Medical Jurisprudence, Forensic medicine and Toxicology. Vol. 1 (part 4 of 5)

Medical Jurisprudence, Forensic medicine and Toxicology. Vol. 1 (part 4 of 5)

As in the case of the chest, so wounds of the abdomen are serious, as a rule, mainly as they involve the abdominal viscera. The viscera may be wounded by a penetrating wound or by rupture, and the fatal result is due sometimes to internal hemorrhage or to shock, but generally to secondary septic peritonitis, which may be fatal in a few hours or only after days or weeks. Occasionally wounds of the abdominal viscera undergo spontaneous cure without surgical interference and with or without medical treatment. But as a rule they are fatal unless they receive proper surgical treatment. A wound of the abdominal wall may be penetrating without wounding any of the viscera. Such wounds may be fatal if they are infected, otherwise they usually heal readily and without danger unless they are extensive and the abdominal contents are exposed to the air. The gravity of penetrating wounds varies somewhat with the particular viscus or viscera injured. It is well not to examine wounds of the abdomen by the finger or probe too freely unless a laparotomy is anticipated; for a simple wound or penetrating wound without wounding of the viscera may thus be infected. Enough examination is necessary to diagnose between a simple and a penetrating wound of the abdominal wall.

RUPTURE OR WOUNDS OF THE ABDOMINAL VISCERA.

THE LIVER is most often wounded of any of the abdominal viscera, with the possible exception of the intestines, because of its size, and it is most often ruptured partly because of its size, but mostly owing to its friable consistence. Such injuries most often involve the right lobe, as it is much the larger of the two principal lobes. The anterior surface and inferior border is the most frequent site both of wounds and ruptures of the organ. Ruptures rarely pass entirely through the organ, but are generally not more than an inch or two in depth. They are usually directed antero-posteriorly or obliquely, rarely transversely, and the lacerated granular edges are not much separated as a rule (see Fig. 21). Rupture of the liver may be due to a blow, crush, or fall, or even to sudden muscular action if the organ is large and fatty. Thus Taylor[679] relates the case of a woman who died after child-birth of uræmic convulsions, and in whom there was quite an extensive hemorrhage into the liver beneath its capsule, and apparently due to violent muscular contraction. As we have already seen, the liver may be ruptured without the abdomen showing the marks of external violence. Rupture or wound of the liver is one of the causes of the fatality of wounds and injuries of the abdomen. The fatal result may be and often is due to hemorrhage; in other cases it is due to shock or the occurrence of peritonitis. Wounds of the liver heal readily and hemorrhage is arrested at once, as a rule, by the approximation of the edges. There may be little blood in and about the wound, but it collects in the right iliac region or in the pelvis and is not wholly coagulated. Unless the wound or rupture involves the vena cava, portal vein, or a large branch of either of these, the hemorrhage is apt to be slow and the victim may survive hours or even days, except for active exertion or repeated violence. Two cases illustrating the slowness of the hemorrhage have occurred in Guy’s Hospital. In one[680] the man, showing no urgent symptoms at the time, was sent away, and died a few hours later in a police-station. In this case the liver was ruptured nearly through its thickness, and a basinful of blood had been effused, causing death. In the other case,[681] which occurred to Wilks, the patient survived the accident ten days, and Taylor[682] cites a case which was reported to have ended fatally eight years after the accident. As a rule the injury is fatal, without treatment, within forty-eight hours. Not being immediately fatal as a rule, the victim of a rupture or wound of the liver can walk about, and may be capable of more or less severe muscular exertion after the injury, though the fact of such exertion has sometimes been used by the defence to prove that the rupture was not due to the particular violence in question.

Wounds and ruptures of the gall-bladder result in the effusion of bile. While rupture of the liver is not necessarily followed by peritonitis, rupture of the gall-bladder with the effusion of bile generally causes peritonitis, and is fatal in this way and not from hemorrhage. Rupture of the gall-bladder may be favored by the presence of gall-stones, but the result is still attributable to the injury.

SPLEEN.—Ruptures of the spleen may be due to a bruising violence in this region, and here too the skin may not show the marks of the contusion, though this fact is still employed by the defence to try to disprove the connection between the injury and the result. It is important to remember, from a medico-legal point of view, that an enlarged and softened spleen may be ruptured from a comparatively slight muscular exertion. This might occur in a sudden movement to avoid a blow, and the charge of manslaughter might be affected by the mode of the production of the injury and the previous abnormal condition. Only direct violence is liable to rupture the healthy normal spleen. Rupture and wounds of the spleen may be and generally are fatal from hemorrhage, owing to the vascularity of the organ; more rarely are they fatal from shock. Peritonitis is not a result to be expected.

The hemorrhage accumulates in the lower and left side of the abdomen or in the pelvis, and coagulation is imperfect if present at all.

KIDNEYS.—These are occasionally ruptured from violence, but more often from accident. Wounds of the kidney are rare, owing to the depth from the surface at which they lie. They are more accessible from behind. A wound from behind is generally extra-peritoneal unless it perforates the organ; not so a wound from in front. Accidents in which the lumbar region is forcedly flexed are most apt to be followed by injury to the kidney. The injury may cause no prominent symptoms, but usually lumbar pain and tenderness, frequent micturition and hematuria, and in severe cases the symptoms of hemorrhage and shock are present. The injury may be speedily fatal from hemorrhage or collapse, or more slowly fatal from peritonitis, when the peritoneum is involved, or from abscess and septic infection, or from uræmia if the other kidney is diseased. Slight injuries are generally recovered from. As is the case with the liver and spleen, so after injuries of the kidney the victim may walk about, etc., unless there is copious and immediate hemorrhage.

THE BLADDER may be wounded directly through the hypogastrium, vagina, or rectum; it may be punctured by a broken fragment of the pelvis, especially the pubis, or it may frequently be ruptured from blows, crushes, or falls. The latter accident occurs especially where the bladder is distended. The bladder may also rupture spontaneously from over-distention, which may or may not be favored by disease of the bladder wall, in which case rupture occurs more easily. Medico-legally the question may arise whether the rupture was spontaneous or due to injury. In this connection it should be remembered that the injury may leave no external mark of violence, and a case is recorded in which the bladder was ruptured by a fall in wrestling; but the question can be determined only by an examination of the bladder. If the wall of the bladder is thinned by the pressure of a calculus or from other causes, or if it is weakened by tubercular, syphilitic, or carcinomatous deposits or ulcerations, it may be spontaneously ruptured from slight distention or a slight degree of violence may rupture it. If violence has been employed it is responsible for the rupture, though the diseased condition may act as a mitigating circumstance; not so a distended bladder, as the latter is not abnormal. In spontaneous rupture from over-distention without disease of the bladder wall, stricture, hypertrophied prostate, or some such condition must be present to account for the over-distention. Spontaneous rupture of the bladder can, therefore, only occur when either disease of the bladder wall or obstruction of the urethra is present. No condition excludes rupture from violence. If there is an injury followed by the symptoms of rupture of the bladder and death and the bladder and urethra are healthy, there can be little doubt that death was due to the injury. Wounds or rupture of the bladder may be extra-peritoneal or intra-peritoneal. Rupture from disease of the bladder wall occurs at the site of the diseased and weakened spot, which is most often at the base of the bladder. Rupture of the bladder from violence occurs most often on the postero-superior wall, running downward from the urachus, in which case the peritoneum would be involved. A punctured wound of the bladder wall may be so minute that the leakage is very slow and the customary symptoms may be obscured, or the opening may be valvular in character, perhaps allowing escape of urine only when the bladder is not distended. The symptoms consist of pain, inability to micturate, and the presence of blood in the little fluid which can be drawn by a catheter. Fluid injected is not all returned and the bladder cannot be distended. After a time varying from a few hours to a few days, depending upon the size of the opening and the condition of the urine, peritonitis or peri-vesical cellulitis is set up, the former being generally fatal, the latter not necessarily so. Prompt surgical treatment may save the patient’s life by avoiding peritonitis. Extra-peritoneal ruptures are far less dangerous than intra-peritoneal, as in the former case cellulitis and abscess in the cellular tissue around the bladder, which may subsequently be treated by operation and drainage, take the place of peritonitis in the latter case, for which prevention is the only safe treatment. In extra-peritoneal rupture death, if it occurs, is generally due to septicæmia; in the intra-peritoneal variety it is due to peritonitis. These cases of injury to the bladder may die suddenly and speedily from shock or from peritonitis in three to seven days, or not until fifteen days or so. In punctured and incised wounds the urine escapes more slowly, peritonitis develops less early, and death is longer delayed. Hemorrhage in injury to the bladder is not usually serious; the blood is found partly in the bladder, partly in the pelvis, where the fluid extravasated by peritonitis is also found. The victim of a wound or rupture of the bladder may often walk about for some time after the injury.

STOMACH AND INTESTINES.—Punctured wounds, or, more rarely, incised wounds of the abdomen may involve these organs, or they may be ruptured by blows, crushes, and falls, or from disease. Stab-wounds of these viscera may be multiple from a single stab, the instrument traversing one coil, perhaps, and then wounding others, though this is less often the case than with gunshot wounds. Ruptures too may be multiple, though less often so than wounds. The ileum is most liable to rupture, though several cases of rupture of the jejunum are on record. Like the bladder, the stomach and, to a less extent, the intestines are more liable to be ruptured when distended. Ruptures of the stomach or intestines are seldom attended with much hemorrhage, while wounds may occasionally cause a serious and fatal hemorrhage from the wounding of a large blood-vessel. The principal danger lies in the leakage of the contents of the stomach and intestines, which almost always sets up a septic peritonitis. This may sometimes become localized and go on to spontaneous cure, though as a rule it becomes general and is fatal. In such cases early operation may avoid the fatal peritonitis. A punctured wound may be so small as to be closed by the mucous membrane, avoiding the escape of the contents of the gut. Or a wound may not entirely penetrate the wall of the stomach or intestines, which only gives way some days, perhaps, after the injury, though the injury is entirely responsible for the delayed result. These injuries are sometimes fatal immediately or very speedily from shock, while in other cases of very extensive injury there may be almost no shock, and the victim is aware of no serious injury. It is an important point to remember medico-legally that spontaneous rupture of the stomach or intestines may occur owing to ulceration due to disease. This can be determined by a careful examination of the wall of the stomach or intestines at the site of the rupture. A slight injury may also cause rupture if the wall of the gut is weakened by disease, as the disease causes greater liability to rupture. Here too it is to be remembered that a severe injury causing rupture may leave no mark of violence on the abdominal wall. The power of walking or other muscular exertion after such injuries of the stomach or intestines is not infrequently preserved, as recorded in numerous cases.[683] The prognosis in such injuries of the stomach and intestines is always extremely grave.

INCISED, PUNCTURED, AND CONTUSED WOUNDS OF THE GENITAL ORGANS.

These are not common as medico-legal cases. Self-castration or mutilation is sometimes practised by lunatics, idiots, or even intoxicated persons. Thus a man who, while intoxicated, cut off his genital organs and died the next day from the effects of hemorrhage was seen by Demarquay.[684] Circumcision in infants is also sometimes fatal from phlegmonous inflammation.[685]

Incised, lacerated, or contused wounds of the female genitals may be fatal from hemorrhage from many small vessels. Deeply incised wounds of the female genitals proves wilful and deliberate malice; accident is out of the question and suicide is improbable in such cases. But we sometimes have to determine between accidental, self-inflicted, and homicidal wounds of these parts, as accidental wounds may occasionally resemble those made by design and so may furnish more or less difficulty, unless all the circumstances are known. Thus Taylor[686] relates the case of a child in whom a sharp-pointed stick entered and passed through the posterior wall of the vagina as she fell from a tree. The stick was removed by a woman, and the child died in a little over a day from peritonitis. Unless the circumstances were known, this case might have caused suspicion of homicide.

Lunatics, idiots, and drunkards sometimes inflict on themselves wounds unlike ordinary suicidal ones. In other cases the various points we have enumerated in a previous section to distinguish between suicide, homicide, and accident may be applied to solve the case.

Contused wounds, such as kicks, etc., of the female genitals may be fatal from hemorrhage due to the laceration of the parts.[687] Like the wounds of the eyebrows, contused wounds of the vulva may sometimes resemble incised wounds owing to the sharp bony surfaces beneath. Careful examination allows a discrimination to be made from incised wounds. If hemorrhage occurs a long time after the alleged violence, it is probably due to natural causes, especially in cases of metrorrhagia, etc. It may be alleged in defence that contused wounds of the female genitals were inflicted post mortem, but besides the other features which we have already seen help to distinguish between ante-mortem and post-mortem wounds, we may add that kicks and other contusions of the vulva, if fatal, are so from hemorrhage or effusion of blood, and no post-mortem hemorrhage is enough to cause death.

INCISED, PUNCTURED, AND CONTUSED WOUNDS OF THE EXTREMITIES.

These may be fatal if a large blood vessel or vessels are opened, or sometimes if a compound fracture or wound of a joint becomes infected. They may also in some cases be fatal from shock, from the severity of the injury. As a rule they are the cause of civil suits, not of criminal ones. The various injuries may cause disability for a longer or shorter time, or even permanently, and more or less deformity may also remain. This may be the case with fractures, especially if they occur near the joints, in which case great caution should be exercised in giving an opinion or prognosis. It is a common mistaken idea of the laity that a fractured or dislocated limb can be made in every case as good as before the injury. On the contrary, they not infrequently leave a slight deformity and impairment of function, sometimes even under the best treatment. Dislocations may also leave a lasting disability or weakness, often owing to the carelessness of the injured person.

Wounds of an artery or vein, or both, may result in an aneurism or an arterio-venous aneurism. Wounds of nerves may cause paralysis and anæsthesia of the parts supplied. Wounds of muscles or tendons may cause weakness or complete loss of motion of particular joints. Wounds of the soft parts, if infected, may lead to cellulitis and phlegmonous inflammation, which may result in much injury. Wounds of joints, if penetrating, are serious, for without the proper treatment they may result in suppuration in the joint, disorganization of the joint, and final ankylosis. Before the use of antiseptic treatment such wounds were not uncommonly fatal. Fractures, simple or compound, or contusions of bone especially in young subjects, may be followed by osteo-periostitis and its consequences, which may require a long time for recovery after the fracture is entirely recovered from, and a still longer time before the limb can be used. These and many other of the various results of wounds and injuries of the extremities, causing deformity or disability, or both, can often be cured or improved by surgical treatment or operation.

THE MEDICO-LEGAL CONSIDERATION

OF

GUNSHOT WOUNDS.

BY ROSWELL PARK, A.M., M.D.,

Professor of Surgery in the University of Buffalo; _Attending Surgeon to the Buffalo General Hospital_; _Fellow of the German Congress of Surgeons_; of the American Orthopædic Association; of the American Genito-Urinary Surgeons’ Association; _of the New York Academy of Medicine_, etc., etc.

GUNSHOT WOUNDS.

GENERAL CONSIDERATIONS.

FEW medical men there are who have long engaged in practice who have not been compelled to take part in some medico-legal controversy in cases of accidental or alleged homicidal gunshot wounds. So soon as death occurs the surgeon ceases to work as such, but may continue to work as a medical jurist, and in preparation for this event must be ready to answer any questions bearing upon the case which, though possibly ridiculous in surgery, are or may be necessary in law. He may be called upon to testify as to the precise nature of a wound inflicted upon the body of a man seen before or after death; as to the means by which it was inflicted; whether the purport was suicidal or homicidal; how much blood was lost; whether the weapon was near to or at a distance from the body when fired; whether it were possible that the deceased could have fired it himself; whether after the reception of the wound the person could have moved or performed any act—in other words, whether death was instantaneous. He may be asked also as to genuine or spurious blood-stains, whether genuine blood-stains were human or from some other animal; whether possibly they were from the body of the deceased. He will be expected to tell from what direction the bullet or missile was fired; which the wound of entrance and which of exit, and many other things possible concerning the circumstances under which death occurred. It is unnecessary to state that questions of this nature call not only for conventional surgical skill, but for the highest degree of shrewdness and general information, as well as sometimes for expert knowledge with regard to small-arms and their ballistics.

It has been well said that the first duty of a medical jurist is to cultivate a habit of minute observation. When this is combined with a knowledge of what the law requires and with the results of a technical education, he will be able to meet all or nearly all of the scientific questions which may be asked of him. A learned judge once said that “a medical man when he sees a dead body should notice everything.” Certainly he should make a minute scrutiny of the body to note whether there are upon the dress or hands of the deceased marks of blood, or whether blood-stains are noted in different parts of the room; whether the body or any part of it is cold or warm; whether the limbs are cold or rigid or pliant, since by these means the accurate date of death may be more accurately determined.

EXAMINATION AND DESCRIPTION.

In determining facts attending a suspicious case of gunshot wound, there should be noted, if known, 1st, the exact time of death, as well as of infliction of the wound; 2d, location and attitude of the body; 3d, condition of clothing; 4th, anything of importance in its environment; 5th, external appearance of the body, as well as state of countenance; 6th, exact description of all marks of violence and of blood-stains; 7th, the presence of cadaveric rigidity and the surface upon which cadaver has been lying, as well as its age and condition of general nourishment; 8th, time when deceased was last seen alive or known to have been alive; 9th, time after death at which examination is made; 10th, all physical circumstances corroborating or arousing suspicions of suicide or homicide; 11th, account of an accurate internal post-mortem examination, in which direction of the bullet or missile is noted, along with a careful description of parts disturbed or injured in its course, large vessels or nerves cut across, effusions of blood, and in every way as accurate a description as possible of the exact damage done. To this also should be added a minute scrutiny of other parts, in order to establish clearly that death was due to the alleged injury, or on the other hand that it may have resulted from natural causes, and that the injury in question was only a consecutive and contributing cause. Especially should there be examined those organs in which occur the most common causes of death, namely, the brain, the heart and great blood-vessels, and the viscera. Moreover, if an operation has been performed the post-mortem examiner should be prepared to speak with reasonable positiveness as to whether said operation was, in the first place, necessary if life were to be preserved, and, in the second place, whether death were due to the injury proper or to the attempt to save life thus made necessary. For the determination of all this, obviously the best time for the performance of the examination is the earliest possible moment after death. Nevertheless, bodies are sometimes exhumed for this purpose, and much information is obtainable even after a considerable interval of time.

If death has been caused by a bullet which has not passed through the body, but lodged, it should by all means be obtained, since evidence of the greatest value may inhere in it. Moreover, in first noting the position of the body, the direction of the wound, or the location of a blood-clot upon the floor or clothing or elsewhere, may indicate to the surgeon or other astute person the point at which the bullet may be found concealed or buried in some soft or hard object. This bullet should be recovered, if possible, at all events, although if taken from the body itself the evidence it conveys may possibly weigh more heavily than if removed from some object outside the body. The exact number of gunshot wounds with a minute description and location of each should be committed to paper at once, as well as any statement, if at all reliable, concerning the number of shots fired, since valuable deductions may be reached as to the number of bullets which have passed through or which have lodged within the body. It is well sometimes, also, before dissecting out the bullet-wound, to insert first a stiff and then a flexible probe or something which shall, if possible, follow the bullet-track, since occasionally a question comes up of the direction in which it was fired. Even though surgeons well know that such questions are impossible of satisfactory answer, owing to the manner in which a bullet is diverted in its course by the various tissues of the body, it will nevertheless create a good impression as to the thoroughness and exactness of an examination should it be brought out, in answer to questioning, that this had been done. Many an excellent surgeon has been surprised upon the stand by the question from one of the counsel as to whether he knew that some certain writer had stated that it was always well, in trying to determine the course and direction of a bullet, to put the patient or the body, as the case might be, in the exact position in which it was when the shot was fired, providing this be known. The accomplished surgeon knows that this is a matter of very trifling import, but the witness’ status will be much better established with the jury if he can show himself familiar with this possible method of examination.

When a suspected person is brought before a magistrate, accused of homicidal attempt, it is very likely that the judge will require a written statement or opinion from the surgeon in attendance as to the extent and danger of the victim’s injuries, and especially as to whether these are of a character dangerous to life. The meaning of these words is left entirely to the sagacity of the surgeon. A mere naked declaration of this fact is insufficient. He must, if called upon by the court, give his grounds for his belief, and these may be rigorously examined by counsel. He will also probably be asked as to the presumable duration of life and possibly the effect of operation. Thus the prisoner’s immediate liberty or restraint may depend upon the surgeon’s words. Perhaps the only advice which can be offered here is to qualify between injuries directly dangerous to life and those in which life is endangered merely by possible complications, such as sepsis, gangrene, etc. Still, aside from wounds which are either fatal or may be nearly completely recovered from, there is another quite large class of those causing grievous bodily harm in which it is a question for the jury always to decide what was the intent of the accused. A medical witness may thus in such a case be of great assistance to the court by giving an account of the injury devoid of technicalities, and of its possible consequences. It should also always be stated, if known, whether the patient was under the influence of liquor or any narcotic at the moment of injury.

In the examination of wounds either of the living or dead body, it should always be determined for medico-legal purposes whether there is about them fluid or coagulated blood or ecchymosis, that is, livid discoloration of the skin from effused blood. The color of the ecchymotic spot will give a valuable clew as to the time between the infliction of the wound and death. Putrefaction of such a wound must not be mistaken for gangrene. In giving reports on such cases care should be taken to distinguish between facts and inferences. In fact, the inferences had better be kept unreported or confined to a separate statement.

Should there be any possible suspicion of a combination of poisoning and gunshot wound, the stomach contents should be carefully preserved and sealed up in the presence of witnesses before turning over the same to the analytical chemist, whose receipt for the package, with a careful description of the same, will probably have to be placed in evidence. Any fact on the condition of the stomach with regard to digestion is always worth noting. In the case of Reg. v. Spicer (Berks Lent Assizes, 1846) a most important point hinged on the examination of the stomach. The body was found at the foot of a stairway. The prisoner stated that after he and his wife had had their dinner he heard a fall. The woman had died instantaneously and the death occurred about the dinner-hour. Upon examination the stomach was found empty, without a trace of food. It was, therefore, clear that a part at least of the prisoner’s story was untrue.

Evidence as to whether the wounds were superficial or deep may be of value. If the edges are swollen or large, or if granulation or cicatrization have commenced, it is evident that the person must have lived some hours or some days after their reception. The same is true of suppuration, adhesion, or gangrene. It must also be remembered in this connection that very few gunshot wounds will show much change in less than ten or twelve hours save that due to the extravasation of blood. Should the question come up as to whether a gunshot wound had been inflicted before or after death, we may remember the principal characteristics of a wound inflicted during life, which are more or less eversion, more or less hemorrhage with diffusion of blood into the tissues, and the presence of clots. In a wound made after death little or no blood is effused, unless it come from some vessel very near the surface, in which case it will be venous in character and will not coagulate as does that which is poured out of a wound in the living. The track of the bullet also will not be found filled with coagula. In these respects a little will depend upon whether the body has lost its animal heat or not. The gunshot puncture of a divided artery in a dead body will present a very different appearance from one inflicted before death, even though it be the cause of death. Bleeding after death is exclusively venous, and there does not occur extravasation of blood in the cellular tissues, nor does it coagulate. Questions of this character come up sometimes in the case of multiple wounds or injuries, and it is, at times, of importance to be able to determine whether the assault or injury has been continued after death. Changes in color of an ecchymosed spot rarely begin until after the expiration of twenty-four hours, when its dark margins become lighter, and as time goes on the whole area passes through successive shades of violet, green, and yellow; its area may also increase sometimes to remarkable proportions, but the central portions are always darker than the periphery, the darkest spot corresponding to the centre of violence. Ecchymosis is longer in disappearing in the old than in the young. Its various features also will vary a little in accordance with the tissues bruised.

Gunshot wounds pertaining to spurious suicidal attempts are usually found not to involve vital parts, while they will have most of the characteristics of injuries inflicted from a weapon near at hand. The skin or the clothing will show powder-marks, and if a wad is a feature of the cartridge used, it may be found in one place or the other. In these cases there is also relatively more laceration and bruising, while sometimes the hand which held the weapon may be blackened or burnt by the discharge of the same. Self-inflicted wounds, in other words, must necessarily partake of the character of near wounds.

EVIDENCE FROM THE SITUATION OF THE WOUND.

It has been generally noted that suicidal wounds are for the most part confined to the front or lateral parts of the body; gunshot wounds of this character being found usually in the region of the heart, the face, and the temples. The presence of an injury to these parts is not necessarily indicative of suicide, but the existence of such injuries in other parts of the body is at least negative evidence of homicidal attempt. Moreover, Orfila has observed that it is not so much the situation as the direction of the wound which gives evidence for or against the presumption of suicide. The question has been raised whether it were possible to have a gunshot wound without external evidence. There has been recorded more than one case where a bullet entering through the open mouth has penetrated the brain without passing through the vertex of the skull and has killed instantly without leaving any external mark.

It is very necessary to establish, if possible, the direction of such a wound, and this may be coupled with a knowledge of the right-handedness or the left-handedness of the person who inflicted it, or may shed light in this way upon some personal peculiarity which may lead to the detection of the guilty person. Thus it is said of Sir Astley Cooper that in one instance he remarked that a certain wound could not have been inflicted except by a left-handed person, and that his observation led to the detection of the murderer. It has been stated that for the detection of the weapon or instrument used it should be placed first in one hand of the deceased and then in the other, while the other extremities are so manipulated that it may be clearly determined whether suicidal attempt were possible or no. There is ordinarily little difficulty experienced in distinguishing suicidal from accidental wounds. In the former case extraneous signs and circumstances point more clearly to the intent of the deceased than do, perhaps, the peculiarities of the wound itself. This is to be settled mainly by the evidence of those who find the body; in other words, by circumstantial evidence.

In suicides ordinarily one wound only is met with. At any rate, probably one only that has destroyed life. Consequently the presence of several wounds, each of which was necessarily fatal, constitutes almost conclusive evidence of murder, the strength of the same depending upon the necessary fatality of more than one of these. Thus it is hardly conceivable that a suicide should shoot himself through the heart and through the brain; the coexistence of two such wounds would be almost conclusive of homicide. The existence of multiple wounds is a rather strong presumption of insanity or drunkenness of the person who inflicted them. Men who kill when under the influence of liquor not infrequently inflict injuries enough to be several times fatal.

The coexistence of wounds made by cutting weapons, as well as firearms, is not unknown. These are occasionally suicidal, ordinarily they betoken murderous attempt. If suicidal the deceased will ordinarily be found to have been a lunatic.

But evidence is to be obtained also from signs and circumstances separable from the wound itself. Thus the position of the body may be such as to invalidate the theory of accident or suicide. The position of the weapon, too, is something to be noted with great care. Whether, for instance, this be firmly held within the hand of the corpse, or whether it had been simply placed there after his death; whether it be found where it would seem to have been most naturally dropped after its discharge, or found somewhere where it could scarcely have been placed or thrown by the deceased; whether it be found at such a point that it is clearly evident from other signs it could not have been dropped by the deceased, since death must have been caused too quickly for him to have traversed the intervening space.

EVIDENCE FROM THE WEAPON AND PROJECTILE.

Evidence of great value may be obtained often from the weapon itself. First of all, from the position in which it is found, as stated above; second, from a careful examination of itself. It should be noted whether there be any blood upon it, and whether this be so fresh as not to have caused any rust; whether it may possibly be so smeared with blood as to indicate a hand-to-hand conflict; or whether any part of the weapon may have been used as a club or bludgeon, as would be shown by the presence upon it of hair entangled in dry blood. When such blood is removed from the weapon it should be carefully examined with the microscope, since from the detection and identification of hair or fibres of fabric evidence of the greatest value may be adduced. Next it should be ascertained whether a weapon shows signs of having been recently discharged or whether it be evident that it could not have been so, and such determination of the time element as may be afforded by a study of this kind should be contrasted with that made after a study of the wound. If the weapon be a revolver or a repeating arm of any kind, it should be determined if possible how many cartridges or bullets have been fired, and whether at or about the same time, and this information should be compared with the evidences obtained from the body and from the room or locality in which the suicide or murder occurred. If, for instance, it be determined that three cartridges have been fired and but two bullet-wounds are found in the body, an examination of the room may show where went the third bullet. Next the calibre of the weapon should be noted and the weight of the ball which it discharged and its dimensions should be compared with any which may be found in or about the body. The weight of the bullets attached to cartridges of various sizes and makes is usually stamped upon the packages in which they are sold, or can readily be obtained from the makers of the same. A bullet taken from a body weighing after its removal more than do the other bullets undischarged in the weapon by which an injury is alleged to have been inflicted is rather presumptive evidence against the injury from that source.

CAN A BULLET LOSE IN WEIGHT BETWEEN THE TIME WHEN IT LEAVES THE BORE OF A GUN AND ITS DISCOVERY IN A BODY?—Here springs up a question upon which some very interesting evidence has been adduced in different trials. To discuss this matter completely the question should be divided into two, the first being:

DOES A BULLET SUFFER LOSS OF WEIGHT DURING ITS COURSE THROUGH THE PIECE AND THE AIR BEFORE IT COMES IN CONTACT WITH THE BODY?—A personal letter received from Captain Charles Shaler, of the Ordnance Department of the United States Army, in reply to certain questions, tends to fully settle that a lead bullet suffers a certain loss of weight in the barrel due to the friction between the bullet and the bore; this is known as “leading” and varies according to circumstances. “Patching” the bullet is often resorted to in order to reduce the leading; lubrication is also practised. The fusing of a bullet takes place especially with lead bullets. A ball which has been partly fused in the bore will lose the fused portions in the bore or in flight, and will move irregularly on account of the resulting irregularity of form. A .45-calibre, 500-grain service bullet, lead alloyed with tin, was weighed without lubricant and was found to weigh 500.5 grains. It was then lubricated in the cannelures and was fired into a butt composed of three barrels placed end to end and filled with sawdust. Tho bullet was recovered, no lubricant being found in the cannelures, and re-weighed, the weight obtained being 485.5. The loss of weight was, therefore, 15 grains or three per cent, some of which may have been due to the bullet penetrating the sawdust. A German-silver “jacketed” .30-calibre bullet, weighing before firing 231 grains, fired without lubrication, when recovered and re-weighed was found to have suffered a loss of weight of one-half grain or one-quarter of one per cent. The other part of the main question is:

DOES THE BULLET LOSE IN WEIGHT IN ITS COURSE THROUGH THE BODY?—This is, of course, intended to pertain only to those instances in which there is no evidence of splitting or division of the bullet, and refers only to the effect of friction or attrition. June 5th, 1878, in Saratoga County, Mrs. Jesse Billings was accidentally killed by a bullet. Her husband was arrested and tried for murder. On the first trial he was acquitted. A second trial, however, was held, and some very interesting expert testimony was brought out on matters pertaining to these questions. The medical evidence is published in full by Dr. Lewis Balch, of Albany, in the Transactions of the Medical Society of the State of New York for 1881. The rifle from which the bullet was supposed to have been fired was found in a well, and was sworn to have belonged to Jesse Billings. In it was found a cartridge of the type known as the Commercial Long No. 44. This gun became an important factor in the case, and most of the evidence as to whether it was the weapon with which the murder had been committed was referred to the medical experts. The defence in the first trial claimed that all the lead fired was found in Mrs. Billings’ head. On the second trial the same claim was not made, but that it was a smaller bullet than a .44 and its weight less than 220 grains; that in consequence this rifle could not have been that from which the shot was fired, for it only called for a .44 ball, and that it would have thrown a bullet with such force that it must have gone entirely through the head. They further claimed that powder-marks and grains of powder were found in the window-sash, showing that the weapon was fired near the window, and that the hole in the glass was not large enough to admit a full-sized .44 ball. The verdict was mainly won upon these statements. A question for the medical experts to answer was, what would be the effect upon the skull of a .44-calibre ball fired from a Ballard rifle, the ball weighing 220 grains and the charge of powder being 28 grains? also what would be the effect upon the ball? Experts from the Ordnance Corps and from the rifle factories were able to testify that the bullet found in Mrs. Billings’ head was originally a .44-calibre ball; also that its markings showed the peculiar left-handed twist used in rifling this particular arm. The defence maintained that it could not have been a .44, claiming that the hole in the window-pane showed that. The original window produced in court was no criterion, since from repeated handling the hole made by the bullet had become enlarged and changed in shape. Both of the experts for the defence believed that the ball could not make a hole smaller than itself when passing through glass. This necessarily supposes that the ball after being fired is the same calibre as before, which, as shown above, is not always the case. So Dr. Balch fired forty-five rounds from the Billings rifle with 220 grains of lead and 28 grains of powder. The shots were fired through glass set in sashes, the glass being 28×13¼, double thick and American make. The rifle was discharged at varying angles and at distances varying from two to seventy feet, and he obtained one shot where the hole made would not admit a full-sized ball. His summary was as follows:

Balls unable to pass through 1 Balls partly passed 3 Balls passed 18 Cartridge passed 21 Glass broken out 2 — Total 45

Other rounds were fired from a Colt’s navy revolver, old style, .36 calibre, at distances varying from ten to twenty feet. The holes made were so large that the barrels and ramrods could be passed without touching. The examination of the one instance noted above where the aperture in the glass was smaller than the ball is explained by Balch as follows: “A ball conoidal in form, passing with great velocity, strikes glass, penetrates, but does not break the glass at the point of entrance. The point struck is instantly disintegrated, and so rapid is the stroke that it has not time to call upon the surrounding particles for support; hence the smallness of the hole. As glass is made it varies in elasticity; some parts which are to be cut into panes cool faster than others. A bullet striking the portion of the glass which has cooled quickly strikes an object which will yield somewhat to the force; in doing this a hole will be made smaller than if that more brittle had been struck. Furthermore, all rifles taper more or less from breech to muzzle, that is, the muzzle will measure one or more thousandths or hundredths less than the breech. The bullet being forced through the narrow aperture yields to the pressure and becomes smaller. The gun under consideration was measured at the New York Armory, and found to be .44 at the breech or chamber and .423 at the muzzle. Considering these various facts, statements that a ball of known size will make a hole through glass smaller than the size of the ball when fired do not admit of doubt as to their verity. Some statements bearing on this same point contained in a recent letter from Captain Shaler, of the United States Army, deserve mention here. The following experiment was made in Washington by Captain Lyon in October, 1880:

“Noticing a statement in a newspaper to the effect that a ball fired from a rifle would, in passing through glass, make a round hole smaller than the diameter of the ball used, the following experiment was made:

“Service ammunition used, in a calibre .45 Springfield rifle to penetrate glass.

═════════════════════╤═══════════════════╤════════════════════════ Time Fired. │ Size of Hole made │ Remarks. │ in Glass, inches. │ ─────────────────────┼───────────────────┼──────────────────────── 1 │ 0.570 │ 2 │ 0.550 │ 3 │ 0.600 │ 4 │ 0.600 │ 5 │ 0.575 │ 6 │ 0.575 │ The frame holding the 7 │ 0.590 │ glass was placed 25 8 │ 0.620 │ yards from the muzzle 9 │ 0.600 │ of the gun. │ │ Average size of hole │ 0.586 │ Calibre of bullet │ 0.458 │ │ ────── │ Difference │ 0.125 │ ─────────────────────┴───────────────────┴────────────────────────

“From the above it will be noted that there is no uniformity in the size of the holes and that they all exceed the diameter of the bullet.

“These experiments were supplemented by some made recently in which a sash containing six panes of ordinary window-glass was placed at twenty-five yards from the firer and the glass was successively penetrated (a separate pane being used in each case) by bullets from a service .45-calibre Springfield rifle, a .30-calibre Springfield rifle, a .45-calibre Colt’s revolver and a .22-calibre revolver. In every case the hole made was much larger than the bullet making it.”

With reference also to the effect of a ball being smaller than its original diameter after it leaves the piece, Captain Shaler states: “All very compressible bullets forced by inertia lose a certain amount even though they also gain force by slugging. Forcing by inertia tends to shorten the bullet and increase the diameter, while slugging tends to lengthen the bullet and reduce its diameter. Whether the bullet is smaller after it leaves the piece depends upon the bullet used and the method of forcing employed.”

To return to the Billings case, it was claimed that the bullet was also too small. It weighed 165 grains, 55 less than when it was fired from the rifle. Balch found in firing at human skulls, the subjects in all the trials but two being placed in a sitting posture, sometimes with a sash like the Billings window in front of the subject, that the ball lost lead in accordance with the resistance it met with and the amount of bone ploughed in its passage. These experiments conclusively prove that the weight of a ball taken from a body after being fired, it having traversed a bone in its flight, is by no means evidence of its weight before firing; in other words, a ball always loses some lead when passing through bone. With the same rifle as that produced at the trial he made a series of experiments in the dissecting-room, endeavoring to make a bullet enter the skull at the same point and in nearly as possible the same direction as in the case of the murdered woman. In six such experiments there were varying losses of lead, all the bullets used being the same general weight. In two trials the distance was but ten feet from the muzzle, yet more lead was lost than in any of the other four. The least loss recorded took place at the longest distance, thirty-five feet. This in part accounts for the loss of lead, for at ten feet the bullet has not acquired its greatest penetrating power, for he showed by experiment that a 220-grain bullet fired at a human skull will lose more lead than was missing from the Billings bullet, thus disposing of the question raised by the defence that a ball could not have weighed 220 grains before being fired.

Just how to account for the missing lead has never been clearly established. We have to remember that a few grains may be left in the bore of a rifle, especially if rusty; that in passing through glass another portion is lost, and finally it is scarcely conceivable that any bullet should penetrate an adult skull, especially in the neighborhood of the mastoid processes, without losing quite a perceptible percentage of its mass by friction.

It was also claimed by the defence that the ball taken from Mrs. Billings’ head had been fired from a weapon of low velocity, which was held to account for the fact that the ball failed to pass out of the skull. The rifle when tested at the Government Arsenal showed a mean velocity of 999 feet per second. Had it been as high as was supposed by the defence, namely, 1,300 or 1,400 feet, the argument that a bullet driven with this force would always go through the skull would have more weight, but with the velocity found by actual test the energy of the ball was lessened to nearly one-half of that supposed. The bullet which killed Mrs. Billings did not pass entirely through the skull. It ploughed into the opposite side and broke before it a triangular piece of bone which broke the skin externally. This shows the resistance of external fascia against perforation. A study of the lines of fracture in this particular case proved very interesting, but perhaps would be somewhat irrelevant here. A measurement of the skull and of the bullet-track through it shows the former to have been of more than ordinary thickness and density, and the channel ploughed in the bone by the bullet along the base of it to have been nearly two inches in length. Dr. Balch gives the following conclusions to his very interesting evidence: 1st. A leaden ball passing through bone loses lead in proportion to the amount of bone traversed. 2d. If the petrous portion of the temporal bone be the part struck by the ball and struck squarely at the base, that portion of the bone is crumbled or broken in such exceedingly fine pieces as to defy restoration. 3d. That if the ball struck any part of the skull the petrous portion will be broken, but can be usually recognized and generally put together again. 4th. That a ball of given calibre fired through glass may make a hole enough smaller than the full size of the ball before firing to prevent an unfired ball of like calibre passing.

In all this kind of experimentation upon cadavers for the purpose of eliciting evidence by reproducing as nearly as possible ante-mortem injuries, we must not forget that Casper has strongly insisted that “it is extremely difficult to break up the organic cohesion of dead organs.... If we endeavor to fracture the skull of a dead adult we shall find that an amount of force which if applied in life would indubitably produce fissures if not fracture, or complete crushing of the skull, leaves the dead skull quite uninjured.... The most powerful blows struck down upon the body, laid down horizontally, were without result, and only after repeated violent blows were we able to produce perhaps one or a few fissures in the occipital or parietal bone, or in the temporal bone (squamous portion), and usually in the latter. We were unable to produce more considerable effects, such as complete smashing of the skull or fissures of its base, even in one single instance. The dead skull seems to have considerably more power of resistance, and after its removal fissures of the bone were more easily produced by similar blows” (Vol. I., p. 245). And again: “The result of my experiments on the dead body in regard to gunshot wounds could only be to make more complete the proof of the resistance of the dead corporeal tissues, in contradistinction to the tissues when alive. After I had already learned this peculiarity from my experiments with contused wounds, this peculiar resistent property was found to be confirmed in a most remarkable manner” (“Forensic Medicine,” Vol. I., p. 271).

If the number of bullets known to have been fired, or, more important still, which have been found exceeds the number which could have been discharged from the weapon in question, a very large element of doubt and uncertainty is introduced which must be quieted by other and more circumstantial evidence. Should two different weapons be in question, it is very necessary to establish from which of them the bullets have been discharged. This can be done mainly by weight and evident calibre of the bullets, or some other peculiarity; possibly in disputed cases even by analysis of the metal.

=Wounds by Shot-Guns.=—In most of what has been said it has been supposed that the injury has been inflicted by an arm of the kind commonly described under the terms pistol, revolver, or rifle. Gunshot wounds are, however, occasionally inflicted with shot-guns and a charge of shot varying in size from small bird-shot up to that generally known as buck-shot. It is characteristic of such missiles that they separate after their discharge from the gun, and a determination of the degree of their separation is approximately a determination of the distance of the mark from the muzzle of the weapon. In suicide or accidental discharges of a shot-gun the muzzle is so near the body that the charge of shot acts very much as would a single bullet of the size of the bore of the gun, and near wounds thus inflicted, while necessarily large, have about them a minimum laceration and disturbance of tissue, so that perhaps only by their size could one say, viewing the wound alone, that the weapon used had been a shot-gun. On the other hand, at a distance of a few feet the shot begin to separate to such an extent that there is much more laceration of tissue, and after separation to an indeterminate, because variable, number of feet we get such marks as individual shot may make. This distance is indeterminate because it is predicated on the size of the gun, the dimensions of shot, and the weight of the charge of powder. The writer, for instance, has recently seen one case where the muzzle of the gun could not have been more than two feet away from the surface of the foot at which it was discharged, the consequence being a round and very slightly ragged hole through the mid-tarsal region from dorsum to sole.

It is possible for a single grain of shot to produce death. Such a case is related by Ollivier d’Angers: a thief scaling a wall received at a distance of fifteen paces a charge of shot from a fowling-piece; he fell dead immediately. The charge had struck him in the breast, centring over a space of three or four inches, but one shot had penetrated the aorta over the attachment of the sigmoid valves, and another had traversed the entire wall of this vessel.

POWDER-MARKS.—A very important part of evidence in case of near wounds of gunshot character pertains to the powder-marks upon the clothing and skin. Naturally every one knows that when a weapon is discharged near a given surface there will be more or less powder-marking upon that surface, the same being due to particles of gunpowder which are incompletely or not at all consumed, and which are black because of the charcoal they contain; but the circumstances under which powder-marks of a given character can be inflicted are so extremely variable that no statistics or information of value in a general way can be given. Thus the fineness of the marks will depend upon the fineness of the powder, and the area covered and the depth of the marking upon the same, upon the distance of the muzzle from the surface; and the only way to make out the exact distance of the muzzle from the surface at the time of the infliction of a given wound is to use the same weapon, if possible, with cartridges or charges out of the same lot as that used at the time of injury. Distances could, perhaps, be stated in round numbers, but their value would only be remotely approximate, and in a given case the best evidence is to be obtained by experiment with the fire-arm in question.

=Dimensions of Perforations.=—At different times a great deal of weight has been attached to the dimension of the perforation through such objects as wood, glass, or even through the bones of the body, made by the bullet which is supposed or known to have destroyed life. Wrong inferences have been drawn sometimes from a study of undischarged bullets or cartridges similar, at least before firing, to that which has been taken from a given body. It has been stated, for instance, that such a bullet was too large to have passed through such an aperture or to have made such a hole, or that it was so much smaller than a certain hole that it was not the particular missile which made that perforation. Upon this matter has hinged a great deal of uncertainty and consequently a good deal of study. The size of opening which a bullet of given calibre will make through wood depends upon the distance of the weapon, the firing charge, the velocity of the bullet, the extent to which its shape has been altered by passing through the given barrier, by the heat of the explosion, by the impact of the air upon the heated and consequently softened metal, and by the density and thickness of the wood, as well as by the resistance which it may have offered mainly from its being fixed in place or movable. There is, however, ordinarily less question about the size of a similar hole through a piece of glass or bone. It is generally supposed that a bullet passing through a window-pane will shatter it. This depends, however, mainly upon the perfection of fixation of the glass in its resting-place. If for purposes of experiment panes of glass be tacked into a shutter and bullets be fired at them from varying distances, they will be practically invariably shattered. It is, however, quite different if the pane of glass be firmly fixed in a frame by means of putty which has become old and hard, and especially if the window-frame itself be closely fitted in the casing. Under these circumstances a bullet will often make a clearly punched hole, or one with very few radiating lines of fracture. Experiment, therefore, to secure evidence should be made under circumstances exactly parallel to those which necessitate such evidence.

EVIDENCE FROM EXAMINATION OF THE DEAD BODY.

=Fractures.=—Considerable evidence of great interest with respect to the effect of a bullet-wound upon the skull and the possibility of fractures being produced at the base by contre coup will be found in the statement of the case of The People v. Elisha B. Fero, published by Dr. Charles T. Porter, of Albany, in the Journal of Psychological Medicine, April, 1870. Mrs. Fero was murdered while in her bed and was found to have been bruised about the head and body, her husband claiming that the deed was that of a robber who had attacked them both. He was found with slight bruises or scratches about the face and black marks as if from burnt powder between the middle fingers of his right hand. The first autopsy appears to have been carelessly made, but a flattened conical ball weighing twenty-six and one-half grains was found lodged in the middle of the right cerebral hemisphere. It had not gone completely through the brain. Its base fitted the shells of the metallic cartridges used in Fero’s revolver. Eight days after death a second examination was made, after which the head was removed and preserved in 95% alcohol. A theory of the prosecution was that Mrs. Fero was murdered by her husband; that he shot her, as well as struck her numerous blows upon both sides of the head and its front and back with some broad, heavy, and elastic body, making fractures found on autopsy. Not the least interesting part of the testimony is that referring to the condition of tissues alleged to have been bruised after long preservation in alcohol. The expert testimony in this case appeared to show that such fractures as were found, without reference to the fact of external bruises, were due to the unskilful manner in which the skull-cap was removed. In this connection it is well right here to emphasize the fact that fresh fractures can be produced in the skull by too forcible or injudicious efforts to remove the calvarium when making autopsies, or that fractures previously existing can be extended or complicated in the same way. Shaw in his “Manual of Anatomy” says: “The question whether there has been a fracture of the cranium previous to death is sometimes more difficult to decide than a person not accustomed to make dissections might imagine. If the fracture has occurred immediately before the patient’s death, there will be found coagulated blood upon the bones and in the fissures. If the patient has survived for some time, there will be marks of inflammation and, perhaps, pus in contact with the skull, but if a fracture has been made in making the examination, which sometimes happens in even very careful dissectors’ hands, the blood in the fracture will not be coagulated, nor will there be any effusions around the portions. In Beck’s Medical Journal, Vol. XXII., p. 28, Mr. Alcock some time since stated in a public lecture in London that he had known a fracture of the base of the skull produced by the awkward and violent tearing of the upper portion by the saw in penetrating enough to divide the bones, and this to be mistaken by the inexperienced operator for fracture of the skull producing death. Being a medico-legal case, it might have led to melancholy consequences had not the error been detected by an observer.” That an extensive and often complicated fracture by contre coup can occur as the result of gunshot injuries of the skull is a fact well known to all surgeons of experience and laid down in all text-books and illustrated in all large museums.

In view of these well-known facts, it would always be well to insist in cases of this kind that the saw alone should be used and not the hammer nor the chisel. When a cranial bone is fractured blood is poured out from the ruptured vessels, as is always the case with any bone. Its amount varies indefinitely with the number and size of the ruptured vessels, the activity of circulation, the length of time a person lives, etc. The blood may collect in circumscribed masses or become infiltrated in the surrounding tissues, although usually both phenomena are observed. The extent to which infiltration takes place depends upon the quantity of blood and the nature of the surrounding tissues. In loose tissues like those about the orbit infiltration is much more rapid and extensive.

=Examination of the Weapon.=—French medical jurists have tried to indicate how we may determine the time elapsed between the death of a person and the discharge of a weapon found near the body, but exact statements in this matter are utterly out of the question. Certain facts bearing on the subject are these: When recently discharged there will be found adhering to the barrel of the piece and consisting of the fouling of which sportsmen complain, a quantity of potassium sulfid mixed with charcoal. This is shown by its forming a strong alkaline solution with water, evolving an odor of hydrogen sulfid, and a dark precipitate with a solution of acetate of lead. Depending upon the degree of exposure to air and moisture, after some hours or days this sulfid becomes converted into potassium sulfate, which forms a neutral solution with water and gives a white precipitate with acetate of lead; but if a considerable time has elapsed since the discharge of the piece oxid of iron (iron rust) with traces of sulfate may be found (Ann. d’Hygiene, 1834, p. 458; 1837, p. 197; 1842, p. 368).

WAS THE WEAPON FIRED FROM A DISTANCE OR NEAR BY?—A gunshot injury from a bullet implies at least one wound, namely, that of entrance, and perhaps another, that of exit. It does not always happen that the bullet passes through the body. The appearance of the wound of entrance is usually one of irregular circular puncture, its edges perhaps slightly torn or lacerated, with a purplish or dark areola, varying in width from a line or two to one-half inch. When the weapon is fired close to the body there are likely to be more or less powder-marks, and possibly actual burning from the heat and flame of the gunpowder. If the part of the body injured had been covered by clothing at the time, the marks of powder and of burning would probably be confined to the same. Bleeding is usually slight and occurs more commonly from the wound of entrance than from that of exit. Regularity of either of these wounds depends in large measure upon the angle at which the bullet has struck the surface. When striking very obliquely the wound may be more oval or the bullet may have ploughed a furrow or a channel, by a study of which the relative position of the assailant and the assailed at the moment of injury may, perhaps, be determined. It is of importance to determine if possible the approximate distance at which the bullet was fired, since the question of self-defence, for instance, may hinge upon evidence of this character. The charge of powder and the weight of the bullet being known, one may sometimes estimate this distance by the depth of penetration or the appearance of the bullet. Still, the nature of the tissues must figure largely in such consideration. Many suicides who shoot themselves in the head show only one wound of entrance and none of exit.

=Experiments Testing Powder-Marks.=—Powder-marks and burns from weapons ordinarily used will scarcely appear when the distance has exceeded ten or twelve feet. LaChese, of Antwerp, found that in firing a gun even from a distance of only four feet the skin was only partially blackened.

As the result of experiments made with a Ballard rifle, old style, .44 calibre, with bullets of 220 grains and 28 grains of powder, Dr. Balch, of Albany, found that powder-marks were made at distances as follows:

At two feet, particles too numerous to count, with some of the lubricant blown upon the board;

At four feet the same;

At six feet the same;

At eight feet, nine grains of powder;

At ten feet, five grains of powder in one case and six in another.

That these were powder-grains were shown in court by picking some of them out, placing them on a glass, and igniting them with a galvano-caustic point. From those at ten feet no distinct flash could be elicited; from those obtained at eight feet distinct flashes were seen (Trans. New York State Med. Soc., 1881).

In the celebrated case of Peytle, brought in 1839 for the murder of his wife, who had been killed by two bullets entering near the nose, the eyebrows, lashes, and lids were completely burned, and a large number of powder grains were imbedded in the cheeks. Experiments being made in order to ascertain the distance necessary to produce these effects, it was found that the weapon must have been held within a distance of twelve inches.

=Wounds of Entrance and of Exit.=—A great deal has been written in time past about the peculiarities of the wounds of entrance and of exit, much of which cannot be maintained under expert criticism. It is true that the wound of entrance will usually be well defined, the skin slightly depressed and appearing as above noted. It is true also that powder-marks will appear about this wound rather than that of exit. Usually, too, the orifice of exit is larger, less regular, its edges everted slightly, with more or less laceration of the skin, and quite free from any powder-marks or evidence of burning. The depression at the border of the wound of entrance differs after some days, by which time the contused margins slough away, and its appearance is daily changed by a process of granulation providing the individual recover or live long enough. According to Dupuytren, the hole in the clothing is smaller than that made by the same bullet in the skin. These are all points worth remembering when fitting bullets into wounds which they are supposed to have made; but the conditions under which gunshot punctures occur are constantly varying, and the significance of local markings is mainly the product of experience, care, observation, and reasoning. Thus the shape of either of these wounds will depend naturally upon the integrity of the bullet and its original shape and dimensions. Matthysen’s experiments give the following: A pistol fired at twelve paces distance, with a ball 15 mm. in diameter, made a wound in chest of 8¼ mm. diameter, and at its point of exit at the back one of 10 mm. In two experiments at the same distance as above, the entrance wound was 4 mm. larger in diameter than that of exit, and when a larger ball with a diameter of 17 mm. was used the same results were preserved, both wounds being less in size than the ball which made them. A spherical ball will usually cause more loss of substance than a conical, while the latter will cause usually more irregularity of outline and may even give the wound of entrance a slit-like appearance. Complications may also occur from other sources; a single wound of entrance may give rise to two or more wounds of exit due to splitting of the bullet, or if the bullet have been divided and the larger part lodged in the bone, only the smaller portion passing out, the wound of exit may in reality be much smaller than that of entrance. Again, a bullet may split into fragments before striking the body, and of these one may enter the body, or one or more of them lodge. Multiple wounds are possible even from one bullet, as when it passes through two different parts of the body. Again, when two wounds, for instance, are discovered, one of them may be regarded as that of exit, when in reality they may be two wounds of entrance, neither bullet having left the body. So while it is possible in some cases to decide which is which, too much dependence should not be placed upon appearances of this kind, least of all until after a careful autopsy has been made.

=Course of the Projectile.=—When a bullet traverses a body the two apertures may be nearly opposite to each other, although the bullet may not have taken a direct course between them, having been deflected by tissues of varying density in its course. This leads to the mention of the effect of animal tissues upon the course of bullets, with which works on military surgery deal extensively.

The following is a remarkable illustration, yet authentic, of a devious path of a ball. In a duel with pistols between two students at Strasburg one fell, apparently mortally wounded in the neck, but recovered without feeling any inconvenience from his wound. It was found that the bullet had struck the larynx and had gone completely around the neck. It was taken out by simply making an incision over it. Other instances may be cited where bullets have made a circuit around the head, thorax, or abdomen. The ball may make a half circuit of the body and lodge or emerge at a point opposite that at which it entered, thus leading one to suppose that it must have passed directly through (Wharton and Stille).

As the writer of a chapter on the effect of projectiles of small-arms, in the Third Surgical Volume of the “Medical and Surgical History of the War of the Rebellion,” p. 709, says: “Such bullets attain great range and effectiveness as oppose least frontage of resistance to air; their velocity consequently is greater. Rotation upon their long axes tends to give them steadier flight and more direct course. By their pointed apices they pierce more easily the structures opposed to them. Such bullets, owing to the elasticity of the skin, make a wound of entrance perhaps a trifle smaller in diameter than themselves, while spherical balls are more likely to carry a portion of the integument in with them.”

The differences of structure and density of the muscle tissues and their aponeuroses encountered by a bullet in its passage materially influence the directness of its course unless its velocity be very great, while round bullets are the more easily deflected from their course. The track of a small conical bullet passing swiftly through a muscle is more cleanly cut than that made by a round bullet, but in all gunshot wounds there is usually found a regular canal, with lacerated walls, with more or less destruction along the area of injury, shading off concentrically until lost in healthy tissue. There is always loss of substance dependent on muscle tension or direction of the bullet, whether transverse or obliquely to the direction of the muscle fibres; the more fibrous structures are torn and lacerated or simply perforated, mainly owing to their different tension at the instant; their openings seldom correspond to those of the muscle tissues or those upon the surface of the body, because of the constant change in the relation of the parts due to muscle action. This makes it often difficult to follow the course of a bullet with accuracy. The irregularity of a bullet-track due to these causes constitutes one of the great sources of danger, since cavities and pouches thus formed give lodgment to foreign matter driven in with the bullet, by retention of which a fertile source of sepsis is maintained. Gunshot injuries of bone may be classified as contusions, simple fractures, partial fractures, penetrations, perforations, and complete fractures with more or less comminution or loss of substance, all of these, of course, in the surgical sense compound. These are all manifestations of mechanical force acting in accordance with established laws. On autopsy these will be ascertained, while one or more portions or all of a bullet may be found imbedded in or attached to some bone. The best illustration of such accidents will be found in the “Medical and Surgical History of the War of the Rebellion.”

Such questions as pertain to the position of the wounded person when shot or that of his antagonist, and other similar inquiries, can only be settled by reference to particular circumstances of individual cases. Position of the wound may help a little. A bullet-wound directly in the centre of the top of the head could scarcely be received by a person standing unless his assailant occupied an elevated position. If accompanied by evidence of severe blows by which the deceased might have been knocked down, it might show that he had been shot after falling.

=Wounds by Small Shot.=—Small shot rarely traverse the entire body unless discharged from such proximity as to make a clean, round opening. Paley relates the following instance: A boy was shot in the neck by the accidental explosion of his own gun, No. 8 shot. He died instantly. He was lying forward of the muzzle so that it was nearly in contact with the skin of the neck. A large round hole was produced, in diameter one and one-half inches, whose edges were slightly darkened by powder. The wound of exit at the back of the neck, at the third vertebra, was a mere slit in the skin scarcely an inch in length with the diameter placed vertically. The smallness of this aperture may have been owing to the greater part of the charge being lodged in the body. Dr. Lowe states that in some experiments it was found that a round aperture might be produced by a discharge of small shot at a much greater distance than that assigned by Dr. LaChese, namely, ten to twelve inches. Even admitting such exceptional instances, it will scarcely ever occur that a wound from a small shot can be mistaken for one produced by a leaden bullet.

De Vergie has shown that when the ball enters a portion of the body well covered with fat, this often protrudes between the edges of the wound and may alter its character. If clothing have been carried in some shreds of it may show upon the wound, and such fragments of texture will nearly always characterize the wound at once as that of entrance.

=Wounds by Blank Charges.=—Experience has shown that no matter with what the piece is charged, it is capable, when fired close by, of producing a wound which may prove fatal. Thus a gun loaded with wadding or gunpowder only may cause death. A portion of clothing may be carried into the wound and lead to death from hemorrhage, or death may occur from many secondary causes, such as tetanus or sepsis. Accidents so frequently occur from weapons discharged in sport, not loaded with ball or shot, that it is worth while to bear this in mind. It has been observed, for instance, that persons attempting to commit suicide have forgotten to put a bullet in the pistol, nevertheless the discharge of the weapon into the mouth has sufficed, from the wadding alone, to produce a considerable laceration and hemorrhage (Taylor). Many fatal accidents have taken place by the discharge of wadding from cannon. LaChese has ascertained by experiment that a piece charged with gunpowder alone is capable of producing a penetrating wound somewhat resembling that produced by gunshot, when the piece is large and fired within six feet of the body (Ann. d’Hygiene, 1836, p. 368). This arises from unexploded grains of powder acting as pellets of small shot. Sweet has experimented with pistols loaded with gunpowder and wadding in order to determine the effect of their discharge at different distances. At twelve inches he found that the clothing was lacerated and the skin abraded, but the wadding did not penetrate; at six inches the clothes were lacerated and the wadding penetrated to the depth of one-half inch; at one and one-half inches from the chest the wadding passed into the thoracic cavity between the ribs, and at a second experiment carried away a portion of the ribs.

It is probable that an ordinary wadding such as loosely wrapped paper, rag, or similar material, especially as prepared by one not accustomed to military use of a weapon, would not produce a wound which would resemble that made by a bullet, and it is doubtful whether such a wound could be produced at a greater distance than six inches from the body.

It is on record that in Paris, in 1858, a circus cannon of four inches bore, loaded with three ounces of grain powder retained by a wad of old theatre bills loosely folded together and rammed home with only moderate force, was discharged in the direction of the boxes at a distance of about one hundred and fifty feet. A man seated in one of these boxes opposite the muzzle of the gun, leaning forward, his arms crossed upon the handle of his umbrella, had his arm broken above the elbow immediately upon its discharge. Several portions of wadding were found beneath the place where the man sat, but no marks existed upon his clothing nor upon the anterior part of the arm, which must have been inaccessible to any projectile that did not first strike the forearm. It was concluded that the fracture had been caused by the violent and sudden starting of the man backward, which must have brought his arm against the hard part of the partition. An experiment tried with the cannon proved that any wadding that could be made with paper was dispersed in passing, or lost all power of mischief, at much less distance than one hundred and twenty feet (Annales d’Hygiene, 1859, p. 420, Wharton and Stille).

=The Mannlicher Rifle.=—It may be of interest here to note the effects of the rifle-bullets used in the most recently invented improved arms. The last new projectile used in the German army, 1892, with the Mannlicher rifle, has an inner core of lead inclosed in a casing of steel or firm metal, which prevents the lead, even when softened by heat, from becoming deformed and enlarged by contact. The weight of the bullet is much less than any of the old, but to its higher rate of velocity and its pointed shape, which is preserved, must be ascribed its greater perforating power. Owing to this immense velocity and the small surface of contact, it meets with little resistance on striking a person, has no time to stretch the various tissues it encounters, causes little or no commotion of the neighboring parts, and merely punches a hole, carrying the contused elements before it clear out of the wound without seriously damaging the surrounding wall of the bullet-track. This absence of contusion must lead to more frequent deaths from hemorrhage, while when this arm is used we shall hear very little of deflection or deviation of the bullet from its path, since it has sufficient power to pass directly through any part of the body which it may meet on its way. The result in battle will be a reduction of the list of wounded, but a terrible augmentation of that of the dead.

IDENTITY FROM A FLASH OF GUNPOWDER.

Taylor states the following: “Among the singular questions which have arisen out of this subject is the following: whether the person who fires a gun or pistol during a dark night can be identified by means of the light produced during the discharge. This question was first negatively answered by a class in physical science in France, whereas later a case tending to show that their decision was erroneous was subsequently reported by Fodere. A woman positively swore that she saw the face of the prisoner, who fired at another during the night, surrounded by a kind of glory, and that she was thereby enabled to identify him. This statement was confirmed by the deposition of the wounded party. Desgranges, of Lyons, performed many experiments on this subject, and he concluded that away from every source of light the prisoner who fired the gun might be identified within a moderate distance; if the flash were very strong, the smoke very dense, and the distance great, the person firing the piece could not be identified. The question was raised in England in the case of Reg. v. White at the Croydon Autumn Assizes, 1839. A gentleman was shot at while driving home on a dark night, being wounded in the leg. When he saw the flash of the gun he saw that the piece was levelled toward him, and the light of the flash enabled him to recognize at once the features of the accused. In cross-examination he said he was quite sure he could see the prisoner and was not mistaken as to his identity; but the accused was skilfully defended and he was acquitted. A similar case was tried at the Lewes Lent Assizes, 1862, Reg. v. Stapley. The prisoner shot at the prosecutor on a dark December evening, and the latter swore that he distinctly saw the prisoner by the flash of the gun and could identify him by the light on his features. His evidence was corroborated and the man was convicted. A case is also quoted, Rex v. Haines, in which some police officials were shot at by a highwayman during a dark night. One of these stated that he could distinctly see from the flash of the pistol that the robber rode a dark-brown horse of remarkable shape, and that he had since identified the horse at a stable in London. He also was positive that the prisoner had on a rough brown great-coat.

There seems to be enough evidence in this direction to show that identification under these circumstances is occasionally possible.

GENERAL MEDICO-LEGAL CONSIDERATIONS.

The result of the wonderful advance in the practice of surgery made during the past fifteen years has been in a large measure to revolutionize the treatment of gunshot wounds, and inasmuch as the result of many homicidal attempts will depend in large measure upon what the surgeon can do for the victim of assault, it may not be amiss to very briefly epitomize in this place something of what modern surgeons believe with regard to the best treatment of bullet-wounds, expressed in a general way. They have learned, among other things, that the harm which a bullet does is done by it during its flight, and that after it has come to a stop it is, per se, an almost invariably harmless foreign body. This is practically always the case unless it has carried in with it foreign material which may serve as a source of septic infection.

In time past there has always been a strong feeling, which had, however, nothing scientific to justify it, that every gunshot wound was a poisoned one. Of late, since bacteriology has attained the proportion of a science, it has been held that bullets were necessarily sterilized by the heat of the discharge of powder behind them. Very recently Dr. B. Von Beck, Medical Director of the 14th German Army Corps, has made experiments upon the amount of heat imparted to leaden and other bullets after firing. After making an allowance for specific heat and the conductivity of the different metals used, he found that even when the projectiles encountered resistance from three to four times greater than that offered by the human body the results were as follows: Temperature of leaden bullets of .45 calibre, when recovered, 69° C.; of .30 calibre, covered with steel, when recovered, 78° C.; of .30 calibre, covered with copper, when recovered, 101° C. He states that these experiments disprove the theory that certain lesions in wounds can be in any way attributed to the heat imparted by the bullet.

While these experiments prove that the bullets may be heated to the above degrees when recovered, they by no means prove that they are so heated at the time when they inflicted the wound. During the year 1892 some very interesting experiments were carried on by Dr. Lagarde, of the Army Medical Department (New York Medical Journal, Oct. 22d, 1892, p. 458). He experimented by deliberately infecting bullets and then firing them into cotton, and animals as well, studying the effect both on the bullets themselves and upon the animals. Some of these bullets were taken from the original packages, while others had been intentionally rolled in dirt. The experiments were carefully carried out and appear reliable, and the conclusions given by the author, which interest us here, are as follows:

(1) The vast majority of cartridges in original packages are sterile or free from septic germs because of the disinfection and absolute cleanliness observed in the process of their manufacture.

(2) The majority of gunshot wounds are aseptic because the vast majority of the projectiles inflicting them are either sterile or free from septic germs.

(3) The heat developed by the act of firing is not sufficient to destroy all the organic matter of the projectile, the cherished notions of three centuries or more to the contrary notwithstanding.

The results as set forth justify the assumption that a septic bullet can infect a gunshot wound. The average bullet-wound, however, is sterile so far as infection from the bullet is concerned, and in accordance with this view of its usual innocence there need be no longer the clamor for removal of the missile which the fears of previous generations have nearly always called for; and the best practice among military surgeons of to-day is rather to let the bullet remain where lodged than to make a more serious wound for its removal. Exceptions to this rule occur only in cases where operation is called for on account of injury done by the bullet while still in motion. It is also held to be a violation of simple physiological and surgical rules to probe or carelessly search for a bullet whose location cannot be made out from a study of signs and symptoms in a given case. The act of probing breaks up blood-clot, often brings on fresh hemorrhage, is in a majority of cases unsatisfactory, frequently introduces specific elements from without, and really gives little, if any, more information than can be gathered from a study of the case without the use of the probe. If every ordinary bullet-wound which did not call for immediate operation because of injury to some essential or vital part—such as a large blood-vessel or nerve-trunk, or some of the viscera—were antiseptically and hermetically sealed at the very outset, there would be a much smaller percentage of death from gunshot wounds, either in civil or military practice, than now obtains. And it might be a matter upon which to go to the jury whether violation of such rules, to-day, does not mitigate the offence of the accused.

Recent discoveries in so-called cerebral localization have instigated numerous operations upon the skull and brain for the relief of pressure, as from blood-clot, or for removal of depressed bone or a bullet which twenty years ago would have been impossible. The brain is no longer the terra incognita of the past generation of medical men, and it is now often possible for the surgeon to intervene in such a way as to save life in cases previously considered hopeless; in fact, such is now his duty when consent can be gained, and it should be held that he is culpable when deficient in general knowledge in this respect.

In wounds of the thoracic cavity it should now be held that so long as air has entered through a bullet-wound there are cases where free incision, even with removal of ribs, can scarcely increase the dangers, while permitting opportunity for much more accurate exploration and determination of life-saving methods. The experiments of numerous investigators, the writer included, have shown that bullet-wounds of the heart need not be always and invariably fatal, and have afforded an element of hope from the possible surgery of even this organ. The writer looks forward to the time when some accomplished yet daring surgeon, getting the right patient at the right time and in the right place, i.e., where conveniences are at hand, shall, in some case of perforating wound of the pericardium or of the heart itself, resect some portion of the anterior thoracic wall, lay open the pericardium, maintaining meanwhile artificial respiration if necessary, and suture a wound in the heart-substance, thereafter closing the pericardium and external wound, and save life which would otherwise be surely sacrificed. With others he has done this upon animals, hence why may it not be done in man?

In the mean time for, first, the recognition and, second, the surgical treatment of perforating wounds of the abdominal viscera, American surgeons have won for themselves the greatest credit, and an already long list of successful laparotomies after gunshot wounds of the intestines, with intestinal suture or resection, has shown the very great value of this procedure, even though it has kept some would-be murderers from the gallows.

These lines are inserted here because the time and effort which surgeons have devoted to this kind of surgery deserve only the highest encomiums and encouragement from the legal profession, although to our deep regret they have not always met with the same.

OF THE VARIOUS CONDITIONS WHICH COMPLICATE GUNSHOT WOUNDS AND MAKE THEIR RESULTS UNCERTAIN,

=Delirium Tremens= is one of the commonest and must always be regarded as one of the most serious. It is well known to surgeons that a slight injury even, and often a severe one, is enough to provoke manifestations of this character in intemperate persons. The medico-legal question under these circumstances is this: Would the same amount of injury have been likely to cause death in a person of ordinary health and vigor? The law as applied to these cases has been stated by Lord Hale: “It is sufficient to prove that the death of a person was accelerated by the malicious acts of the person, although the former labored under a mental disease at the time of the act. The intent of the accused may often be judged by the character of the wound and the means of its infliction. Drunkenness of the victim admits of no excuse when his assailant is aware, or ought to have been aware, of the condition of his victim. It is held that the assailant ought to have known that violence of any kind to such a person is likely to be attended by dangerous results. It is known also that a wound which accelerates death causes death.” The commissioners who were appointed to define criminal law on the subject of homicide have thus expressed themselves: “Art. 3. It is homicide although the effect of the injury be merely to accelerate the death of one laboring under some previous injury or infirmity, for although if timely remedies or skilful treatment had been applied, death might have been prevented” (Taylor, p. 327).

=Death from Surgical Operations Necessitated by Gunshot Wound.=—The modern treatment of serious or so-called penetrating gunshot wounds where the cranium, thoracic viscera, or the abdominal viscera, especially the intestines, have been perforated one or more times, calls for surgical procedures which are of severity and danger in proportion to the gravity of the wound which necessitates them, and which, while they often save life, must necessarily often fail. Indeed, such operations may prove fatal upon the operating-table, i.e., patients may die before the conclusion of the operation. The question may, therefore, arise whether the person who inflicted the wound should be held responsible for his act, or whether by the intervention of the surgeon the responsibility may not at least be shifted from the shoulders of the accused. The law in this respect is explicit and regards such operation as the outcome of necessity and a legitimate part of treatment, so that if it be undertaken in good faith, with reasonable care and skill, the accused will be held responsible, be the result what it may. The question of necessity and the plan of operation are left to the judgment of the surgeon in charge. Considering the responsibility involved in such cases and the possibility of a suit being raised, we should always advise the operator to secure the counsel of other surgeons or practitioners in his vicinity. The verdict of such a counsel of talent will always stand. According to Lord Hale, when death takes place from an unskilful operation under such circumstances, and not from the wound, the responsibility of the prisoner naturally ceases, but the burden of proof that such has been unskilfully performed rests naturally with the defence. It is much better also in these cases that the primary responsibility be borne by one surgeon from the beginning of the case, though he may associate with himself as many others as he chooses, since the ends of justice have more than once been defeated by a division of such responsibilities. Should it be made to appear that the surgeon in charge has not availed himself of such means as are supposed to be in the hands of every competent practitioner and has neglected ordinary antiseptic precautions, it would not be difficult to show that the operation had been unskilfully performed, and the prisoner would naturally get the benefit of such defence. At the present date of writing there exists a large class of the profession who still continue to do surgery according to the views and practices of twenty or thirty years ago, and who, while perhaps carrying out some of the forms of antiseptic surgery, are still ignorant of its fundamental principles and consequently guilty of neglect, since there is now no reason why all should not practise them. The writer holds to the view that if it can be shown that these precautions were not adopted when others would have adopted them, it constitutes criminal neglect.

On the other hand, circumstances may arise where a simple or a more serious operation would have saved life, as, for instance, in cases of hemorrhage, and where a surgeon from timidity or carelessness has failed to take the necessary steps. Such neglect as this should inure to the benefit of the accused, but when at any time it can be shown that the possible benefits of operation have been offered to the deceased before his death and have been declined, the surgeon at least is relieved of all further responsibility. Among the dangers of operations under these circumstances are of course to be reckoned those pertaining to the use of anæsthetics. The surgeon in charge, however, is responsible for the selection of his assistants, at least when assistants are at hand, and must be regarded as equally competent in this as in other features of the operation; and even though the patient die from collapse or the anæsthetic, the burden of proof must rest with the defence to show that it had been unskilfully administered.

NOTE.—The assistance which the microscope may afford in the procurement of evidence in cases of gunshot wound is beautifully illustrated in the expert testimony reported by Dr. James, of St. Louis, in the presidential address before the American Society of Microscopists, in Washington, August, 1891, printed in Vol. XIII. of its Transactions. It occurred in St. Louis, in the case of The People v. Vail, who had a pistol in his pocket at the instant when his wife fell from a wagon against him, knocking him, as he claimed, against the wheel of the wagon, the pistol being discharged by accident. By a minute study of the fibres of the various textures making up his overcoat and of the effect of the explosion of powder upon textile fabrics almost in contact with it, he was enabled to establish the accident and secure the acquittal of the accused.

DEATH

BY HEAT AND COLD,

INCLUDING

INSOLATION IN ITS MEDICO-LEGAL ASPECTS.

BY ENOCH V. STODDARD, A.M., M.D.,

Emeritus Professor of Materia Medica and Hygiene in the University of Buffalo; Member of the Medical Society of the State of New York and of the Central New York Medical Association; Fellow of the New York Academy of Medicine and of the American Academy of Medicine; Late Surgeon 65th Regt. N. Y. Vols.; Late Health Commissioner, Rochester, N. Y.; etc., etc.

DEATH BY HEAT AND COLD.

TEMPERATURE OF THE BODY.

The production and regulation of heat in the body is a problem by no means elucidated. We consider heat production to be of internal origin, by a complex process involving tissue metamorphosis, chemical changes in nutrient elements, muscular movements, etc. Heat regulation is accomplished, not only by variation in the loss of heat by the body, but by what is more important, variations in the amount of heat generated. It is an accepted physiological conclusion that there exists in the body a thermotaxic nervous mechanism which controls its normal, as well as its abnormal, manifestations of heat.

The average temperature of the body in health is 37° C. (98.6° F.), in the axilla. Taken in the vagina or rectum, .9° C. (1.3° F.) higher is noted. The daily average range of variation is about 1° C. (1.8° F.).

In disease or injury considerable variations occur; very high, as well as very low, temperatures are met. In severe neuroses and some forms of malarial disease a temperature of 42.2° C. (115° F.) has been recorded, and after an injury 71° C. (122° F.).[688]

Very low temperatures are reported in several cases of acute alcoholism, accompanied by exposure to cold, where a temperature of 28.8° C. (75° F.) in the rectum was noted, recovery following.[689]

Such extreme temperatures, though authentic, are exceptional.

Very high temperatures in febrile conditions are borne because remitting; and low temperatures, subject to periods of elevation, are met in wasting and other conditions. Very high and very low temperatures are also noted, just before death, in acute diseases and conditions specially involving the nervous system.

The degree to which the temperature may be raised without destroying life has been investigated by Berger, Bernard, Chossat, and others.[690]

Their experiments show that if an elevation of temperature of the body 7.20° C. (13° F.) be maintained for any length of time in warm-blooded animals, death ensues. Depression of the temperature of warm-blooded animals 12° C. (20° F.), or even less than these degrees below the normal, results fatally. Portions of the body may be frozen and yet, under appropriate treatment, recover. But freezing of the whole body must necessarily prove fatal.

Great differences in ability to endure extremes of heat and cold appear among different nations and in different individuals. The very young and the very old are unable to bear exposure to extreme cold. In both, the capacity for heat production is low and the vital powers are soon enfeebled to a critical degree. The healthy adult can, with proper precautions, safely endure great extremes of heat and cold. The experience of arctic explorers in the expeditions of Kane, Nares, Greely, and others has demonstrated the power of endurance, for a considerable period, of a temperature from 90° to 100° F. below the freezing-point. On the other hand, laborers employed in pottery and other establishments, using ovens raised to 148° to 315° C. (300° to 600° F.) or higher, are often exposed for some time without injury to temperatures approaching these intense figures.

EFFECTS OF EXTREME COLD.

Legal inquiry into the conditions of death from cold occurs almost entirely in cases of unintentional exposure. Cold has been employed, however, with homicidal intent. The depressing influence of continued low temperatures is observed in the death-rates of cities, in winters of protracted severity, where the proportionate mortality among infants, the aged and enfeebled shows marked increase. While age is a prominent predisposing and contributing factor, other causes exist. Exhaustion from severe and prolonged exertion, deprivation of food, intoxication, former illness, and other conditions of depression lessen the powers of the body to resist cold. Thus an exposure which might be safely borne in perfect health might result fatally in the same person in conditions of depression just referred to (Case 1).

Investigation may be demanded in case of the death of

A. Young children.

B. The injured.

C. The insane.

=A. In Young Children.=—This may be in the new-born or older children.

In the new-born exposure to cold soon causes death, as warmth is essential to the life of the young being. The length of time necessary to a fatal issue is modified by several conditions. In the immature or prematurely born infant the resisting power is much less than in the child born at full term and otherwise healthy. In cases of suspected infanticide by exposure the question of the maturity of the child at birth is to be decided. Careful examination of the place in which the body was discovered should be made as to its lack of warmth; and the degree of external cold at the time of probable exposure should be recorded. The circumstances as to whether the exposure was inadvertent or accidental, as in cases of premature or unexpected delivery, or whether from intentional and deliberate purpose or from culpable neglect, should be carefully considered. The post-mortem examination should decide whether the appearances and conditions of the body are those peculiar to death from cold (Case 2).

Death may occur from culpably careless exposure to cold, as a contributory if not as a direct cause, in such conditions of enfeeblement. Criminal neglect to provide medical attendance, food, and other essentials has been proven in some cases of the so-called “faith cure” or “prayer cure.” Exposure may be resorted to with deliberate homicidal intent. It may, in some cases of death, become an important legal question to decide whether a studied and persistent neglect of this nature may not have been followed, with the purpose of getting rid of a troublesome care (Cases 2 and 3).

=B. Exposure of the injured or wounded=, thereby inducing some grave condition or complication which under proper care would have been avoided, may raise an important question in injuries inflicted by another, with or without criminal intent. It is undeniable that serious or fatal results may follow a slight wound, otherwise trivial, where the injured person was subjected, accidentally or intentionally, to extreme cold for a considerable period. While such cases are comparatively rare, they may demand investigation.

=C. Exposure of the Insane.=—While it must be admitted that the insane subject is usually indifferent to matters of temperature, death from exposure to cold may call for special examination. Carelessness, incompetence, or wilful neglect on the part of nurses or keepers of insane hospitals, or deliberate criminal intent in such or others having the care of or an interest in the death of an insane person may lead to a judicial inquiry.

Sudden death has been reported as occurring, in several cases, after the ingestion of large quantities of cold water when the person was greatly heated. It is somewhat difficult to explain all such cases reported on a single line of causation. Some observers have attributed death to syncope or asthenia by the shock produced, in the sudden effect of the cold upon the sympathetic nervous system inducing heart failure. This seems the most natural explanation.

Others consider the causative factor to be the formation of thromboses in the capillaries of the brain, lungs, and other organs, inducing active and obstructive congestions causing death by apnœa or coma. Others regard these cases as similar to “heat apoplexy.”

SYMPTOMS.

Under the influence of external cold, the vessels of the skin are contracted and the internal splanchnic areas dilated. Thus the surface of the body contains less blood and the internal organs a larger proportion. This vascular change is one of the important factors in maintaining the uniform temperature of the body. The thermometer, placed in the mouth, in such conditions frequently indicates a rise of temperature. This is probably due, not only to the increased volume of blood collected in the internal organs, but also to an increased production of heat through a thermogenic action.

In exposure for a time to severe cold the nose, ears, cheeks, hands, feet, and other portions of the body, after the first appearance of dusky lividity, become bloodless and white, lose sensation, and become congealed; a condition known as “frost-bite.” From this, recovery without injury is possible under appropriate treatment, by which the temperature is gradually raised and the circulation restored. Where the latter result is not secured, the part becomes gangrenous and is ultimately removed by a process of inflammation and sloughing.

If the application of cold be protracted and the temperature extreme, the loss of heat becomes rapid and symptoms of depression of the heart’s action appear. Painful sensations of the surface and other portions of the body are experienced, succeeded by impaired sensation and anæsthesia. The skin acquires a dusky, reddish, and livid appearance, with the formation occasionally of vesicles or blisters. With the lessened sensation stiffness of the limbs appears, due to failing muscular contractility. The congestion of the central portions of the nervous system induces a condition of advancing stupor, resulting in complete coma with ultimate suspension of respiration and the heart’s action.

Death from exposure to cold may be rapid or slow. In cases of recovery the period of reaction is a critical one. The depression of the heart is apt to continue, and gangrene of parts of the body is likely to occur. Ulcers and sores healing with difficulty develop in some cases.

TREATMENT.

In the treatment of those who are suffering from the effects of extreme cold, the restoration of the congealed or “frost-bitten” portions of the body should be gradually accomplished. Raising the temperature rapidly is liable to induce the death and destruction of the affected parts. Ice or snow should, at first, be rubbed upon the frozen part, to be succeeded later by cold water. The patient should be placed in a cool room and distant from the fire or source of heat. As soon as warmth begins to return the part should be enveloped in wool, cotton, or some substance of poor conducting powers. If the whole body be chilled, frictions of the surface with stimulating lotions are of benefit, wrapping the person in woollen or fur coverings or garments afterward.

Hot coffee or alcoholic stimulants are of value as restoratives, but the latter are to be avoided during an exposure to cold.

POST-MORTEM APPEARANCES.

The appearances indicative of death from cold are sufficiently marked to enable one to decide whether exposure to cold was the chief determining cause of death, provided that a careful consideration of the circumstances of season, temperature, place, and other conditions be also had.

In the examination of a body in a case of apparent death from cold, the limbs and internal organs may be found frozen. It must be remembered that this occurs after, not before, death; and the frozen condition must not be mistaken for “rigor mortis.”

In cases where a body is found, in freezing conditions of atmosphere, showing commencing putrefaction, the death must not be hastily attributed to cold, which prevents putrefaction. It is evident that if cold was the cause of death the temperature of the body had been raised since that event, or, more probably, death occurred from other causes and the body remained some time before becoming frozen.

The finding of a body in the snow or frozen in severe weather must not preclude the search for other causes of death, such as apoplexy, etc., which may have occurred anterior to the freezing.

Observers generally have agreed upon the presence of certain post-mortem conditions in cases of death from cold.

EXTERNALLY.—Upon the skin are found dusky reddish patches, irregular in outline, which are in sharp contrast with the general pallor of the surface. Krajewskey,[691] Ogston,[692] Dieberg,[693] and others, in the several series of cases reported by them, all describe this condition. The skin otherwise is pale.

INTERNALLY.—The viscera, including the brain, are congested. The heart contains a large quantity of blood in the cavities of both sides, and the large vessels leading from it are also full. The color of the blood is a bright red, resembling its arterial hue. This condition has been generally noted and described; but some excellent observers have not referred to it.

EFFECTS OF EXTREME HEAT.

The application of moderate heat to the surface of the body causes dilatation of the cutaneous capillaries. In such application the exhalant and perspiratory function of the skin is increased, by which means a rise in general body temperature is prevented. If, however, severe physical exertion accompany the exposure, a more pronounced result is induced and a depressing effect upon the nervous system becomes manifest. If the degree of heat be raised and the exertion increased and prolonged, marked depression ensues. Under circumstances of quiet and rest a high degree of temperature is borne by man without depression or discomfort, but with continued and severe muscular effort the rise in animal temperature is productive of distress and depressing conditions. In the Turkish or Russian baths, in the healthy subject, a temperature of 48.8° to 54.4° C. (120° to 130° F.) produces profuse perspiration but no depression, and a plunge in or affusion of cold water is not only borne with impunity but is acceptable. In conditions of heat accompanied by physical exhaustion, such sudden exposure to cold would prove extremely dangerous.

In the condition of rest, exposed to external heat, the tendency to elevation of body temperature arises from the external causes alone, which in no way specially modify the nutritive functions. But in the second condition the internal processes of nutrition, which have been subject to great stimulation, are suddenly embarrassed by suppression of the compensating activity of the cutaneous surface, and severe organic and nervous derangements follow.

In the summer season the temperature rises to 32.3° C. (90° F.) and even much higher in certain localities. During the prevalence of such heat, the mortality among young children, the aged and enfeebled is very marked; these two periods of life being very susceptible to the depressing effects of heat. A high temperature is easily borne if the air be pure and the atmosphere be not saturated with moisture. Telluric electric conditions also have a modifying influence, undoubted though obscure.

In certain occupations an intensely heated atmosphere is endured with impunity for a considerable time, provided the air be maintained in a condition of purity and water be supplied to the person exposed. The stokers upon ocean steam-ships, where a forced draught is employed, are subjected to extreme heat, sometimes reaching 60° C. (140° F.). Resort to forced and continuous ventilation of the stoke-rooms, with short hours of duty, renders tolerance of the high temperatures possible.

SUNSTROKE.

The terms “sunstroke,” “insolation,” “coup de soleil,” are applied to conditions induced, not alone by exposure to the rays of the sun, but rather by a combination of great heat with other exciting causes. They are used to designate attacks occurring in very hot weather after exposure to solar or other sources of extreme heat. The striking and usual phenomena are exhaustion, unconsciousness, stertorous respiration, and death, occurring by syncope, within a few moments or hours. In a number of cases the symptoms of cerebral apoplexy with death by coma are present.

In others, the condition seems one of complete exhaustion. The majority of cases seem to be a combination of these several conditions, with death resulting from syncope.

The ordinary phenomena of the attack are pain in the head, hurried respiration sometimes stertorous, violent beating of the heart with failing of its power, oppression within the chest and, occasionally, nausea and vomiting. The pupils are sometimes dilated and sometimes contracted, but in all cases exhibit lessened sensitiveness to light. The suddenness of the attack modifies the symptoms developed.

PATHOLOGICAL CONDITIONS.

These are exhaustion with syncopic tendency and a rapid rise in the temperature of the body to a point destructive to the activity of the nervous centres. This is accompanied by an abnormal condition of the blood, resulting from loss of its watery portions, with retention of effete products and impaired aeration. A tendency to general stasis, specially marked by congestions of the lungs and brain, is present. The change in the blood is a very important factor. In some cases, not fatal at the outset, this induces a septic condition.

The greatly elevated temperature of the body undoubtedly produces certain modifications which type it, in some respects, as a febrile disease; but this, with the septic tendency due to blood changes, is not sufficient to designate it as a purely “thermal fever,” as some have claimed. It is something more than this.

Sunstroke occurs more commonly in tropical than temperate climates;[694] and usually in the day-time, at the period of greatest solar activity, those attacked being engaged in labor involving considerable exertion. It occasionally, though rarely, occurs at night. The military service affords abundant opportunity for observation. Here the seizures are on the march, rarely in camp. Fatigue, prolonged and extreme exertion, ill-adjusted clothing and accoutrements, with the deprivation of cool water, are fully as active factors as the heat of the sun. The death-rate ranges between forty and fifty per cent, the mild cases being excluded. Death in some cases is marked by syncope, in others by apnœa, though the majority seem to die by a combination of both, as in most cases the pulmonary congestion is more or less pronounced. Undoubtedly the character of the symptoms and mode of death are influenced, in many cases, by individual tendencies leading to apoplectic conditions or to cardiac or other complications.

TREATMENT.

This must be adjusted to the pathological conditions of the patient. As already indicated, two classes of cases are met: one marked by exhaustion, with tendency to death by syncope; the other, a state of or tendency to cerebral congestion or apoplectic conditions. Exactly opposite methods of treatment are demanded. In the first, frequency and feebleness of the heart’s action, with faintness of the heart sounds and embarrassment of respiration, indicate the tendency to death by nervous exhaustion, and must be met by placing the patient in a condition of absolute rest and quiet in a cool place. Stimulants must be promptly administered, though cautiously on account of the tendency to nausea and vomiting. Hypodermic injections of alcohol or ether, or rectal enemata of turpentine, alcohol, or other stimulants, afford means of securing speedy effects when the stomach is irritable. Carbonate of ammonia and other cardiac stimulants are recommended. Depleting agents, or such as prove depressing, are to be avoided. In some cases, hypodermic injections of small doses of morphine prove beneficial. Individual cases must modify therapeutic procedures.

In the second class of cases the tendency to cerebral congestion indicates sedative and depleting procedures. Blood-letting has been recommended by some authors, if employed with extreme judgment and discrimination.[695] Cold applied to the head and also to the whole body by rubbing with ice[696] or by effusion and the wet sheet, or other means, is indicated if the temperature is high (104° to 105° F.). Active catharsis, by promptly acting purgative enemata, is also to be resorted to in most cases. The convulsions occurring in some cases are successfully modified and controlled by inhalations of small quantities of chloroform.

POST-MORTEM APPEARANCES.

These, though not clearly characteristic, are pronounced. In some cases no distinct conditions are found.[697] Local congestions are present in nearly all cases. Upon the skin are found petechial and livid spots, pallor being occasionally noted. Ecchymoses and subserous hemorrhages are also common. These conditions have been described as resembling those of spotted typhus (Levick).

Rigor mortis is marked and occurs early, putrefaction beginning soon after death. The lungs are highly congested and often œdematous, and effusions of serum are frequently found in the pleural cavities.[698]

The heart is usually changed in color and consistence, with the left ventricle contracted and the aorta empty, while the right ventricle and pulmonary arteries are dilated and engorged. The blood is fluid and dark.[699] The large vessels of the pia and dura are full of dark blood. Congestion of the cerebral mass is not always noted. The ventricles contain serum; and extravasations of blood into the cervical sympathetic ganglia and vagus are sometimes found. The kidneys are usually moist and œdematous; the liver and spleen congested and dry.

BURNS AND SCALDS.

For all purposes of practice it is unnecessary to draw any distinction between a burn and a scald, for in reality none exists, except as regards the nature of the causative agent. In some cases requiring investigation, this may prove to be a matter of much importance.

=Definition.=—A =burn= is an injury produced by the application to the body of a heated substance, flame or radiant heat.

A =scald= is an injury produced by the application of a liquid at or near its boiling-point.

APPEARANCES AS INDICATING ORIGIN.

A hot body may produce a burn of any intensity, ranging between reddening of the skin and complete charring of the tissues, according as its temperature is elevated and the period of contact prolonged: the shape of the object and its size being indicated by the form of the burn. Metallic substances heated to a temperature of 100° C. (212° F.) are capable of producing redness and vesication and other injurious effects. At this temperature the albuminous elements of the blood and other fluids undergo coagulation. Some bodies require to be heated to redness, or nearly so, in order to produce a defined burn.

Very hot and partially-fused solids cause burns of greater severity than where the heated body is of a character favoring prompt removal. In such cases their adhesion to the skin involves the tearing away of the superficial portions of the derma in their removal, or they by their adherence prolong the contact of the heated body, thus intensifying their destructive action.

=Metals in a state of fusion= produce burns which cannot be easily distinguished from those caused by solid bodies. Such burns are classed as scalds. Their effects may vary in any degree between slight redness and complete destruction of the tissues with charring. Burns caused by melted solids are less regular in form and outline than those caused by heated solids. They are usually of greater severity on account of the high temperature to which they have been raised.[700]

=Boiling Water.=—Scalds by boiling water may be so slight as to produce redness only, or they may be so severe as to cause marked and characteristic symptoms. Those noted in severe cases are an ashy hue of the skin, accompanied by a soaked or sodden appearance and the production of blisters. Occasionally these features are not easily distinguished from those of burns from other sources. Blackening of the skin and charring of the tissues never result from burns by boiling water. As in all burns, a large surface involved renders an early fatal issue probable. In severe cases, not necessarily fatal, gangrene of the parts injured sometimes occurs. Most of those met with are accidental, yet cases of scalding by hot water with intent to injure are not uncommon, aside from injuries and death resulting from explosion of boilers, bursting of steam-pipes, etc. Occasional instances are recorded of death of children, the insane or feeble persons by inadvertent immersion in a bath of hot water (Case 21).

Severe and fatal burns of the mouth, fauces, and larynx in young children occur from inhaling steam or swallowing boiling water from a teapot or kettle in an attempt to drink (Case 5).

=Burns by burning oil= produce effects and appearances similar to those by melted metals.

=Burns by flame= are specially characterized by scorching of the surface. Hairs upon the part actually burned are scorched and usually also those in the vicinity of the burned patches. Such conditions could not result from scalds by hot water, boiling oil, or from a hot body only.

=Burns by petroleum= or its derivatives resemble the burns from flame, except that the injured portions of the body are not only scorched but blackened and are usually burned more severely than by flame alone, as the clothing holds the burning substance in contact with the parts. The odor of the agent is also very noticeable.

=Burns by Acids and Corrosive Agents.=—The injury produced by a mineral acid, the caustic alkalies, etc., has frequently been the source of judicial inquiry. “Vitriol-throwing,” as it has been termed, has been and occasionally is resorted to with malicious intent to injure. No case of death resulting directly and solely from this cause is recorded, but grave injuries, involving loss of sight, etc., have resulted. A case is referred to by Taylor[701] where sulphuric acid was poured into the ear of a woman while asleep by her husband. Death ensued, after six weeks, from disease of the brain resulting indirectly from the use of the acid.

The appearances of a burn by a mineral acid are distinguished from heat burns with little difficulty. The eschar which results is not dry and leathery, as in a burn by heat, but soft and readily sloughing away. There is no redness around the site of the injury, the color of the burn being uniform, and no blisters are formed. There is no blackening of the skin and the hairs are not scorched. The color of the skin around the injured portion may afford valuable evidence of the nature of the agent employed. Nitric acid produces a yellow stain, sulphuric acid a dark brown, and chlorohydric acid a brownish-yellow stain.[702] The clothing also is capable of affording characteristic evidence by the discolorations produced; and the destructive agent employed may be determined by a chemical analysis of the fabric.[703]

It is not possible to distinguish a post-mortem from an ante-mortem burn by an acid when no vital reaction has taken place.

THE CLASSIFICATION OF BURNS.

A classification of burns according to the severity of the injury inflicted is the most practical course. Upon this plan, burns may be divided into four general classes:

I. Burns in which the skin or subcutaneous cellular tissues only are injured.

II. Burns which involve the muscles, nerves, and blood-vessels.

III. Burns involving the internal organs and bones.

IV. Burns in which the other three classes are variously mixed.

CLASS I.—The skin in cases such as may occur from a brief contact with a hot body or water near the boiling-point shows a slight redness or scorching with no enduring mark. Pain is considerable.

CLASS II.—In the mildest cases the cutis is destroyed in its whole thickness, and the parts injured are occupied by eschars of a yellowish-gray or brownish color. The surrounding skin is reddened, and the formation of blisters occurs either immediately or after an interval of a few hours. In these cases a shining cicatrix remains after the healing, without contraction of surrounding parts. In the severer cases the subcutaneous cellular tissue and underlying muscles and nerves are destroyed. The blackish eschars formed are insensible and separate by suppurative process, leaving a granulating surface below. Extensive redness of surrounding tissues, with more or less vesication, is usually noted. The resulting cicatrices, together with the skin and adjoining structures, are prone to contraction, resulting in considerable deformity, according to location and extent. So great is the deformity in injuries of the extremities, or even some parts of the head and trunk, that extensive surgical operations become necessary to relieve it.

CLASS III.—Burns of this class are so severe that an immediately fatal issue is usually the result. Such instances involve a prolonged exposure to flame or to a source of intense heat. The appearances described as belonging to the preceding class are in part found here with the addition of charring or carbonizing the parts destroyed.

EFFECTS OF BURNS.

The effects of burns may be considered as I., Local, and II., Constitutional.

=Local Effects.=—In different instances the effects vary in accordance with the extent and severity of the burn. Redness, blisters, destruction of the cuticle and of the subcutaneous cellular tissue, blackening of the skin, scorching of the hair, and roasting of portions of the body are met with in varying degrees. In some severe cases all these are found upon a single body. The redness produced varies in intensity and extent, according to the nature of the agent producing the burn, its form, and the length of time the part was exposed.

Very soon after the infliction of the burn a special line of redness appears between the burned parts and the uninjured skin. This red line of demarcation is formed by intensely injected vessels and becomes a very important medico-legal sign in some cases. The vesication may be single or multiple, consisting of one or two large and full blisters or a number of large and small ones, scattered over the portions burned, some unbroken and still holding their contents, others broken and denuded of cuticle or with breaks from which their serum has escaped upon the surrounding parts. In some cases of burning cracks or fissures in the skin occur, due to the effect of the heat, making it dry and brittle and causing it to rupture by the movements of the patient (Case 8). These fissures are most frequently noted in proximity to the joints.[704] They resemble wounds, and it occurs occasionally that it is important to accurately distinguish their character. In some cases the skin only is fissured; in others the subjacent tissues are also involved. This difference depends upon the depth of the burn. In the first condition the skin splits, leaving the subcutaneous fat exposed, which in some instances is partially melted by the heat and flows out over the edge of the crack upon the surrounding skin (Cases 8, 13). The blood-vessels in such cases usually are not burned and, owing to their elasticity, remain stretching across the fissure (Case 14). The smaller may be seen by careful examination with a lens: they should always be looked for. In the second class of injuries the vessels are involved in the burn and break with the cracking of the skin. The importance of careful observation of these fissures is emphasized in cases of apparent wounds associated with burning. It may be necessary to decide whether the wounds are the result of the action of heat as above described or were caused by some sharp instrument or weapon. Careful inspection of the edges of the wounds will show whether they are ragged, as the result of fissure, or clean-cut by some sharp instrument. The absence of evidences indicating hemorrhage upon the surrounding parts and the detection of uncut blood-vessels extending across the fissure will establish the differential diagnosis. Wounds of the above character resulting from the action of fire may exist on the same body with wounds of actual violence. It is important, therefore, in all cases to examine each wound with special care and record its position, shape, depth, and other characteristics.

=Constitutional Effects.=—As in all sudden and violent injuries, the effect of a severe burn upon the nervous system is very marked. This is manifest in the symptoms of “shock,” with pallor and coldness of the surface of the body, a feeble pulse, chills or shivering, and a tendency to collapse. In other cases, proving immediately fatal, these symptoms are followed by obstructed respiration with death from coma succeeding. In other cases convulsions precede death, while in such as are not immediately fatal a reaction more or less imperfect ensues upon the first constitutional symptoms.

Death from cerebral congestion or effusion may result before any definite evidence of reaction appears. In some instances pulmonary congestion or œdema occurs, with or without pleural effusion, terminating in death before reaction. This period usually covers the first two days. In some cases immediate death results from the depression produced by the severity of the pain. During the subsequent two weeks a period of inflammatory reaction succeeds, when inflammations of the thoracic and abdominal viscera, with ulcerative processes in some organs, are developed and induce a fatal termination (Cases 10, 11, 16).

CAUSES OF DEATH.

The causes of death are due to several conditions. This fact is explained in part by the relation which exists between the cerebro-spinal and sympathetic nervous systems, and of the nervous supply of the surface to that of the internal organs, which in cases of extensive injury proportionately modify the conditions of the visceral organs. As death in burning results from various causes, it is convenient to consider them under two classes:

1st. Those immediately fatal.

2d. Those fatal after an interval.

The FIRST DIVISION would include cases in which the deprivation of fresh air and the presence of asphyxiating products of combustion (carbon monoxide and carbon dioxide) were the immediate causes of death by suffocation or asphyxia (Cases 9, 18).

Accidents in endeavoring to escape or injuries by falling walls or timbers may cause death immediately, and burning the body occur subsequently.

Immediate death may result from syncope or collapse from the violence of the shock to the nervous system by the pain resulting from the burns.

The SECOND DIVISION includes those conditions where death may result early, from a series of causes less immediate than those just mentioned.

Cerebral congestion and effusion, resulting in death from coma, is not unusual (Case 15). In this connection Taylor[705] cites a case of alleged poisoning by opium, in the treatment of a burn, in a child dying comatose, and emphasizes the undesirability of administering opium or its preparations to children in cases of burns of any severity. The danger claimed to exist is hardly to be considered. In the case referred to, Abernethy, who was a witness in the case, ascribed death to coma induced by the effect of the burn. The powerfully depressing influence of the pain in sensitive organizations and liability to death from shock therefrom must be remembered.

Inflammatory conditions of the respiratory tract or organs are common results; pneumonia, bronchitis, and sudden congestion or œdema of the lungs are frequent (Cases 11, 15, 16).

Inflammation of the intestines, inducing peritonitis and ulcerations of the intestines with or without resulting hemorrhage, occurs as a frequent lesion (Case 10).

Gangrene or septicæmia causes death in other instances.

Exhaustion, from extensive and prolonged suppuration or from severe and long-continued pain and other conditions, terminates other cases (Case 12).

Legally, burns and scalds are included among injuries endangering life, but are not described as wounds. They may be considered dangerous according to the extent of surface which they cover, rather than the depth to which they involve the tissues.

The extensive injury to the sensory nerve structures and the suspension of function or destruction of a considerable portion of the perspiratory tracts render large superficial burns far more fatal than those confined to a small part of a limb, for example, which may be deeply burned. From a medico-legal point it is desirable to establish the fact of how large a surface must be injured to prove fatal. The effort to reduce the subject to a statement of an exact minimum area of square inches seems very objectionable and liable to lead to erroneous conclusions.

It is possible to make a general statement, subject to some qualifications, which may serve as a basis of conclusion, as each individual case must be considered in its own circumstances.

A burn involving two-thirds of the body may be regarded as necessarily fatal; but the injury of a much less proportion, even one-fourth of the surface, has resulted in death. The qualifications to be made in burns of less extent are pronounced. The part affected is of much importance. Burns of the trunk are more fatal than those of the extremities; and those of the genital organs[706] and lower part of the abdomen are especially so (Case 7).

The character of the burn, whether single and continuous or multiple and scattered over various portions of the body, is a very important modifying circumstance, involving the questions of excessive pain and the difficulty in insuring necessary treatment for all parts injured.

The physical condition of the patient and sensitiveness of the nervous system to pain exert a powerfully determining influence. Burns in children and sensitive, nervous females are specially serious and call for an unfavorable prognosis.

=Spontaneous Combustion.=—Spontaneous combustion of the human body has been seriously discussed in this connection, and explanations of popularly reported cases have been attempted. The writer refers to the subject here for the sole purpose of stating that no trustworthy evidence of the possibility of any such condition or result exists.

TREATMENT.

In cases of severe burns the constitutional as well as the local conditions demand attention. Locally, a great variety of applications has been employed: starch, gum, oxide of zinc, solution of caoutchou, collodion, cotton wadding, a mixture of linseed oil and lime-water on cotton or lint, and many other agents are used. The important consideration is to exclude the air from and to afford a protective covering for the injured surface. The constitutional treatment varies in different cases; but its main object is to relieve pain, induce reaction from the shock, and support the depressed nervous system.

For the first opium or its preparations in proper doses is indicated. Alcoholic stimulants in some cases are demanded in addition. After the stage of reaction has occurred the therapeutics must be governed by inflammatory conditions; or later by the exhaustion from continued pain, suppuration, etc.

POST-MORTEM APPEARANCES.

In the EXTERNAL post-mortem examination of a burned body careful note should be made of the sex, probable age, and every circumstance leading to the establishment of the identity of the individual. The parts burned should be specially examined as to their condition, whether exhibiting redness, vesication, or charring. The amount of surface covered by the burns should be computed; also the relation of the burned parts to those uninjured, whether separated by a sharply marked line of redness or merging into the sound skin without a line of demarcation. The condition of the blisters should be examined as to whether they are full or empty and their contents as to whether consisting of clear or turbid serum.

INTERNALLY.—In some cases no lesions are found on examination. These are usually cases where death occurred from shock or severe pain (Case 12). Ordinarily the mucous membrane of the respiratory tracts is congested. In some instances, however, no redness has been discernible. Where death occurred by suffocation and asphyxia, the trachea and bronchial tubes have been found to contain a dark smoky or sooty mucus[707] (Case 9).

The serous membranes of the brain, thorax, and abdomen are in many cases found reddened with effusions, more or less considerable, into the ventricles of the brain and the pleural, pericardial, and peritoneal cavities from the sudden inflow of blood from the surface, caused by the local injuries.

When the body has been badly charred or incinerated the skeleton usually remains, and it is possible to determine the age from the size and development of the bones and the sex from the shape of the bones of the pelvis. Careful search should be made for special articles of identity. False teeth,[708] a watch and chain, buttons, etc., have alone been sufficient to identify the incinerated remains (Case 23). Where the whole body and even the bones have been reduced to ashes, some portions of bone, etc., may be found on careful search. Sifting the ashes will give some pieces of bone, etc., which may be sufficient to disclose the presence of human remains[709] (Case 24). A chemical analysis of the ashes also will aid in establishing this fact. In cases where cremation of the body has been resorted to to conceal crime, the length of time necessary to entirely consume the human body may become an important question. A period of less than ten hours has been proven sufficient.[710]

PERIOD OF THE OCCURRENCE OF DEATH.

As already indicated, death may occur from direct causes during the first forty-eight hours after the infliction of the burn, or may take place during a period extending from the second day to the fifth or even the sixth week. In the great majority of cases the fatal result occurs during the first five or six days. In some instances it may be important to establish the fact as to how long after the infliction of the burn the person may have survived.

Inflammation and suppuration would not ordinarily begin until about the third day, hence the existence of this condition would indicate that the person had probably lived two days or more; and the state of advancement of these processes would afford some further evidence. The existence of intestinal inflammations and ulcerations, which require some days for their appearance and development, would also give some indication of the probable time elapsing.

WAS THE BURN ANTE MORTEM OR POST MORTEM?

In describing the anatomical characters of a burn occurring during life, =vesication=, the formation of blisters, is regarded as a marked symptom.

While it is not an invariable result in a burn of the living body, it is so constant as to become one of the most important factors in answering the question as to the ante-or post-mortem infliction of the burn. Where the burn has been caused by a scalding fluid, or by burning of the clothing, or the direct application of flame, blisters are more likely to occur than where contact with a highly heated body has taken place. In the formation of a blister the cuticle is raised from the derma or true skin by the effusion of a highly albuminous serum, and the surrounding skin is of a bright or coppery red color. The time of the appearance of such a blister is not fixed. It may occur almost immediately or may not do so for several hours, an interval sufficiently long for death to occur from shock. It must be remembered that a burn inflicted in a condition of great depression of the vital powers with insensibility may be followed by no vesication or redness, but upon reaction and return of sensation both redness and blisters may appear (Case 17). In the absence of blisters, therefore, it cannot be decided that for this reason the burn was post mortem. If from a blister formed on the living body the cuticle be carefully removed, the site of the blister will present an intensely reddened base. In the dead body, if the cuticle be removed, no red base appears, but the surface of the blister becomes dry and of a grayish color.

On the other hand, if the presence of blisters is noted, can it be concluded that the burn was ante mortem? While their presence affords reason for an affirmative answer, careful examination of the blisters as to their character and contents must be made in order to decide; the presence of apparent blisters is not alone sufficient (Cases 20, 18; Plate II.).

Elaborate experiments have been made in order to decide the possibility of producing blisters post mortem.

Leuret,[711] in experiments upon dropsical subjects twenty-four hours after death, shows the possibility of raising a blister post-mortem, but one which can be distinguished from one of ante-mortem production, in that it contains a reddish serum very slightly albuminous. He urges extreme care in deciding this question.

Christison[712] found it impossible to produce a blister a few hours after death. In a patient unconscious from narcotic poison, heat applied four hours before death produced a blister and a red line was formed around the burns. In the burns produced half an hour after death, in the same patient, blisters formed in two places only, and these were covered by dry skin and contained air. No redness appeared around them.

Champouillon[713] agrees with Leuret in his conclusions, from experiments upon dropsical subjects.

Kosack[714] considers blisters with albuminous contents diagnostic of burns during life, but states the necessity for care in deciding in the absence of other signs of reaction.

Wright[715] was able to produce blisters three and a half hours after death containing a small quantity of pale serum. On the same body, similar experiments fifteen hours after death produced blisters containing no serum.

Caspar[716] states, as a result of experiments, that blisters may be produced by flame after death; that they result from vaporization of the fluid beneath the cuticle by the heat employed; that they are not found to contain serum and no line of redness is found at their base. The presence after death of vesications containing serum and surrounded by a reddish base is an evidence that the burn was inflicted ante mortem. He distinctly says: “It is quite impossible to confound a burn inflicted during life with one inflicted after death.”

Woodman and Tidy,[717] in an extended series of experiments, conclude that while blisters can be produced post mortem, they are readily distinguished from those formed ante mortem in containing no serum; and even in dropsical subjects, where blisters containing some fluid were formed, the presence of but a mere trace of albumin was shown; and, in all, no redness about the base of the blisters was produced, nor any appearance of redness after removal of the cuticle.

Taylor[718] has never observed vesications in post-mortem experiments on infants. He cites a case of drowning where the person, “pulseless and apparently dead,” was imprudently placed in a hot bath. Blisters containing bloody serum were formed over several portions of the body. He concludes that hot water on the living and recently dead body, so far as vesication is concerned, produces similar effects.

In experiments on the dead body immediately after death the writer has failed to produce any blister containing serum or fluid. The so-called blisters are produced by the rapid expansion and evaporation of the fluid beneath the cuticle over the portion to which the heat was applied, and differ distinctly from blisters caused during life, in the absence of serum or any redness of adjacent or subjacent parts (Plate II.).

Chambert[719] concludes that in living bodies and in dead bodies within twenty-four hours after death blisters can be produced, and that less heat will develop them in the living. He specially emphasizes the difference, in the albuminous character of the contents, of a blister formed ante mortem and of one formed post mortem.

Jastrowitz[720] emphasizes the difference between blisters formed during life and those occurring in œdematous conditions.

Blisters are to be distinguished from the bullæ arising from putrefaction. There is little danger of confounding such cases. In conditions of putrefaction no redness or line of demarcation exists, and the green discoloration and other conditions of the skin will suffice to establish the diagnosis.

Schjerning[721] considers blisters containing highly albuminous serum as diagnostic of burns produced during life. In some conditions of depression of nutrition blisters occasionally form, but are not liable to be confounded with those caused by burning.

A second anatomical feature of much importance, even more so than vesication, is the condition of the skin to which the heat was applied. It assumes a dusky red color and a dry and parchment-like condition (Case 8). Surrounding this is an area of grayish-white skin bounded by a sharply defined and deeply injected =red line=, which in turn shades into the color of the surrounding skin. These features are more or less pronounced according to the degree of heat applied and to the length of time of contact; or, in other words, to the depth and severity of the burn (Plate I.).

MEANS OF DISTINGUISHING ANTE-MORTEM FROM POST-MORTEM BURNS.

Differentially, a distinction is to be made between the surrounding redness and the line of redness. The redness due to capillary distention is transient, disappears under pressure during life, and fades after death. The line of redness is permanent, changing but little under pressure, and remains after death. It is a vital reactionary effort, a true line of separation between living and dead tissue, formed in the same manner as the line of demarcation in sphacelus or gangrene. This line of redness, developed only during life and permanent after death, is of great significance in cases with a medico-legal bearing. It has been already stated that in persons in a condition of depressed vitality the appearance of redness and vesication is sometimes very tardy and imperfect, and that death from shock or pain may occur before their development at all. They are vital processes and require time for their appearance in proportion to the activity of the powers of reaction. Hence in cases of burning resulting fatally where vesication and redness do not appear, the circumstances must be carefully considered before deciding that the burns produced were post mortem. With these qualifications, it may be stated that the presence of the red line is almost uniform in burns inflicted during life and absent in those occurring after death.

If upon a body bearing evidences of exposure to heat there be found blisters containing highly albuminous serum, and such blisters, after the removal of the cuticle, present a bright red base surrounded by a bright and sharp line of demarcation, with redness of adjacent surface, we are justified in concluding that the burns were inflicted ante mortem or, at farthest, within a few moments of death. If, on the contrary, the red line is absent and the blisters contain a thin watery fluid, with a yellowish and dry condition of their base after removal of the cuticle, the presumption is that the burning occurred post mortem.

Where a number of burns are found upon a body, the question whether they were produced simultaneously may be raised. This can be answered by examination as to their condition. If some show signs of recent infliction, while others are in conditions of suppuration or other changes which only occur after an interval, a difference of time in production would be probable. But if all present mainly the same conditions, the probability of their occurring at the same time may be concluded (Plates I. and II.).

=The Condition of the Blood.=—Special examination of the blood of persons dying from the effect of burns has been made by competent observers. While it is not at present possible to define an exact and constant condition, specially characteristic, some features of interest have been recently recorded.

The color of the blood has been variously reported; in some cases as being of a dark color and in others of a bright arterial hue. Death by asphyxia or suffocation, by the deprivation of oxygen, and by the products of combustion, would be accompanied by a dark or venous hue of the blood. An atmosphere containing an excess of carbon monoxide, resulting from combustion, would cause death by apnœa with an arterial hue to the blood.[722] But other influences must be considered. According to Schjerning,[723] it is difficult to deduce positive conclusions from the condition of the blood. The changes induced by the spleen and kidneys, as well as the varying intensity of the degree of heat to which the body may be subjected, tend to render positive and constant conclusions from this source difficult.

Falk[724] refers to the bright red color of the blood found in some cases, and explains this condition in part by the influence of chemical changes in the tissues surrounding the vessels.

Wertheim[725] describes certain conditions observed by him and mentions an increase in the number of the leucocytes, together with the presence of hæmoglobin and melanin.

Hoppe Seyler meets with similar results and arrives at the same conclusions in his observations.

Ponfik,[726] on the contrary, is doubtful of the constant presence of some of these conditions and also of their diagnostic value.

Seliger[727] confirms the conclusions of Wertheim, in that he describes the presence of crystalline bodies and of dark discolorations (melanin).

Some spectroscopic analyses have disclosed the presence of bands additional to those of normal blood. The lack of uniformity of conditions described and of conclusions reached leaves the subject in a position of uncertainty. Examination of the blood of those dying from burns has not been so extensively and minutely followed as to enable us to decide questions which may arise in any case.

EXPLANATION OF PLATE II.

FIGURE 1.—ANTE-MORTEM BURN.

Scald by steam from a boiler bursting, July, 1892.

From a photograph taken sixty hours after the accident. The injury covered one-half of the surface of the body. The red line is sharply marked; the extensive blisters formed are broken and their contents have escaped; the serum drying has produced yellowish discolorations; the blush of redness on adjacent parts is well marked. Death resulted on the fifth day.

FIGURE 2.—POST-MORTEM BURN.

Exp. 1. (Appearances after application of a tin can containing boiling water.) The cuticle was raised by expansion. The blisters contained no serum and no red line is developed.

FIGURE 3.—POST-MORTEM BURN.

Exp. 2. (Appearances after the application of iron at a dull red heat.) No proper blister formed; the cuticle was raised, as in previous experiment. There was no serum and no red line or redness of adjacent parts. The cuticle is charred at one point, where the iron was brought into contact with it.

WAS DEATH ACCIDENTAL, SUICIDAL, OR HOMICIDAL?

Nearly all deaths occurring from burning are accidental, very few homicidal, and hardly more than a few exceptional cases suicidal.

It is important in cases of legal investigation to note the position of the body when found and its relation to the apparent source of fire; the parts of the body and clothing burned, etc.; evidences of violence should be carefully observed, such as contusions, fractures of bones, wounds of the soft parts, evidences of strangling, etc. (Case 22). These should be specially sought in the site of the burned portions, as burning and cremation of the victim are sometimes a resort to conceal homicide. In considering the character of the apparent wounds, it must be remembered that extensive injuries, resembling wounds, may result from the effects of fire,[728] and these must be carefully distinguished.

Inability to detect special marks of violence need not preclude the possibility of its commission and of its being a possible cause of death (Case 19). The parts burned, the character and depth of the burns, and their relation to the apparent source of burning, with consideration of their probable simultaneous exposure, are all circumstances of weight in forming an opinion. The position of the body in relation to the fire should also be considered. In accidental burning, except in cases of intoxication, epileptic seizures, or other sources of helplessness, the victim is quite likely to be found at a distance from the fire, owing to his efforts to escape.

CASES.

CASE 1. Death from Cold. Accidental (Dr. Hilty in Caspar’s Vierteljahrschrift, II., 1865, p. 140).—Male, æt. 52; intoxicated. Severe winter weather; death from exposure. Post mortem: Blood crimson; both sides of heart full; internal organs congested.

CASE 2. Criminal Exposure to Cold (Ann. d’Hygiene, 1868, Vol. II., p. 173).—Girl, unmarried; sudden delivery when at stool. She stated that she had fainted, and found the child dead when she recovered. The child had breathed and the cord was cut. No marks of violence. Evidence of death being caused by wilful exposure. Imprisoned.

CASE 3. Ill-Treatment and Criminal Exposure (Ann. d’ Hygiene, Vol. VI., p. 207, 1831).—Man and wife tried for manslaughter of a child, æt. 11. Wife the stepmother. Starvation and ill-treatment by mother, followed by forcing the child, in a cold December day, to get into a barrel of cold water and remain there. Though removed by a servant, she was again placed in the cold water by the mother, death resulting. The woman was sentenced to life imprisonment.

CASE 4. Sunstroke, High Temperature, etc. (Dr. A. Flint, Jr., New York Med. Jour., 1872, p. 168; Dr. Katzenbach, New York Med. Jour., 1873, p. 93).

CASE 5. Scald, Drinking from a Tea-kettle. Accidental (Mr. Sympson, Brit. Med. Jour., 1875, June 19th, p. 809).—Boy, æt. 2½ years, drank boiling water from spout of tea-kettle. Inflammation of pharynx and glottis. Tracheotomy; recovered.

CASE 6. Fatal Scald of Insane Person in a Bath (Brit. Med. Jour., April, 1871, p. 456).—An insane patient fatally scalded in a bath, through carelessness of an attendant. The charge of manslaughter brought against the attendant.

CASE 7. Fatal Burn of Genitals. Accidental (Caspar, “Forensic Med.,” Vol. I., p. 315).—Female child, 2½ years, fell on a hot flat-iron. Genitals burned; died in eleven days. Vagina gangrenous; blood fluid; lungs anæmic and pale; trachea bright red, etc.

CASE 8. Red, Parchmenty Skin, Cracks, etc. (Caspar, “Forensic Med.,” Vol. I., p. 307).—While a chimney-sweep was cleaning a chimney a fire was lighted below. Death. The entire skin was of a coppery red color, with yellow patches. No carbonization. Skin parchmenty, with fissures upon the edges of which the fat had melted and flowed out.

CASE 9. Asphyxia. Sooty Mucus, etc. (Caspar, “Forensic Med.,” Vol. I., p. 314).—Two children, æt. 3 and 7, burned; death from asphyxia. The youngest, the girl, burned externally; the boy was not. Post mortem in both showed the trachea to contain frothy and sooty mucus. Lungs and vessels of thorax and abdomen distended with dark and fluid blood. Brain congested, etc.

CASE 10. Burn of Body. Inflammation of Stomach (Amer. Jour. Med. Sciences, Jan., 1861, p. 137).—Superficial burn of lower part of body. Death on the thirteenth day. Post-mortem examination showed the stomach inflamed and the intestines also.

CASE 11. Accidental Scald. Pleurisy (Caspar, “Forensic Med.,” Vol. I., p. 312).—Female child, æt. 6; scalded with a pot of boiling coffee overturned upon the side of neck, right axilla, thorax, and right arm. Death on the eighth day. Post-mortem examination revealed inflammation of right pleura, pericardial effusion, etc. Body anæmic.

CASE 12. No Internal Lesion Found (Guy’s Hospital Reports, 1860, Vol. VI., p. 146).—Female, æt. 9. Burn of upper part of chest and arms by clothing taking fire. Death on the ninth day. Post-mortem examination revealed no lesion of the internal organs.

CASE 13. Cracks and Fissures of Skin (Caspar, “Forensic Med.,” Vol. I., p. 314).—Male, æt. 83. Clothing caught fire; death. Body carbonized. On right side were fissures opening into the abdomen; the viscera could be seen, etc.

CASE 14. Fissures, Vessels Crossing, etc. (Taylor, “Med. Jurisprudence,” Vol. I., p. 696).—Boy, æt. 2; death in three-quarters of an hour. On legs were fissures and lacerations near each knee. On right thigh a laceration 2¾ inches long, 1/6 inch deep and 1/4 inch wide; fatty tissue seen beneath. No blood effused; small vessels could be seen stretching across the fissures.

CASE 15. Brain Congested, etc. (Caspar, “Forensic Med.,” p. 316, Vol. I.).—Boy, æt. 1-1/2 years, set fire to his clothing. Death in 1½ days. Post-mortem examination showed congestion of the brain, inflammation of the trachea, engorgement of the lungs with hepatization of the lower part of the right lung.

CASE 16. Burn of Lower Part of Body. Death (same reference).—Woman, æt. 81; burn of lower part of body, including the gluteal region, the perineum and genital organs (external). Death after several days. Post-mortem examination showed the upper lobe of left lung in a stage of red hepatization, etc.

CASE 17. Tardy Appearance of Redness and Vesication (Tidy, “Legal Med.,” Vol. II., p. 124, Case 15).—Woman, insensible from cold, had hot water applied in tins to her sides and feet. The flannel coverings became displaced and the hot tins came in contact with the body. No redness or vesication could be detected two hours afterward. The next day, when consciousness had returned and recovery from insensibility had taken place, the parts had become reddened and vesicated.

CASE 18. Were the Burns Ante Mortem or Post Mortem? (Caspar, “Forensic Med.,” Vol. I., p. 317).—Woman intoxicated; clothing caught fire; death due to asphyxia. Some burns apparently caused during life and some after death. The case was decided upon the character of the vesications and their contents. Lungs and other organs normal. Right side of heart engorged with dark blood.

CASE 19. Murder. Body Burned (Dr. Duncan, Med. Gazette, Lond., Vol. VIII., p. 170).—Man charged with the murder of his wife and attempting to burn the body afterward. The body was so extensively burned as to remove all means of deciding the cause of death. The man claimed that her clothing took fire when she was intoxicated. Persons in the same house had heard sounds of a struggle before smelling smoke and fire. Furniture was not burned, nor the house. The prisoner was found guilty of murder.

CASE 20. Blisters. Was the Scalding Ante Mortem? (Taylor, “Med. Jurisprudence,” 8th Am. Ed., p. 411).—The body of an infant found in a saucepan, boiled. The prisoner admitted that the child had breathed. The boiling water had destroyed the means of positively deciding whether the child had breathed. Blisters found upon it contained yellow serum. Was the child living when put in the water? The prisoner was acquitted.

CASE 21. Scald of a Lunatic in a Bath (Taylor, “Med. Jurisprudence,” 8th Am. Ed., p. 411).—Insane patient placed in a hot bath. Temperature 123° F. Death in collapse next day (1879).

CASE 22. Criminal Burning, Strangling (Report of Profs. Liebig and Bischoff, of Giessen, March, 1850).—The man Stauff was tried at Darmstadt for the murder of the Countess of Goerlitz, whom he had attacked and murdered in her chamber, and then fired the furniture in order to conceal the crime. It was uncertain whether she had died from injury to the head or from strangulation. The tongue protruded and was swollen, as in cases of strangling, and maintained this condition. He was convicted chiefly on circumstantial evidence. After conviction he confessed that he had strangled her and then set fire to the furniture, which he had piled up about her.

CASE 23. Murder. Body Burned. Identified (“Report of the Trial of Prof. Webster,” etc., Boston, 1850).—Prof. Webster killed Dr. Parkman and then burned the body, in portions, in a furnace in his laboratory. Search among the cinders of the furnace disclosed pieces of human bones and a set of false teeth which the dentist who made them recognized as made by him for Dr. Parkman, etc.

CASE 24. Murder. Body Entirely Burned. Identified (the “Druse Case,” Trans. New York State Med. Soc., 1887, p. 417).—Mrs. Druse, with the compulsory aid of her children, killed her husband with an axe. The body was burned in a wood stove, with pine shingles. The ashes were thrown into a swamp near by. They were found and carefully sifted. Pieces of bone of various sizes, identified as human, were found, as also a few porcelain buttons, etc. A few hairs found, with stains, completed the identity. Experiments in this case showed that the body could have been consumed within ten hours. The prisoner was convicted of murder.

THE MEDICO-LEGAL RELATIONS

OF

ELECTRICITY.

BY

WILLIAM N. BULLARD, M.D.

MEDICO-LEGAL RELATIONS OF ELECTRICITY.

AS the frequency of accidents caused by electricity is rapidly increasing, we have of late years been enabled to generalize in a manner never before possible in regard to their results, and although our present conclusions must be recognized as provisional and perhaps temporary—to be changed or modified in accordance with future knowledge—yet we have obtained a basis of fact on which we can securely rely. The general laws of injury and accident through electricity have been fairly well determined, although many of the details are not yet thoroughly worked out or understood. The advances of knowledge in this direction are so rapid that an article on this subject, if it deals too closely with details, is liable to become out of date almost before it has left the press. Like all large subjects when first made objects of general interest and investigation, and in regard to which we are on the threshold only of knowledge, the facts discoverable may lead us at any time in unexpected directions and open out new fields of thought and inquiry. We shall try to limit ourselves here, as far as possible, to proved facts, and leave questions doubtful or in dispute to be settled later; contenting ourselves merely with pointing them out and, perhaps, in some cases giving the facts on either side.

Electrical accidents and injuries may be divided into those which are caused by the atmospheric electricity—lightning proper, globes of fire, St. Elmo’s fire—and those produced through the agency of mechanical or artificial electricity—electrical machines, batteries, dynamos, etc. The effects caused by these different agents probably vary only in degree: the atmospheric electricity in the form of lightning, etc., being so much more powerful than the charges usually produced artificially as to cause some difference in the results.

RESULTS OF ACCIDENTS AND INJURIES FROM ELECTRICAL MACHINES AND CONDUCTORS.

=Medical Electricity.=—In the ordinary use of the mild forms of electricity employed for medical purposes, certain phenomena may at times occur, which, although not of any serious import or of long duration, may yet cause considerable inconvenience, pain, or discomfort to the patient or others, and may even be of some importance from a medico-legal point of view. We shall not enter here into the discussion of the proper methods of application of medical electricity, nor do more than point out that if these be not followed with care the patient may be not only not benefited, but made worse, and may even suffer considerable injury. The increase of pain caused by the improper application of certain currents is usually temporary and of minor consequence. But serious and lasting inflammations may be caused by the careless, ignorant, or injudicious use of the stronger currents internally, and metritis and peri-uterine inflammations have been not infrequently reported from the unskilled practice of the methods of Apostoli. These subjects, however, scarcely come under the scope of this article.

In addition, however, to these troubles we may have external injuries produced. Even in cases where the current amounts to not more than a few milliamperes burns may be caused by the ordinary electrodes of the galvanic battery. The faradic current when medically used does not, as a rule, produce any external injuries. Such might be caused by a spark from a static machine, but it would be due to gross carelessness, and is very unusual. Burns, however, from the use of the galvanic current are not very uncommon. They usually occur under the electrode after it has been for a few moments stationary in contact with the skin. They occur in certain patients with extraordinary readiness, especially in those with organic spinal lesions, and where the sensation is somewhat diminished, and where also some trophic lesion might be supposed to exist. They are not confined, however, to this class of cases, but may occur in any one if the electrode be retained too long in any one place, and especially if it be allowed to become dry. These burns are peculiar in appearance and can usually be recognized at once. They are circular, as if punched out, about the size of a common pencil or a little smaller, comparatively deep, gray with perhaps a dark ring at the circumference, and frequently surrounded by a reddened area. The edges are sharp. Their peculiarity consists (1) in their painlessness and (2) in their size, regular form, their depth in comparison to their extent, and the sharp limitation of the area of tissue destroyed. One or more may occur under a broad electrode, and they are probably produced at those points where the contact is imperfect or the conduction in some other way impeded. They heal without much difficulty and leave no serious results.

Other unpleasant symptoms produced by currents in medical use may be mentioned for the sake of completeness, and also as an introduction to the more serious symptoms caused by stronger currents. Dizziness, vertigo, tinnitus, nausea, vomiting, and syncope are readily caused by even slight currents. The sensation of light in the eyes and the metallic taste in the mouth are the results of medical currents of ordinary strength when applied to the head or in its neighborhood, and stronger currents applied at greater distances cause these sensations. All the above symptoms may be readily caused by even slight currents, whether galvanic or faradic, passed through the head. The syncope thus produced is to be carefully differentiated from the syncope caused psychically by excitement or fear of the application of electricity. Hysterical women, and even persons who show no special signs of nervous instability, may faint at the suggestion of the application of electricity. I have seen a large, strong, well-built Italian man, perfectly sound physically, so far as could be detected, except some slight local neuralgia, faint from pure fright when the electricity was to be applied. But even the application of moderately severe shocks from the ordinary medical battery are not likely to produce serious results. These shocks are ordinarily caused by the opening or closing of the galvanic current, and are most severe when the current passes through some portion of the head. A still more powerful shock may be given by reversing the current in a galvanic battery by means of the commutator.

CURRENTS OF HIGH TENSION—STRONG ARTIFICIAL CURRENTS.

Passing on now to the consideration of the stronger currents, we come to those used for mechanical purposes, for electric lighting, electric railways, and other analogous objects. These currents start from dynamos or from storage batteries, and accidents are caused by them whenever they are diverted from their proper course and are caused to come in contact with or to pass through any portion of the human body in any considerable strength. Accidents not infrequently occur from direct contact with the batteries or dynamos, but still more frequently they are produced in their circuit along the wires or transmitters. They may also be caused, as some of the most fatal have been, by contact with metallic or other readily conducting objects which have themselves accidentally come in contact with some portion of an electric circuit (usually wires) and have diverted the whole, or more usually a portion, of the current to themselves. Thus was killed a young man in New York, the clerk in a store, who while lifting the metal-edged cover of a show-case brought it in contact with the charged wires of an electric light and received an immediately fatal shock. As a rule, those meeting with accidents from dynamos or electric machines directly are employees of electric companies, who are presumed to have more or less knowledge of the risk of carelessness, or they may be workers in institutions or factories in which such machines are in use. Many of the accidents due to wires also occur to linemen and other employees of electric, telephone, or telegraph companies or of electric railway companies in charge of wires or electric outfit. So long as the current transmitters and terminals (wires, etc.) are properly insulated and in their proper position in relation to other conductors, it is unusual for accidents to occur, except in cases of gross ignorance or carelessness. Unfortunately, however, proper insulation is not always accomplished, and frequently wires and other transmitters are removed from their proper positions by accidents and otherwise. So long as and wherever the system of overhead wires exists, if there be among these wires any which are the transmitters of strong electric currents, there is always a risk, and often a very serious one, that at some time or other one of these current-bearing wires will come into contact with some other non-current-bearing and ordinarily harmless wire in such a manner that the current of the first should be diverted, in whole or in part, on to the ordinarily innocuous wire, which thereby becomes at once charged and dangerous. Such an accident may be due to the displacement of either wire or to any other cause which brings the two in contact, either direct or indirect, at a point where the current-bearing wire is not sufficiently insulated. The current having once passed out of its proper circuit will, of course, follow the paths of best conduction, and may hence suddenly appear in unexpected quarters and produce the most dangerous and even fatal effects. It is accidents of this character which most frequently occur among the people who are neither employees of electric companies nor engaged in factories or buildings where electrical machines are employed.

=Insulation of Wires and Other Electrical Transmitters.=—We cannot mention here the various methods employed to insulate wires, as the general principles of insulation are well known. Electric wires even with very strong currents can be insulated and can be kept insulated if sufficient pains be taken and sufficient money be expended. But this is very expensive and in many cases is not done. Only partial insulation is attempted, and even this is not always carried to the degree intended or stipulated. Hence so long as overhead wires of various kinds exist, accidents from the transmission of strong electric currents along ordinarily harmless wires are liable at any time to occur, as practically little or no attempt at keeping the current-bearing wires covered with a thoroughly insulating material is in most cases made. It is usually deemed sufficient that glass or other insulators should be so placed that under ordinary conditions the wire will not come into contact with any conductor which may cause any essential part of its current to diverge. In most cases a so-called insulating material is placed over the wire itself, but this usually is insufficient at the outset or becomes so before very long and is then not renewed.

It must not be supposed, however, that underground electric wires or transmitters cannot produce accidents. On the contrary, the current may be diverted from them to the gas or water pipes or to any other conductors which come into contact with them or can attract to themselves a portion of their current. Severe shocks have been experienced by persons attempting to draw water at their faucet from causes of this character. At the same time, so far as mere safety is concerned and freedom from electrical accidents, it would seem that underground wires are preferable to overhead wires.

Electrical wires have not infrequently come in contact with telegraph and telephone wires causing unpleasant results. Telephone boxes have been set on fire, and also telegraph boards and tables, and in certain cases what might have been serious conflagrations have been started in this manner. By means of proper arrangements on the telegraph and telephone circuits these dangers can be at least partially avoided, but there is always the risk that the automatic alarms and other contrivances do not act, and the still greater one that persons or things may come into contact with these charged wires and receive dangerous or serious injuries.

=Electric Cars.=—The danger from the overhead wires in the trolley system of electric cars would not be great were these wires properly supported, properly insulated, and properly protected. Each of these terms must be explained. Wires which fall for any cause whatever short of being intentionally removed cannot be deemed properly supported in the sense in which we use the term. Any one of these electric wires which falls is liable to produce serious injury to persons or animals (many horses have been killed by them), or to set fire to objects with which it comes into immediate or indirect contact, the amount of injury being in part dependent upon the nature and the condition (wet or dry) of the object and its position in relation to other conductors. Wires as dangerous as these car wires should be so supported that no ordinary accident, no condition of the weather, strong winds, or heavy falls of snow should be capable of wrenching them from their supports, and they should be placed in such positions and with such protection as not to receive blows from passing or falling objects.

Secondly, these wires should be properly insulated. This is to be understood to mean that all the wires which carry the electric current, or are liable to carry it, should be attached to their poles or other support in such a manner that no appreciable quantity of electricity is under any circumstances liable to be diverted to the poles or supports, and in this way cause destruction or injury. In addition to this the side wires should be so covered that if any accident occurs, it will be difficult or impossible for the current to pass away from them to other objects. The middle wire on which the trolley runs cannot be thus covered, but must be left bare, and hence, if knocked down or brought into contact with properly conducting objects, must be the most dangerous; but on the other hand from its position it is less liable to accidents.

When we say that these wires should be properly protected we mean that such arrangements and contrivances should be used as will prevent them while in their usual position from coming into contact with dangerous objects, particularly with other wires. This may be accomplished by guard wires or in other ways. It is plainly of great importance that this should be specially cared for, and particularly in a city where there are many overhead wires, and perhaps a considerable number of dead or non-used wires. If the electricity comes into contact with one of these no one can tell where it may be transmitted or what harm it may do.

The principles which apply to these overhead wires of course apply ceteris paribus to all other electric overhead wires, and in like manner the statements made in regard to the diffusion or spreading of currents in underground wires are applicable to all methods of transmitting electricity mechanically through the ground so far as the conditions are similar. An electric current will always follow the path of best conduction, and where several paths are opened it will follow them proportionally according to the excellence of their conduction or inversely to the amount of their electric resistance.

We shall not enter here into any questions in regard to the diffusion of electricity, its transmission through fluids, water, air or other gases, nor shall we discuss the relations of good or bad conductors to electricity except so far as this relates to certain portions of the human body. An elementary knowledge of physics and electricity must be presupposed.

We can now enter more directly upon the immediate subject of this article, that is, the effect upon the human body of severe or moderately strong currents of electricity derived from artificial sources. The accidents produced by these currents may be divided into two classes, the direct and the indirect. Under the direct we place all those conditions which are apparently produced by the action of the electricity itself, such as the general shock, the loss of consciousness, the burns, etc. On the other hand, all those accidents are to be considered indirect which are not primarily due to the action of the electric current, but are only secondary results thereof. These are largely determined by the immediate surroundings and conditions at the time. Such, for example, are the surgical injuries due to falls caused by the loss of consciousness produced by the electric shock.

INDIRECT ACCIDENTS.

These will be considered first, as they do not demand so detailed a description as the direct. They are traumatic in character and are the result either of loss of consciousness, momentary or lasting, or of the involuntary muscular contraction which may be occasioned by the electric shock. They are among the most frequent effects of severe electric shocks. These accidents consist in contusions, fractures, dislocations, wounds, and any other injuries which may be produced from sudden loss of consciousness while in a dangerous position. Death may readily occur either immediately or as the more or less delayed result of such injuries. If the person shocked falls into the water he may be drowned, or if into the fire he will be burnt. The varieties of such accidents dependent on the sudden loss of consciousness produced by the electricity are, of course, innumerable, and their occurrence must largely depend upon the position of the victim at the moment of the shock. We see, perhaps, most of these accidents in linemen on the tops of poles or houses or in other exposed places, but persons who receive shocks when simply standing on the ground or when sitting are not exempt from severe surgical injuries other than burns. They are often cast to the ground with great violence, and not infrequently are thrown to a distance of several feet. This is caused by the violent muscular contraction produced by the electric shock, and it may occasion, like any violent push or fall, severe injuries from contact with the various objects against which they may be forced. Although much rarer, it is also possible that the violence of these muscular contractions may be such as of themselves to cause injury, as rupture of a muscle or tendon. As practically all these indirect accidents are traumatic and surgical in character, they do not differ from other accidents similar in kind, but otherwise caused, and are to be treated on the same general principles as these.

DIRECT ACCIDENTS.

Quite different from the indirect are the direct accidents; those produced by the immediate (direct) action of the electricity. These are of various kinds, which we shall consider separately. They may be divided into immediate and late symptoms, and they vary much according to the severity of the shock and the constitution of the patient, and the part of the body through which the electricity passes. The character of the current which gives the shock, whether constant or interrupted, also naturally has an influence on the effect.

=General Principles.=—A shock may be given in three ways with an ordinary galvanic battery. If the current be sufficiently strong, a distinct shock will be produced when the circuit is closed and again when the circuit is opened, while with a current of the usual strength for medical purposes, the sensation while the current is passing through the body steadily is much less and is often limited to a sensation of burning at the seat of the electrode. A shock may also (thirdly) be produced by a reversal of the current, and the shock thus caused is stronger for the same current than that produced in either of the other ways.

The strength of these shocks is shown both by the sensation produced and by the amount of muscular contraction caused. When now a shock is caused by a continuous or constant current which starts from an ordinary dynamo or other electric generator or storer, it is practically always caused by the opening or closing of the circuit, or, what is essentially the same, the diversion of a part or the whole of the current from its proper path to and through some portion of the human body causes a shock at the time of the entrance of the body into the circuit and another at the time of its exit therefrom. Shocks from reversal of current when such current arises from a constant machine might occur, but only through some peculiar accident. Hence the shocks (distinguished from any other effects of electricity) which are received by the person coming into contact with a constant current are felt only at the moment of entering the circuit (closure) and of leaving it (opening). If a person introduces himself between the two wires of an electric circuit in which a constant current is used, in such a manner as to cause the current to pass through his body, he will feel the shock only at the moment when he touches the second wire and completes the circuit, and at the moment when he lets go one of the wires and opens the circuit (unless the current be so strong or be so placed that he can divert to himself sufficient electricity to cause a shock, or, in other words, close a secondary circuit in some other way). While the current is passing through the body, although it may burn and cause tingling and other unpleasant symptoms, there is no proper shock. In other words, an electric shock is caused only by a change in the amount of electricity passing through the body or a portion thereof.

If we now consider the effects of =alternating currents=, we find that we have another factor to deal with. The general principles are exactly the same, but inasmuch as the reversal shock is stronger than the closure or opening shocks, other things being equal, we are likely to receive a stronger shock from a current of the same force, and in addition to this, as in alternating machines the reversals occur with considerable rapidity, the person who becomes connected with this circuit receives a number of strong shocks within a short space of time. This is a much more serious matter than to permit a current of equal strength to flow through the body without change.

—The effect of this form of electricity on the human body is first stimulating and then tetanizing to the muscles. It consists in a very rapidly interrupted current, the shocks being at times so frequent that they are not singly perceptible. There is probably also a distinct difference in the action of this current from that of the galvanic current aside from its rapid interruption. This is not, however, of so defined a character as to enable us at the present time to distinguish in man the results of severe injuries and deaths caused by this form from those caused by other strong currents. Practically this form of current is but little used, except in medical batteries and for the purposes of experimentation in laboratories.

=Static electricity= has, so far as we know, rarely or never caused serious injuries or death. The sparks produced in this way have sometimes caused burns, and it is conceivable that a strong electric current produced in this way might be dangerous. The symptoms could not be distinguished from those caused by other forms of electricity.

=Summary.=—The greatest source of danger from electric currents is the shock produced by them. In ordinary constant or continuous currents this is produced only at the moment of the opening and the closure of the circuit. In alternating currents a shock is also produced at each reversal of the machine. Faradic and static currents are rarely or never used mechanically or in the arts.

=Resistance.=—The resistance of the human body to electric currents has been very variously estimated.

The reasons for these variations are: (1) that the different tissues present different resistances; (2) that the resistance in the same tissue varies greatly under different circumstances.

The tissue which offers the greatest resistance and also practically the greatest variation is the skin, or, more properly speaking, the epidermis. The resistance of this is many times as great as that of the rest of the body, and when perfectly dry it is impervious to currents of great strength. Witz states that in using a Ruhmkorf coil with an estimated force of 250,000 volts in Guinea-pigs and rabbits, it is advisable to cut through the skin in order to apply the electrodes directly to the flesh, or, at least, to wet the skin thoroughly, otherwise the shock caused by the full strength of the battery (six jars charged from the coil) would not cause death. Various animals offer rates of resistance which vary somewhat apparently according to the nature of the animal, but are probably largely dependent on the conducting power of its tissues, that is, of its skin. The variations between the resistance of similar animals, according to the condition of the skin at the time of the experiment, are much greater than those which are found between animals of different species under similar conditions, or which are referable to specific susceptibility. Mr. Harold P. Brown testified in the Kemmler case (Court of Appeals, State of New York—State of New York ex rel. William Kemmler against Charles F. Durston, agent and warden) that he had in the course of his experiments seen a horse weighing 1,320 pounds, with a resistance of 11,000 ohms, killed by an alternating current at 700 volts.

The resistance of the different cutaneous surfaces of the human body as measured by Jolly in Siemens’ units was from 400,000 down to 15,000 in the male and to 8,000 in the female (Siemens’ unit is to the ohm as 1.06 to 1.00).

Tschirfew and Watteville made the resistance from 80,000 to 3,000 ohms.

Experiments made at the Edison Phonograph Factory and Edison Laboratory in July, 1889, on 259 males between the ages of eleven and fifty-one, showed a resistance, measured between the hands immersed to the wrists in a solution of caustic potash independent of polarization, averaging 986 ohms and varying from 1,970 to 550 ohms.

The resistance of 236 men employed at Messrs. Bergmann & Co.’s Electrical Works in New York appears to have averaged 1,184 ohms and to have varied from 1,870 to 610 ohms. These measurements were also taken between the hands, which were washed with soap and water and then dipped in jars containing a solution of caustic potash. The battery consisted of four chromic-acid cells each having an E. M. F. of 2 volts.

As shown in all the experiments on animals and more especially in the cases of electrocution, the continuance or duration of the current has much effect on the resistance. As the current continues the resistance diminishes. Thus in the case of McElvaine the resistance between the immersed hands was at the beginning 800 ohms and at the end of the contact of fifty seconds had decreased to 516 ohms. In this case, when the current of 1,500 volts was applied from the forehead to the leg, the resistance was practically steady at only 214 ohms. Of course the small resistance in these cases (electrocutions) depends largely on the perfect contact secured.

According to the amount of resistance offered do the effects of severe shocks of electricity differ. This is shown especially well in the action of lightning, but is also true of powerful currents produced mechanically. If the resistance of the skin be slight at the moment of entering the circuit of a strong current, the current will pass through it with comparative ease and without causing much injury; but if on the other hand the resistance is great, the current will be, as it were, momentarily retarded or stored, heat will be developed, and there will ensue a burning and charring of the tissue of a special kind. These burns occur principally at the places where the current is specially resisted, that is, at the point of entrance of the current to the body and at its point of exit. This is the cause of the frequent burns in the heel or sole of the foot in the case of those struck by lightning while standing, as the electricity passes away from the body into the ground and finds a strong resistance at the point of leaving the body. This is also the cause of the burns where the current leaves the body from any other cause, as from the contact or proximity of a metallic object. The greater the resistance so long as the current passes, other things being equal, the more severe is the burn. It is for this reason that in medical electricity we usually use wet sponges on the skin or electrodes moistened with salt and water or with other fluids which will assist in rendering the passage of the electricity through the skin more easy. Solutions of chlorid of sodium and of certain other salts do this.

=The mechanical effects= of currents vary thus according to the resistance encountered. They also vary according to the intensity or concentration of the current. If a current of moderate force be applied through a small metallic point, it will burn, pain, and produce active irritative symptoms, while if the same amount be applied over a large surface simultaneously, it may have little or no irritating effect. We have, therefore, three factors in determining the mechanical effect of any electric current on the body: (1) the condition of the body, that is, the amount of resistance which the current will encounter at its entrance and exit; (2) the amount and intensity of the current; and (3) the character of the current. For practical purposes of the more severe currents we have only to deal with the continuous and alternating.

SYMPTOMS.

DIRECT SYMPTOMS.

The direct symptoms produced by powerful mechanical currents of electricity may be divided into three classes: I. The mechanical; II. The essential or internal; III. The mental or psychical.

These classes are fairly distinct, but they are not absolute, and certain symptoms are on the borders.

The most important mechanical symptoms produced by these currents are =burns=. These occur at all points of strong resistance externally, hence especially at the points of entrance and departure of the current. They vary from all grades, from the lightest possible, where only the fine hairs on the skin are singed, to those of extraordinary depth and severity. The characteristic burn from powerful currents is, however, well distinguished. It consists in a deep hole of various shapes with clear-cut edges surrounded by an inflamed area and containing in its cavity a mass of blackened tissue which only separates from the portions below after several days, and causes a wound which, though not very painful, heals very slowly. The severity of electric burns is often at first sight underrated, and their duration, when severe, is unexpectedly long. It occasionally happens that after a burn of this character appears nearly healed, the surrounding and, in appearance, healthy tissue breaks down, perhaps under a healthy skin, and a destructive process occurs which much retards recovery. This is evidently due to tissue destruction from a strong electric current of such a character as to produce necrobiosis without the external appearances of a burn. These burns are, perhaps, oftenest seen on the hands, but this is only because these parts are more likely to come into contact with the current. They may occur in any portion of the body.

=Eyes.=—The injurious effect of electric light upon the eyes has been carefully studied by several competent observers. So far as known it has been caused solely by the arc light. The symptoms produced by exposure of the eyes for a considerable period to the electric light may be slight or severe. In the slighter cases we find merely an acute conjunctivitis with a slight central scotoma which passes off within twenty-four to forty-eight hours. The symptoms are those usual in acute conjunctivitis—photophobia, lachrymation, sensation of a foreign body under the lids, discomfort in the eyes, and swelling of the lids. In the more severe cases all these symptoms are increased; the photophobia and lachrymation may be intense. There is sometimes severe pain in the supra-orbital nerve, and occasionally a tendency to somnolence. In these cases we find an intense conjunctivitis with chymosis, a central scotoma which may render the patient for the time practically blind, and on ophthalmoscopic examination a congestion of the vessels of the retina and choroid, a neuro-retinitis, and sometimes even hemorrhages into the retina. There is sometimes peripapillary œdema and infiltration around the optic nerve. The pupil of the eye in these cases is usually much contracted. There is sometimes loss of epithelium from the cornea.

In certain severe cases there is produced in addition to the eye symptoms an erythema of the face. Bresse states that this erythema can be produced on the face, arm, or hand by exposure to the voltaic arc at a distance of thirty to forty centimetres. The blush grows deeper for three or four hours, then remains stationary for a time, and ends in desquamation leaving a very durable pigmentation. The erythema is accompanied by a sensation of smarting.

The strength of the light and the length of time required to produce these effects probably vary somewhat according to the color of the light. Emrys Jones states that he is informed that either excess or defect of current gives a less injurious light than the normal current; the excess gives a more violet, the defect a more orange light. On the other hand, Charcot considered that the harmfulness of the electric light was due at any rate in considerable part to the chemical or violet rays, and Bresse found that when violet rays were added to an electric light as by aluminium it was more injurious than before to animals. What part the brilliancy of the light plays in determining the pathological results is not yet fully settled. The heat, however, does not, as a rule, seem to have much effect unless in extraordinary instances where the cornea is burned.

=Muscular Contractions.=—Another effect of electricity which is externally visible on the human system is muscular contraction. Slight muscular contractions are produced purposely in many cases in medical treatment therapeutically or for the sake of diagnosis. When the stimuli are sufficiently strong and follow each other with great rapidity, or when a strong continuous current is passed through the muscles, they are brought into a state of continuous contraction or tetanus, and in this condition they will remain for a long period or until the electric stimulus is removed. In cases where a severe electric shock is received as from an electric wire, the muscles which come in contact with the wire immediately contract and remain contracted while the current continues to pass through them. As a result of this we often find that when a severe electric shock has been received through the hands by means of a wire or other conductor the sufferer’s hands are involuntarily closed upon the wire or conductor, and cannot be unclosed by any voluntary effort until the current is stopped. While thus holding the conductor the hands are often very severely burnt. Under these circumstances a strong force is required to remove a person from a charged wire if the current be not turned off, and it can only be done at a considerable risk unless by those expert and provided with special means.

Not only the muscles immediately in contact with the conductor, but nearly all the voluntary muscles of the body may be thus affected by a powerful current. Another effect of this involuntary muscular contraction is the forcible muscular movements produced by the shock. As previously stated, when a sufficiently strong shock occurs, the voluntary muscles of the trunk and limbs may be thrown into sudden contraction in such a manner as to throw the person violently and forcibly on to the ground, or against some object or objects in the neighborhood. In this way one may be propelled several feet, and many varieties of surgical injury may be caused. Rarely the force of the contraction is such as of itself to rupture muscles or tendons, and it might even fracture bones or dislocate joints already predisposed.

ESSENTIAL OR INTERNAL SYMPTOMS.

We pass now to what we may consider the internal or essential conditions of electric shock, leaving the mental or psychical results for examination later.

When a person receives a severe electric shock, the symptoms are usually as follows: In the first place there may be little or nothing except a burn or burns, though usually there is some sensation at the moment of the shock. This may be a simple dizziness, and is often accompanied by the sensation of a brilliant flash of light before the eyes, and sometimes by a sense of impending danger. Usually, however, there is a loss of consciousness more or less complete and more or less lasting according to the severity of the shock and the character and course of the current. In the less severe cases this gradually passes away, and in many cases the patient, although weak and feeling shaken and tired, suffers no further ill effects beyond those of the burns and mechanical injuries. Sometimes there follows a general tremor which may last a few hours or for days, and occasionally a clonic rhythmical spasm of one or more extremities. The loss of consciousness may, however, be accompanied or followed by a condition of collapse, in which the pale face, profuse perspiration, cold extremities, and feeble pulse all suggest the administration of stimulants and restoratives. As a rule, in the stage of unconsciousness the face is reddened and rather cyanotic. The pupils are dilated as a rule and the respiration stertorous or absent; the pulse may be full or feeble, sometimes imperceptible for a time. The unconsciousness sometimes lasts for hours, and all means of stimulation, electricity, artificial respiration, rubbing, have to be applied before the patient can be restored. Sometimes this condition is succeeded by delirium (Moyer). In a certain number of cases the shock is immediately fatal, and in others the patients cannot be recalled from their unconsciousness.

The secondary results of the shock, aside from the injuries, may be very slight or again may be serious and lasting. They are far more apt to be of the first class, and when long or continued motor or sensory changes unconnected with injuries follow, we are justified in suspecting mental or psychical phenomena. One class of secondary results is the motor. In addition to weakness, unsteadiness and tremor of the limbs and trunk, it is not uncommon for the patient to suffer from grand rhythmical movements, at first, perhaps, of all extremities, but soon limited to the extremity or extremities which were most exposed or injured by the current. We have personally seen these movements, and feel convinced that they can be distinguished from most of the ordinary forms of convulsive motions and tremors. The whole limb is moved at once and not separate muscles, and the movement is a large, rhythmical one, slow and co-ordinated, not at all suggestive of tremor. Movements of this character are sometimes seen in so-called functional disease (hysteria and allied conditions). They more nearly resemble the movements seen in some forms of Jacksonian epilepsy than any others known to me as occurring in organic disease, but I believe them in these cases to be always strongly suggestive, if not absolutely significant, of functional affections. A case reported by Dr. Robert, of El Paso, well illustrates this condition. The patient, a male, twenty-eight years old, received a shock through a telephone wire. When seen first, reaction was slowly taking place, the entire muscular system was in clonic convulsions. Temperature 97°; pulse rapid and of low tension; respiration 50; no cerebral symptoms. An hour later the movements were limited to the left upper and the right lower extremities, and there was pain running from the region of the spine down the left arm. Twenty-four hours after the shock, temperature 99.5°; respiration 40; pulse 100. Had slept well, but the movements in the left arm had never ceased. The next day these motions were limited to the muscles of the forearm, and on the fourth day they had wholly ceased. These convulsions consisted in extensive motions of the whole extremity or of muscles or muscle-groups, and not of simple tremor. If the movements were forcibly controlled, severe pain ensued.

Next to the motor symptoms the sensory are the most important. Pain not infrequently occurs after the recovery of consciousness in the affected limb; it is apt to be sharp, severe, darting and neuralgic in character. This may last at intervals for some days, a dull ache occurring at first between the intermissions. It disappears of itself in time without lasting effects.

Hyperæsthesia may exist at first. Should this continue, or if anæsthesia not due to secondary traumatic conditions should appear later, we should be inclined to place these symptoms in the third class.

Of other symptoms occurring in accidents from currents of high potential, those which seem to be due to the direct action of the electricity are not serious. Buzzing in the ears and a metallic taste in the mouth often occur at the very beginning before the consciousness is involved. Nausea and vomiting frequently occur later. There is often considerable dizziness and vertigo. Patients sometimes complain of sensations as of an electric shock running through the body which occur without cause some hours or even days after the real shock. Some of these sensations are certainly to be reckoned under the mental or psychical symptoms. Susceptibility to the effects of electricity, of lightning, and of thunder-storms, though undoubtedly in many cases psychical, has probably in some cases an actual foundation. This is certainly the case in lightning stroke. On the other hand, in the large majority of cases of electric accidents no such result follows, and in many we are expressly told that such a result was looked for but not found.

The temperature, as affected by the electricity alone and not as secondary result of injuries, is not always easy to determine. It seems to be in most cases lowered at first, being in that of Moyer 97.5° and in that of Robert 97°. Later it may rise to a certain extent, usually to not more than 101°, but here again the influence of traumata is difficult to separate.

The pulse may be full and soft or weak and compressible. It is frequently very feeble, sometimes almost imperceptible, and often rapid. It is apt to remain rapid and somewhat soft for days in severe cases.

The respiration is at first rapid in severe cases unless the shock be so great as to cause its cessation. This rapidity remains for a varying period and then disappears.

As a typical case of the results of shock from an electric wire, we will mention the one reported by Dr. F. W. Jackson. The patient, a man twenty-two years old, came in contact with a live electric-light wire, touching it with his hands. He was thrown a distance of about ten feet and then back again, “swinging back and forth two or three times.” His hands were in contact with the wire about three minutes, when the current broke and he fell to the ground unconscious. Was seen two hours later by physician. Temperature 100°; pulse 100, strong and bounding; pupils dilated; headache; nervous and irritable; reflexes increased. The headache was accompanied by insomnia which continued for three days, after which it disappeared, and he resumed work apparently none the worse for his accident. The palmar surfaces of both hands and the anterior surfaces of the forearms were blackened from the tips of the fingers to a point midway between the wrists and the elbows, and these parts were exceedingly sensitive to the touch. The least irritation of the muscles would cause them to contract violently. This condition ceased on the second day. The current was from a fifty-light arc circuit of about 2,100 volts; 6.8 amperes. The accident took place out-of-doors on a very rainy night. The amount of electricity which the patient received was, as in all such cases, very uncertain.

FATAL CURRENT.

The amount of current which will produce a fatal effect varies with the character of the current and with the points of contact. Currents passing through the head or those which affect the pneumogastric nerves are much more dangerous than others of the same character and equal strength passing through one extremity, for example.

The same current will, of course, also produce different effects, according to the facility of its conduction into and through the body, and this depends again on the completeness of the contact and whether the body or the portion thereof concerned enters directly into the circuit or only forms, as it were, a partial conductor and diverts a certain portion only of the current to itself. Again, the condition of the epidermis, whether dry or wet, and the position of the person in relation to good conductors, metallic or otherwise, has much effect.

If the skin and clothes be wet, the resistance to the current is lessened and it passes more readily into the body. In the same way, if a person stands in close relation to a good conductor and places his hand on one wire of a high-tension electric circuit, he will receive a much more severe shock than if not connected with such conductor. Thus a person standing in a pool of water (water is a good conductor), and more strongly if standing on the metallic rail of a railway track, and touching one wire of an electric circuit with one hand, receives a much stronger shock than if he were standing on dry land, or if his boots were rubber or he was otherwise insulated.

The accidents most frequent in practice are those in which the current has been partially diverted from its original course and the person has not entered fully into the circuit. In such cases it is not usually possible to estimate accurately or even approximately the amount of current which the person has received. No calculations can, therefore, be based on these accidents. Again, we find that a person may be seriously or even fatally injured by a current which another person seems to bear with impunity.

D’Arsonval in 1887, in France, advised 500 volts as the maximum for the continuous current and 60 volts as the maximum for the alternating current which might be employed without special permission.

Our only accurate knowledge in regard to fatal currents comes from the experience derived from electrocutions. From these it appears that an alternating current of 1,500 volts is deadly if it passes through the body for more than a few seconds and if the contact is perfect.

=Death.=—Death may ensue immediately as the result of an electric shock without any evident preliminary symptoms, or it may occur later, either as the direct result of the shock or as the consequence of the exhaustion produced by the burns and other injuries, or directly from the injuries themselves. If death does not occur immediately and if appropriate means of aid are at hand, the sufferer usually survives and the effect of the electric shock gradually passes away. The danger after this arises from the burns and other injuries, and almost all the deaths not immediate are the results of these.

ELECTROCUTION.

Electricity has been adopted in the State of New York as the agent for the execution of condemned criminals. This has given rise to much discussion as to what form of current were the best adapted for this purpose and as to what amount were required to produce death at once and painlessly. These questions may now be regarded as practically settled, at least so far as regards the purposes mentioned, and we shall only refer incidentally to the discussions and their results.

Early in 1890 a committee consisting of Dr. Carlos F. MacDonald, Dr. A. D. Rockwell, and Prof. L. H. Landy made a report to the superintendent of prisons at Albany in regard to the efficiency of the electrical appliances and dynamos placed in the State prisons of Sing Sing, Auburn, and Clinton. This report gave details of various experiments made on animals to determine the amount of current and the time required to produce a fatal result.

On the 6th of August, 1890, occurred the first electrocution, that of William Kemmler, alias John Hart, at Auburn Prison. Dr. MacDonald in his official report to the governor in relation to this says: “It is confidently believed that when all the facts in the case are rightly understood the first execution by electricity will be regarded as a successful experiment. As might have been expected at the first execution by this method, there were certain defects of a minor character in the arrangement and operation of the apparatus. But in spite of these defects the important fact remains that unconsciousness was instantly effected and death was painless.”

The efficiency, rapidity, and painlessness of this form of execution have been confirmed by the later experiences. Up to the present date (May 26th, 1892) eight condemned criminals have been executed in the State of New York. Apparently all the officials who are intrusted with the care and inspection of this subject seem satisfied that this is, on the whole, the wisest, easiest, and most effective form of death thus far practised among civilized nations. The Medico-Legal Journal of New York, in printing the official report of the recent executions of four men made by Drs. C. F. MacDonald and S. B. Ward to the warden of Sing Sing Prison, states that it furnishes “indisputable evidence of the fact (1) that the deaths were painless and the victims unconscious from the instant of contact; (2) that they were certain and unattended with any of the revolting scenes so frequently witnessed at the scaffold; (3) that the method is humane so far as inflicting physical pain or suffering, and from all sides considered infinitely preferable to the death by hanging; and that so long as capital punishment for murder exists in New York, we need not desire to change the method of punishment.” These claims would seem to be thus far substantiated.

The value of this method of execution is now beyond doubt. When properly performed it is rapid, painless, and not repulsive. The criminal has probably no physical sensation of pain or discomfort due to the mode of death from the moment the first shock occurs. Since the rapidity of the transmission of the electric current through the body is in these cases much greater than the rapidity of the transmission of sensation, it seems just to conclude that no sensation from the electricity reaches the consciousness. The only distress suffered by the criminal is the unavoidable mental suffering natural to his position.

The mechanical means employed in electrocution are practically the same at Sing Sing, Clinton, and Auburn prisons. A special room is provided for the purpose, which should be, if possible, in the basement with a concrete floor: this room must be of sufficient size to admit readily the criminal with the attendant officers, the warden and other officials in charge or on duty at the execution, and the witnesses for whom seats are usually provided at a little distance from the criminal’s chair, and also to allow of plenty of room for the management of the electrical apparatus, and a good space around the chair in which the criminal is placed. The electrical plant consists of an alternating-current dynamo and its accessories, placed wherever may be convenient, according to the arrangements of the buildings of the institution, but connected by means of wires with the switch-board in the execution-room. In the execution-room also should be the voltmeter, the ammeter, and such other instruments of measurement or precision as may be required. In charge of these and of the switch-board during the execution is the electrical expert, an official paid by the State of New York. Means of communication by electric bells or otherwise are, of course, arranged between the execution-room and the engineer in charge of the dynamo, so that the current can be produced as desired.

The chair in which the criminal is placed is made of stout beams of oak and is securely fastened to the floor and insulated. It is perfectly plain, with broad arms and an upright back, which latter can be tilted backward a little by means of a special arrangement and firmly fixed in the desired position. This is accomplished by means of a bar of wood which is firmly attached at one end to the lower portion of the back and runs forward thence parallel to the seat of the chair and alongside of it; to the anterior end of this is fastened a perpendicular bar running downward, which can be raised or lowered at will, and securely fastened at any height. As this is raised or lowered, it raises or lowers the anterior end of the horizontal beam and correspondingly lowers or raises the opposite end to which the back of the chair is attached, thus moving the latter. When the anterior end of the horizontal bar is raised the posterior end is lowered and the back of the chair is straightened. Attached to the upper portion of the back of the chair is a head-rest, which can be raised or lowered as desired: it may, as in the case of Kemmler, have a horizontal arm which projects forward and from which the head-electrode may be suspended. The chair is also furnished with broad leather straps firmly attached, two of which pass around the body, one around each upper arm, one around each lower arm, and one around each leg. There is also a broad conjoined or compound strap which passes over the head, encircling the forehead and the chin and securing the head firmly to the head-rest. When these straps are properly adjusted and fastened, any marked degree of movement is impossible. The adjustment and fastening of these straps can be performed very rapidly, in practiced hands taking not more than forty seconds.

The electrodes used have varied slightly in different cases. In the case of Kemmler they each consisted of a bell-shaped rubber cup about four inches in diameter, with a wooden handle through which passed the wires into the bell to end in a metallic disk about three inches in diameter, faced with sponge. The upper electrode was so arranged as to rest firmly on the top of the head, where it was held closely by means of a spiral spring: it was attached to the horizontal arm of the head-rest, a sliding arrangement shaped like a figure 4. The lower electrode was in this case attached to the lower part of the back of the chair, and projected forward at a level with the hollow of the sacrum. There was also connected with it a sliding arrangement, and a spiral spring which in connection with a broad strap around the prisoner’s lower abdomen rendered contact secure.

In the later executions these electrodes have been somewhat modified and differently applied. The head-electrode is now so formed as to cover the forehead and temples, and can be easily fastened in this position without a spring. The lower electrodes have been applied to the leg in each case, sometimes apparently to the calf and sometimes more to the outer side, where they are securely strapped. They are made of such a shape as to cover a considerable portion of the surface in this region. It is not a matter of importance to which leg the indifferent electrode is attached, but they have actually been applied in most cases to the right leg, though in some they were attached to the left. They are thoroughly moistened, usually with a solution of salt and water, and a drip may be arranged so as to keep them wet during the passage of the current or other means employed to this effect.

The electromotive pressure, as shown by readings of the voltmeter by Professor Laudy, in the cases of Slocum, Smiler, Hood, Jugigo, and Loppy, varied from 1,458 to 1,716 volts. The ammeter showed a variation of from two to seven amperes.

The alternating current in the case of McElvaine made roughly 150 periods per second.

The number of contacts made in each case and the duration of each contact were as follows:

═══════════════════╤════════════╤═════════════════════════════════════ │ │ TIME, SECONDS. │ Number of ├─────────┬────────┬────────┬───────── │ Contacts. │ 1st. │ 2d. │ 3d. │ 4th. ───────────────────┼────────────┼─────────┼────────┼────────┼───────── Kemmler │ 2 │ 17 │ 70 │ │ Slocum │ 2 │ 27 │ 26 │ │ Smiler │ 4 │ 10 │ 10 │ 10 │ 19 Hood │ 3 │ 20 │ 20 │ 20 │ Jugigo │ 3 │ 15 │ 15 │ 15 │ Loppy │ 4 │ 15 │ 11 │ 15½ │ 10½ McElvaine │ 2 │ 50 │ 36 │ │ Tice │ 4 │ Total time, 50. ───────────────────┴────────────┴─────────────────────────────────────

In the case of McElvaine, the first contact of fifty seconds was made through the hands, the second contact of thirty-six seconds from the head to the leg. The hands were immersed in cells containing tepid salt water, connected respectively with the opposite poles of the dynamo. Kennelly states that in this case, with the hands immersed and the electromotive force at 1,600 volts, the current began at 2.0 amperes, and in fifty seconds had increased to 3.1 amperes, indicating a resistance between the electrodes of from 800 ohms at the beginning to 516 ohms at the end. In the second application from the forehead to the leg with an electromotive force of 1,500 volts, the current amounted to 7.0 amperes during the thirty-six seconds contact, indicating a resistance practically steady at 214 ohms.

Alternating currents of from 1,600 to 1,700 volts and upward may be considered fatal currents, and as capable of producing death when contact is perfect. Dr. MacDonald goes so far as to say: No human being could survive the passage through his body of an alternating current of more than 1,500 volts for a period of even twenty seconds, contact being perfect.”

The physical phenomena caused in the body by electrocution as at present conducted are comparatively simple, and such as we should logically expect. The instant the body of the patient enters into the circuit of the current, all the voluntary muscles appear to be thrown into a condition of violent contraction which continues so long as the current lasts, and on cessation of the current is replaced by a condition of extreme muscular relaxation. All consciousness is apparently lost immediately on the application of the current. This probably has never returned in any case, but on the removal of the body from the circuit of the current the relaxation of the muscles causes movement, and sometimes, as in the case of Kemmler, slight spasmodic movements of the chest have occurred. The pupils in this case were dilated. The condition of contraction and rigidity is renewed at each new application of the current, to cease immediately when the current is removed.

In Kemmler chest movements and possibly heart-beat occurred after the first contact, the former perhaps half a minute after the cessation of the current.

In Slocum there were chest movements and radial pulsation after the first contact. In Smiler no movement of the chest, but radial pulsation after the third contact. In Jugigo a slight fluttering of the radial pulse when final contact was broken, which rapidly ceased. In Hood no movement or pulse-beat.

In some of the patients superficial burns have been caused by imperfect contact of the electrodes, either on the head or at the position of the lower electrode. In Kemmler’s case the cerebral cortex was somewhat affected under the head-electrode.

The practical effect of the application of the current to the criminal fastened in the death-chair, as seen by the bystander, is that immediately on its reaching him the whole body is straightened and rendered rigid in extension, the extremities tend to straighten out, and the face may grow red and turgid. There is reported at times swelling and turgidity of the neck. The whole body remains in this tetanic, stiffened condition until the removal of the current, when all the muscles relax and the body sinks back into the chair in a state of complete muscular collapse.

MENTAL OR PSYCHICAL SYMPTOMS.

The third class of results which are found after electrical shocks from high-tension currents are the mental or psychical. By the use of these terms we do not wish to imply that they are voluntary. They are, however, so far as our present knowledge of pathology reaches, largely functional. This is precisely the class of cases which, when resulting from railway accidents, are placed under the head of railway-brain or railway-spine. They may be considered in the present state of our knowledge as traumatic functional neuroses, though it is probable that when our means of examination and investigation are more complete we may succeed in discovering a visible or perceptible lesion. The symptoms affecting motion and sensation in these cases are frequently accompanied by others of an emotional character, and in many cases there seem to be partially or wholly voluntary conditions and symptoms with the involuntary. There is in many cases a characteristic loss or diminution of the force and power of volition, but in others this is not perceptible.

These conditions are so well known when produced by other causes that we do not consider it proper to enter into a full consideration of them here, but we cannot leave this important subject without a few general remarks.

No form of affection or disease has caused more discussion among the medical profession or figured more prominently in the courts than this, and even now there are many questions in relation to these conditions still under dispute. Our own view, confirmed both by observation and experience, is that the tendency in New England, at least, has been on the whole to underrate the severity, the duration, and the amount of suffering caused by these conditions. That because there have been cases of malingering, of deception, and of rapid cure after the receipt of damages, and because in addition to this a certain visible emotional and at times apparently controllable element exists, the profession, and above all the laity, are led to conclude that this forms the essential condition and basis of the disease. On the contrary, in a very large proportion of cases the symptoms are such as cannot possibly be voluntarily assumed; they produce extreme discomfort and often much suffering for the patient, and frequently last for years, rendering their victims incapable of carrying on their former occupations.

Fortunately in the patients suffering from electric shock the severer forms of these affections are not so common. In most of the cases reported recovery has been more or less rapid. Cases in which previous hysteria or neurasthenia have existed are more liable to these manifestations than persons of a previously equable nervous constitution, but these latter are by no means wholly exempt. To consider these conditions, as is sometimes done, as the fault of the patient seems to us both unwarrantable and unjust.

LIGHTNING.

We now come to the consideration of the action of electricity in another form, that of natural electricity or lightning. The effects of this are practically the same as those of the forms previously described, except such differences as seem to be fairly accounted for by the vastly greater force of the currents with which we have to deal. Injuries and deaths from lightning stroke have been recognized and described for many centuries, and we have now a large collection of careful observations on them. They occur in most temperate regions with comparative frequency. In France the number of deaths from 1835 to 1852 inclusive (eighteen years) was 1,308. In England, including Wales, there were in twenty years, 1865 to 1884 inclusive, 416 deaths. In 1846 Mr. Eben Merriam, of Brookline, wrote to Mr. Arago that in the three last years about 150 persons had been killed by lightning in the United States. In thirty years, from 1855 to 1884 inclusive, we find 101 deaths in Massachusetts from this cause.

=Exposure.=—Injuries and deaths from lightning may occur in various places and under various conditions. The severe lightning strokes are popularly supposed to occur only during thunder-storms, and in this latitude this is undoubtedly, as a rule, true, but lightning strokes are reported to have occurred, particularly in the South, from a clear sky, and there seems no reason to doubt that this may happen. It is said also that dangerous discharges from the earth to the atmosphere may take place at a considerable distance from an atmospheric storm. As a rule, the lightning is more likely to strike some tall object, as a tree or a tower or steeple, and for this reason, and to avoid injury from falling branches, the shelter of trees should not be sought during thunder-storms if lightning stroke be dreaded. Ships at sea are frequently struck by lightning, partly perhaps on account of the height of the masts and partly on account of the metal in or on them.

Lightning obeys the same general laws as the other forms of electricity and naturally follows the paths of least resistance. Persons, therefore, who are in the neighborhood of or in contact with good conductors are in more danger of injury by lightning than when surrounded by or in contact with poor conductors. The proximity or contact of a large metallic object exposed in a thunder-storm is consequently more or less dangerous. On the other hand, the absence of tall objects or of specially good conductors of any kind does not insure safety. In many cases persons in fields are struck, and cases are related of persons struck on the prairies in the West. In Fredet’s case a shepherd was found dead in the midst of the barren moors (landes) in Southern France.

More accidents appear to occur directly to persons out-of-doors than to those in houses or other buildings. When inside buildings, persons struck are usually near an open door or window through which the lightning enters, and they are more exposed to danger from this source if there be some metal object or good conductor in the vicinity. Persons carrying or wearing metallic objects render themselves thereby more liable to be injured in this way.

Not only does the liability to injury from lightning vary somewhat according to the exposure or position of the person, both in relation to the free access of the atmospheric air and to the contact with or neighborhood of metallic objects or other good conductors, but also the severity of the injuries may be largely dependent upon what they are wearing or carrying and the condition of their clothing at the time. If the clothing be wet it will act as a good conductor, as will also any metallic object about the person. We have already referred to the action of metallic objects upon the passage of the electricity to and from the body and to the condition of the skin in relation thereto. The laws of conduction and resistance are precisely the same for the electricity of lightning as for the other forms. Hence the greater the resistance to the electricity at the points where it enters or leaves the body, the deeper will be the burn. Thus we find not infrequently that the lightning, in its course from the head to the feet, meets with a chain or a truss, and almost invariably at least a portion of the current follows this, causing a deep burn where it again passes into the skin. All the external burns of the lightning, except the initial one, are determined by the position and conditions of the body, the clothing, and the conductors near. All electricity obeys the same law and, roughly speaking, follows the path or paths of least resistance.

The clothing worn by a person when struck by lightning may be acted upon in the most various ways. Sometimes it is wholly stripped off the unfortunate sufferer, who, as in a case reported by Cook and Boulting, may have to be protected with sacks or other hastily improvised coverings. In a case reported by Nason, a girl of thirteen was struck while in the street and most of her clothes stripped off and torn to shreds, and the top of her hat, which contained steel wires, was torn from the brim. In the case of Wilks the body was stripped entirely naked and absolutely nothing left on except a portion of the left arm of the man’s flannel shirt. The clothing is sometimes torn to the finest shreds, like those of a mouse’s nest, as described by Van Horn, and in another case (Claes), where the patient was struck while on board ship, his woollen jacket was torn into fine bits, which stuck to the ropes, and the deck was covered with fibres of wool as fine as those of cotton-wool. In this case the woof of the trousers was said to have been wholly destroyed, while the web was untouched.

The clothing is also often burnt. Not only are holes burnt in it as is usually the case at the point where the lightning strikes and at the point where it leaves the body, but it may be set on fire. It may be found smoking or in flames.

Of all portions of the clothing injured, perhaps the coverings of the feet are the most frequently so, as the electricity is very apt to leave the body through the feet, and the resistance opposed is great. Hence the boot or shoe is frequently injured. Sometimes it is pierced as by a bullet, or a large hole is torn in it, or it may be torn to pieces or reduced almost to lint, while the foot remains uninjured. It may be torn, shrivelled, and burnt. In one case the soles of the shoes had disappeared; in another the leg of the boot was clearly divided from the sole and both straps were torn out; while again in another the shoe was carried wholly off.

The amount of injury to the clothing does not necessarily correspond to the amount done to the body. A person may be killed by lightning while the clothing is uninjured. On the other hand, the clothing may be torn to pieces, carried away, or even partially burnt, while the portion of the body underneath remains unhurt.

=Symptomatology.=—The symptoms of stroke by lightning resemble, in a general way, those due to high-tension currents of electricity. As in the case of the latter, they can be divided into the direct, produced immediately by the lightning itself, and the indirect, or secondary, produced through the medium of other factors.

In the milder cases the person struck feels dazed and benumbed and may or may not lose consciousness for a short time. At the moment struck they may have the sensation of a blow, and they often see a blinding flash. On recovery of their faculties there may be a temporary anæsthesia or weakness of one or more extremities, which rarely lasts more than twenty-four hours. There is a general shock to the system, sometimes slight loss of memory for a time, and occasionally nausea and vomiting. There are often discolorations of the skin of medium extent, and frequently burns and blisters. These persons have usually received the stroke on one extremity or have escaped the full force. In the more severe cases the patient loses consciousness immediately and may continue unconscious for some hours. He passes into a condition of collapse with rapid, feeble pulse and cold extremities, and the pupils are dilated. On recovery of his senses the same symptoms as in the less severe cases, only more pronounced, are found. The loss of memory may be marked and the intellect temporarily weakened, while the weakness and anæsthesia of the extremities persist longer. The external injuries, burns, and wounds are liable to be more severe.

In the fatal cases where death is directly due to the electricity it is usually instantaneous or at least without recovery of consciousness. It may be caused by shock or by apoplexy, i.e., intracranial hemorrhage or by the direct effect of the electricity on the brain. Of course death is often due to burns or to indirect traumatic injuries.

The indirect traumatic injuries caused by lightning are due either to the loss of consciousness of the patient, which causes him to fall and thus sustain injury, or to the direct action of the electricity upon him, knocking him down or throwing him to some distance, sometimes with great violence, or lastly, and perhaps the most frequent cause, to the impact or pressure of objects which are torn or cast down by the electricity and by striking or falling on a person produce great injury. Thus persons have been killed by the fall of buildings, sheds, or trees which were struck by the lightning, or their branches. Of course all kinds of traumata may be produced thus.

The direct external injuries caused by lightning are burns, subcutaneous hemorrhages, discolorations and markings of the skin either dendritic or metallic, lacerations or wounds.

=Burns= occur in nearly all, perhaps all, severe cases of lightning stroke. They may be of any or all degrees, and may extend over very small points or over the whole or nearly the whole body. They may consist in a simple singeing of the hair, or they may be very deep and extend to the bone. As before stated, the deep burns are found at the points of resistance to the current, at its points of entrance and exit from the body, and, to a lesser degree, at all points where its course is impeded. This occurs wherever the clothes are fastened tightly or pressed against the body, hence especially at the neck, waist, knees, and sometimes at the ankles. The position of the burns is determined, therefore, by the point at which the lightning strikes the person, the position at the moment, and by the arrangement of the dress and the presence of metallic substances. In the large majority of cases the upper portion of the body is the part first touched by the lightning, and thence it descends along the body to the ground. We are apt, therefore, to find a severe burn about the upper portion of the body, the head, neck, or shoulders; then a scorching, singeing, or burning, more or less severe, in the form of a stripe or stripes more or less broad down the body: the burns being deeper where the clothes are tighter or where metallic objects come into contact with or are near the body; and finally a deep burn at the nearest point of contact with the ground, usually the heel or some portion of the foot.

The burns, however, vary greatly. The eyes may be burnt and severely injured or destroyed. The lightning has been known to enter the mouth and burn the mucous membrane within. The deeper burns not infrequently assume the form of holes. In Heusner’s cases about twenty whitish-gray spots, varying from the size of a lentil to that of a pea, were found on the soles of the feet. The hair is usually singed and may be burnt off in large areas, or wholly as in a case reported by Bernard.

=Wounds.=—These may be direct or indirect. We shall speak here only of the first. Like burns they occur usually at the points of greatest resistance, that is, the places of entrance and exit, but they may be found in any part of the body. They may be clean-cut, as if made by a sharp knife, or they may be lacerated and ragged with the edges contused or burnt. They may consist of holes which look as if they had been punched out.

=Contusions= or ecchymoses. These may also be produced directly by the lightning, and like burns and wounds are most apt to occur where the resistance is greatest. They may be of considerable importance in a medico-legal sense, as in Fredet’s case, where there were ecchymoses on the neck similar to those produced by the fingers of a hand applied for strangulation. In the case related by Cook and Boulting the right side of the body appeared like an exaggerated example of post-mortem staining. There are sometimes found also dark-brown spots, small or large, which may be soft and, when cut, containing fluid blood, or they may be hard and like parchment, dry, and bloodless on section.

Closely connected with these are the so-called dendroid or dendritic marks, which are dark-colored reddish bands or stripes, often more or less dichotomously branched, not disappearing under pressure, found on the bodies of those struck by lightning. Though usually of the form mentioned, they may assume other shapes, as that of an irregular star with zig-zag rays. Balfour has figured an excellent example of these.

=Metallic staining= of the skin has been known to occur where metals were in contact with it at the time of the lightning stroke. These stains may be permanent and are due to the introduction of the finely divided metal. Richardson has succeeded in producing this artificially in animals. He found two conditions required, that the metallic conductor should be sufficiently fine to offer resistance to the current and that the current itself should be an electric discharge of low tension.

Loss of hair is said to have occurred from lightning, though the hair was not burnt. One case has been reported where after a severe stroke all the hair on the body is said to have fallen out.

SYMPTOMS.

Under this heading we shall consider only such symptoms as are, so far as can be ascertained, the direct result of the electricity and not those secondary to injuries.

We will consider first those relating to the nervous system.

=Loss of Consciousness.=—This occurs to a greater or less extent in all but the very mildest cases. It varies throughout all degrees from a slight momentary benumbing of the faculties to the most profound stupor or coma. It may then last hours or even days. On recovery the patient is apt to have some loss of memory, to be dazed and confused for some time, and a certain obtuseness or blunting of the intellectual faculties may persist for a considerable period. This loss of consciousness is often accompanied by flushing of the face and dilatation of the pupils, or on the other hand the patient may present all the symptoms of collapse.

=Loss of memory= in regard to the lightning stroke after recovery of consciousness is not rare. It is frequently complete so far as any recollection of the lightning goes, and there may be no remembrance of the thunder-storm. Sometimes a defective memory persists together with general mental impairment (James).

=Mental Disease.=—A condition of mental impairment lasting at least weeks or months may occur. Mania and the delirium of terror are said to have occurred.

Various symptoms of the disturbance of the nervous equilibrium are not uncommon. Among these we may mention tremor, insomnia, and nervous dread of thunder-storms and of electricity. There is no doubt that some persons who have been exposed to lightning stroke do, at least for a time, become unusually susceptible to the influences of atmospheric electricity.

=Loss of Motion—Paralysis.=—This is a very frequent result of a stroke from lightning. Hemiplegia is not uncommon. In Bonnet’s case the patient was struck on the head by the lightning, which caused a lacerated wound in the left temple, but did not injure the aponeurosis. On recovery of consciousness the patient was found to have a left hemiplegia involving the face and both extremities accompanied by a diminution of sensation over the left half of the body. The sensation became normal in two days, but a partial hemiplegia remained permanently. In the case of Durand there was a nearly complete right hemiplegia with accompanying hyperæsthesia and some affection of speech. Deglutition and mastication were difficult, and there was persistent hiccough. There was photophobia and hyperæsthesia. The patient improved in two weeks and finally recovered. There is often a temporary hemiplegia.

Nearly all forms of paralyses of the extremities may occur. We may have paralysis of all the extremities or of both arms or legs, or monoplegias. Paraplegia occurs not very rarely. It is usually of short duration. It may be accompanied by paralysis of the bladder. Single muscles or muscle groups only may be affected.

Ptosis may occur with paralysis of other branches of the third nerve, causing diplopia. Facial paralysis occurs also alone; in one case it lasted only twenty-four hours, in another one month.

Difficulty in mastication is sometimes found, but much more frequently difficulty in deglutition is reported.

Retention of urine, dysuria, or incontinentia urinæ may all occur, and there is sometimes a paralysis of the rectum, usually temporary, and sometimes obstinate constipation, which in one case was combined with paralysis of the bladder and monoplegia.

Aphasia in various degrees and various forms of dysphasia or difficulty in speech are not uncommon. They are apt to be temporary.

Loss of co-ordination in the lower extremities with partial paralysis of bladder and rectum is reported.

=Convulsions.=—Epilepsy may be brought on by lightning: this would be more likely to occur in a person previously subject to epileptic attacks. Hysterical convulsions and spasms may also be produced, both immediately and as a more remote result, usually in persons predisposed. Tetany and catalepsy are said to occur.

Clonic spasms of the whole body and convulsive movements of the limbs are not very infrequent. In some cases a marked sensitiveness remains for a time in the limbs struck, so that if touched they are immediately thrown into clonic spasms.

=Disturbances of Sensation.=—Pain occurs in nearly all cases. It is most frequently a secondary result of the burns and other injuries. Not rarely, however, it exists as a direct symptom in the form of a burning or stinging neuralgia in the limb or limbs affected. Sometimes the first sensation on the recovery of consciousness seems to be pain all over the body or confined to some portions only, but the amount and character of the pain, aside from that produced by the injuries, varies much. One patient had a burning pain in the back and leg lasting only half an hour after recovery of consciousness. In another case there were pains all over at the end of the first week. On the whole, severe pain in some or all of the limbs, and less commonly in the head, without paralysis and lasting some days is not rare. In one case reported by Paige the patient had intense pain in the head, neck, arms, and chest; that in the head was constant, severe, and lasted seven days, elsewhere less constant.

Pain in the arms accompanied by paralysis and anæsthesia and lasting three months has been reported.

Headache is not rare as a later or secondary symptom.

Disturbances of sensation other than pain are not rare.

A certain amount of hyperæsthesia almost always exists in the portion affected immediately after the stroke. This is often so marked that it cannot be wholly due to the burns or other injuries. It is usually very temporary and ceases in a few hours. In some cases a permanent or lasting sensitiveness to the action of electricity is said to remain.

Anæsthesia, loss or diminution of sensation, occurs either with or without paralysis. In the cases reported by Balfour, one boy said he could not feel his legs and another that his arms were cut off. In a case reported by Free there was loss of sensation in the right upper extremity from the elbow to the fingers and in the left lower extremity from the knee to the toes. As a rule, the loss of sensation is temporary and quickly passes away, but it may last, in company with paralysis, for some time. In such cases either an organic lesion or a traumatic neurosis is to be suspected.

Paræsthesiæ are very common after lightning stroke. Most frequent, perhaps, is the subjective sensation of numbness. Tingling, formication, and the sense of “pins and needles” may occur.

Reflexes.—As a rule, the deep reflexes seem to remain normal. The superficial reflexes of the parts affected are at least temporarily increased.

=Special Senses.=—Sight.—Affections of the eye. The eye and the surrounding parts may be directly injured by burning. We also find many serious conditions caused by the lightning the pathology of which will be considered later. When a person is first struck he may perceive a flash of light or a ball of fire before losing consciousness. While unconscious the pupils are usually dilated, but react. Sight may be at once totally lost, but this is usually only temporary. There may be amblyopia; photophobia, lachrymation, and pain are not uncommon for a time. Cataract may be produced and other severe ocular affections may result.

Hearing.—Sudden and total deafness may be caused by lightning, as in the case of Cook, where perforation of both tympana was found. This may prove to be only temporary, as in the case of Nason, where the patient, though totally deaf at first, is reported as hearing fairly on the fifth day; on the seventeenth day, however, the hearing was still dull. The deafness may be permanent. With deafness tinnitus is apt to occur. Hyperacustia, or extreme sensitiveness to noise, has also been reported in several cases.

Smell and Taste.—The person affected sometimes has noticed a smell resembling that of sulphur, and this has also been said to have been apparent to others. A metallic taste in the mouth is not rare.

=General Symptoms.=—When first struck by lightning and while still unconscious, the patient has usually a flushed and reddened face, with dilated pupils. Immediately following, or perhaps without this preliminary stage, appear the symptoms of collapse. Cyanosis may occur, and the patient may appear to be asphyxiated.

Fever, not caused by injuries, may sometimes occur, but certainly not to any extreme degree. In many cases the temperature when taken was normal, and even in cases of severe stroke without serious surgical injury the temperature has not risen above 101°. In these latter cases it is hard to say how far the temperature is affected by the burns which are always present.

The pulse is sometimes slow, sometimes rapid and feeble, or almost imperceptible; at times it is irregular.

The respiration is apt to be labored. In Paige’s case there was marked dyspnœa. It may be almost imperceptible. It is sometimes slow and sometimes rapid.

Nausea and vomiting occur often after recovery of consciousness. Vertigo and reeling may exist from various causes.

It is probable that seminal emissions may occur at the moment of shock.

Menstruation, when present, may be checked or may continue. Pregnant women do not necessarily abort.

PATHOLOGY AND PATHOLOGICAL ANATOMY.

A few words must be said in regard to the pathological conditions which may be directly produced by lightning and can be detected during life. The burns, wounds, ecchymoses, dendritic marks, and other external signs have already been fully considered.

Certain pathological changes, however, have been found in the eyes which are capable of being verified during life. In addition to swelling and œdema of the lids, to the injuries from burns and to the various paralyses of the ocular muscles, changes in the tissues of the eye itself may occur. In the first place we may find corneal opacities and adhesive iritis. Iridocyclitis may occur. Cataract formation is not rare, and its causation has given rise to many theories. Optic neuritis and neuro-retinitis are sometimes found; and we have sometimes optic atrophy. Structural changes in the choroid may also be caused by lightning. Rupture of the choroid, hemorrhage from the choroid and retina, and partial detachment of the retina may occur from the shock without the patient being struck by the lightning and without rupture of the external tissues.

Ears.—Perforation of the tympanum is reported in more than one case.

AUTOPSIES.

We shall consider here the pathological conditions found in deaths from electricity, whether due to artificial or to atmospheric sources. The results are or may be the same in either, so far as we now know, and it is probable that the action of the electricity is practically the same in either case, only varying as regards the strength and tension of the current.

=Rigor Mortis.=—This has generally been found in cases of death from artificial electricity. In the case of Jugigo, who was executed by electricity, it was present four and one-half hours after death. As regards its occurrence in death by lightning and the rapidity of its onset, there has been much discussion. It is certainly present in many cases, and the probability is there is nothing diagnostic in regard to it in deaths by lightning. When absent, its absence is probably due to the presence of some external factor and has no relation to the form of death. We have, on the other hand, no proof that the rapidity of its onset is increased.

=Coagulation of the Blood.=—It has been observed frequently that the blood of persons struck by lightning does not coagulate readily. Sullivan states that in certain cases of complete disorganization after lightning shock the blood is left fluid and incoagulable and its color changed to a deep black. In one of the cases of death from artificial electricity reported by Grange, the heart was found sixty-two hours after death to be filled with liquid blood of a rosy vermilion color, which quickly became darker on contact with the air. A spectroscopic examination of the blood showed the normal lines of oxidized blood reducible by sulphydrate of ammonium. In a case reported by Matzinger the blood as submitted was black and perfectly fluid, the corpuscles, both red and white, were normal, and no fibrin was detected. In those executed by electricity the blood seems to have been fluid and not in any way remarkable.

There seems to be no evidence that the bodies of those dying from electricity in any form suffer unusually rapid decomposition.

The only absolute sign of death from electricity is decomposition of the tissues, but the usual signs are to be relied upon to the same extent as in ordinary cases of death.

=Internal Organs.=—In the cases of death from mechanical electricity no changes in the internal organs other than those due to accidental traumata have been found, except a considerable degree of congestion and sometimes minute hemorrhages in the heart substance beneath the pericardium and into the pulmonary air-vesicles and pleura. In one of Grange’s cases the heart was filled with liquid blood; in the other it was completely empty, the right ventricle collapsed, the walls of the left ventricle hard and contracted.

Careful autopsies were made in the cases of the criminals executed by electricity, but no important changes caused by the electric current have been detected either macroscopically or microscopically. A few petechial spots (Tardieu’s spots) are apt to be found underneath the pericardium in the heart tissue and sometimes beneath the pleura. The organs were not extremely congested. In the case of Jugigo the vessels of the spinal cord and its membranes contained if anything less blood than usual. In this case the amount of blood found in the brain seems to have been about normal, the vessels of the dura were moderately dilated and those of the pia “in a medium state of congestion.” In the case of Kemmler the portion of the intracranial contents underneath the head-electrode was somewhat affected directly by the heat, the meningeal vessels in the dura were carbonized, and the brain cortex was sensibly hardened to one-sixth of its depth, “where there was a broken line of vascularity.” The post-mortem temperature in this case seems to have remained unusually high, being 97° F. in the fourth ventricle and 99° F. at the back of the neck three hours after death in a room where the temperature was only 83°.

In autopsies after death by lightning the results are in general analogous. The brain and its membranes may be anæmic or congested. Effusions of blood may be found beneath the dura or in the brain substance itself, due to the laceration or injury of vessels. Rupture of the brain is said to have occurred, and Phayre reports a case in which the left hemisphere was entirely destroyed and changed into a dark gray homogeneous fluid mass, only a small portion of the corpus callosum remaining. No extravasation of blood, laceration of the vessels or membranes, or injury of the bones was detected.

Ecchymotic spots are frequently found beneath the serous membranes, pericardium, pleura, and peritoneum.

Schmitz states that parenchymatous inflammation of the internal organs may occur, and Sullivan reports a case where the stomach was found to be gangrenous over a large surface, the patient having lived several days. Cases of rupture of the heart, the liver, and the spleen are reported.

THE MEDICO-LEGAL CONSIDERATION

OF

DEATH BY MECHANICAL SUFFOCATION

INCLUDING

HANGING AND STRANGULATION.

BY

DANIEL SMITH LAMB, A.M., M.D.,

Pathologist Army Medical Museum, Washington, D.C.; Professor of Anatomy Medical Department Howard University, Washington; Secretary Association of American Anatomists; Late Acting Assistant Surgeon United States Army; President of Association of Acting Assistant Surgeons U. S. A.; Member of Learned Societies.

MECHANICAL SUFFOCATION.

=Suffocation= is the name applied to both the act of and condition resulting from the deprivation of atmospheric air. If the deprivation is due to mechanical interference, the term MECHANICAL SUFFOCATION is used.

Mechanical interference may be by pressure upon or obstruction within some portion of the respiratory tract. Suffocation by pressure upon the neck is called =hanging= when the constricting force is the weight of the body itself; and =strangulation= in all other cases. German writers designate strangulation by cords, ropes, and the like as Erdrosselung, and by the hand as Erwürgung; French writers do not make this distinction. In English the word throttling is probably oftener applied to strangulation by the hand than by cords.

The term =suffocation= is also applied in a special sense to the act and result of pressure on the mouth, nose, or chest and abdomen, stopping the breathing; or of obstruction within the respiratory tract; or of pressure upon the tract from the œsophagus, etc.; or of breathing of irrespirable gases.

Strangulation is almost always homicidal, hanging almost always suicidal, and suffocation (limited) usually accidental, but also often homicidal.

Strangulation may be admitted, therefore, as including all cases of suffocation by pressure on the neck, whether by cords or the hand; but excluding hanging.

It will facilitate the study of the subject if we use the word ligature as a general term to cover the many forms of cords, ropes, etc., used in strangulation and hanging.

The word GARROTING is often used to indicate the forcible compression of the neck by the hands of thieves. The assault is usually made from behind, and the victim is robbed while the throttling proceeds. The brevity of the process explains why death is not more frequent. The word garroting comes from the Spanish; criminal execution in Spain and Italy is usually by means of the GARROTE, a steel collar which is tightened on the neck of the condemned by a screw. The notorious thugs of the East Indies used sometimes a soft loin-cloth, at others a lasso or long thong with a running noose. In Turkey and some other Eastern countries the bowstring is a common mode of execution.

An examination of the reported cases of strangulation and hanging shows a great variety of forms of ligature: cords, ropes, thread, thongs, lassos, flexible twigs, bamboos, leather straps, girdles, turbans, fishing-nets, collars, cravats and other forms of neckwear, bonnet strings, handkerchiefs, sheets, etc. Women have even strangled themselves with their own hair (Case 34). Stones, sticks, coal, and other hard substances have sometimes been inserted in the ligature to increase the pressure (Cases 36, 38, 42, 43, 44). Drunken and otherwise helpless persons have been strangled by falling forward with the neck against a firm substance.

STRANGULATION.

SYMPTOMS AND TREATMENT.

The symptoms and post-mortem appearances in strangulation will vary, according as the deprivation of air is sudden or gradual, partial or complete; and whether there is coincident pressure on the great arteries, veins, and nerves of the neck.

The deprivation of air disposes to asphyxia; pressure on the great arteries by cutting off the supply of arterial blood to the brain disposes to anæmia of the brain and syncope; pressure on the great veins, by preventing the return of blood to the heart, to congestion of the brain and coma; pressure on the great nerves, the pneumogastrics, to syncope. Statistics of hanging show that in about seventy per cent of cases death is by a mixture of asphyxia and coma. While it is probable that the proportion is less in strangulation, yet it is also probable that a mixed result frequently occurs.

Asphyxia is from α priv. and σφίξις, pulse—absence of pulse. Apnœa from α priv. and πνέω, I breathe—absence of breathing. Syncope, συνκοπή, a faint; suspended animation from sudden failure of heart. Coma, κῶμα, deep sleep. Richardson[729] makes the following distinction between asphyxia and apnœa: Asphyxia is difficulty of taking in breath; apnœa is breathlessness. There is asphyxia when the blood from the heart can go to the lungs, but there is no access of air; apnœa, when there is access of air, but the blood fails to reach the lungs. In asphyxia the lungs obstruct the circulation; in apnœa the obstruction is in the heart. In asphyxia the air cannot reach the blood; in apnœa the blood cannot reach the air.

Quinquaud[730] and Fredericq[731] conclude from experiments on animals that asphyxia is due to the deficiency of oxygen, not to the accumulation of carbon dioxide.

Page[732] divides the phenomena witnessed in an animal killed by simply depriving it of air, without interfering with the blood-vessels of the neck, into four stages:

First. A short stage. (In the human subject this stage could scarcely last longer than fifty seconds, which is said to be the extreme limit of the most expert divers. The breath can be held longest if a number of deep breaths have previously been taken, so as to surcharge the blood with oxygen.)

Second. The stage of “besoin de réspirer,” when the want of air begins to be felt; the animal makes vigorous and violent efforts to overcome the obstacle. This stage may continue for three to four minutes.

Third. Unconsciousness supervenes with irregular and spasmodic movements; efforts at respiration continue.

Fourth. Efforts at respiration cease, but the heart still beats. This stage may last from two to four minutes. Hofmann[733] says that it may last a half-hour. In new-born infants, asphyxiated, it may be quite long.

The post-mortem appearances in such an animal were as follows: the lungs were pale, reddish, not much distended; there were a few dilated air-cells toward the anterior border; hemorrhages irregularly dispersed over the surface of the lung, varying in number and size. The right cavities of the heart contained dark fluid blood, the left were empty. The pulmonary artery and systemic veins, even the smallest branches, were gorged with dark blood. Page adds that when the great vessels of the neck are interfered with death may occur “by coma, syncope, and even asthenia.”

Colin[734] made twenty-five experiments on horses, and records three of them as follows: they were all strangled with a hempen cord at the middle of the neck. The first was quiet till the second or third minute, then there were violent movements and strong efforts to dilate the chest; at four minutes, spasms; four and one-half minutes, quiet; six minutes, pupils dilated, tongue hanging out, limbs flaccid; blood black. Second horse: Carotid artery denuded to observe its action. In fifteen seconds, blood nearly black; four and one-quarter minutes, no pulsation in carotids; five and one-half minutes, no respiratory movement; six minutes, heart-beat ceased, except feeble contraction of auricles, which continued till twenty-first minute. Third horse: In five minutes respiration ceased; tracheotomy performed, but there was no attempt to breathe; eight minutes, heart ceased to beat. Similar results were obtained in ruminants and in small animals, except that the larger animals lived longer than the smaller.

Faure[735] made the following experiment on a large dog. He tied a cord tightly round its neck; for fifty-five seconds it was quiet, then suddenly it became agitated, threw itself against the wall, rolled on the ground, twisted itself; bloody mucus escaped from the nose and mouth; the teeth were ground together; urine and fæces were passed. The efforts at respiration became very rapid. It fell dead at the end of three and one-half minutes.

The symptoms of strangulation in the human subject resemble closely those just described as occurring in the dog.

The FIRST or PRELIMINARY STAGE lasts a variable time, according to the suddenness and completeness with which the access of air is prevented; it lasts until there is a demand for the air. In a case of homicide, injuries may be inflicted on the victim in this stage which may have an important bearing on the cause of death. Blows on the head may cause unconsciousness, or even apoplexy; upon the stomach, may cause syncope; stab-wounds may tend to cause death from hemorrhage.

The SECOND STAGE begins with the demand for air and lasts till unconsciousness supervenes. It is characterized by frantic efforts to breathe, efforts in which the entire body takes part. If the subject is conscious, he is intensely so; the expression of the face is intense; the eyes may protrude, the hands be clinched; the memory is unusually active, and the events of a lifetime may rapidly pass before the mind in a few minutes. The tongue may be thrust between the clinched teeth and bitten; and urine, fæces, and semen may be discharged.

The THIRD STAGE usually appears suddenly, and is characterized by unconsciousness and irregular involuntary movements, i.e., spasms; these may end in opisthotonos; the veins become turgid, and hemorrhages may occur from the eyes, nose, mouth, throat, ears, and into the connective tissues of the lungs, pleura, pericardium, etc. The circulation of venous blood in the arteries is shown by the general lividity, especially where the skin is thin, as the lips and tips of fingers. Hofmann[736] states that coincident with the oncoming of unconsciousness and convulsions the respiratory effort becomes expiratory, followed still later by inspiratory efforts.

The FOURTH STAGE begins with the cessation of spasms and of efforts to breathe. The subject is quiet, but the heart still beats. The stage ends with the cessation of the heart-beat.

Discharges of semen, urine, and fæces may occur in the first and second stages, from terror; in the second and third from the general agitation, and in the third and fourth from paralysis.

Strangulation according to Bernard[737] causes a rise in temperature, varying from one to two degrees (Cent.). He thinks that this is due to the changes from arterial to venous blood, especially in the muscles.

Lukomsky[738] concluded from experiments that in asphyxia both arterial and venous pressure is increased in the systemic circulation, but diminished in the pulmonary artery. The highest degree of blood pressure coincides with the strongest respiratory movements, especially expiration. He also concluded that the Tardieu spots (subpleural ecchymoses) directly depended on the efforts of breathing and blood pressure.

Some writers, as Taylor and Tidy, think that death occurs sooner in the human subject than in the lower animals; where the access of air is suddenly and completely prevented death may be immediate. Tardieu says that death follows pressure of the hand sooner than that of a ligature.

Fleischmann[739] placed cords round his own neck between hyoid bone and chin, tied them tightly, sometimes at the side, sometimes at the back, without respiration being interfered with, because there was no pressure on the air passages. But his face grew red, eyes protruded slightly, there was a feeling of great heat in the head, of weight, commencing dizziness, and suddenly a hissing and rustling in his ears. The experiment should stop at this point. The same symptoms occurred from applying the cord over the larynx. The first experiment lasted two minutes, the second a half-minute. The difference was due to the different situation of the cord.

Dr. G. M. Hammond[740] gives an account of a personal experiment in strangulation. He sat down; a towel was passed around his neck, and the ends twisted together, making forcible compression of the neck. At first he had a feeling of warmth and tingling, first in the feet, then passing over the entire body; vision partly lost; his head felt as if it would burst; there was confused roaring in ears, like the sound heard on placing the ear to a shell; he remained conscious. In one minute twenty seconds all sensibility was abolished. After a few minutes’ rest a second similar trial was made, with similar results, except that sensibility was lost in fifty-five seconds. A stab with a knife drawing the blood caused no sensation.

Should the subject recover from the immediate effects of the strangulation there may yet be serious secondary results. Among these are convulsions and paralysis; extreme swelling of face, neck, and chest; loss of voice; lesions of larynx and lungs; abscesses. Death may occur suddenly and remotely from one of the sequelæ.[741]

In the =treatment= of strangulation the first indication obviously is to remove the pressure from the neck. Artificial respiration will probably be required, and may be aided by ammonia applied to the nostrils, tickling of the fauces, and galvanism. Colin[742] states that artificial respiration is useless after cessation of heart-beat. (See the treatment by galvanism under “Suffocation.”) If the body is cold, artificial heat by means of hot bottles, etc. Venesection may be necessary. Colin strongly advises venesection to relieve the distention of the heart. Stimulants and light food are often required.

Limousin[743] recommends the use of oxygen. Cobos[744] experimented on animals by injecting oxygen hypodermically, as a means of artificial respiration. His conclusions are that the oxygen is absorbed and carbon dioxide eliminated in the same place. The oxygen thus introduced causes no trouble. Testevin[745] cures asphyxia by hypodermic injection of ether.

The after-treatment will depend on the after-conditions.

The =prognosis= is good if there is no serious injury to the neck and treatment is promptly applied.

POST-MORTEM APPEARANCES.

The =post-mortem appearances= in strangulation are external and internal.

The external appearances are of two kinds: those directly due to violence and accident and those due to asphyxia.

=External Appearances Directly Due to Violence or Accident.=—The MARKS on the neck. In some fatal cases there are either no marks at all or they are but slight; this is more likely to be the case in suicides than homicides, and is usually due to the ligature being soft and yielding. The victim of a homicide may, however, first be stunned and afterward strangled.

Marks are said to be plainer after the body has become cold and where subjects have recovered from attempts at suicide.

The marks of the ligature in strangulation usually encircle the neck more completely and more horizontally than in hanging. These conditions may, however, be reversed, because a body may be dragged by the neck after strangulation, and there have been suicides by hanging in whom the mark of the cord was horizontal. As a rule, however, a horizontal mark with the knot on the same level as the cord, especially if below the larynx, suggests strangulation rather than hanging; and if there are several marks the probability is even greater. In compression with the fingers the marks are not in a horizontal but oblique line.

The mark of the ligature is usually circular, well defined, and corresponds closely to the breadth of the ligature; rather depressed, and usually below the larynx. As a rule this depression is not deep; the skin at the bottom of the groove is usually very pale, while the adjacent parts are red or livid. Sometimes the bottom of the groove shows ecchymoses. Neyding[746] says that suggillations in the groove made by the ligature on the neck are rare, but are oftener found in strangulation than hanging, because the conditions favoring their formation are oftener found in strangulation. In most cases the skin and connective tissue of the groove and of the parts in the vicinity show, microscopically, hyperæmias and hemorrhages. Liman[747] states that when we find suggillation in the groove or its vicinity, we may know that some other form of violence has been applied at the same time as that of the ligature or hand. He had not seen suggillation in the furrow either in strangulation or in hanging, except when the injured persons had lived some time, and in cases of twisting of the umbilical cord. The absence of suggillation and ecchymosis was due, he thought, to the pressure on the capillaries. Bremme[748] says that in the subcutaneous connective tissue of the mark of the ligature there is no hemorrhage either in strangulation or hanging, if death occurs at once and the cord is removed at once after death; but if the cord remains for some time after death there may be hemorrhage, or if death does not occur at once whether the ligature is removed or not. It is impossible to distinguish ante-mortem from post-mortem hemorrhage.

The parchment skin seen in hanging is seldom seen in strangulation. Neyding[749] says that the dryness and induration called parchment skin depend mainly on the amount of excoriation of the skin, and this is greater in hanging. Tardieu explains this frequency as being due to the fact that the constriction in hanging lasts a longer time. Liman has seen the parchment skin in those strangled.

The violence used may cause ecchymoses and abrasions of the skin of the neck adjacent to the mark of the ligature.

The marks of very different constricting ligatures may be quite similar. Taylor[750] mentions a case in which a soft silk handkerchief was used, and the appearance was the same as that of a narrow cord, due to the tightness with which it was tied.

Where a hard substance like a piece of coal or stone is inserted into the ligature, usually then a soft cloth, and presses directly against some part of the neck, there is usually a corresponding bruise.

Marks of pressure by the thumb and fingers are usually on the front of the neck, and either just above or below the larynx. In many cases these marks are only those of the finger-tips with some scratches. These marks may show definitely the probable size of the assaulting hand, and whether right or left.

Marks of strangulation may disappear rapidly after the removal of the ligature. Assailants usually constrict the neck much more violently than is sufficient to cause death. Marks of violence on the neck are, therefore, greater in strangulation than in hanging.

A great variety of external injuries other than those on the neck have been found in the different cases reported where other forms of violence were used. With few exceptions such additional injuries indicate homicide.

=External Appearances Due to Asphyxia.=—A few of these have already been given under the caption “Symptoms.” If death occurs quickly there may not be any signs of asphyxia. The general LIVIDITY which comes on in the second stage usually remains after death. The face varies in color from violet to black and may be swollen. Casper[751] says that the face has the appearance of any other corpse. Liman[752] found the face livid in only one of fourteen cases. Hofmann[753] says that the cyanosis appears during the agony because of paralysis of the circulation and gravitation of blood. The cyanosis of the face, projection of the eyes, and congestion of the conjunctivæ are due to the expiratory effort. These signs are also seen in fat persons who do not die of strangulation. Tardieu[754] mentions a dotted redness or minute ecchymosis of the conjunctivæ and skin of face, neck, and chest as constant; but this cannot be considered characteristic, because it has been seen, though not so well marked, in death from other causes. It has been found in suffocation from compression of the chest and belly; and also where there is respiratory interference in the prolonged efforts of tedious labor and in convulsions. Liman[755] found it in those who were hung. It is due, according to Hofmann,[756] to increased blood pressure and consequent hemorrhages. It is of importance as tending to show that there was stasis of blood in the head and face during life. Liman[757] found cyanosis in the conjunctivæ, lips, back of mouth, and in the muscles. Maschka[758] in 234 cases of asphyxia found capillary hemorrhages of the eyes and eyelids 87 times.

Dastre and Morat[759] claim that in asphyxia the cutaneous circulation becomes more active than in the normal state, while at the same time the vessels of the abdominal cavity are contracted. Laffont[760] considers the mechanism of this peripheral dilatation.

POST-MORTEM STAININGS (hypostases) are usually darker in strangulation than in other forms of death. They appear soon, as does also putrefaction, because of the quantity and fluidity of the blood.

Signs of HEMORRHAGE from the nose, eyes, and mouth may be visible; as also bloody froth from the mouth and nose. Chevers[761] never saw bleeding from the ears in strangulation. Taylor[762] states that Dr. Geoghegan informed him of a case of suicidal strangulation by a ribbon; the violence was great, there was bleeding from the ear, and the drum was found ruptured. In this case the mark on the neck, which was deep, nearly disappeared after the ligature was removed. Taylor also says Wilde, of Dublin, saw a case of rupture of drum and hemorrhage in strangulation. Pellier[763] says that Littré mentions a case of rupture of tympanic membrane in strangulation by a cord. Zoufal and Hofmann have offered explanations of the occurrence (Case 35).

The FACE usually shows pain and suffering; although sometimes the features are calm. In the latter case there may have been syncope.

The EYES are usually staring, prominent, and congested, and the pupils dilated. Casper[764] doubts their prominence. Budin and Coyne[765] state that in asphyxia the dilation of the pupil progresses to a maximum and then convulsions occur. Ophthalmoscopic examination during the dyspnœa of asphyxia shows a lessened fulness of the retinal vessels.

The TONGUE is often swollen, dark, protruding, and sometimes bitten. Maschka[766] states that if the ligature lies above the hyoid bone, the tongue will be drawn backward; if over or below the bone, the tip of the tongue may appear more or less between the jaws.

The HANDS are usually clinched and may have in their grasp articles which, under the circumstances, have a medico-legal value.

The EXTERNAL GENERATIVE ORGANS are sometimes congested; erection of the penis may have taken place and persisted. The vagina may be moist. Tardieu, Devergie, and Casper[767] deny that these appearances are usual.

INVOLUNTARY DISCHARGES of urine, fæces, and seminal fluid may have occurred. There is nothing characteristic in their appearance.

All the external appearances of asphyxia are usually more marked in strangulation than in hanging.

=Internal Appearances.=—THE MARK. Usually there is hemorrhage into the loose connective tissue under the mark and in the subjacent muscles; in most cases isolated and circumscribed, but sometimes extending beyond the line of the mark. Hemorrhage from compression by the fingers is more marked than that from ligature.[768] Sometimes there is only fulness of the subcutaneous veins.

The CAROTID ARTERIES may suffer rupture of their inner and middle coats, especially in atheromatous subjects and when the compression has been great. Friedberg[769] states that the injury of the carotid, if there is hemorrhage into its middle and internal coats, is a proof that the strangulation occurred during life, and probably from pressure of the fingers on the neck, without any regard to any disease of the artery. He reports two cases. The examiner should be careful not to injure the artery with his forceps. The vessels may contain clots.

The NECK occasionally suffers extreme injury, and, owing to the violence used, this occurs oftener in strangulation than in hanging.[770] Occasionally the neck is broken.

The HYOID bone may be fractured (see Case 5). Maschka[771] saw one case in eighteen of Erdrosselung and five cases in fifteen of Erwürgen.

The TRACHEA is sometimes torn, or may be folded on itself.

The cartilages of the LARYNX, especially if calcareous, may be fractured. This is more likely to affect the thyroid than cricoid. The fracture would appear to occur only as the result of enormous force; especially in the young in whom the cartilages are so elastic. The experiments of Keiller[772] on cadavers led him to conclude that falls on the larynx, even from a height and with superadded force, are unlikely to fracture that organ; that severe pressure or violent blows against the larynx from before backward may cause fracture; but that severe lateral pressure, as in ordinary throttling, is more likely than other forms of violence to fracture the alæ of the thyroid or even the cricoid cartilages and also the hyoid bone. Taylor[773] states that Dr. Inman, of Liverpool, had informed him of a case of splitting of rings of windpipe from pressure (see Cases 5, 13). Maschka[774] in fifteen cases of choking found six fractures of the larynx.

Chailloux[775] has collected eight cases of fracture of larynx in strangulation. They were all made with the fingers. The experiments of Cavasse[776] seem to show that there is no great difficulty in fracturing the thyroid in strangulation.

=Internal Appearances Due to Asphyxia.=—The VEINS of the entire body are distended with very dark and very fluid blood, while the arteries, especially in the young, are mostly empty. Experiments on the lower animals have shown that the pulmonary artery and systemic veins to the finest ramifications are distended with dark blood.[777]

THE HEART.—The right side, especially the auricle, is usually full of dark fluid blood, due to the mechanical impediment to the passage of blood through the lungs. If the heart continues to beat after the respiration has ceased the right ventricle is commonly well contracted, like the left cavities, and nearly empty, the lungs being much congested. Sometimes the left cavities of the heart contain blood. This would be most likely to occur if the heart should stop in the diastole. Sometimes clots are found in the right ventricle. Maschka[778] found clots in the heart 25 times in 234 cases of asphyxia.

The LUNGS are usually much congested, resembling red hepatization, except that the blood is darker. Hemorrhages (apoplexies) into the substance of the lungs are common. Tardieu found patches of emphysema due to rupture of the surface air-vesicles, giving the surface of the lung the appearance of a layer of white false membrane. Ogston admits this occurrence in pure strangulation but to a less extent in mixed cases. Liman[779] found the lung surface uneven, bosselated, the prominences being of a clearer color and due to emphysema. The lungs were in the same condition of congestion and emphysema in strangulation, suffocation, and hanging. He failed to find the apoplexies described.

The lungs are sometimes anæmic. In healthy young subjects, especially children, the blood-vessels of the lungs often empty themselves after the heart stops. The lungs may, therefore, be bloodless, but emphysematous from the violent efforts to breathe. Page’s experiments on the lower animals showed the lungs of a pale reddish color and not much distended; a few dilated air-cells might be seen toward their anterior borders, and there might be small hemorrhages over the surface. His experiments appear to show that subpleural ecchymoses occur as a result of violent and repeated efforts to breathe. Among other experiments[780] he stopped the mouth and nostrils of a young calf long enough to excite violent efforts at respiration; it was then instantly killed by pithing. The lungs were found pale red, not congested, but showed subpleural ecchymoses. Page believed these were due to the changed relation between the capacity of the thorax and volume of lungs. Liman found these ecchymoses in cases of strangulation, hanging, drowning, poisoning, hemorrhage, and œdema of brain, in the new-born, etc. He failed to find them in some cases of suffocation. He believes them due to blood pressure from stasis in the blood-vessels. Ssabinski[781] made many experiments on dogs and cats to ascertain the presence or absence of subpleural ecchymoses in strangulation, drowning, section of pneumogastrics, opening of pleural sac, compression of chest and abdomen, closure of mouth and nose, burial in pulverulent materials, etc. Similar hemorrhages may appear on the mucous and serous membranes, as the respiratory, digestive, and genito-urinary tracts, and pleuræ, pericardium, peritoneum, membranes of brain, and the ependyma. These are sometimes minute and stellate, at others irregular in shape; many are bright-colored. According to Tardieu the punctiform ecchymoses are rarely present except in suffocation. Maschka,[782] in 234 cases of asphyxia, found the lungs congested 135 times, anæmic 10, and œdematous 42. He thinks the subpleural ecchymoses valuable signs of asphyxia.

The BRONCHIAL TUBES are usually full of frothy, bloody mucus, and the mucous membrane is much congested and shows abundant ecchymoses.

The lining membrane of the LARYNX and TRACHEA is always congested and may be livid; the tube may contain bloody froth or blood alone.

Tidy comparing strangulation and hanging concludes that because strangulation is usually homicidal, and greater violence is used, therefore the external marks are more complete in strangulation and the congestion of the air passages is invariably much greater.

Maschka found the PHARYNX cyanotic in 216 of 234 cases of asphyxia.

The other MUCOUS MEMBRANES are generally much congested. Serum is found in the serous cavities.

Maschka[783] considers the rounded, pin-head ecchymoses of the inner surface of the scalp and pericranium valuable evidence of asphyxia.

The BRAIN and membranes are sometimes congested; occasionally apoplectic. Maschka[784] found congestion of brain and membranes 48 times and anæmia 30 times in 234 cases of asphyxia.

The ABDOMINAL ORGANS are generally darkly congested, although Maschka denies this for the liver and spleen in asphyxia.

The congestion of the viscera generally is doubtless due largely to the prior congestion of lungs and engorgement of heart.

Page[785] experimented on six kittens, strangling three of them by the hand, the other three by ligature. The results of the post-mortem examinations were nearly similar: the veins were full of dark fluid blood; the right cavities of the heart were similarly gorged, the left empty; lungs pale red, not congested and not distended. Brain normal. The differences were in the lungs; in the first series there were many small, irregular, circumscribed, dark-red ecchymoses scattered over the general surface; in the second, a small number of bright-red ecchymoses, somewhat larger than a large pin-head.

Langreuter[786] made some experiments on a cadaver from which enough of the posterior part had been removed to enable him to view the throat. He saw that the lateral digital pressure on the larynx closed the glottis; stronger pressure made the vocal cords override each other. Similar pressure between the larynx and hyoid bone caused apposition of the ary-epiglottic folds and occlusion of the air-passages. He experimented on sixteen bodies to ascertain the effect of blows and pressure on the larynx, with the following results: In eight cases, women, the thyroid cartilage was injured three times, the cricoid four; in eight, men, the thyroid eight and cricoid five. Whence he concluded that the larynx is better protected in women. In the sixteen cases the hyoid bone was fractured ten times.

THE PROOF OF DEATH BY STRANGULATION.

Tidy[787] says that “nothing short of distinct external marks would justify the medical jurist in pronouncing death to be the result of strangulation.” On the other hand, Taylor[788] considers the condition of the lungs described as characteristic. Liman[789] did not think there were any internal appearances which could distinguish suffocation, strangulation, and hanging from each other.

In estimating the value of testimony it will be well to consider the following facts:

A victim may be strangled without distinct marks being found. The practice of the thugs shows that this may be done with a soft cloth and carefully regulated pressure without making marks. Taylor,[790] while admitting the possibility, states that this admission “scarcely applies to those cases which require medico-legal investigation.”

The subject while intoxicated or in an epileptic or hysterical paroxysm may grasp his neck in gasping for air, and leave finger-marks.

Different constricting agents may make quite similar marks. Marks may be made on the neck within a limited time after death, similar to those made during life. Tidy’s experiments led him to fix this limit at three hours for ecchymoses and six hours for non-ecchymosed marks. Taylor,[791] however, doubts if such marks could be made one hour after death. He says that the period cannot be stated positively, and probably varies according to the rapidity with which the body cools.

It is, however, unlikely in such post-mortem attempts at deception that the other conditions usual in strangulation would be found—such as lividity and swelling of face; prominence and congestion of eyes; protrusion of tongue; rupture of surface air-vesicles and apoplexies in the lung; congestion of larynx and trachea, etc.

No conclusion can be drawn from the presence or absence of any single appearance.

A cord may be found near a body or even around its neck; there may even be a mark around the neck. These may be attempts at deception.

Marks much like those of violence may be made by tight collars and handkerchiefs remaining until the body is cold.

Cases are reported of bodies having been first strangled and then burnt or hung to cover the crime; and of partial suffocation by gags, followed by or coincident with strangulation (see Cases 18, 20, 24).

In apoplectics with short and full neck we may find at the borders of the folds of skin in the neck one or more depressions, red or livid, that bear some resemblance to the marks of a ligature; but on section there are no ecchymoses.

Froth, tinged with blood, in the air-passages is considered by Tardieu[792] one of the most constant signs of strangulation.

The marks of topical medical applications, as plasters, sinapisms, etc., must not be confounded with marks of violence.

In strangulation by ligature the marks are usually horizontal; in hanging, oblique. In hanging too they are usually dry and parchmenty. Ecchymoses are more marked in strangulation.

The dotted markings of face, neck, and conjunctivæ described by Tardieu are more characteristic of strangulation.

The principal distinctions between strangulation and suffocation would be the absence in the latter of marks on the neck.

Taylor[793] quotes the case of Marguerite Dixblanc, in which the question was raised whether she had strangled her mistress, Madame Riel, or whether the body had been dragged by a rope around the neck. The question was left unsettled by the medical evidence.

The only motive for attempting to simulate strangulation on a corpse would seem to be to inculpate an innocent person.[794]

Both suicides and murderers are usually more violent than is necessary to destroy life; murderers more than suicides.

Putrefaction may cause external marks to disappear.

All marks on a body should be carefully noted; the cavities of the skull, thorax, and abdomen carefully examined; the possibility of death having occurred from other causes, even in strangulation, must be considered.

As Taylor well says, our judgment must not be swayed to the extent of abandoning what is probable for what is merely possible.

In all cases the cord or strangulating ligature should be carefully examined for marks of blood, for adherent hair or other substances. The precise manner in which the cord has been tied should be noted.

STRANGULATION: ACCIDENTAL, SUICIDAL, HOMICIDAL, SIMULATED.

The question whether a case of strangulation is accidental, suicidal, or homicidal is very difficult to answer.

ACCIDENTAL strangulation is rare. If the body has not been disturbed, there is usually no difficulty in arriving at a conclusion; but if disturbed a satisfactory conclusion may not be reached.

It is worthy of mention that the umbilical cord may be twisted around the neck of a new-born infant and may have caused strangulation; the mark may give the appearance of death by violence.

SUICIDAL strangulation is rare. The experiments of Fleischman (supra) suggest that one may commit suicide by compressing his throat with his fingers (see Case 48).

Where a ligature of any kind has been used it is important to notice the number and position of the knots. In a general way a single knot either in front or at the back of the neck might suggest suicide; more than one would suggest homicide. There are, however, exceptions.

Suicide has been committed by mere pressure of a cord fixed at both ends a short distance from the ground; by twisting a rope several times around the neck and then tying it (the coils may continue to compress even after death); by tightening the cord with a stick or other firm substance; by tightening the cords or knots by means of the hands or feet or some portion of the lower limbs; by the use of a woollen garter passed twice around the neck and secured in front by two simple knots, strongly tied one to another.

It is difficult to simulate suicide; requires great skill and premeditation on the part of a murderer. “The attitude of the body, the condition of the dress, the means of strangulation, the presence of marks of violence or of blood on the person of the deceased, on his clothes or the furniture of the room, or both, rope or ligature, are circumstances from which, if observed at the time, important medical inferences may be drawn.” The assassin either does too little or too much. Taylor[795] cites a number of cases of simulation.

Strangulation is generally HOMICIDAL. The marks of fingers or of a ligature on the neck suggest homicide. This is true even if the mark is slight; because infants and weakly persons may be strangled by the pressure of the hands on the throat. Even a strong man, suddenly assaulted, may lose his presence of mind and, with that, his power of resistance; with approaching insensibility his strength still further diminishes. This is true even if his assailant is the less powerful. It requires more address to place a ligature on the neck than to strangle with the hand.

A victim may be made insensible by drugs or blows and then strangled by a small amount of compression; or suffocation by gags and strangulation may both be attempted.

The importance of considering the position and number of the knots in a cord is mentioned under suicidal strangulation.

In homicide, in addition to the marks on the neck, there is likely to be evidence of a struggle and marks of violence elsewhere on the body. It is important, therefore, to notice any evidence of such a struggle.

The nature of the cord may assist in identifying the assailant.

It must be remembered that homicidal strangulation may be committed without disturbing noise even when other persons are near.

=Simulation.=—False accusations of homicidal strangulation are on record. Tardieu[796] states that a distinguished young woman (for some political purpose) was found one evening at the door of her room apparently in great trouble and unable to speak. She first indicated by gestures and then by writing that she had been assaulted by a man who tried to strangle her with his hand, and also struck her twice in the breast with a dagger. She was absolutely mute—did not even attempt to speak—quite contrary to what is always observed in unfinished homicidal strangulation. On examination by Tardieu, no sign of attempt to strangle was found, and the so-called dagger-openings in her dress and corset did not correspond in position. She confessed that she had attempted deception.

The celebrated Roux-Armand[797] case was another instance of attempted deception. A servant named Roux was found on the ground in the cellar of his employer Armand; his hands and legs were tied and there was a cord around his neck. He was partly asphyxiated, but after removal of the ligature from his neck he rapidly recovered, except that he was weak and voiceless. He stated by gestures that he had been struck by his employer on the back of the head with a stick and then bound as described. The next day he could speak. Armand was imprisoned. Tardieu examined carefully into the case and the results may be stated as follows: The asphyxia was incipient, else he could not have so rapidly recovered. The cord around his neck had not been tied—simply wound around several times; the mark was slight and there was no ecchymosis. Although the legs and hands were tied, the hands behind the back, there was no doubt but that Roux could and did tie them himself. He had stated that he had been eleven hours in the cellar, in the situation in which he was found. This could not be true, for a very much shorter time, an hour probably at the furthest, would have caused death, in view of the condition of asphyxia in which he was found. Again, if his limbs had been bound for so long, they would have been swollen and discolored; but they were not. Again, if the ligature had been around his neck so long as he said, the impression of it would have been more marked. Again, if his stertorous breathing had lasted long it would have been heard by neighbors. The injury on the back of the head, said to be due to a blow, was believed by Tardieu to be due to dragging him on the ground. He further had stated that when he received the blow on the head he became unconscious, and yet he also described how Armand bound him after knocking him down. Again, he had made no outcry; but if he had been strangled while partly unconscious and afterward recovered his senses, he would have been unable to give an account of the matter; if, however, he had been strangled while conscious, there was no reason why he should not have cried out. His inability to speak the first day was assumed, because what was a simulation of absolute mutism should have been simply a loss of voice. The innocence of Armand was ultimately established.

ILLUSTRATIVE CASES.

HOMICIDE.

1. Cullingworth: Lancet, May 1st, 1875, p. 608.—Woman. Believed to have been intoxicated. Face, especially right side, swollen and livid; a little blood had oozed from mouth, nose, and inner angle of each eye. Immediately over (in front of?) larynx and on each side of middle line were marks of irregular outline such as might be caused by pressure of thumb and fingers. Several dark, bruise-like discolorations on flexor surface of each forearm. Hands clinched. Elbows flexed. Discharge of fæces by rectum. Necroscopy: Brain and membranes normal. Hyoid bone and laryngeal cartilages uninjured. Mucous membrane of larynx and trachea congested and covered with frothy mucus. Lungs intensely congested. Several hemorrhages; masses of tissue of each lung, chiefly toward base, were solidified by effused blood. All the heart cavities empty. Stomach normal, empty. No congestion of abdominal viscera.

2. Taylor: “Med. Jur.,” Am. Ed., 1892, p. 412.—Man and woman. Strangled by cord, tied so tightly that there was hemorrhage from mouth and nose.

3. Harvey: Indian Med. Gaz., December 1st, 1875, p. 312.—Hindoo woman, age 45. Strangled with the right hand. Necroscopy: Two contusions and abrasions on temple. Neck discolored from right to left jugulars; marks of thumb on right side and three fingers on left, extending from jugulars to windpipe. Eyes half protruded. Tongue discolored. Blood-vessels full of clots. Brain congested (?) and showed external hemorrhages (?). Lungs normal. Heart empty. Liver ruptured to the extent of four inches, with adherent blood-clot. Spleen, stomach, and intestines normal. Muscles of chest, both sides, congested, discolored, and there were clots of blood over and under them. First six ribs of left side and first three of right fractured.

4. Harris: Ibid., p. 313.—Boy, age 10. Abrasions over front of neck, especially near left ear, probably from ligature; also abrasion on upper part of chest, probably from forcible pressure. Underneath these marks the veins were much distended. Trachea minutely congested; contained much frothy fluid. Lungs showed rupture of some of the air-vesicles; entire tissues distended with blood and frothy fluid. Dark fluid blood in both sides of heart. Large quantity of fluid in pericardium. Brain much congested. Eyes congested. Tip of tongue between teeth. Other organs normal.

5. Mackenzie: Ibid., February, 1889, p. 44.—Hindoo woman, age not given, strangled by another, stronger woman. Necroscopy: Abrasion on front and lower part of neck just above sternum and clavicles; four inches long, three broad; five superficial lacerated wounds on sides of neck, four on left, one on right, apparently nail scratches. Two contusions below and behind lower jaw. Also contusions on thighs. No spots of ecchymosis on neck. Contusion under skin of lower part of neck and upper part of chest, eight inches long, four broad. Left greater cornu of hyoid bone fractured. Both upper cornua of thyroid cartilage fractured; cricoid fractured on each side. Larynx, trachea, and bronchi contained pink frothy mucus; mucous membrane congested. Lungs much congested; pink frothy mucus in bronchi; no emphysema nor apoplexies. Right side of heart full of dark blood; left side empty. Liver, spleen, and kidneys congested. Stomach and intestines normal. Bladder empty. Internal genitals normal. Brain congested.

6. Mackenzie: Ibid., August, 1888, p. 232.—Hindoo man, age about 30. Strangled by soft cloth cord. Necroscopy: Circular mark of cord, one-fourth inch diameter around lower part of neck; indistinct in front, but distinct at sides and back. Superficial abrasions of lips and right cheek as from a gag. Faint marks of blisters on temples. Fingers not clinched. Face livid, swollen. Eyes closed; conjunctivæ congested; corneæ hazy; pupils normal. Tongue protruding and bitten; not swollen. Fluid blood oozing from mouth and nose. Clotted blood under scalp of left temple. Skin beneath cord had the color and consistence of parchment. Muscles not torn. Hyoid, thyroid, and cricoid not injured. Larynx, trachea, and bronchi empty; congested. Lungs much congested. Some dark fluid blood in right side of heart; left side empty. Liver, spleen, and kidneys congested. Small patch of congestion in stomach. Intestines normal. Bladder normal, contained some urine. Brain congested.

7. Ibid., p. 234.—Hindoo woman, age about 40. Broad, circular, depressed “parchment” mark, one inch broad, around the neck, between hyoid bone and thyroid cartilage; made by two pieces of cloth, each three feet seven inches long and one inch broad, twisted into a single cord and tied tightly by three ordinary knots on right side of neck. Superficial wound on left side of head above ear. Face turgid, swollen. Eyes closed. Tongue between teeth and bitten; not swollen. Muscles of neck uninjured. Trachea uninjured. Lungs congested. Right side of heart full of dark fluid blood; left side empty. Liver and spleen congested. Other organs, including brain, normal.

8. Ibid., p. 235.—Hindoo woman, age about 25. Piece of cloth twisted tightly twice around mouth. Double cord made of two twists of thin coir rope tied tightly around middle of neck just below thyroid cartilage; beneath the cord the skin was “parchment” like. No injury to muscles of neck nor windpipe. Eyes closed. Face not flushed. Tongue not ruptured nor bitten. Hands not clinched. Larynx, trachea, and lungs congested. Right side of heart full of dark fluid blood; a little fluid blood in left. Liver, spleen, and kidneys congested. Other organs, including brain, normal. Dr. Mackenzie considered death to be due to “asphyxia or suffocation.”

9. Harvey: Ibid., January 1st, 1876, p. 2.—Hindoo woman, age 12 or 13. Faint mark on front of neck; none at back. Severe bruise on top of head, under which was much clotted blood, but no fracture. Lungs congested. Clots in right ventricle; left empty. Brain, larynx, and trachea congested. The examiner believed that she had been stunned and then suffocated by pressure of some soft substance against the neck.

10. Ibid.—Hindoo man, age 20. Dead seven days; much decomposition and discoloration. Wrists and ankles were bound. The two corners at one end of a cotton lungi (turban) were passed one on each side of the neck and fastened in a knot under left angle of jaw. The lungi was then passed around the body under the arms, etc., so as to draw upon the neck and be buried deeply in the swollen flesh. Under the bands the skin was blanched; the tissues above the bands were black and much swollen. Lungs, larynx, and trachea much congested. Heart empty.

11. Ibid.—Cases of strangulation by sticks and other hard substances. Boy, age 7 or 8. No external marks of violence. There was hemorrhage from mouth and nose. Face swollen and crepitant. Congestion of subcutaneous tissues and bruising of muscles of right side of neck. Mucous membrane of larynx and trachea covered with blood. Lungs much congested; blood in both pleural cavities. Heart empty; bloody serum in pericardium. Brain congested; slight hemorrhage on surface. Abdominal organs normal. Dr. Harvey states that the boy was no doubt strangled by pressure of a lathi on his neck.

12. Ibid.—In another subject two sticks were tightly tied together, one pressing on the front, the other on the back of the neck, flattening larynx and other soft parts. In the following case some hard substance, like a brick, had been wrapped in a cloth and used for compression. Boy, age 15. Necroscopy: Large dark ecchymosis in subcutaneous tissue of front of neck and upper part of chest. Also marks of violence on chest and left side of face. Dissection of neck showed blood-clot and also laceration of muscles. Trachea folded on itself, showing that compression had lasted several minutes. Tongue protruding and bitten. Eyes closed. Features calm. Trachea much congested. Lungs congested. Great veins of heart and neck full of fluid blood. Heart, dark fluid blood in both sides, mostly in right. Brain and membranes much congested.

13. Pemberton: Lancet, May 22d, 1869, p. 707.—Woman, age 60. Found dead. Nose partly displaced and cartilages injured. Lips pale. Mouth closed. Lividity of front of neck from jaw to sternum. Cricoid cartilage ossified (cretified?) and broken on left side; hemorrhage in surrounding tissues. Lungs and heart as usual in suffocation.

14. Cullingworth: Med. Chron., Manchester, 1884-85, i., p. 577.—Woman, married, found dead. Bruise and ecchymosis beneath the ear; effusion of blood in underlying tissue. Other bruises on face, etc. Several bruises in mouth, on lips and tongue. Blood dark and fluid. Brain and membranes much congested. No marks of injury on throat. Lungs congested; surfaces emphysematous. Heart contained dark fluid blood. Urine and fæces had been discharged.

15. The Gouffé Case.—Murdered by Eyraud and Bompard in 1889. Archiv anthropologie criminelle, Paris, 1890, v., pp. 642-716; vi., 1891, pp. 17 and 179. Reports by Bernard, Lacassagne, and others. Gouffé was decoyed into a room and strangled; afterward his body was tied up, placed in a trunk, and taken some distance away. The murderers fled to America; but eventually Bompard returned to France and Eyraud was captured; both confessed. When found, the body was well advanced in putrefaction; after a very careful examination was identified. He was strangled by the pressure of fingers; the head was afterward wrapped in a cloth which was held in place by five turns of a cord around the neck; traces of the furrows made by these cords were found. Heart empty; no blood in muscles of neck; hyoid bone intact but superior thyroid cornua fractured at base.

16. Horteloup: Ann. d’Hygiène, 1873, xxxix., pp. 408-416.—Man found dead on some leaves in a fountain at bottom of staircase; skull and spine fractured. The murderers stated that they had struck him on the head with a crutch; then, believing him to be dead, carried him and threw him into the fountain. When examined, his face was livid, tongue between teeth and bitten nearly in two; and three parallel abrasions on left side of neck and one on right; slight wounds about the face in addition to the fractures mentioned. No report of examination of lungs or larynx. Horteloup concluded that the man had been strangled to death, and that when thrown into the fountain, alighting on his head, the jaws were brought together and tongue bitten.

17. Laennec: Journ. de med. l’ouest, 1878, xii., pp. 68-71.—Woman, age 53; attempted strangulation by her husband. There were slight ecchymoses on each side of neck under angle of jaw, most marked on left side; when seen, she complained of lassitude and lively pain in hypochondria and region of lower ribs antero-laterally; no sign of lesion. She stated that she was awakened from sleep by pressure on neck and chest and feeling of suffocation; she soon lost consciousness and so remained for some hours. Her statements were corroborated by other testimony. Laennec considered the case one of prolonged syncope from pressure on carotids.

18. Lancet, ii., 1841-42, p. 129.—Woman, found dead, her clothing on fire and lower part of her body burnt. Necroscopy showed face and neck swollen as low as thyroid cartilage, and purple; eyes prominent and congested; mouth closed; tongue not noticed; front of neck below swollen part showed two dark-brown hard marks and slight marks also of pressure; on incision the vessels were engorged. Blood, fluid; brain, congested. There were no vesications from the burns and no sign of inflammation.

19. Alguie: “Étude méd. and exp. de l’homicide réel ou simulé par strangulation, relativement aux attentats dont Maurice Roux a été l’objet,” Montpellier, 1864, p. 121.—This essay contains the reports of many interesting experiments on animals and the cadaver. His conclusions in this case were that the victim had first been struck on the neck by a club; then a ligature was placed on the neck, with many turns, tied tightly, but the knots did not remain tight. [The marks were visible four months afterward.] The assailant then tied the limbs. The victim recovered with temporary loss of voice, memory, etc.

20. Gatscher: Mittheil. d. Wien. med. Doct. Colleg., 1878, iv., p. 45.—A man found hanging. The examiner declared that he had hung himself. Eight years afterward, suspicion of violence. A commission appointed. The protocol had shown the blood fluid; a red-brown dry furrow around the neck; ecchymoses in connective tissues of same; the entire back and posterior parts of limbs showed post-mortem suggillation. The commission declared that the man had been strangled, had lain for at least three hours on his back, and then been hung up. The murderer confessed.

21. Ibid., p. 46.—Woman, age 50, found dead in bed. Blood fluid; two ecchymoses size of beans in crico-thyroid muscles of each side; patch of hepatization size of fist, in lung; injury of body. The examiner declared that she had been strangled by compression of larynx with two fingers, but he could not say how long the pressure had continued, that is, whether she had died of the strangulation or of the pneumonia. The assailant stated that he had choked her and when she seemed to be dead, had left her. The woman lived alone.

22. Waidele: Memorabilien, 1873, xviii., pp. 161-167.—Husband and wife quarrelled and fought; he stated that he choked her with her neck handkerchief, and as she turned round toward him, then choked her with his hand until she died. The examiner declared that she died of asphyxia; there was a brownish-red dry streak on each side of the neck in the laryngeal region corresponding to the handkerchief, and also two small abrasions of skin which might have been made by the hands; he concluded, however, that she had been choked to death by the handkerchief, because there were no ecchymoses.

23. Rehm: Friedreich’s Blätter f. ger. Med., 1883, xxxiv., pp. 325-332.—Woman, age 37. Choked by the hand on the neck, and at the same time assailant’s knee pressed against her abdomen, pressing her against a wall, causing hemorrhage around the pancreas. Death stated as due to asphyxia.

24. Schüppel: Vier. ger. öff. Med., xiii., 1870, pp. 140-156.—Woman, just delivered of child, and boy ten years old, were burnt to death in a fire which consumed their house. Examination of the bodies showed upon the neck of the boy a groove, and his tongue protruded. The husband was charged with murder, was imprisoned, and committed suicide.

25. Weiss: Ibid., xxvii., 1877, pp. 239-244.—Woman strangulated by the bands of her nightcap.

26. Isnard and Dieu: Rev. cas jud., Paris, 1841, p. 101.—Man, age 65. Marks of fingers on face and neck. Opinion that he had been assaulted by two men. The two murderers confessed.

27. Friedberg: Gericht. gutacht., 1875, pp. 211-224.—Woman found hanging to branch of tree, but in half-lying position, feet on ground. Opinion given that she had been strangled and then hung.

26. Tardieu: “Pendaison,” p. 223.—New-born infant. Question whether its death was due to asphyxia from compression of neck by the mother with her hand to hasten delivery. He doubted the possibility of the mother thus assisting her child. But the direction of the seven excoriations on its face contradicted the mother’s statement. The traces of finger-nails were distinct. The lungs and alimentary canal showed that the child had lived. Opinion given, infanticide.

29. Ibid., p. 219.—Woman, advanced in years, habits dissipated; found strangled. Four excoriations on left side of larynx, one on right; blood in subcutaneous tissue. Marks of nails and long scratches on wrist. Injuries on face and left breast. She had been strangled by one hand on her neck while the other was over her mouth and nose. Face livid; eyes congested; frothy bloody liquid flowing from mouth and nose; tongue behind teeth; bloody froth in larynx and trachea; lungs large, much congested, splenized in places, surface emphysematous, looking like white spots; black fluid blood in heart; brain somewhat congested.

30. Ibid., p. 216.—Wife of the celebrated painter Gurneray; found dead in bed, where a fire had been placed and slowly burnt and charred her lower limbs, belly, chest, and right hand. A running noose around her neck. Injuries of head; face livid; tongue between teeth; brain normal; mark of cord slight; subcutaneous tissue infiltrated with blood. Marks of pressure on chest; bloody froth in trachea; lungs congested; heart contained fluid blood. Opinion given that she had been struck on head, causing unconsciousness; then partly stranded and partly suffocated by pressure on neck and chest. Body afterward burnt to cover up the crime.

31. Ibid., p. 211.—Three murders by one man. All women. All injured about the head and then strangled by both hand and ligature. Two died; one had an odor of alcohol and had apparently not resisted. The third was resuscitated. She was strong and stout, and resisted. Marks of fingers and nails on neck. Afterward she had headaches and giddiness for a long time.

SUICIDE.

32. Francis: Med. Times and Gaz., December 2d, 1876, p. 634.—Hindoo lunatic, a giant, strangled himself. He passed two or three coils of stout thread around his neck, attached the ends securely to his wrists, and then extended his arms to their utmost limit. This occurred during a ten-minute absence of his attendant, who, returning, found the man had fallen to one side from a kneeling position, with his back against a wall, quite dead. No reason to suspect homicide.

33. Badahur: Indian Med. Gaz., December, 1882, p. 330.—Hindoo woman, age about 17, strangled herself with the border of her saree. Necroscopy: Circular depressed mark caused by the border of a band of cloth, which she had passed in three coils around her neck, the coils tightly overlapping each other; the short ends had been knotted together with a “granny” knot at the back of the neck, like the native women tie up their hair. The coils were so tight that they had to be cut off. Face swollen, dark purple; conjunctivæ congested. Tongue between the shut teeth; bloody froth issuing from mouth and nostrils [the examination was in September, thirty hours after death]. Skin of neck reddened in nearly a continuous line all around, both above and below the band, about three-fourths inch wide, evidently caused by the pressure of the three folds. Considerable ecchymosis above and below the coils; the neck underneath the folds was swollen and red. Brain and membranes much congested. Trachea, pharynx, and œsophagus congested. Lungs congested. Right cavity (auricle?) of heart full, left empty. Liver, spleen, and kidneys congested. Intestinal peritoneum congested. Stomach contained half-digested food. Small intestines empty; fæces in large intestine. Bladder empty. Uterus and appendages congested; no evidence of catamenia.

34. Harris: Ibid.—Woman; made a loop of her hair around her neck, knelt down so as to put it on the stretch; when found, was nearly dead.

35. Geoghegan: Taylor’s “Med. Jur.,” Am. Ed., 1892, p. 413.—Informed Dr. Taylor of a suicidal strangulation by a ribbon. The mark on the neck nearly disappeared after removing the ligature. There was bleeding from one ear, from rupture of tympanic membrane. No froth from mouth or nostrils; but little lividity or swelling of face.

36. Taylor: “Med. Jur.,” Am. Ed., 1892, p. 418.—Boy: found dead with handle of pitchfork under necktie; marks of strangulation on larynx; eyes and tongue protruded; tongue livid and marked by teeth; brain congested. Also man found dead with handkerchief tied around neck and twisted by razor strop. Taylor considered both as suicides. Also a third case (Amer. edit., 1880, p. 465). A man of unsound mind twisted a fishing-net firmly around his neck several times; it remained secure without the aid of a knot.

37. Fargues: Rec. de mém. de méd., etc., Paris, 1869, xxii., pp. 443, 444.—Soldier, age 32, while drunk, strangled himself with his handkerchief, wrapping many folds around his neck, making a deep furrow without ecchymosis; face pale, eyes closed, lips partly closed.

38. Borchard: Jour. de méd. de Bordeaux, 1860, v., p. 349 et seq.—Collation of cases of suicide by strangulation: First, an officer who placed his sabre scabbard under his cravat. Second, a woman strangled herself with a silk cravat, tightly tied. Third, a man tied the sleeve of his jacket around his neck and fastened the end to a window, so that the strangulation was partly due to suspension. Fourth, a woman strangled by a cord.

39. Hofmann: Wien med. Presse, 1879, xx., p. 16, et seq. Also Lehrbuch, p. 559.—Woman, age 20, found dead in bath-room, with a thick thread passed three times around the neck, and tied tightly in front at the second and third turns; so tightly that even after cutting the cords the pressure continued. No signs of violence. (Illustration.)

40. Zillner: Wien med. Woch., 1880, xxx., pp. 969, 999.—Woman, age 33; found dead on the floor; a neck-handkerchief tied in a firm knot in front of the neck; and underneath, a cord passed twice around the neck and knotted in front in the middle line between the larynx and hyoid bone. Blood was flowing from the ears. No sign of violence or struggle.

41. Bollinger: Friedreich’s Blätter f. ger. Med., 1889, xl., p. 3.—Man, age 48; melancholic; found dead. Had torn up part of a sheet, fastened it around his neck and the ends around a bed-post, then placed his feet against the farther post and pressed, tightening the ligature. (Illustration.)

42. Roth: Ibid., p. 9.—Man, age 68; melancholic; found dead in bed. Had made loose ligature of cravat, tied into it a piece of wood; the ligature lay in front of larynx. Had attempted suicide once before.

43. Ibid.—Son-in-law at 36 years of age had committed suicide in the same way.

44. Ibid.—Man, age 63; found dead in his bed; cord around neck inclosing piece of wood.

45. Maschka: Vier. ger. öff. Med., 1883, xxxviii., pp. 71-77.—Woman, age 45. A cloth was found wound tightly three times around her neck in front of larynx, and tied in a simple knot. There were also injuries of the head. At first it was thought that she had been murdered, but Maschka concluded that she had committed suicide.

46. Ibid.—Woman; supposed to have been murdered by her son. There were marks on the neck and other injuries, and hemorrhage into the brain. Maschka concluded that the marks on the neck were not due to strangulation.

47. Hackel: Dorpat Diss., 1891, p. 34.—Man, age 48; strangled himself with part of a mattress. Was found lying on his back, dead, holding the ends in his hand. There was a double mark of ligature.

48. Binner: Zeitsch. f. Med-beamte, 1888, i., pp. 364-368.—Woman; suicided by choking herself with her hands.

For other cases, see Tidy, “Med. Jur.,” Cases 20 to 65; Maschka, “Handbuch,” p. 625.

ACCIDENT.

49. Bédié: Rec. de mém. de Méd., etc., Paris, 1866, xvi., pp. 482-484.—Soldier, age 39, found dying, lying on his bed; had returned to his room drunk and lay down in his uniform. Face much congested; lips cyanosed; eyes closed. Skin of neck below thyroid cartilage showed deep mark from pressure of collar of uniform where the collar was fastened; had passed urine into his clothing. When examined after death his face was pale yellow, lips cyanosed, eyes closed; large hypostatic patches; traces of pressure on neck still visible; lungs congested; larynx, above level of pressure, congested; below was normal. Fibrin clots in both ventricles of heart. Liver, spleen, stomach, and intestines congested. Brain somewhat congested. Bladder contained urine.

50. Liégey: Jour. de Méd. chir. et pharm., Brussels, 1868, xlvi., pp. 339-342.—Infant, age 8 months, accidentally strangled; it had been placed in its cradle; coverlet over it and held in place by a cord passed across. Some time afterward it was found dead beside the cradle, its head hanging with the right side pressing on the cord. Liégey had the mother replace everything as it had been and satisfied himself that the above statement was correct. When found, the face was pale, eyes and mouth closed; transverse furrow on right side of neck, level of larynx, 3.5 cm. long, one deep; muscles in vicinity congested. Lungs congested. Right side of heart contained clotted blood; left side nearly empty. He concluded that the case was one of accidental strangulation.

51. Friedberg: Gericht. gutacht., p. 240.—New-born child found dead in closet. Mother stated that she had taken the child by the neck and drew it into the world. Opinion given that the child had been accidentally choked to death by the hand.

For other cases, see Tidy, “Med. Jur.,” Cases 15 to 19, 59, and 62; Maschka, “Handbuch,” p. 623.

HANGING.

Hanging is a form of mechanical suffocation by ligature of the neck, in which the constricting force is the weight of the body itself. The French call it “Pendaison” or “Suspension,” preferably the former; the Germans, “Erhängen.” The expression “incomplete hanging” is applied to those cases in which the subject is partially supported; kneeling, sitting, or otherwise. The same expression has also been used for cases which did not prove fatal.

The pathological effects of hanging are partly those of strangulation, to which must be added the effects of the weight or fall of the body, sustained as it is only by some form of ligature around the neck. These additional injuries will, of course, be proportioned to the weight of the body, length of rope, and suddenness of the fall.

In some countries, as the United States, England, Germany, and Austria, hanging is a mode of capital punishment. It is desirable that for judicial purposes it should be divested, as far as possible, of unnecessarily cruel features; the victim should quickly be made insensible, and death be speedy. Many suggestions to this end have been made, among which is that of Haughton. He recommended that the drop be long, say ten feet, so that the cervical vertebræ may be dislocated. He also advised that the knot be placed under the chin. Others advise that it be placed under the left ear; and others yet, as Barker, of Melbourne,[798] near the spine. In any event the rope should be “freely elastic.” G. M. Hammond[799] thinks that the object in judicial hanging should be strangulation, and that the criminal should be pulled up and left to hang thirty minutes; the rope should be soft and flexible so as to closely fit the neck; a weight should be attached to the feet of persons under 150 pounds. Larimore[800] also advocates strangulation instead of attempting dislocation of the vertebræ. Porter[801] suggests that for dislocation the noose be drawn tightly around the neck at the last moment, the knot being either at one side or, still better, in front. Dislocation may be still further assured if a hollow wooden or leaden ball be placed over the knot close to the neck, thus forming a fulcrum to throw the spinal column out of the perpendicular line at the point of pressure.

Hanging is a common mode of suicide, especially in insane asylums and prisons. It is sometimes accidental, and rarely homicidal. It is said to have been attempted for erotic purposes.

The compression of the neck acts in line with the axis of the body; while in strangulation it acts perpendicularly to that axis.

The final cause of death will depend on: 1. The suddenness and completeness of interference with the access of air; asphyxia. 2. Pressure on the large veins of the neck, preventing the return of blood from the head, causing congestion of brain and coma. 3. Pressure on the large arteries of the neck, preventing access of blood to the brain; causing anæmia of the brain and syncope. 4. Injury to spinal cord or pneumogastric nerves or all of them; causing paralysis. A combination of numbers 1 and 2 is usually found in suicidal hanging; and probably all of them in homicidal and judicial hanging. The more protected the air-passages are from pressure the greater part will coma or syncope have in the cause of death.

Mackenzie,[802] as the result of examination of 130 suicidal hangings, says that 119 died of asphyxia, 8 of asphyxia and apoplexy, 2 of syncope, and 1 of apoplexy alone. Coutagne[803] thinks œdema of the lungs, “œdema carminé,” has an important part in causing death.

The following conditions tend to produce asphyxia: a tight ligature, or a loose ligature above the hyoid bone. To produce coma, a loose ligature pressing against the hyoid bone or larynx, especially a cretified larynx. To both asphyxia and congestion of brain, a ligature just beneath the lower jaw, or around lower part of neck.

Hofmann[804] states that when the ligature is placed between the larynx and hyoid bone, the base of the tongue is pushed upward against the posterior wall of the pharynx, completely stopping respiration and causing asphyxia. Taylor[805] states that if the rope presses on or above the larynx, the air-passages are not so completely closed as when pressure is below the larynx. In the latter case death would be immediate; in the former a slight amount of respiration might continue. The instantaneous loss of consciousness is due, not to asphyxia alone, but to compression of the large vessels, especially the carotids, against the transverse processes of the vertebræ, causing rupture of the middle and inner coats, and at the same time compression of the jugular veins and pneumogastric nerves. Immediate unconsciousness will almost certainly follow compression of the pneumogastrics. He also believes that the loss of consciousness and of power of self-help occur at the moment that the noose is tightened around the neck. There is no record of any one who attempted suicide by hanging seeking to recover himself, although no doubt some would have done so if the speedy unconsciousness had not prevented. Hofmann mentions the case of a man who was found hanging, and with a loaded revolver in his hand, apparently having intended to shoot as well as hang himself, but lost consciousness before he had time to discharge the revolver. According to him the causes of death are three: occlusion of the air-passages, interruption of passage of blood to brain, and compression of pneumogastric nerves.

Von Buhl[806] experimented on cadavers and concluded that in hanging, the epiglottis and arytenoids are pressed over the glottis, and the tongue and the œsophagus against the vertebræ, causing death by apnœa. When the trachea was isolated from the vessels and tied, the air-passages below became dilated and the lungs emphysematous and anæmic. The heart continued to beat and blood to circulate.

The vertebral arteries being much smaller than the carotids, the circulatory disturbance in the brain is not adjusted with sufficient promptness. Compression of the pneumogastrics, according to Waller,[807] has caused subjects to fall to the ground as if struck by lightning. He holds that the unconsciousness in hanging is the result of the compression of the pneumogastric nerves and not of the arteries. Thanhöfer[808] knew a student who had acquired a certain dexterity in compressing these nerves. One day he compressed the two nerves, his pulse stopped and he became unconscious. Thanhöfer[809] tried bilateral compression of pneumogastrics in a young man sentenced to be executed. The pulse fell at once and the heart soon stopped; the eyes were fixed and glassy. It was some time before he regained consciousness and for two days there was malaise.

Hofmann says that the compression irritates and, in a higher degree, paralyzes the pneumogastric nerves and causes disturbance of the action of the heart.

Faure[810] denies that the constriction of the vessels of the neck has any effect in the production of symptoms[811].

Coutagne believes that the pressure on the pneumogastric nerve is a factor in causing death. He hung two dogs; in one the pneumogastric nerves were dissected out and placed in front of the ligature; this dog (No. 1) lived a quarter of an hour and died of pure asphyxia with efforts at inspiration continued to the end. The other dog (No. 2), in which the nerves were compressed, died in five minutes. In both, the abdominal organs were congested and the cavities of the heart were full. The lungs of the first were dry and uniformly red; of the second were resisting, crepitant, and quite œdematous. No subpleural ecchymoses in either. The experiments on animals by Corin[812] led him to conclude that pressure on the pneumogastrics caused increased frequency of the heart-beat and slowing of respiration. Pellier[813] considers the subject quite fully. It would appear that the pressure on the pneumogastrics disposes to stop the action of the heart and cause rapid, perhaps instant death. The pressure on the carotids causes cerebral anæmia and is then only a secondary cause. Levy[814] does not think the action of the pneumogastrics is sufficiently well known.

Tidy states that a dog lived for three hours suspended by a rope placed above an opening in the windpipe; and that Smith[815] mentions the case of a criminal who was hung; Chovet tried to save the man by making an opening in the trachea before the execution and introducing a small tube. The man was alive forty-five minutes after the drop, but could not be resuscitated, although the surgeon bled him.

In a small proportion of cases of hanging, homicidal and judicial, death occurs by dislocation of the spine. This is said to have been first noticed by the celebrated Louis, who states that the Paris executioner was in the habit of giving a violent rotary movement to the body of the convict as the trap was sprung, causing a dislocation of the odontoid process and compression of the cord and almost instant death. Taylor[816] says that for dislocation the body must be heavy and the fall long and sudden. Devergie[817] found this to occur in about two per cent of cases. It is said that the Paris hangman placed the slip-knot under the chin in front, which is as Dr. Haughton suggests.

Death may occur from secondary causes after apparent recovery; from congestion of brain and other lesions of the nervous system; these may prove fatal at remote periods.

Fracture of the odontoid process according to M. de Fosse is more common than dislocation, and the giving away of the intervertebral substance more likely than either of the others. The phrenic and other respiratory nerves are likely to be paralyzed; the vertebral and carotid arteries may be ruptured. The medulla oblongata is also likely to be fatally injured. Death may also occur from hemorrhage upon the cord, causing pressure.

Besides the ropes used as ligatures in judicial hanging, almost every conceivable article that could be made into the semblance of a cord has been used by suicides; usually, however, some portion of the bedding or clothing. When one resolves on suicide, all the precautions of the managers of prisons and asylums fail to prevent.

The secondary effects in those who recover involve the respiratory organs—dyspnœa, cough, bloody sputa, bronchial râles, and fever; or the nervous system—aphonia, dysphagia, numbness, chilliness, spasms, pains in neck, face, or shoulder; sometimes paralysis of bladder and rectum, and loss of memory. The marks on the neck slowly disappear.[818] Verse[819] collated a number of cases in which the hanging was not completed and the subjects lived for varying periods afterward. Wagner and Möbius[820] discuss the spasmodic seizures and amnesia, which often appear after the restoration from hanging.

SYMPTOMS IN HANGING.

Obviously these will be in some respects identical with those of strangulation. In considering the latter, some of the similarities and dissimilarities of symptoms and post-mortem appearances of strangulation and hanging were mentioned.

Death may be immediate and without symptoms.

There is, of course, no preliminary or “waiting” stage, as in strangulation, except in those rare cases of suicide where the subject inclines his body forward with his neck against the ligature, his body being near the floor or ground. The absence of a drop makes this condition very similar to ordinary strangulation. The body of a victim of homicide might be similarly placed for the purpose of deception, and also that of a subject previously made unconscious; in these cases the symptoms and appearances would resemble those of strangulation.

In other words it is necessary that there should be a drop or fall, or at least the weight of the body, to produce the characteristics of hanging. The jerk of the fall or sudden dependence of the body upon the ligature causes a much greater constriction of the ligature on the neck, and in a different direction, than in strangulation; and also a much greater pressure on the blood-vessels and nerves of the neck.

Tidy divides hanging into three stages:

First stage: Partial stupor lasting thirty seconds to three minutes, according to the length of the drop, the weight of the body, and tightness of the constriction. The testimony seems to be uniform that there is no pain in this stage; indeed, that the feeling is rather one of pleasure.[821] The subjective symptoms described are an intense heat in the head, brilliant flashes of light in the eyes, deafening sounds in the ears, and a heavy numb feeling in the lungs. Sometimes there is a feeling of absence of weight. In many cases efforts to breathe are made for a time after the air-passages are closed. It is doubtful whether there are any voluptuous feelings, as has been suggested.

Chowne[822] reports the case of Hornshawor, “Monsieur Gouffé,” who was in the habit of hanging himself for exhibition. He fixed the noose with a knot that would not slip, sprang into it, the rope coming behind the lower jaw and the two sides passing up behind the ears. He would hang for ten to fifteen minutes, and in addition to his own weight would sustain one hundred and fifty pounds. Three times the rope slipped and he would have died but for the help of spectators. He described his sensations as follows: He lost his senses all at once. The instant the rope got in the wrong place he felt as if he could not get his breath, as if some great weight was at his feet; and could not move only to draw himself up; felt as if he wanted to loosen himself but never thought of his hands. He said: “You cannot move your arms or legs to save yourself; you cannot raise your arms; you cannot think.”

Taylor[823] mentions the case of Scott, the American diver, who was in the habit of making public exhibitions of hanging. The last time he hung for thirteen minutes, the spectators not suspecting that he had died. It is supposed that the ligature had slipped. Taylor also reports a case (from Dr. Elliott) of a boy, age 11, who, to frighten his parents, tied a knot in a handkerchief and put it around a knob and his neck in one continuous ligature. The pressure against the trachea was so effective that he became unconscious and died before he could relieve himself.

Second stage: The subject is unconscious and convulsions usually occur. The convulsed face, however, is a part of the general agitation and does not indicate pain. In judicial cases the face is covered with a cap. Sometimes there are no spasms. Urine, fæces, and semen may be discharged in any stage. Jaquemin, however, in forty-one cases of hanging, noted discharge of urine and fæces only twice. Semen has, however, been found in the urethra where none was ejected externally.[824]

Third stage: All is quiet except the beating of the heart. As a rule, the pulse may be felt for ten minutes.

Blankenship[825] reports an execution of a man by hanging. After the rope was adjusted the pulse was 121; first minute after drop, pulse 54; second minute 52; third 39; fourth 20; fifth 0; sixth 70; seventh 73; eighth 0; ninth 34; not perceptible afterward. Died from strangulation; neck not dislocated. The heart beat once in the nineteenth minute; from the ninth to the nineteenth, only two or three times. No priapism.

In judicial executions, however, the right auricle is found in action when the subject is taken down at the end of the usual period of suspension (see Case 89). Tardieu mentions a case where the heart was beating 80 to the minute one and one-half hours after supposed death. It is probable that in these cases the deprivation of air and compression of the vessels has not been complete. In such cases life may sometimes be restored. Cases are reported where restoration has been possible within a period of a half-hour of suspension; although the fatal period is usually five to eight minutes at most. If, however, the tissues and especially the spinal cord are injured, or the ligature has compressed below the larynx, the chance of recovery is very small, even if the body is cut down at once. According to Faure, animals experimented upon die in twelve to twenty minutes.

Many cases of “incomplete” hanging have been reported; where the feet touch the floor, or would do so if the subject should choose to have it so. Tardieu[826] collected 261 cases, in 168 of which the feet touched the ground, in 42 the subject was on his knees, in 29 the body was lying, in 29 sitting and in 3 squatting. Hackel,[827] in 67 cases of hanging, found it incomplete in 34 per cent.

In one of the experiments of Faure[828] a large dog was hung, his feet touching the ground. For five minutes he was quiet, breathing without difficulty. He then tried to release himself, but instead tightened the knot; he made still greater efforts to release himself, became comatose and fell, apparently dead, at the end of ten minutes; was really dead in twenty-eight minutes.

In incomplete hanging the upper limbs may have any position; the lower limbs are disposed according to the position of the body (Cases 1, 10, 18, 19, 20, 22, 24, 26, 28, 37, 43, 50, 56).

Faure[829] made many observations on dogs which he killed by hanging. He describes the results as follows: The dog remains quiet usually twenty to thirty seconds, sometimes eight to ten minutes; then becomes violently agitated, the body being thrown forward and backward so powerfully that it bounds to a great height; the head is in motion; the jaws parted; the feet extended and flexed; sometimes brought up to the mouth and neck, trying to remove the obstruction; the inside of the mouth is violet-colored; tongue blackish, livid, may be bitten, often falls backward; the teeth are ground together; the eyes sometimes protrude; conjunctivæ congested; urine and fæces discharged. The agitation lasts two to five minutes, and then the dog gradually becomes quiet. Toward death, however, the agitation is renewed but in a different way; the fore feet are raised and put forward, the tongue often has a peculiar spasm, the chest is raised, the eyes drawn back into the orbits, pupils contracted; all of this is over within two seconds. Such paroxysms may be repeated half a dozen times. In dying, the eye oscillates from side to side and the pupil dilates. The heart beats some time longer.

Francis Bacon records that he knew a man who wanted to find out by experience if there was any suffering in hanging. He placed the cord around his neck and stepped off a bench, intending to step back again, but became immediately unconscious and would have died but for the opportune arrival of a friend. He said he saw a light before his eyes.

TREATMENT.

The first indications obviously are to let the subject down, and remove all constriction of neck and chest. Artificial respiration should then be used, and this may be assisted by the vapor of ammonia to the nose and tickling the fauces. If the body is warm, cold affusions may be applied to the head and chest, and galvanism may be used.

If the body is cold, apply warmth. Friction of the limbs aids in restoring warmth. If the subject can swallow give stimulants; these may also be used by rectum. Venesection may be required to relieve cerebral congestion or distention of the right heart and pulmonary circulation.

The following cases illustrate what may be done to resuscitate one who has been hanged: A man, age 35, in good health, weight one hundred and sixty pounds, was executed with a drop of over six feet; the rope slipped behind the mastoid process. After three minutes his struggles ceased; the radial beat ceased at six and one-half minutes; all signs of life at ten and one-half minutes, and the body was blue. Fourteen and one-half minutes, body let down; mark about one-fourth inch deep on neck; swelling above and below; no fracture of vertebræ. Strong galvanism of the pneumogastrics after sixteen or seventeen minutes at intervals of four seconds caused marked respiratory efforts; sixty-six minutes, galvanism renewed; heart-beat and radial pulse recognized; epiglottis swollen, requiring the tongue to be drawn forward; a few ounces of blood removed; pupils contracted. One hundred and four minutes, galvanism renewed; subject swallowed a little brandy-and-water. One hundred and thirteen minutes, slight muscular action; cornea sensible. One hundred and eighty-six minutes, feet warm, carotid pulsation. Signs of life now increased till six hours after drop, when pupils began to dilate again. Twelve to fifteen ounces of blood were taken and pupils again contracted and pulse beat strong and steady; breathing easy, more regular; eyes followed movements of persons around the room. Died nine hours later, fifteen hours after drop. The experiments were repeatedly interrupted by the sheriff.[830] Taylor[831] reports a case of recovery. Woman, age 44; found hanging from a clothes-line, thrown over a door and fastened to a handle on the other side; her knees on the floor; white froth around the mouth; tongue protruding and swollen; face dusky and swollen; lips dark blue; brown parchment mark on neck; skin abraded over larynx; conjunctiva insensible; pupils dilated and fixed; fingers clinched; limbs flaccid; no reaction from tickling feet; no respiration; faint heart-beat and fine thready pulse. Sylvester’s artificial respiration method used at once and continued for four and one-half hours; tongue held forward by forceps. One hundred and fifteen minutes after body was first seen there was spontaneous movement of legs. One hundred and forty-five minutes, conjunctivæ sensible. One hundred and seventy-five minutes, retching. Two hundred and five minutes, free vomiting. She recovered but remembered nothing of the hanging. Keen[832] reports the results of experiments upon a criminal who was executed by hanging. He was cut down about half an hour after the drop. Faradization and galvanization of pneumogastric and recurrent laryngeal nerves caused movements of left vocal cord, but not the right; there was no reflex motion in the larynx. The left phrenic nerve made no response to stimulus. The internal intercostal nerves caused the raising of the cartilage below them (inspiratory), the external intercostals depressed the upper seven ribs (expiratory), and raised the eighth. The other four not examined. The muscles of the face retained their contractility.

Very few, comparatively, however, have been restored after hanging. For cases of recovery see Medical Times and Gazette, London, 1871, Vol. I., p. 669 (Cases 12, 13, 42, 44, 47, 49, 66).

POST-MORTEM APPEARANCES.

The post-mortem appearances are external and internal.

The =external= appearances are those due to the action of the ligature on the neck and to other violence, if any has been done, and those due to asphyxia or syncope.

The MARKS of the ligature. If the suspension be very brief and the ligature soft and supple, and the body instantly cut down after death, there may be no mark. Allison[833] questions the value of the mark, contending that it is post mortem, and reports cases; says it is present only if the drop be considerable or the suspension continue after death. Tidy says that the mark is, in a measure, independent of the ligature and duration of suspension, and does not usually acquire its color for some hours after death; sometimes, however, it has occurred in a much shorter time. It may be slight because the ligature has been placed over the clothing. The longer a body hangs after death, the more the mark shows. It can be produced upon the cadaver.

Harvey[834] says: “The characteristic mark is sometimes found in non-fatal cases.... In eight instances in the present returns (of nearly 1,500 cases of hanging) there was a distinct mark.”

Coutagne,[835] in twenty-four necroscopies on subjects hung, found only slight or doubtful lesions in five cases; but of these, one was in a condition of advanced putrefaction, another was apparently weakened by loss of blood from wounds, and in the other three there were marks of violence. In seventeen cases the lesions of the neck were plain; hemorrhage in connective tissue or muscle.

The direction of the mark is usually oblique, following the line of the lower jaw upward and backward behind the mastoid processes; it may, however, be horizontal. If the ligature encircles the neck more than once, one mark may be circular, the other oblique. If a running noose is used the mark may be circular, and be seen all the way around the neck, looking like the mark of a strangulation. Taylor[836] states that if the noose should be in front, the mark may be circular, the jaw preventing the ligature from rising upward in front as much as it does behind. If it encircles the neck but once, its continuity is apt to be broken by the prominence of the hyoid bone, thyroid cartilage, sterno-mastoid muscles, etc.

In four-fifths of the cases (117 out of 143, Tardieu) the mark is found between the chin and larynx; in nearly all the remaining fifth, over the larynx; in a very few below the larynx; the last position is due to the protection of the neck by a handkerchief or beard, or where there is some anatomical or pathological peculiarity which prevents the ligature from going higher.

Hofmann[837] had seen two cases of tumor of neck; one in a woman, where the cord was below the larynx; and in a man where it was over the larynx. He quotes[838] as follows: Remer, above larynx, 38; over larynx, 7; below larynx, 2. Devergie, above larynx, 20; over larynx, 7; below larynx, 1. Casper, above larynx, 59; over larynx, 9. Roth[839] in 49 cases found the ligature mark above the hyoid bone in 5; between the bone and the larynx, 31; over the larynx, 8; below the larynx, 1. Hackel found the ligature in forty per cent of cases between hyoid bone and larynx; in sixty per cent lower down. The ligature always appears lower after the body is laid down than it was in suspension. Maschka found the furrow 147 times in 153 cases above the larynx.

The mark will vary in character according to the kind of ligature used, its mode of application, the vitality of the tissues, and the period that has elapsed since death. The result is different according as the knot or loop is single or double, a running or slip knot.

The mark may differ in character in one part of the neck from another. The same furrow may be soft in one part and dry in another. The width of the mark does not necessarily correspond to the diameter of the ligature. A double mark usually means that the ligature has been twice passed around the neck, although the marks may not be continuous or parallel. Tardieu states that a large single leather thong pressing on the neck only by its borders may make a double mark. The mark is usually depressed. The depth of the depression, groove, or furrow, as it is called, is greater the narrower and firmer the ligature, the longer the suspension, and the greater the weight of the body. The mark may be merely a slight depression, without color, or only a red blush, if the subject is young, tissues healthy, and suspension brief. Roth,[840] in 49 cases of hanging, found the furrow of the ligature was brown in 40, red-brown in 6, and 3 times bluish.

In about two-thirds of the cases the bottom of the furrow, the place of greatest pressure, is white, especially so where the knot is tied; while the edges of the furrow are usually slightly raised and red or livid. If the subject is very fat, there may be only a slight depression. Harvey[841] says that this hard, white, shining, translucent band from compression of the connective tissue is the first stage of the parchment or vellum skin, and is chiefly noticed in fresh bodies. The borders are swollen and œdematous, called by Lacassagne “bourrelet de sillon.”

The skin beyond the furrow is usually violet. Authors differ as to whether this is due to congestion or hemorrhage. Roth[842] in 49 cases found swelling below the furrow 27 times. Hackel found ecchymoses above the mark in thirty-five per cent of the cases of hanging. Hofmann thinks that the lividity of the upper border of the furrow is due to the stopping of the venous blood descending from the head.

The dry, hard, yellowish-brown, or reddish-brown “parchment” furrow, described by writers, is said to be common. Ogston[843] found it in one-third of his cases. It is found only when the body has remained suspended for several hours after death; indeed, may be produced by applying the ligature to the cadaver; is not at all, therefore, a proof of suspension during life. Liman states that constriction by a ligature even for some time does not necessarily cause a mummified or excoriated furrow. He saw cases in which the mark was soft, flat, scarcely colored, but little interrupted, and not parchmenty. The parchment skin seems to depend very much upon a previous excoriation of the skin. Its appearance can be prevented or delayed by examining a body soon after death or by rehanging it; and after it has appeared it will disappear on the application of some liquid. Taylor[844] compares this parchment mark to the cutis from which the cuticle has been removed for two or three days.

Slight abrasions and ecchymoses are sometimes found in the furrow. Ecchymoses alone do not indicate whether suspension has been before or after death; but abrasions with hemorrhage strongly suggest suspension during life. Devergie regards ecchymoses of the neck as strongly suggestive of homicide. Neyding[845] says that suggillation in the groove is oftener found in strangulation than hanging. And Bremme[846] that there is no hemorrhage in the subcutaneous tissue of the mark if death occurs at once and the cord is removed at once after death; but if the cord remains for some time after death there may be hemorrhage, or if death does not occur at once, whether the ligature be removed or not.

Roth[847] found ecchymoses or small bladders at the lower margin of the furrow, 9 times in 49 cases. Riechke found only once in 30 cases a hemorrhage beneath and on both sides of the mark. Chevers did not find ecchymoses of the skin of the mark in cases of hanging. Casper found no ecchymoses in 50 of 71 cases. Maschka has seen two cases where burns on the neck resembled mark of ligature.

The furrow, when once distinct, remains constant for a long time after death, even in putrefaction. Marks from soft substances, however, disappear sooner than those from strong and uniform compression.

The NECK nearly always appears stretched. According to Roth the mobility of the head is increased by this stretching. The HEAD is always inclined to the opposite side to that of the knot. In suicides the head is usually bent forward on the chest. The HANDS are often clinched so tightly that the nails are driven into the palms. This occurs more especially when the hanging has been done with violence. When the feet touch the ground, as often occurs in suicide, the hands may be stretched out. Roth found the hands and feet flexed in 44 of 49 cases. Taylor says that we may expect to find the hands clinched when constriction of the neck is sudden and violent. The LEGS are usually livid.

The FACE varies with the duration of the suspension; at first it is pale, afterward livid; congested and swollen, if the subject has been long suspended. Roth found the face pale in 43 of 49 cases. In about one-half the cases the features are calm and placid (syncope). Maschka found the lips bluish in 98 of 153 cases. The EYES are often prominent, staring, and congested, and usually the pupils are dilated. Lacassagne and Maschka[848] look upon ecchymoses of the eyelids and conjunctivæ, “piqueté scarlatin,” as important as favoring the idea of hanging or strangulation. Roth found in 49 cases the eyelids closed 28 times; half open, 12; congested in 6; ecchymosed in 2. Pupils dilated in 31; narrowed in 2. Dilated in 97½ per cent of Ogston’s cases (Cases 85, 86; rupture of crystalline lens). Harvey[849] says the blood was found flowing from the EAR in 6 cases of nearly 1,500, but no details were given. Ogston, one case. Hofmann saw a case in which there was bleeding from the ears. He says this is not due, as has been supposed, to rupture of the tympanic membrane, but to hemorrhage from subcutaneous vessels (Case 27).

The TONGUE is usually livid and swollen, especially at the base. According to Tidy, Dr. Guy looks on this as showing that suspension took place very probably during life. In about one-third of the cases the tongue is protruded and compressed between the teeth; sometimes bitten. Some observers found it protruded only as a result of putrefaction. The protrusion of the tongue is not believed to depend on the position of the ligature. Hackel in 67 cases found the tongue lying forward in all cases where the cord was between the larynx and the hyoid; in 55 per cent in front of the teeth, in 18 per cent between the teeth; where the ligature was lower down, the tongue was behind the teeth. He found by experiment that in the spasmodic expiratory effort the tongue was thrust forward; in the inspiratory movement, drawn backward. He concluded that the forward movement was the result of reflex action. Maschka[850] found the tongue between the teeth 58 times in 149 cases. Roth in 49 cases found the tongue projecting and bitten in 22, the teeth shut in 15 others; in 15 the mouth was open; the tongue was retracted in 30 cases.

Harvey, after examining reports of nearly fifteen hundred hangings, says: “In the majority of instances immediately after death the features were placid, the face pale, the eyes not unduly prominent, the mouth closed or half open, the tongue pressed against the teeth but not protruding; the superficial veins full, but the head, neck, and trunk free from lividity. After a longer or shorter time, however, and apparently after a very few hours, in India, all this is changed. Livid patches appear about the chest, back, and shoulders; the face and head become bloated and puffy, the tongue and eyes protrude.”

Bloody froth is sometimes seen at the nose and mouth.

SALIVA is invariably secreted and runs out of the mouth down on the chin and chest. Its presence is considered as evidence that suspension occurred during life. The URINE and FÆCES are sometimes found to have been expelled. These discharges occur in all kinds of violent death. Tardieu found them, however, but twice in 41 cases of hanging. Roth in 49 cases found discharges of fæces in 17 and urine in 4; in 15 cases not noticed.

Harvey mentions a case where internal piles had burst, and there were stains and clots of blood about the perineum and anus. In such cases without careful examination there would naturally be a suspicion of violence.

In about one-fourth of the cases the GENITAL ORGANS are congested. The penis is large and more or less erect; seminal fluid, generally prostatic, and sometimes mixed with blood, is often expelled. The fluid may pass only into the urethra and it may be necessary to press the urethra to secure it. The clitoris may be found erect, and there may be a sort of menstrual flow. Orfila showed by experiment that swelling of the sexual organs and emission of semen can be produced after death in those who had been suspended during life. The flow of semen is found in all kinds of death by violence. Roth in 39 cases of hanging of men found the penis enlarged 18 times and ejaculation in 19. Hackel found the penis swollen in 43 per cent of cases of asphyxia. Erection may come on soon or late, even days after death.

=Internal Appearances.=—The CONNECTIVE TISSUE UNDER THE MARK is usually white and condensed, the more so if the body has been long suspended. This dryness or condensation was found by Hackel in 52 per cent of hangings. Deeper-seated parts are injured only when the hanging has been violently done. The MUSCLES, especially the sterno-mastoid, are sometimes ruptured. Hofmann[851] reports several cases. Lesser[852] in 50 hangings saw 11 ruptures of muscle. Maschka never saw the rupture in suicides. The sterno-mastoid was ruptured in the case of Wirtz (Case 96) and Guiteau (Case 95). Hackel in 67 cases failed to find the muscle ruptured. Hofmann[853] believes that the rupture of the muscle is sometimes post mortem. Coutagne[854] found the sterno-mastoid muscle ruptured once in 24 cases (Cases 29, 89, 95, 96).

The LARYNX may be fractured or dislocated. These lesions are very rare in suicide; more frequent in homicide and judicial hanging, and in the old where the cartilages are calcareous. Remer found the injury in but 1 case in 101 of suicidal hanging. Barker found the larynx lacerated in his judicial cases.[855] Harvey says that the TRACHEA was reported lacerated 11 times in nearly 1,500 cases; twice the laryngeal cartilages were separated from each other. In 5 these cartilages were fractured, but there was nothing to show under what conditions. Hemorrhage in vicinity of larynx, 43 times. Pellier[856] reports 1 case, and adds that the existence of the lesion easily escapes notice because of the mobility of the cornua. Roth in 49 cases failed to find any fracture. Pellier found the cricoid was injured oftener than the thyroid, which is the reverse of what is found in strangulation. Cavasse[857] was unable to cause fracture of larynx by hanging the cadaver. Chailloux[858] collected 6 cases of fracture of larynx in hanging. He concluded that the fracture could not be produced on the cadaver by hanging, and is, therefore, caused during life. Coutagne[859] in 24 cases found fracture of thyroid cartilage 8 times (Cases 9, 51, 82).

The HYOID BONE is rarely dislocated. Orfila mentions a case of fracture. Barker found the bone usually fractured in judicial cases. In the case of Wirtz (supra) the greater cornu was broken. Pellier reports 2 cases. Hofmann[860] says the hyoid cornua are often fractured, especially when the ligature is between the hyoid bone and thyroid cartilage. Coutagne found fracture of hyoid bone 8 times in 24 cases. He attributed the fracture to pressure against the spine. Pellier speaks of fracture of STYLOID PROCESS (Cases 51, 84, 88, 89, 95, 96).

Dr. Barker, of Melbourne,[861] states that in 50 cases of hanging by the old method there was not one case of fracture or dislocation of vertebræ. After adopting his suggestion to place the knot near the spine, he found that dislocation occurred between the second and third cervical vertebræ with fracture of the third and pressure on the spinal cord. Death was sudden and complete. The drop in these cases was short, three to four feet. Coutagne thinks that the ordinary mobility of the head, axis, and atlas on each other have led reporters into the mistake of supposing a dislocation of vertebræ. Roth failed to find fracture of vertebræ in any of 49 cases. These injuries are especially rare in suicide; but in violent hanging, dislocation or fracture may occur and also rupture of the ligaments. Harvey gives 5 cases of dislocation of vertebra and 4 of fracture of vertebra in suicides. Three of the latter were doubtful. Tardieu says these fractures have no significance as to the hanging having occurred during life. They can be produced on the cadaver; but infiltration of clotted blood around injured vertebræ shows that suspension occurred during life (Cases 5, 7, 8, 68, 76 to 79, 83, 84, 91, 92, 94).[862]

The CAROTID ARTERIES may be injured; usually the inner and middle coats are torn; and hemorrhage may occur into the wall of the vessel. The common carotids are the ones usually affected, and just below the bifurcation, but the external is also occasionally injured. The injury is said to be due to the stretching and squeezing of the artery, stretching being the most effective since the rupture often occurs at a distance from the mark of the ligature. Such injury of the artery does not prove that hanging took place during life because it has been produced on the cadaver; but hemorrhage into the wall of the vessel or wound or rupture after death is very improbable. Maschka says the lesion is very rare. Tardieu says that the injury to the carotid is rare and therefore unimportant. Pellier reports 4 cases of rupture of carotid in a total of 23. Levy records the experiments of Hofmann, of Vienna, and Brouardel and himself, of Paris, 5 in number. He concluded that compression of the carotid arteries, if it produces obliteration, can cause rapid loss of consciousness and death; and explains why in incomplete suicide the subject is unable to help himself. Coutagne found rupture of carotids 10 times in 24 cases. He insists on the importance of the lesion.

Hofmann[863] says the rupture is always transverse, may be simple or multiple and may occur in suicides; more apt to occur when the ligature is thin. Lesser[864] tabulated 50 fatal cases of suicidal hanging; in 29, he was satisfied that the hanging occurred during life. In 3 of these the skin of the neck alone showed any lesion; there was a double mark, the skin being otherwise bloodless. In 5 the deeper soft parts were the only ones affected. In 3 the skin showed lesions, the deeper soft parts none, but either the hyoid bone, larynx, or vertebræ were involved. In 12 the skin showed no mark, but the deeper soft parts and either the larynx or hyoid bone were involved; and in 6 the hyoid bone only or the bone and larynx were injured. In the remaining cases it was not possible to say that the hanging occurred during life. In 2 cases there were no marks at all; in 9 there were changes in the skin; in 4, changes in the skin and deeper parts; in 2, changes in the skin, deeper parts, and hyoid bone or larynx; in 3, changes in the skin and hyoid bone or larynx, or both. In 14 of the 50 cases the hyoid bone was fractured; in 20 the larynx; and in 1 the vertebræ. The common carotid arteries were injured in 6. The number and severity of the lesions bore no constant relation to the thickness of the ligature, nor to the force used, but rather to the position of the body.

Ecker[865] reported a case of suicidal hanging in a man, age 40, where the soft palate was swollen and filled up the passage so that the air evidently could not enter.

The LARYNX and the TRACHEA are usually deeply congested, of a red color; a violet color indicates putrefaction. Ogston reports mucus but not bloody froth 9 times in the pharynx, 6 in the trachea, and 4 in the lungs, in a total of 40 cases. In one case there was a quantity of blood in the larynx and pharynx. Taylor thinks that pinkish froth in the trachea indicates incomplete obstruction; and Chevers that it is due to spasmodic efforts to breathe when the obstruction is nearly complete. Chevers always found clear mucus in the larynx and upper part of trachea, each follicle being marked by a minute globule of mucus. Harvey states that this was noted a few times in his reports. Baraban[866] discusses the condition of the epithelium of the air passages in hanging.

The condition of the lungs and heart varies according to whether death is due to syncope or asphyxia. Ogston found, in 22 cases, the lungs were expanded in 4 and collapsed in 2.

Harvey says the LUNGS are congested in over seven-eighths of the cases; emphysematous in a few; and subpleural ecchymoses present in a few. Patenko[867] experimented on dogs by hanging them. When the constriction occurred after expiration the lungs were congested; when after inspiration, not congested. In the first case (p. 223) the blood flows from the periphery to the heart and thence to the lungs, but cannot flow from the lungs because of the difficult circulation in the dilated pulmonary vessels and deficiency of intrathoracic pressure. There is in both cases cerebral congestion in the region of the bulb. Tardieu holds that punctiform ecchymoses and apoplexies do not occur in hanging unless suffocation has preceded. Pellier,[868] however, found these ecchymoses 14 times in 22 cases. He says that the lesion is not characteristic of suffocation, and quotes Lacassagne, Grosclaude, Dechoudans, Vicq, Chassaing, and Legroux to the same purpose. Hofmann[869] says that the ecchymoses are relatively rare in adults. Maschka[870] found them 18 times in 153 cases.

Harvey states that the presence of serum in the PERICARDIUM seems more a matter of time elapsed after death than anything else. Still the fact is that it is found much oftener in strangulation than in hanging. The difference is explained by the comparative slowness of death in strangulation. Harvey finds that in about one-half of the cases, if the body is fresh, the right side of the HEART, pulmonary artery, and venæ cavæ are full of dark fluid blood, the lungs being also much congested, and the signs of death by asphyxia well marked. When blood is found in both sides of the heart, it is probable that death is due to neuro-paralysis. When decomposition is advanced all the cavities are often empty. Taylor says that if the examination is delayed for several days, the distention may not be observed.

The STOMACH is often much congested, and this fact might sometimes suggest the possibility of poisoning. The LIVER, SPLEEN, and KIDNEYS are usually much congested. Hofmann[871] says that this occurs in the kidney only when the body has been hung a long time.

The BRAIN is rarely much congested. In 101 cases Remer found hemorrhage but once; and in 106 cases Casper failed to find it. Tardieu[872] says the brain is oftenest anæmic. If, however, the body is cut down and placed horizontally, the blood-vessels of the brain may fill up. Evidence may be found in the brain suggesting insanity and therefore an explanation of a probable suicide. Harvey says that hemorrhages in or about the brain are found in a much larger proportion of cases in India than in Europe in cases of hanging. “No common condition likely to cause extravasation is apparent, only one man being noted as plethoric, but in many the rope seems to have been very tight.” Champouillon[873] reports a case of suicide in a man, age fifty-two; the rope broke and the body fell. The physician who made the necroscopy reported a rupture of the pons Varolii. Champouillon believed that the rupture must have been made in removing the brain from the skull. Wilkie[874] reports a judicial hanging in which a man age about twenty-five, fell about three and one-half feet. A recent clot was found in the brain. The experiments of Brouardel of hanging rabbits showed the brain anæmic.

The conjunction of the following appearances would suggest that the hanging had been of some duration: lividity of face, congestion and prominence of eyes, dryness of skin under the ligature, deep furrow, congestion of sexual organs, swelling and lividity of lower limbs, hypostatic congestion of lungs.

Page experimented on a young cat and young dog; both were hung in the same way. Examination of the cat showed the veins generally engorged; sublingual veins much engorged; tongue protruded slightly and much swollen; no frothy mucus in bronchi. In the dog the tongue did not protrude and was not swollen; right cavities of heart contained blood, left empty; brain and other organs normal. In the cat, the lungs were uniformly congested, dark red; no ecchymoses. In the dog, the lungs were much distended, posterior borders mottled violet; emphysematous patches on surface; no apoplectic effusions; subpleural ecchymoses bright red, irregular, clearly defined in outer surface, most numerous toward the roots and on the lower lobes.

Pellereau[875] gives an account of hanging as seen by him in warm climates. He had not seen the elongation of the neck described nor the erection of the penis, nor subconjunctival ecchymoses, nor fracture of larynx, nor rupture of walls of carotid artery, nor subpleural ecchymoses, nor fracture of vertebra. He always found a mark on the neck; the left cavities of the heart always empty, the right always full of black blood. Mackenzie says that in 130 cases of suicidal hanging, the protrusion of the tongue between the teeth, the open and protruding eyes, clinched hands, and blue nails were very frequent, the tongue was found bitten many times, there were urethral and rectal discharges and rupture of carotid artery. The penis was found erect several times. The hyoid bone fractured 24 times in 93 cases. In no case was the larynx or vertebra fractured. In 73 cases ropes were used; in 30, portions of clothing. The marks of ropes were always well defined, indented, and parchment-like; the marks of soft ligatures faint and reddish. In no case were the muscles of the neck, the larynx, trachea, or large bronchi injured, and in none was there subcutaneous hemorrhage or blister.

PROOF OF DEATH BY HANGING.

As in strangulation, no single sign in any given case is sufficient of itself to prove that death was caused by hanging. But the sum total of the lesions found, viewed in the light of the surroundings of the body, will suffice to lead to a definite conclusion.

The fact that a body has been found suspended does not of itself prove that hanging caused the death, because the victim may have been killed in some other way, and the body afterward hung up to avert suspicion. Chevers records many cases of this kind.

The value of the presence or absence of marks on the neck and the characters of the marks has been questioned. Orfila, Casper, and Vrolik have shown by experiment that if a body is hanged within one or two hours after death the furrow, parchment skin, lividity, and the density of the connective tissue will appear just as is seen when suspension has occurred during life; but ecchymoses and infiltration, clotted blood in the skin, connective tissue, and muscles of the neck suggest suspension during life.

If a cord is removed immediately after death, there may be scarcely any mark at all.

Tardieu collected 261 cases of suicide by hanging where the subject was not entirely off the ground. In 168 the feet rested on the ground; in 42 the subject was kneeling; in 29 lying down; in 19 sitting, and 3 were huddled up or squatting. Fatal hanging may, therefore, occur in almost any position of body. He shows incomplete hangings by thirteen plates. Taylor also collected reports of 11 cases in a few years; in 3 the subjects were nearly recumbent; in 4, in a kneeling position; in 4, sitting. Remer in 101 cases of suicidal hanging found in 14 that the body was either standing or kneeling; in 1, sitting. Duchesne published 58 cases of partial suspension, 26 of which were new. Some of these failures of complete suspension were due to soft and elastic cords.[876]

Taylor says that “that which is difficult to a conscientious medical jurist in confining himself to the medical facts is often easily decided by a jury from these as well as the general evidence afforded to them.”

The limbs may be secured by the suicide before hanging himself. Persons even with some disability of the hand have suicided by hanging. Blindness is no obstacle, nor age; a boy as young as nine and a man as old as ninety-seven.

Burger[877] fully discusses the question whether the hanging is before or after death.

HANGING—SUICIDAL, HOMICIDAL, OR ACCIDENTAL?

Hanging is usually =suicidal=. Lesser[878] states that for three years, 1876-79, there were admitted to the Berlin morgue 274 bodies of “hanged,” of which 272 were suicidal; 2 infants of three and eighteen months, homicidal. One man had first tried to kill himself with sulphate of copper; another by cutting his throat; a woman by cutting her arm. The other cases were uncomplicated. Pellier states that the number of suicides in France from 1876-1880 was 13,445, and nearly all were by hanging. Taylor[879] states that 2,570 persons committed suicide by hanging in England in five years, 1863-67; four-fifths of these were males. Harvey[880] reports for three years 1,412 cases of hanging in India, of which 2 were accidental, in 3 there was presumption of homicide, the rest probably all suicidal.

Feebleness of body does not preclude subjects taking their lives in this way. They sometimes also wound or poison themselves first and hang themselves afterward. A subject being found suspended in a room fastened on the inside, would be suggestive of suicide. The absence of signs of struggling or of any marks of injury also favors the idea of suicide.

The possibility of a suicide breaking a rope, being injured by the fall, and rehanging himself successfully, must be admitted (Cases 57, 58). The possibility of blood flowing after death must not be forgotten.

It is worthy of note that after beating or other violence children and women may commit suicide from shame. Again, as Tardieu says, many have hung themselves while partially intoxicated, and it is likely that some such have just previous to the suicide met with falls or other accidents which have left marks like those of violence. He also records the case of a woman who fastened a cord to a bed-post, put her head in a noose while kneeling on the bed, and made a deep wound in her arm with a razor. She closed the razor, laid it aside, and fainted from loss of blood. She must then have fallen forward and died from the pressure of the cord on her neck.[881]

=Homicidal= hanging is rare but does occur. Where the hands are tied together; where the injuries produced by the cord are severe; where there are contusions and well-marked ecchymoses; where the laryngeal cartilages and hyoid bone are fractured or the cervical vertebræ dislocated or fractured; or where the carotids are injured or there is hemorrhage into their walls; where there are severe wounds, the hemorrhage from which would be sufficient to threaten syncope; where there are many marks of violence on the body; where there is evidence of a severe struggle—in all these cases murder may be reasonably suspected. The number, situation, extent, and direction of must be carefully noted and weighed. If these are out of proportion to the ligature, the suspension, etc., they strongly suggest homicide, although they may occur in suicide (see Cases 4, 11, 18, 20, 28, 29, 44, 52, 55, 59, 66).

Homicidal hanging may be committed by an assailant who is strong on a subject who is weak, on a child, a woman, an old person; on one stupefied by liquor or narcotic poison; or by many combined against one person.

Cases are reported where injuries were inflicted or poison given, and the subject was afterward hanged to avert suspicion. Most of these cases are those of murder either by strangulation or suffocation (Cases 64, 65, 67, 68, 69, 70, 74).

Sometimes hanging is =accidental=. Children and even older persons play at hanging successfully. Taylor mentions the case of a boy who witnessed a hanging and afterward tried the experiment himself to ascertain the sensation, and caused his own death.

Tardieu[882] relates the case of a man, T., age 37, of small stature, feeble constitution, very thin, of sinister face, eyes hollow but lively, cunning nose and mouth, who meeting a man aged 81, learned that he had some trouble with his leg and promised to cure him. The old man lived alone. T. told him to buy a strong cord as thick as his little finger and one and one-half yards long, and keep the whole thing a secret. T. would see him at his room at 7 P.M. The old man became suspicious and had T. arrested. The investigation showed that already T. had made away with three old men by hanging, who were known to be opposed to suicide. Their bodies showed no trace of violence. Two others had escaped when the cord was passed around their necks.

Tardieu gives a number of cases of suicidal hanging which were falsely attributed to criminal violence, in which the pressure of public opinion joined to circumstances improperly explained by inexpert physicians caused deplorable judicial errors.

ILLUSTRATIVE CASES.

SUICIDE.

1. Harvey: Indian Med. Gaz., 1876, xi., p. 2.—Man, age 30. Found hanging by turban to bars of cell door; slip-knot around neck; heart beating feebly; died in about a minute after being cut down. “The point of suspension was forty-seven inches from the ground, the position of the noose twenty-eight inches, and the feet were forty-two inches away from the door supported on the toes.” Experiment showed that the turban could not have borne the full weight of the body. He died from strangulation.

2. Ibid., p. 3.—Insane man, age 60. Put his neck in a V-shaped fork of a tree and let his body swing. A broad abrasion found on each side of neck. Scalp, brain, and membranes much congested; reddish serum in lateral ventricles; two ounces clear fluid in pericardium. Lungs congested; all the heart cavities contained blood.

3. Ibid., p. 5.—Woman, age 28. Two marks of ligature on neck; one deep and circular passed up behind left ear; the other passed from the circular mark behind, crossed it on either side under lower jaw, thence up to chin. Appeared at first to be a case of strangulation following hanging; but the two marks were finally explained, that after the body was taken down it was ordered up again until the police should arrive.

4. Ibid., p. 5.—Man, age 45; first cut his throat and then hung himself. “He had probably only just had time to hang himself before dying.”

5. Ibid., p. 30.—Woman; hung herself with a twisted cloth. There was much ecchymosis about the neck and upper part of chest; lungs much congested; fibrin clot in left mitral orifice; liver, spleen, and stomach congested; transverse ligament of atlas ruptured.

6. Ibid.—Man, age 39. Distinct mark of cord around neck; no other mark of violence; laceration of larynx and dislocation of odontoid process; hands clinched; involuntary discharge of semen; thoracic and abdominal organs normal.

7. Ibid.—Man, age 70. Mark of cord around the neck, superficial in front, deep behind; second cervical vertebra dislocated; tongue slightly protruding; fingers clinched; meningeal vessels engorged; lungs tubercular, congested; right heart contained a little coagulated blood.

8. Ibid.—Sex and age not given. Found hanging on a tree; usual signs; odontoid process fractured; rope in a double noose without knot, a common dooree, such as is used for drawing water.

9. Ibid., p. 32.—Man, age 50. Face livid, eyes red and protruding; teeth clinched; lower jaw retracted; tongue behind the teeth; hands and feet contracted; anus covered with fæcal matter; circular depressed mark of cord around neck, hard as parchment, slightly ecchymosed along edges; some infiltration of blood in connective tissue beneath the cord; some tearing of soft parts; laryngeal cartilage displaced. Brain and membranes congested. Right cavities of heart distended with dark blood. Trachea congested.

10. Hurpy: Ann. d’ Hygiene, 1881, vi., pp. 359-367, with illustration.—Woman, age 77, suicided by hanging in the following way: a short cord was fastened by one end to a table leg; the other end was around her neck; she lay on the floor, face downward, clothing not disordered. The brain was congested; lungs congested and emphysematous; left side of heart empty (see Fig. 23).

11. Champouillon: Same journal, 1876, xlvi., p. 129.—Man, age 62; first tried to suffocate himself with charcoal smoke and then hung himself, but the rope broke and the body fell. He lived two days.

12. Pellier: Lyon thesis, 1883, No. 188, p. 72.—Boy, age 16, hung himself; rope broke; he was resuscitated; reddish circular furrow on neck, not like parchment; he had erection and ejaculation; buzzing in his ears and flashes before his eyes.

13. Lacassagne: Pellier thesis (supra), p. 71.—Man; hung himself; was cut down and sent to hospital; was aphonic for four days; then a severe bronchitis set in, and at the end of a week a gangrenous expectoration. The mark of the cord lasted fifteen days.

14. Maschka: Archiv. de l’anthrop. crim., Paris, 1886, i., pp. 351-356.—Man, age about 60, found dead under a tree in the woods near Prague. No sign of violence. A cord thick as a sugar-loaf around the neck; another cord attached to a branch of the tree. There was at first a strong suspicion of violence, but the conclusion reached was that he had hung himself and that the body had fallen from breaking of the cord; that death was due to asphyxia was shown by the furrow on the neck, the dark liquid blood, and the congested lungs. There was no infiltration below the furrow in the neck, and no lesion of larynx. The man had shown signs of melancholy.

15. Friedberg: Virchow’s Archiv, 1878, lxxiv., p. 401.—Suicidal hanging. Examination twenty-eight weeks after death. The front of the neck showed a groove above the larynx, firm and of gray color; ecchymosis in subcutaneous tissue.

16. Bollinger: Friedreich’s Blätt. f. ger. Med., 1889, xl., p. 7.—Man, age 48; found dead. Had made a ligature out of a night-gown and tied it around his neck, the other end around top of a low bed-post; his neck hung by the ligature placed below the larynx. Illustrated.

17. Med. Times and Gaz., London, 1860, ii., p. 39.—Woman; had collected accounts of celebrated persons who had been hanged; finally hanged herself.

18. E. Hoffman: Mitt. d. Wien. Med. Doct. Colleg., 1878, iv., pp. 97-112.—1st. Woman, age about 25; found dead sitting in bed, a handkerchief around her neck fastened to the bed-curtain. The police thought she had been killed and then hung, but the physician concluded that she had committed suicide. An examination of the stomach showed that she had previously tried to poison herself with arsenic.

19. 2d. Woman, age 51; found hanging in half-lying position.

20. 3d. Man, age 50. First tried to kill himself with phosphorus, then sulphuric acid; finally hung himself in a half-kneeling position.

21. Müller-Beninga: Berlin. klin. Woch., 1877, xiv., p. 481.—Man, age 40; hung himself. There was no swelling of genitals and no soiling of clothing. Necroscopy showed death from asphyxia, and in urethra near meatus quite a quantity of seminal fluid, as shown by microscopical examination.

22. Tardieu: Op. cit., p. 18.—The Prince of Condé was found hanging in his room, August 27th, 1830. He was suspended by two handkerchiefs to a window fastening, his feet, however, touching the floor. The knot was at the back of the neck (as shown by the illustration), the face turned slightly to the left, the tongue protruding; face discolored; mucus at the mouth and nose; arms hanging and stiff; fists shut; heels raised; knees half bent. The text says that the knot was nearly under the right ear, but the illustration shows a different position (see Fig. 22, p. 743).

23. Allison: Lancet, 1869, i., p. 636.—Three cases of suicide by hanging, in which there was no mark: 1st. Woman, hung herself with a piece of sheep-net band; cut down before death. 2d. Man, hung with plough-string; cut down in about six minutes. 3d. A heavy man.

24. Tardieu: Op. cit., pp. 93-105.—Woman, died of coma and asphyxia from suicidal hanging, according to report of Drs. Costan and Facieu. Tardieu approved their report. It was at first thought a case of homicide with subsequent hanging, more especially because of the kind of knot used, nœud d’artificier. But Tardieu showed that it was also a nœud de batalier. Her feet touched a chair, and her knees were bent. There was a neckcloth in front of her mouth, but it did not seem to have interfered with respiration.

25. Ibid., pp. 67-72.—The famous case of Marc-Antoine Calas, who committed suicide by hanging (see Voltaire, “Traité sur le tolérance,” etc., in Nouv. Philos. Histor., 1772, xxxii., p. 30). He hung himself to a door. No sign of violence. The city hangman said it was impossible for a man to commit suicide in that way. The father was accused and convicted of homicide. Tardieu shows that the act was a suicide.

26. Ibid., p. 72.—Another famous case. A woman, age 30, hung herself to the key of her bedroom door. Her husband cut her down. He was accused and convicted of the crime and condemned to prison, where he died. Tardieu showed that the case was one of suicide.

27. Hofmann: Wien. med. Presse, 1880, xxi., p. 201.—Man, age 68, suicide by hanging. There was profuse hemorrhage from both ears.

28. Ibid.: 1878, xix., pp. 489-493.—Woman, found dead sitting in bed. She first tried to poison herself with arsenic, then hung herself.

29. Ibid.—Man, tried to poison himself with phosphorus and sulphuric acid, then hung himself. There was a transverse rupture of the sterno-cleido mastoid muscle and suffusion in its sheath.

30. Maschka: Wien. med. Woch., 1880, xxx., pp. 714, 747, 1075.—Man, age 63. It was at first a question of suicide by hanging or homicide by strangling. He concluded that it was the former.

31. Ibid.—Also man, age 58. Similar case. Same opinion.

32. Ibid. 1883, xxxiii., pp. 1118-1120.—Woman. age 23. Question whether she committed suicide by hanging or was strangled and then hung. Opinion, that it was a case of suicide.

33. Hofmann: Allg. Wien. med. Zeit., 1870, xv., pp. 192-214.—Man, age 60. Suicide by hanging or homicide; opinion, that it was the former.

34. Van Haumeder: Wien. med. Woch., 1882, xxxii., pp. 531-533.—Suicide by hanging or homicide. There were many wounds in the head; these occurred during the delirium of typhus.

35. Maschka: “Sammlung gericht. Gutacht.,” etc. (Prag), Leipzig, 1873, p. 137.—Boy, age 9; found dead in sitting position. Injuries on neck and elsewhere. Question, had he hung himself or been choked? Were the injuries inflicted before or after death? Opinion, suicide.

36. Ibid., p. 144.—Boy, age 13. Found hanging in sitting position. Question whether murder, suicide, or accident. Opinion, suicide.

37. Ibid., p. 149.—Woman, age 60; found hanging, sitting position. Suicide or homicide. Opinion, suicide.

38. Ibid., p. 156.—Woman, age 30; found hanging. Opinion, suicide.

39. Ibid., p. 165.—Man, age 63. Suicide by hanging, or homicide by strangling? Opinion, suicide.

40. Berliner: Viert. f. ger. Med. und öff. San., 1874, xx., pp. 245-253.—Woman, age 30; found hanging. Opinion, suicide.

41. Deininger: Friedreich’s Blät. ger. Med., 1884, xxxv., pp. 47-59.—Woman, age 61; found hanging. Opinion given, suicide.

42. Mader: Bericht d. k. k. Rud. Stift., Wien. (1875), 1876, p. 378.—Woman, age 43; tried to hang herself. She was at once cut down, bled, and taken to hospital unconscious. Next day, face red; pulse and temperature normal. Third day, conscious and could speak, but not aloud; tongue twisted and turned to right; paralysis of right hypoglossal nerve. Uvula drawn to left. Skin of right limb felt “furry.” Applied electricity and gave strychnine; phonation was more distinct during the use of the battery. Two months later she was still aphonic, but the vocal cords were in better action. The right hemiparesis was lessened.

43. Grant: Lancet, 1889, ii., p. 265.—Man, age 48; found sitting against a door, hung to the knob by a handkerchief.

44. White: Lancet, 1884, ii., p. 401.—Woman, age 53, insane. Made several attempts at suicide; once with a stocking around her neck, once with an apron; the last time by fastening a portion of her dress to a ladder. She was quickly cut down, cold affusion applied, and artificial respiration (Sylvester). The eyes were prominent and glassy, pupils widely dilated, no reaction to light; conjunctivæ insensitive; lips livid; tongue swollen and pale; face pale; oblique depressed mark on neck, most marked on left side; skin cold; no pulse; no heart-beat recognizable; no respiration; no reflex action. Galvanism failed to arouse any muscular action. The details are too numerous to give all of them. There was reduplication of heart-sounds for several days, due to interference with pulmonary circulation. She recovered both bodily and mental health.

45. Richards: Indian Med. Gaz., 1886, xxi., p. 78.—Man, age 20; suicide; was cut down and lived for four days.

46. Kite: Univ. Med. Mag., 1888-89, i., p. 475.—Man, age 69; suicide.

47. Terrier: Prog. Méd., 1887, vi., pp. 211-214.—Two men, age 29 and 25, insane. Attempted suicide by hanging. Both resuscitated.

48. Nobeling: Aertz. Intellig.-bl., 1884, xxxi., p. 213.—Two suicides by hanging; men, ages 24 and 40.

49. Ritter: Allg. Wien,. med. Zeit., 1886, xxxi., p. 375.—Soldier, found hanging. Cut down in ten minutes. Artificial respiration applied; fifteen minutes later, an effort at respiration; face changing from blue to white and then to red; pulse small, irregular; still unconscious; mark of ligature distinct; a few hours later had a maniacal seizure; gave morphia hypodermically and he slept; was also aphonic. Gradually recovered and returned to duty.

50. _Strassmann: Viert. f. ger. Med., 1888, xlviii., pp. 379-381._—Three cases of suicidal hanging in men, ages 27, 37, and 40. The last was found kneeling.

51. Balta: Pest. Med. Chir. Presse, 1892, xxviii., p. 1244.—Man, age 45-50; hanging; suicide. Thyroid cartilage and hyoid bone broken.

52. Hackel: Op. cit., p. 35.—Man, found hanging to a beam by a sheet. Had previously tried to choke himself with his hands.

53. Ibid.—Two cases of suicidal hanging where the cord made no mark. In the first the body hung free; in the second the body was partly supported. In the first there was no rubbing of the skin; in the second the body was soon cut down.

54. Freund: Wien. klin. Woch., 1893, vi., pp. 118-121.—Man, found hanging; cut down, but could not be resuscitated. Ligature between hyoid bone and larynx, then crossed over itself about middle line of neck, passed up along each side of face, knotted above the head, then thrown over a beam, and on the other side the loop was caught between his legs.

55. Hoffman: Op. cit., p. 525, illustrated.—Case communicated by Dr. Rosen, of Odessa. Man, age 21, and woman, age 17, hung themselves by same ligature thrown over an open door, one of them on each side. They had previously tried other means of suicide without success (see Fig. 24).

56. Ibid., p. 530.—Man found hanging by handkerchief to branch of tree but sitting on the ground. Mark of handkerchief superficial and pale. When the necroscopy was made the mark had disappeared. Also a similar suicide where there was no mark at all.

57. Ibid., p. 541.—Man found hanging to a window. Another man cut the cord and the suspended one fell into a cellar, fracturing his skull.

58. Ibid.—Man found hanging; cut down; the fall caused rupture of liver.

59. Ibid., p. 539.—Drunkard hung himself; there was evidence that he had previously injured himself during his drunkenness.

60. Ibid.—Boy hung himself because he had been punished by the schoolmaster. There were marks on his back and lower limbs from the punishment.

See also Taylor, “Medical Jurisprudence,” pp. 451-452; Tidy, “Medical Jurisprudence,” incomplete hanging, Cases 33 to 36 and 62; Hofmann, “Lehrbuch,” p. 538.

HOMICIDE.

61. Harvey: Indian Med. Gaz., 1876, xi., p. 3.—Woman, age 20, feeble. Her mother-in-law had kicked her; she probably had fainted; supposing her to be dead, the husband hanged her to a tree within half an hour after the supposed death. Autopsy: No marks of injury; oblique mark of cord on right side of neck; tip of tongue between the teeth; face somewhat livid; right side of heart full of dark blood; lungs congested posteriorly.

62. Ibid., p. 4.—Woman, age 38. Rope close under the chin passed upward behind the ears. Head bent on chest. Large wound above clavicle. Under the rope was a depression (made after death) but no hemorrhage. Much blood in abdomen and a hole in the liver. Kidney bruised and blackened. Right lung torn through; blood in pleuræ. Wounds were supposed to be gunshot, but the husband confessed that he had thrust a sharp solid bamboo into her body and afterward hung it up. She died of hemorrhage.

63. Rehm: Friedreich’s Blät. f. ger. Med., 1883, xxxiv., pp. 332-362.—Man, age 73; first roughly maltreated; afterward hung.

64. Tardieu: Op. cit., p. 125.—Woman found hanging in her room. Circumstances indicated homicidal strangulation and that the hanging was done to avert suspicion. Post-mortem examination showed the base of the tongue ecchymosed, and ecchymosis extending up to the soft palate; mucous membrane of pharynx congested; connective tissue and mucous membrane between hyoid bone and larynx congested posteriorly; epiglottis showed slight ecchymosis, mucous membrane red. These ecchymoses were not caused by the cord, for the latter was placed below the hyoid bone and this bone was not broken. There were also marks on the collar-bone like the mark of two hands.

65. Ibid., p. 124.—Girl, 15 years old. Body found hanging. Post mortem showed beyond doubt that she had been violated, then strangled, then hung. Her head showed many ecchymoses from either the fist or the foot; blood flowing from left ear. Brain slightly congested. Tongue between teeth, bitten and bloody. On front of neck were two marks: the lower were impressions of fingers close together, nearly uninterrupted, and which had bruised, flattened, and tanned the skin, which here was dry, hard, and horny. This lesion was above the intraclavicular notch and extended toward the sides of the neck with regularity of curve and neatness of imprint, evidently made with the right hand. Above the first furrow under the skin was a kind of track, less extended, more regular, a bruising of the same nature as the preceding, but continued, due to the pressure of the index finger and thumb of left hand. A little below the jaw was a livid place on the skin, which was otherwise unaffected by the ligature. There was nothing to indicate a circular action of the ligature. Froth in larynx and bronchi. Lungs apparently normal. Food had passed from stomach into œsophagus and air-passages.

66. Ibid., p. 122.—Woman found hanging in her room, and was resuscitated. She stated that the man who lived with her had tried to strangle her and then hung her. Tardieu saw her in hospital. Respiration short and embarrassed; pains in neck and jaw. Found narrow, circular, sinuous, horizontal, uninterrupted line around the neck below thyroid cartilage; line everywhere equal, deep, and three to four mm. wide; the skin excoriated and covered with thick crust. Below this were several superficial excoriations. There were many contusions on other parts of the body. Tardieu concluded that the mark on the neck was from attempt to strangle; the wounds elsewhere to prevent resistance. She had at the time pulmonary consumption. She died of this disease aggravated by the assault.

67. Ibid., p. 106.—The Duroulle affair. Woman found hanging. Presumption of homicide; arrest of husband; acquitted. She was found with her face to the floor, one end of a cord around her neck; another similar cord attached seven feet above to a rafter, over which it passed three times. Bidault and Boulard reported it a suicide. The results of the post mortem were as follows: Skin of a red-violet color; face swollen; eyes prominent and congested; conjunctivæ a vinous red; lips violet; tongue swollen, tip between teeth; froth in air-passages; lungs congested; brain congested; blood fluid. Circular depression around neck with congestion of skin above and below; ecchymosis in subcutaneous tissue on level of angle of jaw and about one centimetre in size, supposed to correspond to the knot. Tardieu reported that the marks rather resembled those of strangulation than hanging; the ecchymoses were more like those produced by the hand over the mouth. The marks on the face supposed to have been made by a supposed fall of the body were by him considered to have been caused by violence. He believed the woman had been strangled and then hung.

68. Ibid., p. 130.—The Daugats affair. Man found hanging, sitting on the ground, head and trunk somewhat inclined to the left; legs stretched out; clothing not disordered; the part of the cord which was around the neck was applied to the neck of the waistcoat and shirt; on his head a woollen cap. The ground had been recently swept. Necroscopy twenty-four hours afterward. Face pale; right eye open and prominent, left closed; mouth closed, contained food apparently from the stomach; tongue retracted; slight mark on neck under which the tissue was normal: atlas dislocated on axis, but tissues around were normal; no lesion in spinal canal; penis not erect; moisture having the odor of urine on the shirt; large ecchymosis and infiltration of left cheek; extensive contusions on scrotum, with hemorrhagic infiltration, especially around right testicle. Veins of head engorged with black fluid blood. Brain normal. Some black fluid blood in right cavities of heart, left side empty. Lungs black. Other organs normal. Causse and Orfila concluded that the man had been suffocated and then hung. The wife and son confessed that they had injured the testicle through the pantaloons; he then fainted; they then suffocated him with the woollen cap placed over the mouth and nose; the son kneeled on the man’s belly, the body was then hung up and the head violently twisted.

69. Passauer: Viert. f. ger. Med. und öff. San., 1876, xxiv., pp. 26-49.—Woman found hanging in a kneeling position. The ligature on the neck was loose. The necroscopy showed the following: Tongue between the teeth; eyelids swollen and livid; livid spots on face and left ear; lower lip torn; a number of marks on neck; one red stripe not sharply limited; skin not parchmenty and no ecchymosis; ecchymoses of scalp; periosteum of skull reddened; hemorrhage in temporal muscle; brain and pia mater congested; much fluid in ventricle. Larynx and trachea dirty red-brown; right side of heart empty; a little dark fluid blood in left; great vessels, including aorta, containing much dark fluid blood. Lungs congested and œdematous. Liver, spleen, and kidneys congested. Opinion given that she died of asphyxia and was either choked or hanged. Reference to Royal College of Medicine, Königsberg, where the opinion was given that she died of injuries on head and neck and was afterward hanged.

70. Becker: Same journal, 1877, xxvii., pp. 463-473.—Woman, age 52; found hanging. Death caused by shock and incipient asphyxia from strangulation and probably the wounds on head and limbs.

71. Maschka: “Samm. gericht. Gutacht.,” etc. (Prag), Leipzig, 1873, published a number of interesting cases, in each of which there was a question raised as to the cause of death.

72. Ibid., p. 127.—Man found dead. Had he been strangled or hung, or had he died some other way? Opinion, death from paralysis of the brain.

73. Ibid., p. 133.—Woman, age 42; found hanging; a mark around her neck. Did she hang herself or die of other injuries? Opinion, died of other injuries.

74. Rehm: Friedreich’s Blätt., 1883, xxxiv., pp. 322-362.—Man, age 73; found hanging. Opinion, while weak, sick, and suffering from wounds inflicted by his own son, he was hanged by his daughter-in-law.

75. Hofmann: “Lehrbuch,” p. 538.—A father hung his five children, the eldest 9 years. Another man hung two children, the eldest 13 years.

See also Tidy, “Med. Juris.,” Cases 40, 48, 51, 57(?), 58(?); “Hanging after Death,” Case 50.

JUDICIAL HANGING.

76. MacLaren: Indian Med. Gaz., 1873, viii., p. 234.—Three cases of judicial hanging; hung at the same time and cut down and necroscopy begun forty minutes afterward; drop twelve inches. In the first and third there were reflex movements for a few minutes after drop fell. First man, age 40; pupils slightly dilated; no protrusion of tongue or eyeballs; mark of cord above thyroid cartilage; no discharge of semen or fæces; ecchymosis under cord, left side; dislocation of atlas from axis; odontoid ligaments ruptured; transverse ligament uninjured. Brain and membranes much congested; clear fluid in lateral ventricles. Lungs collapsed, anæmic; one ounce straw-colored serum (measured) in pericardium; dark fluid blood in both ventricles of heart; liver much congested.

77. Second man, age 16; pupils widely dilated; eyeballs protruding. Marks of cord same as in preceding case. No discharge of fæces or semen. No ecchymosis under cord; dislocation and rupture of ligaments between axis and third vertebra. Brain did not show well-marked congestion. Lungs collapsed and anæmic. One and one-quarter ounces serum (measured) in pericardium. Heart normal; dark blood in both ventricles; liver normal.

78. Third man, age 20; pupils slightly dilated; eyeballs and tongue not protruded. Marks of cord as in preceding. No discharge of fæces or semen. Slight ecchymosis under cord; mark in front of neck. Dislocation of occipital bone from atlas. Brain and membranes much congested. Lungs collapsed and anæmic. Half ounce serum in pericardium. Heart normal; dark fluid blood in both ventricles; liver normal.

79. Cayley: Ibid., p. 122.—Man, age 35; executed by hanging. Scarcely any convulsive movements after drop fell. Necroscopy two hours afterward. No congestion or protrusion or swelling of the tongue; no muscular rigidity or contractions. About half-way around the neck was indentation of cord, obliquely directed; hardly perceptible in front; its surface appeared rubbed and compressed; no discoloration; no ecchymosis under skin. Cord lay across upper part of thyroid cartilage. Larynx and trachea not injured. Fracture and dislocation of upper cervical vertebræ. Lungs collapsed, not congested. Pericardium empty; heart distended, left side with red blood just beginning to clot; right side with fluid black blood. Liver and other abdominal organs much congested. No discharge of fæces or semen.

80. Garden: Same journal, 1880, xv., p. 12.—Man, age 40, weight about one hundred and twenty pounds; drop two feet; was in a fainting condition, and had to be supported; was not probably fully conscious when platform fell. There were spasmodic retractions of arms and legs for about two minutes; forty seconds after the drop his jungeas fell off; his penis was in strong erection, and the ejaculatory movements were seen. Necroscopy one and one-quarter hours after drop fell. Head and limbs cold; eyes open, natural; tongue not protruding; fingers clinched; superficial veins contained fluid black blood. Mark of cord extended from just below left mastoid process, where the knot was applied, across the thyro-hyoid membranes to a place on right side about two inches below ear. There was scarcely a trace of it behind. Skin dark and ecchymosed, but no ecchymosis of subcutaneous connective tissues. No discoloration nor fracture in neck. Subarachnoidal fluid in excess; puncta vasculosa unusually numerous. Under surface of epiglottis reddened and showed two small dark red ecchymoses; mucous membrane of larynx and trachea pale. Lungs showed venous congestion; no infarctions or small ecchymoses; right lung emphysematous; the left showed old firm adhesions throughout. Heart large, flabby, pale, a very little blood in each ventricle; subpericardial ecchymosis one-fourth inch square anteriorly, another larger one posteriorly; extensive pericardial adhesions. Liver and kidneys congested.

81. See two cases of judicial hanging by Wilkie, same journal, 1881, xvi., p. 275.

82. Porter: Archiv. Laryngol., New York, 1880, i., p. 142.—Redemier hung. Drop five feet. Pulse beat rapidly a few minutes, then lessened in frequency and stopped beating in fifteen minutes. During this time there was violent spasm of muscles of thorax and upper limbs. Necroscopy, dark groove around neck crossing larynx just below pomum Adami. Brain congested. Lungs emphysematous. Cricoid cartilage fractured diagonally. Laryngeal mucous membrane showed ecchymosis and œdema. Vertebræ neither fractured nor dislocated.

83. Another criminal hung at the same time had dislocation of cervical vertebræ.

84. Fenwick: Canada Med. Jour., 1867, iii., p. 195.—Man executed; drop six feet; second cervical vertebra torn from attachment to third; medulla torn across; hyoid bone and tongue torn from thyroid cartilage; general congestion of viscera; lenses normal; eyes congested; clot between sclerotic and choroid coats left eye.

85. Dyer: Trans. Amer. Ophthal. Soc., 1866, p. 13.—Man, age 24; weight one hundred and seventy-four and a half pounds; drop three feet; knot under left ear; for two minutes at intervals, slight motion of abdomen, like effort at respiration, and at same time knees drawn up a little. Death speedy and quiet. Cut down at end of thirty minutes. Necroscopy thirty-five minutes after drop. Body and head moist and warm; emission of semen; face livid; upper lid discolored; abrasion of skin under right ear; deep red mark around neck. Eyeballs not prominent; eyelids closed; corneæ dull; pupils a little dilated. Both lenses fractured. Brain normal; spinal cord normal. Heart empty.

86. Dyer: Same Trans., 1869, pp. 72-75.—Man hung. One eye showed fracture of lens, the other lens showed fine lines. A second case showed dislocation of a cataractous lens. A third showed fissure of lens.

87. Green: Same Trans., 1876, p. 354.—Man hung; drop seven or eight feet. Died quietly and without struggle. One-half to one hour after drop fell, eyes were examined. No lesion of capsule or lens.

88. Keen: Amer. Jour. Med. Sci., 1870, lix., p. 417.—Two criminals hung; drop five feet. Hyoid bone fractured in one; no fracture of vertebræ in other.

89. Clark: Boston Med. and Surg. Jour., 1858, lviii., p. 480.—Execution of Magee. Man, age 28; weight 130 pounds. Drop seven to eight feet. No struggle nor convulsion. Urine discharged at once. Seven minutes after drop fell, heart-beat one hundred; nine minutes, ninety-eight; twelve minutes, sixty and fainter; fourteen minutes, not audible; twenty-five minutes, body lowered. Face purple; pupils dilated; eyes and tongue did not protrude. Mark of cord just above thyroid cartilage, a deep oblique furrow except a small space under left ear; knot over mastoid process. Forty minutes, cord and strap removed; body, especially face, became paler. Necroscopy a little over an hour after drop fell. Body pale; skin mottled; small ecchymosis just above line of cord right side. Right sterno-mastoid muscle torn. Hyoid bone fractured; spine not injured. No seminal discharge. Ninety minutes, pulsation in right subclavian vein; heart-beat, eighty per minute; thorax opened, heart exposed; right auricle showed full and regular contractions and dilatations. The spinal cord was then divided. One hundred and twenty minutes, heart-beats forty per minute. These pulsations of right auricle continued at intervals for three and a half hours longer; readily excited by point of scalpel. Heart normal; left ventricle contracted; right ventricle not so; no coagulation. Brain normal; lungs collapsed; liver and spleen congested; mucous membrane of small intestine pinkish; other organs normal. In the discussion, Dr. Gay thought the absence of cerebral congestion was due to the circulation continuing in the left carotid.

90. Hofmann: Wien. med. Woch., 1880, xxx., pp. 477-480.—Man, a criminal, hung; after hanging ten minutes, the body was cut down. Examination half-hour after drop fell. He was resuscitated and partly regained consciousness, but died three days afterward of œdema of lungs after repeated severe convulsions. He had tumors of the neck which probably interfered with the compression of the trachea. See also Allg. Wien. med. Zeit., 1880, xxv., p. 161, and Wien. med. Blät., 1880, i., pp. 423-430; translated in Ann. Mal. Oreill. and Larynx, Paris, 1880, vi., pp. 99-112.

91. Kinkhead: Lancet, and 701-703.—Cases of hanging. In one, the body of the third cervical vertebra was broken across and the two pieces separated; in another case dislocation of second and third cervical vertebræ.

92. Nelson: Southern Clinic, 1885, viii., pp. 198-202.—Two colored men hung; drop five feet. In one there was atlo-axoid dislocation.

93. Dercum: Phila. Med. Times, 1886-87, xvii., p. 368.—Description of the brain of a man executed by hanging.

94. Kirtikar: Trans. M. and P. Soc., Bombay, 1885, vi., pp. 104-107.—Man, age 25, and woman, age 35. Both hanged. Drop nine feet. Knot tied over cricoid cartilage, a little to left side. In falling, the knots slipped to below the ear. There was fracture of the body of third cervical vertebra and rupture of ligaments. The cord was ruptured in each; in the woman in two places—once at the third cervical, the other at the dorso-lumbar junction.

95. Lamb: Med. News, Philadelphia, 1882, xli., pp. 42-45.—Execution of Guiteau. Drop six feet; knot placed under left ear, but slipped to back of head. Yellowish furrow a few lines wide around the neck, directed downward and forward. Sterno-mastoid muscles torn transversely about midway of their length. Thyro-hyoid ligament ruptured; hyoid bone and thyroid cartilage widely separated. Large blood-vessels not injured. No fracture or dislocation of vertebræ.

96. Thomson and Allen: Catalog. Surg. Sec. Army Med. Mus.; specimens 298 to 302.—Execution of Wirtz. Rope one-half inch diameter; drop five feet; knot under left ear. Several slight shrugs of shoulders, after which body was quiet; let down in fifteen minutes. No involuntary evacuation. Face pale, placid. Eyes partly open; pupils dilated; slight injection of conjunctivæ. Mouth open; tongue not protruding. Just above thyroid cartilage extending on right side from median line in front to spinous process was a dirty brown deep furrow with congested walls; on left side a line of discoloration due to direct action of rope. Soft parts above and below the line much swollen, particularly on right side. Larynx and hyoid bone unnaturally mobile. Right trapezius muscle torn; sterno-mastoid divided transversely, leaving an interval of two inches. Slight ecchymoses between muscle and larynx. Ecchymoses on ligamentum nuchæ. Hyoid bone, both greater cornua fractured and dislocated from body; lesions more marked on right side. Several small ecchymoses in vicinity. Larynx not injured. Brain normal. No bloody or frothy mucus in air-passages. Lungs not congested. One drachm of straw-colored serum in pericardium. Heart empty. Abdominal organs normal. Bladder somewhat distended with urine.

See also Tidy, “Med. Juris.,” Cases 1 to 4 and 60.

ACCIDENT.

97. Harvey: Indian Med. Gaz., 1876, xi., p. 3.—Boy, age 1½ years; was swinging by two ropes attached to two posts; the ropes became twisted around his neck. Necroscopy showed mark of very small rope in front of neck from ear to ear; mucous membrane of larynx dark; lungs much congested.

98. Hackel: Op. cit., p. 35.—Man, age 19, sitting on a load of wood, with the lines around his neck, fell and was hung by the lines.

99. Biggs and Jenkins: New York Med. Jour., 1890, lii., p. 30.—Case 16; child, 6 months old, sitting on a high chair, fell between the chair guard and seat and was asphyxiated by compression of neck.

See also Tidy (op. cit.), Cases 53 and 54.

SUFFOCATION.

The term suffocation is applied in a special sense to the act and condition of preventing access of air in other ways than by pressure on the neck, as by pressure on the chest, by obstruction at the mouth or nose, by obstruction in the air-passages or on them from neighboring organs, by irrespirable gases, etc.

This article will consider all of these except drowning and irrespirable gases, which are treated of elsewhere by other writers.

=Smothering= is generally understood to mean the act and effect of stopping the mouth and nose.

CAUSES.

=External Causes.=—OVERLAYING is a frequent cause of suffocation in infants, which in such cases have usually occupied the same bed with one or both parents. In some cases the parents have been drunk or otherwise unable to prevent the injury, and the infant may also be partly stupefied with the alcohol derived from its mother’s milk. Infants are also sometimes overlaid by domestic animals. Again, they have been suffocated by being pressed too closely to the mother’s breast, or by covering with bedclothes, shawls, etc. Noble[883] attributes some cases of asphyxia in the new-born to anæmia of the brain from pressure on the skull by forceps, etc., and recommends as treatment for this condition hanging the child head downward, so that the blood may gravitate to the brain (Cases 12 and 30).

Infants are sometimes smothered for mercenary purposes.

Persons have been suffocated by the pressure of a crowd. Pressure on the chest combined with forcible closure of the mouth and nose was the method of Burke and Williams, in the notorious burking murders (Case 58). The close application of a hand, cloth, or plaster over nose and mouth is of itself sufficient to cause suffocation, especially in children and feeble persons. Pressure on the abdomen crowds up the diaphragm and interferes with breathing. It is very likely that no external mark will be found in cases of pressure on the chest and abdomen, but the lungs will be marbled and emphysematous.

Taking plaster casts of the face and neck without inserting tubes in the nostrils has caused death in some cases. Suffocation often follows the falling of walls, houses, banks of earth, piles of coal or corn or wheat. One may fall into and be imbedded in some mobile substance as coal, wheat, corn, quicksand, or nightsoil, and be suffocated. Infants have been destroyed[884] by burying them in manure, ashes, bran, etc. In these cases there is not only the entrance of the foreign body into the air-passages, but the pressure of the mass against the chest and abdomen.

=Internal Causes.=—The air-passages may be closed up by foreign bodies within them, or within adjoining organs, especially the œsophagus. A great variety of substances in one of these two ways has caused suffocation: mud, cotton, rags, corn, meat, beans, pepper, potato skins, the fang of a tooth, artificial teeth, buckles, shells, flint, buttons, screws, crusts of bread, bones, fruit, stones, heads of grass, coins, slate pencils, nuts, nut-shells, shot, penholders, worms, fish, etc. (see Cases 6 and 55). Taylor[885] states that there were eighty-one deaths in one year in England and Wales from food in the air-passages.

Should an inspiration occur in the act of vomiting, the vomitus may pass into the air-passages; a similar accident may occur in a person who attempts to swallow and speak at the same time. Infants have been suffocated by inspiring vomited milk. Fitz[886] states that food may pass from the digestive tube to the air-passages after death.

A case of suffocation in an infant by retraction of the base of the tongue is recorded. It has been stated that negroes have committed suicide by doubling back the tongue into the throat, or, as it is called, swallowing the tongue.[887] In giving anæsthetics, the subject being supine, and the head and neck somewhat flexed, the tongue, epiglottis, and soft palate may fall backward and suffocation may follow. Howard[888] states that pulling the tongue forward under such circumstances may reopen the pharynx, but will not lift the epiglottis. The thorax should be raised and head and neck extended backward. He believes that in giving anæsthetics the head should be lower than the shoulders. In order to avoid vomiting no food should be taken for some hours before the anæsthetic.

Cases are recorded of artificial teeth having fallen from the mouth into the air-passages during anæsthesia and sleep, and in epileptic and puerperal convulsions. It would appear advisable that these teeth should be worn only while eating (Case 13).

Hemorrhage from the lungs, from rupture of an aneurism or from injury of the mouth or throat, may make its way into the air-passages and cause suffocation. So also the bursting of an abscess of the tonsils or other part near the air-passages (Case 7).

Œdema of the glottis from scalding or other irritation of the fauces or glottis, or from disease of the kidneys; tumors pressing on some portion of the air-passages; rapid, profuse bronchial secretion in infants; acute double pleuritic effusion; cheesy glands ulcerating into trachea; simultaneous œdema of both lungs—all of these may cause suffocation (Cases 18 and 49). [For cases of enlarged thymus gland, see Hofmann, op. cit., pp. 587, 588.]

Paralysis of the muscles of swallowing, from diphtheria or other cause, predisposes to suffocation. Progressive asthenia in which the muscles are exhausted; injury of spinal cord or pneumogastrics; paralysis of muscles of respiration from the use of curare; the spasms of tetanus and strychnia poisoning; the entrance of air into the pleural cavities with collapse of the lungs—all tend to cause mechanical suffocation either by pressure or by paralysis (for deaths in epileptics, see Cases 1, 10, 11, 33, and 40).

It is not necessary that the air-passages should be absolutely closed to cause suffocation.

The cause of death is more likely to be pure asphyxia, because of the absence of the complicating pressure of the hand or ligature on the vessels and nerves of the neck, and of fracture of larynx or vertebræ.

=Symptoms.=—Foreign bodies[889] entering the trachea naturally fall toward the right bronchial tube instead of the left because of the size and position of the entrance of the right tube. If then but one tube is involved, the signs will usually be on the right side; whereas if the foreign body stop in the larynx or trachea, both sides will be affected. The latter condition is much more dangerous. The symptoms would be resonance over the lung with the respiratory murmur partly or wholly absent; less mobility; puerile breathing on the unaffected side. In either case there may at first be little disturbance, especially if the shape of the foreign body is such as not to greatly interfere with the access of air; otherwise there may be at once, and almost always will be after a time, more or less urgent dyspnœa. Diminution of the necessary oxygen may cause convulsions, apoplexy, and other brain symptoms. Acute emphysema of the portion of lung not obstructed may follow its forcible distention. The local effect of the foreign body is an irritation which causes spasm and cough. It may be carried upward by the expirations and downward again by each inspiration. Inflammation is likely to appear eventually and may involve the lung. If the obstruction is not complete there may follow periods of alternation of good and bad health, ending perhaps in recovery. The foreign body may be expelled after a greater or lesser interval. On the other hand death may result from secondary causes. In the absence of correct history the symptoms may lead to a wrong diagnosis and inappropriate treatment; as where a patient whose symptoms resulted from the presence of a piece of bone in the larynx, was treated for syphilis. A foreign body may be coughed up from the lung into the trachea and fall backward into the opposite lung.

Partial closure of the larynx, most likely caused by a flat or irregular substance, rather than globular, may cause gradual asphyxia with symptoms of apoplexy, making the diagnosis difficult.

When a foreign body remains a long time in the larynx, spasmodic cough and croupy breathing usually ensue, expectoration tinged with blood, hoarseness, or complete aphonia, pain, dyspnœa, possibly crepitation and dulness over the lungs. The case may end suddenly in death from closure of the glottis, or the foreign body may pass into the trachea and set up a new train of symptoms, or it may be expelled.

The frequency with which foreign bodies in the pharynx or œsophagus obstruct respiration, and the facility with which they may usually be removed, suggest a careful examination. Otherwise the patient may be treated indefinitely for supposed obstruction in the air-passages. Foreign bodies in the œsophagus have perforated into the trachea, and even the lungs, heart, and aorta.

In complete suffocation death will occur in from two to five minutes (see remarks under Strangulation). Death may also occur instantaneously.

The experiments of the Committee on Suspended Animation[890] showed that when the trachea of a dog was exposed, incised, and a tube tied in, the average time covered by the respiratory efforts after stopping up the tube with a cork was four minutes five seconds; the heart-beat stopping at seven minutes eleven seconds on the average. After four minutes ten seconds it seemed to be impossible for the dog, unaided, to recover. Faure[891] made the following experiment upon a large dog: He fixed a cork in the trachea. At first the dog was quiet; it then extended its neck, parted its jaws, and made efforts as if to vomit; then tried to walk, but its gait was uncertain; fell down and rose up. Its eyes became dull, and finally it fell down on its side, and became convulsed; then after several seconds stretched itself out. The thoracic movements were at first tumultuous, then became rapidly feeble; the heart beating very slowly. At the necroscopy the lungs filled the thorax, were full of thick dark blood and emphysematous. The blood was black and fluid in the left ventricle and arteries, and in the right cavities and veins resembled molasses. Liver darkly congested. There was no mucus in the trachea and no ecchymosis in the lungs. He also (p. 306) tried the experiment upon a large dog of fastening boards against its thorax and tightening them by means of cords. For some minutes it was quiet, but suddenly it became much agitated, stood upon its hind legs, threw itself against the wall, rolled on the ground, and uttered frightful cries; finally fell on its side. There was no movement of the thorax, but the muscles of the neck and belly were in full and rapid action, dry and sonorous râles were heard, and a large quantity of mucus appeared at the nose and mouth. The movements grew feebler, the respirations infrequent, and at the end of thirty-four minutes it was dead. The necroscopy showed the blood black and thick; heart relaxed; lungs red, a little emphysematous, containing but little blood, and on their surface were blackish points and small red spots.

The death of Desdemona (Shakespeare’s “Othello”) has been much criticised. The declaration that she was strangled (or suffocated) does not consist with the symptoms described (see Med. News, Philadelphia, May 1st, 1886, p. 489).

TREATMENT.

The obvious indication is to search for and remove the obstruction. The means and methods of treatment are fully treated of in surgical works, but may be briefly mentioned here.

Laryngoscopical examination may be necessary. A curved forceps is usually the best instrument for removing the foreign body. A tallow candle may serve to push it into the stomach if there is no bougie at hand. Suction may be used. Sneezing may be brought on by tickling the nostrils; coughing by tickling the glottis; vomiting by irritating the fauces, or by emetic; the body of the subject may be inverted and in this position the fauces may be tickled, or fingers may be passed back into the pharynx. Johnson[892] says that at the moment of inversion the patient should try to take a deep inspiration; this opens the glottis and facilitates the expulsion of the foreign body. The inspiratory current has no appreciable effect in retarding the movement of the foreign body in the direction of gravity.

Noble recommends inversion of the body in new-born infants in which asphyxia may be supposed to be due to anæmia of the brain. Tracheotomy or laryngotomy may be necessary. It may be necessary to administer oxygen. Foreign bodies like beards of grass and fish-heads can be withdrawn only with difficulty because of their sharp projections. Intense suffering and dyspnœa in a robust subject may necessitate venesection. Generally speaking it is better to bring up the foreign body than to push it down into the stomach. Beveridge suggests to blow into the ear, to induce a reflex action and cause expulsion of the foreign body. Cold affusions, artificial respiration, galvanism, frictions of the limbs, artificial heat, stimulants by mouth and rectum, may one or all be needed.

Hamilton[893] says that it is useless to expect good results from electricity if five minutes have elapsed since life appeared to be extinct; Althaus,[894] that three hours after death the muscles will cease to respond to faradization; and Richardson,[895] that a low temperature prolongs the sensitiveness of the muscle.

With regard to insufflation, Le Bon[896] objects to it in asphyxia as being hurtful and not useful. Colin[897] tamponed the trachea of a horse; in four minutes fifty seconds it was apparently dead; the tampon was removed and insufflation practised for fifteen to twenty minutes without effect. He claims that artificial respiration is useless after the circulation ceases.

Fell[898] and O’Dwyer[899] recommend forced inspiration. McEwen[900] uses a tracheal tube by the mouth.

Dew[901] offers a new method of artificial respiration in asphyxia of the new-born; Lusk[902] considers the subject of life-saving in still-births; Forest,[903] artificial respiration in the same; Read[904] discusses Schultze’s method with approval; Duke[905] plunges the infant into hot water; Richardson[906] recommends artificial circulation by injection of vessels, or electric excitation; Jennings[907] recommends the same; Richardson[908] also considers fully the subject of artificial respiration and electrical excitation; Woillez[909] has described and recommended what he calls a spirophore.

After the removal of a foreign body the irritation remaining may cause a sensation as if the body was still lodged.

Death may occur from hemorrhage after its removal.

POST-MORTEM APPEARANCES.

These are mainly those of asphyxia. There may also be evidences of external violence, homicidal or accidental, as of pressure on the chest. Persistent deformity, flattening of the nose and lips, and excoriation of these parts may result from forcible closure of mouth and nose.

The SKIN AND CONJUNCTIVA usually show patches of lividity and punctiform ecchymoses; especially lividity on the lips and limbs. The face may be pale or violet; it is often placid, especially if the suffocation is accidental. Tardieu[910] admits that infiltration of the conjunctiva and punctiform ecchymoses of the face, neck, and chest may also be found sometimes in women after severe labor, and in epileptics. He records the result of the examination of those who died from suffocation at the Pont de la Concorde, 1866. The face and upper parts of the trunk were generally light red to a deep violet or black color, with punctated blackish ecchymoses on the face, neck, and upper part of chest.

The EYES are usually congested. Mucus and sometimes bloody froth are found about the NOSE and MOUTH. The TONGUE may or may not protrude.

The BLOOD is usually dark and very fluid. Wounds after death may bleed. According to Tardieu[911] fluidity of the blood is most constant in compression of the chest and abdomen, as also its accumulation in the vessels and right side of heart. Its color varies from red to black.

The BRAIN and pia mater are generally congested. This is said to be invariable if the eyes are congested. Mackenzie in thirteen cases found the brain congested in all.

The HEART varies much in appearance and condition. The right side is often full of blood; occasionally empty. Sometimes subpericardial ecchymoses are found, usually along the coronary vessels. The blood in the heart may be partly coagulated if the agony has been prolonged and there has been a partial access of air, which is gradually diminished. Mackenzie[912] found the right cavities full and the left empty in nine out of thirteen cases. Johnson[913] as a result of experiment on animals claims that when access of air is prevented there is a rise in pressure in the arteries, the right side of the heart fills, the pulmonary capillaries become empty, and therefore the left side of the heart becomes empty. As a result of further experiments[914] he verified his former conclusion, and added that in the last stage of asphyxia there is increased pressure on the pulmonary artery and lessened pressure in the systemic vessels. He thinks[915] that when both sides of the heart contain blood, there is paralysis of vaso-motor nerves and the arteries.

The TRACHEA is usually bright red and often contains bloody froth. The LARYNX or trachea as well as PHARYNX or ŒSOPHAGUS may contain a foreign body. If the latter has been removed the resulting irritation may be seen. The LUNGS are sometimes congested, at others normal; color red or pale. Sometimes one lung only is affected. They may be emphysematous. Mackenzie found them congested in all of thirteen cases examined by him. The lungs of young persons may be found comparatively small, almost bloodless, and emphysematous. Tardieu, Albi, and others believed that the punctiform subpleural ecchymoses indicated suffocation, and were due to small hemorrhages from engorged vessels which ruptured in the efforts at expiration. These spots are usually round, dark, from the size of a pin-head to a small lentil, and well defined. They are not like the petechiæ in the lungs and heart after purpura, cholera, eruptive fevers, etc., nor like the hemorrhages under the scalp after tedious labor, all of which are variable in size. These punctiform spots are usually seen at the root, base, and lower margin of the lungs. Hofmann states (“Lehrbuch”) that they are found in the posterior part of the lungs and in the fissures between the lobes. They are indisputably frequent after death from suffocation, and if well marked either in adults or infants that have breathed, they indicate suffocation, unless some other cause of death is clear. Simon, Ogston, and Tidy, however, have shown that they are sometimes absent in fatal suffocation, and are sometimes present in the absence of suffocation, as after hanging and drowning; in fœtuses before labor has begun; often in still-births, although some of these are probably due to suffocation from inhaling fluid or from pressure. Also in death from scarlet fever, heart disease, apoplexy, pneumonia, and pulmonary œdema. Grosclaude[916] quotes from Pinard, who declares that these ecchymoses are found in fœtuses which die from arrest of circulation. Grosclaude himself made a large number of experiments on animals by drowning, hanging, and strangling, and fracturing the skull. The ecchymoses were found in nearly all the cases.

The ecchymoses are partly the result of venous stasis, which overcomes the resistance of some capillaries; and the latter rupture, partly from the aspirating action of the thoracic wall, the lung being unable to fill itself with air, but mainly[917] from vaso-motor contraction and lateral pressure at the maximum of the asphyxia, the time of tetanic expiration. If the asphyxia is interrupted before this stage, the spots do not appear. Similar ecchymoses may be found under the scalp, in the tympanum, retina, nose, epiglottis, larynx, trachea, thymus, pericardium, in the parietal pleura, along the intercostal vessels, rarely the peritoneum, in the stomach, and sometimes the intestines; and in other parts of the body, especially the face, base of neck, and front of chest; in convulsive affections, as eclampsia and epilepsy, and in the convulsions of strychnia and prussic acid poisoning there may be suffusion and congestion of the lungs though not the punctated spots.

Mackenzie, in thirteen cases of suffocation from various causes, failed to find the Tardieu spots either externally or internally. Briand and Chaudé[918] state that they are less constant and characteristic in those who have been buried in pulverulent substances.

Ogston[919] holds that in infants that are smothered the ecchymoses are found in greater number in the thymus gland; while in adults dying from other forms of asphyxia they were found only once in that gland. The spots are found in clusters in infants that are smothered, but only single and scattered in adults who die from drowning, hanging or disease. They were wanting in the lungs of but one infant.

They may be recognized as long as the lung tissue is unchanged. The apoplectic spots in the lungs seen in strangulation are not found in suffocation.

Tardieu[920] from experiments on animals and examination of twenty-three new-born infants who showed traces of violence around the mouth, found the lungs rather pale and anæmic, subpleural ecchymoses well marked. All the deaths were rapid. In cases of compression of chest and abdomen[921] the congestion of the lungs was extensive, and pulmonary apoplexy frequent; more so than in other forms of suffocation. He gave strychnia to animals which died in convulsions, and found very irregular and partial congestions, generally not marked because death was so prompt; blood always fluid; no subpleural ecchymoses.

The LIVER, SPLEEN, and KIDNEYS are generally congested; the kidney more than the other organs named. The spleen is said to be often anæmic. Semen has sometimes been found, unexpelled, in the urethra.

Page[922] experimented on three kittens, suffocating them in cinders. The post-mortem examinations showed the veins engorged, left side of heart empty, right side full of dark, half-clotted blood. Lungs distended, much congested, color violet; many small fluid hemorrhages in substance; no subpleural ecchymoses. Frothy mucus tinged with blood in trachea and bronchi; bronchi congested. Brain and abdominal organs normal.

PROOF OF DEATH BY SUFFOCATION.

It is sometimes difficult in a given case to state WHETHER DEATH IS DUE TO SUFFOCATION. There is no lesion which of itself could be accepted as proof. But a collation of the lesions found taken in connection with the surroundings of the body will in many if not in most cases lead to a definite conclusion.

Infants have been found alive four and five hours after having been buried in the earth.[923] If the pulverulent material has penetrated into the œsophagus and stomach, the burial has occurred during life. Exceptionally when burial has occurred after death and traces of the material are found in the air-passages, they are not found in the œsophagus or stomach.

The committee on “Suffocation,” of the New York Med. Leg. Soc., reported[924] the following group of appearances as evidences of death by suffocation: The general venous character of the blood, the turgidity of the larger veins, the congestion of the parenchymatous organs, especially at the base of the brain, the lungs congested in a variable degree and œdematous, frothy mucus in the bronchi, the right side of the heart always fuller than the left. Fitz[925] holds that suffocation is a condition composed of a group of symptoms and appearances due most probably to accumulation of carbon dioxide in the blood and a deficiency of oxygen. The appearances are: The blood dark and fluid (though in gradual suffocation there may be clots in the right side of the heart), the right side of the heart full, venous congestion of the lungs (not constant), interstitial emphysema of the lungs, and venous congestion of the liver, kidneys, and brain. He prefers the word engorgement to congestion in this connection.

Tardieu[926] holds that when in infants buried in pulverulent substances we find emphysema of the lungs in high degree, bloody froth in the air-passages, abundant subpleural and subpericardial ecchymoses and the blood fluid, the burial has occurred during life. The same lesions are found in small animals similarly treated.

It must not be forgotten that an intoxicated person or one in an epileptic spasm is practically helpless, and can, therefore, be suffocated, accidentally or otherwise, under circumstances in which one in possession of his senses would be able to escape.

ACCIDENTAL, HOMICIDAL, AND SUICIDAL SUFFOCATION.

=Accidental suffocation= is frequent, as has already appeared. =Suicidal suffocation= is very rare. =Homicidal suffocation= occurs. Foreign bodies have been forced into the air-passages. Smothering has been done by holding the face in various materials to prevent access of air; by pressure on the chest; by forcible closure of the mouth and nose as in burking; by laying compresses over the face, as in the case of King Benhadad,[927] whom Hazael killed. “And it came to pass on the morrow that he took a thick cloth and dipped it in water, and spread it over his face so that he died; and Hazael reigned in his stead.” Benhadad was already quite ill and not expected to live.

Death by suffocation[928] may be considered as presumptive of homicide unless the facts are already referable to accident.

In infants, suffocation is, of course, either accidental or homicidal; in adults usually accidental. The absence of signs of a struggle in adults suggests accident; unless there is cause of suspicion of previous stupefying with narcotics.

Taylor[929] calls attention to a dangerous practice among some attendants upon infants, of putting into the mouth of the child to quiet it a bag containing sugar; and instances a case in which the child would have died of suffocation but for the fortunate discovery of a part of the bag protruding from the mouth.

In ten years, 3,612 deaths were reported in the city of London, of infants smothered by being overlaid.[930]

Infants may be born into a mass of blood and fæces, from which the unattended mother in her weakness may be unable to remove them.

Page[931] shows by experiment that the inspiratory effort when violently exerted is sufficient to convey small objects into the air-passages. Cinders passed thus into the trachea and œsophagus of kittens and rabbits. Berenguier[932] experimented on new-born pups, placing them in ashes, plaster, and starch. In ashes they lived fifteen hours; these found their way into the middle of the œsophagus, but were stopped at the glottis. Plaster and starch formed a paste with the oral mucus and the movement of the mass was not so great as the ashes. In no case did either of the materials pass beyond the glottis. Tardieu[933] examined three infants which had been buried during life. One was in ashes: the nose was obstructed, mouth full: ashes also in the œsophagus and stomach, but none in larynx or bronchi. The second infant was in manure; a greenish stuff was found in the mouth and stomach. The third in bran (confessed to by the mother); the nose and mouth were full, but there was none in the throat; a few grains in the trachea. Tardieu experimented on rabbits and Guinea pigs by burying them in bran, sand, and gravel, some of them being alive and the others dead. In those buried alive he found the substance filling the mouth and nose to the base of the tongue; in most of the cases the œsophagus and trachea were not penetrated. In the animals first killed and then buried, the substance had not passed into the mouth or nose. In one case only he found ashes in the larynx and trachea of a rabbit which had been buried many hours after death in a box of ashes. Matthyssen[934] held a Guinea pig, head downward, with its nose under mercury; the lungs were full of globules of mercury (which has a specific gravity of 13.5). A dog was plunged head first into liquid plaster-of-Paris; the plaster was found in the bronchial tubes.

ILLUSTRATIVE CASES.

ACCIDENTAL.

1. Huppert: Vier. ger. Med. und öff. San., 1876, xxiv., pp. 237-252.—Two cases. A man choked by piece of bread in pharynx. Second, an epileptic, suffocated by flexion of chin on larynx. In both cases seminal fluid was found in urethra near meatus, unexpelled; determined by microscope.

2. Johnson: Lancet, 1878, ii., p. 501.—Boy swallowed penny, became black in face; eyeballs protruded; symptoms soon subsided. Some hours afterward it was found that he could not swallow solids, and liquids only with difficulty and coughing. Throat much irritated; discharge of mucus sometimes tinged with blood, from mouth; moist rattling noise in throat in respiration; frequent cough; could not sleep. Laryngoscope showed penny in upper part of œsophagus, just below laryngeal opening. Removed by long curved forceps.

3. Ibid.—Man suddenly fell while at dinner; face blue; breathing stertorous. Died. Piece of tendon found under epiglottis.

4. Ibid.—Boy, age 5 years. Button in larynx. Aphonia, dyspnœa, stridulous breathing. Distress gradually subsided. Many years afterward found mucous membrane of larynx thickened; vocal cords red and uneven.

5. Ibid.—Man, drunk, swallowed a half-sovereign. Urgent dyspnœa; pain in throat; aphonia; stridulous breathing; dysphagia; cough; copious mucous expectoration. Laryngoscopic examination showed coin in œsophagus. The crico-thyroid membrane was incised and coin pushed upward and ejected.

6. Med. Times and Gaz., 1874, i., p. 486.—Man, age 20, had severe dyspnœa. In taking a living fish in his teeth (it was about four inches long and had large dorsal fin), the fish passed into the pharynx and lay doubled up. Impossible to remove it because of spines. Tracheotomy at once. Twenty-four hours afterward the fish had decomposed enough to be partly removed. Patient died of exhaustion.

7. Littlejohn: Edin. Med. Jour., 1875, xx., p. 780.—Woman found dead in bed. Suffocated by pus from abscess of tonsil which burst during sleep. Found pus in air-passages down to smallest bronchi; lungs congested; right side of heart distended with dark fluid blood; left side contracted and nearly empty. Blood everywhere fluid. Some lividity of face. The woman had died quietly lying beside her husband, who was not awakened.

8. Sayre: New York Med. Jour., 1874, xix., p. 420.—Girl, age 7, swallowed a bead. Had continuous cough; much pain under middle of sternum. The bead moved upward and downward in respiration. Tracheotomy. Four days afterward she coughed the bead out, inspired once, and apparently died. Artificial respiration used; alcohol injected into rectum; galvanization of phrenic nerves. She finally coughed up a piece of thick mucus and recovered.

9. Duffy: Trans. Med. Soc. No. Car., 1874, p. 126.—Boy, age 8, swallowed a cow-pea. It lodged in the trachea. Some months afterward, laryngotomy performed. The boy seemed to die at once. Artificial respiration used. After a while he expelled first some mucus, then the pea. Recovered.

10. Tardieu: Op. cit., p. 290.—Man, age 50, found dead on the floor. At base of neck and front of chest were many punctated ecchymoses. Brain and lungs much congested; the latter showed subpleural spots. Tongue and lips bitten. Death was due to cerebral and pulmonary congestion from an epileptic seizure.

11. Oesterlen: Vier. f. ger. Med. und öff. San., 1876, xxiv., p. 10.—Woman, age 30, epileptic. Found dead. Examination showed signs of asphyxia; blood-vessels engorged, marked œdema of lungs, etc. Opinion given that she died in epileptic paroxysm, and certain injuries observed were caused by a fall.

12. Tardieu: Op. cit., p. 322.—Two children, one 2 months old, the other 18 months old; in bed together. The older overlay the younger, which died. Necroscopy: lungs voluminous, in places congested, in others pale; abundant subpleural ecchymoses; quite emphysematous. Fluid blood in heart.

13. Blum: New York Med. Jour., 1885, xlii., p. 207.—Woman, found dead. Vulcanite plate of usual size, with four teeth attached, found wedged in trachea about two inches below larynx.

14. Wyeth: Same journal, 1884, xl., p. 487.—Boy, age 12, inspired a pin-dart in trying to blow it through a blowgun. Violent cough, gasping for breath, lividity of face for a few minutes; symptoms subsided leaving slight cough. The dart had lodged in right bronchus beyond first bifurcation, as shown by hissing, fluttering sound in both inspiration and expiration. Tracheotomy. The dart could not be reached. At a later date the dart was brought up into the mouth by a strong expiration.

15. Partridge: Same journal, 1890, li., p. 303.—Child, 4 months old, found dead; fluid, partly digested milk in air-passages.

16-41. Biggs and Jenkins: Same journal, 1890, lii., p. 30.—Report of many cases of fatal suffocation from foreign bodies, etc. Boy, age 15—collar-button in larynx. Boy, age 10—mass of butter in larynx. Boy, age 5—bronchial gland discharged into trachea at bifurcation. Boy, age 3—screw in larynx. Boy, age 5—rubber balloon with whistle attached; it was partly inflated with each expiration. Girl, age 10—a “jack” in larynx. Man, age 45—had been drinking freely; piece of meat in larynx. Man, age 40—piece of meat in larynx and pharynx. Man, age 40—ditto. Insane patient—piece of meat in trachea. Man—piece of meat in larynx. Man, age 40—crackers and cheese in larynx. Child—rubber nipple in larynx. During administration of ether, patient vomited; vomitus entered larynx. Two children in bed asleep; one, 3 years old, overlay the face of the younger, age 5 months. Woman, age 25, epileptic—fell on a child and smothered it. Two children found dead, covered with bedclothing. Man, age 21, epileptic—found lying on his face in bed. Girl, age 12, epileptic—ditto. Woman, age 21—ditto. Girl, age 18—ditto. Woman, age 35, epileptic—fell on the floor. Woman, age 28—ditto. Man, age 35, epileptic; vomited while in spasm; vomitus entered larynx. From Dr Janeway: Man, epileptic, fell on his face in pile of manure, which entered larynx. Man, drunk, lying on his face.

42. Roy. Indian Med. Gaz., 1880, xv., p. 71.—Man, believed to be drunk, had vomited in bed; vomitus entered trachea and bronchi.

43-47. Mackenzie: Same journal, 1890, xxv., p. 257.—Reports fatal cases: Boy—bone button in larynx. Sailor—meat in larynx. Boy—vomited matter in larynx. Infant—while taking the breast, a rush of milk suddenly filled the air-passages. Also three cases of crushing under walls; two buried in loose earth; two crushed in a crowd; one by bags of grain.

48. Feulard: Bull. Soc. Anat., 1883, viii., pp. 384-386.—Woman, age 79. Piece of beef in larynx. Necroscopy showed hematoma in dura mater.

49. Poupon: Bull. Soc. Clin., Paris (1882), 1883, vi., pp. 236-238.—Boy, age 5½ years. Death from cheesy gland in trachea.

50. Pons: Jour. Méd., Bordeaux, 1889-1890, xix., pp. 57-61.—Woman, age 24. Death from œdema of larynx from presence of particles of food.

51. Kemény: Wien. med. Blat., 1890, xiii., p. 37.—Man, age 45. Suffocated by curdled milk in air-passages.

52. Maschka: Vier. ger. Med., 1885, xliii., pp. 11-14.—Man, age 65. Accidental compression of chest.

53. Heidenhain: Same journal, 1886, xliv., pp. 96-101.—Vomited matter passed into air-passages while subject was drunk.

54. Langstein: Wien. med. Woch., 1880, xxx., pp. 624-626.—Child found dead in bed; had vomited food while asleep and breathed it into air-passages.

55. Ward: Catalog. Army Med. Mus., Med. Sec., p. 33.—Soldier, age 17; choked to death by lumbricoid worm passing from pharynx into right bronchus. Specimen 7,737.

SUICIDE.

56. Sankey: Brit. Med. Jour., 1883, i., p. 88.—Epileptic; found dead in bed, lying on his back. A round pebble in each nostril; strip of flannel rolled up and stuffed in throat.

57. Macleod: Ibid., 1882, ii., p. 1246.—Suicidal maniac. Had to be fed because he refused food. Was seen to be blue in the face and breathing hard. His mouth was forced open; roll of flannel found in throat. Macleod refers to another case, a woman in dissecting-room, with similar roll of flannel in throat.

See Tidy, “Med. Jur.,” Cases 15 to 17.

HOMICIDE.

58. Christison: Edin. Med. Jour., 1829, xxxi., pp. 236-250.—The famous Burking case. A woman was struck down to a sitting posture. Burke then threw himself on her, kept her down by the weight of his body, covered her mouth and nose with one hand and placed his other hand under the chin for ten to fifteen minutes, till she died. Necroscopy showed a severing of the posterior ligamentous connections of the third and fourth cervical vertebræ, with blood in spinal canal but not under the dura mater; cord not injured. Christison made experiments to ascertain if the injury to spine had been made during life.

59. Hackel: Dorpat Diss., 1891, p. 35.—Case of choking with pressure on breast and belly. Woman found lying on floor, with many injuries.

60. Tardieu: Op. cit., p. 315.—New-born infant; found buried in earth. Mother stated that the child had not breathed. Putrefaction had begun. There was a brownish tint of skin of upper front part of neck below jaw; drops of sanious fluid flowing from nose; umbilical cord had not been tied; subcutaneous hemorrhage in right temporal region; brown bruised surface and contused wounds of pharynx, where particles like ashes and vomited matter were found. Lungs filled the pleural cavities, were rose-colored and showed abundant punctated subpleural ecchymoses; bloody, frothy mucus in trachea and bronchi; some serum in pericardium; respiration had been complete. Opinion given, that the infant had been suffocated by obstruction of pharynx, probably by fingers.

61. Tardieu: Op. cit., p. 323.—New-born infant found under a cask, partly eaten by a dog. The head showed transverse flattening and subcutaneous hemorrhage. Lungs voluminous, rosy; abundant subpleural ecchymoses; hemorrhage in left lung. Heart filled with fluid blood. Coagulated blood in abdomen. Opinion given, suffocation by pressure on head, chest, and abdomen. The mother confessed that she had placed the child under the cask.

62. Ibid., p. 325.—New-born infant found buried in the earth; gravel and earth in pharynx and œsophagus down nearly to stomach, and in trachea and right bronchus. Lungs congested, crepitant. Opinion given, that the child had been buried while living.

63. Ibid., p. 326.—New-born infant found in ashes; nose and lips obstructed, mouth filled; ashes in œsophagus and stomach; none in larynx or trachea. Lungs distended with air, emphysematous; subpleural ecchymoses; fluid blood in heart.

64. Ibid., p. 327.—New-born infant, buried in bran; nose and mouth filled; some in trachea; none in œsophagus or stomach. Lungs distended with air, emphysematous; subpleural ecchymoses; heart empty.

65. Devergie and Raynaud: Ann. d’Hyg., 1852, xlviii., pp. 187-206.—Man found dead on a pile of grain; mouth, nose, and eyes contained some of the grain; some also in stomach, larynx, trachea, and bronchi. Some marks of injury on face and other parts of body. Internal signs of asphyxia. Opinion given, that the case was homicide. The defence offered was that the man had fallen into the grain.

66. Rauscher: Friedreich’s Blat., 1886, xxxvii., pp. 324-330.—Woman, age 71, suffocated by a cloth over nose and mouth.

See Tidy, “Med. Jur.,” Cases 1 to 11.

DEATH FROM SUBMERSION

IN ITS

MEDICO-LEGAL RELATIONS.

BY

IRVING C. ROSSE, A.M., M.D., F.R.G.S. (ENG.),

Professor of Nervous Diseases, Georgetown University; Membre du Congrès International d’Anthropologie Criminelle, etc.

DEATH BY SUBMERSION OR DROWNING.

GENERAL CONSIDERATIONS.

THE frequence and importance of drowning having arrested attention from the days of Noah’s Ark and those of Hippocrates down to the present time, it is quite possible to array in chronological order the fictitious, transitory, and positive periods that mark the sequence of ideas touching the subject.

Mooted questions relative to drowning have been debated since the fourteenth century; and modern statistics show the great development of this class of emergency, than which none is of more startling character. In France between four and five thousand cases of this kind of accident are officially recognized each year, which is about one-third of all the accidental deaths, and the number appears to increase yearly. Nearly the same figures apply to the inland waters of England and Wales, not including the coast. The Board of Trade Return shows that out of 86,695 seamen who died in English ships abroad, 53,673 were drowned, and a late report of the Fisherman’s Federation places the number drowned in the inland waters and upon the immediate coasts of the United Kingdom and its adjacent islands as 6,268 annually. The many hundreds drowned in the late Victoria disaster and in the great storm that swept the British Isles are matters of current knowledge. In our own country accounts of drowning are of daily occurrence, and help to the drowning forms the greater part of the work done by that noble governmental branch, the Life Saving Service. Not only does the sea claim its numerous victims, but the great floods and cyclones have destroyed thousands, while on the lakes and rivers drowning accidents are lamentably frequent. If the statistics of such accidents were as available as those of the late war, for instance, the exhibit would doubtless be surprising. Where the aggregation of killed in action is shown to be 67,058, there were drowned 106 officers and 4,838 men. The small regular army lost 5 officers and 89 men from this cause; the negro troops, 6 officers and 289 men; and the volunteers furnished a large contingent, the State of Ohio alone having lost 14 officers and 770 men from drowning.[935]

Aside from the point of view of public hygiene and that of pathology, further evidence is not wanting to show the medico-legal value of the phenomena of drowning, and the frequency and importance of the judicial questions that may arise in this class of accidents.

DEFINITION AND PHENOMENA OF DROWNING.

Late studies as to the cause and mechanism of asphyxia by submersion or drowning warrant our speaking of submersion as immersion complete enough to menace or to extinguish life.

When an animated body or a part only of the body is immersed a sufficient time in water or any liquid medium whatever in such a way as to exclude fresh air from the respiratory orifices, suffocation follows, and death by submersion or drowning takes place.

The phenomena occurring in such instances are mostly those common to imperfect aeration or non-aeration of the blood, and for this reason the majority of medical writers describe asphyxia or apnœa, that is, death beginning at the lungs, as the determining cause of death by drowning. It must not be thought that asphyxia is always the mode of death in those submerged, although it is commonly present in a certain number of cases. Other causes may often modify the circumstances of the death or directly produce it, as congestion of the brain and syncope, or the cause of death may be a mixed one. Occasionally one reads accounts of persons resuscitated from drowning who, on recovering from the primary effects of the asphyxia, die suddenly without apparent cause after a lapse of a few minutes or several days. Such cases are explained as the secondary results of the arrested interstitial nutrition that took place during the period while breathing was temporarily arrested. Another secondary cause is physical injury to the lungs from water penetration, which may result in a fatal pneumonia. A case related in England last summer is that of a drowning boy who, on being resuscitated after submersion in contaminated water, suddenly died of cholera.

MODE OF DEATH IN DROWNING.

Since various lesions may be found, accordingly as the death from drowning has taken place from one or more of the foregoing modes, it is necessary to have a clear notion of asphyxia and to study in detail the mechanism of arrest of the thoracic movements and of the hindrance to hæmatosis.

Broadly speaking, there will be asphyxia when any obstacle hinders air from entering the pulmonary vesicles, or when the fluid that penetrates them is of any other nature than the medium in which the animal is destined to live. Consequently the name asphyxia is applied generically to all accidental conditions in which life is threatened by any intervention whatever of the respiration. (See MECHANICAL SUFFOCATION, Vol. I., p. 705 et seq., and ASPHYXIATING GASES, Vol. IV.)

Submersion in any liquid medium causes asphyxia. This condition may be caused on being surrounded by a medium devoid of oxygen and improper to support sufficient hæmatosis, as hydrogen, nitrogen, and the protoxide of nitrogen, gases not toxic properly speaking, but considered irrespirable. Diminished respiration from deficiency of oxygen is the true cause of asphyxia. No animal can maintain the respiratory process in an atmosphere devoid of oxygen or in one that does not contain at least ten per cent of this gas, and such quadrupeds as whales, hippopotami, and seals or the pygopodous birds would drown in the same manner as a dog if kept submerged long enough. The suppression of the gaseous exchange by submersion is also fatal to such aquatic insects as hydrophiles, dytiscidæ, and the like, which drown in the same manner as the hymenoptera, coleoptera, diptera, or other terrestrial insects. Ants drown in less than a minute when the body is wet, and the disappearance of apparent vitality is accompanied by convulsive movements indicating functional trouble of the nervous apparatus. Sir John Lubbock found that after eight hours of immersion they could be restored to life, and several ants after two days and five days were restored to momentary life with feeble motions, followed by death in two hours. Even a terrestrial plant when submerged drowns like a terrestrial animal, the mechanism of asphyxia by submersion being the same in plants and aerian animals, and due to closure of the principal way of gaseous exchange.

Notwithstanding the interruption of the gaseous exchange necessary to support life, there is long persistence of vitality after submersion of some creatures in which an intra-molecular respiration or gaseous dialysis with aerated water takes place, as in ants who have not been wetted before submersion.

The resistance of new-born animals to this mode of asphyxiation is especially noted in the greater time required to drown a pup than an adult dog. One minute and a half usually suffices to drown a dog, while a new-born pup often requires as much as fifty minutes. This great difference is owing to the less active change of tissue and the smaller consumption of oxygen in the young animal. The more active the vital combustion and the greater the demand upon the general store of oxygen in the blood, the quicker the young animal perishes when the respiration is obstructed.

It is observed in a general way that all kinds of death caused by the privation of respirable air have between themselves the greatest resemblance. Whatever be the obstacle that intercepts the connection of the lungs with the atmosphere, the apparent differences are only secondary and the essential symptoms are identical, because all act in suppressing the functions of the blood and hæmatosis. In fact, the phenomena of asphyxia are constant and related to disturbances in the respiration, innervation, and circulation, which vary according as the asphyxia is the result of submersion or of the absence of oxygen in the surrounding medium, according as asphyxia is immediate or slow. The fatal result of asphyxia is owing to the introductory arrest of the pulmonary circulation, the capillaries of the lungs being incapable of conveying venous blood. The stagnation of the blood in the lungs is followed by paresis of the respiratory centre and stoppage of the heart.

STAGES AND SYMPTOMS OF DEATH BY DROWNING.

The authorities are that an individual who dies asphyxiated by submersion passes through three stages. At first he experiences a violent shock, followed by an inspiration of surprise, which results from the contact of water with the lungs causing a reflex cough. Then for some seconds there is a voluntary suspension of respiration, giving rise to other forcible involuntary expirations. In this dyspnœic second period the face and brain become congested, owing to slowing of the encephalic circulation. Loss of consciousness soon follows, when the drowning person enters the third stage, which is that of asphyxia. In this period the individual gasps deeply, the pupils are dilated, the sphincters paralyzed, and the limbs are agitated by clonic convulsions. This is followed by complete insensibility and speedy death.

When a fatal termination in drowning results from that form of neuro-paralysis known as syncope, in which death begins at the heart, we infer from experiments that the sudden loss of consciousness arises from the violent impressions that the sensitive nerves convey to the bulb. Such a result is more likely to occur in persons with weak heart and languid circulation, who are more susceptible to fright and shock or to the sudden collapse from intense cold. It is also shown that stammerers, who have a defective innervation of the phrenic and of the pneumogastric, succumb more rapidly than others.

The importance of syncope as a cause of death in drowning is much restricted when we consider the fact that the circulation is the last of the functions extinguished in an animal that for purposes of experiment has been subjected to submersion. This has been shown in a sensuous way by experiment, aided by the resources of the graphic method, which registers the respiratory modifications as shown by the pneumograph and also the condition of the femoral artery in connection with a kymographion. The heart continues to beat as much as three minutes after the animal has succumbed, and recent autopsy gives almost constant proof of asphyxia. In fact, it is held that syncope takes but small part in this form of death, the general agreement of opinion being that nothing short of a syncope that would be fatal either in or out of the liquid medium can account for the entire absence of some of the signs of death from asphyxia.

Among the symptoms often present in drowning persons, many relate to nervous phenomena and the mental state, which may vary with individual presence of mind and moral force. Persons who have escaped this kind of death have observed auditory and visual hallucinations, as flashes of light, the ringing of distant bells, and the like. Just before the outset of the asphyxiation a rather curious functioning of the brain known as hypermnesia[936] takes place, in which the revivescence of ideas, of objects, or of facts relates to anterior impressions long past that seem to have been forgotten. According to the narratives of many drowning persons who have escaped the last consequences of asphyxia, this condition was attended by general exaltation of the memory of such a nature that their whole previous conscious existence seemed, in an incredibly short period and with great clearness and precision, to pass before them in panoramic review. In Admiral Beaufort’s letter to Dr. Wollaston, the memory impressions are said to have occurred in retrograde succession. A medical man resuscitated from drowning reports that just before losing consciousness this particular cerebral activity, in his case, took on a most realizing sense of the situation and of the consequences to his family. This cerebral superexcitement is not, however, a constant thing, nor do all subjects experience the ineffable agony of drowning. Persons have been taken from the water apparently dead who, on regaining consciousness, declared that they experienced neither oppression nor suffering and had no recollection of what had passed. A very intelligent woman of my acquaintance, having such an experience a few years since at Newport, quotes herself as and really believes that she is an instance of a person once dead and afterward restored to life.

This peculiar vividness of mind has been observed in other kinds of death than drowning, notably in chronic insanity. A priest with extended experience at the Government Hospital for the Insane tells me that he has often noticed the vaticinatio morientium in the form of so-called lucid interval of the insane when called on to administer the last rites of the Church. The condition is explainable from the stoppage of the pulmonary artery and the stimulus caused by circulation of non-oxygenated blood in the brain.

The condition known as asynesia, or amnesia, sometimes follows the return to consciousness in persons asphyxiated and apparently dead from drowning. Dr. F. A. Burrell reports the case of a boy of eighteen, submerged for six minutes and resuscitated after four and three-quarter hours, in whom the memory of everything that had occurred from half an hour previous to the accident up to return of consciousness had been entirely obliterated. When last heard from the lapse of memory still remained.[937]

The statement that death from submersion results from true asphyxia or from asphyxia in a more or less modified form rests on the authority of a large number of facts. Indeed, recent investigators make the proportion so much greater than formerly as to warrant the statement that asphyxia is the generic cause of death by drowning. Dr. S. Coull Mackenzie[938] reports 305 cases of drowning, in which 297, or 93.37 per cent, died from asphyxiation; 1, or .32 per cent, from syncope; 1, or .32 per cent, from apoplexy and asphyxia; and in 6, or 1.96 per cent, the mode of death could not be determined because of advanced putrefaction.

As the post-mortem signs of drowning are known to vary according to a number of circumstances, it is difficult to deal with the subject unless certain fundamental points be kept in mind. These relate more particularly to the external signs and to the different lesions that follow the mode of death, although they are not constant. Surgeon-Major E. G. Russell[939] illustrates how widely the post-mortem appearances may vary in cases of drowning, even when the outward circumstances of the period of death are identical and the bodies have been subjected to precisely similar conditions as regards duration of immersion, subsequent exposure to air, and times of necropsy. He relates that five persons were drowned while proceeding to a ship in the Hooghley River. Three died the same death; and at the same time the bodies were recovered together after the same period of immersion, and were examined together; thus from beginning to end they had been under exactly similar conditions, yet there were very marked differences in the state of preservation of the bodies and in the post-mortem appearances. After five hours’ exposure in air at 88° F., one body, in which the tissues were extremely fatty, showed beginning decomposition; in the other two there were no signs. Decomposition in the scalp, face, and neck indicative of drowning had begun under water, although in ordinary cases it first invades the abdomen, genitals, breasts, etc. Rigor mortis present in one case was absent in the other. The penis was semi-erect in one case, flaccid in the other, retracted and shrunken in the third. Emission of semen and expulsion of fæces were also noted. Tongue not swollen or protruded in any case, and cutis anserina absent in all three, which may have been owing to the high temperature. Water was inspired into the lungs in two cases. The larynx, trachea, and bronchi had regular congestion and scarlet ecchymoses in one case characteristic of asphyxia, and there was muddy water in the stomach.

The first question likely to arise when a drowned body has been found is the one of identity. All the circumstances in which the body was observed before its removal to the place where it lies for examination should therefore be minutely detailed, and all lethal injuries and the like should be noted with care, since the smallest accessories often lead to identification. The locality in which a drowned body is found may be a fact of considerable importance that may help to complete the chain of evidence in which the matter of crime or of accident turns upon the question of identity. It must be remembered that bodies often drift many miles away from the spot where the drowning occurred, owing to tides or currents. Such a circumstance I noted a few years ago at Brownsville, Texas, where it was a common sight to see bloated cadavers going down the Rio Grande. Time and putrefactive changes are also elements that enter into the matter of recognizing the drowned cadaver. To resolve this question with desirable precision, the reader is referred to more detailed instruction in the chapter on Identity.

TREATMENT OF THE APPARENTLY DROWNED.

Help to the drowned does not properly come within the province of judiciary medicine, being rather a humane question that belongs to public hygiene. Systematic writers, however, treat the subject at considerable length, and the statistics of institutions for helping the drowned give such marvellous results that it would manifestly not be out of place to cite briefly some of the means employed for restoring life to persons taken from the water asphyxiated and apparently dead.

The prime object in resuscitating the drowned is the introduction of air into the pulmonary vesicles, which is best accomplished by artificial respiration, and the employment of such means as excite the nervous system with a view to reanimate sensibility and develop the reflex movements that contribute to the re-establishment of the respiratory function.

The exigencies of drowning also call for special means to restore the animal heat and the circulation, as well as the precaution of removing mucus and fluids from the obstructed air-passages.

As the knowledge of securing patency of the air-passages by artificial respiration is generally diffused among medical students and is taught in some schools, it would be superfluous to repeat in detail the procedures of Hall, Sylvester, and others.

Laborde’s method of resuscitating those apparently dead has lately gained some notoriety. It consists in stimulating the respiratory reflex by regular rhythmical traction of the tongue, which should be vigorously pulled forward fifteen or eighteen times a minute, to correspond in frequency to the normal respiration.

Another method, alleged to have marvellous effects over the respiration, is that of anal dilatation. Its advocates claim that irritation of the anus is a much more effective measure in resuscitating the drowning or narcotized.[940]

Respiration may be further promoted by alternate dashes of hot and cold water on the face and chest, by smelling-salts, tickling the throat and nares with a feather, and by electrization of the diaphragm and inspiratory muscles. Protracted galvanism may, however, prove dangerous.

When signs of life appear, a warm tonic stimulating drink should be given. A hypodermic injection of caffeine is also recommended.

Whatever means are employed should be used on the spot in the open air and without a moment’s delay.

Restorative efforts may be kept up for two or three hours, although in the majority of cases life is extinct in the human subject after two minutes’ submersion or even less, and the chance of restoration after five minutes’ complete submersion is doubtful. To be sure, trained tank performers remain under water longer than two minutes, and exceptional instances occur of recovery after twenty minutes’ submersion in individuals in a state of syncope or with catalepsy.

CADAVERIC SIGNS IN CASES OF DROWNING.

The signs alleged to be common to death by drowning and characteristic of it are difficult to deal with, for the reason that there are no sure signs of drowning and the lesions furnished by necropsy are of feeble importance. There is consequently a divergence of opinion on this subject.

EXTERNAL SIGNS.

Among the external diagnostic signs consistent with the supposition of death by drowning, the presence of froth at the mouth and nostrils is of first importance. Cadaveric rigidity, pallor, goose-skin, rosy or violet discolorations on various parts of the body, retraction of the penis and scrotum, fish-like expression of the eye, peculiar position of the tongue, maceration of the palmar and plantar epidermis, and convulsive contraction of the limbs, particularly of the hands, which may be clinched after the manner that marks death by asphyxia, are all signs which when united form strong presumption in favor of submersion.

These typical and classic signs may, however, be varied by many circumstances. Hence the dissidence of authors. Dr. F. W. Draper states that after inspecting 149 drowned bodies, he has never observed that important sign of death, the presence of substances grasped in the hands.[941] Sand or mud in the hollow of the nails and excoriations of the fingers are also regarded as probable, not certain, signs, since each of these might have occurred either before or after death. The peculiar clinched condition of the hand is not pathognomonic, though strongly suggestive of drowning, as it may appear in asphyxiation from other causes. I have lately noticed this among the external appearances of the bodies taken from the Pompeiian excavations. The further index of drowning known as washer-woman’s or cholera hand, with non-adherent tendency of the epidermis, is an effect that may be produced upon the living after a prolonged bath, notably in the aged and habitually unclean. Nor is the position of the tongue a special and distinctive characteristic of drowning. Only a few months ago I observed its presence in some of the victims of mechanical suffocation in the Ford’s Theatre disaster in Washington.

The shrunken state of the genital organs is apparently of little positive value as a thanatological sign, since the negative and opposite state of erection has been often observed, and Dr. Ogston states that he met semi-erection in twenty-two cases.

The value of “goose-flesh” as a link in the chain of evidence is also weakened when we consider that it frequently occurs after other violent modes of death. Anserine skin is often met with during life, and cases of drowning are recorded where this appearance has been absent.

The aspect of the face and the general position of a drowned cadaver may likewise vary according to the mode of death. Immobility of the body in the attitude of agony, the horrible grimaces of asphyxia, the pale, calm features of syncope, and putrefactive changes are further circumstances of medico-legal detail that may complicate the problem and render an autopsy necessary in order to invalidate or confirm the uncertain conclusions furnished by the external signs.

INTERNAL LESIONS.

Autopsies on the drowned are remarkable owing to their negative signs. But as an extension of diagnostic means, the autopsy may show the vertical (though not invariable) position of the epiglottis; the presence of water and foreign matter in the bronchi; swelling and emphysema of the lungs; hydræmic engorgement of the liver; fulness of the right heart and emptiness of the left; fluidity of the blood; water in the stomach and middle ear; and a characteristic frothy mucus or lather more or less bloody, which most observers and writers consider the only constant post-mortem appearance of drowning.

Examination of the respiratory apparatus is of extreme importance in a question of this kind, for it is contended that the presence of foreign bodies is a proof of submersion.[942]

This opinion is in part erroneous, since it has been observed that when a body is submerged after death water will penetrate the larynx, trachea, and remote bronchi, as well as the stomach and middle ear. Moreover, Dr. Ogston states that in 48.7 per cent of cases of drowning no water was found in the lungs.

The emphysematous condition of the lungs, which are said to force their way out of the chest on removing the sternum, is difficult to distinguish from the result of putrefaction. Dr. Gilberti shows that in the drowned the lungs disintegrate rapidly, while the heart, in which putrefaction begins chronologically, is relatively in a good state of preservation.[943]

Since many cases have been observed in which both sides of the heart may be partly filled or both be empty and flaccid, or the left side distended more than the right, we are obliged to regard the exceptions concerning this post-mortem sign of drowning as co-extensive with the rule.

Excessive fluidity of the blood depends upon the rapidity with which the drowning took place. Slight hydræmia occurs in rapid submersion, but when the drowning has taken place slowly a large amount of water passes into the blood. In certain poisonings by opium this fluidity also exists; but it is claimed that analysis and the spectroscope may clear up the diagnosis.

Hydræmic engorgement of the liver is regarded as a characteristic fact by Lacassagne, who claims to be able to diagnosticate drowning from a single examination of this organ.[944]

It is now generally admitted that the presence in the stomach of a certain quantity of liquid in which the body was found immersed may be considered as a sign almost certain of asphyxia by submersion.

Dr. Fagerlund concludes from his experiments that liquids do not penetrate after death either the stomach or anus unless strong pressure be made. But when asphyxia occurs in water the liquid is found in the stomach and the intestines, where it is helped on by peristaltic movements. The pylorus is an obstacle to the passage of this water, the movement of which is easier when the stomach is empty and the submersion prolonged.[945]

The quantity and quality of the water may constitute important evidence; but to be of full value the water or other fluid found in the stomach ought to be the same as that in which the immersion has taken place.

The liquid, which may have been taken just before drowning, should not be noticed unless it exceeds half a pint; but anything peculiar in the fluids, either of the lungs or stomach, should be subjected to microscopic or other examination.

Presence of water in the middle ear is regarded as a thanatological sign of great value. Dr. Bourgier claims as the result of his examination that 23 cases out of 27 had water in the middle ear. Several German observers pretend to have found amniotic liquid in cases of fœtal asphyxia. The fluid may be aspired by a small pipette.

Many of the foregoing signs and lesions disappear or undergo variable alterations after sojourn in water, putrefaction, etc. They may, as they have done in the past, give rise to many controversies, so that presumptions only can be established. Hence the necessity for careful and detailed necropsy in such cases, with a view not only to minimize conjecture and uncertainty, but to prevent opposing counsel from entering the plea of negligence and incompleteness.

WAS THE DROWNING ACCIDENTAL, SUICIDAL, OR CRIMINAL?

Assuming the probabilities to be in favor of death by submersion, the question next turns upon the character of the event.

In the absence of lesions it is almost impossible to say whether the individual fell in, jumped in, or was pushed in the submerging fluid. The person’s antecedents should be inquired into—whether subject to epilepsy, vertigo, intemperance, or mental aberration. Alcoholism is an important factor in accidental drowning, and a person intoxicated may be drowned in very shallow water. A few years ago a young man over six feet tall, while bathing in a tributary of the Potomac River, near Washington, was drowned in only three feet of water. On considering all these circumstances, it may not be possible, even after careful inspection of the body and minute exploration of all the organs, to declare the drowning the consequence of an accident. The existence of traces of violence or of injury which may have occasioned death or disability, of such a nature as to render the person unable to defend himself, would seem to merit particular attention. But their presence leads to further consideration—were the marks of injury caused by the water itself, by some object in the water, or were they self-inflicted? Dislocations, fractures, and other injuries have been caused by jumping or falling into the water from a great height. I know an instance of a professional who, on jumping from a height of ninety feet, split his upper lip on striking the water with his mouth open. The autopsy in the case of Odlum, the Brooklyn Bridge jumper, is said to have shown rupture of the liver. On the other hand, many persons jump from great heights into water with perfect impunity. For many weeks at the London Aquarium a performer has nightly jumped into a tank from an elevation of 127 feet, and several persons have successfully jumped from bridges much higher.

Objects in the water that may account for cadaveric lesions are numerous. I have known a soldier, a good swimmer, to break his neck on diving from a river bank.[946] Other traumatic lesions may occur in a rapid current, from the breaking up of ice, from the screw or paddle-wheel of a passing steamer, or from aquatic animals.

A matter much discussed in connection with this subject—that of shark-bites—may enter into the question of survivorship where it is alleged that several persons during shipwreck or other disasters at sea have been devoured by sharks. Though an occasional accident, such bites are more a figment of the mind than a reality, as the concurrent testimony of disinterested observers will show. After years of investigation among nautical people and much experience as a swimmer in widely different parts of the world, I have no personal knowledge of such injuries, and have met but two persons that had any actual personal knowledge of shark-bites.

Documentary evidence as to shark-bites is also very scanty. During the last fifty years soldiers by the tens of thousands have swum at Fort Monroe, Virginia, yet there is no record of one having been bitten by a shark; nor have I been able to ascertain that any accident of the kind has occurred at Malta or at Gibraltar. There does not appear to be a record of any one ever having been bitten off the British Isles. I have been unable to ascertain that a single bite of the kind is reported among the medical records of our War or Navy Department or those of the Marine Hospital. In the West Indies but few facts are reported indicating danger from sharks, and these are not well authenticated. The same may be said as to newspaper accounts, which deserve about as much credence as the reports concerning sea-serpents. A few years ago a public journal gave an account of a boy who was bitten while swimming near New York and afterward died in a hospital.

But medical literature has a few reports of shark-bites. After ten years’ diligent search I have found seven references, the earliest in the London Medical Gazette, 1823, and the latest in the London Lancet, 1886. The bites occurred in Australia, South Africa, and India. The Hooghley and Ganges Rivers are the worst place in the world for sharks and alligators. A particular kind of shark, the Carcharras Gangeticus, which is very fierce and bold, sometimes dashes among the crowds at the bathing ghâts, and has been known to bite a boy in two feet of water. All persons bitten at these places generally die from the bite, for the reason that the shark, living on carrion, portions of which stick between the teeth, carries infection to those whom it may afterward bite. The former habit of throwing the dead in the river is supposed to account for the boldness of these particular sharks in attacking the human species.

Self-inflicted wounds rather suggest suicide, as numerous instances attest, where one or two kinds of death were intended to make assurance doubly sure. I once saw an Eskimo stab himself and then jump overboard from a ship off the Siberian coast. But as a rule suicidal drowning is unaccompanied by traumatic lesions, unless it be those produced by falls. Hence the absence of lesions leads to the presumption that the individual while living fell into the water or other fluid accidentally or voluntarily.

Exception may be made in the case of infanticide and homicidal submersion as the result of surprise, where a person taken unawares is suddenly and unexpectedly pushed or thrown into the water. A case in point is that of a man suddenly robbed and seized by three persons, who threw him into the river. Another is that of a man who, wishing to get rid of his wife, gave her arsenic. The effects of the poison being slow he induced her to take a walk along the river, and when her back was turned he pushed her rapidly off the bank into the stream, where she drowned. Death by submersion is rarely the result of murderous intent, and in the case of adults it is suddenly resorted to in order to paralyze resistance and facilitate the success of crime.

Submersion is oftener intended to hide a crime. A body may be taken from the water after murder or rape. Whether the cadaver is recent or one that has lain in the water a long time, the expert is confronted with a question of the differences that he may expect to find in a body drowned and one thrown into the water after death. This difficulty can only be resolved by considering all the signs and lesions furnished by the autopsy. No single sign or post-mortem appearance is characteristic of drowning, and none enables us surely to diagnosticate death by submersion either in putrid or fresh cadavers. Nor do we have any significant infallible signs that may serve as a parallel between the immerged post mortem and the submerged. The exterior signs being nearly the same in the two, the diagnosis must necessarily depend upon assembled circumstances, and these are liable to vary.

CIRCUMSTANCES THAT MAY AFFECT THE TIME OF SUBMERSION.

Putrid decomposition is the chief obstacle to diagnosis in a body that has been drowned. This presents great differences. The death happening in winter or summer, in a temperate or intertropical country, and sojourn of the cadaver in salt or fresh water, are each and all important details to be considered in studying the submergence of a body.[947]

It is only by studying the events in this order, along with the immediate signs of death, that the duration of the submergence may be conjectured. With anatomical appearances as the only guide it is impossible to fix the time of immersion. Many elements combined may affect even the gaseous putrefaction that takes place in submerged bodies. Summer heat and shallow or stagnant water hasten the development of putrid gas and subcutaneous emphysema which bring the cadaver to the surface, and that, too, sometimes in spite of precautions taken to insure the submersion. A case in point is the body of the Italian admiral, Caraccioli, mentioned in Southey’s “Life of Nelson.” Bodies weighted with lead or other heavy substance for the purpose of hiding crime have also been known to float in consequence of the putrefactive phenomena.

At Evansville, Ind., unsuccessful efforts were made to raise a sunken steamer with thirty head of cattle between decks. A few days after the attempt was abandoned the steamer was suddenly seen to float. The carcasses of the putrefying animals, swollen by gas, had sufficed to bring the wreck to the surface.

A great development of gas is very noticeable in what is known as a “blasted” whale, the stomach of which assumes balloon-like proportions. A few summers ago, at Provincetown, Mass., it was my rare fortune to be within a few feet of an enormously distended putrid whale, which suddenly exploded.

In cold countries drowned bodies are longer in coming to the surface. In Russia, for instance, in spring after the rivers and lakes have thawed, the bodies of numerous victims of alcoholism and accidental drowning of the previous winter are taken from the water. Last summer, at Quebec, I was present when the body of a man drowned the winter before came to the surface of the St. Lawrence River. On a visit to the northern lakes many persons connected with the navigation of Lake Superior told me that bodies drowned in its waters seldom or never came to the surface.

Specific gravity of the water itself may be an additional cause for the body coming to the surface. Dr. Tidy says that every structure of the human body floats in the water of the Dead Sea. The same cannot be said about the buoyancy of the water of Great Salt Lake, the accounts of which have been greatly exaggerated. It does not “support a bather as if he were sitting in an arm-chair and float him like a fresh egg.” Experience shows that there is no difficulty either in swimming or in sinking in its waters, the solid constituents of which are estimated to be about six and a half times more than that of sea-water. Analysis of Dead Sea water places the solid constituents at 24.580, while that of Salt Lake is 22.282. Another strong natural brine in the United States is said to be that of Syracuse Saline, New York, which contains 17.35 per cent of sodium chloride.

It is evident from what has been stated that no positive assertion can be made as to how soon a drowned body will rise to the surface, and at best any conclusion as to the date of submersion is so unsatisfactory that it may be said to be an unscrupulous use of guessing privileges. Errors in legal medicine are sadder in their consequences than those of medical diagnosis. The medical legist would therefore do well to preserve the frame of mind that often doubts and rarely affirms, and he should be circumspect enough to avoid dogmatic assertions about matters of uncertainty.

DEATH FROM STARVATION.

IN ITS MEDICO-LEGAL ASPECT.

BY

ENOCH V. STODDARD, A.M., M.D.,

_Emeritus Professor of Materia Medica and Hygiene in the University of Buffalo; Member of the Medical Society of the State of New York and of the Central New York Medical Association; Fellow of the New York Academy of Medicine and of the American Academy of Medicine; Late Surgeon 65th Regt. N. Y. Vols.; Late Health Commissioner, Rochester, N. Y.; etc., etc._

STARVATION.

GENERAL CONSIDERATIONS.

PHYSIOLOGY teaches that life can only be maintained in the living organism by a constant equilibrium between its waste and repair. =Nutrition= is a term by which we describe this double movement of renewal of the molecular structure of the body, and in this general sense only, that nutrition is synonymous with the maintenance of the organism in a stable condition, is it employed here.

This condition of equilibrium is maintained by a regular and constant supply of food.

=A food= may be defined to be a substance which, after introduction into the body, supplies material for the renewal of its tissues or sustains some of its vital processes. Foods vary greatly in their properties as restorative or constructive agencies, some containing but few essential properties, while others combine almost all of the elements required. As some foods contribute elements for tissue restoration, others are specially concerned in the calorifacient activities of the organism,[948] while others are marked in their tendency to take part, almost exclusively, in special chemical processes.[949]

The various articles used as foods contain nutritive elements combined with innutritious substances. They have been variously classified, but are conveniently divided into

I. Organic foods, {a. Nitrogenous (C.H.O.N.). {b. Non-nitrogenous (C.H.O.), {Oleaginous {Carbohydrates.

II. Inorganic foods, {a. Water, H_{2}O. {b. Saline substances.

Nitrogen enters largely into the composition of the body, and hence must be abundantly supplied and in combination.

Of the non-nitrogenous elements the most important are fat, sugar, and starch.

The inorganic principles are essential to the process of nutrition. Water, constituting 87 per cent of the bulk of the body, is demanded in constant supply; while the saline substances are necessary for the perfect performance of many of its chemical processes.

It is apparent that no single element can alone carry on the nutrition of the body, and hence variety in the supply of food, as well as sufficiency in its quantity, is essential to normal nutrition. Nor are these the only factors in this complex problem. Proper preparation of food, its supply at necessary temperatures,[950] and other requirements enter into the question of normal or sufficient alimentation.[951]

Alimentation is sufficient when it is so regulated that all the functions of the body are performed in a complete and regular manner. Insufficient alimentation induces a series of phenomena and a result which have been designated “inanition,” or “starvation.”

The exact amount of aliment required by each individual can only be stated in a general way. In the circumstances in which he is placed, the supply must be of such character and quantity as shall be proportionate to the constructive and reparative needs of his body. It is possible, however, to state a mean for the various ages and occupations of life.

Physiologists generally agree that in ordinary conditions of exercise the following represents the amounts of the several food elements necessary for the adult individual daily:

Albuminous substances 120 gms. = 4 oz. Fatty substances 60 ” = 2 ” Carbohydrates 360 ” =12 ”

Taking the fatty matters as the unit, the daily allowance would bear the following proportions:

Fats, 1; albuminoids, 2; carbohydrates, 6.

These quantities and especially the fats and carbohydrates, in conditions of hard muscular labor, must be increased; and the proportion would then stand:

Fats, 1; albuminoids, 1.7; carbohydrates, 7.

The division of this amount of food elements into proper portions during twenty-four hours is important. This must be regulated by the habits and other circumstances of the individual.[952]

The occurrence of death solely from privation of food is comparatively rare; yet it is sufficiently frequent to be considered as one of the causes of violent death and to demand investigation, since circumstances may be such as to constitute a homicide from criminal neglect or a suicide from intentional abstinence from food.

“=Starvation=,” or “=inanition=,” may be considered as being acute or chronic according as the requisite food has been suddenly and completely or gradually withheld.

ACUTE STARVATION.

The complete deprivation of food induces a series of modifications of the functions of the body, differing somewhat from those developed by a partial and prolonged deprivation. The length of time during which complete absence of food can be endured varies with circumstances. In absolute stoppage of the food supply the acute sensations of hunger pass away after the first one or two days, and are succeeded by profound functional disturbances with weakness and depressing sensations over the epigastric region, accompanied by distressing thirst.[953] The mouth is dry and the tongue heavily coated; the breath is fetid; the skin is harsh, dry, and exhales a disagreeable odor; the feces become more and more scanty until the latter days of life, when diarrhœa usually supervenes; the face and extremities become rapidly emaciated; the person walks with a weak and tottering gait;[954] the urine is small in quantity and very acid; muscular feebleness gradually reaches complete inability to move; ringing in the ears, insomnia and, in some cases, hallucinations[955] with delirium and convulsions precede death, though these latter symptoms are not uniformly observed.[956]

“CHRONIC STARVATION,” “CHRONIC INANITION.”

This form of starvation, met with most extensively during the prevalence of famine, also occurs in conditions demanding legal investigation.

=The symptoms= are sufficiently constant and characteristic. Emaciation becomes extreme, the skin dry and rough, exhaling a disagreeable odor and often covered with a coating not entirely attributable to filth; the breath is fetid and offensive. With some exceptions, the victim retains his consciousness and ability to move about, muscular efforts becoming more and more feeble; the voice becomes faint; the evacuations infrequent, dry and dark; the urine scanty and high-colored, death occurring suddenly at the end, with delirium in some cases.

The length of time during which these symptoms are developed and their intensity depend mainly upon the amount and character of the aliment actually supplied during the period before death.

Upon the PULSE and CIRCULATION the effects of starvation are manifest in increased frequency and feebleness of the cardiac contractions and lessened force of the cardiac impulse; this is more and more marked as the anæmic condition becomes profound. In some cases the pulse is greatly reduced in frequency, as well as in force, dropping as low as thirty-seven beats in the minute,[957] and auscultation reveals the existence of cardiac bruits.

In connection with enfeeblement of the circulation, a tendency to hemorrhagic conditions is common, with purpuric and petechial eruptions in some cases.

TEMPERATURE.—A subnormal temperature is frequently noted in the progress of chronic wasting disease. In inanition, which in some respects induces a similarly profound disturbance of the functions of nutrition, an analogous lowering of the body temperature occurs. Chossat clearly shows in his experiments the influence of starvation in depressing the body temperature. This abasement of temperature does not remain constant, but daily oscillations appear, differing from those occurring in conditions of normal alimentation.

While the normal diurnal variation in the fully nourished is about 0.3° to 1.0° C. (0.5° to 1.7° F.), in the starving this variation reaches 3.28­­° C. (5.4° F.). This rises to nearly double this amount during the latter days of life, and is greatly increased above this figure during the day preceding death. The temperature at the close falls to a mean of 24.9° C. (76° F.), and at the moment of death has been noted at 18.5° C. (66° F.).

EMACIATION.—Loss of weight is the most striking and constant symptom of starvation. The rapidity of its production and its extent are modified by circumstances. A very considerable loss of weight can be sustained by the ordinary individual without a fatal result.

Chossat[958] fully demonstrated the effects of inanition upon the various functions and organs of the body in animals, and has drawn the conclusion that a loss of weight exceeding four-tenths of the entire weight of the body is productive of a fatal result. These deductions may be adopted as applicable to the human species. This statement must be accepted as a mean, as it is capable of variation by circumstances, such as age, obesity, etc.

Death may occur before so great a loss has been reached in some cases, and in the obese the fat may disappear entirely and cause a loss reaching five per cent of the entire weight of the body, in a very fat animal, without a fatal result.

Bouchardat[959] considers that the important question is the extent to which the blood and organs of the body contribute to this loss of weight. Impoverishment of the blood by inanition, which at the time of death has been found to amount to six-tenths of its solid constituents, is one of the most vitally serious elements of this loss; and a relative increase of its watery portion appears, without regard to the employment of water as a beverage.

It must be remembered that in wasting diseases extreme emaciation may occur under a liberal diet, and may continue for a considerable time before death.[960]

The muscular system becomes greatly enfeebled, atrophied, and unable to perform its functions; the loss sustained by the muscles least used being most marked. The extent of muscular power possible in starvation varies in different individuals and in various circumstances.

The vigorous and healthy adult, as a rule, retains muscular power to a greater extent and for a longer period than the child or aged person, under similar circumstances.

Exposure to a rigorous climate, prolonged fatigue, etc., rapidly reduce capacity for muscular effort in conditions of inanition.

THE PERIOD AT WHICH DEATH OCCURS.

This is influenced by many circumstances. It is difficult to fix an exact period for the duration of life in complete deprivation of food, or acute starvation, and it is certainly more so in chronic inanition, when the modifying circumstances are increased in number and complexity.

A large number of cases of prolongation of life during a period of absolute deprivation of food which has been stated to extend over weeks and even months, cannot be accepted as free from error, and hence are not considered here.

A sufficient number, accurately observed and well attested by unimpeachable authorities, have led to the conclusion that the healthy adult, in a total deprivation of food, can exist for a period not exceeding ten to twelve days. On one of the Inman line of steamers, a young man, aged twenty years, endured absolute deprivation of all food and water during eleven days, recovery following.[961]

Sarah Jacobs, a child of thirteen years (“the Welsh fasting girl”), had been exhibited by her parents as a miraculous being under the pretence that she had eaten nothing during two years.

The child being placed under complete surveillance by four nurses from Guy’s Hospital for eight days, during which period no food was taken, died on the ninth day.

The post-mortem examination showed all organs of the body to be in a healthy condition. The stomach was empty, with the exception of three teaspoonfuls of a thin acid fluid. The intestines were also empty and their walls were not thinned. A layer of fat, half an inch or more in thickness, was found under the skin of the chest and abdomen. The liver was in a healthy condition, as also the kidneys and spleen. The bladder was empty.

The parents were tried on a charge of manslaughter and were convicted of causing death by criminal negligence.[962]

Caspar gives the details of a case observed by him of a man aged thirty-six years, who endured total abstinence from all food for eleven days, recovery following.[963]

Cases are reported of miners who have been imprisoned by accidents in mines for eight, nine, and nine and one-half days, with recovery following rescue at the end of this time.[964]

While the period stated may serve as a maximum limit to which life may be extended in acute starvation, there are circumstances which must be considered as modifying this.

=Body Condition.=—It need hardly be stated that the individual in perfect health can sustain complete inanition longer than the enfeebled or diseased. The presence or absence of fat modifies considerably the power of endurance.

=Age.=—Infants bear starvation badly and succumb more quickly than the adult. The aged, while they bear a moderate amount of food better than the young adult, do not endure a complete deprivation for so long a time.

=Cold.=—The depressing influence of cold upon the vital functions, especially in the young and feeble, renders it a powerful factor in shortening the duration of life in starvation.

=The Supply of Water.=—When all food is withheld, free use of water as a drink tends to increase the length of the interval before death. In several cases of protracted fasting, the use of water in moderate amount has been resorted to with the apparent result of amelioration of some of the distressing symptoms and lengthening the period of endurance.

Dr. Tanner, a physician, attempted in July and August, 1880, at New York, a complete fast of forty days’ duration, with the exception of the free use of water. In this case absolute abstinence from all nourishment is questioned, as no strict medical surveillance was maintained.

The Italian Succi, at New York, in 1890, undertook a voluntary abstinence from food for forty days, under surveillance, with the use of simple liquids and of some narcotic substance. He completed the fast, but beyond this fact the case is without scientific value.

=Catalepsy.=—Certain abnormal conditions of the nervous system are met where the activity of the vital functions is very considerably lowered and the various processes of the economy are in a condition of semi-suspension. Cases of this character have been observed where the supply of food has been almost entirely suspended for a period of several days, with but little emaciation and other symptoms characteristic of inanition.

WAS STARVATION ACCOMPANIED BY OTHER ILL TREATMENT?

This question may arise where evidences of starvation are apparent.

Such cases are met among young children neglected or abused by parents or those in whose care they may have been placed, or among the alienated or sick in the care of cruel or unsympathetic attendants.

Infants placed with “wet-nurses” or found in the so-called “baby farms” also furnish cases which fall under this head.

A careful examination into the collateral circumstances of the case, together with the results of a careful post-mortem examination, usually render a positive answer to this question possible.

POST-MORTEM EXAMINATION.

The dead body exhibits appearances quite characteristic.

=Emaciation= is very marked and sometimes reaches an extraordinary degree, surpassing that of prolonged and wasting diseases.

In extreme cases the fat entirely disappears throughout the body; the omentum and mesentery are entirely devoid of it, as well as the subcutaneous and intermuscular cellular tissue. The muscles are atrophied and the heart is sometimes considerably reduced in size; the liver and kidneys in some cases show great reduction of volume. The spleen also is small and often softened.

The =stomach= and =intestines= usually display an extensive thinning of their walls, so much so that their contents may be distinguished through them; their calibre also is frequently found to be diminished, though occasionally they may be distended with gas. Usually they are empty, or contain only a small quantity of bile and fecal matter. In some cases various foreign substances which have been swallowed by the victims to appease hunger have been found in them.

The thinning of the walls, so constantly noted, has been considered as a specially characteristic symptom of starvation.[965]

The congestion, softening, and ulcerations which have been observed in some cases cannot be considered as evidences of starvation or as its results, but rather as being due to an enteritis induced by the ingestion of improper substances.

The =gall bladder= is usually found filled with dark and inspissated bile. In death by starvation the entire organs of the body exhibit no specific form of disease. Evidences of the existence of an organic affection observed in the post-mortem examination at once raise the question:

WAS DEATH CAUSED BY STARVATION OR DISEASE?

Was the original disease aggravated by a failure to supply the patient with food, or are the lesions observed the result of starvation? A positive conclusion can be reached in such cases by carefully considering the results of a post-mortem examination together with other facts elicited by the inquiry.

Harriet Staunton,[966] a young girl, had been kept in close confinement by four interested persons, and removed in great haste, when in a condition of extreme prostration, to Penge, where she died, on the day succeeding her removal, in a state of extreme exhaustion and emaciation. Fat was absent from every part of the body; the stomach and intestines were empty, contracted, and their walls were greatly thinned.

A small deposit of tubercle was found at the summit of the left lung and a recent deposit of miliary tubercle beneath the arachnoid, upon the surface of one of the cerebral hemispheres. No other tuberculous deposits were found. The opinion given by the physicians making the post-mortem examination was that death resulted from starvation. This opinion was shared by Professor Virchow, of Berlin, who stated that the tuberculous deposits found could not explain the cause of death.

In this case the extreme emaciation, entire absence of fat, thinning of the intestinal walls, etc., were the determining conditions. While extreme emaciation alone is not sufficient to decide the case to be one of starvation, its existence, taken in connection with some of the conditions found constantly in persons known to have died of starvation, is a strongly corroborative fact. Nor can its absence be taken as conclusive evidence that death occurred from other cause than starvation, since in some cases of death from inanition emaciation has not been extreme and in a few cases not at all marked.[967] Instances of this character are reported by Taylor and others.

DISEASES PRODUCED BY STARVATION.

The effect of insufficient alimentation in the production of disease has long been recognized. It is understood that this result follows the deficiency in either quality or quantity. The so-called “famine fever,” prevalent in times of dearth, has afforded extensive opportunity for observation of the effects produced. The symptoms developed are those directly referable to impoverishment of the blood. Pallor, emaciation, nervous depression, derangement of the digestive organs, and muscular enfeeblement appear in every case.

The development of strumous, herpetic, and cutaneous diseases generally is marked.

Of the secondary effects, the cachectic condition induced expresses itself in pulmonary phthisis largely, while in infants and very young children intestinal disorders are specially frequent. Organic diseases already existing are seriously aggravated; wounds fail to heal, become ulcerative and sometimes gangrenous; while all degenerative processes are rapidly hastened to a fatal issue.[968]

INDEX.

ABDOMEN, contusions of, 580 post-mortem examination of, 370 wounds of, 580

ABDOMINAL VISCERA, rupture of, 582 wounds of, 582

ABSCESS of brain, 563

ACTIONS TO RECOVER FOR SERVICES (see Privileged Communications), 26 amount of recovery in, 45 elements to be proved in, 47 evidence in, 22-48

ACTIONS FOR MALPRACTICE, 73-87

ADIPOCERE, 451

AGE, determination of, 399

ALCOHOLISM, 564

ANTHROPOMETRY, 432

APNŒA, 709, 796

ARTERIES, wounds of, 578

ASPHYXIA, 708 by submersion, 796, 797 external appearances due to, 715 internal appearances due to, 718

AUTOPSIES, 301, 349 in cases of poisoning, 356, 371 late, 378 of fragments, 380 order of, 356

BILLS FOR SERVICES, effect of, 43

BLADDER, rupture of, 585 wounds of, 585

BLANK CHARGES, wounds by, 617

BLOOD, coagulation of, 488, 701 condition of, after burns, 653 extravasation of, in brain, 565 on weapons, 535 stains, 350

BODY (see Dead Body), examination of, 537 temperature of, 629

BONES, identification of, 390 old or recent? 391

BOOKS, medical, when and where used in court, 64 of original entry, when admissible as evidence, 48 of physician, see Privileged Communications

BRAIN, abscess of, 563 concussion of, 561 congestion of, in drowning, 796 extravasation of blood in, 565 post-mortem examination of, 362 wounds of, 569

BULLETS, 595 loss of weight of, 601 track of, 595

BURKING, 775

BURNS, 360, 639 by acids, 641 burning oil, 640 corrosives, 641 electrical currents, 664, 676 flame, 640 fused metals, 640 lightning, 694 petroleum, 641 cases of, 657 causes of death by, 645 classification of, 642 constitutional effects of, 644 local effects of, 643 period of death from, 649 post-mortem appearances of, 647 whether ante- or post-mortem, 649

CADAVERIC CHANGES (see Post-mortem), 441

CADAVERIC SAPONIFICATION, 451

CASES of burns, 657 of hanging, 760 of strangulation, 726 of suffocation, 787

CATALEPSY, 822

CAUSE OF DEATH, see Coroners from burns, 645 severe mechanical injury, 499 submersion, 797 wounds, 496, 497

CAUSE OF DEATH, hemorrhage as, 497 latent disease as, 503 shock as, 499 was it natural? 503 wounds as secondary, 509

CLOTHING, examination of, 352, 537

COLD, effects of extreme, 630

COMBUSTION, spontaneous, 647

COMMUNICATIONS, privileged (see Privileged Communications), 33

COMPENSATION, see Physician and Patient; Expert Witness; Coroners; Medical Examiners

CONCUSSION, 472 of brain, 561 spinal cord, 573

CONGENITAL PECULIARITIES, identity from, 403

CONSTITUTIONALITY of statutes regulating practice of medicine and surgery, 7-11

CONTRACTS between physician and patient (see Physician and Patient), 25

CONTRE-COUP, 559, 611

CONTUSIONS, 358, 467, 470, 523 by lightning, 695 of abdomen, 580 of head, 558 of neck, 570

CORONER (see Post-mortem Examinations), 331 is virtute electionis in America, 332 duties of, are both judicial and ministerial, 332 judicial authority of, relates to inquiries into cases of death, 332 jurisdiction of, 332 kinds of, at common law, 331 presumption that he has acted in good faith, 332 protected under same principles which protect judicial officers, 333 Effect of evidence and verdict, 343 at common law was equivalent to indictment by grand jury, 343 not so now, yet inquisition has same power until grand jury passes upon the case, 343 Evidence before, when admissible upon a subsequent trial, 344 Inquest, all evidence must be presented to jury, 342 coroner cannot hold a second inquest while the first is undischarged, 334 coroner has power to hold, 332, 334 is a judicial investigation, 333 must be held in view of the body, 335 separate inquests must be held over each of several bodies, 333 Jury and inquest, coroner may compel attendance of witnesses, 341 Jury and inquest, jurors must be from jurisdiction wherein coroner is empowered to act, 341 jurors must be sworn by coroner, 341 jurors must investigate and determine the facts, 341 jurors must view the body, 341 jurors not challengeable, 341 witnesses must be sworn by the coroner, 342 Massachusetts, see Medical Examiners office abolished by statute in, 338 statutory provisions in, 338 who may hold an inquest, 338 New York, coroner may issue warrant of arrest of person charged with the death, 341 must, after examination of charges, hold defendant to answer or discharge him, 341 must proceed to examine charges against accused upon his arrest, 341 inquisition and testimony must be filed, 340 jurors must inspect the body and hear the testimony, 340 jury must render verdict and certify it by an inquisition, 340 six or more jurors must be sworn, 340 statutory provisions, 339 testimony must be reduced to writing, 340 when inquest may be held, 339 Powers of, cannot delegate authority or appoint deputy, 333 contract will bind county for payment of reasonable compensation, 336 may employ professional skill to aid him, 335 may have body disinterred, 335 may issue process of apprehension, 343 Return of inquisition, 342 inquisition should be signed by the coroner and jury, 343 should certify that witnesses before the coroner were sworn, 343 verdict of the jury is final, 342 Rights of accused party before, 342 has not the right to be represented by counsel or to cross-examine witnesses, 342 is not permitted to produce witnesses to show himself innocent, 342 privilege of prisoner upon arrest, 344 testimony may be taken by the coroner in his absence, 342 under New York criminal code defendant is entitled to a hearing before a magistrate, 344

CRANIOMETRY, 394

CREMATION, 389

CUSTOM of physicians to serve each other gratuitously, 52

DEAD BODY, autopsies, 301, 349 changes in, 441 chemical examination of, 303 cooling of, 441 coroners’ duties concerning (see Legal Status of, Appendix), 301 crimes against (see Legal Status of, Appendix), 299 disposal of, 298 dissection, when permitted (see Legal Status of, Appendix), 302 district attorney’s powers concerning, 303 duty of burial, 298 examination of gunshot wounds, 610 exhumation of, 300 external examination of, 358 flaccidity of, 442 internal examination of, 360 legal status of, 297 Appendix, giving statutes concerning, 304 physical examination of (see Autopsies), 302 post-mortem examination of (see Autopsies; Post-mortem Examiners), 303 putrefaction of, 445 right of burial or removal, 301 saponification of, 451 seizure for debt forbidden, 299 statutes regulating interment or exhumation, etc., generally, 304 Alabama, 309 Arizona, 309 Arkansas, 309 California, 310 Colorado, 311 Connecticut, 311 Delaware, 312 Florida, 312 Georgia, 312 Idaho, 313 Illinois, 313 Indiana, 313 Iowa, 314 Kansas, 314 Kentucky, 314 Louisiana, 315 Maine, 315 Maryland, 315 Massachusetts, 316 Michigan, 316 Minnesota, 317 Mississippi, 317 Missouri, 318 Montana, 318 Nebraska, 318 Nevada, 319 New Hampshire, 319 New Jersey, 320 New Mexico, 320 New York, 320 North Carolina, 321 North Dakota, 321 Ohio, 322 Oklahoma, 322 Oregon, 323 Pennsylvania, 323 Rhode Island, 324 South Carolina, 324 Tennessee, 324 Texas, 325 Vermont, 325 Virginia, 325 Washington, 326 West Virginia, 326 Wisconsin, 326 temperature of, 441, 453

DEATH, apparent, 439 from anæsthetics, 516 burns, causes of, 645 period of, 649 whether accidental, suicidal, or homicidal? 657 cold, 633 post-mortem appearances in, 634 electrical currents, 683 hanging, proof of, 757 latent disease, 503 natural causes, 503 slight injuries, 507 starvation, 813 strangulation, proof of, 721 submersion, 794, 798 suffocation, proof of, 784 surgical operations, 515, 624 wounds, causes of, 496, 497 signs of, 440 time of, 437

DEFORMITIES, identity from, 403

DELIRIUM TREMENS, 514, 624

DIAPHRAGM, rupture of, 579 wounds of, 579

DIPLOMA OR LICENSE, how proved in court, 20

DISLOCATIONS, 476

DROWNING (see Submersion), 793

ECCHYMOSES, 467 ante-mortem, 444 post-mortem, 443, 444, 485

ELECTRIC CARS, 668

ELECTRIC LIGHT, effects of, on eyes, 676

ELECTRICAL APPARATUS, injuries from, 664

ELECTRICAL CURRENTS, burns from, 664, 676 direct injuries from, 671 direct symptoms of injury from, 676 fatal, 682 high tension, 666 indirect injuries from, 670 injury from, 664 internal symptoms caused by, 678 mechanical effects of, 675 mental symptoms from, 689 muscular contraction from, 677

ELECTRICAL RESISTANCE, 673

ELECTRICITY, 661 medical, 664 static, 673

ELECTROCUTION, 683

EROSION, 471

ERYSIPELAS, 511

EXAMINATION of body, 537 of clothing, 537 of surroundings, 541

EXCORIATION, 471

EXPERIMENTS, testing powder-marks, 613 with cadavers, 607

EXPERT WITNESS (see Privileged Communications), 49-72 compensation of, 60 competency of, 61 conduct of, in court, 65 definition of, 53 examination of, scope of, 65, 68 impeachment of, 64 in civil and criminal cases, 61 medical books, how may be used in examining, 64 practical suggestions, 70 summons of court must be obeyed, 60 system in Germany and France compared with that in United States, 54

EXPOSURE, effects of, 630

EXTREMITIES, wounds of, 589

FACE, wounds of, 569

FALLS, 549

FARADISM, 672

FIREARMS, evidence from, 600 examination of, 612

FLASH, identity by, 619

FOOTPRINTS, 427

FRACTURES, 359, 474, 491, 553 by gunshot wounds, 610 of ribs, 574 skull, 559 spine, 571 spontaneous, 474

GALL-BLADDER, wounds and rupture of, 584

GARROTTING, 571, 707

GENITAL ORGANS, post-mortem examination of, 376 wounds of, 588

GUNSHOT WOUNDS, see Wounds, Gunshot

HÆMATOMATA, 468

HAIR, identity from, 406 on weapons, 535

HANDWRITING, 434

HANGING, 707, 735 accidental, cases of, 774 cases of, 760 homicidal, 759 cases of, 767 judicial, cases of, 770 post-mortem appearances, 746 proof of death by, 757 suicidal, 758 cases of, 760 symptoms in, 740 treatment in, 744

HEALTH, BOARDS OF, see Practice of Medicine and Surgery physicians reporting contagious diseases to, not liable for mistaken reports, 23 powers, how governed, 23, 24

HEAD, post-mortem examination of, 361 wounds of, 557

HEART, in strangulation, 719 post-mortem examination of, 366 rupture of, 578 wounds of, 575

HEAT, effects of extreme, 635

HEMORRHAGE, 483, 497, 716

HYPOSTASES, 443, 716 internal, 444

IDENTIFICATION, 383 by flash of gunpowder, 619 from congenital peculiarities, 403 deformities, 403, 430 entire skeleton, 392 imprints, 427 injuries, 403 scars, 419 stigmata, 426 tattooings, 421 teeth, 401 in death from submersion, 802 of burnt remains, 389 human bones, 390 mutilated remains, 408 recently dead, entire cadaver, 415 surface signs for, 419

IMPRINTS, 427, 542

INCISED WOUNDS, see Wounds

INFANTS, liability of, for medical services, 37

INFORMATION, duty of patient as to (see Physician and Patient), 33

INJURIES, coagulation of blood in, 488 fatal, acts performed after, 493 identification from, 403 medical inspection of, 101 of abdominal walls, 580 viscera, 580 spinal cord, 571 spine, 571 slight, death from, 507 whether ante- or post-mortem, 482

INQUEST, see Coroners

INSANE PERSONS, liability of, for medical services, 39

INSOLATION, 636

INSULATION of electrical conductors, 667

INTESTINES, post-mortem examination of, 371 wounds of, 586

KIDNEYS, post-mortem examination of, 370 rupture of, 584 wounds of, 584

LARYNX, in death from hanging, 754 strangulation, 718 post-mortem examination of, 369

LICENSE (see Practice of Medicine and Surgery), 7 (or diploma), how proved in court, 20 licensed physician presumed competent as an expert witness, 58 licensed practitioner, pretending to be, when not a misdemeanor, 22 statutes requiring, constitutional, 7 suits cannot be maintained by persons without, 18 unlicensed practitioner not presumed competent as expert witness, 62 when may be compelled by courts, 14 when presumed, 19

LIGHTNING, 690 burns from, 694 contusions by, 695 effects on internal organs, 702 loss of consciousness from, 696 memory from, 696 paralysis from, 697 pathology of, stroke of, 700 staining of skin by, 696 symptoms produced by, 693, 696 wounds by, 695

LIVER, post-mortem examination of, 375 rupture of, 582, 808 wounds of, 582

LUNGS, in death from strangulation, 719 submersion, 805 post-mortem examination of, 368 wounds of, 575

LYMPHORRHAGIA, 470

MALPRACTICE, 73-87 abortion is, 74 civil cases concerning, 80 contributory negligence in, 87 criminal cases concerning, 73 damages for, 83 definition of, 73 degree of care and skill in, 80 evidence in, 84 inspection before trial in, 85 partners liable for, 84

MANNLICHER RIFLE, effects of, 619

MARKS OF POWDER, 608

MARRIED WOMEN, liability of, for medical services, 37

MASTER, liability of, for services rendered servant, 39

MASSAGE, not practising medicine or surgery, 28

MEDICAL EXAMINERS, see Coroners contract of coroner with, binds county to payment of reasonable compensation, 336 coroners may employ, 335 In Massachusetts: cannot hold autopsy unless authorized, 338 cannot hold an inquest, 338 in place of coroners, 338

MEDICAL SOCIETIES, by-laws of, 15 fee bill, 22

MEDICINE AND SURGERY, see Physician and Patient; and Practice of Medicine and Surgery

MUSCULAR CONTRACTION, from electrical current, 677

MUTILATED REMAINS, identification of, 408

NAILS, identification from, 406

NECK, contusions of, 570 wounds of, 569

ŒSOPHAGUS, post-mortem examination of, 369

OVERLYING, 774

PANCREAS, post-mortem examination of, 375

PATIENT, rights of, concerning confidential communications, 96

PHYSICIAN, action for professional services, 133 his books containing confidential entries, 110 his rights and duties concerning confidential communications, 132 receiver not entitled to his books of account, 110 what is a professional capacity? 123

PHYSICIAN AND PATIENT, contracts between, compensation for services, 37 conditional and unconditional, 34 consulting physicians, 44 duties of patient, 29, 30 physician, 28 employment, how terminated, 26, 28, 30 may be declined, 24 estates of deceased persons, when liable for, 43 express or implied, 26 express, 27 implied, elements of, 28 infants, liability of, 43 insane persons, when liable, 45 married women, generally not liable, 43 masters, liable for services rendered servants, 45 measure of recovery for, 45 patient presumed liable, 37 person calling in physician not presumed liable, 36, 41 physicians treating each other, when they may recover, 47 railway company, when liable for, in case of accident, 42 railway physicians, authority of, 42 relation of physician and patient, 119 compensation for services, right to sue for in United States, 26 how lost, 19 students’ services, 44 skill and care required of (see Malpractice), 28, 31, 32, 33 schools of medicine not recognized by courts, 15 standard of school professed must be attained, 31 stranger may not be called in without patient’s consent, 29

PITHING, 572

POISONING, 597

POSITION OF VICTIM, 541, 546

POST-MORTEM APPEARANCES, in death from burns, 647 cold, 634 hanging, 746 starvation, 822 strangulation, 713 submersion, 801, 804 sunstroke, 638

POST-MORTEM CHANGES, 441 ecchymoses, 443, 485 hypostasis, 443 lividity, 443 rigidity, 442, 453

POST-MORTEM EXAMINATIONS (see Autopsies, Coroners), 354 when and ow made by coroner, 337

POST-MORTEM WOUNDS, 355

POWDER-MARKS, 608, 612

PRACTICE OF MEDICINE AND SURGERY (see Physician and Patient), 7-25 acquirement of right, regulated by statutes, 7 constitutionality of, statutes regulating, 8 criminal cases, proof of, 19, 22 license for, may be compelled, 14 how proved, 20 medical societies and by-laws of, 14 fee bills, 15 massage not, 22 patent medicines, 14 statutory regulations concerning, in: Alabama, 137 Arizona, 139 Arkansas, 140 California, 141 Colorado, 144 Connecticut, 145 Delaware, 148 Dist. of Columbia, 149 Florida, 150 Georgia, 151 Idaho, 152 Illinois, 153 Indiana, 155 Iowa, 157 Kansas, 160 Kentucky, 160 Louisiana, 162 Maine, 164 Maryland, 165 Massachusetts, 167 Michigan, 167 Minnesota, 168 Mississippi, 169 Missouri, 171 Montana, 173 Nebraska, 175 Nevada, 177 New Jersey, 178 New Hampshire, 181 New Mexico, 181 New York, 183 North Carolina, 189 North Dakota, 191 Ohio, 193 Oklahoma, 193 Oregon, 194 Pennsylvania, 197 Rhode Island, 203 South Carolina, 203 South Dakota, 204 Tennessee, 205 Texas, 207 Utah, 209 Vermont, 211 Virginia, 212 Washington, 215 West Virginia, 219 Wisconsin, 222 Wyoming, 223 Great Britain, 224 Scotland, 224 England, 224 Ireland, 224 Brit. Columbia, 238 Manitoba, 242 N. Brunswick, 248 Newfoundland, 255 N. W. Terr., 258 Nova Scotia, 262 Ontario, 268 Prince Edw. Is., 278 Quebec, 284

PRIVILEGED COMMUNICATIONS, 91 cause of death, 111 communications to physician not privileged at common law, 91 “confidential communications,” 115, 118 between physician and patient, when privileged, 94 dependent upon professional capacity, 98 effect of excluding privileged evidence, 130 evidence admitted not to be commented on, 111 in criminal actions, 101 in lunacy proceedings, 103 of abortion, 102 of adultery, 102 of crime in civil actions, 101 of criminal intimacy, 102 of habitual drunkenness, 103 of value of physician’s services, 133 to establish privilege, 106 function of the court, 128 ground of privilege, 91 harmless admission no ground for exception, 111 how evidence of physician taken in New York, 97 how privilege established, 131 in actions for divorce, 102 in criminal actions, 101 “information,” 97, 115 “matters confided,” 99 “matter committed,” 97, 118 “matter necessary to enable a physician to prescribe or a surgeon to act,” 124 mental condition of patient, 103 necessity, 98 objections to evidence, 109 when made, 110 objection once made need not be repeated, 111 partner of physician, as privileged witness, 122 patient’s ignorance immaterial, 110 rights concerning confidential communications, 96 physician defined, 105 “duly authorized,” 105 as witness to establish privilege, 131 physician’s advice, 98 books, 110 cannot refuse to disclose when patient waives privilege, 99 knowledge, 98 presumption from failure to give privileged evidence, 130 privilege is patient’s, not physician’s, 107 “professional capacity,” 123 purpose of statutes prohibiting disclosures, 96 relation of physician and patient, 119, 122 result of legislation, 134 rights and duties of physician, 132 statutory privileges concerning confidential communications, 93 statutory privileges for waiver of privilege, 96 surgeon defined, 105 testamentary causes, 103 waiver after death of patient, in New York, 98 waiver of privilege after patient’s death, 108 by application for insurance, 111 by proof of death to insurance company, 111 by contract, 112 by infant, 108 by patient’s attorney, 107 by representative of deceased patient, 103 by requesting physician to witness will, 113 certificate of death, 115 effect of, 107, 110 infant’s, 113 taking physician’s deposition, 112 testimony of patient, 111 what constitutes, 111 what evidence is excluded, 97 what is privileged, 115 when patient may be contradicted by physician, 112 who may waive, 106 whose testimony is privileged, 105 witness, 97

PROJECTILE, course of, 615 evidence from, 600

PUNCTURED WOUNDS, see Wounds

PUTREFACTION, 445, 453 circumstances favoring, 447 retarding, 448 of immersed bodies, 450, 810

PYÆMIA, 511

RACE, determination of, from hair, 393 skeleton, 393

RAILWAY COMPANIES, when liable for medical services, 41

RAILWAY PHYSICIANS, authority as to employing nurses, 42

REPORTS, medico-legal, 381

RESISTANCE, electrical, 673

RESPIRATION, suspended, 439

RIBS, fracture of, 574

RIFLE, Mannlicher, 619

RIGOR MORTIS, 442, 453, 701

RUPTURE of abdominal organs, 582 bladder, 585 gall-bladder, 584 of heart, 578 internal organs, 553 kidneys, 584 liver, 582, 808 spleen, 584 stomach, 586

SAPONIFICATION, 451

SCALDS, 639

SCARS, in relation to identity, 419

SCHOOLS OF MEDICINE not recognized by courts, 15

SEPTICÆMIA, 510

SEX, determination of, 400

SHARKS, bites of, 808

SHOCK, 499

SHOT-GUNS, wounds by, 607

SIGNS OF DEATH, 440

SKIN, marks on, 419

SKULL, fracture of, 559 measurements of, 394

SMALL SHOT, wounds by, 617

SMOTHERING, 774

SPINAL CORD, concussion of, 573 post-mortem examination of, 377 wounds of, 571

SPINE, dislocation of, 572 fracture of, 571 wounds of, 571

SPLEEN, post-mortem examination of, 371 rupture of, 584 wounds of, 584

SPONTANEOUS COMBUSTION, 647

STABS, 463

STAINS, could assailant have escaped without? 538

STARVATION, acute, 817 chronic, 818 death from, 813 diseases produced by, 824 or disease, which was cause of death? 823 period of death from, 820 post-mortem appearances in, 822 whether accompanied by other ill-treatment, 822

STATURE, determination of, 398

STERNUM, fracture of, 574

STIGMATA, 426

STOMACH, post-mortem examination of, 373 rupture of, 586 wounds of, 586

STRANGULATION, 707, 708 accidental, 724 cases of, 734 cases of, 726 external appearances due to, 713 homicidal, 725 cases of, 726 internal appearances due to, 727 post-mortem appearances, 713 proof of death by, 721 simulated, 725 stages of, 710 suicidal, 724 cases of, 732 symptoms of, 708 treatment of, 712

STRUGGLE, signs of, 536

SUBMERSION, 793 asphyxia by, 796 cadaveric signs in death by, 804 circumstances modifying time of, 810 definition of, 796 mode of death by, 797 post-mortem appearances, 801 stages and symptoms of death by, 798 treatment of apparently drowned, 802 whether accidental, suicidal, or homicidal, 807

SUFFOCATION, 707, 774 accidental, 785 cases of, 787 by submersion, 796 cases of, 787 external causes of, 774 homicidal, 785 cases of, 790 internal causes of, 775 mechanical, 705 post-mortem appearances, 781 proof of death by, 784 suicidal, 785 cases of, 790 symptoms of, 777 treatment, 779

SUNSTROKE, 636

SURGEON, definition of term, 56 duties of, see Physician and Patient

SURGICAL OPERATIONS, death from, 515

SURVIVAL, 556

SYNCOPE, 796, 799

TATTOOING, 421

TEETH, determination of identity from, 401

TEMPERATURE of body, 629 of dead body, 441, 453

TETANUS, 513

THORAX, post-mortem examination of, 365 wounds of, 573

TIME OF DEATH, 437 how determined, 452

VEINS, air in, 579 wounds of, 578

WEAPONS, 353, 524 evidence from, 600 as to origin of wounds, 533, 549 examination of, 612 presence of blood and hair on, 535 was it fired from a distance or near? 612

WITNESS, see Expert Witness; Privileged Communications physician as expert and ordinary witness, 50 when must testify as, 60

WOUNDS, 358, 457 as directly cause of death, 497 as secondary cause of death, 509 by what instrument made? 517, 524 cause of death from, 496, 497 coagulation of blood in, 488 consequences of non-fatal, 556 contused, 467, 470, 523 death from, after long periods, 508 definitions of, 459 description of, 482 direction of, 529 eversion of lips of, 489 evidence from weapon, 533, 549, 600 examination of, 476 from crushing, 553 falling, 549 lightning, 695 gunshot, 593 by blank charges, 617 by shot-guns, 607 gunshot, by small shot, 617 complications of, 624 course of projectile, 615 death from surgical operations in, 624 description of, 594 dimensions of perforations, 609 direction of, 599 examination of, 594 of body in, 610 of entrance, 614 of exit, 614 situation of, 598 treatment of, 620 imputed, 544 incised, 460, 517, 557 diagnosis of, 462 kinds of, 459 lacerated, 471, 523 mortal, 460 nature of, 548 number and extent of, 531 of abdominal viscera, 580 walls, 580 arteries and veins, 578 bladder, 585 brain, 569 diaphragm, 579 extremities, 589 face, 569 gall-bladder, 584 genital organs, 588 head, 557, 558 heart, 575 intestines, 586 kidneys, 584 liver, 582 lungs, 575 neck, 569 spinal cord, 571 spine, 571 spleen, 584 stomach, 586 thoracic viscera, 573 thorax, 573 throat, incised, 526 origin of, evidence from weapons, 533, 549 punctured, 463, 518, 557 regionally considered, 557 retraction of sides of, 490 severe, 460 situation and position of, 527, 548 slight, 460 whether accidental, 547 ante-mortem or post-mortem, 482 necessarily the cause of death, 500 self-inflicted or by another, 525, 544, 548 which of several was first inflicted? 544 two was cause of death? 500

FOOTNOTES:

[1] The distinction made in the text and in the title of this work is not new. It was recognized by the father of medico-legal science, Zacchias, in his two prefaces, one to the “lector medicus,” the other to the “lector legumperitus” (“Quæst. Med. Leg.,” Ed. Venet., 1727, fol.). In a note to the introduction of the “Medical Jurisprudence” of Dr. Paris and Mr. Fonblanque (the first work produced by joint authorship of a physician and a lawyer, in 1823) is the following (p. i.): “Some authors have objected to the term Medical Jurisprudence as implying a knowledge of the laws relating to medical topics, rather than an acquaintance with the medical science necessary for the elucidation of legal subjects. As it is our peculiar object to unite the sciences and to show their mutual relevance, the title becomes most applicable to this, although it may have been improperly affixed to former works.” The title of one of two existing French works in whose authorship a lawyer is associated is: “Traité de Médecine légale, de Jurisprudence médicale et de Toxicologie,” par Le Grand du Saulle, Geo. Berryer et Gab. Pouchet, 2d ed., 8vo, Paris, 1886.

[2] “Bibl. Hist.,” I., ii., 77; Miot’s transl., Paris, 1834, i., 157.

[3] L. c., I., ii., 82; transl., i., 165.

[4] L. c., I., ii., 75, 76; transl., i., 152.

[5] The “Papyros Ebers,” in the University of Leipzig, the most ancient medical text known, was written about 1550 B.C., and is probably one of the books referred to by Diodorus. It contains no statement bearing upon our subject. It is, however, simply a collection of descriptions of remedies, and their uses, including the incantations to be used with them. (See “Papyros Ebers,” H. Joachim, Berlin. 1890.) The same is true of the Berlin and Leyden papyri. The Bibl. Nat. (Tf. 2) possesses a Chinese manuscript on legal medicine. The catalogue does not, however, state to what period it belongs.

[6] For an account of early Indian medicine, see Th. A. Wise, “Review of the Hist. of Med.,” Lond., 1867, i., 272 et passim; “Hindu System of Medicine,” 1845, by the same author; Haeser, “Lehrb. d. Gesch. d. Med.,” 3. ed., i., 5-40.

[7] Hippocr.: “De Superfœtatione,” ed. Littré, viii., 472.

[8] Hippocr.: “De Septimestri partu;” ibid., “De Octimestri partu,” ed. Littré, viii., 432, 436, 452.

[9] “Aphorismi,” vi., 18, 24; “De Morbis,” ed. Littré, vi., 144.

[10] Petit, S.: “Leges Atticæ,” Lugd. Bat., 1742, lib. iii., tit. 8.

[11] “Od.,” iv., 229; xvii., 384.

[12] For an excellent account of Attic criminal procedure, see Kennedy, C. R.: “Demosthenes’ Orations,” ed. Bohn, iii., 326-372.

[13] “Var. Hist.,” iii., 38.

[14] Kennedy’s transl., ed. Bohn, v., 95.

[15] What the contents of these depositions were and by whom made is unknown, as the papers referred to by the orator are not given. In the Attic courts the testimony was taken at a preliminary trial, and referred to at the trial by the orator.

[16] “Oratores Attici,” C. Müller, Paris, 1877, i., 20.

[17] “Oratores Attici,” C. Müller, ed. Didot, Paris, 1877, i., 200-203.

[18] In a doubtful fragment of Lysias the expression “as physicians andmidwives declare” (ὡσπερ οὶ ἰατροὶ καὶ αὶ μαῑαι ἁπερηναντο) is used in connection with the question whether a fœtus has life and may be murdered. Cf. “Orat. Attici,” Müller and Hunziker, Paris, Didot, 1858, ii., 257.

[19] “Jul. Cæs.,” 82.

[20] “Hist. Nat.,” xi., 71.

[21] “Hist. Nat.,” vii., 4.

[22] A. Gellius: “Noct. Att.,” 1. 3, c. 16: “requisitis veterum philosophorum et medicorum sententiis.” The word “veterum” seems to indicate that the emperor consulted books, not living physicians.

[23] “Medici non sunt proprie testes, sed majis est judicium quam testimonium.”

[24] For accounts of the medico-legal provisions of the Justinian enactments, see: G. A. v. d. Pfordten, “Beiträge z. Gesch. d. ger. Med. aus d. Justin. Rechtssam.,” Würzburg, 1838: M. F. Eller, Bull. Med. Leg. Soc. N. Y., 1879, i., 226-237; and Friedreich, Blt. f. ger. Anthr., Nürnberg, 1850, I., iii., 1-64; 1862, xiii., 188-215.

[25] See Mende: “Handb. d. ger. Med.,” Leipzig. 1819, i., 83-87.

[26] “Etablissements et Coûtumes, Assises et Arrêts de l’Echiquier de Normandie au xiii. Siècle,” A. J. Marnier, Par., 1839: “veue d’homme en langueur, veue de méfaits, veue d’homme occis et veue de femme despucelée.”

[27] “Ut peritorum judicio medicorum talis percussio asseveretur non fuisse letalis,” Mende, “Handb. d. ger. Med.,” i., 91.

[28] Hensschel, in “Janus,” Breslau, 1847, ii., 135.

[29] Assises de Jérusalem,” Beugnot, Paris, 1841-43, quoted by Ortolan, l.c., infra.

[30] Ortolan: “Débuts d. l. Méd. lég.,” Ann. d’Hyg., Par., 1872, 2 s., xxxviii., 361.

[31] “Registre Criminel du Châtelet de Paris,” Par., 1861, i., 255.

[32] Ibid., i., 313.

[33] Ibid., i., 375, 409.

[34] “Quæst. Medico-legales,” t. ii., lib. vi., tit. ii.: vol. ii., pp. 33-49, ed. Venet., fol., 1737.

[35] See also “Reg. Crim. Chât. de Paris.,” i., 204, ii., 429; Desmaze: “Hist. Méd. Lég.,” 11-20, 33-41.

[36] Isensee: “Gesch. d. Med.,” i., 216.

[37] “Constitutio criminalis Carolina.” The first edition was printed at Mayence, 1533, fol., by J. Schöffer. See also Kopp, “Jahrb. d. Staatsarznk.,” Frankf., 1808, i., 183.

[38] “Con. cr. Car.,” art. 147.

[39] Ibid., art. 149.

[40] Ibid., arts. 35, 36, 131, 133; “Bambergische Halssgerichts-Ordenung.” Bamb., 1507, art. 44.

[41] “Con. cr. Car.,” art. 37.

[42] Ibid., art. 134.

[43] Ibid., arts. 135, 179, 219.

[44] “Non per quoslibet, nec per insipidos et imperitos, sed tantum per peritos ac doctos medicos aut chirurgos,” p. 245.

[45] “Praxis Rerum Criminalium,” Antw., 1554 (the dedicatory epistle is dated 1551), pp. 245-252, 223-228.

[46] Wildberg, “Bibl. Med.-for.,” Berl., 1819, Nos. 553, 554, 1,124, 1,125, 1,126, 1,304, 1,835, 1,836, 2,342, cites nine works earlier than 1575. These are, however, monographs on the period of gestation, witchcraft, fasting girls, drunkenness, and wounds of the head.

Works on toxicology were written at a much earlier date: the Θηριακά and Αλεξιφάρμᾶκα, of Nicander, ca. B.C. 135; θeπερὶ δηλητηρίων φαρμάκων, of Dioscorides, ca. A.D. 50; the treatises, “De Venenis,” of Petrus de Abbano (ca. A.D. 1250), first printed Mantua, 1472; of Arnoldus da Villanova (ca. A.D. 1300), first printed (sine loc. et an.) ca. 1470; of Santes de Ardoynis, Venice, 1492, and of F. Ponzetti, Venice, 1492, are among the earliest. Works on toxicology are not considered in this Introduction, the historical sketch of that science being reserved for a later volume.

[47] Ed. Malgaigne, 1840, t. iii., l. xxvii., pp. 651-658; ed. princ., Paris, 1575, fol., pp. 931-944. On the title-page of an earlier work, printed in 1562, Paré is referred to as “chirurgien ordinaire du Roi, et Juré à Paris.” Ploucquet, “Lib. Med. dig.,” Tüb., 1809, iv., 349, mentions a monograph by “Tygeon, Th.,” printed at Lyons, 1575.

[48] S. Pineau: “De notis Integritatis et Corruptionis Virginum,” Paris, 1598; A. Hotman: “De la Dissolution du Mariage par l’Impuissance,” etc., Paris, 1581; de la Corde, “Ergo Virgo ... lac in mammis habere potest,” Paris, 1580. Wildberg, l. c., Nos. 555, 1,308, 1,309, are not properly medico-legal.

[49] In his “De Vitiis Vocis,” etc., Frankf., 1597. He had previously published a treatise, “De morbis veneficis ac veneficiis,” Venet., 1595.

[50] “De relationibus medicorum ... in quibus ea omnia quæ in forensibus ac publicis causis medici referre solent,” etc., Panormi, 1602. Mongitore, “Bibl. Sic.,” Panormi, 1707-14. i., 199, mentions an edition of 1598, Pan., under the title: “Bissus [Birrus?], sive medicorum patrocinium,” etc.

[51] “Quæstiones Medico-legales,” Rome, 1612-35, 3 t., fol. See also Kerschensteiner: Friedr. Bl. f. ger. Med., etc., Nürnb., 1884, xxxv., 401-410.

[52] Wildberg, “Bibl. Med.-for.,” gives the titles of thirty-four treatises on legitimacy, impotence, sterility, signs of virginity, etc., published in France during this period.

[53] On reports: Réné Gendri, 1650; Nicolas de Blegny, 1684; J. Devaux, 1693; Prevot, 1753; H. M. Maret, 1757. On signs of death: P. E. Dionis, 1718; J. B. Winslow, 1740; S. J. Bruhier, 1745.

[54] On the signs of death, 1752; on the distinction between suicide and murder by hanging, 1763; on the duration of pregnancy, 1764, etc. These and other articles on drowning, etc., are collected in his “Œuvres diverses de Chirurgie,” 2 vols., Par., 1788.

[55] Cases of Monbailly, Syrven, Calas, Cassaigneux, Baronet, etc.

[56] “Recueil de pièces relatives à la question des naissances tardives,” Amst. and Par., 1766, 2 vols.

[57] “Consult. Méd.-lég. s. u. Accus. d’Infanticide,” 1785; “Obs. Chir.-lég.,” 1790; “Méd.-lég.,” 1809; “Consult. et Rapp. sur diverses obj. d. Méd.-lég.,” 1824; “Mém. méd.-lég. s. l. Viabilité,” 1826; “Consult. Méd.-lég. s. u. cas d’amp. d. l. Cuisse,” 1828.

[58] “Les Lois éclairées par les Sciences physiques,” Par., 1798, 3 vols., 8vo; “Traité de Méd.-lég. et d’Hyg. publ.,” Par., 1813, 6 vols., 8vo.

[59] “Méd.-lég.,” etc., Rouen, 1801; Paris, 1807, 1811.

[60] “Cours. de Méd.-lég.,” Paris, 1809, 1811, 1819.

[61] “Aperçu et obs. s. l. Méd.-lég.,” Lyon, 1811; “Secours aux Asphyxies,” Lyon, 1818; “Man. d. Méd.-lég.,” Lyon, 1821.

[62] In the later editions Chaudé took the place of Brosson, and a chemist, J. Bouis, was added.

[63] Devergie, “Méd.-lég.,” 1836, contains a legal chapter by de Robécourt. Paris and Fonblanque, “Med. Jurispr.,” Lond., 1823; Wharton and Stillé, “Med. Jur.,” Phila., 1855; Le Grand du Saule, Berryer et Pouchet, “Tr. de Méd.-lég. de Jur. méd. et de Tox.,” 2d ed., Par., 1881.

[64] “Sur les Attentats aux Mœurs,” 1st ed., 1857; 7th ed., 1878; “Sur l’Avortement,” 1856, 1861, 1868; “Sur la Pendaison,” etc., 1865, 1870, 1879; “Sur l’Empoisonnement” (with Z. Roussin), 1867, 1875; “Sur l’Infanticide,” 1868; “Sur la Folie,” 1872; “Sur les Blessures,” 1879; “Sur les Maladies, etc.,” 1879.

[65] Lib. iv., cap. ix.: Qua ratione morbum simulantes deprehendi queant; cap. x.: testificandi methodus circa eos, quibus venenum fuit exhibitum; cap. xi.: testificandi ratio in vulneribus capitis; et in iis qui aquâ fuerunt suffocati; cap. xii.: Quomodo amissa virginitas: et alterius utrius conjugis sterilitas deprehendatur.

[66] “De renunciatione vulnerum,” etc., Lips., 1689, 8vo (“Egregium opus,” Haller).

[67] “De officio medici duplici, clinico nimirum et forensi,” Lips., 1704, 4to (“Eximius liber,” Haller).

[68] “Pandectæ Medico-legales,” etc., Francof., 1701, 4to; “Novellæ Medico-legales,” etc., Francof., 1711, 4to; “Corpus Juris Medico-legale,” etc., Francof., 1722, fol.

[69] “Medicina forensis, hoc est responsa facultatis medicæ Lipsiensis ad quæstiones et casus medicinales, ab anno 1650 usque 1700,” Francof., 1706, 2 vols., 4to.

[70] “Der medicinische Richter, oder Acta physico-medico forensia Collegii medici Onoldini,” Onolzbach, 1755, 4to.

[71] “Systema Jurisprudentiæ Medicæ,” etc., 6 vols., 4to, Halle, Leipzig, and Görlitz, 1725-47.

[72] “Institutiones Medicinæ legalis et forensis,” Jena, 1723, 1731, 1740, 1762.

[73] “Medicina forensis demonstrativa,” etc., Frankf., ad Viadr., 1723; “Introductio in historiam litterariam scriptorum qui medicinam forensem commentarius suis illustraverunt,” Frankf., 1723, 1735.

[74] “Elementa Medicinæ forensis,” Jena, 1767, published posthumously.

[75] Hebenstreit: “Anthropologia forensis,” Lips., 1753; Ludwig: “Institutiones Medicinæ forensis,” ed. 2, Lips., 1774.

[76] “Beiträge zur medicinischen Gelehrsamkeit,” etc., Halle. 1748-54; “Sammlung medicinischen ... Zeugnissen,” etc., Leipz., 1776; “Institutionum Medicinæ publicæ,” etc., Lips., 1778.

[77] “Kurzgefasstes System der gerichtlichen Arzneywissenschaft,” Königsb. u. Leipz., 1793.

[78] “Entwurf der gerichtlichen Arzneiwissenschaft,” etc., Frankf., 1796-1801, 4 vols.

[79] “Collectio Opusculorum selectorum ad Medicinam forensem spectantium.” Lips., 1785-90, 6 vols.

[80] “Conspectus Medicinæ legalis,” etc., Prague, 1780.

[81] “Elementa Medicinæ et Chirurgiæ forensis,” Viennæ, 1781; “Toxicologia,” etc., Viennæ, 1785.

[82] Magazin für die gerichtliche Arzneikunde und medicinische Polizei, Stendal, 1782-87, 6 vols. Pyl also published “Aufsätze und Beobachtungen aus der gerichtlichen Arzneiwissenschaft,” Berlin, 1783-93, 8 vols. Uden was the first to edit a medical journal in Russia.

[83] “Vollständiges System der gerichtlichen Arzneikunde,” Stendal, 1795-1800; “Beiträge zur praktischen und gerichtlichen Arzneikunde,” Stendal, 1799.

[84] Jahrb. der gesam. Staatsarzneikunde, Leipzig, 1835-40, 7 vols.; Bibliotheca Medicinæ publicæ,” Berol., 1819, 2 vols. Between 1804 and 1849 Wildberg published fifteen books and treatises on medico-legal subjects.

[85] Kritische Jahrb. f. d. Staatsarznk. f. d. xix. Jahrb., 1806-09. Jahrb. d. Staatsarznk., 1808-19.

[86] Zeitschrift für die Staatsarzneikunde, Erlangen, 1821-64, 118 vols.; “Lehrbuch der ger. Med.,” 1te Aufl., Berlin, 1812, 13te Aufl., Berlin, 1859.

[87] “Visa Reperta,” Wien, 1827-45, 3 vols.; “Systematisches Handb. d. ger. Med.,” Wien, 1te Aufl., 1813, 5te Aufl., 1846.

[88] “Ausfürl. Handb. d. ger. Med.,” Leipzig, 1819-32, 6 vols.

[89] “Handb. d. ger. Med.,” Berlin, 1841.

[90] “Enzyklop. Handb. d. ger. Arzneyk.,” Leipzig. 1838-40, 2 vols.; Magazin f. die Staatsarzneykunde.

[91] Centralarch. f. d. ges. Staatsarznk., Ansbach, 1844-49; Blätter f. d. gerichtliche Anthropologie, Erlangen, 1850, now published at Erlangen under the title Friedreich’s Blätter f. ger. Med. u. Sanitätspolizei.

[92] “Gutachten u. Aufsätze,” etc., Leipzig, 1847; “Auswahl von Gutachten,” etc., Dresden, 1853.

[93] “Beiträge z. medicin. Statistik,” etc., Berl., 1825-35, 2 vols.; “Denkwürdigkeiten z. medicin. Statistik,” etc., Berl., 1846; “Gerichtl. Leichen-Oeffnungen,” Berl., 1851-53, 1850-52; “Klinische Novellen,” etc., Berl., 1863.

[94] “Pract. Handb. d. ger. Med.,” Berl., 1te Aufl., 1857-58; 8te Aufl., Berl., 1889, also translation of Geo. Balfour, New Sydenham Soc., London. 1861-65. The fourth and succeeding editions, published after Casper’s death (1864), were edited by Karl Liman, his successor in the chair of medical jurisprudence (d. 1892).

[95] Vierteljahresschr. f. ger. u. öffentl. Med., Berl., 1852, edited after Casper’s death by Horn, 1865-70, Eulenberg, 1871-90, Wernich, 1891.

[96] “Handb. d. ger. Med.,” Tübingen, 1881-82, 4 vols.

[97] Daniel: “Bibl. d. Staatsarznk.,” Halle, 1784, No. 107, mentions: “E. Prat, Rationarium chirurgicum, oder nothwendiges Handbuch des Wundarztes, wie er Bericht an die Obrigkeit thun soll u. s. w., aus dem Engl.,” Hamb., 1684. 4, 690. 8. The same title is reproduced by Wildberg (No. 239) in 1819, and the edition of 1684 is mentioned by Ploucquet, “Initia” (1803), Suppl. iv., 36, and “Litt. med. dig.” (1809), iii., 54, the name of the author being given as “Pratt (Elias).” This may be an early work by Ellis Pratt, but we can find no mention of it elsewhere. In the years 1734, 1761, and 1787 dissertations on abortion were defended at Edinburgh by Arnot, Harris, and Murray. Three treatises on death from suffocation by Goodwyn, Frank, and Coleman appeared in 1788-91. In 1788 S. Farr published at London his “Elements of Medical Jurisprudence,” to which Percival (“Med. Ethics,” Oxford, 1849, p. 102) justly refers as “a valuable epitome of S. F. Faselii’s “Elementa Medicinæ Forensis [Regiom., 4to, 1787], in English by Dr. Farr.”

[98] “Med. Jur.,” iii., p. 226 seq. Report that Joseph Lane died of poison (1623). Report that Sir James Standsfield was strangled and not drowned, with account of autopsy (1687). Also extracts from the medical evidence in the cases of Spencer Cowper (from 13 Howell’s “State Trials”); Mary Blandy (Oxford, 1752); John Donellan (Warwick, 1781); and R. S. Donnall (Launceston, 1817).

[99] “Heads of Lectures on Medical Jurisprudence, or the Institutiones Medicinæ legalis,” vi., 24 pp., 8vo, Edinb., 1792.

[100] See Beck “Med. Jur.,” 7th ed., xvi., and note.

[101] In the preface Dr. Percival says: “This work was originally entitled ‘Medical Jurisprudence,’ but some friends having objected to the term Jurisprudence it has been changed to Ethics.” An unfinished and unpublished edition, written prior to 1794 and containing Chapter IV., was printed about 1800 (see Editor’s Preface, p. 2, and note, Author’s Preface, pp. 25, 26, ed. Oxford, 1849).

[102] “An Epitome of Juridical or Forensic Medicine,” etc., viii., 199 pp., 8vo, London, 1816, also in Th. Cooper’s “Tracts on Med. Jur.,” Phila., 1819. In the preface the author refers to the lectures of Prof. Duncan.

[103] This excellent work (“The Principles of Forensic Medicine”) went through three editions in six years. Dr. Smith, who was a teacher of medical jurisprudence in the Royal Institution, Westminster Hospital, and University of London, and also published a number of papers in the Edinb. M. and S. Jour., and “Hints for the Examination of Medical Witnesses,” Lond., 1829, died at the age of forty-one in 1833, after fifteen months’ imprisonment in a debtors’ prison.

[104] “Med. Jur.,” 3 vols., 8vo, London, 1823. See note 1, p. v.

[105] “A Manual of Med. Jur.,” London, 1831, 2d ed., 1836, Amer. ed., with notes by R. E. Griffith, Phila., 1832.

[106] “Outlines of a Course of Lectures on Med. Jur.,” Edinb., 1836, 2d ed., 1840, Amer. ed., Phila., 1841.

[107] A. Amos, Lond. M. Gaz., 1830, vii.; 1831, viii. A. T. Thomson, Lond. M. and S. J., 1834-35, vi.; 1835, vii.; also Lond. Lancet, 1836-37, i., ii. (Thomson’s lectures were printed in German in book form, Leipzig, 1840.) H. Graham, Lond. M. and S. J., 1835, vi., vii. W. Cummin, Lond. M. Gaz., 1836-37, xix. T. S. Smith, Lond. M. Gaz., 1837-38, xxi.; 1838, xxii.

[108] Dease: “Med. Jur.,” and Haslam: “Med. Jur. Insanity,” along with the treatises of Farr and of Male, are reprinted in Cooper’s “Tracts on Med. Jur.,” Phila., 1819.

[109] Synop. Mod. Med. Jur.,” Lond., 1829.

[110] “Treatise on Med. Jur.,” Lond., 1834; Phila., 1836.

[111] “Homicide by External Violence,” Lond., 1837.

[112] “Med. Jur.,” Dublin, 1839.

[113] “Cases in Leg. Med.,” Edinb., 1840.

[114] “Med. Jur. of Insanity,” Lond., 1840.

[115] “Criminal Jurisprudence in relation to Mental Organization,” London, 1841.

[116] “Principles and Practice of Med. Jur.,” 1st ed., Lond., 1865; 3d ed., Lond., and Phila., 1883. “On Poisons,” 1st ed., Lond., 1848; 3d ed., Lond., 1875. “Lectures on Med. Jur.,” Lond. M. Gaz., 1846, n. s., ii., iii.; 1847, n. s., iv. Articles on arsenic, antimony, strychnine, and other toxicological subjects, strangulation, blood-stains, etc., in Guy’s Hosp. Repts.

[117] “Principles of Forensic Medicine,” Lond., 1844. The work is now in its sixth edition. Prof. D. Ferrier, Dr. Guy’s successor in King’s College, having been associated in the authorship of the 4th ed. in 1875 and subsequently.

[118] “Lectures on Med. Jur.,” edited by Fr. Ogston, Jr., Lond., 1878.

[119] Woodman and Tidy: “A Handy-book of Forensic Medicine and Toxicology,” Lond. and Phila., 1877. Tidy, “Legal Medicine.” 2 vols., Lond., 1882-83; also, Phila., 3 vols., 1882-84; New York, 3 vols., 1882-84.

[120] “Cirurgia Forense,” etc., 3 vols., 12mo, Madrid, 1796-97. Wildberg mentions two earlier monographs: “De partu Septimestri,” Antw., 1568, by F. Mena, physician in ordinary to Philip II.; and “Diez privilegios para mugeres prennantes,” Complut., 1606, by J. A. de Fontechia, professor at Alcala de Hénares.

[121] “Elementos de Medicina y Cirurgia legal,” etc., Madrid, 1834; 4th ed., Zaragossa, 1844.

[122] “Tratado de Medicina y Cirurgia legal,” etc., Madrid, 1844; 5th ed., 4 vols., 8vo, Madrid, 1874-75.

[123] “Instituições de Medicina forense,” Paris, 1832; 2d ed., Lisbon, 1840.

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