Signs of intravital drowning. Modern problems of science and education

Drowning is a type of mechanical suffocation that occurs as a result of filling the lungs with liquid. The time and nature of death in water depends on external factors and the state of the body. Approximately 70,000 people worldwide die each year from drowning. Most of the victims are young men and children.

Causes of drowning

Risk factors are alcohol intoxication, the presence of a person with heart disease, damage to the spine when diving upside down. Also, the causes of drowning can be a sharp fluctuation in temperature, fatigue, various injuries when diving.

The risk of drowning is increased in the event of a whirlpool, high water flow, and the presence of key sources. Being calm in an emergency and not panicking can greatly reduce the risk of drowning.

Types of drowning

There are three types of drowning.

The true type of drowning is characterized by filling respiratory tract liquid to the smallest branches - alveoli. In the alveolar septa, under the pressure of the fluid, the capillaries burst, and water or other fluid enters the bloodstream. As a result, there is a violation of the water and salt balance and the breakdown of red blood cells.

Asphyxic type of drowning is characterized by spasm of the airways, which ultimately leads to suffocation from lack of oxygen. When water or liquid enters the respiratory tract, laryngospasm occurs, which leads to hypoxia. In the final stages of drowning, the airways relax and fluid enters the lungs.

The syncope type of drowning is characterized by the onset of death from reflex cardiac and respiratory arrest. This type of drowning happens from hypothermia or a strong emotional shock. It accounts for 10-14% of all cases of drowning.

Signs of drowning

The main symptoms and signs of drowning depend on its type.

With true drowning, there is a sharp cyanosis of the skin and mucous membranes, pink foam is ejected from the respiratory tract, the veins in the neck and extremities are very swollen.

With asphyxic drowning, the skin does not have the same blue color as with true drowning. A pink, finely bubbling foam is released from the lungs of the victim.

With syncopal drowning, the skin is pale in color due to capillary spasm, such victims are also called "pale". This type of drowning has the most favorable prognosis. It is known that with syncopal drowning, even after 10 or more minutes of being under water, revival is possible.

It should be noted that the prognosis for drowning in sea waters is more favorable than in fresh water.

Help with drowning

Help with drowning is to carry out resuscitation. It must be remembered that the sooner resuscitation measures are taken, the better the prognosis will be, and the higher the chances of the victim to recover.

The main treatment for drowning is mechanical ventilation and indirect massage hearts.

Artificial respiration is desirable to carry out as early as possible, even during transportation to the shore. First, it is necessary to free the oral cavity from foreign bodies. For this, a finger wrapped in a bandage (or any clean rag) is inserted into the mouth and all excess is removed. If a spasm of the masticatory muscles is observed, which makes it impossible to open the mouth, then it is necessary to insert a mouth expander or any metal object.

To free the lungs from water and foam, special suction can be used. If they are not there, then it is necessary to lay the victim with his stomach down on the rescuer's knee and vigorously compress the chest. If the water does not go away within a few seconds, you need to start artificial ventilation of the lungs. To do this, the victim is laid on the ground, his head is thrown back, the rescuer puts one hand under the neck, and the other on the patient's forehead. It is necessary to push the lower jaw so that the lower teeth protrude forward. After that, the rescuer inhales deeply and, pressing his mouth to the mouth or nose of the victim, exhales the air. When respiratory activity appears in the victim, artificial ventilation of the lungs cannot be stopped unless consciousness is restored and the rhythm of breathing is disturbed.

If there is no cardiac activity, then simultaneously with artificial respiration, it is necessary to conduct an indirect heart massage. The rescuer's hands should be placed perpendicular to the patient's sternum in her lower third. Massage is performed in the form of sharp shocks with intervals of relaxation. The frequency of shocks is from 60 to 70 per minute. With proper chest compressions, blood from the ventricles enters the circulatory system.

If the rescuer performs the revival alone, then it is necessary to alternate the massage of the heart muscle and artificial ventilation. For 4-5 shocks, one blowing of air into the lungs should fall on the sternum.

The optimal time for resuscitation is 4-6 minutes after rescuing a person. When drowning in ice water, revival is possible even half an hour after being removed from the water.

In any case, as soon as possible, even with the restoration of all vital functions, it is imperative to deliver the victim to the hospital.

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Drowning

Drowning is a relatively common cause of death, ranking third among all deaths from unintentional injury worldwide. Especially often drowning in water occurs in spring and summer, with the beginning of the swimming season. This state does not always end in death. Timely medical assistance for drowning helps to save a person's life. You just need to know what to do. First aid for drowning is a series of simple actions that even children should know. This issue is given Special attention, practical and theoretical classes on this topic are held in all educational institutions, starting from primary school age.

Drowning is a pathological condition or death of a person that develops due to the inability to breathe, since the respiratory organs are closed by water. This process is complex, but very little time passes from the moment it enters the water to death. And if emergency assistance is not provided in time for drowning, a person will die. In order for death to occur, it is not at all necessary for a person to get to a great depth. Drowning can only occur when the head is immersed in liquid. This happens in accidents when a person, intoxicated or unconscious, falls face down into a puddle or a nearby container with liquid.

Drowning in water and other liquids

Most often, drowning of a person occurs in water, but situations can sometimes occur when asphyxia occurs with some other liquids. Most often these are accidents at work. Drowning in water has its own characteristics, depending on the composition of the water. It has been observed that drowning in fresh water has some distinctive features from drowning a person in salt water. These data have great importance when establishing the mechanism and cause of death, which is very important if there is a suspicion of the criminal nature of this case.

Drowning in fresh water

The ingress of water into the lungs leads to the fact that due to the difference in osmotic pressures of ordinary water and blood plasma, the liquid is inevitably absorbed into the blood. The blood is diluted with water, and the total volume of blood increases by 2 times. Due to the ingress of water into the general circulation, hemolysis (destruction) of red blood cells occurs, followed by the release of hemoglobin. The doubled volume of blood creates a colossal load on it, which it is unable to withstand. A decrease in the concentration of red blood cells can lead to ventricular fibrillation. Shells from erythrocytes, free hemoglobin try to excrete the kidneys - an acute kidney failure. Drowning in fresh water is also accompanied by irritation of lung receptors, which provokes abundant foam formation, which only accelerates the onset of asphyxia.

The electrolyte composition of sea water is significantly different from the electrolyte composition of humans. The concentration of salts in sea water is much higher. According to the law of osmosis, when salty sea water enters the lungs, the liquid part of the blood is “attracted” from the blood vessels to the lung. This mechanism is directly opposite to that of drowning in fresh water. Pulmonary edema develops, and the formation of persistent foam in the airways is also characteristic. Death occurs from cardiac arrest, which develops as a result of oxygen deficiency resulting from blood clotting. It is believed that in salt water, a person drowns a little more slowly, which is due to the increased buoyancy of the body in sea water. Also noted is the fact that it takes about 8 minutes to develop cardiac arrest from anoxia (lack of oxygen), which develops as a result of blood clotting, while when drowning in fresh water, it takes 2-3 minutes to stop the heart from hemodilution (blood thinning). Such knowledge will be useful in the implementation first aid when drowning.

Drowning a person in other liquids

Drowning a person can occur not only in water. It can be any other liquids. Most often these are accidents at work. There are stories when drowning occurred in huge containers with milk, gasoline, wine. Such a tragedy can also occur at home, when small children are left unattended. Drowning in this case can occur in any liquids left by adults in buckets, bathtubs, tanks in places accessible to kids.

Types of drowning

Drowning in water and liquids can occur in different ways. In connection with the differences found, the following types of drowning began to be distinguished:

• True, or "pale" drowning;
• Asphyctic, or "blue" drowning;
• syncopal drowning;
• Mixed type of drowning.

It is important to be able to differentiate the types of drowning, since the volume and duration of first aid for drowning depends on the knowledge of the mechanism by which the pathological process developed in the body.

True or "pale" drowning refers to the process when fluid (water) flows into the lungs, is absorbed into the bloodstream, leading to hemodilution. It is noted that more often this type of drowning occurs in cases where the drowning person resisted the water element for a long time. This species is called "pale" drowning due to the color of the skin of the drowned. The color of the skin during drowning by this mechanism is very pale. And the term "wet" was fixed, because water is found in the internal organs. The lungs become large, heavy, filled with fluid. Water is found in the stomach, intestines, sinuses.

Asphyxic (spastic, "blue", "dry")

The asphyxic type of drowning is the result of a spasm of the larynx, resulting from irritation of the receptors in the respiratory tract with water. In this case, water in the lungs may not be detected at all or may flow after death from asphyxia. On this basis, it is also called "dry". In contrast to "pale" drowning, the color of the skin during drowning by this mechanism is cyanotic. Therefore, such drowning is also called "blue".

Syncopal drowning (reflex)

The onset of death due to vasospasm and reflex cardiac arrest is called syncopal drowning (syn. reflex). Syncopal drowning can occur due to a person having heart and lung diseases, if they are allergic to water. In this case, death occurs even before the onset of those changes that cause the filling of the respiratory tract with water. Therefore, pathognomonic for drowning changes in the blood and during the study of internal organs with syncopal drowning are not detected.

Mixed view of drowning

When mixed, signs of both true and asphyxic types of drowning are found. Registered in 20% of cases.

The processes that occur in the body due to the closure of the respiratory tract with water can proceed in different ways. It depends, as we have already said, both on the composition of the water and on the type of drowning. But, according to experts, the mechanism of drowning in all cases is similar and has a number of successive stages.

Reflex breath holding

As soon as the body is immersed in water, the breath is reflexively delayed. The duration of this stage is different for each person and depends on the reserve capacity of the organism. After holding the breath, movements of the respiratory muscles are made involuntarily.

Stage of inspiratory dyspnoea

Movements that imitate inhalation predominate, during which water begins to actively flow into the lungs. Irritation of receptors with water causes a cough reflex. At this point, water, mixing with air in the lungs, forms foam characteristic of drowning.

Stage of expiratory dyspnea

Breathing movements predominate. The pressure in the chest increases heartbeat becomes more frequent, extrasystoles develop against the background of oxygen starvation of the heart muscle. The stages of shortness of breath on inhalation and exhalation are the time of struggle, when a person is trying with all his might to save himself. Loss of consciousness from hypoxia may interfere with this.

Relative rest stage

At this moment, the respiratory movements stop due to the processes of inhibition in the respiratory center, relaxation of all muscle groups occurs, the body of the drowned man goes to the bottom.

Stage of terminal respiration

The spinal control center of the respiratory center is activated, trying to somehow correct the situation. Irregular sharp respiratory movements appear. As a result of these movements, water penetrates even deeper into the sections of the lungs, tearing the alveoli and penetrating into the blood vessels.

Final cessation of breathing

The final cessation of breathing is the result of transcendental inhibition in the central nervous system.

The causes of drowning are manifold, and to better understand why it occurs, one has only to think about what situations force a person to be in close contact with water. The main cause of drowning is an accident, which can be caused by various factors. Less often, drowning in water can be the result of a planned action by criminals. But this method of killing is not used very often. Natural disasters, such as floods, can contribute to human drowning. In such situations, it is difficult to cope with water, even being a master of sports in swimming.

Indirect causes of drowning, which are risk factors:

• Access to water

Naturally, in regions with a large number of reservoirs, drownings are much more common. Moreover, the cause of drowning is almost always the neglect of simple rules of behavior on the water: swimming behind buoys, swimming in reservoirs with unknown indicators of depth and bottom relief, swimming while intoxicated, swimming in adverse climatic conditions, etc.

• Inability to swim

We can say the main cause of drowning. People who do not know how to swim should not be in the water at all without special devices that can keep them on the water (circle, vest).

• Swimming or being near water while intoxicated

Alcohol is the cause of many troubles in human life. Being intoxicated, a person is not able to assess the current situation, which often leads to sad consequences.

• Male gender

According to statistics, among all drowning people, men are more often registered. This is due to the hobbies of the stronger sex (fishing, diving, rafting, surfing, etc.), as well as the fact that men drink alcohol more often, are not afraid to swim alone, etc.

• Childhood

A huge percentage of childhood deaths from drowning occur between the ages of 1-14 years. Left unattended even for a couple of minutes, they become victims of the water element.

• Bathing in cold water

Cold water, when it enters the respiratory tract, causes irritation of the receptors, spasm of the larynx and asphyxia occur. This is how the “dry” type of drowning develops. Swimming in cold water or accidentally entering ice water (for example, while ice fishing) can cause death from cramps in the limbs, making it difficult for a person to swim ashore. Being in cold water in combination with alcohol intoxication can especially quickly contribute to drowning.

• Health problems

When a person is in the water, diseases do not disappear, and sometimes they can cause an accident. Drowning in water can be caused by heart attacks that caught a person while swimming, an epileptic seizure, etc.

There are different types of help for a drowning person. It is important to remember that a drowning person needs emergency care when drowning. The whole process of drowning lasts 6-8 minutes. If you do not have time to provide first aid for drowning, a person can be lost.

Types of assistance for drowning:

• First aid for drowning (PMP for drowning);
• Resuscitation at drowning.

First aid for drowning

First aid for drowning - these are the actions that any person who finds himself next to a drowning person should carry out. These simple skills are taught even to schoolchildren.

The volume of PMP for drowning includes:

• The first step is to get the person out of the water. To do this, it will be right to swim up to him from behind, so that he does not grab the rescuer in a panic and pull him into the depths. You need to grab a drowning person by the hair or under the arms from the back and swim to the shore.
• On the shore, place the victim in a position on his side, inspect the oral cavity. In the presence of sand, algae, debris, vomit in the oral cavity, empty the mouth.
• Call an ambulance.
• You can press your finger on the root of the tongue, artificially inducing vomiting. So there will be a cleansing of the stomach fluid, the person will begin to come to his senses.
• Assess for pulse, heartbeat, and pupillary response to light.
• If the victim does not show signs of life, urgently proceed with resuscitation in case of drowning.

Resuscitation for drowning

Resuscitation for drowning includes heart massage through the chest (indirect) and artificial respiration at the stage of first aid for drowning. Upon the arrival of doctors, the drowned person is delivered to a medical facility, where, if necessary, resuscitation measures can be continued in a hospital in the department intensive care. The rescuer of a drowning person must immediately begin resuscitation after release oral cavity from possible contamination. The implementation of artificial respiration in combination with a heart massage should be carried out until the arrival of the ambulance or until the moment when the victim regains consciousness. These events must be completed within 30 minutes.

Upon the arrival of doctors, the victim undergoes a series of resuscitation measures aimed at restoring respiratory function(artificial ventilation of the lungs), the release of the stomach from fluid (gastric sounding). If stated clinical death, doctors are taking measures to get out of this state: cardiopulmonary, the introduction of adrenaline, etc.

Even if a person comes to his senses after medical assistance for drowning and assures that everything is in order, he should not be allowed to go home. The risk of developing "secondary drowning" is high, when death occurs some time after drowning and resuscitation of the drowning person. Therefore, he is taken to the hospital, where doctors treat the complications of drowning (pulmonary edema, inflammation of the respiratory tract, electrolyte disturbances, acute renal failure).

PMF for drowning and types of drowning

Activities included in the scope of first aid for drowning may have their own nuances depending on the type of drowning. You need to know about this, because the right tactics of behavior will help not to lose valuable minutes on which a person’s life depends.

First aid for drowning aspiration type

"Wet" drowning, types of assistance:

• PMP for drowning aspiration type

The provision of first aid in case of drowning, characterized by filling the respiratory and digestive organs with water, boils down to the fact that after moving the drowned person to the shore and freeing the oral cavity, it is necessary to remove the fluid that has entered the body. To do this, it is enough to press on the root of the tongue and put the body of the victim on his own knee with his stomach. Perform a push between the shoulder blades. This action should take no more than 15 seconds. Even if the liquid did not come out, there is no point in wasting time. It is necessary to quickly switch to artificial respiration and heart massage.

Resuscitation during drowning of this type does not have any features, it is carried out according to well-known rules until the ambulance arrives.

Treatment of complications that occur in the long term. This is a therapy aimed at preventing and treating pulmonary edema, restoring the rheological properties of the blood (combating hemolysis), restoring the functions of the brain, kidneys, etc.

"Dry" drowning, types of assistance:

• First aid for drowning asphyxic type

No measures are required to remove fluid from the body, since with this type it may not be. But you need to examine the mouth for the presence of foreign objects. After that, proceed to cardiopulmonary resuscitation according to general principles.

• Emergency assistance for drowning in conditions medical institution with "dry" drowning, it is carried out symptomatically and is aimed at restoring all body functions.

The asphyxic type of drowning is considered somewhat more favorable in the sense that a successful result in the provision of emergency assistance for drowning is possible if the body has been in water for up to 8 minutes. Whereas with aspiration drowning, this period is no more than 6 minutes.

Emergency care for drowning of a reflex nature

The provision of first aid for drowning of a reflex nature has the same principles as the PMP for drowning of an asphyxiant type. It is believed that first aid for drowning in the case of syncopal drowning can give positive result, even if the body of the victim was in the water for about 12 minutes. And if the water was cold or icy, then due to the fact that metabolic processes slow down in the cooled brain, this period can be shifted up to 20 minutes.

Signs of drowning

Signs of drowning are divided into external and internal. External signs are visible to the naked eye, and to detect internal signs, it is necessary to conduct a study of the organs and tissues of the drowned special methods. This is to confirm drowning as the cause of death. After all, the discovery of a person in the water does not mean that he drowned. Types of drowning play an important role in the appearance of certain symptoms.

At the time of the drowning process itself, the picture may be different. We are used to seeing from TV screens that a drowning person is actively waving his arms, floundering in the water and calling for help. But this is not always the case. Most often, this behavior of a drowning person is associated with the panic that has gripped him. Moreover, during the cry, the air leaves the lungs, which only accelerates the movement of the body to the bottom. In most cases, filling the airways with water prevents sounds from being made. It is possible to suspect that a person is drowning by such signs as emerging from the water, taking deep breaths and again immersing in water. At the same time, the eyes have a “glassy” look, the mouth is open.

• Skin color when drowning

Noteworthy is the color of the skin when drowning. True and syncope types of drowning are characterized by pale skin with a bluish or pink-blue tint. Skin color in "dry" type drowning: the skin becomes blue or dark blue.

• Foam at mouth and nose

The presence of white or pink foam at the mouth and nose is hallmark drowning. Such foam is formed as a result of mixing air with water during attempts to breathe. Its feature is a persistent character, the foam is difficult to separate from the mucous membranes. When dried, it leaves a characteristic fine-mesh gray mesh on the surface of the skin.

• Mucous edema

There is swelling of the conjunctiva, lips, sometimes there is puffiness of the entire face.

When a drowning person is recovered from the water alive, the following symptoms may occur:

• Cough;
• Vomit;
• Diarrhea;
• Violation of consciousness, up to coma.
• Respiratory failure, up to stop.

Internal signs of drowning

The body of a drowned person is subjected to a thorough examination. This is necessary to confirm drowning as the cause of death. The internal organs of a drowned person are examined by various methods. This is a description of the changes in internal organs found during the autopsy, as well as a number of studies conducted in special laboratories using a microscope and other technologies.

Persistent airway foam

In the mouth, nose and bronchial cavity, a characteristic finely bubbled foam is found. With the true type of drowning, it has a pink color, may be mixed with blood, while with asphyxic (“dry”) drowning, the foam remains white or grayish.

• Wet lung swelling

The lungs become enlarged, rib prints are noted on their surface, which arose from the fact that a sharp increase in the volume of the paired organ led to the fact that the cavity chest became small for them. When cut, a pink liquid flows from the lung tissue, the color of the lungs is pale, with pink areas. Such changes are called "marble lung".

• Hemorrhages in the muscles

When examining the muscles in the neck, arms and back, hemorrhages can be detected - this is the result of very active attempts by a drowning person to escape. The movements become so strong and abrupt that small vessels can be damaged.

• Swelling of internal organs

When examining the internal organs, you can notice that some organs are edematous, such as the liver, lungs, gallbladder. This is confirmed by further examination of organs under a microscope.

• Eardrum ruptures

Rupture of the tympanic membrane cannot be considered a specific sign, according to some authors, such a phenomenon can occur posthumously. But the fact that the rupture of the eardrum and the ingress of water into the cavity of the middle ear is detected in drowned people is considered undoubted.

• Compression fracture cervical spine

It often happens that a person who dives into the water appears already dead on the surface of the water. The reason for this is a fracture of the cervical vertebrae, which happens when jumping into the water in shallow water or in an unknown reservoir with a rocky bottom.

It is also necessary to establish the diagnosis of drowning by laboratory methods of research. The discovery of a person in the water does not yet mean that his death was due to drowning. Often the body is placed in water to hide the traces of the crime, simulating an accident. But experts, after conducting a series of studies, can give a reliable conclusion about whether an accident occurred or the body fell into the water after death.

• Plankton research

Main and highly informative method research is the detection of plankton in the body of a drowned person. Plankton are small inhabitants of plant and animal origin that inhabit water bodies. They cannot be seen with the naked eye, but they are clearly visible under a microscope. Of particular value for research is a special class of microorganisms, the shell of which consists of silicon. This is diatom plankton (diatoms), its detection in the human body is possible even after a long time after drowning. Their shell is so hard that it is not subject to destruction from the influence of environmental factors.

Each reservoir is inhabited by certain types of plankton. In different areas and nooks and crannies of the globe, the plankton composition of water is different. This, too, has its value in a drowning investigation. Therefore, when examining human tissues and organs for the presence of plankton, a water sample taken in the reservoir where the drowned person was found is also subjected to research.

If the body was found out of the water, samples are taken from the water bodies of the area. Later, the results are compared: the diatoms found in the body are compared with diatoms in water samples. If plankton is found in the lungs and respiratory tract, it only means that the person was in the water. An undoubted sign of drowning is the presence of plankton in the kidneys, bones, where these microorganisms got into the bloodstream when the blood is mixed with water.

• Microscopy of internal organs

To detect reliable signs of drowning, it is also necessary to study the internal organs of a drowned person under a microscope. There are no specific signs of drowning, but there are small changes indicating possible drowning. And, together with other signs obtained from an external examination of the body of a drowned person, they make it possible to establish or refute the diagnosis of "drowning".

The most informative in this regard are the lungs. So, when examining lung tissue, areas of emphysema (bloating) with ruptures of the interalveolar septa alternate with areas of the alveoli containing fluid (edema). Inside the alveoli, as well as in the bronchi, pale pink contents are found, red blood cells are sometimes visible. Also in these structures you can find particles of algae, elements of plankton.

• Lymphohemia

The reflux of blood into the common lymphatic duct, resulting from an increase in venous pressure in the vena cava system, is called lymphohemia. The lymph is examined under a microscope, the detected erythrocytes are to be counted using a special counting chamber.

An important aspect in the prevention of drowning is teaching children from the period of primary school age the rules of safe behavior on the water, swimming skills, as well as first aid methods for drowning.

The main features from the monograph by V.A. Sundukov are given. " Forensic-medical examination drowning, see

Signs characteristic of drowning in water (compendium) / Chests V.A. — 1986.

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Signs characteristic of drowning

Signs revealed during the external examination of the corpse:

1. Persistent, finely bubbling foam around the openings of the nose and mouth (Krushevsky's sign) in the form of lumps resembling cotton wool ("cap of foam"), is the most valuable diagnostic sign of drowning. At first, the foam is snow-white, then it takes on a pinkish tint due to the admixture of bloody liquid. Foam is formed during drowning due to the mixing of mucus with water and air. It consists of a frame in the form of mucus, exfoliated epithelial cells and its own foam covering the frame. When the foam dries, traces of it remain around the openings of the nose and mouth. If there is no foam on the corpse removed from the water, then it is recommended to press on the chest, after which it may appear. Usually, the foam disappears after 2-3 days, and only sanious fluid is released from the openings of the nose and mouth of the corpse due to the development of imbibition and hemolysis processes.

2. Due to the increase in the volume of the lungs (with the development of hyperhydroaeria), there is an increase in the circumference of the chest, as well as smoothing of the supraclavicular and subclavian fossae and reliefs of the clavicles.

3. The color and severity of cadaveric spots may vary depending on the type of drowning. So, Bystrov S.S. (1974) with the "true" type of drowning found cadaveric spots paler, blue-purple in color with a pinkish or reddish tinge, and with asphyxic type they were plentiful, dark blue, dark purple color. Due to loosening of the epidermis, oxygen penetrates into the blood of the superficial vessels of the skin, which leads to the formation of oxyhemoglobin (from reduced hemoglobin), so cadaveric spots quickly take on a pinkish color. With partial immersion of the corpse in water at the level of the boundary line, a bright red stripe with a bluish tint is observed, gradually turning into the color of the upper and lower parts of the cadaveric spots. Sometimes, during drowning, cadaveric spots appear evenly over the entire surface of the corpse (and not only in the underlying sections, as usual) due to the displacement (turning) of corpses by the flow of water.

4. The color of the skin of the face, neck and upper chest also changes depending on the type of drowning (S.S. Bystroy). With the "true" type - the skin of these areas is pale blue or pinkish-blue in color, and with asphyxia - blue or dark blue.

5. You can detect hemorrhages in the conjunctiva and sclera, as well as identify gelatinous swollen folds of the conjunctiva due to their edema.

6. Puffiness of the face is sometimes noted.

7. Less often you can see traces of defecation. Separate external signs: the nature and color of cadaveric spots, the color of the skin of the face, neck, upper chest, hemorrhages (in the conjunctiva and sclera, puffiness of the face and traces of defecation - are not signs characteristic only of drowning, equally they are found in other types mechanical asphyxia.

Signs revealed during the internal examination (autopsy) of the corpse

1. In the lumen of the trachea and bronchi, a finely bubbling persistent foam is found, which, with the "true" type of drowning, has a pinkish color, sometimes with an admixture of blood and water; in the asphyxial type - this foam appears white (S. S. Bystrov).

2. When opening the chest cavity, the lungs are sharply enlarged in volume. They completely fill the pleural cavities. Their front sections cover the heart shirt. Their edges are rounded, the surface has a colorful "marble" appearance: light gray areas alternate with light pink. Stripe-like imprints of the ribs may be visible on the surfaces of the lungs. When released from the chest cavity, the lungs do not collapse. Lungs don't always look the same. In some cases (with the asphyxic type of drowning), we are dealing with the so-called "dry swelling of the lungs" (hyperaeria) - this is a condition of the lungs when they are sharply swollen, but dry on the cut or a small amount of liquid flows from the surfaces. Hypereria depends on the penetration of air into the tissue under the pressure of the liquid. There is a strong degree of swelling of the alveoli. This is accompanied by stretching and rupture of the alveolar walls and elastic fibers, often by the expansion of the lumen of the small bronchi and, in some cases, the entry of air into the interstitial tissue. There is a small number of foci of tissue edema. The surface of the lungs is uneven, mottled. The fabric feels spongy. It is dominated by small limited hemorrhages. The weight of the lungs is not increased compared to the norm. In other cases (with the "true" type of drowning), there is "wet swelling of the lungs" (hyperhydria) - this is the name of the condition of the lungs of a drowned person, when a large amount of aqueous liquid flows from the surface of the cuts, while the lungs are heavier than usual, but everywhere airy. noted average degree swelling of the alveoli, the presence of a large number of foci of edema and large diffuse hemorrhages. The surface of the lungs is smoother, the tissue is less variegated, and has a doughy texture to the touch. The weight of the lungs exceeds the normal by 400 - 800 g. Hyperhydria is less common than hyperaeria; it is believed that it happens when a person falls under water after a deep exhalation. Depending on the state of the foci of swelling and edema, a third form of acute swelling of the lungs is distinguished - intermediate, which is also characterized by an increase in lung volume. When probing, there is a crypitation in places, in some places the consistency of the lungs is doughy. Foci of swelling and edema alternate more evenly. The weight of the lungs increased slightly, by 200-400 g. Microscopic examination in the lungs during drowning should look for foci of acute swelling and foci of edema. Acute swelling is recognized by a sharp expansion of the lumen of the alveoli; interalveolar septa are torn, "spurs" protrude into the lumen of the alveoli. The foci of edema are determined by the presence in the lumen of the alveoli and small bronchi of a homogeneous pale pink mass, sometimes with an admixture of a certain amount of erythrocytes. Further, studying the lungs, you need to pay attention to the blood supply to the vessels. When drowning, it is expressed unevenly. According to the air areas, the capillaries of the interalveolar septa are collapsed, the tissue appears anemic, in the foci of edema, on the contrary, the capillaries are dilated and full-blooded. The microscopic picture of the lung tissue during drowning is supplemented by the presence of atelectasis foci and the presence of hemorrhages in the interstitial tissue; the latter are limited and spilled. In addition, elements of plankton and mineral particles, particles of plant fiber, etc., can be found in small bronchi and alveoli.

3. Rasskazov-Lukomsky-Paltauf spots when drowning - an important diagnostic sign - they are large blurry hemorrhages in the form of spots or stripes under the pleura of the lungs, which have a pale pink, pale red color. However, this feature is not permanent.

4. The presence in the stomach of a liquid in which drowning occurred (Fegerlund's sign), with asphyxic type - a lot of liquid, with "true" - little. Water may also be in primary department intestines. The presence of admixture to the gastric contents of silt, sand, algae, etc., has a certain diagnostic value. During lifetime ingestion, up to 500 ml of liquid can be found in the stomach. The possibility of posthumous penetration of fluid into the gastrointestinal tract is rejected by most authors (S. S. Bystrov, 1975; S. I. Didkovskaya, 1970, etc.).

5. In the sinus of the main bone, a liquid (5.0 ml or more) is found, in which drowning occurred (V. A. Sveshnikov, 1961). When laryngospasm (asphyctic type of drowning) occurs, the pressure in the nasopharyngeal cavity decreases, which leads to the flow of the drowning medium (water) into the sinus of the main bone through the pear-shaped cracks. In the left half of the heart, blood diluted with water has a cherry-red color (I. L. Kasper, 1873). Hemorrhages in the muscles of the neck, chest and back (hemorrhages in the sternocleidomastoid muscle, Paltauf; hemorrhages in the muscles of the neck and back - Reiter, Wahholz) as a result of strong muscle tension of a drowning person when trying to escape.

6. Edema of the liver, bed and wall of the gallbladder and hepatoduodenal fold F. I. Shkaravsky, 1951; A. V. Rusakov, 1949). On microscopic examination, liver edema is expressed by the expansion of the pericapillary spaces and the presence of protein masses in them. The swelling may be uneven. In those places where it is significant, intralobular capillaries and central veins are full-blooded. In the crevices and lymphatic vessels of the interlobular connective tissue with edema, a homogeneous pale pink mass is found. Gallbladder edema is often diagnosed macroscopically. In some cases, it is found during microscopic examination - this reveals a characteristic state of the connective tissue of the bladder wall in the form of expansion, loosening of collagen fibers, and the presence of a pink liquid between them.

Signs found in laboratory tests

These include signs associated with intravital penetration of the drowning environment (water) into the body and changes in the blood and internal organs caused by this environment (water):

1. Detection of diatom plankton and pseudoplankton in blood, internal organs (except lungs) and bone marrow.
2. Positive "oil test" by S. S. Bystrov - detection of traces of technical liquids (petroleum products).
3. Identification of quartz-containing mineral particles (B. S. Kasatkin, I. K. Klepche).
4. The difference between the freezing points of blood in the left and right heart (cryoscopy).
5. Establishment of the fact and degree of blood dilution in the arterial system and in the left heart (study of electrical conductivity and refractometry).

Signs characteristic of drowning:

• finely bubbling persistent foam at the openings of the mouth and nose (Krushevsky's sign);
• an increase in the circumference of the chest;
• smoothing of supraclavicular and subclavian fossae;
• the presence in the lumen of the trachea and bronchi of pinkish persistent fine bubble foam;
• "wet swelling of the lungs" (hyperhydria) with imprints of the ribs;
• fluid in the stomach and upper small intestine with an admixture of silt, sand, algae (Fegerlund's sign);
• in the left half of the heart, blood diluted with water is cherry-red in color (I. L. Kasper);
• spots of Rasskazov-Lukomsosky-Paltauf;
• fluid in the sinus of the main bone (V. A. Sveshnikov);
• swelling of the bed and wall of the gallbladder and hepatoduodenal fold (A. V. Rusakov and P. I. Shkaravsky);
• hemorrhages in the muscles of the neck, chest and back as a result of strong muscle tension (Paltauf, Reiter, Vahgolp);
• visceral pleura somewhat cloudy;
• air embolism of the left heart (V.A. Sveshnikov, Yu.S. Isaev);
• lymphohemia (V.A. Sveshnikov, Yu.S. Isaev);
• swelling of the liver;
• compression fracture of the cervical spine;
• ruptures of the gastric mucosa;
• detection of diatom plankton and pseudoplankton in blood, internal organs (except lungs) and bone marrow;
• identification of traces of technical fluids - a positive "oil test" (S. S. Bystrov);
• identification of quartz-containing mineral particles (B. S. Kasatkin, I. K. Klepche);
• the difference between the freezing points of blood in the left and right heart (cryoscopy);
• statement of the fact and degree of blood dilution in the arterial system, left heart (refractometry, electrical conductivity study).

Signs characteristic of the presence of a corpse in the water:

• "goose pimples";
• skin is pale;
• nipples and scrotum wrinkled;
• hair loss;
• maceration of the skin (wrinkling, pallor, "washerwoman's hand", "gloves of death");
• rapid cooling of the corpse;
• signs of decay;
• the presence of signs of adiposity;
• the presence of signs of peat tanning;
• detection of traces of technical liquids (oil, fuel oil) on the clothes and skin of the corpse.

General ("similar") signs - general asphyxia and drowning:

• hemorrhage in the conjunctiva and the white of the eyes;
• cadaveric spots of dark blue or blue-crimson color with a purple tint;
• the skin of the face, neck, upper chest is pale blue or dark blue with a pinkish tint;
• puffiness of the face;
• traces of defecation; "dry swelling of the lungs" (hyperaeria), subpleural ecchymosis (Tardier spots);
• liquid blood in vessels and heart;
• overflow of blood in the right half of the heart;
• plethora of internal organs;
• plethora of the brain and its membranes;
• anemia of the spleen;
• bladder emptying.

General ("similar") signs - the presence of the corpse in the water and drowning:

• cadaveric spots are pale, blue-purple with a pinkish or reddish tint;
• swelling and swelling of the folds of the conjunctiva;
• swelling and maceration of the mucous membrane of the larynx and trachea;
• fluid in the middle ear cavity with a perforated tympanic membrane;
• the presence in the upper respiratory tract of silt, sand, algae;
• fluid in the abdominal (Moro sign) and pleural cavities.

Isaev Yu.S., Sveshnikov V.A. : Information mail. - Irkutsk, 1988. - 8 p.

Prepared by the Head of the Department of Forensic Medicine of the Irkutsk State medical institute, Head of the Bureau of Forensic Medical Examination of the Irkutsk Regional Health Department, Candidate of Medical Sciences, Associate Professor Isaev Yu.S. and Ph.D. Sveshnikov V.A.

Forensic medical substantiation of death from drowning in water

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Irkutsk State Medical Institute

Yu.S. Isaev, V.A. Sveshnikov

Forensic medical substantiation of death from drowning in water

Information mail

Irkutsk - 1988

Evaluation of the results of a forensic medical examination of the corpses of persons removed from the water presents certain difficulties, due to the need to resolve 3 main issues:

• 1 - to prove the lifetime entry of a person into a reservoir;
• 2 - to establish the thanatogenetic mechanism of death;
• 3 - try to find out the reasons that led to drowning in water.

In most cases, forensic experts try to substantiate the diagnosis of drowning in water as a variant of mechanical asphyxia from closing the respiratory tract with water, using, as a rule, signs indicating the penetration of the reservoir medium into the body. In this regard, drowning is considered by a forensic expert as one of the types of obstructive or aspiration asphyxia. It should be noted that this provision was approved and fixed by a similar wording of the definition of drowning in all textbooks and manuals on forensic medicine.

However, the possibility of the existence of several thanatogenetic variants of drowning in water has now been convincingly proven, each of which is characterized by certain diagnostic features. An analysis of the literature data and our own observations, covering more than 500 studies of the corpses of persons taken from the water, made it possible to formulate new concepts regarding the thanatogenetic mechanisms of drowning and diagnostic possibilities for differentiating types of drowning. The correctness of our provisions was confirmed by the editors of the journal "Forensic Medical Examination" (SME, 1986, No. 1, pp. 26-29, SME, 1989, No. 1, pp. 23-25) and the Great Medical Encyclopedia (third edition, 1985, v. 26, pp. 142-146), materials of the II All-Russian (Irkutsk, 1987) 1 , III All-Union (Odessa, 1988) congresses of forensic physicians, the plenum of the All-Russian Scientific Society of Forensic Physicians (Krasnoyarsk, 1988). In this regard, we considered it possible to summarize the results of our work in the form of this letter.

The process of drowning in water is complex, associated with a complex of exogenous and endogenous factors that precede drowning and cause deep disorders in the body's vital functions. Initial acute functional disorders do not leave noticeable morphological features on a corpse.

In addition, they are usually obscured by pathological processes resulting from the closure of the respiratory tract by water and the penetration of the drowning medium into the body. These changes form the signs that form the basis of the existing methods of forensic medical diagnosis of drowning. But the severity of these changes is not constant and depends on the thanatogenetic variant of drowning, which often complicates the recognition of this type of death.

At the same time, the phenomena of obturation or aspiration during drowning in water are possible only in those cases when a person is immersed in water as a result of acute violations of the basic functions of the body (central nervous

system, respiration, circulation). In the absence of such violations, drowning becomes impossible. If, however, conditions arise under which only the head or its parts are immersed in a liquid (a puddle, a basin of water, etc.) with the respiratory openings closed, for example, in persons in a state of alcoholic intoxication, during an epileptic seizure, or in other acute developed painful conditions with impaired consciousness and not related to the influence of the aquatic environment on the body, they should be considered as obstructive or aspiration asphyxia, and not as a variant of drowning.

Consequently, drowning is a type of violent death that occurs when a person is immersed in water (rarely another liquid) and due to acute violation functions of vital body systems (CNS, respiration, circulation) under the influence of the aquatic environment.

Drowning in water is enough frequent view death in almost all regions of the globe, including our country. According to the WHO, death from drowning has an average global rate of 1.0-1.2 per 10,000 population. In this regard, the forensic solution of the entire complex of the above issues acquires a significant role in increasing the objectivity of the expert opinion, has importance in developing preventive measures drowning and methods of treatment of drowning.

THANATOGENESIS OF DROWNING IN WATER

The process of drowning in water is complex, associated with a complex of exogenous and endogenous factors that precede drowning, which determine the development of specific pathogenetic mechanisms, each of which, in turn, is characterized by certain changes in the body.

There are 4 main types of drowning in water:

1. Aspiration type of drowning(until now very inaccurately referred to as "true") is characterized by penetration into the respiratory tract, lungs and blood of the reservoir environment. This type of drowning, according to our materials, occurs on average in about 20% of observations. Our data on the frequency of occurrence of various types of drowning do not contradict the statistical observations of other researchers. So, R.A. Klimov (1970), S.S. Bystrov (1975), G.P. Timchenko (1975) et al. in more than 50% of observations did not encounter the phenomena of water penetration into the body of humans and animals during death from drowning. Depending on the nature of the water (fresh or salty), the resulting changes in the body will be different:

• a) drowning in fresh water is accompanied by a significant influx of water from the lungs due to osmotic processes into the bloodstream, causing hypervolemia, hydremic hemolysis of erythrocytes, a significant increase in the concentration of potassium in the blood plasma, which leads to heart fibrillation and the development of acute heart failure. The duration of the drowning period (according to experimental data) is 3-5 minutes, accompanied by a short-term increase blood pressure with its subsequent decrease and a stable decrease in venous pressure. The cessation of cardiac activity occurs 10-20 seconds earlier than breathing is completely turned off;
• b) drowning in salt water(marine), which in relation to the blood is a hypertonic medium, entails the release of the liquid phase of the blood into the lumen of the alveoli with the development of a sharp pulmonary edema and the occurrence of acute pulmonary insufficiency. In the initial period of drowning (according to experimental data), high systolic pressure is observed against the background of a decrease in diastolic pressure, which leads to a significant increase in pulse pressure, and peripheral venous pressure increases. Cardiac arrest, as a rule, as a result of asystole develops gradually, within 7-8 minutes with an increase in myocardial hypoxia. Cardiac activity stops after breathing for 10-20 seconds.

2. Spastic (asphyctic) type of drowning associated with the occurrence of persistent laryngospasm as a response to irritation of the receptor apparatus of the mucous membrane of the larynx by the drowning environment, which prevents the latter from penetrating into the respiratory tract and lungs. The duration of the drowning period (according to experimental data) is 5.5-12.5 minutes, accompanied by a progressive decrease in blood pressure and an increase in central venous pressure. The cessation of cardiac activity occurs against the background of arterial hypotension 20-40 seconds after respiratory arrest. This type of drowning occurs in 35% of cases. It is accompanied by significant changes in the lung tissue due to the occurrence of false-respiratory respiratory movements with a closed glottis. The phenomena of acute hyperaeria of the lung tissue develop with damage to its structural elements, it becomes possible for air to penetrate into the pulmonary vessels and the left part of the heart, significant disturbances occur in the microcirculatory bed of the lungs, which leads to acute pulmonary insufficiency, brain hypoxia and air embolism of the heart.

3. Reflex (syncope) type of drowning due to the simultaneous cessation of respiratory and cardiac functions when a person suddenly enters extreme conditions. This type of drowning can develop in a state of psychogenic tension of the body (fear), as well as when exposed to water, especially low temperatures, on the receptor apparatus of the skin, larynx, pharynx, middle ear cavity in the presence of a defect in the eardrum, etc. In the occurrence of this type of drowning, it may be important pathological changes in the heart, lungs, specific allergic reaction to the aquatic environment. The reflex type of drowning is observed on average in 10% of cases and is more common at a young age and in women, nervous system characterized by heightened emotionality.

4. mixed type drowning occurs on average in 35% of observations and is characterized by polymorphism of the detected features, which is associated with a combination of different types of dying. More often, this type of drowning can begin with laryngospasm, subsequently it resolves into later phases of drowning, which entails the penetration of water into the respiratory tract and lungs with the development of phenomena characteristic of the aspiration type of drowning. However, other combinations are also possible (spastic type plus reflex, aspiration plus reflex).

Thus, the existence of several types of drowning with certain changes in the body requires their mandatory consideration in the expert substantiation of the cause of death in persons taken from the water.

DIAGNOSTIC SIGNS OF DROWNING

Depending on the type of drowning, the tactics of a forensic medical expert in substantiating the conclusion should be strictly unified and include the phased use of morphohistological, planktonoscopic and laboratory physicochemical research methods.

However, the implementation of the above task is somewhat difficult without attempts to find out the reasons that led to the development of extreme conditions associated with a number of exogenous and endogenous factors.

Exogenous factors, or risk factors, include:

• a) sudden entry into the aquatic environment with the development of a traumatic situation (feeling of fear) - more often a reflex type of drowning develops;
• b) the occurrence of psychogenic tension (stressful situation) associated with swimming and diving in an unfamiliar reservoir and having unusual conditions for a particular person (bottom unevenness, increased vegetation of the reservoir, uneven temperature due to spring waters, fast flow with the formation of water funnels, etc.) . At the same time, reflex, spastic, mixed and less often aspiration types of drowning can develop;
• c) entry of a person into an aquatic environment that differs sharply from the temperature of the human body, with the development of cold shock phenomena (especially dangerous is the temperature difference between the aquatic environment and the human body, exceeding 20-25 ° C). Such a situation is more often accompanied by the development of a reflex, less often spastic type of drowning, due to a sharp inhibition of the central nervous system;
• d) hydrostatic pressure at a depth of 1.5-2 meters or more causes compression of peripheral vessels and can lead to collapse. Pressure on the pliable abdominal wall causes organ compression abdominal cavity, displacement of the liver, stomach, intestines, change in the position of the diaphragm, disrupting cardiac activity.

Endogenous factors form a risk group. It includes various negative causes that entail the occurrence of extreme conditions, namely:

a) seasonal maladjustment of the organism to the aquatic environment. Long-term absence of contact of the body with the aquatic environment of reservoirs violates the stabilization of physiological processes when the human body is immersed in water. A similar situation occurs in almost all regions of the country, where the mass swimming season lasts only 2-3 months. At the same time, even in a practically healthy young person, during the first bath after a long break, there are acute functional changes in the central nervous system, cardiovascular and pulmonary systems. There is rapid fatigue, decreased blood pressure, a significant increase in heart rate with a weak pulse wave, rapid shallow breathing, etc. Physiological parameters are normalized only 15-30 minutes after leaving the reservoir. With subsequent bathing, such changes become less pronounced and quickly return to normal. Complete adaptation of the body to the aquatic environment with the stabilization of physiological parameters occurs on average after at least 5 regular daily baths, carried out in a strict regimen. In cases of death of persons in this group, the pathogenetic type of drowning may be different, including all 4 variants;

b) decompensation of the physiological capabilities of the body in case of overstrain of the cardiovascular and respiratory systems during long or intensive swimming and diving (sports swimming, swimming in an attempt to self-rescue, etc.). In this case, the aspiration type of drowning develops more often;

in) accompanying illnesses, which are a trigger for the development of drowning:

• - organic and functional diseases of the cardiovascular system, lungs, central nervous system (IHD, heart defects, cardiopathy various genesis, pneumosclerosis, chronic pneumonia, epilepsy, etc.);
• - diseases of the hearing organs with perforation of the eardrum;
• - unfavorable allergic status (including specific allergy to the aquatic environment).

In this group, a spastic or reflex type of drowning occurs more often, a mixed type is possible;

G) the presence of alcohol intoxication organism, leading to inadequate actions of the deceased. In cases of intoxication, an aspiration or mixed type of drowning often develops. When assessing the degree of alcohol intoxication, it is necessary to take into account the possibility of reducing the true concentration of ethanol due to the hydremic effect - hemodilution;

e) traumatic injuries(mainly the skull, cervical spine, chest and abdomen), occurring before entering the water, at the time of immersion in a reservoir or in the reservoir itself. With injuries, various types of drowning are observed, determined by the nature of the damage and the body's response to the aquatic environment;

e) swimming and diving after a heavy meal. The overflow of the stomach leads to redistribution of blood, its deposition in the gastrointestinal tract, which causes relative hypoxia of the brain, other organs and systems, thereby reducing the body's resistance and its reserve capabilities in the fight against oxygen starvation. In addition, the pressure of the aquatic environment on the anterior abdominal wall causes vomiting. In this group, the aspiration type of drowning is more often observed.

Thus, exogenous and endogenous factors play a certain role in the development of drowning, which creates the need to systematize diagnostic features depending on the type of drowning. The complexity of the implementation of this task lies in the fact that for the purposes of diagnosing drowning, a set of various signs and methods, most of which were developed without taking into account the type of drowning, which significantly reduced their practical significance. In addition, when tested in expert practice, a number of diagnostic features turned out to be untenable, and some, although evidence-based, were not widely used in forensic medical examination due to the excessive technical complexity of their detection.

In this regard, the further presentation of the material is carried out taking into account this provision, focusing the attention of forensic experts on a rational set of the most reliable, easily detected and implemented diagnostic signs and methods.

1. Diagnostic signs for aspiration type of drowning

a) Drowning in fresh water.

The skin is pale, cold, often "goose-like". Corpse spots are grayish-bluish (gray) due to blood thinning with water, appear quickly, after 30-40 minutes. After removing the corpse from the water and exposure to air, the spots turn pink due to oxygenation through the loosened epidermis, but their bluish hue remains. At the mouth, nose, and airways, white, finely bubbling, persistent foam, sometimes with a pinkish tinge, is associated with hemolysis of red blood cells. The lungs are enlarged in volume, heavy due to hyperhydria ("balloon" appearance). For an objective assessment of the degree of airiness of the lung tissue, as a diagnostic sign of aspiration of the drowning environment, a technically simple and fairly objective method for examining the lungs is proposed. After the isolation of the thoracic organ complex, the lungs are separated with ligatures applied to the bronchi, they are weighed, and then each of the lungs is placed in a vessel with water, preferably glass, on the wall of which the liquid (water) level is marked until the lungs are immersed. After that, the lung is completely submerged under water, the level of liquid (water) rise is noted. The lung is removed and its volume is determined by the amount of liquid displaced in the vessel by adding water from a measuring container (measuring cups, flask, cylinder, etc.) to the upper mark (water level in the vessel after the lung is immersed). The coefficient of airiness of the lung tissue, determined by the ratio of the volume of the lungs to their mass, was, according to our data, an average value of 1.43±0.13. Due to significant damage to the surfactant (a substance lining the alveoli and preventing the alveoli from collapsing and penetrating the water-air environment through their wall), the hypotonic environment of the reservoir in the lungs causes atelectasis foci with fluid accumulation in the pulmonary alveoli, early edema of the interstitial tissue. Under the pleura, more on the posterolateral surfaces of the lungs, banded, large-focus, reddish hemorrhages without clear boundaries (Paltauf-Rasskazov-Lukomsky spots) are formed. Heart failure is realized according to the left ventricular type, as it is associated with heart fibrillation and is accompanied by an overflow of liquid blood in its left section. Confirmation of ventricular fibrillation is an increase in the transverse striation of the myocardium (contractural degeneration), bands of contraction and rupture of individual myofibrils or the entire muscle fiber (myofragmentation).

Attention is drawn to the increased extravasation of fluid into the serous cavities, swelling of the wall and bed of the gallbladder, membranes and substance of the brain. There is a significant amount of urine in the bladder. Hydremia by the drowning environment leads to the rapid development of the phenomena of osmotic hemolysis of erythrocytes, the severity of which is established both with the help of conventional biochemical studies for free hemoglobin, and by staining the blood plasma pink, imbibition of the intima of the vessels with blood pigment. In connection with heterogeneous hemodilution, the processes of hemolysis are significantly expressed in the arterial system.

At the time of drowning, together with water through the wall of the alveoli, the constituent particles of the reservoir environment enter the body. Of particular expert importance is plankton (diatoms), which is present in almost any reservoir and is extremely resistant to various kinds of external influences. The silica shell of diatoms is not destroyed in the body under the influence of post-mortal autolytic processes, and plankton can be established in the medullary canal of long tubular bones even in skeletonized corpses. Each reservoir has a certain species specificity of plankton, and the number of diatoms mainly depends on the season. The maximum of vegetative activity falls during the warm period, and therefore, when drowning in the swimming season, diatoms will be clearly detected in the internal organs, bone marrow, and vascular plexuses of the brain. The number of identified diatoms can reach several tens in each seized object. When carrying out a planktonoscopic study, in addition to establishing plankton, it is necessary to carry out a qualitative identification of diatoms in the environment of a reservoir, in the lungs and other organs and tissues (liver, kidneys, bone marrow, choroid plexuses of the brain). The latter allows, in addition to a reliable statement of the fact of intravital penetration into the body, together with the environment of the reservoir, to resolve the issue of the place of drowning.

The flow of water from the lungs into the arterial bed during drowning entails significant changes in the water and electrolyte balance of the body, characterized mainly by heterogeneous hemodilution and a violation of the potassium-sodium ratio, which acquires diagnostic significance for substantiating the causes of death.

The phenomena of hydremia are established on the basis of a comparative study of blood taken from the arterial and venous bed. For these purposes, blood obtained from the right and left hearts, from the common iliac artery and the inferior vena cava, is examined using methods well known in the art. clinical medicine(determination of the specific gravity of plasma and whole blood, dry residue, viscosity, plasma protein, etc.). However, osmotic and especially post-mortem hemolysis to a certain extent neutralizes the processes of heterogeneous hemodedulation, which somewhat reduces the practical significance of these methods. In this regard, it is more expedient to study the value of the refractive index of the hemolysate or protein-free filtrate of the compared blood samples according to the method of S.S. Bystrov (1975). Hemolyzation of blood is carried out using solid carbon dioxide (dry ice) and acetone. Protein-free blood filtrate is obtained by adding an equal volume of 10% trichloroacetic acid solution to it, followed by centrifugation. Comparative ratios of the refractive indices of hemolysates and protein-free filtrate in the blood from the arterial and venous system with a high degree of reliability show a more significant dilution arterial blood. For the same purposes, it is recommended to perform a diagnostic test directly at the dissection table with separate application of drops of arterial and venous blood on filter paper, evaluating the results by the area of ​​the spot and the severity of the yellowish halo around it; the wider the halo and the larger the spot area, the greater the degree of blood thinning with water. With heterogeneous hemodilution (aspiration and mixed types of drowning), the area of ​​the spot and halo that arose from a drop of arterial blood often increases by 50% or more compared to that from a drop of venous blood (this sign should be considered reliable if the indicator increases by 30%).

The content of sodium and potassium in the blood with this type of drowning also undergoes significant changes, which are of a regional nature. When studying the level of electrolytes according to the generally accepted method using flame photometry or using ion-selective electrodes, a significant increase in the concentration of potassium in the plasma (3-4 times) and a decrease in the sodium content (by 50%) are clearly revealed. Moreover, more significant changes occur in the arterial system, especially in the blood from the left side of the heart, where the value of the potassium-sodium ratio increases by more than 5 times.

Thus, the listed signs indicate the fact of the penetration of the drowning medium (fresh water) into the human body, which allows them to be used to prove the aspiration type of drowning.

b) Drowning in salt (sea) water

This type of aspiration type of drowning has no signs indicating the penetration of the reservoir environment into the blood. The phenomena of hemolysis and heterogeneous hemodilution are absent, on the contrary, there are processes of hemoconcentration of arterial blood with an increase in its viscosity coefficient and hypovolemia.

In the lungs, there is a picture of focal atelectasis, sharp edema and large-focal hemorrhages with a significant decrease in the airiness of the lung tissue. The foam found in the airways and lungs is fine-meshed and bright white in color. Planktonoscopic examination of the organs of the deceased was unsuccessful. The study of the state of the electrolyte balance of the blood also does not reveal noticeable changes, and therefore no conditions are created for the occurrence of ventricular fibrillation of the heart.

Thus, the diagnostic substantiation of expert conclusions about the cause of death is carried out mainly on the basis of changes in the lungs.

2. Diagnostic signs in spastic (asphyxic) type of drowning.

The leading link in the pathogenesis of this type of drowning is the development of acute functional disorders. external respiration with the occurrence of hypoxia phenomena, which leads to the formation of morphological features characteristic of the so-called asphyxic picture of death. However, a thorough analysis of the totality of all detected signs makes it possible to prove the spastic type of drowning with a high degree of certainty. In the sectional picture, attention is drawn to the severity of cadaveric spots and their blue-violet color, cyanosis of the skin, especially the face; the presence of petechial hemorrhages in the mucous membrane of the eyelids, albuginea eyeballs, point hypostatic hemorrhages in the skin in the area of ​​cadaveric spots. Often there are signs of involuntary excretion of feces, urine, sperm, discharge of the Christeller plug from the cervical canal of the uterus. Bladder contains a small amount of urine. The internal organs are sharply plethoric, with petechial hemorrhages. There is a sharp filling of the right side of the heart with blood. At the same time, due to the increased lymph outflow from the lungs and the flow of lymph in significant quantities into the thoracic lymphatic duct, venous blood is thinned compared to arterial blood. Loose blood clots are often found in the left side of the heart.

Persistent spasm of the larynx causes the formation of a number of signs that are pathogenetic for this type of drowning. In connection with laryngospasm and chest excursion in case of pseudorespiratory respiratory movements the intrapleural pressure sharply decreases, which leads to an increase in the volume of the lungs, their significant airiness (the coefficient of airiness reaches a value of 2.0 units and above). In the lungs, there is a thinning of the interalveolar septa, their ruptures with hemorrhages in the lung tissue, acute emphysema of the lungs (“marble” lungs) occurs. The lungs are dry, as a rule, they do not find foam, but if it is found, then in a small amount and has a bright white color. In the pulmonary veins, especially in the left side of the heart, air bubbles are often found, which penetrate into the vascular bed through the damaged lung tissue. This sign is reliable only when taking into account the severity of air embolism and the exclusion of the possibility of presence of putrefactive gases in the cavity of the heart. For these purposes, it is recommended to use a simple device (like a blood transfusion system), consisting of a container with a drain tube in the bottom area (tube), a rubber catheter with an injection needle at the end, a glass measuring burette, both end drain tubes of which are connected to the catheter, two adjustable clamps applied to the catheter in the area of ​​the burette. Using clamps, the entire system is filled with water, after which the needle is inserted into the left side of the heart, both clamps open. The level of the water container should be such that air from the heart cavity, displacing water, enters the measuring burette. The amount of air is determined by the volume of water it displaces from the burette. To eliminate expert errors associated with the possibility of putrefactive gases in the heart cavity, the system used must be filled with weakly concentrated colorless aqueous solutions of lead salts (from 0.1 to 1.0%). It is more expedient for these purposes to use a 0.5% aqueous solution of lead acetate. This lead salt is easily soluble in water and does not change the color of the solution. If there are putrefactive gases in the cavities of the heart, one of the products of which is hydrogen sulfide, they will cause a clearly visible reaction with the formation of lead sulfides, which will precipitate black.

In addition, it is also necessary to perform a puncture of the right side of the heart, where putrefactive gases usually form much earlier and in a larger volume than in the left side.

The occurrence of laryngospasm with the loss of communication with the atmosphere, as you know, leads to a significant decrease in pressure in the nasopharynx. In this regard, due to the pressure difference, the drowning medium through pear-shaped cracks begins to flow into the sinus of the main bone. Its volume can reach 5 ml or more. After removing with a chisel top wall sinus fluid is taken with a syringe, its volume is determined, then native preparations are prepared for microscopic examination in order to identify plankton, plant spores, protozoa and other elements of the reservoir environment. In cases of late section of the corpses of persons removed from the water (a skeletonized corpse or with pronounced putrefactive changes) or during repeated examinations (exhumations), the study of the sinus of the main bone is also advisable. If there is no liquid in it, it is recommended to inject 2 ml of distilled water into the sinus with a syringe, followed by its extraction and examination of native preparations under a microscope for the presence of elements of the drowning environment. Even with a long post-mortem period, it is often possible to obtain positive results.

A decrease in pressure in the nasopharynx and involuntary swallowing movements lead to the penetration of large amounts of water into the stomach and duodenum. Up to 1 liter or more of fluid can be found in the stomach.

To exclude its food origin, it is necessary to identify the liquid with the environment of the reservoir, in particular, by the presence of contaminants. A method (S.S. Bystrov, 1975) is recommended for studying fluid from the stomach using ultraviolet rays, which cause the luminescence of oils and petroleum products, which often pollute water bodies.

Acute circulatory disorders in the area of ​​the small circle in the spastic type of drowning causes significant venous stasis of blood, mainly in the system of vena cava, which leads to venous hypertension. As a result of this phenomenon, a retrograde reflux of erythrocytes into the lumen of the thoracic lymphatic duct occurs. The degree of lymphohemia and its extent along the duct depends on the severity of laryngospasm. In this regard, microscopic examination of the thoracic lymphatic duct is recommended to prove the type of drowning. Before the separation of the thoracic lymphatic duct in the area of ​​its mouth and in the initial section, two main ligatures are applied, then, with the help of additional ligatures, the duct is divided into 3 fragments: initial, middle, final. The isolated and ligated duct is fixed in formalin, and each fragment is subjected to histological examination (hematoxylineosin staining), and a counting chamber is used to quantify lymphemia.

Thus, the spastic type of drowning, without signs of penetration of the reservoir medium into the lungs and vascular bed, can be objectively substantiated by a diagnostic tetrad (water in the sinus of the main bone, acute pulmonary distention, air embolism of the left heart, lymphohemia of the thoracic duct), indicating intravital occurrence of laryngospasm when a person enters the water.

3. Signs of a reflex type of drowning.

Since this type of drowning is not characterized by laryngospasm and the penetration of the reservoir environment into the body, there are no changes in the lungs. There is a sharp pallor of the skin and skeletal muscles due to angiospasm, a sharp plethora in the system of the inferior vena cava and signs of acute death. Careful histological examination is necessary, especially endocrine system, which allows you to establish the presence of acute functional disorders in the human body. Thus, the reflex type of drowning does not have pronounced diagnostic signs and can be determined on the basis of a combination of data on the circumstances of the incident, anamnestic status and the results of a study of corpses, excluding the possibility of other variants of thanatogenesis.

4. Signs of a mixed type of drowning.

Depending on the predominance of one or another type of drowning, the sectional picture and the results of additional laboratory methods will be extremely different. Common to this type are signs that indicate a violation of external respiration to one degree or another, which is determined by the pathomorphological picture of the lungs. The level of morphological manifestation of acute hypoxia will also vary. The severity of signs indicating the penetration of the drowning environment into the body or accompanying a spasm of the larynx will vary widely. For expert substantiation of thanatogenesis in this type of drowning, it is important to quantify the entire complex of diagnostic features that characterize aspiration, spastic or reflex types of drowning.

Given that the cause of drowning may be a mechanical injury, in any case, when examining corpses removed from the water, it is necessary to conduct a targeted study to identify it. In order to establish or exclude barotrauma when jumping into the water, it is necessary to examine the eardrums. The presence of hemorrhages in soft tissues of the cranial vault, sternocleidomastoid muscles, the region of the nuchal ligament and in the interspinous ligaments of the lumbar spine requires an examination of the spine, spinal cord. For the cervical spine, the method of V.A. Sveshnikova (1957), and for breastfeeding and lumbar- methods of A.A. Solokhina (1986) and Yu.S. Isaeva (1982). When examining the corpses of persons removed from the water, it is necessary to take into account the possibility of a human corpse falling into a reservoir, which is what the forensic medical expert must establish by determining the cause of death before the body enters the water.

METHOD FOR ESTABLISHING THE TYPE OF DOWNING

The recommended method, which makes it possible to objectify the conclusion about the type of drowning, is based on a quantitative assessment of the severity of a number of diagnostic features, taking into account their interdependence. Evaluation of the severity of each of the features used is made conditionally on a 5-point system.

All signs are divided into 2 groups. The first group of signs is a consequence of the penetration of the drowning environment into the body. The second group is associated with the severity of spasm of the larynx and its duration.

The first group includes the following features:

a. Presence of plankton (P) in internal organs and tissues:

• 1) no plankton - 1 point;
• 2) single diatoms in only one of the studied objects - 2 points;
• 3) single diatoms in each of the seized objects - 3 points;
• 4) up to 10-20 diatoms in each of the objects - 4 points;
• 5) a lot of diatoms in each of the objects - 5 points.

b. The phenomena of heterogeneous hemodilution (D): dilution of arterial blood compared to venous:

• 1) identification of the reverse pattern: statistically significant dilution of venous blood by lymph (t> 3.0) - 1 point;
• 2) no signs of dilution in terms of arterial and venous blood - 2 points;
• 3) tendency to dilute arterial blood (statistically weak degree reliability, 2.5
• 4) statistically significant difference in the index due to dilution of arterial blood (3.0
• 5) a sharp difference with a high degree of statistical significance (t> 3.5) compared indicators due to arterial hemodilution - 5 points.

in. Osmotic hemolysis (D) due to the dilution of arterial blood:

• 1) absence of hemolysis - 1 point;
• 2) the initial phenomenon of arterial blood hemolysis in the absence of it in the venous blood (established only by laboratory methods) - 2 points;
• 3) moderately pronounced phenomena of hemolysis of arterial blood (staining of plasma in a pinkish color) - 3 points;
• 4) clearly visible phenomena of hemolysis of arterial blood (plasma staining red, aortic intima acquires a pinkish tint) - 4 points;
• 5) pronounced phenomena of hemolysis of arterial blood (the impossibility of obtaining plasma, the supernatant becomes dark red, the endocardium and aortic intima are dark red) - 5 points.

d. Morphological features (M), indicating the possibility of penetration of the reservoir environment into the body (see pages 10-13):

• 1) absence of morphological features - 1 point;
• 2) a tendency to the appearance of individual indistinct signs - 2 points;
• 3) the presence of only a few distinct features - 3 points;
• 4) identification of several well-defined morphological features - 4 points;
• 5) a clear expression of the absolute majority of morphological features - 5 points.

The second group consists of the following diagnostic signs:

a. Establishment of air (B) in the left side of the heart:

• 1) lack of air - 1 point;
• 2) traces of air (separate air bubbles) - 2 points;
• 3) the presence of up to 3 cm3 of air - 3 points;
• 4) the presence of up to 5 cm3 of air - 4 points;
• 5) the presence of a large amount of air (more than 5 cm3) - 5 points.

b. The degree of airiness of the lung tissue (L):

• 1) air coefficient within 1.00-1.20 - 1 point;
• 2) air coefficient within 1.20-1.50 - 2 points;
• 3) air coefficient within 1.50-1.70 - 3 points;
• 4) air coefficient within 1.70-2.00 - 4 points;
• 5) air coefficient over 2.00 - 5 points.

in. The degree of lymphemia (E) in the thoracic lymphatic duct:

• 1) absence of erythrocytes in the thoracic lymphatic duct - 1 point;
• 2) single erythrocytes in the final section of the thoracic lymphatic duct (mouth area) - 2 points;
• 3) single erythrocytes in the middle section of the thoracic duct in the presence of a moderate number (tens) of them in the final section - 3 points;
• 4) single erythrocytes in the initial section of the thoracic duct, if they are present in the final and middle sections of it - 4 points;
• 5) a lot of red blood cells throughout the thoracic lymphatic duct - 5 points.

d. Detection of fluid in the sinus of the sphenoid bone (G):

• 1) lack of fluid - 1 point;
• 2) traces of liquid (no more than 0.5 ml) - 2 points;
• 3) the presence of liquid up to 1.5 ml - 3 points;
• 4) the presence of liquid up to 3 ml - 4 points;
• 5) the presence of fluid over 3 ml - 5 points.

The type of drowning (t) in persons removed from the water is determined by the ratio of the severity of the above signs, evaluated on a 5-point system, using the following formula:

t \u003d (v + l + w + e) ​​/ (p + e + g + m)

• T is the ratio of the studied features;
• C - scoring degree of air embolism of the left heart;
• L - point indicator of the degree of airiness of the lung tissue;
• E - scoring the degree of lymphohemia in the thoracic lymphatic duct;
• W - score for the presence of fluid in the sinus of the main bone;
• P - point indicator of the presence of plankton in the studied organs;
• D - score indicator of the degree of heterogeneity of hemodedulation (the degree of dilution of arterial blood);
• G - score of the degree of osmotic hemolysis;
• M - scoring the degree of severity of morphological diagnostic features.

With various types of drowning in quantitative terms, the coefficient T ranges from 0.2 to 5.0. So, with a spastic (asphyxic) type of drowning, accompanied by a pronounced spasm of the larynx, the T coefficient is significantly higher than 1.0 (approaching 5.0). With the aspiration type of drowning, the numerical index of the coefficient is much lower than one (within 0.2-0.4). In cases of the reflex type of drowning, which proceeds without significant violations of the function of external respiration and without the penetration of the drowning medium into the body, the digital indicators of the T coefficient are within 1.0.

The mixed type of pathogenesis of drowning is characterized by various fluctuations in the numerical indicators of the T coefficient, both upward and downward, which will depend on the specific mechanism of death.

Thus, the use of the proposed methodology makes it possible to objectively prove the type of drowning and the immediate cause of death.

BASIC PRINCIPLES FOR PATHOLOGICAL AND ANATOMICAL DIAGNOSIS AND CONCLUSIONS IN THE STUDY OF THE BODIES OF PERSONS DIE FROM DROWNING

Compilation of a pathoanatomical diagnosis is carried out on the basis of the generally accepted provision on the rationale for the nosological form of the pathological process. In the structure of the diagnosis, three main sections are clearly distinguished. In the first section, based on the forensic examination of the corpse and data additional methods research, the main pathology is indicated, its thanatogenetic mechanism is revealed with mandatory confirmation by specific diagnostic criteria. The second section of the diagnosis, which includes complications of the underlying pathological process, reflects signs that prove a specific immediate cause of death. And, finally, the third part of the diagnosis combines concomitant pathological processes or premortal factors (trauma, alcohol intoxication, etc.) that contribute to the onset of death.

In the forensic medical report, the expert must reflect, in addition to substantiated answers to specific questions posed by the lawyer, pathogenic mechanism and the conditions under which drowning occurred. Regardless of the issues required for resolution, the forensic medical report must necessarily include the rationale for the following sections:

1. Establishment of the cause of death and the pathogenetic mechanism of its onset.
2. Determining the statute of limitations for death.
3. The presence of injuries and the nature of their connection with the onset of death.
4. Identification of diseases and their influence on the development of a lethal outcome.
5. The presence and degree of alcohol intoxication.
6. Exo- and endogenous factors contributing to the development of drowning.

Literature

1 Methodology for proving the pathogenetic type of drowning / Isaev Yu.S. // Mater. II All-Russian. congress of forensic doctors: abstracts. - Irkutsk-M., 1987. - S. 282-284.

The analysis of the literature devoted to modern and historical principles of drowning diagnostics was carried out. The article reflects the evolution of approaches to solving this problem, ranging from the most banal and absurd views dating back to the Middle Ages, ending with modern methods widely used in the global forensic practice. The most complete classification of drowning with a detailed description of the pathogenesis of each of its types is presented. A separate part of the article is devoted to aspects that are often ignored by many authors. We are talking about establishing the fact of posthumous immersion of the body in water, death in water and the allocation as such to an independent group of the reflex type of drowning. The key place of research is occupied by differential diagnostics of types of drowning. Despite the lack of specific data and markers, it was possible to identify groups of features most characteristic of each of them. The final part of the publication shows modern methods microscopy. The main nuances of the histological examination and the diatom test are disclosed in detail.

death in water

drowning diagnosis

drowning

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Drowning is a type of violent death that occurs when a person is immersed in water (rarely another liquid), due to an acute violation of the functions of the vital systems of the body under the influence of the aquatic environment. In the study of corpses removed from the water, a number of fundamental questions arise: lifetime entry of a person into a reservoir, thanatogenesis of death, clarification of other causes contributing to the development of drowning.

The purpose of the study was the coverage of modern methods and methods for diagnosing death from drowning, used both in domestic and foreign forensic practice, as well as considering the evolution of approaches to solving this problem.

Materials and methods of research

The research methods were the study modern approaches to the diagnosis of drowning, as well as a comparative historical analysis with subsequent generalization and systematization of the data obtained. The materials of the study were domestic and foreign journalistic research publications, reflecting the range of approaches to the study of this issue. The use of these methods, as well as the analysis of the material used, made it possible to ensure the objectivity of the conclusions and results obtained.

Research results and discussion

The problems of diagnosing drowning have been known since ancient times. The first references are already found in Hsi Yuan Chi Lu (1247). The chapter "Drowning" includes both common beliefs, devoid of any scientific basis (the position of the hands, eyes and hair of the victim as a way to determine the nature of death; determining the posture during swimming, characteristic of men and women), and a description of the signs used until now in modern expert activity (the presence of a foamy liquid in the nasal and oral cavities of the victim, the discovery of a drowning environment in the stomach as evidence of the victim's lifetime exposure to water). In Europe, the first works on forensic medicine appeared during the Renaissance. The textbooks of Pare, Fidelis, de Castro, Platter, Zakia, Bona, Valentini were the most representative. Ambrois Paré le Houvre (1575) (France) outlined the signs proving the survival of drowning: the presence of water in the stomach and abdominal cavity, the presence of foam released from the external nasal passages and oral cavity, abrasions on the forehead and fingers resulting from involuntary movements with damage to the bottom before death. Fortunatus Fidelis, Italy, points out in De Relationibus Medicorum (1602) that the diagnosis of drowning is usually not difficult: when the victim is drowned bloated belly; mucous discharge from the external nasal openings and foamy discharge from the mouth are observed. The cause of swelling is not a large amount of absorbed water, but the release of steam formed when the liquid is heated during the process of decay. Rodrigo de Castro (Portugal) classifies bloating, mucus from the nostrils and foam from the mouth as signs of drowning, which are absent in cases of post-mortem immersion in water. At the same time, he refutes abrasions on the fingertips as a sign of drowning, which also occurs when the body is posthumously immersed in water. The author argues that the rise of the body to the surface may be the result of its being in the water. The work of Paulus Zakia emphasizes the difficulties in the differential diagnosis of drowning and post-mortem immersion of the body in water. He, along with Pare, Fidelis, and de Castro, unanimously recognize the following symptoms: swollen abdomen filled with water, mucous discharge from the nasal passages and frothy discharge from the mouth. The secret from the nasal passages is a consequence of the filling of the ventricles of the brain with water after breathing stops. The released foam from the oral cavity appears as a result of increased expulsion of air from the lungs and respiratory tract, respectively, the cause of death is respiratory arrest, and not the absorption of water. The third sign highlighted by Paulus is abrasions on the fingers and face that occur when trying to swim out, grabbing the bottom soil. Johannes Bohn (Germany) in 1711 criticized the signs of drowning mentioned by Pare, Fidelis, de Castro, Platter and Zakchia, emphasizing that these signs are uncharacteristic in some cases of drowning. Such a sign as the presence of fluid in the stomach and respiratory tract is often weakly expressed, since the volume of water is detected insignificant.

According to Yu.S. Isaeva and V.A. Sveshnikov distinguish four main types of drowning in water: aspiration, spastic (asphyxic), reflex (syncope), mixed type.

1. The aspiration type of drowning is characterized by the ingress of water into the airways and lungs with the further development of mechanical asphyxia from the closure of the airways. When drowning in fresh water, liquid penetrates into small alveoli with their further rupture due to hydrostatic pressure, water penetrates into the general circulation, causing hemodilution, hemolysis of erythrocytes and, as a result, a violation of the water and electrolyte balance, leading to fibrillation of the left heart. The duration of the drowning period is 3-5 minutes. When drowning in salt water (sea), water from the bloodstream enters the lumen of the alveoli due to osmotic pressure, thereby causing the process of acute pulmonary edema. Cardiac arrest, as a rule, as a result of asystole develops gradually, within 7-8 minutes with an increase in myocardial hypoxia. Cardiac activity stops after breathing for 10-20 seconds.

2. Spastic (asphyxic) type of drowning is characterized by the occurrence of persistent laryngospasm in response to irritation of the larynx mucosal receptors by the drowning environment, which also triggers the mechanism of mechanical asphyxia from closing the airways. Foreign authors claim that the experimentally proven spasm lasts about 2 minutes, then it is replaced by other pathological mechanisms, such as vagal-vagal cardiac arrest, which reflexively occurs when fluid comes into contact with the upper respiratory tract. The duration of the drowning period is 5.5-12.5 minutes. The cessation of cardiac activity occurs against the background of arterial hypotension 20-40 seconds later than respiratory arrest. The frequency of occurrence, according to various authors, is from 35% to 61%.

3. Reflex (syncope) type of drowning is characterized by a sudden stop of respiratory and cardiac activity. An important role is played by the emotional background (feeling of fear, panic), as well as the presence of concomitant diseases. Given this, it would be more correct to speak not about drowning, but about death in water. The reflex type of drowning is observed on average in 10% of cases and develops more often in children and women.

4. A mixed type of drowning occurs on average in 35% of observations and is characterized by polymorphism of the detected signs, which is associated with a combination of different types of dying. More often this type of drowning can begin with laryngospasm, subsequently it resolves into the later phases of drowning, which entails the penetration of water into the respiratory tract and lungs with the development of phenomena characteristic of the aspiration type of drowning.

The diagnosis of drowning consists of a set of non-specific signs, each of which individually is not a reliable confirmation of the diagnosis. Numerous cases of death in the water due to acute pathological conditions cardiovascular and respiratory systems, injuries, as well as cases of post-mortem immersion of bodies in water in order to conceal a criminal act. In this regard, the diagnosis of "drowning" is a diagnosis of exclusion and is established when other causes of death are denied. The presence of an additional load tied to a corpse is not always evidence of forcible immersion in water; methods of suicide and posthumous concealment of a corpse are also possible.

The circumstances of death that make it possible to suspect death from drowning are: the removal of a corpse from the water of large reservoirs, the discovery on the shore of these reservoirs and in artificial containers with water or near them. The depth of the reservoir does not play a decisive role, just immersing the head or just closing the breathing holes with liquid is enough. In this case, the helpless state of the victim (alcohol and drug intoxication, unconsciousness, disability, etc.) is of decisive importance. Physically healthy people are also at risk of drowning, even professional swimmers. The risk increases with the development of asphyxic and reflex types of drowning, in particular with a sharp and unexpected immersion in water, when, as a rule, the victim becomes helpless and loses the ability to use swimming skills.

External examination begins with the inspection of clothing, which in most cases is wet with traces of silt and aquatic vegetation (algae). The skin, as a rule, is pale, cold to the touch, wrinkled on the palmar and plantar surfaces ("washerwoman's hands"). With a long stay of the corpse in the water, subcutaneous emphysema and areas of exfoliation of the epidermis appear along with appendages (“socks and gloves of death”), “goosebumps” - a sign of death in the cold. The totality of these signs in one combination or another is common to all types of drowning, as well as post-mortem immersion of the body in water, and for the most part carries information only about the presence of a corpse in water. The most valuable feature is persistent finely bubbling foam protruding from the mouth and nasal passages. However, it can also be observed with cardiogenic pulmonary edema, epilepsy, intoxication and electric shock. An important aspect is the detection of general asphyxia signs, such as subconjunctival hemorrhage and hemorrhage under the sclera of the eyes, puffiness and cyanosis of the face, involuntary urination, defecation, ejaculation and extrusion of the mucous plug in women. The nature of cadaveric spots can vary: from intense spilled (with asphyxial type of drowning) to light pink (with aspiration, due to dilution of blood with water).

The presence of general asphyxic signs detected during internal examination can also be characteristic of all types of drowning. These signs include: dark liquid blood, overflow of blood in the right half of the heart, plethora of internal organs, anemia of the spleen, subpleural and subepicardial hemorrhages (Tardier spots). The presence of liquid in the stomach, a drowning medium, with a characteristic admixture of silt and algae (Fegerlund's sign) with asphyxic type - there is a lot of liquid, with "true" - little. The possibility of post-mortem penetration of fluid into the gastrointestinal tract is rejected by most authors. Sign of Paltauf-Reiter-Wahholz - hemorrhages in the sternocleidomastoid muscle, muscles of the neck, chest and back - as a result of a strong muscle tension of a drowning person when trying to escape. Sample Bystrov S.S. ("oil sample" as a result of contamination of almost all water bodies with oil products) - a sample for determining intravital ingress into water. Ulrich sign - massive hemorrhage into the middle ear cavity ear canal- characteristic of a sharp dive to a great depth. Moro's sign - the accumulation of a small amount of fluid in the abdominal cavity - confirms only the presence of the corpse in the water, develops after 6-8 hours.

Despite the difficulty of diagnosing death in corpses removed from the water, a number of signs can be identified that contribute to resolving this issue. Conventionally, two groups of deaths can be distinguished. The first group is the causes of death not associated with direct exposure to water, and the second is directly drowning.

The first group includes all cases of posthumous immersion of the body in water, which is characterized only by the presence of signs of the corpse being in the water. Identification of clear signs of death, contrary to drowning, somewhat facilitates the diagnosis, however, the question remains about the lifetime entry of the victim into the aquatic environment and its (aquatic environment) influence on the development of the immediate cause of death.

Diagnosis of drowning is logically divided into its types. The aspiration type of drowning (drowning in fresh water) is characterized by persistent finely bubbling foam with a pinkish tint in the trachea and bronchi, possibly with an admixture of bottom soil and aquatic vegetation. The lungs are enlarged and heavier than normal, due to which they almost completely fill the pleural cavity. The lung tissue is hyperhydrated due to the penetration of fluid from the drowning environment (“balloon view”). On the posterolateral surfaces, large blurry hemorrhages of a pale red color in the form of stripes or spots (Rasskazov-Lukomsky-Paltauf spots) are found. Swelling of the bed and wall of the gallbladder and hepatoduodenal fold (a sign of F.I. Shkaravsky, A.V. Rusakov). There are a number of tests comparing blood samples in the right and left halves of the heart according to various indicators (such as electrolyte composition, specific gravity, freezing point difference, etc.), but the essence is to establish the fact of blood dilution in the arterial bed, which is also not typical. just for drowning. When drowning in salt water, processes of hemoconcentration of arterial blood occur with an increase in its viscosity coefficient and hypovolemia. In the lungs, there is a picture of focal atelectasis, sharp edema and large-focal hemorrhages with a significant decrease in the airiness of the lung tissue. The foam found in the airways and lungs has a fine-meshed appearance and a bright white color as a result of inspiratory dyspnea, as a result of which water begins to actively enter the respiratory tract, irritates the mucous membrane of the trachea and large bronchi, causing coughing movements. The mucus released in this case mixes with water and air, forming a foamy mass of a grayish-white color that fills the lumen of the respiratory tract. The diatom test, the study of the state of the electrolyte balance of the blood do not reveal noticeable changes. Thus, the diagnostic substantiation of expert conclusions about the cause of death is carried out mainly on the basis of emerging changes in the lungs.

Laryngospasm in asphyxic type of drowning leads to a number of processes that are characteristic of this type of drowning. Firstly, this is a decrease in pressure in the nasopharynx, which leads to a pressure difference with the environment and the flow of fluid into the sinus of the main bone (Sveshnikov's sign), and traces of fluid can also be found in the frontal sinus and in the middle ear cavity. Another consequence is the ingestion of a large amount of fluid and, as a result, its detection on the section (Fegerlund's sign). Secondly, this occurrence expiratory dyspnea, which leads to hyperaeration of the lungs, the development of acute emphysema and their increase in volume, rupture of the interalveolar walls with the occurrence of small focal hemorrhages, the development of air embolism. Lungs of a "marble look", increased airiness, fill almost the entire pleural cavity, rib prints are noted on the lateral surfaces. In the trachea and bronchi, fine bubble foam is absent or its small amount. Puncture of the left side of the heart reveals air bubbles. Thirdly, this is venous stasis of blood in a small circle, as a result - venous hypertension, as a result of which erythrocytes are thrown into the thoracic lymphatic duct.

During autopsy of corpses with a reflex type of drowning, there are no signs of drowning and blood changes, only the detection of concomitant diseases from the cardiovascular and respiratory systems is possible.

The mixed type of drowning occurs on average in 35% of cases and is characterized by polymorphism of the detected features characteristic of different types of drowning.

At histological examination lung tissues are determined by emphysematous foci and foci of edema. In the zone of swelling, the alveoli are expanded, their walls are thinned with areas of rupture of the partitions. The vessels collapsed. In the foci of edema, the picture is opposite: the capillaries are plethoric and dilated, the alveoli are of normal size and filled with a pinkish mass containing desquamated epithelium and erythrocytes. It is also possible to detect foci of atelectasis of the lung tissue, as well as areas of interstitial and intraalveolar hemorrhage. Exogenous particles in the form of impurities of bottom soil, aquatic vegetation and plankton are rarely detected by microscopy. Changes in the brain tissue are characterized by vascular changes, namely the expansion of capillaries and veins. The blood is liquid, in limited areas in the lumen of the vessels, adhesive accumulations of erythrocytes are found, as well as small-focal hemorrhages in the perivascular spaces. On Nissl-stained preparations, nerve cells with swollen shoots. The cytoplasm stains pale blue. The nucleus is enlarged, painted pale. The vessels of the pia mater are plethoric. Vascular changes in the heart are characterized by spasm of the interstitium vessels and anemia of the epicardial capillaries. The interstitial tissue is edematous and loosened, and in the thickness of the epicardium, foci of hemorrhage are found, which are different in nature. In the kidneys, the capillaries of the medulla are sharply dilated and filled with blood. The tubular epithelium is swollen, weakly stained. Shumlyansky's capsules are edematous, in the lumen of individual glomerular capsules there is a homogeneous mass with an admixture of erythrocytes. Intralobular capillaries of the liver and central veins are dilated and plethoric. Perivascular spaces for some extent contain a pale pink mass. The interstitial tissue is loosened, weakly colored. Liver cells are also weakly stained. The stroma of the gallbladder is loosened and edematous. Spleen - collagen fibers of the capsule and stroma are loosened. The vessels of the pulp are sharply anemic, erythrocytes are detected only over separate sections of the sinuses and arteries. The follicles are hyperplastic, the pulp is anemic.

The diatom test is based on the detection of diatom plankton present in any aquatic environment. When the drowning medium enters the lungs during life, during inhalation, plankton overcomes the pulmonary barrier and is carried by the blood stream to organs and tissues. When water enters the lungs posthumously, diatoms are not able to penetrate into the general bloodstream, and therefore do not spread throughout the body. According to its structure, diatom plankton are eukaryotic unicellular or colonial algae, which are present not only in water, but also in soil and air. The cell wall of diatoms contains a large amount of silica, due to which they do not break down for a long time, remaining in the tissues of the body, which contributes to their detection even in putrefactive corpses. For analysis from a practical point of view, it is recommended to remove an unopened kidney with a capsule and a ligature at the gate, as well as a fragment of the brain substance weighing at least 100 g. tubular bone. A sample of the drowning medium is taken as a control. In cases where there is no need to identify a reservoir, a piece of lung tissue is removed for control, since the lung tissue contains the fluid of the drowning medium. To avoid false-positive results, it is forbidden to use running water until the moment of material sampling is completed. Tools used during work, as well as containers for storing and transporting biomaterial, should be treated with a chromium mixture and rinsed with distilled water, or disposable sterile ones should be used. diagnostic sign it is recommended to count the detection of at least 20-30 diatoms in each of the studied preparations. In cases where a smaller amount is found, the samples are compared with controls. A false positive result is possible if the correct technique for removing, storing and examining the biomaterial is not observed. Some authors argue about the possibility of post-mortem penetration of plankton into the body, especially in the presence of damage. skin; at the use by the dead shortly before death of products or waters which could contain diatom plankton. Plankton can enter the body throughout life and, due to the difficult evacuation from the body, remains in the tissues for a long time. A false negative result may be due to the low concentration of diatoms in the drowning environment, the small volume of inhaled fluid (asphyxic and reflex types of drowning), as well as their destruction during sample preparation.

conclusions

The article describes the modern possibilities of forensic medicine in the diagnosis of death from drowning, as well as reflects the different points of view of the authors and the evolution of approaches to this issue. Despite the constant interest of global science in the topic of drowning and extensive research on this issue, there are still many blank spots. As before, it is not possible to accurately judge the prescription of death and the exact timing of the corpse's stay in the water, most accurately to carry out differential diagnosis related somatic diseases and "dry" types of drowning, to determine the reliability of the results of samples and analyzes, etc. Modern look in the future, connected with the solution of the issue of diagnosing death from drowning, is aimed at studying the molecular changes that occur in the body of victims under the influence of the drowning environment. Researchers are trying to establish more specific changes that are characteristic of drowning, and possible methods their detection.

Reviewers:

Zheleznov L.M., Doctor of Medical Sciences, Professor, Head of the Department of Human Anatomy, Orenburg State Medical Academy, Orenburg;

Polyakova V.S., Doctor of Medical Sciences, Prof., Head of the Department pathological anatomy SBEE HPE "Orenburg State Medical Academy" of the Ministry of Health, Orenburg.

Bibliographic link

We bring to your attention the journals published by the publishing house "Academy of Natural History"