major organ. Although on inspection the abdomen wound was small and the patient's condition good, extensive damage had been inflicted within the peritoneal cavity. The patient almost certainly would have died without surgical intervention suggesting however small an injury is sustained, stingray puncture injuries should always be explored if they potentially involve body cavities or vital organs.

Cadzow W H (1960) Puncture wound of the liver by stingray spines. Med. J. Aust, Vol. 1, pp 936-937.

A seven-year-old male child was admitted to the Talasea Hospital, New Britain, New Guinea on the 3rd July 1959. 28 hrs previously he had been struck in the abdomen by the spines of a small stingray while grasping the creature trying to bring it ashore. One spine broke off flush with the skin; he commented that he did not notice any pain at the time. A short time after a nursing sister attempted to remove the spine but this was accompanied by much bleeding from the wound. The patient was transferred to hospital the following day.

Upon admission he was found to be moderately shocked with a weak, rapid pulse, cold extremities and mental confusion and a normal temperature. Two puncture wounds were noticed about 2-3 cm’s apart in the same horizontal plane just below the right costal region and just lateral to the tip of the ninth costal cartilage. The outer ends of the spines were noticeable in both puncture wounds and moved up and down with respiration. The abdomen was tender with guarding but was not absolutely rigid and peristalsis was present.

The patient was given 500 ml of blood and 100,000 units of crystalline penicillin, vitamin K i.v and 3,000 units of tetanus antiserum, and a premedication with one-twelfth of a grain of morphine and one-hundredth of a grain of atropine. The abdomen was opened under surgery by a right subcostal incision below the puncture wounds. A considerable amount of blood was found in the peritoneal cavity, most of which was gravitated toward the pelvis. The two spines had entered the right lobe of the liver about 4-5 cm’s from its border, the direction of the spines was upwards and backwards with the tip of more medial spine palpable through the inferior surface of the right lobe. The medial spine was embedded about 15 cm into the liver substance. Bleeding from wounds in the liver had ceased. Both spines were pulled out of the liver by the way they had entered which required considerable force. This caused fairly brisk bleeding from the liver that was stopped by squeezing the area between forefinger and thumb. Owing to their re-curved barbs they could not be pulled through the abdominal wall wounds, rather they were removed through the main incision. Finally blood was mopped out of the peritoneal cavity and the abdomen closed allowing draining through the stab wound.

Post-surgery crystalline penicillin was given and the drain was removed on the second day. Recovery was uneventful except for a superficial wound infection of the puncture wounds and main incision. The patient was released one month after admission.

Comment: This case also demonstrates the potential for damage to major organs and the need for surgical inspection in such cases.

Russell F E (1953) Stingray injuries: a review and discussion of their treatment. Am. J. Med. Sci. Vol. 226, pp  611-622.

Case report 1.

A 27-year-old male was stung by a stingray in Alamitos Bay, California. He complained of almost immediate intense and stabbing pain over the lateral aspect and ankle of the injured foot. On examination a bleeding wound of about 2 cm was observed which could be probed to a depth of 1.5 cm. Both the flexor and extensor muscles in the foot were tensed. The patient went into primary shock but was quickly revived. About five minutes after the injury sporadic muscular fibrillations could be seen along the length of the peroneus longus and brevis. Deep reflexes of the leg and foot were hypertonic but there were no pathological reflexes. For a further 30 minutes the patient complained of dizziness, nausea and severe pain over the right ankle and lower third of the leg and he continued to hold the leg in a flexed position even while reclining. The pain reached its greatest intensity 20 minutes after the injury, at this point his blood pressure was 102/62 mmHg and cardiac rate 82 beats/min. Meperidine hydrochloride (75 mg) was given i.m for pain. The ankle was edematous and quite sensitive to pressure and the edges of the wound were ragged and appeared purple in colour.

The laceration was irrigated and a sterile nitrofurazone dressing applied. Soaking the foot in warm water reduced pain in the proceeding hours. The wound took about 16 days to heal and edema was apparent for two weeks of this period.

Case report 2.

A 9-year-old boy received two lacerations on the dorsum of the right foot near the first metatarsal bone. The injury occurred in Newport Harbor, California. The wound was painted with iodine and bandaged but owing to intense pain the patient was taken to hospital 1 hour later. The wound was probed and one sting and “a small piece of slime” removed from one of the lacerations. Both wounds and the foot were extremely sensitive to pressure and an area around the wound was red and skin temperature increased. The leg and foot were flexed and the patient complained of extreme pain. Morphine sulfate (1/10 grain) was given for pain, but the patient began vomiting thereafter. The patient continued to complain of extreme pain for the following 2 hours. The patient was also given calcium gluconate (3 grains and Phenobarbital (1 grain) and penicillin 300000 units i.v. Fours hours after the injury the patient complained of abdominal pain, nausea and pain on deep respiration and 10 minutes after he began to vomit. His temperature was 99 degrees Fahrenheit. Pulse 96 beats/min, respirations 24 and blood pressure 85/60 mmHg. The heart and lungs were normal on examination and the abdomen was flat, slightly rigid but without tenderness and increased peristalsis. Pitting edema extended over the entire dorsum of the right foot and the peripheral pulses were feeble. Deep reflexes of the leg were hyperactive and superficial reflexes were hypoactive and there was no pathological reflexes.

Upon hospitalization the patient was given 250 cc of 5 % glucose in water with 3 units of Eschatin added. Pain diminished over the next 12 hrs and recovery was uneventful. Edema persisted for 6 days in spite of continual elevation of the extremity and the wound was healed by the ninth day.

Case report 3.

A 22-year-old women was struck by the spine of a stingray while swimming in the surf off Seal Beach, California. The patient reportedly fainted several minutes later and was taken to hospital. Upon arriving at hospital 15 minutes later the patient complained of severe pain in the injured foot, cramps in the ipsilateral leg, faintness, nausea and some dizziness. Examination revealed a deep laceration several centimeters in length freely bleeding, just anterior of the medial malleolus of the left foot. The edges of the wound were ragged and swollen and the patient held the foot flexed at the ankle and inverted. Her temperature was 98.6 degrees Fahrenheit, pulse 92 beats/min, respiration 20 and blood pressure 110/66 mmHg and the lungs were clear and there were no cardiac abnormalities. Patellar and Achilles tendon reflexes on the affected leg were hyperactive and there were no sensory changes.

The wound was cleansed and irrigated with a 5 % solution of potassium permanganate and some debridement was undertaken. One hour after the injury the patient complained of pulsating pain that was intense at times. Morphine sulfate (1/4 grain) and Phenobarbital (2 grains) i.v was given for pain and two hours later the patient was considerably improved and released. The area around the wound was deep red and edematous the following day, localized edema and tenderness persisted for 11 days and the laceration was not well healed to about two weeks after the injury.

Comment: All 3 cases demonstrate the very severe nature of the pain associated with stingray injuries.

Ronka E K, Roe W F. (1945) Cardiac wound caused by the spine of the stingray. Milit. Surg, Vol. 97, pp 135-136.

A 28-year-old male was admitted to Tripler General Hospital in San Francisco on the 2nd July 1944. He was injured when his brother, while fishing with a net, trapped a large fish. The patient on hearing the loud splashing tried to free what he believed to be a shark, placing his arms around the head of the fish and pressing it against his chest. The specimen proved to be a stingray that wrapped its long whip-like tail around his chest and drove two of its spines, near the base of its tail, into the left chest wall.

On admission the patient's temperature was normal and pulse 110 and blood pressure 120/74 mgHg. One spine was in the subcutaneous tissue and the other had penetrated the chest in the 5th intercostal space slightly lateral to the mid-clavicular line. This spine was directed medially and moved with each cardiac beat with the hilt of this spine laying just beneath the skin. Lung fields were clear on physical examination, as were cardiac sounds and pulse rate. Emergency roentgen studies revealed two foreign bodies, one in the subcutaneous chest tissue and the other projecting from the left lateral chest all into the pericardial sac at the level of the 5th inter-space interiorly. There was no evidence of hemopericardium or hemo-throrax. Under surgical conditions the wound entrance was enlarged and the superficial spine, measuring 4 cm removed. This incision was extended in depth in the 5th inter-space and the end of the spine grasped with a hemostat and gently teased out of the thoracic cavity. The spine in its course had perforated the pleura and the pericardium and had penetrated through into the muscular wall over the right ventricle. The removed spine was 10 cm long and 1 cm wide. With the lung expanded while the patient held his breath the cardiac wound measured about 3 mm but did not bleed. After closing of the chest wound an X-ray revealed a mild pneumothorax.

Post-surgery was uneventful, there was no accumulation of fluid in the pleural cavity and no subcutaneous emphysema. The wound healed by primary intention. Sulfadiazine was given orally and food and liquids were well tolerated with blood pressure remaining at normal levels throughout his convalescence. The patient was released 18 days after admission with the wound well healed.

Comment: No evidence of necrosis from the venom in this case. As there was incomplete penetration of the ventricular wall, there was no substantial blood leakage and no cardiac tamponade, making this dramatic injury survivable.

Wright-Smith R J (1945) A case of fatal stabbing by a stingray. Med. J. Aust, Vol.  2, pp 466 - 467.

On January 9, 1945, a member of the armed forces of Australia was bathing with other soldiers at sea baths in St Kilda, Melbourne Australia. He was seen to suddenly go underwater and began waving his hand over his head while partially submerged. Upon his colleagues assisting him from the water he was breathing in gulps and it was noted that he had a wound in his left breast on the surface of which a drop of blood was seen. Artificial respiration was immediately begun with no apparent bleeding from the wound. Life was pronounced extinct 20 minutes after removal of the patient from the water.

An autopsy revealed dried superficial abrasions on the left shoulder and elbow and on the right wrist. Below and medial to the left nipple was an oval-shaped wound approximately 2 cm in length and with serrations in its lower border. On the medial side of the wound approximately 2 cm away was a tiny rounded puncture wound. The wound entered the chest in the fifth left intercostals space, penetrating the left pleural cavity and pericardium through a slightly irregular tear 2 cm in length. It entered the anterior wall of the left ventricle near the apex through a slightly irregular tear 1 cm in length. The direction was upwards and backwards with a probe passing through the wound for a distance of 8-9 cm’s, while the smaller wound did not penetrate below the subcutaneous tissue. The pericardial sac contained fluid blood and the left pleural sac contained a large amount of fluid blood and a red clot. Hemorrhage had occurred in the muscle about the wound in the left ventricle and the cavities of the heart contained little fluid blood. Coronary orifices and arteries were normal as were aortic valves and the lungs were red and firm. Moderate oedema was present through the right lung and the left lung was partially collapsed. There was no wound in the tissue of the left lung and air passages were pale and empty. All other viscera were normal.

Comment: This paper concluded death was due to hemorrhage from a stab wound of the heart. It seems cardiac tamponade likely occurred and would have been the mechanism of death.

Liggins J B. (1939) An unusual diving fatality. N Z Med. J, Vol. 20, pp 27-29.

An 18-year-old woman was bathing with her partner at Hauraki Gulf near Thames. She was wading in about 3 feet deep water when she called out for help and someone rushed to her side. Then she collapsed and was carried to a passing motor vehicle and to hospital. It was reported that she was breathing while she was in the van but was dead by the time they arrived at the hospital. On her chest there was an incised wound 2 inches long exposing the intercostal space. There were 3 wounds on the inner left thigh. The man with her reported that when he went to assist her she pointed to the water, and he saw a fin and a movement. The coroner found the cause of the death to be hemorrhage from a wound to the heart caused by a barb of a stingray. However there was not enough evidence to conclude that this was actually a stingray injury.

Comment: Detail is scant, but consistent with a stingray injury to the chest, with lethal cardiac tamponade.