A CASE OF DROWNING, WITH RESUSCITATION.

By F.A. BURRALL, M.D., New York.

As is usual at this season, casualties from drowning are of frequent occurrence. No class of emergencies is of a more startling character, and I think that a history of the case which I now present offers some peculiar features, and will not be without interest to physicians.

The accident which forms the subject of this paper occurred August 29, 1890, at South Harpswell, Casco Bay, Me., where I was passing my vacation.

At about 9.30 A.M., M. B——, an American, aged eighteen, the son of a fisherman, a young man of steady habits and a good constitution, with excellent muscular development, and who had never before required the aid of a physician, was seen by the residents of the village to fall forward from a skiff into the water and go down with uplifted hands. I could not learn that he rose at all after the first submersion. Two men were standing near a bluff which overlooked the bay, and after an instant's delay in deciding that an accident had occurred, they ran over an uneven and undulating pasture for a distance of two hundred and fifty paces to the shore. One of them, after a quick decision not to swim out to where the young man had fallen in and dive for him, removed trousers and boots and waded out five yards to a boat, which he drew into the shore and entered with his companion, taking him to a yacht which lay two hundred and forty yards from the shore, in the padlocked cabin of which was a boat hook. The padlock was unfastened, the boat hook taken, and they proceeded by the boat directly to where the young man lay. He was seen through the clear water, lying at a depth of nine feet at the bottom of the bay, on his back, with upturned face and arms extended from the sides of the body. He was quickly seized by the boat hook, drawn head upward to the surface, and with the inferior portion of the body hanging over the stern of the boat, and the superior supported in the arms of his rescuer, was rowed rapidly to the shore, where he was rolled a few times, and then placed prone upon a tub for further rolling. I was told that much water came from his mouth. Meantime I had been sent for to where I was sitting, one hundred and fifty-one yards from the scene, and I arrived to find him apparently lifeless on the tub, and to be addressed with the remark, "Well, doctor, I suppose we are doing all that can be done."

I have given these details, as from a study of them I was aided in deciding the time of submersion, as well as the intervals which transpired before the intelligent use of remedies. It is also remarkable that, notwithstanding all which has been written about ready remedies for drowning, no one present knew anything about them, although living in a seafaring community.

I immediately directed that the patient should at once be placed upon the ground, which was sloping, and arranged his rubber boots under the back of the head and nape of the neck, so that the head should be slightly elevated and the neck extended, while the head was turned somewhat upon the side, that fluids might drain from the mouth. The day was clear and moderately warm. Respiration had ceased, but no time was lost in commencing artificial respiration. The patient had on a shirt and pantaloons, which were immediately unbuttoned and made loose, and placing myself at his head, I used the Silvester method, because I was more accustomed to it than any other. It seems to me more easy of application than any other, and I have often found it of service in the asphyxia of the newly born.

The patient's surface was cold, there was extensive cyanosis, and his expression was so changed that he was not recognized by his fellow townsmen, but supposed to be a stranger. The eyelids were closed, the pupils contracted, and the inferior maxilla firmly set against the superior. One of the men who had brought him ashore had endeavored to find the heart's impulse by placing his hand upon the chest, but was unable to detect any motion.

I continued the artificial respiration from 9.45 until 10, when I directed one of his rescuers to make pressure upon the ribs, as I brought the arms down upon the chest. This assistance made expiration more complete. When nature resumed the respiratory act I am unable to say, but the artificial breathing was continued in all its details for three-quarters of an hour, and then expiration was aided by pressure on the chest for half an hour longer. Friction upward was also applied to the lower extremities, and the surface became warm about half an hour after the beginning of treatment.

About twenty minutes after ten, two hypodermic syringefuls of brandy were administered, but I did not repeat this, since I think alcohol is likely to increase rather than diminish asphyxia, if given in any considerable quantity. A thermometer, with the mercury shaken down below the scale, at this time did not rise. At 11.8 the pulse was 82; respiration, 27; temperature, 97.

After a natural respiration had commenced, the wet clothing was removed, and the patient was placed in blankets. Ammonia was occasionally applied to the nostrils, since, although respiration had returned, there was no sign of consciousness; the natural respiration was at first attended by the expulsion of frothy fluid from the lips, which gradually diminished, and auscultation revealed the presence of a few pulmonary rales, which also passed away. There were efforts at vomiting, and pallor succeeded cyanosis; there were also clonic contractions of the flexors of the forearm. The pupils dilated slightly at about one hour after beginning treatment. Unconsciousness was still profound, and loud shouting into the ear elicited no response. Mustard sinapisms were applied to the præcordium, and the Faradic current to the spine.

Coffee was also administered by a ready method which, as a systematic procedure, was, I believe, novel when I introduced it to the profession in the Medical Record, in 1876. I take the liberty of referring to this, since I think it is now sometimes overlooked. It was described as follows:

"A simple examination which any one can make of his own buccal cavity will show that posterior to the last molar teeth, when the jaws are closed, is an opening bounded by the molars, the body of the superior, and the ramus of the inferior maxilla. If on either side the cheek is held well out from the jaw, a pocket, or gutter, is formed, into which fluids may be poured, and they will pass into the mouth through the opening behind the molars, as well as through the interstices between the teeth. When in the mouth they tend to create a disposition to swallow, and by this method a considerable quantity of liquid may be administered."

After I had worked with the patient in the open air, for four and three-quarter hours, he was carried to a cottage near by and placed, still unconscious, in bed. There had been an alvine evacuation during the time in which he lay in the blankets.

Consciousness began to return in the early part of the following morning, and with its advent it was discovered that the memory of everything which had occurred from half an hour previous to the accident, up to the return of consciousness, had been completely obliterated. With this exception the convalescence was steady and uncomplicated, and of about a week's duration. From a letter which I recently received from my patient, I learned that the lapse of memory still remains.

My experience with this case has taught me that, unless the data have been taken very accurately, we cannot depend upon any statements as to the time of submersion in cases of drowning. My first supposition was that my patient had been from thirteen to fifteen minutes under water, but a careful investigation reduced the supposed time by one-half. This makes the time of submersion about six minutes, and that which elapsed before the intelligent use of remedies about three minutes longer.

For a long time the opinion of Sir Benjamin Brodie concerning the presence of water in the lungs of the drowned was accepted, who says "that the admission of water into the lungs is prevented by a spasm of the muscles of the glottis cannot, however, be doubted, since we are unable to account for it in any other manner."

Later experiments made by a committee of the Royal Medico-Chirurgical Society, of London, demonstrated, on the contrary, that "in drowned animals not only were all the air passages choked with frothy fluid, more or less bloody, but that both lungs were highly gorged with blood, so that they were heavy, dark colored, and pitted on pressure, and on being cut exuded an abundance of blood-tinged fluid with many air bubbles in it." Dr. R.L. Bowles¹ also holds that the lungs of the drowned contain water, and supports his views by a list of cases. In his words, "These examples show very conclusively that in cases of drowning in man, water does exist in the lungs, that the water only very gradually and after a long time is effectually expelled, and that it is absolutely impossible that any relief should be afforded in that way by the Silvester method." Dr. Bowles believes that the method of Dr. Marshall Hall is superior to any other in this class of cases. He thinks that on account of the immediate adoption and continued use of the prono-lateral position, this method is more to be trusted than any other for keeping the pharynx clear of obstruction. "It also empties the stomach and gradually clears the lungs of the watery and frothy fluids, and will surely and gently introduce sufficient air at each inspiration to take the place of the fluid which has been expelled." In the light of even my limited experience I cannot but feel that Dr. Bowles' opinion concerning the Silvester method would admit of some modification. This is often the case with very positive statements concerning medical matters. In my own case the Silvester method answered well, but I was much impressed with Dr. Bowles' claims for the Marshall Hall method, and should bear them in mind were I called upon to attend another case of drowning.

I think it must be admitted that pulling the tongue forward as a means of opening the glottis, which has become a standard treatment in asphyxia, is unscientific, and not warranted by the results of experiments made to determine its value.²

Dr. Bowles also believes that "the safety of the patient is most perfectly secured by keeping him on one side during the whole treatment, one lung being thus kept quite free." With the account of my case I have brought forward such views of other writers as it seemed to me would be of practical service and throw light on a subject which is of great importance, since the yearly record of mortality from drowning is by no means inconsiderable. I think, however, that a knowledge of what ought to be done in cases of drowning should be much more generally diffused than is the case at present. It should be one of the items of school instruction, since no one can tell when such knowledge may be of immense importance in saving life, and the time lost in securing medical aid would involve a fatal result.

It is also very desirable that all doubt should be removed, by the decision of competent medical authorities, as to which "ready" method or methods are the best, since there are several in the field. With this should be decided what is the best means for securing patency of the air passages, and, in short, a very careful revision of the treatment now recommended for drowning, in order that there may be no doubt as to the course which should be adopted in such a serious emergency.—Medical Record.

[1]

Resuscitation of the Apparently Drowned, by R.L. Bowles, M.D., F.R.C.P., Medico-Chirurgical Transactions, vol. lxxii., 1889.

[2]

Dragging on the tongue's tip would not affect its base or the epiglottis sufficiently to make it a praiseworthy procedure. Medico-Chirurgical Transactions, vol. lxxii. See also Medical Record, April 4, 1891. Pulling out the tongue is a mistake, since irritation of nerves of deglutition stops the diaphragm.—Medical Times and Gazetteer.