Chapter XXXIII: Section 6: ,216, same as 303, N. Y. P. C (14)

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.

BURN, TWO HOURS AFTER DEATH, BY IRON AT A DULL RED HEAT.

BURN, TWO HOURS AFTER DEATH, BY TIN CAN CONTAINING BOILING WATER.

BURN BY STEAM, SIXTY HOURS AFTER INJURY.

POST-MORTEM AND ANTE-MORTEM BURNS.]

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.