DROWNING is one of the various forms of death from suffocation, the asphyxiating agent being water; and, accordingly, all the appearances characteristic of death from asphyxia or apnœa are present,—varying in intensity accord-ing to the manner of the death, whether it has or has not been attended with violent struggling. In addition, owing to the medium in which the death occurs, certain other signs specially characteristic of drowning are never absent.
By older authors a peculiar form of death by drowning was described, in which the appearances of asphyxia were awanting, and also the special signs of this form of death. To this the name of syncopal asphyxia was given. Hence, in treating of drowning, descriptions of these two forms were given, and in the case of bodies recovered from the water death was said to have occurred either from asphyxia or from syncope. Now, undoubtedly it often happens when persons fall or are thrown into the water that, in consequence of fright or of the shock sustained by violent con-tact with the surface of the water, no effort is made to save themselves, and death rapidly ensues from syncope. In such cases none of the characteristic signs of drowning are found, and, so far as the examination of the body is con-cerned, it is impossible to decide upon the exact cause of death. It is quite within the bounds of possibility that in such cases death may have been effected by other means, and the body have been thrown into the water to conceal the true cause of death.
No such uncertainty, however, attends the investigation of a case of drowning by true asphyxia, as it was called. The drowned individual struggles to reach the surface of the water in his efforts to respire ; as he does so he draws water into his windpipe which provokes cough. This expels the air from his lungs, and the water which threatened to suffocate him ; and as he sinks, in his struggles he endeavours again to respire, but now draws water into his mouth which chokes him, and can only be got rid of by swallowing. Insensibility then comes on, and death rapidly but placidly ensues from a true asphyxia.
If the body be recovered—say within two hours—it is relaxed, and generally presents a pallid appearance. The face is slightly congested, the features placid and composed. The lips are livid, and the tongue is either protruded from the mouth, firmly grasped by the teeth, or it is applied so closely to the dental arch that the various teeth leave along its edge a distinct imprint. Here and there on the surface of the trunk may be observed patches of lividity which cannot be accounted for by the usual gravitation of blood which takes place more or less in all forms of death. On the thighs the skin presents a roughened appearance, owing to the unusual development of the papillae, and to this the name of otitis anserina, or goose-skin, has been applied. Among the external signs which we are passing in review the state of the hands and fingers merits special attention. In his dying agonies the drowned individual spasmodically clutches for help in all directions ; and, should it be a pond or a canal with built retaining walls into which he has fallen, his nails may be injured, sand or mud may be found beneath them, and, firmly grasped in the hand, may be vegetable structures from the sides or the bottom of the pond; or, on the other hand, his fingers may present traces of recent injury.
Internally, the usual signs of asphyxia or apnoea are well marked. These are :—(1) A distended condition of the right cavities of the heart with dark fluid blood, while the left are well contracted, and are either empty or contain only a small quantity of dark-coloured blood. (2) The lungs are developed, and highly congested. On their tissue being incised, the cut surfaces on pressure give out dark-coloured blood and frothy mucus in large quantity. (3) There is congestion of the mucous lining of the air passages; and (4) dark colour and fluidity of the blood through the body.
Among the signs specially characteristic of this form of asphyxia we have:—(1) An unusual quantity of water in the stomach (amounting to one or two pints), which can only be accounted for by water having been swallowed during the last agonies of death. In many cases this cannot be determined with any degree of certainty, the fluid found in the stomach presenting no characters by which it can be positively identified as having formed a portion of the water in which the drowning occurred. In other cases, the fluid by certain characters, as its taste, can be determined to be sea-water, or from its containing some foreign substances, such as aquatic plants or insects, <fcc, can be identified as the water of the pond or river in which deceased was found. (2) Water in small quantity has been detected in the air-passages. But this, as we shall show, is a sign of little im-portance, and even in the most favourable circumstances one not easily observed. (3) A peculiar foamy froth presents itself in the throat and windpipe. The appearance of this froth is most striking.- It is of a silvery whiteness, and when closely examined is seen to be composed of an infini-tude of minute bullae of air. Its origin is easily explained. In the struggle for breath, mucus is poured out along the air passages in greatly increased quantity, and this, together with any water that may have entered, is churned up along with the air which is pent up in the windpipe. Where death has been attended with violent struggling this froth is poured out in great quantity, and may occupy the mouth and nostrils. It is a sign of great importance, as showing that the person was alive while in the water. It is, how-ever, apt to be confounded with a somewhat similar appearance in two other forms of death. When acute bronchitis proves fatal, the air-passages are filled with frothy mucus—'Which, however, differs in its external characters from the froth found in the drowned. It is not foamy, and the bullae of air are much larger. In addition the special signs of an acute disease of the bronchial tubes are present. In death occurring during a fit of epilepsy, frothy mucus is also often found in the windpipe, but in comparatively small quantity as compared with death by drowning, and the bullae are of larger size.
Of course when all the characteristic signs are present the evidence of drowning is so much the stronger; but it is quite possible, from the presence of a well-marked sign, to be certain as to the cause of death. A girl had fallen asleep during the night close to a stove in the cabin of a coal barge, Her clothes accidentally caught fire, and the pain of the burning quickly awoke her. In her desperation she rushed up the cabin stairs and threw herself into the water. In the morning her body was recovered consider-ably burned and covered with the charred dress. The conduct of the parties in the barge at the time was open to suspicion, and it was of importance to determine whether the body had not been thrown into the water after death. All the signs of death by drowning were well marked. The stomach contained water in considerable quantity, and floating on the surface of this fluid were two charred frag-ments of the dress. These must have been swallowed. The burnt dress was very friable, and portions of it similar to those found floating in the stomach broke away on the slightest touch. The surface of the canal in the immediate neighbourhood of deceased must, during her dying agonies, have been covered with these fragments, and the water which she swallowed happened to contain two of these fragments. Their presence clearly indicated that deceased was alive after she had reached the water. Again, cases have come under our notice, and many such are on record, where in the hand of the deceased have been found firmly grasped a bunch of aquatic vegetable structures which were known to grow only at the bottom of the pond in which the body was found.
Experiments on dogs show that complete immersion produces fatal asphyxia in four minutes, and in man from one to two minutes suffices to cause death. On the other hand, a certain amount of practice enables experienced swimmers to resist asphyxia; and it is related that in 1872 the champion swimmer of England, of the name of Johnson, remained under water for three minutes and ten seconds. It is also known that recovery has followed after an immersion of twenty minutes. In such cases it is to be presumed that the immersion was not complete. As to the sensations of the drowned, after the first struggle for breath, the brain becomes loaded with venous blood, and unconsciousness to external objects ensues. Captain Marryatt tells us that his sensations as he was drowning were rather pleasant than otherwise : " The first struggle for life once over, the water
closing round me assumed the appearance of waving green fields It is not a feeling of pain, but more like sinking down, overpowered by sleep, in the long soft grass of a cool meadow." (Life, vol. i. p. 74.) Hence drowning is a favourite death with suicides, in whom—resolutely bent, as they generally are, on self-destruction—the preliminary struggle is soon over. The presence of marks of violence is our only indication of homicide, and when these are absent the verdict of the medical jurist must be that the case is either one of suicide or of simple accident.
One circumstance, however, interferes with the recognition of the signs which we have passed in review, and that is the presence of putrefaction or decay. In consequence of death having occurred in such a medium as water, and as from the sinking of the body it is not exposed to atmospheric air, putrefaction in the colder months of the year proceeds slowly ; but in summer, owing to the rapid development of gas in all the soft structures of the body, but especially in the intestines, the body quickly comes to the surface of the water, and decomposition proceeds with great rapidity. All the canals of the body are relaxed, and the pressure of gas is such as to force the froth from the air passages, the water from the stomach, and the blood from the heart. " Almost never," says Devergie, the great authority on the effects of putrefaction in the drowned, " can the signs of drowning during life be determined in summer, so quick is the gaseous putrefaction." Hence, too great caution cannot be exercised by the medical jurist in giving a positive opinion in such cases.
It is remarkable that the progress of putrefaction in persons who have died by drowning should differ widely from that of the same process in other forms of death. In ordinary cases, the first signs of putrefaction manifest themselves in the lower parts of the abdomen. The rest of the trunk is attacked, then the extremities, and lastly the face. In drowning, on the contrary, the first part of the body to show evidence of decay is the face ; and in the course of a few hours, so rapid is the advance of the putrefactive process, that it becomes utterly impossible to recognize the features. Hence it is that it has been chiefly in cases of drowning that difficulties have arisen as to identification, in consequence of that part of the body by which persons are most readily recognized undergoing alteration so rapidly. Devergie, who, from his official connection with the Morgue at Paris, enjoyed unusual facilities for watching the various stages of putrefaction in the drowned, has carefully described them, and we now proceed to give a resume of his observations. The 1st stage includes a green discoloration of the skin, first noticed on the face and neck, which gradually extends over the body. The 2d is the evolution of gas, distending the abdomen, and causing chose changes to which we have already adverted. The 3d is that of brown putrefaction, which affects all the parts of the body previously coloured green. The 4th is that of putrilage. The discoloured parts soften, liquefy, and disappear. Under such circumstances the body rapidly decays, and the bones fall asunder. On the other hand, in cool weather the process of liquefaction is arrested, and the soft parts become solidified, owing to their conversion into adipocire, a peculiar kind of animal soap. To this stage— the 5th—Devergie gives the name of saponification. The 6th stage is termed desiccation, or drying, from the con-tinued removal of the fluids from the body, which, thus hardened, is liable, from the action of the elements, to undergo corrosion ; and at the same time long immersion leads to the formation of various incrustations. Devergie treats of these two conditions under the heads of corrosion and incrustation. In the 9th and last stage we have the destruction of the soft parts generally. In the liquid decomposition the part of the body first attacked was the face, and the same order is observed in the later stages— the soft parts of the face, now hardened by their transfor-mation into adipocire, fall off, and leave nothing but a grinning skeleton of a face behind, the rest of the body being comparatively perfect. This peculiar progress of the process of decomposition in the drowned explains the cases recorded of apparently decapitated heads, and of bodies consisting of headless trunks, having been found floating in the sea. These stages of the putrefactive process Devergie states do not follow any definite order or period of sequence, and each case demands careful investigation as to the con-dition of the body and the time of the year when the drowning occurred, but as the result of his experience he finds that the respective seasons of summer and winter make at least a month's difference in the period at which the earlier changes occur.
As to the treatment of the drowned, a complete revolu-tion has in recent times taken place in its details. To induce a renewal of the respiration it was formerly recom-mended that air should be forcibly introduced into the lungs by means of a pair of bellows, and, according to the older directions of the Humane Society, the body was " to be well shaken every ten minutes in order to render the process of animation more certain." These expedients proved singularly inefficacious except in cases where the other proposals of the society, such as rubbing and the application of warmth, would of themselves have procured recovery. In 1856 Dr Marshall Hall devised his ready method or postural treatment of the asphyxiated, and by dissections, and by actual results in cases of still birth and of drowning, proved that respiration could be imitated by simply changing the position of the body. Since then Dr R. Silvester has suggested a still more simple plan of postural treatment which, along with that of Dr Marshal] Hall, has been adopted by the Humane Society and also by the National Life Boat Institution, from whose published directions we give the modern treatment of the drowned by both methods, which is "in use in Her Majesty's Fleet, in the Coast-guard Service, and at all the stations of the British Army at home and abroad."
DIRECTIONS FOR RESTORING THE APPARENTLY DROWNED.
I. Send immediately for medical assistance, blankets, and dry clothing, but proceed to treat the patient instantly on the spot, in the open air, with the face downward, whether on shore or. afloat; exposing the face, neck, and chest to the wind, except in severe weather, and removing all tight clothing from the neck and chest, especially the braces. The points to be aimed at are—first and immediately, the restoration of breathing; and secondly, after breathing is restored, the promotion of warmth and circulation. The efforts to restore breathing must be commenced immediately and energetically, and persevered in for one or two hours, or until a medical man has pronounced that life is extinct. Efforts to pro-mote warmth and circulation, beyond removing the wet clothes and drying the skin, must not be made until the first appearance of natural breathing ; for if circulation of the blood be induced before breathing has recommenced, the restoration to life will be endangered.
II.—To RESTORE BREATHING.—To clear the throat.—Place the patient on the floor or ground with the face downwards, and one of the arms under the forehead, in which position all fluids will more readily escape by the mouth, and the tongue itself will fall forward, leaving the entrance into the windpipe free. Assist this operation by wiping and cleansing the mouth. If satisfactory breathing commences, use the treatment described below to pro-mote warmth. If there be only slight breathing—or no breathing— or if the breathing fail, then—
FIG. 1.—Inspiration (Dr Marshall Hall's method).
To excite breathing—Turn the patient well and instantly on the side, supporting the head, and excite the nostrils with snuff, harts-
FIG. 2.—Expiration (Dr Marshall Hall's method).
horn, and smelling salts, or tickle the throat with a feather, &c. if they are at hand. Rub the chest and face warm, and dash cold water, or cold and hot water alternately, on them. If there be no success, lose not a moment, but instantly—
To imitate breathing—Replace the patient on the face, raising and supporting the chest well on a folded coat or other article of dress. Turn the body very gently on the side and a little beyond, and then briskly on the face, back again, repeating these measures cautiously, efficiently, and perseveringly, about fifteen times in the minute, or once every four or five seconds, occasionally varying the side. (By placing the patient on the chest, the weight of the body forces the air out; when turned on the side, this pressure is removed and air enters the chest.) On each occasion that the body is replaced on the face, make uniform but efficient pressure with brisk move-ment on the back between and below the shoulder-blades or bones on each side, removing the pressure immediately before turning the body on the side. During the whole of the operations let one person attend solely to the movements of the head and of the arm placed under it. (The first measure increases the expiration—the second commences inspiration.) The result is respiration or natural breathing, and, if not too late, life.
Whilst the above operations are being proceeded with, dry the hands and feet, and as soon as dry clothing of blankets can be procured, strip the body, and cover or gradually reclothe it, but taking care not to interfere with the efforts to restore breathing.
FIG. 3.—Inspiration (Dr Silvester's method).
III. Should these efforts not prove successful in the course of from two to five minutes, proceed to imitate breathing by Dr Silvester's method, as follows :—Place the patient on the back on a flat surface, inclined a little upwards from the feet; raise and support the head and shoulders on a small firm cushion or folded article of dress placed under the shouldei'-blades. Draw forward the patient's tongue, and keep it projecting beyond the lips ; an elastic band over the tongue and under the chin will answer this purpose, or a piece of string or tape may be tied round them, or by raising the lower jaw, the teeth may be made to retain the tongue in that position. Remove all tight clothing from about the neck and chest, especially the braces.
FIG. 4.—Expiration (Dr Silvester's method).
To imitate the movements of breathing—Standing at the patient's head, grasp the arms just above the elbows, and draw the arms gently and steadily upwards above the head, and keep them stretched upwards for two seconds. (By this means air is drawn into the lungs.) Then turn down the patient's arms, and press them gently and firmly for two seconds against the sides of the chest. (By this means air is pressed out of the lungs.) Repeat these measures alternately, deliberately, and perseveringly, about fifteen times in a minute, until a spontaneous effort to respire is perceived, imme-diately upon which cease to imitate the movements of breathing, and proceed to induce circulation and warmth.
IV.—TREATMENT AFTER NATURAL BREATHING HAS BEEN RE-STORED. To promote warmth and circulation—Commence rubbing the limbs upwards, with firm grasping pressure and energy, using handkerchiefs, flannels, &c. (By this measure the blood is propelled along the veins towards the heart.) The friction must be centinued under the blankets or over the dry clothing. Promote the warmth of the body by the application of hot flannels, bottles, or bladders of hot water, heated bricks, &c, to the pit of the stomach, the arm-pits, between the thighs, and to the soles of the feet. If the patient has been carried to a house after respiration has been restored, be careful to let the air play freely about the room.
On the restoration of life, a teaspoonful of warm water should be given ; and then, if the power of swallowing have returned, small quantities of wine, warm brandy-and-water, or coffee should be administered. The patient should be kept in bed, and a disposition to sleep encouraged.
GENERAL OBSERVATIONS.—The above treatment should be per-severed in for some hours, as it is an erroneous opinion that persons are irrecoverable because life does not soon make its appearance, persons having been restored after persevering for many hours. The appearances which generally accompany death are the follow-ing :—breathing and the heart's action cease entirely ; the eyelids are generally half closed, the pupils dilated; the tongue approaches to the under edges of the lips, and these, as well as the nostrils, are covered with a frothy mucus ; coldness and pallor of surface increase.
The following cautions should be attended to:—Prevent unneces-sary crowding of persons round th body, especially if in an apartment. Avoid rough usage, and do not allow the body to remain on the back unless the tongue is secured. Under no circumstances hold the body up by the feet. On no account place the body in » warm bath unless under medical direction, and even then it should only be employed as a momentary excitant.
Dr Silvester's method is more generally practised than that of Dr M. Hall,—its special advantages being that it com-mences by imitating inspiration, and more completely distends the chest. But we are of opinion that the combina-tion of the two methods as recommended above should undoubtedly be practised in every case.
It has frequently been pointed out that in fatal cases of drowning the right auricle of the heart is very much dis-tended ; and it has been plausibly urged by Professor Struthers of Aberdeen (Edinburgh Medical Journal, 1857, p. 418) that the movements of respiration may be successfully imitated, and air may enter the lungs, and yet the patient may not recover in consequence of the stoppage of the action of the heart. He recommends that blood should be drawn from the external jugular vein, so as to relieve the engorged auricle, which, from its distension, is paralyzed. The abstraction of a small quantity of blood is all that is required to effect this—from half to one or two table-spoonfuls. Finally, as a last resource, galvanism must be had recourse to. Both this and the blood-letting must be practised by a qualified medical man ; but it is important to know that the methods of Dr Hall and Dr Silvester can easily be learned by any one, and that, if early and perseveringly applied, they are attended with a large measure of success. The treatment must be continued for at least eight hours, should there be an absence of extreme pallor, and while any heat of the body remains.
The question of the treatment of the drowned cannot be regarded as definitely settled, and the plans of Hall and Silvester have from time to time been subjected to criti-cism. Among the latest suggestions is that of Dr B. Howard of America, who, by means of what he terms his " direct" method, which mainly consists in pressure of the chest from above (the patient being placed on his back), claims that air is more easily introduced into the lungs, and that the expansion and contraction of the chest are more perfectly attained (see Lancet, August 11, 1877). At the meeting of the British Medical Association at Man-chester 1877, Dr Howard practically demonstrated his plan on the living subject, and there can no doubt that involuntary respiration was readily produced. Further evidence, however, is necessary from actual cases of sus-pended animation.
See the treatises on Medical Jurisprudence by Devergie, Orfila, Caspar, Taylor, Guy, and Woodman and Tidy; article " Apncea," by G. Harley, M. D., in vol. v. of Holmes's Surgery, 2d edition, pp. 889; and Report on Asphyxia by Committee of the Royal Medical and Chirurgical Society of London, in vol. xlv. of Transactions, 1862. (H. D. L.)