restore animation. On the contrary, the means should be applied without delay, even to bodies which have remained so long in water as to afford but little hope of ultimate recovery. Devergie states that it has been found impossible to restore some who had not been entirely submerged for more than a minute, even when the bodies were removed with all the warmth and pliancy of life about them; but, on the other hand, persons have been resuscitated who, there was reason to believe, had been entirely submerged for five minutes. Many of the reported recoveries have no doubt been cases of the resuscitation of persons who had not been entirely submerged, i.e. whose heads were not entirely below water for the period alleged. In most of the recorded instances of recovery after alleged protracted submersion, the evidence has rested upon the loose statements of ill-informed persons.

Woolley, for many years medical officer to the Royal Humane Society, met with in the Society's records only two cases of recovery after five minutes' submersion. In the Report of the Society for 1840 there are two cases of recovery after a minute and a half, and two after three entire minutes' submersion. A boy recovered after a submersion of from five to ten minutes: another is reported of a girl, aged two years, after ten minutes' immersion. (Lancet,' July, 1841.) It is not certain whether the head of the child was under water during the whole of this period. A case of recovery occurred after six minutes' alleged submersion ('Med. Gaz.' vol 29, p. 78), and in another there was partial recovery after a submersion, it is supposed, of at least eight and probably thirteen minutes. A man is stated to have recovered after having been fourteen minutes under water, but the time was not determined by actual observation. (Ibid. 31, p. 448.) The longest case recorded, with any claim to authenticity, is one in which a woman is stated to have recovered by prompt treatment after a submersion of twenty minutes. (Am. Jour. Med. Sci.' Ap. 22, 1853, p. 348.) In the author's experiments it was found that an animal could not be restored after its body had been entirely submerged for a period of four minutes; and in one instance, a stout healthy man, who had been submerged five minutes, could not be restored, although he was submitted to treatment very soon after his removal from the water. It has been a general opinion that so long as any spontaneous movement of the heart continues there is a chance of recovery, but this strictly applies to the rhythmical pulsations, and not to the mere convulsive movements of the organ. Brodie states, as the result of his observations on animals, that the rhythmical pulsations cease in from four to four and a half minutes after submersion, and that no animal recovered after these had once ceased, although some convulsive movements of the heart manifested themselves for a longer period. (Med. Chir. Trans.' 1861, vol. 44, p. 149.) These facts lead to the conclusions, that in drowning life is very rapidly destroyed; that the time within which a person may be resuscitated is subject to variation; but that after five minutes' complete submersion there can be little hope of success by any method of treatment, and even then our efforts would probably fail unless the treatment were commenced immediately on the removal of the body from water. Guérard quotes a case in which a young man is said to have recovered after entire submersion for an hour. This case is reported to have occurred in 1774, but the evidence on the time of submersion is not satisfactory. (Ann. d'Hyg.' 1850, 2, 306.)

These views are in accordance with the experimental results obtained by a Committee of the Medico-Chirurgical Society. (Rep. on Suspended Animation, Med. Chir. Trans.' 1862, p. 449.) Thus it was found by the Committee that four minutes' complete submersion in water effectually killed dogs, although after removal from water the heart continued to beat

RECOVERY AFTER SUBMERSION.

7

from four to five minutes. The continuance of the heart's action furnishes, therefore, no criterion of the power of recovery.

A submersion of a minute and a half was found sufficient to destroy the life of a dog. After only one minute's submersion—or with a large dog after a submersion for a minute and a quarter-the animal recovered almost immediately on removal from the water. Other experiments showed that in asphyxia from simple privation of air a dog would recover after four minutes' suspension of breathing; but as in drowning a minute and a half was sufficient to destroy life without any sign of recovery, it was obvious that some additional cause was at work to render drowning more speedily fatal than ordinary suffocation. This was found not to be owing to exhaus tion from struggling, after the violent efforts made to breathe, nor from the effect of cold in immersing the whole of the body, but to the introduction of water by aspiration into the minute air-tubes and cells of the lungs. Two dogs of the same size were submerged at the same moment, but one had his windpipe plugged, so that neither air nor water could enter; while the other had the windpipe open. At two minutes they were taken out together: the one with the windpipe plugged recovered at once, the other died. In three experiments dogs with their windpipes plugged were kept below the water for four minutes: the animals recovered perfectly when removed from the water. (Report, p. 459.) An inspection of the bodies at once revealed the cause of the difference. In animals simply deprived of air by plugging the windpipe, the lungs were merely congested; but in those which were submerged in their ordinary condition, the lungs, besides being more congested and showing ecchymosed points on the surface and in the substance, contained in their bronchial tubes a bloody mucous froth, formed of water, blood, and mucus, completely filling the small air-tubes. The respiratory efforts made by the animal before death had caused the production of this froth, which formed a mechanical impediment to the entrance of air by the movements of the chest, as in respiration. The mucous froth or foam issued from the lungs on section, and appeared to penetrate their entire substance, which was saturated with water tinged with blood. The lungs were sodden with water, heavy,.soft, and doughy, so that they retained an impression produced by the finger and were incapable of collapsing. In the lungs of animals which recovered after a short submersion, little or none of this mucous froth was found in the aircells. In the fatal cases the quantity was great in proportion to the time of submersion. There is no doubt that it is produced by the violent efforts to breathe which are made within a minute after submersion.

It may be inferred from these results, that the power of recovery in human beings has a direct relation to the presence of the mucous froth in the air-tubes, and to the penetration of the substance of the lungs with water. The larger the amount produced, the less the hope of recovery; for when the lungs have undergone these changes they are physically unfitted either to receive or expel air by respiration, and they are incapable of collapsing. Hence it is that a state of syncope is favourable to recovery, as in this condition there are no violent efforts at respiration when the head is below the surface of the water. In one case, a girl recovered after having been six minutes under water; but it appeared in evidence that she had fallen into the water in a state of syncope. ('Med. Chir. Trans.' 1846, 44, 149.)

Treatment.-The facts above mentioned have a close relation to the treatment of the drowned. The subject is hardly of a medico-legal nature, but occasionally questions have arisen at coroners' inquests in reference to the propriety of the treatment adopted by a medical practitioner. When it is stated that conflicting methods have been apparently equally success

ful-that the warm bath and frictions, as well as artificial inflation of the lungs by various appliances, have each succeeded with some, and failed in the hands of others-it will be perceived that there is great difficulty in making a selection or laying down rules. Artificial inflation of the lungs appears à priori to be the proper plan for resuscitation; but when we consider the physical state of these organs in those who have struggled much and have made violent efforts to breathe while under water, it will be obvious that the lungs are frequently not in a condition either to receive or to expel air. In a remarkable case of recovery after fourteen minutes' submersion (Med. Gaz.' vol. 31, p. 449), warmth and friction were the only means employed. Inflation of the lungs was tried, but not persisted in, because it did not appear to be attended with any good effect. Artificial inflation in some form is now, however, generally employed, in addition to the application of warmth and stimulating frictions to the skin. The Committee of the Medico-Chirurgical Society, discarding the use of apparatus which is rarely at hand when most required, recommends the method of inflating the lungs suggested by Silvester, in which the action of the pectoral and other muscles passing from the shoulders to the parietes of the chest in deep inspiration, is imitated. An inspiratory effort is induced by extending the arms upwards by the sides of the head: on restoring them to their original position by the sides of the body, the expanded walls are allowed to resume their previous state, and expiration takes place, the quantity of air expelled being in proportion to that which had been previously inspired' (Report, p. 468). This plan, as below, has been adopted by the Royal Humane Society, the Committee having demonstrated by experiment that it is superior to the method recommended by Marshall Hall, inasmuch as it commences with the act of inspiration, while the latter begins with expiration, and it more completely fills and empties the air-cells of the lungs :-1. Remove from the neck and chest all articles of clothing; 2. Wipe the body dry, and cover it with dry clothes; 3. Clear the nostrils, month, and throat of all mucous froth, or of substances likely to interfere with free respiration: pull forward the tongue, and keep it in this position, so that it may not fall back and cover the opening of the windpipe; 4. Place the body at full length with the face downwards, the forehead resting on one arm: this is for the purpose of allowing all fluids to flow readily out of the mouth; 5. Ammonia, aromatic vinegar, snuff, or other stimulants, may be cautiously applied to the nostrils; and 6. If respiration is not quickly restored spontaneously, then the body should be placed upon its back, with the head slightly raised. The arms should be gently carried outwards and upwards from the chest, raised above the head, and maintained in this position for about two seconds. By this movement air penetrates into the lungs as during the act of inspiration. The arms are now lowered and brought closely to the sides of the chest, by which expiration is effected. Pressure on the lower part of the chest-bone (sternum) aids this expiratory action. This movement should also occupy two seconds. These alternate movements of the arms may be repeated from twelve to fourteen times in a minute. All rough handling should be avoided. So soon as any spontaneous respiratory action is observed, warmth may be applied to the skin by the warm bath or otherwise, and stimulating frictions may be used, or simple frictions with warm flannels, &c. Heat should be applied especially to the region of the heart, the loins, soles of the feet, and palms of the hands. When the power of swallowing returns, warm water, alone or with a little brandy as a stimulant, may be given. The patient should then be placed in bed and allowed to sleep.

This treatment should be persisted in for some hours, except in those

HOWARD'S METHOD OF ARTIFICIAL RESPIRATION.

9

cases in which the body has been long under water, and is taken out cold and rigid. In the case in which there was recovery after fourteen minutes' immersion, there were no signs of returning animation until after the treatment had been carried on for eight and a half hours. The tendency to restoration is indicated by the occurrence of slight flushing in the face, convulsive twitchings in the facial muscles, warmth of the skin, gasping or sobbing respiration at intervals, and sometimes convulsive movements of the body and limbs. The unfavourable signs are these:-complete insensibility, coldness and paleness of the body, no spontaneous act of respiration, entire absence of pulsation in the region of the heart, the eyelids half-closed, the pupils dilated, the lower jaw stiff, the fingers half-bent inwards, and the mouth and nostrils containing mucous froth, which is continually escaping from them. In a large proportion of all cases of recovery after submersion, the act of respiration in the form of sobbing, sighing, or gasping commences spontaneously soon after the person has reached the air, and the only treatment then required is not to interfere with this natural action of the chest. Whatever may be the plan adopted under such circumstances, if recovery take place it is accredited with the favourable results. This is probably the explanation of the fact that means which have succeeded in the hands of one operator have failed in those of another. In the latter case the lungs of the patient were probably in a state unfitted to receive air, and the patient was therefore beyond the reach of any treatment. Cases in which the submersion has been short, the respiratory struggles below water slight, and the treatment is applied immediately on removal from water, may be expected to recover; but under opposite conditions recovery is, with rare exceptions, hopeless. In Paris, from 1821 to 1826, out of 570 cases of drowning it is stated that 430 were resuscitated.

In 1878, Howard, of New York, introduced an improved method of artificial respiration, which is thought by some to present advantages over any of the methods previously employed. ('Guy's Hosp. Gaz.' 1878, p. 42.) To remove the fluid from the throat and stomach, the patient is stripped to the waist, and then placed on the face, with a firm pad-e.g. his coat rolled up-beneath the region of the stomach, matters being so arranged that the mouth is the lowest part of the tract along which the fluid has to pass. The operator now gets above the patient, and placing one hand over the stomach, and the other slightly lower down, throws his whole weight upon him suddenly, at the same time exerting pressure with his hand in an upward direction-both drainage and ejection being thus efficiently produced. To remove obstruction from the mouth and throat, the tongue is drawn forwards by means of a piece of cotton cloth, and held protruded at either angle of the mouth. A bystander may relieve the operaor of the charge of the tongue. The patient is now turned on his back, a firm pad being placed under the region of the stomach, and the head being the most dependent part. The tongue is kept protruded, as already explained, and the neck is now extended backwards, so that the whole respiratory tract is as open and free as possible. The operator then seizes the patient's wrists, bringing them back above the head until they cross each other, the arms being held in this position by a bystander, or fastened in some manner. To effect expiration, the patient being placed in the last position, compression is made by kneeling astride the patient, and placing the balls of the thumbs so that the fingers fall into the spaces between the ribs near the sternum. The hands being then kept as a fixed point, the operator throws his whole weight downwards, whilst he slowly counts three, increasing the pressure. He then suddenly springs back into his former position, inspiration being

now heard to occur with an audible blowing sound. The process is less fatiguing than either that of Silvester or that of Marshall Hall.

It is unnecessary in this place to describe in detail the method for restoring respiration recommended by Marshall Hall. It has been shown by experiment that it is less adapted to the intended purpose than the plan recommended by Silvester. It does not allow of the introduction of a sufficient quantity of air into the lungs, nor, if introduced, does it provide for its proper expulsion from them. (For a medico-legal examination of these methods of treatment, the reader is referred to a paper by Tardieu, in the 'Ann. d'Hyg.' 1863, 1, p. 312; and 1865, 2, 209; also to the Med. Times and Gaz.' 1861, 1, p. 131.)

Death from secondary causes.-Drowning may operate indirectly as the cause of death. Thus it has been repeatedly remarked that persons who have been rescued from water in a living state, and who have apparently recovered from the effects of submersion, have died after the lapse of some minutes or hours: others have lingered for one or two days, and then have sunk apparently from exhaustion. In those who perish soon after removal from water, death may arise either from exhaustion or from the obstruction of respiration by the penetration of water into the air-cells of the lungs. In one case death was clearly owing to the secondary effects of submersion. The deceased was removed from the water and conveyed to the hospital. He was cold and insensible, but he breathed tolerably well, and had a fair pulse. In about three hours he became conscious, and spoke a little. The insensibility subsequently returned, accompanied by great difficulty of breathing, and he died in abont twenty hours from the time of submersion. Marcet states that spasm of the glottis has been among the secondary symptoms in those who have been removed from the water apparently drowned. A severe spasm of this kind manifested itself in one case while placing the person in a warm bath. (Med. Times and Gaz.' Feb. 1857, p. 148.) When death takes place at a remote period, it may be caused by disease; and a question will then arise, whether the disease was produced by the immersion in water or not. Such cases occasionally present themselves before the Courts. In one of these (Reg. v. Pulham, Gloucester Sum. Ass. 1845), the prisoner was charged with the death of the deceased by pushing him into a pond of water, from the effects of which he died. The deceased was an old man; he was taken out of the water in an exhausted condition, and died a few weeks afterwards. One medical witness referred death to the effects of the immersion; but as he had not seen the deceased after the violence, and there was no clear account of the cause of death, the prisoner was acquitted. In most of these cases it will be found exceedingly difficult to connect death with the immersion, when the fatal result does not take place until after so long a period of time. As the basis of medical evidence, we must rely upon the nature of the disease alleged to have been caused by the immersion-i.e. inflammation of some cavity or organ, and its progress until death without intermediate recovery or interference by improper treatment.

POST-MORTEM APPEARANCES.

In conducting the examination of the body of a drowned person, it is necessary to remember that the external and internal appearances vary much, according to the length of time during which the body has remained in water, or the period that has elapsed after its removal and before it is examined. Thus, in reference to the bodies of two persons drowned by a common accident, if one is examined immediately, and the other is not removed from the water until after the lapse of several days, and is then inspected, the appearances will be different. So, if two bodies are