51. _Friedberg: Gericht. gutacht., p. 240._—New-born child found dead

in closet. Mother stated that she had taken the child by the neck and drew it into the world. Opinion given that the child had been accidentally choked to death by the hand. For other cases, see Tidy, “Med. Jur.,” Cases 15 to 19, 59, and 62; Maschka, “Handbuch,” p. 623. HANGING. Hanging is a form of mechanical suffocation by ligature of the neck, in which the constricting force is the weight of the body itself. The French call it “Pendaison” or “Suspension,” preferably the former; the Germans, “Erhängen.” The expression “incomplete hanging” is applied to those cases in which the subject is partially supported; kneeling, sitting, or otherwise. The same expression has also been used for cases which did not prove fatal. The pathological effects of hanging are partly those of strangulation, to which must be added the effects of the weight or fall of the body, sustained as it is only by some form of ligature around the neck. These additional injuries will, of course, be proportioned to the weight of the body, length of rope, and suddenness of the fall. In some countries, as the United States, England, Germany, and Austria, hanging is a mode of capital punishment. It is desirable that for judicial purposes it should be divested, as far as possible, of unnecessarily cruel features; the victim should quickly be made insensible, and death be speedy. Many suggestions to this end have been made, among which is that of Haughton. He recommended that the drop be long, say ten feet, so that the cervical vertebræ may be dislocated. He also advised that the knot be placed under the chin. Others advise that it be placed under the left ear; and others yet, as Barker, of Melbourne,[798] near the spine. In any event the rope should be “freely elastic.” G. M. Hammond[799] thinks that the object in judicial hanging should be strangulation, and that the criminal should be pulled up and left to hang thirty minutes; the rope should be soft and flexible so as to closely fit the neck; a weight should be attached to the feet of persons under 150 pounds. Larimore[800] also advocates strangulation instead of attempting dislocation of the vertebræ. Porter[801] suggests that for dislocation the noose be drawn tightly around the neck at the last moment, the knot being either at one side or, still better, in front. Dislocation may be still further assured if a hollow wooden or leaden ball be placed over the knot close to the neck, thus forming a fulcrum to throw the spinal column out of the perpendicular line at the point of pressure. Hanging is a common mode of suicide, especially in insane asylums and prisons. It is sometimes accidental, and rarely homicidal. It is said to have been attempted for erotic purposes. The compression of the neck acts in line with the axis of the body; while in strangulation it acts perpendicularly to that axis. The final cause of death will depend on: 1. The suddenness and completeness of interference with the access of air; asphyxia. 2. Pressure on the large veins of the neck, preventing the return of blood from the head, causing congestion of brain and coma. 3. Pressure on the large arteries of the neck, preventing access of blood to the brain; causing anæmia of the brain and syncope. 4. Injury to spinal cord or pneumogastric nerves or all of them; causing paralysis. A combination of numbers 1 and 2 is usually found in suicidal hanging; and probably all of them in homicidal and judicial hanging. The more protected the air-passages are from pressure the greater part will coma or syncope have in the cause of death. Mackenzie,[802] as the result of examination of 130 suicidal hangings, says that 119 died of asphyxia, 8 of asphyxia and apoplexy, 2 of syncope, and 1 of apoplexy alone. Coutagne[803] thinks œdema of the lungs, “œdema carminé,” has an important part in causing death. The following conditions tend to produce asphyxia: a tight ligature, or a loose ligature above the hyoid bone. To produce coma, a loose ligature pressing against the hyoid bone or larynx, especially a cretified larynx. To both asphyxia and congestion of brain, a ligature just beneath the lower jaw, or around lower part of neck. Hofmann[804] states that when the ligature is placed between the larynx and hyoid bone, the base of the tongue is pushed upward against the posterior wall of the pharynx, completely stopping respiration and causing asphyxia. Taylor[805] states that if the rope presses on or above the larynx, the air-passages are _not_ so completely closed as when pressure is below the larynx. In the latter case death would be immediate; in the former a slight amount of respiration might continue. The instantaneous loss of consciousness is due, not to asphyxia alone, but to compression of the large vessels, especially the carotids, against the transverse processes of the vertebræ, causing rupture of the middle and inner coats, and at the same time compression of the jugular veins and pneumogastric nerves. Immediate unconsciousness will almost certainly follow compression of the pneumogastrics. He also believes that the loss of consciousness and of power of self-help occur at the moment that the noose is tightened around the neck. There is no record of any one who attempted suicide by hanging seeking to recover himself, although no doubt some would have done so if the speedy unconsciousness had not prevented. Hofmann mentions the case of a man who was found hanging, and with a loaded revolver in his hand, apparently having intended to shoot as well as hang himself, but lost consciousness before he had time to discharge the revolver. According to him the causes of death are three: occlusion of the air-passages, interruption of passage of blood to brain, and compression of pneumogastric nerves. Von Buhl[806] experimented on cadavers and concluded that in hanging, the epiglottis and arytenoids are pressed over the glottis, and the tongue and the œsophagus against the vertebræ, causing death by apnœa. When the trachea was isolated from the vessels and tied, the air-passages below became dilated and the lungs emphysematous and anæmic. The heart continued to beat and blood to circulate. The vertebral arteries being much smaller than the carotids, the circulatory disturbance in the brain is not adjusted with sufficient promptness. Compression of the pneumogastrics, according to Waller,[807] has caused subjects to fall to the ground as if struck by lightning. He holds that the unconsciousness in hanging is the result of the compression of the pneumogastric nerves and not of the arteries. Thanhöfer[808] knew a student who had acquired a certain dexterity in compressing these nerves. One day he compressed the two nerves, his pulse stopped and he became unconscious. Thanhöfer[809] tried bilateral compression of pneumogastrics in a young man sentenced to be executed. The pulse fell at once and the heart soon stopped; the eyes were fixed and glassy. It was some time before he regained consciousness and for two days there was _malaise_. Hofmann says that the compression irritates and, in a higher degree, paralyzes the pneumogastric nerves and causes disturbance of the action of the heart. Faure[810] denies that the constriction of the vessels of the neck has any effect in the production of symptoms[811]. Coutagne believes that the pressure on the pneumogastric nerve is a factor in causing death. He hung two dogs; in one the pneumogastric nerves were dissected out and placed in front of the ligature; this dog (No. 1) lived a quarter of an hour and died of pure asphyxia with efforts at inspiration continued to the end. The other dog (No. 2), in which the nerves were compressed, died in five minutes. In both, the abdominal organs were congested and the cavities of the heart were full. The lungs of the first were dry and uniformly red; of the second were resisting, crepitant, and quite œdematous. No subpleural ecchymoses in either. The experiments on animals by Corin[812] led him to conclude that pressure on the pneumogastrics caused increased frequency of the heart-beat and slowing of respiration. Pellier[813] considers the subject quite fully. It would appear that the pressure on the pneumogastrics disposes to stop the action of the heart and cause rapid, perhaps instant death. The pressure on the carotids causes cerebral anæmia and is then only a secondary cause. Levy[814] does not think the action of the pneumogastrics is sufficiently well known. Tidy states that a dog lived for three hours suspended by a rope placed above an opening in the windpipe; and that Smith[815] mentions the case of a criminal who was hung; Chovet tried to save the man by making an opening in the trachea before the execution and introducing a small tube. The man was alive forty-five minutes after the drop, but could not be resuscitated, although the surgeon bled him. In a small proportion of cases of hanging, homicidal and judicial, death occurs by dislocation of the spine. This is said to have been first noticed by the celebrated Louis, who states that the Paris executioner was in the habit of giving a violent rotary movement to the body of the convict as the trap was sprung, causing a dislocation of the odontoid process and compression of the cord and almost instant death. Taylor[816] says that for dislocation the body must be heavy and the fall long and sudden. Devergie[817] found this to occur in about two per cent of cases. It is said that the Paris hangman placed the slip-knot under the chin in front, which is as Dr. Haughton suggests. Death may occur from secondary causes after apparent recovery; from congestion of brain and other lesions of the nervous system; these may prove fatal at remote periods. Fracture of the odontoid process according to M. de Fosse is more common than dislocation, and the giving away of the intervertebral substance more likely than either of the others. The phrenic and other respiratory nerves are likely to be paralyzed; the vertebral and carotid arteries may be ruptured. The medulla oblongata is also likely to be fatally injured. Death may also occur from hemorrhage upon the cord, causing pressure. Besides the ropes used as ligatures in judicial hanging, almost every conceivable article that could be made into the semblance of a cord has been used by suicides; usually, however, some portion of the bedding or clothing. When one resolves on suicide, all the precautions of the managers of prisons and asylums fail to prevent. The secondary effects in those who recover involve the respiratory organs—dyspnœa, cough, bloody sputa, bronchial râles, and fever; or the nervous system—aphonia, dysphagia, numbness, chilliness, spasms, pains in neck, face, or shoulder; sometimes paralysis of bladder and rectum, and loss of memory. The marks on the neck slowly disappear.[818] Verse[819] collated a number of cases in which the hanging was not completed and the subjects lived for varying periods afterward. Wagner and Möbius[820] discuss the spasmodic seizures and amnesia, which often appear after the restoration from hanging. SYMPTOMS IN HANGING. Obviously these will be in some respects identical with those of strangulation. In considering the latter, some of the similarities and dissimilarities of symptoms and post-mortem appearances of strangulation and hanging were mentioned. Death may be immediate and without symptoms. There is, of course, no preliminary or “waiting” stage, as in strangulation, except in those rare cases of suicide where the subject inclines his body forward with his neck against the ligature, his body being near the floor or ground. The absence of a drop makes this condition very similar to ordinary strangulation. The body of a victim of homicide might be similarly placed for the purpose of deception, and also that of a subject previously made unconscious; in these cases the symptoms and appearances would resemble those of strangulation. In other words it is necessary that there should be a drop or fall, or at least the weight of the body, to produce the characteristics of hanging. The jerk of the fall or sudden dependence of the body upon the ligature causes a much greater constriction of the ligature on the neck, and in a different direction, than in strangulation; and also a much greater pressure on the blood-vessels and nerves of the neck. Tidy divides hanging into three stages: First stage: Partial stupor lasting thirty seconds to three minutes, according to the length of the drop, the weight of the body, and tightness of the constriction. The testimony seems to be uniform that there is no pain in this stage; indeed, that the feeling is rather one of pleasure.[821] The subjective symptoms described are an intense heat in the head, brilliant flashes of light in the eyes, deafening sounds in the ears, and a heavy numb feeling in the lungs. Sometimes there is a feeling of absence of weight. In many cases efforts to breathe are made for a time after the air-passages are closed. It is doubtful whether there are any voluptuous feelings, as has been suggested. Chowne[822] reports the case of Hornshawor, “Monsieur Gouffé,” who was in the habit of hanging himself for exhibition. He fixed the noose with a knot that would not slip, sprang into it, the rope coming behind the lower jaw and the two sides passing up behind the ears. He would hang for ten to fifteen minutes, and in addition to his own weight would sustain one hundred and fifty pounds. Three times the rope slipped and he would have died but for the help of spectators. He described his sensations as follows: He lost his senses all at once. The instant the rope got in the wrong place he felt as if he could not get his breath, as if some great weight was at his feet; and could not move only to draw himself up; felt as if he wanted to loosen himself but never thought of his hands. He said: “You cannot move your arms or legs to save yourself; you cannot raise your arms; you cannot think.” Taylor[823] mentions the case of Scott, the American diver, who was in the habit of making public exhibitions of hanging. The last time he hung for thirteen minutes, the spectators not suspecting that he had died. It is supposed that the ligature had slipped. Taylor also reports a case (from Dr. Elliott) of a boy, age 11, who, to frighten his parents, tied a knot in a handkerchief and put it around a knob and his neck in one continuous ligature. The pressure against the trachea was so effective that he became unconscious and died before he could relieve himself. Second stage: The subject is unconscious and convulsions usually occur. The convulsed face, however, is a part of the general agitation and does not indicate pain. In judicial cases the face is covered with a cap. Sometimes there are no spasms. Urine, fæces, and semen may be discharged in any stage. Jaquemin, however, in forty-one cases of hanging, noted discharge of urine and fæces only twice. Semen has, however, been found in the urethra where none was ejected externally.[824] Third stage: All is quiet except the beating of the heart. As a rule, the pulse may be felt for ten minutes. Blankenship[825] reports an execution of a man by hanging. After the rope was adjusted the pulse was 121; first minute after drop, pulse 54; second minute 52; third 39; fourth 20; fifth 0; sixth 70; seventh 73; eighth 0; ninth 34; not perceptible afterward. Died from strangulation; neck not dislocated. The heart beat once in the nineteenth minute; from the ninth to the nineteenth, only two or three times. No priapism. In judicial executions, however, the right auricle is found in action when the subject is taken down at the end of the usual period of suspension (see Case 89). Tardieu mentions a case where the heart was beating 80 to the minute one and one-half hours after supposed death. It is probable that in these cases the deprivation of air and compression of the vessels has not been complete. In such cases life may sometimes be restored. Cases are reported where restoration has been possible within a period of a half-hour of suspension; although the fatal period is usually five to eight minutes at most. If, however, the tissues and especially the spinal cord are injured, or the ligature has compressed below the larynx, the chance of recovery is very small, even if the body is cut down at once. According to Faure, animals experimented upon die in twelve to twenty minutes. Many cases of “incomplete” hanging have been reported; where the feet touch the floor, or would do so if the subject should choose to have it so. Tardieu[826] collected 261 cases, in 168 of which the feet touched the ground, in 42 the subject was on his knees, in 29 the body was lying, in 29 sitting and in 3 squatting. Hackel,[827] in 67 cases of hanging, found it incomplete in 34 per cent. [Illustration: FIG. 22.—Suicide of Prince Condé. (See page 763.)] In one of the experiments of Faure[828] a large dog was hung, his feet touching the ground. For five minutes he was quiet, breathing without difficulty. He then tried to release himself, but instead tightened the knot; he made still greater efforts to release himself, became comatose and fell, apparently dead, at the end of ten minutes; was really dead in twenty-eight minutes. In incomplete hanging the upper limbs may have any position; the lower limbs are disposed according to the position of the body (Cases 1, 10, 18, 19, 20, 22, 24, 26, 28, 37, 43, 50, 56). Faure[829] made many observations on dogs which he killed by hanging. He describes the results as follows: The dog remains quiet usually twenty to thirty seconds, sometimes eight to ten minutes; then becomes violently agitated, the body being thrown forward and backward so powerfully that it bounds to a great height; the head is in motion; the jaws parted; the feet extended and flexed; sometimes brought up to the mouth and neck, trying to remove the obstruction; the inside of the mouth is violet-colored; tongue blackish, livid, may be bitten, often falls backward; the teeth are ground together; the eyes sometimes protrude; conjunctivæ congested; urine and fæces discharged. The agitation lasts two to five minutes, and then the dog gradually becomes quiet. Toward death, however, the agitation is renewed but in a different way; the fore feet are raised and put forward, the tongue often has a peculiar spasm, the chest is raised, the eyes drawn back into the orbits, pupils contracted; all of this is over within two seconds. Such paroxysms may be repeated half a dozen times. In dying, the eye oscillates from side to side and the pupil dilates. The heart beats some time longer. Francis Bacon records that he knew a man who wanted to find out by experience if there was any suffering in hanging. He placed the cord around his neck and stepped off a bench, intending to step back again, but became immediately unconscious and would have died but for the opportune arrival of a friend. He said he saw a light before his eyes. TREATMENT. The first indications obviously are to let the subject down, and remove all constriction of neck and chest. Artificial respiration should then be used, and this may be assisted by the vapor of ammonia to the nose and tickling the fauces. If the body is warm, cold affusions may be applied to the head and chest, and galvanism may be used. If the body is cold, apply warmth. Friction of the limbs aids in restoring warmth. If the subject can swallow give stimulants; these may also be used by rectum. Venesection may be required to relieve cerebral congestion or distention of the right heart and pulmonary circulation. The following cases illustrate what may be done to resuscitate one who has been hanged: A man, age 35, in good health, weight one hundred and sixty pounds, was executed with a drop of over six feet; the rope slipped behind the mastoid process. After three minutes his struggles ceased; the radial beat ceased at six and one-half minutes; all signs of life at ten and one-half minutes, and the body was blue. Fourteen and one-half minutes, body let down; mark about one-fourth inch deep on neck; swelling above and below; no fracture of vertebræ. Strong galvanism of the pneumogastrics after sixteen or seventeen minutes at intervals of four seconds caused marked respiratory efforts; sixty-six minutes, galvanism renewed; heart-beat and radial pulse recognized; epiglottis swollen, requiring the tongue to be drawn forward; a few ounces of blood removed; pupils contracted. One hundred and four minutes, galvanism renewed; subject swallowed a little brandy-and-water. One hundred and thirteen minutes, slight muscular action; cornea sensible. One hundred and eighty-six minutes, feet warm, carotid pulsation. Signs of life now increased till six hours after drop, when pupils began to dilate again. Twelve to fifteen ounces of blood were taken and pupils again contracted and pulse beat strong and steady; breathing easy, more regular; eyes followed movements of persons around the room. Died nine hours later, fifteen hours after drop. The experiments were repeatedly interrupted by the sheriff.[830] Taylor[831] reports a case of recovery. Woman, age 44; found hanging from a clothes-line, thrown over a door and fastened to a handle on the other side; her knees on the floor; white froth around the mouth; tongue protruding and swollen; face dusky and swollen; lips dark blue; brown parchment mark on neck; skin abraded over larynx; conjunctiva insensible; pupils dilated and fixed; fingers clinched; limbs flaccid; no reaction from tickling feet; no respiration; faint heart-beat and fine thready pulse. Sylvester’s artificial respiration method used at once and continued for four and one-half hours; tongue held forward by forceps. One hundred and fifteen minutes after body was first seen there was spontaneous movement of legs. One hundred and forty-five minutes, conjunctivæ sensible. One hundred and seventy-five minutes, retching. Two hundred and five minutes, free vomiting. She recovered but remembered nothing of the hanging. Keen[832] reports the results of experiments upon a criminal who was executed by hanging. He was cut down about half an hour after the drop. Faradization and galvanization of pneumogastric and recurrent laryngeal nerves caused movements of left vocal cord, but not the right; there was no reflex motion in the larynx. The left phrenic nerve made no response to stimulus. The internal intercostal nerves caused the raising of the cartilage below them (inspiratory), the external intercostals depressed the upper seven ribs (expiratory), and raised the eighth. The other four not examined. The muscles of the face retained their contractility. Very few, comparatively, however, have been restored after hanging. For cases of recovery see _Medical Times and Gazette_, London, 1871, Vol. I., p. 669 (Cases 12, 13, 42, 44, 47, 49, 66). POST-MORTEM APPEARANCES. The post-mortem appearances are external and internal. The =external= appearances are those due to the action of the ligature on the neck and to other violence, if any has been done, and those due to asphyxia or syncope. The MARKS of the ligature. If the suspension be very brief and the ligature soft and supple, and the body instantly cut down after death, there may be no mark. Allison[833] questions the value of the mark, contending that it is post mortem, and reports cases; says it is present only if the drop be considerable or the suspension continue after death. Tidy says that the mark is, in a measure, independent of the ligature and duration of suspension, and does not usually acquire its color for some hours after death; sometimes, however, it has occurred in a much shorter time. It may be slight because the ligature has been placed over the clothing. The longer a body hangs after death, the more the mark shows. It can be produced upon the cadaver. Harvey[834] says: “The characteristic mark is sometimes found in non-fatal cases.... In eight instances in the present returns (of nearly 1,500 cases of hanging) there was a distinct mark.” Coutagne,[835] in twenty-four necroscopies on subjects hung, found only slight or doubtful lesions in five cases; but of these, one was in a condition of advanced putrefaction, another was apparently weakened by loss of blood from wounds, and in the other three there were marks of violence. In seventeen cases the lesions of the neck were plain; hemorrhage in connective tissue or muscle. The direction of the mark is usually oblique, following the line of the lower jaw upward and backward behind the mastoid processes; it may, however, be horizontal. If the ligature encircles the neck more than once, one mark may be circular, the other oblique. If a running noose is used the mark may be circular, and be seen all the way around the neck, looking like the mark of a strangulation. Taylor[836] states that if the noose should be in front, the mark may be circular, the jaw preventing the ligature from rising upward in front as much as it does behind. If it encircles the neck but once, its continuity is apt to be broken by the prominence of the hyoid bone, thyroid cartilage, sterno-mastoid muscles, etc. In four-fifths of the cases (117 out of 143, Tardieu) the mark is found between the chin and larynx; in nearly all the remaining fifth, over the larynx; in a very few below the larynx; the last position is due to the protection of the neck by a handkerchief or beard, or where there is some anatomical or pathological peculiarity which prevents the ligature from going higher. Hofmann[837] had seen two cases of tumor of neck; one in a woman, where the cord was below the larynx; and in a man where it was over the larynx. He quotes[838] as follows: Remer, above larynx, 38; over larynx, 7; below larynx, 2. Devergie, above larynx, 20; over larynx, 7; below larynx, 1. Casper, above larynx, 59; over larynx, 9. Roth[839] in 49 cases found the ligature mark above the hyoid bone in 5; between the bone and the larynx, 31; over the larynx, 8; below the larynx, 1. Hackel found the ligature in forty per cent of cases between hyoid bone and larynx; in sixty per cent lower down. The ligature always appears lower after the body is laid down than it was in suspension. Maschka found the furrow 147 times in 153 cases above the larynx. The mark will vary in character according to the kind of ligature used, its mode of application, the vitality of the tissues, and the period that has elapsed since death. The result is different according as the knot or loop is single or double, a running or slip knot. The mark may differ in character in one part of the neck from another. The same furrow may be soft in one part and dry in another. The width of the mark does not necessarily correspond to the diameter of the ligature. A double mark usually means that the ligature has been twice passed around the neck, although the marks may not be continuous or parallel. Tardieu states that a large single leather thong pressing on the neck only by its borders may make a double mark. The mark is usually _depressed_. The depth of the depression, groove, or furrow, as it is called, is greater the narrower and firmer the ligature, the longer the suspension, and the greater the weight of the body. The mark may be merely a slight depression, without color, or only a red blush, if the subject is young, tissues healthy, and suspension brief. Roth,[840] in 49 cases of hanging, found the furrow of the ligature was brown in 40, red-brown in 6, and 3 times bluish. In about two-thirds of the cases the bottom of the furrow, the place of greatest pressure, is white, especially so where the knot is tied; while the edges of the furrow are usually slightly raised and red or livid. If the subject is very fat, there may be only a slight depression. Harvey[841] says that this hard, white, shining, translucent band from compression of the connective tissue is the first stage of the parchment or vellum skin, and is chiefly noticed in fresh bodies. The borders are swollen and œdematous, called by Lacassagne “_bourrelet de sillon_.” The skin beyond the furrow is usually violet. Authors differ as to whether this is due to congestion or hemorrhage. Roth[842] in 49 cases found swelling below the furrow 27 times. Hackel found ecchymoses above the mark in thirty-five per cent of the cases of hanging. Hofmann thinks that the lividity of the upper border of the furrow is due to the stopping of the venous blood descending from the head. The dry, hard, yellowish-brown, or reddish-brown “parchment” furrow, described by writers, is said to be common. Ogston[843] found it in one-third of his cases. It is found only when the body has remained suspended for several hours after death; indeed, may be produced by applying the ligature to the cadaver; is not at all, therefore, a proof of suspension during life. Liman states that constriction by a ligature even for some time does not necessarily cause a mummified or excoriated furrow. He saw cases in which the mark was soft, flat, scarcely colored, but little interrupted, and not parchmenty. The parchment skin seems to depend very much upon a previous excoriation of the skin. Its appearance can be prevented or delayed by examining a body soon after death or by rehanging it; and after it has appeared it will disappear on the application of some liquid. Taylor[844] compares this parchment mark to the cutis from which the cuticle has been removed for two or three days. Slight abrasions and ecchymoses are sometimes found in the furrow. Ecchymoses alone do not indicate whether suspension has been before or after death; but abrasions with hemorrhage strongly suggest suspension during life. Devergie regards ecchymoses of the neck as strongly suggestive of homicide. Neyding[845] says that suggillation in the groove is oftener found in strangulation than hanging. And Bremme[846] that there is no hemorrhage in the subcutaneous tissue of the mark if death occurs at once and the cord is removed at once after death; but if the cord remains for some time after death there may be hemorrhage, or if death does not occur at once, whether the ligature be removed or not. Roth[847] found ecchymoses or small bladders at the lower margin of the furrow, 9 times in 49 cases. Riechke found only once in 30 cases a hemorrhage beneath and on both sides of the mark. Chevers did not find ecchymoses of the skin of the mark in cases of hanging. Casper found no ecchymoses in 50 of 71 cases. Maschka has seen two cases where burns on the neck resembled mark of ligature. The furrow, when once distinct, remains constant for a long time after death, even in putrefaction. Marks from soft substances, however, disappear sooner than those from strong and uniform compression. The NECK nearly always appears stretched. According to Roth the mobility of the head is increased by this stretching. The HEAD is always inclined to the opposite side to that of the knot. In suicides the head is usually bent forward on the chest. The HANDS are often clinched so tightly that the nails are driven into the palms. This occurs more especially when the hanging has been done with violence. When the feet touch the ground, as often occurs in suicide, the hands may be stretched out. Roth found the hands and feet flexed in 44 of 49 cases. Taylor says that we may expect to find the hands clinched when constriction of the neck is sudden and violent. The LEGS are usually livid. The FACE varies with the duration of the suspension; at first it is pale, afterward livid; congested and swollen, if the subject has been long suspended. Roth found the face pale in 43 of 49 cases. In about one-half the cases the features are calm and placid (syncope). Maschka found the lips bluish in 98 of 153 cases. The EYES are often prominent, staring, and congested, and usually the pupils are dilated. Lacassagne and Maschka[848] look upon ecchymoses of the eyelids and conjunctivæ, “_piqueté scarlatin_,” as important as favoring the idea of hanging or strangulation. Roth found in 49 cases the eyelids closed 28 times; half open, 12; congested in 6; ecchymosed in 2. Pupils dilated in 31; narrowed in 2. Dilated in 97½ per cent of Ogston’s cases (Cases 85, 86; rupture of crystalline lens). Harvey[849] says the blood was found flowing from the EAR in 6 cases of nearly 1,500, but no details were given. Ogston, one case. Hofmann saw a case in which there was bleeding from the ears. He says this is not due, as has been supposed, to rupture of the tympanic membrane, but to hemorrhage from subcutaneous vessels (Case 27). The TONGUE is usually livid and swollen, especially at the base. According to Tidy, Dr. Guy looks on this as showing that suspension took place very probably during life. In about one-third of the cases the tongue is protruded and compressed between the teeth; sometimes bitten. Some observers found it protruded only as a result of putrefaction. The protrusion of the tongue is not believed to depend on the position of the ligature. Hackel in 67 cases found the tongue lying forward in all cases where the cord was between the larynx and the hyoid; in 55 per cent in front of the teeth, in 18 per cent between the teeth; where the ligature was lower down, the tongue was behind the teeth. He found by experiment that in the spasmodic expiratory effort the tongue was thrust forward; in the inspiratory movement, drawn backward. He concluded that the forward movement was the result of reflex action. Maschka[850] found the tongue between the teeth 58 times in 149 cases. Roth in 49 cases found the tongue projecting and bitten in 22, the teeth shut in 15 others; in 15 the mouth was open; the tongue was retracted in 30 cases. Harvey, after examining reports of nearly fifteen hundred hangings, says: “In the majority of instances immediately after death the features were placid, the face pale, the eyes not unduly prominent, the mouth closed or half open, the tongue pressed against the teeth but not protruding; the superficial veins full, but the head, neck, and trunk free from lividity. After a longer or shorter time, however, and apparently after a very few hours, in India, all this is changed. Livid patches appear about the chest, back, and shoulders; the face and head become bloated and puffy, the tongue and eyes protrude.” Bloody froth is sometimes seen at the nose and mouth. SALIVA is invariably secreted and runs out of the mouth down on the chin and chest. Its presence is considered as evidence that suspension occurred during life. The URINE and FÆCES are sometimes found to have been expelled. These discharges occur in all kinds of violent death. Tardieu found them, however, but twice in 41 cases of hanging. Roth in 49 cases found discharges of fæces in 17 and urine in 4; in 15 cases not noticed. Harvey mentions a case where internal piles had burst, and there were stains and clots of blood about the perineum and anus. In such cases without careful examination there would naturally be a suspicion of violence. In about one-fourth of the cases the GENITAL ORGANS are congested. The penis is large and more or less erect; seminal fluid, generally prostatic, and sometimes mixed with blood, is often expelled. The fluid may pass only into the urethra and it may be necessary to press the urethra to secure it. The clitoris may be found erect, and there may be a sort of menstrual flow. Orfila showed by experiment that swelling of the sexual organs and emission of semen can be produced after death in those who had been suspended during life. The flow of semen is found in all kinds of death by violence. Roth in 39 cases of hanging of men found the penis enlarged 18 times and ejaculation in 19. Hackel found the penis swollen in 43 per cent of cases of asphyxia. Erection may come on soon or late, even days after death. =Internal Appearances.=—The CONNECTIVE TISSUE UNDER THE MARK is usually white and condensed, the more so if the body has been long suspended. This dryness or condensation was found by Hackel in 52 per cent of hangings. Deeper-seated parts are injured only when the hanging has been violently done. The MUSCLES, especially the sterno-mastoid, are sometimes ruptured. Hofmann[851] reports several cases. Lesser[852] in 50 hangings saw 11 ruptures of muscle. Maschka never saw the rupture in suicides. The sterno-mastoid was ruptured in the case of Wirtz (Case 96) and Guiteau (Case 95). Hackel in 67 cases failed to find the muscle ruptured. Hofmann[853] believes that the rupture of the muscle is sometimes post mortem. Coutagne[854] found the sterno-mastoid muscle ruptured once in 24 cases (Cases 29, 89, 95, 96). The LARYNX may be fractured or dislocated. These lesions are very rare in suicide; more frequent in homicide and judicial hanging, and in the old where the cartilages are calcareous. Remer found the injury in but 1 case in 101 of suicidal hanging. Barker found the larynx _lacerated_ in his judicial cases.[855] Harvey says that the TRACHEA was reported lacerated 11 times in nearly 1,500 cases; twice the laryngeal cartilages were separated from each other. In 5 these cartilages were fractured, but there was nothing to show under what conditions. Hemorrhage in vicinity of larynx, 43 times. Pellier[856] reports 1 case, and adds that the existence of the lesion easily escapes notice because of the mobility of the cornua. Roth in 49 cases failed to find any fracture. Pellier found the cricoid was injured oftener than the thyroid, which is the reverse of what is found in strangulation. Cavasse[857] was unable to cause fracture of larynx by hanging the cadaver. Chailloux[858] collected 6 cases of fracture of larynx in hanging. He concluded that the fracture could not be produced on the cadaver by hanging, and is, therefore, caused during life. Coutagne[859] in 24 cases found fracture of thyroid cartilage 8 times (Cases 9, 51, 82). The HYOID BONE is rarely dislocated. Orfila mentions a case of fracture. Barker found the bone usually fractured in judicial cases. In the case of Wirtz (_supra_) the greater cornu was broken. Pellier reports 2 cases. Hofmann[860] says the hyoid cornua are often fractured, especially when the ligature is between the hyoid bone and thyroid cartilage. Coutagne found fracture of hyoid bone 8 times in 24 cases. He attributed the fracture to pressure against the spine. Pellier speaks of fracture of STYLOID PROCESS (Cases 51, 84, 88, 89, 95, 96). Dr. Barker, of Melbourne,[861] states that in 50 cases of hanging by the old method there was not one case of _fracture or dislocation of vertebræ_. After adopting his suggestion to place the knot near the spine, he found that dislocation occurred between the second and third cervical vertebræ with fracture of the third and pressure on the spinal cord. Death was sudden and complete. The drop in these cases was short, three to four feet. Coutagne thinks that the ordinary mobility of the head, axis, and atlas on each other have led reporters into the mistake of supposing a dislocation of vertebræ. Roth failed to find fracture of vertebræ in any of 49 cases. These injuries are especially rare in suicide; but in violent hanging, dislocation or fracture may occur and also rupture of the ligaments. Harvey gives 5 cases of dislocation of vertebra and 4 of fracture of vertebra in suicides. Three of the latter were doubtful. Tardieu says these fractures have no significance as to the hanging having occurred during life. They can be produced on the cadaver; but infiltration of clotted blood around injured vertebræ shows that suspension occurred during life (Cases 5, 7, 8, 68, 76 to 79, 83, 84, 91, 92, 94).[862] The CAROTID ARTERIES may be injured; usually the inner and middle coats are torn; and hemorrhage may occur into the wall of the vessel. The common carotids are the ones usually affected, and just below the bifurcation, but the external is also occasionally injured. The injury is said to be due to the stretching and squeezing of the artery, stretching being the most effective since the rupture often occurs at a distance from the mark of the ligature. Such injury of the artery does not prove that hanging took place during life because it has been produced on the cadaver; but hemorrhage into the wall of the vessel or wound or rupture after death is very improbable. Maschka says the lesion is very rare. Tardieu says that the injury to the carotid is rare and therefore unimportant. Pellier reports 4 cases of rupture of carotid in a total of 23. Levy records the experiments of Hofmann, of Vienna, and Brouardel and himself, of Paris, 5 in number. He concluded that compression of the carotid arteries, if it produces obliteration, can cause rapid loss of consciousness and death; and explains why in incomplete suicide the subject is unable to help himself. Coutagne found rupture of carotids 10 times in 24 cases. He insists on the importance of the lesion. Hofmann[863] says the rupture is always transverse, may be simple or multiple and may occur in suicides; more apt to occur when the ligature is thin. Lesser[864] tabulated 50 fatal cases of suicidal hanging; in 29, he was satisfied that the hanging occurred during life. In 3 of these the skin of the neck alone showed any lesion; there was a double mark, the skin being otherwise bloodless. In 5 the deeper soft parts were the only ones affected. In 3 the skin showed lesions, the deeper soft parts none, but either the hyoid bone, larynx, or vertebræ were involved. In 12 the skin showed no mark, but the deeper soft parts and either the larynx or hyoid bone were involved; and in 6 the hyoid bone only or the bone and larynx were injured. In the remaining cases it was not possible to say that the hanging occurred during life. In 2 cases there were no marks at all; in 9 there were changes in the skin; in 4, changes in the skin and deeper parts; in 2, changes in the skin, deeper parts, and hyoid bone or larynx; in 3, changes in the skin and hyoid bone or larynx, or both. In 14 of the 50 cases the hyoid bone was fractured; in 20 the larynx; and in 1 the vertebræ. The common carotid arteries were injured in 6. The number and severity of the lesions bore no constant relation to the thickness of the ligature, nor to the force used, but rather to the position of the body. Ecker[865] reported a case of suicidal hanging in a man, age 40, where the soft palate was swollen and filled up the passage so that the air evidently could not enter. The LARYNX and the TRACHEA are usually deeply congested, of a red color; a violet color indicates putrefaction. Ogston reports mucus but not bloody froth 9 times in the pharynx, 6 in the trachea, and 4 in the lungs, in a total of 40 cases. In one case there was a quantity of blood in the larynx and pharynx. Taylor thinks that pinkish froth in the trachea indicates incomplete obstruction; and Chevers that it is due to spasmodic efforts to breathe when the obstruction is nearly complete. Chevers always found clear mucus in the larynx and upper part of trachea, each follicle being marked by a minute globule of mucus. Harvey states that this was noted a few times in his reports. Baraban[866] discusses the condition of the epithelium of the air passages in hanging. The condition of the lungs and heart varies according to whether death is due to syncope or asphyxia. Ogston found, in 22 cases, the lungs were expanded in 4 and collapsed in 2. Harvey says the LUNGS are congested in over seven-eighths of the cases; emphysematous in a few; and subpleural ecchymoses present in a few. Patenko[867] experimented on dogs by hanging them. When the constriction occurred after expiration the lungs were congested; when after inspiration, not congested. In the first case (p. 223) the blood flows from the periphery to the heart and thence to the lungs, but cannot flow from the lungs because of the difficult circulation in the dilated pulmonary vessels and deficiency of intrathoracic pressure. There is in both cases cerebral congestion in the region of the bulb. Tardieu holds that punctiform ecchymoses and apoplexies do not occur in hanging unless suffocation has preceded. Pellier,[868] however, found these ecchymoses 14 times in 22 cases. He says that the lesion is not characteristic of suffocation, and quotes Lacassagne, Grosclaude, Dechoudans, Vicq, Chassaing, and Legroux to the same purpose. Hofmann[869] says that the ecchymoses are relatively rare in adults. Maschka[870] found them 18 times in 153 cases. Harvey states that the presence of serum in the PERICARDIUM seems more a matter of time elapsed after death than anything else. Still the fact is that it is found much oftener in strangulation than in hanging. The difference is explained by the comparative slowness of death in strangulation. Harvey finds that in about one-half of the cases, if the body is fresh, the right side of the HEART, pulmonary artery, and venæ cavæ are full of dark fluid blood, the lungs being also much congested, and the signs of death by asphyxia well marked. When blood is found in both sides of the heart, it is probable that death is due to neuro-paralysis. When decomposition is advanced all the cavities are often empty. Taylor says that if the examination is delayed for several days, the distention may not be observed. The STOMACH is often much congested, and this fact might sometimes suggest the possibility of poisoning. The LIVER, SPLEEN, and KIDNEYS are usually much congested. Hofmann[871] says that this occurs in the kidney only when the body has been hung a long time. The BRAIN is rarely much congested. In 101 cases Remer found hemorrhage but once; and in 106 cases Casper failed to find it. Tardieu[872] says the brain is oftenest anæmic. If, however, the body is cut down and placed horizontally, the blood-vessels of the brain may fill up. Evidence may be found in the brain suggesting insanity and therefore an explanation of a probable suicide. Harvey says that hemorrhages in or about the brain are found in a much larger proportion of cases in India than in Europe in cases of hanging. “No common condition likely to cause extravasation is apparent, only one man being noted as plethoric, but in many the rope seems to have been very tight.” Champouillon[873] reports a case of suicide in a man, age fifty-two; the rope broke and the body fell. The physician who made the necroscopy reported a rupture of the _pons Varolii_. Champouillon believed that the rupture must have been made in removing the brain from the skull. Wilkie[874] reports a judicial hanging in which a man age about twenty-five, fell about three and one-half feet. A recent clot was found in the brain. The experiments of Brouardel of hanging rabbits showed the brain anæmic. The conjunction of the following appearances would suggest that the hanging had been of some duration: lividity of face, congestion and prominence of eyes, dryness of skin under the ligature, deep furrow, congestion of sexual organs, swelling and lividity of lower limbs, hypostatic congestion of lungs. Page experimented on a young cat and young dog; both were hung in the same way. Examination of the cat showed the veins generally engorged; sublingual veins much engorged; tongue protruded slightly and much swollen; no frothy mucus in bronchi. In the dog the tongue did not protrude and was not swollen; right cavities of heart contained blood, left empty; brain and other organs normal. In the cat, the lungs were uniformly congested, dark red; no ecchymoses. In the dog, the lungs were much distended, posterior borders mottled violet; emphysematous patches on surface; no apoplectic effusions; subpleural ecchymoses bright red, irregular, clearly defined in outer surface, most numerous toward the roots and on the lower lobes. Pellereau[875] gives an account of hanging as seen by him in warm climates. He had not seen the elongation of the neck described nor the erection of the penis, nor subconjunctival ecchymoses, nor fracture of larynx, nor rupture of walls of carotid artery, nor subpleural ecchymoses, nor fracture of vertebra. He always found a mark on the neck; the left cavities of the heart always empty, the right always full of black blood. Mackenzie says that in 130 cases of suicidal hanging, the protrusion of the tongue between the teeth, the open and protruding eyes, clinched hands, and blue nails were very frequent, the tongue was found bitten many times, there were urethral and rectal discharges and rupture of carotid artery. The penis was found erect several times. The hyoid bone fractured 24 times in 93 cases. In no case was the larynx or vertebra fractured. In 73 cases ropes were used; in 30, portions of clothing. The marks of ropes were always well defined, indented, and parchment-like; the marks of soft ligatures faint and reddish. In no case were the muscles of the neck, the larynx, trachea, or large bronchi injured, and in none was there subcutaneous hemorrhage or blister. PROOF OF DEATH BY HANGING. As in strangulation, no single sign in any given case is sufficient of itself to prove that death was caused by hanging. But the sum total of the lesions found, viewed in the light of the surroundings of the body, will suffice to lead to a definite conclusion. The fact that a body has been found suspended does not of itself prove that hanging caused the death, because the victim may have been killed in some other way, and the body afterward hung up to avert suspicion. Chevers records many cases of this kind. The value of the presence or absence of marks on the neck and the characters of the marks has been questioned. Orfila, Casper, and Vrolik have shown by experiment that if a body is hanged within one or two hours after death the furrow, parchment skin, lividity, and the density of the connective tissue will appear just as is seen when suspension has occurred during life; but ecchymoses and infiltration, clotted blood in the skin, connective tissue, and muscles of the neck suggest suspension during life. If a cord is removed _immediately_ after death, there may be scarcely any mark at all. Tardieu collected 261 cases of suicide by hanging where the subject was not entirely off the ground. In 168 the feet rested on the ground; in 42 the subject was kneeling; in 29 lying down; in 19 sitting, and 3 were huddled up or squatting. Fatal hanging may, therefore, occur in almost any position of body. He shows incomplete hangings by thirteen plates. Taylor also collected reports of 11 cases in a few years; in 3 the subjects were nearly recumbent; in 4, in a kneeling position; in 4, sitting. Remer in 101 cases of suicidal hanging found in 14 that the body was either standing or kneeling; in 1, sitting. Duchesne published 58 cases of partial suspension, 26 of which were new. Some of these failures of complete suspension were due to soft and elastic cords.[876] Taylor says that “that which is difficult to a conscientious medical jurist in confining himself to the medical facts is often easily decided by a jury from these as well as the general evidence afforded to them.” The limbs may be secured by the suicide before hanging himself. Persons even with some disability of the hand have suicided by hanging. Blindness is no obstacle, nor age; a boy as young as nine and a man as old as ninety-seven. Burger[877] fully discusses the question whether the hanging is before or after death. HANGING—SUICIDAL, HOMICIDAL, OR ACCIDENTAL? Hanging is usually =suicidal=. Lesser[878] states that for three years, 1876-79, there were admitted to the Berlin morgue 274 bodies of “hanged,” of which 272 were suicidal; 2 infants of three and eighteen months, homicidal. One man had first tried to kill himself with sulphate of copper; another by cutting his throat; a woman by cutting her arm. The other cases were uncomplicated. Pellier states that the number of suicides in France from 1876-1880 was 13,445, and nearly all were by hanging. Taylor[879] states that 2,570 persons committed suicide by hanging in England in five years, 1863-67; four-fifths of these were males. Harvey[880] reports for three years 1,412 cases of hanging in India, of which 2 were accidental, in 3 there was presumption of homicide, the rest probably all suicidal. Feebleness of body does not preclude subjects taking their lives in this way. They sometimes also wound or poison themselves first and hang themselves afterward. A subject being found suspended in a room fastened on the inside, would be suggestive of suicide. The absence of signs of struggling or of any marks of injury also favors the idea of suicide. The possibility of a suicide breaking a rope, being injured by the fall, and rehanging himself successfully, must be admitted (Cases 57, 58). The possibility of blood flowing after death must not be forgotten. It is worthy of note that after beating or other violence children and women may commit suicide from shame. Again, as Tardieu says, many have hung themselves while partially intoxicated, and it is likely that some such have just previous to the suicide met with falls or other accidents which have left marks like those of violence. He also records the case of a woman who fastened a cord to a bed-post, put her head in a noose while kneeling on the bed, and made a deep wound in her arm with a razor. She closed the razor, laid it aside, and fainted from loss of blood. She must then have fallen forward and died from the pressure of the cord on her neck.[881] =Homicidal= hanging is rare but does occur. Where the hands are tied together; where the injuries produced by the cord are severe; where there are contusions and well-marked ecchymoses; where the laryngeal cartilages and hyoid bone are fractured or the cervical vertebræ dislocated or fractured; or where the carotids are injured or there is hemorrhage into their walls; where there are severe wounds, the hemorrhage from which would be sufficient to threaten syncope; where there are many marks of violence on the body; where there is evidence of a severe struggle—in all these cases murder may be reasonably suspected. The number, situation, extent, and direction of must be carefully noted and weighed. If these are out of proportion to the ligature, the suspension, etc., they strongly suggest homicide, although they may occur in suicide (see Cases 4, 11, 18, 20, 28, 29, 44, 52, 55, 59, 66). Homicidal hanging may be committed by an assailant who is strong on a subject who is weak, on a child, a woman, an old person; on one stupefied by liquor or narcotic poison; or by many combined against one person. Cases are reported where injuries were inflicted or poison given, and the subject was afterward hanged to avert suspicion. Most of these cases are those of murder either by strangulation or suffocation (Cases 64, 65, 67, 68, 69, 70, 74). Sometimes hanging is =accidental=. Children and even older persons play at hanging successfully. Taylor mentions the case of a boy who witnessed a hanging and afterward tried the experiment himself to ascertain the sensation, and caused his own death. Tardieu[882] relates the case of a man, T., age 37, of small stature, feeble constitution, very thin, of sinister face, eyes hollow but lively, cunning nose and mouth, who meeting a man aged 81, learned that he had some trouble with his leg and promised to cure him. The old man lived alone. T. told him to buy a strong cord as thick as his little finger and one and one-half yards long, and keep the whole thing a secret. T. would see him at his room at 7 P.M. The old man became suspicious and had T. arrested. The investigation showed that already T. had made away with three old men by hanging, who were known to be opposed to suicide. Their bodies showed no trace of violence. Two others had escaped when the cord was passed around their necks. Tardieu gives a number of cases of suicidal hanging which were falsely attributed to criminal violence, in which the pressure of public opinion joined to circumstances improperly explained by inexpert physicians caused deplorable judicial errors. ILLUSTRATIVE CASES. SUICIDE.