Chapter XXXII: Section 6: ,216, same as 303, N. Y. P. C (13)

=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.