five minutes. Voisin says that of eighty-seven drowned people who were restored to life, eight remained five minutes under water, and thirteen longer than that period, one of them twenty minutes. This last case he explained as one of inhibition of respiration. Laub cites a case of resuscitation after fifteen minutes, and there is another case of twenty minutes reported from the United States."

368. Symptoms.-The symptoms of drowning in the cases of inhibition are merely those of shock,-the loss of consciousness and the absence of all activities for an indefinite period until death supervenes. The cases are rare and have not been well understood. The symptoms of the usual type may be divided into three stages." In the first stage the person voluntarily holds his breath, a period which lasts in the neighborhood of one minute. In the second stage the symptoms of dyspnea come on. It is no longer possible for the person to hold his breath, and a series of short inspirations begins, each inspiration being followed by forcible expiration, due to the irritation of the larynx by the water that is inspired. The person is conscious, and the reflexes are normal. In the third stage there commences the unconsciousness, loss of reflexes, and convulsions. With the loss of reflexes the water is breathed deeply into the lungs, the inspirations being long and deep, with open mouth and bending of the trunk. Until this terminal stage very little water has entered the lungs; a large part of that which has entered the mouth and nose has, however, been swallowed; but in this third stage the fluid enters freely, even to the finest bronchi or alveoli. Brouardel and Logés measured the quantity of water that entered the lungs in the different stages of drowning in the dog. In the first stage, which lasted seven seconds, there entered 210 c.c. In the second stage, lasting twentythree seconds, no water entered; but in the third stage, during the first fifteen seconds, 407 c.c. entered the lungs. The following two minutes admitted 45 c.c., the next minute 90 c.c., and the next fortyfive seconds admitted 30 c.c.

369. Post-mortem appearances; external. The post-mortem appearances of the exterior of the body of a drowned person are usually very characteristic. The skin is usually pale, cold, and damp. The paleness at times is marked, and often, in the early stages, is

Voisin, Note sur l'Organization du Service des Secours Publics dans le Département de la Seine, Paris, 1878.

Laub, Hospitals Tidende, Kopenhaven, 1868.

Amer. Jour. Med. Sci., 1853, p. 348. See also 131, ante.

'See Hofmann, Ger. Med., p. 585.

Brouardel and Logé, Recherches Experim. sur la Mort par Submersion Brusque, Arch. de Physiol., 1889, 1, 2, and 3.

associated with reddened areas of cadaveric discoloration. The coldness of the skin is striking, but is not characteristic, as it is found in all bodies that have lain in the water. The hairs and papillae of the skin stand out in the characteristic manner of "goose flesh" (cutis anserina) very constantly. On the other hand, it is not characteristic of drowning, as it is found, also, in other forms of death. Similarly there may be shriveling of the skin of the penis, scrotum, breasts, and nipples under the same conditions as the production of cutis anserina. The thick skin of the palms of the hands and the soles of the feet, after remaining for a certain length of time in the water, becomes wrinkled like the skin of a washerwoman's hand. This wrinkling is more marked in proportion to the thickness of the skin, being more pronounced in the working classes than in the delicate-skinned people. It may follow not merely submersion in water, but also wrapping the parts in wet clothes. It becomes more and more marked until the skin begins to separate from the deeper tissues.

370. Froth at nostrils. The appearance of foam at the nostrils has been considered of marked value in the diagnosis of drowning, the water and mucus becoming mixed with air during the final respirations. Although found to a certain extent in other modes of suffocation, such as hanging and epilepsy and extensive bronchitis, it does not, in these cases, present the same characteristics as in death. by drowning. In these other cases the quantity of froth is very small, often bloody, and, being composed entirely of mucus mixed with air, is viscid, in larger bubbles, and closely adherent to the tis sues; while the watery froth of the drowned is, on the contrary, abundant, foamy, and made up of a larger number of small bubbles, which soon disappear on exposure to the air. The absence of froth cannot be assigned as proof that the person did not die of drowning. In certain cases it is not formed; as, in the cases where the person has remained completely immersed in the water, or has died without a struggle. If, on the contrary, the person has struggled considerably and has come to the surface, and so breathed both air and water during the process, the quantity of foam may be considerable. Again, from its very nature this sign is evanescent. If the body has lain for several days in the water, if it has been removed from the water with the head down, or if the inspection is not made soon after the removal of the body from the water, the froth that may have existed will no longer be found.

371. Abrasions of the hands. Abrasions of the hands, mud or

sand under the finger nails, and foreign bodies grasped in the hands are at times found. In the struggles made by a drowning person to save himself, he clutches wildly at every object in the water. Hence, if the water is not very deep, or the drowning person is near the bank, the fingers will most probably bear the marks of the sand or gravel, and weeds or sticks may remain firmly grasped in the hands. Unless the substances thus found are peculiar to the water, it may be impossible to exclude their having come from a struggle on the bank; or, indeed, they may have been produced after death by the hands striking against the bottom of the stream. The absence of such signs is not at all significant.

372. Internal appearances, in general. The internal appearances of asphyxia are not characteristically present, as in suffocation, though they may be found. The blood is, however, even more fluid than in most other cases of suffocation, and in place of congestion of the organs anemia is frequently present, being especially marked in the liver. This great fluidity of the blood accounts for the great bleeding that follows wounds on the drowned, the rapid transudation, and the imbibition.

373. Condition of the lungs. The condition of the lungs is very significant. Immediately after removal from the water, water may be poured out of the lungs by lowering the head of the victim and compressing the chest; but frequently a very large portion of the water has been removed before the body comes to the physician for examination, and, even if the lungs do contain water, it is significant only of the presence of the body in the water after death. On opening the chest the lungs are found to be bloated, and not to collapse as usual. The surface of the lungs at times shows a diffuse bluish mottling, due to the imbibition of the blood and water. Between the air vesicles may be found small areas of emphysema where, with the air, water is also mixed. If the body has been long enough in the water the pleural cavities may also contain water by transudation. The air passages, on opening the lungs, may show the presence of the water, and also of the watery froth similar to that found on the lips. and nose. If the fluid contained in the lungs is of a peculiar character, it may be identified with that of the liquid from which the body was removed. A certain small quantity of water may enter the lungs when the body is submerged post mortem, but the alveoli will not be so completely filled as in the cases of drowning.

374. Water in the stomach.- The presence of water in the stomach is of even more significance than the presence of water in the

lungs in the diagnosis of death from drowning. For while water may enter the lungs after death, practically none enters the stomach except during life, or in a very late period of decomposition. During the first and second stages of drowning the person usually swallows more or less of the fluid in which he is submerged. Naturally, the quantity of water in the stomach varies a great deal. If the quantity is very slight it is not significant; and, on the other hand, if the person has drank freely just before submersion, the water cannot be considered; but if the character of the water or fluid found in the stomach is like that of the medium in which the person is found, and of such a character that the person would not have drank it, the evidence from the fluid in the stomach is of considerable value. This is especially true if the fluid contains sand, gravel, parts of water plants, etc. If the person be found lying in a morass, a stagnant pool, or a privy well, there will, of course, be no difficulty in recognizing liquids from such places, if found in the stomach. If such fluid has penetrated as far as the duodenum or small intestine, the drowning is practically proved.

375. Marks of violence. Independent of the changes due to drowning, there are often found on the body marks of violence produced by different means, as in the cases where death has been due to soine other cause, and the body later thrown into the water; or in the cases where, after death from drowning, the body has been caught in the wheels of a steamer, for instance, and been more or less mangled. So, also, death may have been due to some natural cause, such as apoplexy, and the person have fallen into the water immediately after the apoplectic stroke. Here, for instance, we should find, perhaps, a hemorrhage on the surface of the brain, which might be attributed to violence. So, too, the person, in diving, may have struck a rock or some obstacle which has inflicted wounds of a very suspicious character. Sometimes a mark similar to that of hanging is made by the collar or fastening of the dress, made tense by the imbibition of water. A case is recorded in which the body of the man who had voluntarily drowned himself was drawn out of the water by a rope around his neck for that purpose. This was done probably half an hour after death. The thyroid cartilage was fractured, and there was a distinct ecchymosis over it, made by the rope. A similar mark might be expected where a man has tied a stone around his neck in order to insure his drowning. These associated lesions form a very important part of the post-mortem examination, for on them, to a

'Henke's Zeitschr., 1844, H. 1.

large extent, depends the distinction between ante-mortem and postmortem submersion, and between accidental, suicidal, and homicidal drowning.

376. Ante-mortem versus post-mortem violence.-The question as to whether these associated lesions have been inflicted before or after death becomes a still more difficult one to answer than in the cases where the bodies have not been in the water.10 In the latter class of cases it is possible to estimate the probabilities as to ante-mortem or post-mortem violence from the conditions of the body and the surroundings, the quantity of bleeding, and the infiltration of the tissues in the vicinity of the injury; but if the body has been in the water, we have no such help. So, too, the blood clots have probably been washed from the surface of the wound. Even the gaping of the edges of the wound is usually obscured by the swelling of the tissues, due to imbibition of the water. In the subcutaneous wounds we are but little better off, for there is a marked diffusion of the blood through the tissues of the drowned, from the great fluidity of the blood. If there are any signs of vital reaction, healing, or suppuration, of course the diagnosis is as clear as in the cases where the body has not been in the water. On the other hand, we see a much larger number of cases with post-mortem destruction of tissue, due to the depredations of fish and aquatic animals, if the body remains submerged, and of rats, birds, etc., if the body is exposed to the air; and these lesions produced by animals may be very difficult to interpret.

Hofmann describes11 the case of a child ten or twelve years of age whose body was found in a macerated condition. In both temporal regions were several slit-like openings 0.5 to 1.5 cm. long, down to the periosteum, out of which hung what appeared to be cords 29 centimeters long. The skull was uninjured, and there were no other signs of violence; and yet these wounds simulated stab or cut wounds very closely. The interpretation was long in doubt till a similar condition was found in another decomposed body, that was explained as being the work of birds. The cord-like structure hanging from the wound turned out to be a bit of pericranium, to which a macerated reed had become twisted.

377. Submersion, ante-mortem versus post-mortem.-The question as to whether the submersion has taken place before or after death, so far as the medical evidence goes, is fairly satisfactory. The dis

10 See §§ 242 et seq., ante, for distinction between ante-mortem and postmortem wounds in general.

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11

Hofmann, Ger. Med., p. 597.