Chapter XXXV: Section 6: ,216, same as 303, N. Y. P. C (16)

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

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

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

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

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

SYMPTOMS.

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

We will consider first those relating to the nervous system.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Headache is not rare as a later or secondary symptom.

Disturbances of sensation other than pain are not rare.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

PATHOLOGY AND PATHOLOGICAL ANATOMY.

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

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

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

AUTOPSIES.

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

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

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

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

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

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

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

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

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

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

THE MEDICO-LEGAL CONSIDERATION

OF

DEATH BY MECHANICAL SUFFOCATION

INCLUDING

HANGING AND STRANGULATION.

BY

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

_Pathologist Army Medical Museum, Washington, D.C._; _Professor of
Anatomy Medical Department Howard University, Washington_; _Secretary
Association of American Anatomists_; _Late Acting Assistant Surgeon
United States Army_; _President of Association of Acting Assistant
Surgeons U. S. A._; _Member of Learned Societies_.

MECHANICAL SUFFOCATION.

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

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

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

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

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

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

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

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

STRANGULATION.

SYMPTOMS AND TREATMENT.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

POST-MORTEM APPEARANCES.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

THE PROOF OF DEATH BY STRANGULATION.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Putrefaction may cause external marks to disappear.

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

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

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

STRANGULATION: ACCIDENTAL, SUICIDAL, HOMICIDAL, SIMULATED.

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

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

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

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

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