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. Bowles[1] 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.
[Footnote 1: Resuscitation of the Apparently Drowned, by R.L.
Bowles, M.D., F.R.C.P., Medico-Chirurgical Transactions, vol.
lxxii., 1889.]
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]
[Footnote 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._]
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._
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