This term usually signifies the extinction of life by total submersion; but it ought also to be applied to that species of suffocation which is produced by the exclusion of atmospheric air from the lungs by any liquid; for the effects produced in all such cases are similar. Drowning, therefore, may be considered as having taken place when the animal perishes from immersion of its head, or even from the obstruction to the air passages by a fluid.
The ordinary phenomena of drowning may be witnessed by submerging a small animal in a glass vessel filled with water. The animal at first struggles violently, and is soon observed to make a forcible expiration, as is indicated by the escape of bubbles of air from its mouth and nose. It next attempts to inspire; an effort marked by the strong heaving of its thorax, and convulsive efforts of its abdominal muscles. This effort is vain, and is speedily followed by the extrication of a few more air bubbles from its lungs. These convulsive motions are repeated at shorter intervals, while smaller portions of air are forced from the lungs at each succeeding expiration, until the air cells are deprived of a considerable portion of the air they contained at the moment of submersion. Insensibility soon comes on; but convulsive movements of the limbs mark the progress of cerebral congestion, and the influence of unoxigenated blood on the centre of the nervous system.
After these struggles, the animal is apparently dead; but a feeble motion may still be perceived in the chest; and before it ceases altogether, the muscles of the thorax are once more thrown into action by an ineffectual effort to breathe. Brodie has remarked, that in drowning, the action of the heart and diaphragm cease almost at the same instant. Unless the animal be removed from the water before the movements of the heart and diaphragm have entirely ceased, it perishes, and a minute or two more are sufficient to destroy it. If the animal be removed from the water while the heart and diaphragm are yet in action, it may escape from the immediate risk of suffocation, but yet may die from injury to the brain produced by congestion of dark blood on that organ. Bichat, Cruickshank, and Brodie, have proved, that dark unoxigenated blood acts as a poison on the brain, causing diminished nervous energy, laborious respiration, feeble pulse, dilated pupils, stupor, and convulsive twitches of the voluntary muscles.
Signs of death from drowning.—The signs of death from drowning are external and internal. 1. The external signs most usually perceived are either a very pale countenance, or the face bloated and livid; the lips, and not unfrequently the whole head, swelled; the eyes half open, and the pupils much dilated; the tongue swelled, and protruded between the teeth, so as to be in contact with the inner surface of the lips; the lips and nose often lined with a whitish froth; the chest and epigastrium tumid, Drowning, and much arched; the ends of the fingers usually excoriated; and the spaces under the nails often filled with sand or mud. 2. The most usual internal signs are more or less cerebral congestion; but in some cases no morbid change appears in the brain. We usually find the blood in the vessels of the head, and indeed in the whole body, of a blackish colour. There is generally frothy mucus in the trachea, which is sometimes tinged with blood; the lungs are dilated and gorged with blood; the diaphragm descends low into the abdomen, and has lost more or less of its concave surface towards that cavity. The right cavities of the heart, and the great vessels connected with it, are gorged with black blood, whilst the left side and its vessels are usually found empty. The blood in the body always remains fluid, and readily flows wherever an incision is made. Water is sometimes found in the bronchial tubes and cells of the lungs; and not unfrequently some water has been swallowed in the act of drowning. These symptoms will generally enable us to detect a death from drowning, if we examine the body before putrefaction is advanced.
The immediate cause of death from drowning has given rise to much controversy; and physiologists have appealed to contradictory experiments and observations in support of their different hypotheses. But this difference of opinion has originated in physiologists supposing that the suspension of the vital functions on submersion always depended on the same proximate cause. It is singular that the very dissimilar appearances which the face presents in different cases did not suggest some difference in the cause of death. In some drowned persons, the face is remarkably pale, and rather pinched; in others, the countenance is livid, and the whole head swelled; the first indicating the deficiency of blood in the head, the latter its redundancy. This led Dr Desgranges to the conclusion that there were two different modes in which drowning proved fatal.
The first, which he terms nervous or syncopeal asphyxia, occurs when the person, either from the terror of impending fate, the effect of surprise, or from the sudden immersion in extremely cold water, faints at the instant of immersion. The instantaneous arrestation of the movements of the heart in such cases prevents the transmission of unoxigenated blood to the brain; the principle of life is merely suspended; the resources of the animal machine are not destroyed, but are capable of being again called into action by suitable means. The second Desgranges terms asphyxia by suffocation. In this species the heart continues to act for some time after respiration is impossible. The brain thus becomes loaded with black or unoxigenated blood, which is known to act as a direct sedative or a poison on that delicate organ. When this has gone on for a short time, its functions are annihilated, and cannot be restored when the body is again exposed to atmospheric air. In this second species water often finds its way into the air tubes, and even into the cells of the lungs, during the vain efforts of the individual to breathe.
These distinctions are important, will serve to explain most of the anomalies which have been observed as effects of submersion, and render probable the very extraordinary instances of resuscitation after long-continued submersion, which have been related by men worthy of credit, but which have appeared marvellous to those whose ideas of drowning are founded on a few experiments made on the lower animals forcibly submerged.
Amongst individuals who have recovered from insensibility induced by long submersion, by far the majority are those who have been affected by syncopeal asphyxia, in whom there has been instantaneous arrestation of the mo- Drowning.
Drowning: tion of the heart, and suspension of consciousness. This distinction will enable us also to explain why, when several persons are submerged together, some will be found quite irrecoverable; whilst others, who have been considerably longer under water, may be capable of resuscitation.
The recovery from syncopal asphyxia is well illustrated by a case given by Plater. A female, condemned for infanticide, was inclosed in a sack, according to the provisions of the Caroline Code of Germany, and thrown into a lake. She fainted at the moment of immersion; and, after having been under water for a quarter of an hour, was drawn out and restored to life.
Pouteau relates the history of a man at Lyons, who suddenly fell into a river covered with ice, and remained submerged for three hours, yet was restored to life by the long-continued assiduity of his medical attendant. Morgagni mentions the case of a man who was resuscitated after having been under water for half a day; and Pecklin relates the instance of a Swedish gardener, who was submerged in a frozen pond for sixteen hours, and yet was recovered by similar means.
In all such cases, Desgranges conceives that the capability of recovery is to be attributed to the sudden arrestation of the vital motions at the moment of immersion. The action of the heart and of the lungs ceasing simultaneously, no vitiated blood could be transmitted to the brain. A stop would at the same time be put to all secretions and excretions, so that there could be no expenditure of vital power. How long this suspension might continue without extinction of vitality, is unknown; but something resembling it occurs in some long-continued paroxysms of hysteria, and in persons who have for several days lain apparently dead, but have been resuscitated.
Drowning has been ascribed to water finding its way into the stomach and air passages; but this opinion was proved to be fallacious by Senac and Cullen. The former denied that water ever entered the lungs; but Morgagni showed that it actually does sometimes enter the air cells; and he ascribes the frothy mucus found in the fauces and air tubes to the intermixture of air with that water. The opinion of Morgagni on this last point is, however, incorrect; for the froth is found in many cases of asphyxia from noxious gases in epilepsy and apoplexy; and in the recent experiments of Dr M. Hall, it was observed in dogs that had been bled to death. It appears to be produced by the escape of air from the lungs mixing with the natural mucus lining the air passages, and indeed is common to all cases of laborious respiration. Goodwyn and Cullen showed the insufficiency of the water which finds its way into the lungs in drowning to cause speedy death.
The excoriation of the ends of the fingers is produced by the person endeavouring to save himself by catching at the bottom, or the first solid which meets his hands; and the sand and mud under the nails have the same origin. In fact, we are, by these marks, often able to discover whether a person has been drowned, or thrown into the water after death. The tumid state of the chest, and descent of the diaphragm into the abdomen, are caused by the violent efforts made to dilate the chest, for the relief of the sense of suffocation. The fluidity of the blood is remarkable, and seems almost universal in drowning. This appearance takes place wherever death is caused by the exclusion of oxygen, or when the blood does not undergo the usual changes in the lungs.
Treatment of drowned persons.—Various directions have been given for the treatment of persons who have been found in a state of asphyxia from submersion. The subject claimed the especial attention of De Haen, of John Hunter, and Cullen, each of whom have made many judicious remarks on the best means of restoring animation; and the Humane Society of London have published twelve general rules for the recovery of drowned persons, which are, on the whole, useful, although some of them are now obsolete, and require emendation.
The principal objects in such cases should be,
1st. To restore or keep up the animal heat. 2d. To induce a renewal of respiration. 3d. To rouse latent animation by the exhibition of stimuli.
1. As soon as the body is removed from the water, the wet clothes should be taken off, and the body rolled in warm blankets or dry clothing, while it is transporting to the nearest house. The body should be carried in the arms of men, or on a bier, with celerity, but without jolting, to a room which, in hot weather, should have the windows open, but in winter should have a fire. The head, during the transporting, should not be suffered to hang down, but be laid in an easy position. When brought into the apartment in cold or damp weather, the body should be laid on a mattress before a fire, when the surface is to be diligently rubbed with dry warm flannel, both to dry the surface, and to rouse the excitability of the capillaries. Whilst this is going on, it is important to permit the free access of warm air. No more persons should be present than are useful about the patient; and the Humane Society limit the number to six. Sometimes the body has been placed in warm water; but this practice is objectionable. Some recent experiments have rendered it more than probable that the influence of the free application of air to the general surface of the body is not unimportant in restoring animation in cases of asphyxia; and the cutaneous circulation is more readily induced by dry and diligent frictions of the surface than by immersion in warm water. Applications of bags of hot sand, bran, or the like, to different parts of the body, as the arm-pits, scrobiculus cordis, and extremities, are obvious means of restoring animal heat not to be neglected; and in some instances much benefit seems to have been derived from switching the soles and palms with twigs, or striking them with the open hand. Whilst these means are being employed, we must not neglect the important object, viz.
2. The restoration of respiration, by insufflation of the lungs. The best and simplest mode of effecting this object is, to introduce the nozzle of a pair of common bellows into one nostril, whilst the operator closes the other nostril and the mouth with his left hand, and applies his right to the thyroid cartilage, pressing it gently backward, in order to shut up the esophagus, and prevent the air entering the stomach instead of the lungs. The bellows should be wrought by an assistant, so as moderately to inflate the chest. A third person is to press the chest with his hands, to expel the air. These motions are to be alternated, so as to imitate natural breathing as much as possible. This mode of insufflation is much preferable to the proposal of introducing a tube into the glottis, and still more so to the hazardous operation of tracheotomy, which never can be necessary in a case of simple drowning, and which, even in the hands of the celebrated surgeon Mr Justamond, proved fatal, by permitting the infiltration of blood into the air passages.
When a sufficient supply of oxygen gas can be obtained, it would probably expedite recovery; but perhaps it should not in general be employed undiluted. Where a pair of bellows cannot be obtained, the life of a person may be saved by introducing any sort of pipe into the nostril, as above directed, and blowing air from the mouth of the operator into the lungs of the drowned person. In this case, care should be taken not to use the air from the lungs of the operator, but merely that which his mouth In the directions of the Humane Society, we read (art. 10) that the body, especially if the subject be a child, "is to be well shaken every ten minutes, in order to render the process of animation more certain." This practice is justly condemned by most modern authors, as either useless or dangerous. All the benefit of "shaking" may be obtained by frictions and switchings, without the risk of extinguishing the feeble remains of animation by rude concussions, "pullings, and pushings," which have been generally employed in cases of asphyxia. It is scarcely necessary to caution the practitioner against the exploded practice of hanging the drowned person by the heels, or laying him across a barrel with his head hanging downwards; a practice of which even Fothergill approves, on the principle of making him disgorge the water that might have found its way into the stomach and lungs, which was erroneously imagined to be the chief cause of suspended animation.
3. The application of various stimulants internally and externally, to facilitate resuscitation, is limited, but not unimportant. The vapour of ammonia, to irritate the Schneidarian membrane of the nose, has been generally adopted, and is useful in rousing the dormant excitability. When a tube can be introduced into the stomach, a portion of warm spirit and water, with or without ammonia, will generally be useful. The introduction of warm stimulants by the arms is likewise desirable, both to rouse the latent powers of life by their stimulant effect, and to restore the animal heat.
The eighth rule of the Humane Society recommends the injection of tobacco smoke into the fundament. This practice was borrowed from the savage Indians of North America; but it is of very questionable utility. The excessive faintness produced by this strong narcotic is a great objection to its employment in cases where the powers of life are already too low; and we have abundant means of exciting the peristaltic motion of the alimentary canal, by aloetic and other warm purgatives, without running the risk of extinguishing the feeble remains of vitality by the introduction of a narcotic. The objection is still stronger to infusions of the plant, which have also been recommended.
The application of Voltaic electricity bids fair to aid resuscitation, especially if not used too strong. It has a powerful effect in rousing the voluntary muscles, but its influence on the heart is doubtful. Yet there can be no doubt of its capability of stimulating the diaphragm and abdominal muscles, to cause the dilatation of the chest; and its application to the parts of the body most suitable for this end, as about the lower ribs and the pit of the stomach, should be tried. Common electricity is less suited to this purpose; but neither should be passed through the head, lest the excitability of the nervous system should be exhausted by so powerful and general a stimulant.
Blood-letting was reprobed by John Hunter; and in cases of drowning, when there are marks of syncopeal asphyxia, it will probably prove injurious; but when there are decided marks of cerebral congestion, venesection under the direction of a medical practitioner will facilitate recovery.
These methods of resuscitation should be diligently employed for four or five hours at least, before the case is given up as hopeless. It is a vulgar and a dangerous error to suppose that because our efforts do not seem successful for one or two hours, that the patient is irrecoverably dead. There are instances of persons submerged, in whom no symptoms of returning animation have been obvious until after four, or even six hours of unremitting efforts.