introduction into the blood and tissues of the bacteria themselves.

Depending on the two sources of origin, we have two forms of septicæmia: 1. Septic intoxication or sapremia, due to the absorption of a chemical poison, ptomaïnes, and often readily influenced and cured by the removal of the source of these ptomaïnes in decomposing blood-clots, secretions, etc. 2. Septic infection comes on less rapidly but is more serious than the former is, if properly and quickly treated, because the source of the trouble cannot be removed, but is in the blood and the tissues. The latter form is the more common one in wounds, though the former may occur in abdominal wounds, especially when a blood-clot is present. The first form begins acutely, the second form more gradually. The infection in septicæmia takes place through a wound and may be due to the weapon which caused the wound, the unclean condition of the parts wounded, or to the subsequent treatment or want of treatment. It may even take place through the intestinal mucous membrane as in cases of tyrotoxicon poisoning. It is most likely to occur during the first four or five days before the surfaces of the wound granulate, and it consists in the introduction of bacteria, especially staphylococci and streptococci. The disease is characterized by severe constitutional symptoms, acute continuous fever, inflammation of certain viscera and of the wound, and nervous disorders. A pronounced chill ushering in the fever is generally absent. Prostration is especially marked, the patient finally passing into a typhoid condition indifferent to surroundings. Anorexia and headache are usually present; diarrhœa is common, vomiting is not. The skin is pale and dusky, but not commonly icteric; at first it is hot and dry, later moist and finally cold and clammy. The spleen is often enlarged. The pulse becomes weak and rapid and delirium is followed by coma. The prognosis is grave. Antiseptic treatment generally prevents and often cures the disease, as is the case with many other of the wound diseases; hence the failure to employ it may be alleged by the defence in mitigation of the responsibility of the assailant for the fatal result. PYÆMIA is closely allied to septicæmia. It is due to the setting free of bacterial emboli or septic emboli from a broken-down, septic thrombus in the neighborhood of the wound, and the circulation of these emboli in the blood until they are arrested and form the characteristic metastatic abscesses, especially in the lungs, joints, abdominal viscera, and parotid gland. Almost always the source of infection is an infected wound. Granulation does not prevent the occurrence of pyæmia, which, as a rule, commences at a later stage than septicæmia. It is most important, however, for our purpose to remember that there is such a thing as spontaneous pyæmia. An injury not causing a wound may here be the exciting cause, but the resulting pyæmia is an unexpected consequence. A bruise of a bone, for instance, by allowing bacteria, which in certain conditions may be circulating in the blood, to find an exit from the vessels into the bruised part, may develop an acute osteo-myelitis, which may be a starting-point of a pyæmia. It is but proper to state, however, that spontaneous pyæmia is a rare occurrence. In fact, it is so rare that if pyæmia occurs and we find ever so trifling an infected wound, we can safely attribute the pyæmia to the wound and not to a spontaneous origin. Pyæmia begins, as a rule, in the second week of the healing process or even later. It usually begins with a chill, which may be frequently repeated. The fever is very irregular and exacerbations occur with each metastatic abscess. The skin is icteric, the icterus being hematogenous. The pulse is rapid and becomes weaker. Infective endocarditis may develop, which increases the danger of metastatic abscesses, which may then occur in the brain. Otherwise the mind is clear and unaffected until the final delirium and coma. The disease may become chronic, but usually lasts a week or ten days. The prognosis is very grave. ERYSIPELAS is a still more frequent complication of medico-legal wounds, and though not so fatal as the two preceding, it is probably more often the secondary cause of death on account of its far greater frequence. It too is an acute infective inflammation due to the presence of a micro-organism, _streptococcus erysipelatis_. This occurs mostly in the lymphatics of the skin, and effects an entrance through some wound or abrasion of the skin or mucous membrane, which may be almost microscopic in size. Probably there is no such thing as true _spontaneous erysipelas_, though the wound may be often overlooked and only visible on the closest examination. If a wound has been inflicted, the size and severity of it cannot be alleged as a reason why it was not the starting-point of an erysipelas. The erysipelas must be clearly traced to the injury. That is, it must occur before recovery from the wound or not later than a week after it has healed, for the incubation is probably not longer than this. It is difficult to connect an erysipelas with a wound if it occurs some time after it has healed or if it occurs at a different place and not about the wound. Wounds of certain regions, as, for instance, scalp wounds, are especially liable to develop erysipelas, but this is probably owing to the imperfect antiseptic treatment or delay in applying it. Certain individuals are more prone to it than others; thus it has been stated that blondes and those suffering from Bright’s disease are more susceptible, though how true this is it is hard to say. It is also probably more prevalent at certain times of the year, particularly in the spring. A wound after it has scabbed over or has begun to granulate, that is, after the first four or five days, is very much less apt to serve as the avenue for infection. Erysipelas usually begins with a chill, or a convulsion in children. Nausea and vomiting are the rule. The fever is remittent and ranges from 102° to 104° F., and the temperature may be subnormal when the inflammation is subsiding. Prostration is marked and the pulse more or less weak. There may be delirium while the fever is high. Locally there is rarely anything characteristic until twenty-four hours or so after the chill. Then we have a reddish blush with some tension, burning and itching of the skin. At first the redness is most marked about the wound, later at the edge of the advancing, serpentine margin. It spreads widely and rapidly, and after three or four days the part first attacked begins to improve. Desquamation follows. The duration may be a week or ten days or as long as a month. The inflammation may be much more severe, involving the subcutaneous connective tissue in _phlegmonous erysipelas_. FACIAL ERYSIPELAS is a common variety and was once regarded as idiopathic, but a wound on the skin or mucous membrane is probably always present. The prognosis of erysipelas is usually favorable. Since the use of antiseptics it is far less common than formerly, though still the most common of the infective wound diseases. If a man wounded in an assault is taken to a hospital where erysipelas prevails, the question of responsibility arises, for, medically speaking, he is subjected to great and avoidable risks. TETANUS is an infective bacterial disease affecting chiefly the central nervous system and almost always, if not always, originating from a wound. Tetanus, like erysipelas, is probably always traumatic and never strictly idiopathic. The wound may be so slight as to escape notice. When it follows such injuries as simple fracture internal infection probably occurs, though such cases are extremely rare. It is said that the weather influences the development of tetanus, and that it is more common in the tropics. There are also certain sections where tetanus is much more common than elsewhere and where it may be said to be almost endemic. Punctured wounds are most likely to be followed by tetanus, for they offer the best opportunity for the development of the bacteria, which are anaërobic. Wounds in dirty parts of the body, like the hands and feet, are more apt to be followed by tetanus than those elsewhere. Tetanus usually appears about the end of the first week after a wound has been received, but it may not appear for a longer period, even three or four weeks, so that the wound may have been some time healed. To connect tetanus with a particular wound, note (1) if there were any symptoms of it before the wound or injury, (2) whether any other cause intervened after the wound or injury which would be likely to produce it, and (3) whether the deceased ever rallied from the effects of the injury. Tetanus comes on suddenly without warning. The injured person first notices that he cannot fully open the mouth, he has lock-jaw, and the back of the neck is stiff. The muscles of the abdomen and back are next involved so that the back is arched in the position known as _opisthotonos_, and the abdomen presents a board-like hardness. The muscles of the fauces, pharynx, and diaphragm may next become involved, causing difficulty in swallowing and breathing. The thighs may or may not be involved, but the arms and legs almost never. Owing to the spasm of the abdominal muscles, micturition and defecation are difficult and respiration is hindered. The muscles are in the condition of tonic spasm which permits the patient no rest, the face bears the “risus sardonicus,” and the suffering is extreme. If the patient lives more than two or three days the tonic spasm partly gives way to increased reflex irritability, in which a noise, jar, or draught of air may give rise to clonic and tonic spasms in the muscles affected. The patient may die at such times from tonic spasm of the respiratory muscles, or he may die of prostration from want of food and sleep, worn out by the suffering and muscular spasm. The mind is usually clear to the last. Fever is not characteristic of the disease. Tetanus may be rapidly fatal; in two or three days, or it may be or become more chronic. The _prognosis_ of acute tetanus is almost invariably fatal; that of chronic tetanus is grave, but a certain proportion of cases recover. _Diagnosis._—This is easy. It differs from a true neuritis in the peripheral nerves in that no matter where the wound is situated the first symptom is in the muscles of the jaw and the back of the neck, and not at the site of the injury and distally from this point. _Trismus_ is applied to a milder form of the disease in which only the face and neck muscles are involved and “lock-jaw” is a prominent symptom. Some cases of _tetany_ may be mistaken for so-called spontaneous tetanus. Tetany may follow child-bed, fevers, mental shocks, exposure to cold and wet, extirpation of goitre, intestinal irritation, etc. It consists of painful tonic spasms of the muscles of the arms and feet. The attacks last one-half to two hours or more, and may be preceded by a dragging pain. They may be brought on by pressure on the nerve leading to the muscles affected. Striking the facial nerve often causes contraction of the face muscles. There is no trismus but there may be opisthotonos. The patient seems well between the attacks and most cases recover without treatment. DELIRIUM TREMENS may occur as a secondary consequence of injuries, or necessary surgical operations in the case of those who are habitually intemperate. Those who habitually use opium, tobacco, cannabis indica, or even tea or coffee to excess are said to be subject to it. It may, therefore, be justly alleged that death is avoidable in very many cases, but for an abnormal and unhealthy state of the body. The disease is characterized by delirium, a peculiar tremor of the muscles, insomnia, and anorexia. Pneumonia may complicate the case. The patients die in fatal cases from exhaustion due to insomnia, lack of nourishment, and their constant activity of body and mind. The prognosis is usually favorable, taking all cases together, but in delirium tremens secondary to surgical injuries or operations the prognosis is serious. DEATH FROM SURGICAL OPERATIONS performed for the treatment of wounds. The operation is a part of the treatment, and if it is done with ordinary care and skill the accused is responsible for the result. The necessity and mode of operation must be left to the operator’s judgment. As the defence may turn on the necessity for and the skilful performance of the operation, it is well to wait for the advice and assistance of others if practicable, for death is not unusual from severe operations. The patient may die on the operating-table after losing little blood, from fear, pain, or shock. Or he may die from secondary hemorrhage or any of the secondary causes of death from wounds enumerated above. The evidence of the necessity of the operation must, therefore, be presented by the operator. If an operation is necessary and not performed, the defence might allege that death was due to the neglect of the surgeon. Another question for the medical witnesses to determine is whether the operation was rendered necessary because of improper previous treatment, for if it was the responsibility of the assailant may be influenced. The meaning of the term “necessity” is here a matter of importance. Unless an operation is necessary to the preservation of life, if death occurs there is some doubt whether the assailant is responsible. But, medically speaking, we would not hesitate to urge an operation on a wounded man in order to preserve function, or even to save deformity as well as to save life. In the case of operations done under a mistaken opinion, neither necessary to save life nor, as the result proves, to save function or guard against deformity, if death follows the assailant may be relieved from responsibility. Thus an aneurism following an injury might be mistaken for an abscess and opened with skill but with a fatal result. It is also for the medical experts to determine whether an operation was unnecessary or unskilfully performed, for if it were and death resulted from it, the responsibility of the prisoner is affected unless the original wound would be likely to be fatal without operation. According to Lord Hale, if death results from an unskilful operation and not from the wound, the prisoner is not responsible. But yet death may occur as the result of the most skilful operation necessary to the treatment of a wound, and not be dependent at all on the wound itself. If the operation is skilfully performed, and yet the patient dies from secondary causes, such as those above enumerated or any others, the prisoner is still responsible, and the medical testimony is concerned with the performance of the operation and the secondary causes of death. The relative skill of the operator or surgeon is probably not a question for the jury in criminal cases, on the ground that the man who inflicts the injury must take all the consequences, good or bad. In a civil suit, for instance an action for malpractice, the case is otherwise, and all the medical facts and opinions are submitted to the jury. The law regards three circumstances in death after surgical operations: (1) The necessity of the operation, (2) the competence of the operator, and (3) whether the wound would be fatal without operation. _Death_ may occur _from anæsthetics_ used in an operation without any recognizable contributing disease of the patient, or carelessness or lack of skill in the administration of the anæsthetic. Of course, the question of absence of contributing disease on the part of the patient and of its proper administration must be satisfactorily answered in cases of death from the anæsthetic in an operation rendered necessary in the treatment of a wound. Death from an anæsthetic may occur before, during, or after an operation itself. Medically speaking, the necessity of the use of an anæsthetic in operations cannot be questioned, and in emergencies where an operation becomes necessary, and not a matter of choice, its use, with special care, is justifiable even with existing organic disease, which usually contraindicates it. As death may be alleged to be due to the use of a particular anæsthetic, it is always best in operating on account of an injury which may require a medico-legal investigation, to use that anæsthetic which is most generally used and indorsed in the particular section of country in question. Of course, it is not lawful to operate against the will of a person who preserves consciousness and will. It may be added in this connection that if a medical man be guilty of misconduct, arising either from gross ignorance or criminal inattention, whereby the patient dies, he is guilty of manslaughter, according to Lord Ellenborough. Omissions or errors in judgment, to which all are liable, are not criminal. IV. WAS THE WOUND MADE BY THE INSTRUMENT DESCRIBED? It is not often necessary to prove that a weapon was used, though it may affect the punishment. For the use of a weapon implies malice and intention and a greater desire to do injury. The prisoner may swear that no weapon was used when the nature of the wound clearly proves that one was used. The explanation of the prisoner of the origin of the wound may thus be discredited. We cannot often swear that a particular weapon was used, but only that the wound was made by one similar to it in shape and size. Thus Schwörer tells of the case of a man stabbed in the face by another. The medical witness testified that the wound was caused by a knife shown at the trial which had a whole blade, but a year later the point of the knife which had really caused the wound was discharged from an abscess in the cheek at the site of the wound. The surgeon thus made a too definite statement in regard to the knife shown. It is often very difficult to answer the above question. We base our opinion chiefly on two sources: 1st, and most important, by an examination of the wound, and, 2d, by an examination of the instrument said to have been used. Certain particulars of the wound may furnish indications as to the weight, form, and sharpness of the instrument used. There are certain wounds which must have been made by an instrument, namely, incised and punctured wounds. The above question is determined more or less by what has been said in a former section on wounds, but we will now consider what special features of these and other classes of wounds indicate the nature, shape, size, etc., of the weapon used. =Incised wounds= must be made by a cutting instrument. We would here exclude those contused wounds of the scalp and eyebrows which closely resemble incised wounds, but we have already seen that we can diagnose between these wounds and incised wounds by careful inspection. But the locality should put us on our guard, so that in case of wounds of these two regions we should be especially careful in making the examination. In the case of incised wounds we cannot often tell the shape or size of the weapon, but we are able to tell certain characteristics about it. _The sharpness_ of the instrument may be inferred from the clean and regular edges. The depth of the wound may also indicate the sharpness of the weapon. A long “tail” in the wound indicates that the weapon was sharp as well as that this was the part of the wound last made. If the edges of the wound are rough, we may infer that the edges of the weapon were rough and irregular. Wounds caused by bits of china or glass or fragments of bottles, besides having rough and lacerated edges, are characterized by an irregular or angular course in the skin. Some cutting weapons, like an axe, act as much by means of their weight as by their cutting edges. Wounds caused by such weapons we can often distinguish by the following signs: The edges are not as smooth as is the case with a cutting instrument, and they may be more or less lacerated and show signs of contusion. The wound is often deep in comparison with its length, and the ends of the wound abrupt instead of slanting up from the bottom to the surface. The section of resisting organs and the impression of the edge of the weapon on the bone are further signs of the use of such a weapon. The form and direction of a wound may possibly give some indication of the form of the instrument—for instance, whether it be straight or curved like a pruning-knife, as in the case cited by Vibert[636] of a wound of the neck which suddenly became deeper toward its extremity and changed its direction; the whole being explained on the supposition that it was made by a pruning-knife. But it is in =punctured wounds= especially that we are enabled most often and most accurately to determine the kind of a weapon used. Here from the form of the wound we may judge of the form and size of the weapon. In speaking of punctured wounds in a former section we divided them into four groups, reference to which may here be made. In the first group, or those caused by cylindrical or conical weapons, when the weapon is very fine it may leave no track at all; if a little larger, we may infer from a linear bloody track that the weapon was needle-like in shape. The length of the instrument or the depth to which it penetrated may be found, as a rule, only by dissection. If the weapon were larger and conical, we have seen that the wounds would be linear with two angles, the length of the wound being parallel to the direction of the fibres in the skin. Here we may judge of the form of the weapon from the following circumstances: From a comparison of the depth with the size of the opening, we know that it was a punctured wound. The edges and angles are not smooth and even enough for a stab-wound with a knife, for the edges are torn and not cut, and a stab-wound would be the only form of wound with which we would be likely to confuse it. Furthermore, the direction of the long axis of the wound parallel to that of the skin fibres in the region in which it occurs and the very slight retraction of the edges distinguish it from a stab-wound. By these signs we can almost always distinguish such wounds from stab-wounds, and thus tell the form of the weapon used. As to the size of weapon used, these wounds if of any size are generally smaller than the weapon, for the skin is put on the stretch by the weapon and yields to a certain extent. The actual wound, therefore, is smaller in circumference than the weapon. The size of the wound is smaller than that part of the weapon occupying the wound when the weapon was arrested; it may be very much smaller than the weapon at its largest point. Small wounds of this kind are generally larger than the instrument producing them. The second group of punctured wounds, or _stab-wounds_, are by far the most common and, therefore, the most important variety of punctured wounds. If the _stab-wound_ is _perpendicular_ to the surface the _form_ of the wound may represent pretty closely that of the weapon at the point where the latter was arrested, whether it has a single or double cutting edge. But even here there are exceptions. Frequently a weapon with a broad back and only one cutting edge may produce a wound resembling that of an instrument with two cutting edges, the second angle tearing as in the former class. Here on close examination we can sometimes distinguish the difference between the two angles, and judge correctly of the shape of the weapon. In fact, wounds made by common pocket-knives are regularly slit-like and not wedge-shaped, as the wound is caused only by the cutting edge of the knife. Again, if the single cutting edge is blunt, in rare cases the wound is produced in the same manner as those of the first group, or conical and cylindrical instruments. We would be led to suppose that the wound was produced by such an instrument, as both angles are torn, unless the direction of the wound might not follow that of the fibres of the skin, in which case we would be left in doubt. Stab-wounds are sometimes angular from the knife being withdrawn in a slightly different direction from that in which it was introduced or from an unequal retraction of the skin (see Fig. 9). If the _stab-wound_ is _obliquely directed_, we can still judge of the general _shape_ of the weapon, with exception of the cases above mentioned. The dimensions and size of the weapon are here much harder to determine. The _dimensions_ of a stab-wound in the skin may be the same as those of the weapon, or of that part of the weapon which is arrested in the wound, but often they are not so. To measure the size of a wound exactly so as to get at the exact size of the instrument, we should place the region of the wound in the same position, etc., that it was when the wound was inflicted, and this we cannot often do. As the skin was tense or relaxed at the time the wound was inflicted, so the wound in the skin appears smaller or larger, just as with a sheet of rubber under similar conditions. If the instrument is very blunt, the wound in the skin may be smaller than the weapon whether the skin near the wound is tense or not. Thus Hofmann saw the wound from a blunt bayonet one centimetre shorter than the weapon. The wound of the skin may be shorter and broader than the weapon used on account of retraction of the edges of the wound, and this is especially marked when the wound lies transversely to the direction of the skin fibres. On the other hand, the length of the external wound is more often greater than that of the weapon, because the wound is elongated by making pressure toward the cutting edge on withdrawal of the weapon, and an oblique wound measures longer than the weapon. If the blow is from above downward and the cutting edge of the weapon is uppermost, the length of the wound is not so likely to be increased much beyond the measurement of the weapon as when the cutting edge is directed downward. There is but one condition in which a stab-wound is at all likely to correspond in dimensions with that of the weapon, and that is when the wound is perpendicular to the surface. Even here the wound may be lengthened on withdrawal of the weapon, and we have to allow for retraction of the edges and try to put the parts in the same condition of tension or laxity as at the time of wounding. Even in the most favorable case, therefore, we cannot with certainty tell the exact size of the weapon. If a stab-wound be directed obliquely to the surface, then the length of the wound is greater than that of the weapon, unless this increase be exactly counterbalanced by the lateral retraction of the wound. The size of the weapon in such oblique wounds is further obscured by the changes of size due to withdrawal of the weapon, retraction of the edges, and the condition of the tension of the skin at the time the wound was inflicted. [Illustration: FIG. 9.—Angular Stab-Wounds of the Anterior Chest Wall caused by a Strong Pocket-Knife.] Dupuytren remarks that stab-wounds are smaller than the weapon owing to the elasticity of the skin, but a lateral motion of the weapon may cause considerable enlargement of the wound. If a stab-wound has traversed a part of the body, the wound of exit is smaller than that of entrance. The _depth_ of a punctured wound may be any part of the length of the weapon, or it may even be deeper than the length of the weapon owing to a depression of the surface by the force of the blow, or the pressure of the handle of the weapon or the hand holding it. We have already seen that this may occur in a marked degree in penetrating wounds of the abdomen involving one of the movable viscera, also in wounds of the thorax, partly from depression of the surface and partly from an expansion of the thorax when opened at the autopsy, thus increasing the measured depth of the wound. Punctured wounds of the third class made by instruments with ridges or edges, like foils, files, etc., present more or less the shape of the weapon if the edges are cutting, but not always so if the direction of the wound be oblique or the parts unevenly stretched. If the edges are not cutting they cause wounds more or less like the first class of punctured wounds, but we can often distinguish them from the latter by little tears in the edges. The entrance and exit wounds may not be alike. Wounds made by bits of _glass and earthenware_ have irregular and uneven edges. Taylor[637] relates a case, Reg. _v._ Ankers (Warwick Lent Ass., 1845), where the wound was attributed to a fall on some broken crockery, but the wound was cleanly incised and the prisoner was convicted. As it may be alleged in defence that a given wound was caused by a fall on broken crockery or other substances capable of producing a punctured wound, it is important to notice whether the edges are lacerated and irregular or smooth and clean. The author quoted above cites another case which occurred to Watson, where the prisoner alleged that a deep, clean-cut wound of the genitals of a woman which had caused her death was due to a fall on some broken glass. The character of the wound disproved this defence. Another feature of such wounds, especially if they be deep in comparison to their length, is that they are very apt to contain small particles of the glass or earthenware which caused them. In fact, in all wounds it is well to search for any small fragments which will throw light upon the weapon used. Wounds caused by _scissors_ are often of characteristic shape. If the scissors were open we find two symmetrical, punctured diverging wounds, presenting more or less clearly the form of the blades of the scissors. If the blades have been approximated there is a triangular interval between the punctures, the apex of which is truncated if any skin remains between the punctures. _Lacerated wounds_ may not indicate the weapon used as clearly as punctured wounds, but the agent which produced them is often indicated by the appearance of the wound. They are generally accidental. But where they occur, as they not infrequently do, on the bodies of new-born children, they may give rise to the charge of infanticide. In some cases the weapon which caused the wound fits the wound produced, and thus important evidence may be furnished the prosecution. Taylor[638] cites the case of Montgomery (Omagh Sum. Ass., 1873), where a bill-hook which fitted the injuries on the skull of the deceased was found buried in a spot to which the prisoner was seen to go. These facts connected the prisoner with the weapon and the weapon with the murder. In other cases the wounds may be so lacerated or contused that the indications of the weapon are obscured. =Contusions and Contused Wounds.=—The shape of a contusing body is sometimes reproduced by the contusion and the ecchymosis. Thus we are enabled to distinguish the marks of a whip, the fingers, the fist, etc. This is best seen when the ecchymosis is fresh, for soon the edges extend and the outline is less clearly marked. Plaques parcheminées, which we have already described as the marks of contused erosions, may show the form of finger-nails, etc. Contused wounds like simple contusions may show the shape of the weapon. If the contusing body has a large area, the whole of this area cannot often strike the body at once, so that the outline of the contusion does not represent that of the weapon. But in general, severe contusions present greater difficulties than the preceding classes of wounds. We must generally be content if we can determine whether the wound was caused by a weapon, including the fist, or by a fall, and we are often unable to say even this. A fall is often alleged by the defence as the cause of the injury, but of course if the prisoner was responsible for the fall he is responsible for the results of the fall. If there are contusions or contused wounds on _several parts_ of the head, or if the wounds are on the _vertex_ of the head, it is presumptive of the use of weapons. We cannot often swear that each and every wound on the head was due to the use of a weapon. On the other hand, the presence of grass, sand, gravel, etc., in a wound is presumptive of a fall and of the origin of the wound in this manner. In case of a fall from a height the wound or wounds might be in almost any part of the body, on the vertex or elsewhere. Such a fall may be the result of accident, suicide, or murder. It is not unusual for female complainants to ascribe their wounds to a fall to exculpate the prisoner, especially if this happens to be her husband. We should remember that in the scalp or over the eyebrows a contused wound caused by a blunt instrument may resemble an incised wound. As already stated, however, if the wound is fresh careful examination will lead to a correct opinion, and the use of a sharp instrument may be disproved. If the wound is not recent there is great difficulty in judging of the cause. It is well to caution against accepting the interested statements of others in regard to the use of a weapon, unless the character of the wound bears them out very strongly. There may be a bad motive for imputing the use of a certain weapon to the assailant. It is far better to rely solely upon the evidence furnished by the wound in such cases. It would be useful if we could lay down some general rules to discriminate between wounds caused by the blow of a weapon and those caused by falls, but this we are unable to do so as to cover all cases. Each case must be judged by itself. If the question is asked _which of two weapons_ caused certain contusions or contused wounds, we are still less likely to be able to answer it. In such a case we must make an accurate examination of the form of the wound and compare it closely with that of the weapon. In such cases also the second source of information on which we base our opinion as to the relation of a weapon to the wound may be of use, namely, the examination of the weapon. The presence of blood, hair, cotton or woollen fibres on one of two weapons indicates that this was the weapon used. The presence of blood is particularly to be looked for, and in those parts of the weapon from which it could be washed off least easily. We should further note the condition of the point and edge of the weapon, and if the edge is broken or nicked at all, whether this condition is old or recent. The sharpness of the edge should further be noted, and if the edge is sharp note whether it has recently been sharpened. All these points have a certain bearing on the case. Also the location, shape, depth, etc., of the wound should be carefully noted to see if an accidental fall would be likely to account for it. For these features of the wound may be such that no fall could cause it. We see, therefore, that in incised and punctured wounds the use of a weapon may not be hard to make out, but that in general the question whether a particular instrument caused the wound is often difficult or impossible to answer. Often the best we can do is to say that the wound could have been produced by the weapon. V. WAS A WOUND SELF-INFLICTED OR WAS IT INFLICTED BY ANOTHER? In other words, was it _suicidal_ or _homicidal_? Speaking of suicide in general, its most common cause is alcoholism. It is not infrequent in youth. Lutaud[639] states that in fifteen years, presumably in France, there were 1,065 cases of suicide between the ages of ten and fifteen years. This seems to be only explicable on the ground of heredity or of cerebral affections. Among 27,737 cases of suicide, observed in France, the same author gives the following commonest causes in the order of greatest frequence: Drowning, strangulation, pistol-wounds, incised and punctured wounds, poison. The age, sex, and social conditions influence the choice of means. Thus among males drowning is preferred by the young, pistol-wounds by the adult, and hanging by the aged, while among females asphyxia is the favorite method, as there is no pain and no disfigurement. While many pathologists consider suicide an act of mental alienation, and though such may be the case in a large number or even in a majority of cases, yet in a considerable number it is a voluntary and rationally planned act. The question, Is it suicide or homicide? may be put in all cases of death by cutting instruments, and in many from other kinds of wounds. It is often, if not generally, impossible to answer it with absolute certainty. It is hardly suitable for the medical witness to try to reconstruct the scene of the crime from the medical facts, for he should abstain from everything not medical and should distinguish that which is positively proven from that which is merely probable. Suicides often leave a letter or some such indication to show that the wound was self-inflicted. If such is not the case, the question as to the cause of the wound may or may not be medical. If the question is a medical one, there are certain points to notice as to the wound, such as its _nature_, _situation_, _direction_, and the _number_ and _extent_ of the wounds, from which we are to form an opinion. There are also other circumstances which furnish evidence and thus assist us in answering the question. This evidence is furnished by the weapon, the signs of struggle, the examination of the clothes and body of the deceased and the accused, the position and attitude of the body, and any organic lesions, etc., predisposing to suicide. The =nature= of the wound bears upon the question of the homicidal or suicidal origin in the following way: Most suicidal wounds are incised or punctured wounds. _Incised wounds of the throat_ are generally presumptive of suicide, but a homicidal wound may be inflicted here to conceal the source of infliction of the wound. Such a wound if homicidal would imply malice, on account of the attempt at deception and concealment, and would convict the assailant of murder. Unless the deceased was asleep or drunk or was otherwise incapable of resistance, such a homicidal wound can often be distinguished from a similar suicidal wound by the form and direction of the wound, by its irregularity, and by other wounds on the hands or person of the deceased. Taylor[640] mentions a case in which the peculiar form of the wound, like that made by butchers in killing sheep, led to the suspicion that homicide had been committed by a butcher, who was subsequently arrested, tried, and convicted of murder. The _regularity_ of the wound has been taken to indicate suicide rather than homicide. That it does so is not questioned, but it is more or less fallacious if resistance is impossible, in which case a murderer may easily make a regular, clean, incised wound here. _Contused wounds_ are seldom suicidal, for they are not sufficiently speedily or certainly fatal. They are also more painful and disfiguring. Contused wounds usually indicate murder or accident, though there are not wanting cases of suicide by such weapons as a hatchet or a hammer. There is more difficulty in the case of a contused wound from a fall instead of from a weapon; for here we have to decide whether the fall was accidental, suicidal, or homicidal. The nature of the wound is of little assistance in the case of insane or delirious patients, who may commit suicide in the most unusual and curious manner. Taylor[641] relates the case of a delirious patient in Guy’s Hospital, in 1850, who tore away the whole of the abdominal muscles from the lower part of the anterior abdominal wall. If the case had not occurred in the hospital or where there were witnesses of the deed, the nature of the wound would have indicated homicide except for the delirium. The following case, quoted by the same author, illustrates a wound of very unusual nature and situation, which might have been taken for a homicidal wound with intent to conceal as far as the situation of the wound was concerned. The wound was accidental and occurred in the following way. A girl fifteen years old jumped on to her uncle’s knee while he was holding a stick between his legs which she did not notice. The Stick passed up her anus, but she withdrew it and went on playing, though she complained of pain. On the following night acute symptoms of peritonitis set in, and she died of it in forty-eight hours. On post-mortem examination a rent was found in the anterior part of the rectum penetrating the peritoneal cavity. =The Situation or Position of the Wound.=—A suicidal wound must be in such a position that the deceased could have inflicted it himself. Such wounds are, therefore, generally anteriorly or laterally situated. The “site of election” for suicidal wounds is the neck for incised wounds and the chest, especially in the region of the heart, for punctured wounds. The situation of suicidal wounds, of lunatics, etc., shows all kinds of fantasies. The mere situation does not suffice to distinguish suicidal wounds, as a murderer may simulate a suicidal wound for purposes of concealment. Some regard a wound in the back as proof against suicidal origin, but it is not so much the situation of a wound as the situation taken in connection with the direction which furnishes the proof against suicide in such wounds. As a rule, a suicidal wound, besides being in an accessible part of the body, is also in a part commonly known to be rapidly mortal, as the neck and heart. But suicidal wounds are not always in the situation which is anatomically best for being rapidly fatal. Concealed wounds or wounds in inaccessible parts presumptive of murder may be suicidal and so placed to impute them to another and give rise to the suspicion of murder. The blood-vessels of the arms and legs may be selected as the site of a suicidal wound. This situation is often regarded as uncommon, though the writer has met with it in one or more cases of attempted suicide. It is illustrated in the famous case of Abdul Aziz, the Sultan of Turkey. He was found dead under suspicious circumstances with two oblique, ragged wounds at the bend of each elbow, directed from above downward and from within outward. The joint on the left side was penetrated, while only the skin and veins were involved on the right side. Death was due to bleeding from the ulnar artery and the veins. The clothing was soaked with blood and scissors stained with blood were found on the sofa. These wounds were consistent with suicide, though not what would be expected. Nineteen physicians who examined the body agreed in reporting it as suicidal, though one reason given for this opinion, namely, “that the direction and nature of the wounds, as well as the instrument which might have effected them, lead to the conclusion of suicide,” was hardly a valid one, for the wounds were not typical of suicide in nature, direction, or position. Such wounds are rarely homicidal, though at least one such case is mentioned. Suicidal incised wounds, as has been said, are usually in the neck, where they may sometimes be arrested by the larynx, especially if it be ossified, though the incision often divides the larynx. The situation of the wounds is often between the larynx and the hyoid bone, and then meeting no bony resistance, they may divide the great vessels and even nick the vertebræ. But it is rare to be so deep, at least on both sides at once. As a rule, it is deepest on the side on which it is begun and ends more superficially. As far as the situation of a wound is concerned, there is no wound which a suicide can inflict but what may also be inflicted by a murderer. The reverse, however, is not true. We cannot always certainly distinguish between suicidal and homicidal wounds from their situation. =The direction of the wound= is one of the most important points to notice. It is considered by some to furnish presumptive evidence for the medical jurist, and taken in connection with the nature and situation of the wound may often lead us to a positive opinion as to the question of the suicidal or homicidal nature of a wound. The evidence from the direction of wounds is only furnished by incised and punctured wounds, rarely by contused wounds. Suicidal incised wounds of the throat are almost always directed from above downward and from left to right if the suicide be right-handed, and in the same direction from right to left if the person be left-handed. Transverse wounds in this situation without obliquity are also compatible with suicide, though perhaps more common in homicide, while obliquely transverse wounds from above downward and from right to left in a right-handed individual are indicative of their infliction by another. Homicidal incised wounds of the neck inflicted from behind or the right side, if the victim and assailant are right-handed, or from the left side if they are left-handed, may have the same direction as similar suicidal wounds. Such a wound may be inflicted by a murderer to deceive as to the cause of the wound by raising the suspicion of suicide. If an incised wound of the throat be inflicted by another from in front, then its direction is usually the reverse of a similar self-inflicted wound. Homicidal incisions, especially in the throat, may extend at one or the other end beyond the skin wound. In similar suicidal wounds at both angles of the wound the skin is the first and the last part injured, and in such wounds the spine is seldom reached. It should be borne in mind in this connection that a given suicide may be ambidextrous and this fact may be unknown to the friends of the deceased. This is especially the case in the use of the razor from practice in shaving, and the razor is the usual weapon used in such incised wounds of the throat. Neglect of this point may lead to an unwarranted suspicion of murder. The two following cases cited by Taylor[642] well illustrate this fact: In the case of Sellis,[643] the man was generally supposed to be right-handed, though he was found dead in bed with his throat cut and the razor on the left side of the bed. In point of fact, he was ambidextrous in the use of the razor. The second case, which occurred in London in 1865, was still more remarkable. A publican was found dead in bed with his throat cut in a left-handed manner. He was supposed to be right-handed and there was bloody water in a basin in the room. His wife, who gave the alarm, had marks of bruises on her, and though she said she had found her husband dead in bed after having left it for a short time, suspicion fell upon her, especially as they were in the habit of quarrelling. The suspicions were removed, however, by the explanation that he had been brought up as a wood-carver, which required him to use both hands equally, and that he had frequently threatened to kill himself, and further that the bloody water in the basin was due to a daughter washing her hands after having touched her father. It is even conceivable that an ambidextrous person, to avoid suspicion of suicide or to impute murder to another, might inflict a suicidal wound from right to left. Notwithstanding all this, the above cases are very rare exceptions, and the rules stated above as to incised wounds in the throat hold in almost every case. In the case of stab-wounds of the chest, especially in the cardiac region, the same rule as to the direction holds good, and in these wounds we can often define the direction more accurately than in the case of incised wounds. If the suicide is right-handed the wound is regularly on the front or side of the body and directed obliquely from above downward and from right to left, while it is from left to right in case of a left-handed suicide. A murderer from behind, or from that side the hand of which the victim would use, may inflict a wound in the same situation and direction as a suicidal one. Here again this may be done with the motive of concealment of the nature of the crime. Homicidal stab-wounds inflicted from in front, as they generally are, are usually directed from left to right, and they may be directed from above downward or in the opposite direction. Oblique wounds from above downward may be either suicidal or homicidal; those directed from below upward are almost always homicidal. When a wound is caused by an instrument both cutting and puncturing, suicide cannot be admitted unless the direction of the wound is compatible with that which the weapon which inflicted the wound, held in the hand of the deceased, might cause. Taylor recommends to place the weapon in the hand of the deceased to see if the direction of the wound could possibly correspond with that which could be taken by the weapon in the hand of the deceased with any position possible for the arm and hand. Therefore certain wounds by position and direction exclude suicide, but if a wound is possibly suicidal it is also possibly homicidal. Though suicidal wounds vary, the above points are sometimes of real assistance in distinguishing between suicide and homicide, especially if the body has not been moved. =Evidence Furnished by the Number and Extent of Wounds.=—Multiplicity of wounds, as a rule, indicates homicide, and indeed the reverse is true in a majority of cases that a single wound points to suicide. There are many exceptions, however, to both statements. Multiple wounds are possible in suicide, and that, too, with different weapons; even drowning or hanging may be resorted to after self-inflicted wounds have failed. If several wounds are found, each one of which or more than one of which may be considered grave, it is usual to conclude that the wounds were not self-inflicted, but the medical expert should not judge too hastily from this fact alone, for most wounds do not kill instantly. With the presence of several wounds in a case of suicide only one of these, as a rule, is “mortal” in character. This being so, some have asserted that if two mortal wounds are present, especially if one of them is stupefying, such as a wound about the head, such wounds are incompatible with suicide. A definite statement of this kind cannot go unchallenged unless the two wounds are in different parts of the body, and both of such a nature as to be immediately or very rapidly fatal. For all cases of suicide or homicide do not die immediately from wounds commonly called mortal; in fact, this may be said to be the exception rather than the rule. We may safely say, however, that if there are several distinct wounds on the throat, each involving the large vessels, the inference is plainly murder. [Illustration: FIG. 10.—Suicidal Cut Throat from Left to Right, showing the Tentative Cuts at the Commencement and the Serrations at the Termination of the Wound.] Several wounds by the same or different weapons cannot, therefore, be proof of homicide. The case of a lunatic suicide is reported who inflicted thirty wounds upon his head. In a case of homicide with multiple wounds the situation or direction of some one or more of them may give evidence as to the origin of the wounds. Ogston, Sr.,[644] states that especially in the case of incised wounds of the throat a suicide may make a number of small or superficial tentative cuts besides the principal one, but these incisions are all usually parallel (see Fig. 10). In the case or multiple homicidal incised wounds of the throat, on the other hand, the wounds are not parallel, owing probably to the resistance of the victim in this case and his remaining passive in the former. The extent of the wound refers to the number and importance of the parts injured. In regard to incised wounds of the neck, this point has been thought by some to furnish presumptive evidence of suicide or homicide—of homicide if the wounds are deep, of suicide if they are not. While it is true that suicidal wounds of the neck are, as a rule, not very deep, and that they seldom reach the vertebræ and generally do not divide the vessels on more than one side, yet sometimes such wounds are as deep and extensive as homicidal ones. This may imply a determined purpose not to be foiled in the attempt at suicide. Thus Marc reports a case of suicide by an incised wound of the neck, where the wound was so deep as to reach the vertebræ or their anterior ligaments and to divide the trachea and œsophagus, both carotids and jugular veins. The extent of this wound was greater than in most suicides, but still we can hardly lay down a hard-and-fast rule of much practical value according to which extensive wounds are evidence of murder. Such wounds are, however, presumptive of murder taken in connection with other signs pointing that way. [Illustration: FIG. 11.—Homicidal Cut Throat from Right to Left, showing a Tentative Cut at the Commencement and the Serrations at the Termination of the Wound.] The question may arise in regard to a wound, _whether the victim wounded himself by precipitating himself on the weapon_. This may be alleged by the defence, but it is difficult to believe if the wound is deep, for the body would naturally repulse the weapon. If the wound is deep the weapon must at least have been strongly held, which may or may not be consistent with the theory of self-defence. If the direction of the wound is oblique from above downward, or if there is one external wound and two separate tracts internally, from a second use of the weapon on the part of the person holding it, then the above allegation is doubtful, if not impossible. By comparing the relative positions of the deceased and accused, as indicated by the witnesses and accused, with the position and direction of the wound, we may often judge whether the allegation is possible or probable. Besides the above points derived from the wound itself, there are several other factors which belong to the category of circumstantial evidence, but which come within the province of the medical expert. These latter points of evidence are sometimes almost as important as the former, while taken in connection with them they help to make the evidence far more conclusive. =Evidence furnished by the weapon= as to the origin of wounds. We have already seen in a former section that we can often tell, by various signs of the wound, with what kind of a weapon it was made. We may thus be able to say that a wound was made by a weapon similar to one exhibited. Also by examination of the weapon itself and from the circumstantial evidence of where and how it was found, we may sometimes say that the wound was inflicted almost certainly with a particular weapon. All this evidence may sometimes be made use of in judging between the suicidal and homicidal origin of a wound. The POSITION _of the weapon_ or the place where it is found is a matter of considerable importance. If it has not been touched, its position should be carefully examined, or inquired about if it has been moved. The presence of a weapon which might have caused the wounds in the hand of the victim is in general proof of suicide. The weapon must not merely lie in the hand, it must be gripped by the hand. One might suppose that the weapon placed and held in the hand until rigor mortis sets in would still be firmly held. Casper says that this is not so, but that the weapon falls from the grasp as soon as the hand is unbound. Also Hofmann’s[645] experiments proved the same point. By the use of ligatures and several artificial means he tried to confine a weapon in the hand of a recently dead body so that it would be as firmly held as by a contraction of the muscles during life. These experiments were entirely unsuccessful, for though the fingers remained closed, the object was simply held and not grasped, and fell from the hand on the release of pressure. In suicide the weapon is sometimes held so firmly that force is required to dislodge it. It seems as if the muscular spasm or grip persists after death, as cadaveric spasm, until rigor mortis occurs and sets it, as it were. The murderer, therefore, cannot imitate this grip, and an unsuccessful attempt to do so would indicate murder. It should be borne in mind that the weapon in the hand of the deceased may have been for the purposes of defence; therefore it is necessary to note whether the wounds on the body correspond to those which could be made by the weapon. Indeed, this fact is most important to note in all cases of suspected suicide where the weapon is found. If the weapon is not in the hand of the deceased, note carefully where it lies. If death is due to a suicidal or accidental wound which is immediately or very rapidly fatal, the weapon is generally found near the body. If so, it is well to note on which side it lies, and if it lies near, whether it has apparently fallen or been thrown or placed there. If the relation of the body and the weapon has been disturbed by moving either, the position of the weapon as found by the medical witness is of little value. In cases of suicide the weapon _may_ possibly be found at some distance or even concealed, though this is exceptional. Thus Taylor[646] states that the razor in one instance was found shut at the side of the deceased, who had committed suicide by cutting his throat. In another instance the razor was found in the pocket of the deceased, bloody and closed. As a rule, the weapon is found lying at the side of a suicide if it is not grasped in the hand. If the weapon is far from the body and the wound was quickly fatal, especially if the weapon is hid or cannot be found, it is strongly presumptive of murder. If the weapon is found near the body it is well to note whether the edge is sharp or blunt, straight or bent, or notched, as these points may assist us in forming a judgment as to suicide or murder. A weapon belonging to the victim may be substituted by the murderer for the one really used, and the former may be placed by the side of the body. Therefore the weapon found should correspond to the wounds as to length, depth, sharpness, etc., to be compatible with suicide. Generally a suicide foiled in the attempt to take his life uses the same weapon over again if he persists in the attempt. But he may not do so; on the contrary, if the first attempt was made with a knife, the second may be made with a pistol, etc. Several wounds by the same or different weapons cannot therefore be an absolute proof of homicide. =The presence of blood, hair, and other substances on the weapon= used, or probably used, is a matter of some importance. Blood is not necessarily found on the weapon used to inflict a mortal wound, especially in the case of blunt instruments. In stab-wounds, too, the vessels may be compressed by the blow or the weapon may be wiped as it were on withdrawal by the elasticity of the skin and by the clothing, except for a thin yellowish film. Thus it is that the first stab-wound shows no blood on the outside of the clothes but only on the inside, but the outside of the second is usually bloody but may be but little so. To make sure whether or not there is blood on a knife or other weapon it is necessary to examine all the depressions on the instrument, as the blade itself may have been washed, and only those traces of blood remain which are less accessible to cleaning by washing. Blood coagulated on a blade indicates, as a rule, blood from a living animal, but it may not do so. Furthermore, it may be hard to distinguish between a thin layer or spots of dried blood not coagulated or coagulated and dried blood in a similar form. If blood is not found on a weapon, hair and other substances which can be identified may be. This is especially the case with blunt weapons, on which, as we have seen, blood usually fails. A fragment of the weapon may break off in the wound, as in stab-wounds, and may be identified as belonging to one in the murderer’s possession. =The signs of a struggle= furnish important evidence, as they are not likely to be found in the case of suicide. If the wounds were inflicted by a cutting instrument, the existence of a struggle may be indicated by incisions on the palm of the hand or fingers or on the dorsum (see Fig 12). Such wounds would not be self-inflicted and would indicate a struggle with the murderer. Or if contusions or ecchymoses indicating the form of the foot, fist, fingers, or finger-nails are found on the face, neck, chest, forearm, or hand of the deceased, this again indicates a struggle with the assailant, and goes far to prove murder. The same is true of the imprint of a bloody or dirty hand on the clothes of the victim when the victim’s hands were not bloody. Also such an imprint in a position where the deceased could not have reached with the particular hand indicated, as is the case if the impression of a right hand be found on the victim’s right arm; this indicates a struggle with a murderer, etc. In one case of murder, on the back of the left hand of the deceased there was found the bloody mark of a left hand evidently not that of the victim himself. The presence of marks of violence about the mouth of the deceased, done to close it to prevent the victim from giving an alarm, especially if surprised during sleep, is presumptive of murder. Sometimes hair or fragments of clothing belonging to the accused are found in the grasp of the deceased, indicating a desperate struggle, and they are very suspicious of murder. Thus Taylor[647] cites the case of a murder trial in Ireland, in 1877, where hairs found firmly grasped in the hands of the deceased were found to correspond to the hair of the accused. The clothes of the deceased, as well as those of the accused, often indicate a struggle unless the accused can satisfactorily account for the condition of his own clothes in some other way. [Illustration: FIG. 12.—Incised Wounds of Right Hand in the Struggle of Defence. Homicide.] =The examination of the clothes and body= of the deceased and the accused may furnish important evidence. If suicide is accomplished by a weapon like a knife, it is rare for the hand not to be bloody. If it is not bloody we may well suspect a case of supposed suicide. The presence of blood on the hand does not prove suicide, though its absence may disprove it, as the hand is generally bloody in case of murder by being carried to the wound. The _examination of the clothing of the deceased_ is of great importance. As we have noticed before, a suicide generally opens them, a murderer rarely. A suicide is often partly or even wholly undressed when he inflicts the wound, while murder is usually committed on those entirely dressed. The wound of the clothes should correspond to that of the body in case of murder. In suicide the wounds of the body and of the clothes may not correspond, especially if there exists a motive to falsely impute the crime. The clothes of the deceased as well as those of the accused may indicate a struggle, as we have already noticed. Of course, in regard to the clothes examined, it is necessary to clearly prove that they were worn at the time by the deceased or accused, otherwise serious mistakes may be and sometimes are made. In examining the blood-spots on the clothing, note whether the blood occurs in large patches or sprinkled as by a spurting vessel or by continued violence. The _body of the accused_ may present scratches, marks of nails, contusions, bites, or other wounds indicative of a struggle. It would be well to ask the accused how he received the wounds or scars, to see if his explanations tally with the injuries. It is hard to tell when wounds which have cicatrized were inflicted; we can only distinguish between old and recent ones, and thus control the statements of the accused. An examination of the finger-nails of the prisoner soon after the crime may reveal blood underneath when the rest of the hands and person are free from it. Note also the site and shape of the blood-spots, if they exist, and whether or not they came from an arterial jet. These spots may be on the body or clothes of the accused. The account of the accused as to these spots may or may not correspond to the facts as indicated by them. The above leads us to the more or less important question: COULD THE ASSAILANT HAVE ESCAPED WITHOUT STAINS? It is possible for the murderer to escape without being spotted with blood, but the probability of this occurrence depends on the nature of the wound and the relative positions of the deceased and the assailant at the time the wounds were inflicted. This latter fact is very largely, if not altogether, a matter of speculation as far as the medical evidence goes. It is a popular, though false, idea that a murderer’s clothes must be bloody, and the police may be misled in expecting to find them so in every instance. Taylor[1] cites several cases in which either no blood was found on the murderer’s clothes, or only small spots wholly out of proportion to the amount of blood which must have spurted or flowed from the wound. Absence of blood on the prisoner’s clothes is often made use of by the defence to prove the prisoner’s innocence, whereas, besides the possibilities of having had no spots in the first place, the clothes may have been changed or washed before the examination was made. This has occurred in more than one murder trial. Taylor[648] mentions the following cases in illustration: It was alleged that the absence of blood-stains on the prisoner’s clothing was a strong proof of his innocence in the trial of Sub-Inspector Montgomery for the murder of Mr. Glasse (Omagh Ass., July, 1873). In this case the weapon was a bill-hook which had produced contused wounds on the head. There was blood on the floor about the body, but the wounds were not likely to have been accompanied by much spurting. Yet it was assumed that the assailant in this case must have been covered with blood. Much stress was laid upon the absence of blood-stains. On the first two trials the jury could not agree, owing chiefly to the absence of blood-stains, but on the third trial he was convicted and afterward admitted that he had removed the blood-stains from the clothes with cold water. Also in the case of Reg. _v._ Courvoisier (C.C.C., 1840) the accused, who was tried for the murder of Lord William Russel, had no blood-stains on his clothes. All the vessels of the throat of the deceased had been cut to the vertebræ while he was asleep. It was contended most strongly that the accused could not possibly have committed the crime, as he had no blood-stains. But after conviction he confessed that he wore no clothes when he committed the murder, and he only had to wash his hands and the carving-knife he used. Again, in the case of Reg. _v._ Thompson (Durham Wint. Ass., 1863) the defence mainly relied on the absence of blood on the prisoner’s clothing. The wound in the throat of the wife of the accused was five inches long, directed from left to right, dividing all the vessels and nerves of the neck. The medical witness stated justly that no such wound could be self-inflicted. It was rapidly fatal. No weapon was found near the body. The prisoner was convicted. The same author cites the case of a prisoner on whose trousers worn soon after the murder no blood-marks were found, but the trousers actually worn by him were found with blood upon them. Juries have even acquitted the prisoner apparently only because no marks of blood were found, though the other circumstances were explicable only on the theory of murder. It should be remembered in this connection that blood-stains may be found on the clothing of many, especially on the coarse clothing of working-people. This may be accounted for by the occupation, flea-bites, accidental circumstances, or it may occur without definite explanation. Such persons may be accused of murder and yet the blood-stains be consistent with innocence. Too much importance should not, therefore, be attached to them, even if the accused cannot satisfactorily explain them and if he does not attempt to do so in a suspicious way. That blood on the clothing even under suspicious circumstances may be consistent with innocence is illustrated by the case of a suicide by cutting the throat, in 1872, cited by Taylor.[649] In this case the son first found his father dead, and thought that he had broken a blood-vessel. He raised the body, staining his hands and clothes, then went for help. At the inquest he was closely questioned as to the presence of the blood-stains, but there could be no doubt that the case was one of suicide. In general, we may say that a murderer is much more likely to escape without blood-stains in contused wounds, and more likely in the case of punctured wounds than in incised wounds, for in punctured wounds the bleeding is much less free and is less likely to spurt from the wound. In the case of incised wounds he is most apt to escape without stains if he is behind or to the side of the victim when he inflicts the wound—in other words, when a part of the body of the deceased was between the assailant and the wound inflicted. Furthermore, the assailant is more likely to escape without blood-stains if there is a single wound than if there are several, and each additional wound makes it more likely that he will be spotted with blood. The _examination of the ground or floor and the furniture_, etc., may furnish some evidence as to the nature of the crime, and also help the witness to answer the questions which may sometimes be asked, _i.e._, AT WHAT SPOT WAS THE VICTIM WOUNDED? and WHERE DID HE DIE? This question is sometimes settled by examination of the spot where the deceased lay and the furniture, etc., about. Sometimes the floor or ground and the furniture or surrounding objects at a distance give the requisite evidence. The examination of the cracks and corners of the floor and furniture should not be neglected, and Taylor instances a case where the hair of a dog helped to clear up the case. If the body has not been disturbed the most blood is usually found where the deceased died. If the victim succumbs at the spot where he was wounded, blood is found only in the immediate neighborhood, except for arterial jets, which may be as far distant as two metres. The separate blood-spots of an arterial jet are circular if the jet strikes the object perpendicularly, oval or wedge-shaped with the larger end away from the body if it strikes the object obliquely. If the blood-stains are more diffused and are found in other places, careful notice should be taken as to whether the different places communicate with one another by traces of blood. If they do not communicate, it goes to show that the body was moved after active bleeding had ceased, that is, after death, but this indication is not absolutely positive. If traces of blood do connect the larger blood-spots, it is of interest and importance to know where the deceased was wounded and where he died, also whether he moved or if he was moved before or after death. This question is not always capable of solution. Some injuries exclude the possibility of active motion. Stupefying contused injuries of the head or an incised wound opening a great artery are both inflicted where there is the greatest hemorrhage, and the spot where the deceased was wounded and died should be identical. In such cases a second large spot of blood, connecting or not with the first wound, indicates that the body has been moved. But if the wound does not bleed much or rapidly, the wounded person may fall at a distance from the spot where he was injured, and death occurs, as a rule, where there is the greatest amount of blood; for a certain amount of bleeding occurs for a short time after the victim falls or even after death. One can find in many places the signs of arterial jets marking the movement of the deceased from one blood-spot to another. This is quite different from the tracks caused by dragging a bleeding body. All this it is important to notice, for the dragging or passive moving of the body strongly indicates murder. Blood at a distance may indicate the occurrence of a struggle, or that the body was moved, or it may show the tracks of a murderer. As to the latter point, _the imprints of the hands and feet_, whether bloody or not, may indicate murder and establish the identity of the murderer. We have already seen how they may occur on the deceased and indicate a struggle, and thus be presumptive of murder. When the marks are made by the naked foot, it is well to examine it by lining it off in squares, and so to compare it with the imprint of the foot of the accused. Simple inspection can sometimes give the required evidence. We may even get an impression of such imprints in the snow. Imprints of the boots or shoes worn by the accused compared with those imprints found at and near the scene of the crime may sometimes help to clear up the case, but this may perhaps be considered outside of the sphere of the medical witness. Such and other signs of a struggle about one of the blood-spots would indicate that the wound was received there, though death may have occurred at another spot. In such a case it would be well to examine to see if there was much blood where the body was found, for if there was not it would indicate that the body had been moved there after death, and thus be strongly presumptive of murder. As furnishing some evidence which may help to distinguish between suicide and homicide in the origin of wounds, the question may be asked, WHAT WAS THE POSITION OF THE VICTIM WHEN INJURED OR DYING? and also, WHAT WERE THE RELATIVE POSITIONS OF THE VICTIM AND ASSAILANT? The position of the victim at the moment of the injury is sometimes indicated by the position of the wound, the direction of its tract, and the direction from the wound of the blood on the body and clothes. On the neck or extremities the course and form of the wound may indicate the position of these parts when the wound was inflicted, for sometimes in flexions of these parts the skin lies in folds, and a wound inflicted when these parts were so flexed would be irregular, wavy, or zig-zag. Further, the position and movement of these parts necessary to restore directness to the wound may indicate the position of the parts when the wound was inflicted. The examination of the relative positions of the wound in the clothes and the body may help to indicate the position of the body when wounded. The position of the blood on the body and the direction of the blood from the wound, whether below or at the sides, etc., tends to show the position of the body when bleeding. Thus if the body was at any time in the erect position, some of the blood-stains will be vertically below the wound, or if the victim was lying on the back then the stain would be at the sides only and not below the wound, except such stains as indicate that they were produced by arterial jets. Few suicides cut the throat in the recumbent position; therefore it may be considered in the light of an indication of homicide if the blood-stains show that the victim was not erect after the wound was inflicted. It is well also to note the form, direction, and obliquity of the blood-spot. This would indicate, by comparison with the wound, the relative position of the wounded person and the blood-spot, and thus show whether the body had been moved or not, as, for instance, by the murderer for the purpose of robbery. The force of the bleeding is also indicated by the form of the spot, and this would indicate how rapidly death probably ensued. This fact might thus help us to judge whether the victim probably died where he was wounded, and whether other and remote blood-spots would not be presumptive of murder. If the victim is found in night-clothes, this fact would help to show that he was lying down when wounded. The medical evidence as to the position of the victim when injured is, therefore, circumstantial and not very positive; that in regard to the _relative position of the victim and assailant_ is even less positive. We presuppose in this question that the case is one of murder. We are not to prove murder or refute suicide. We can rarely be _positive_ as to the relative position of the assailed and the assailant. A wound in the back may be caused by some one in front with an arm behind. The direction of the wound would indicate this, for if the assailant is right-handed and inflicts a wound on the back from in front, a stab-wound would almost always be directed from left to right, an incised wound from right to left, both from above downward. With a left-handed murderer the direction would most likely be from right to left and from above downward for a stab-wound, and from left to right and from above downward for an incised wound. If the assailant were at the back of the victim and wounded him in front, the direction of these wounds would be the opposite of the above, _i.e._, from right to left for a stab-wound and from left to right and from above downward for an incised wound with a right-handed assailant and _vice versa_ with a left-handed assailant. These wounds occur more commonly than those of the back, and are especially noticeable in incised wounds of the throat. In the case of these incised wounds of the throat inflicted from behind, the direction from left to right and from above downward resembles that of self-inflicted wounds in the same situation. As a general rule, wounds are on the same side of the victim that the assailant was; the facts given above help to show us the exceptions. Thus a wound on one side is presumptive that the murderer was on that side, or possibly at the front or back and only exceptionally on the opposite side. The presence of wounds on one side only may help to confirm the testimony of a witness that the victim was against a wall or some other obstacle which protected the other side. The question of the relative position of the combatants in duels and the nature of the weapons used as shown by the wounds has sometimes come up, especially in other countries, to determine whether the combat was regular and fair. In all cases of suspected suicide, but where a doubt exists between suicide and murder, or even accident, _hereditary disposition and organic affections_ of the body, such as alcoholism, incurable or painful diseases, chronic inflammation of the brain and meninges or of the genito-urinary organs—all such and hereditary predisposition may support the idea of suicide. IMPUTED OR SELF-INFLICTED WOUNDS. Closely allied with the question of the suicidal or homicidal origin of wounds is the question whether a wound imputed to another is self-inflicted or inflicted by another. These wounds are seldom fatal. In discussing the question whether a wound is self-inflicted or inflicted by another, we have referred occasionally to suicidal wounds where the circumstances were such as apparently purposely to imply murder and impute the cause of death to some one else. This happens more often in cases of unsuccessful suicide. Here we have recourse to the same evidence that we have gone over in the present section which helps to distinguish between a suicidal and a homicidal wound. The case may be somewhat more difficult, as the unsuccessful suicide may manufacture evidence against the accused and hide to some extent the evidence of suicide. These cases can usually be decided, however, in connection with the circumstantial and other evidence. The majority of cases of imputed but self-inflicted wounds are very superficial, often not below the true skin. Being self-inflicted they have many of the characters of suicidal wounds. Thus they are usually situated in front and on the left or right according as the wounded person is right or left handed, and the direction is usually similar to that in suicidal wounds. Such wounds are generally incised or punctured wounds, seldom contused wounds, and in this respect they resemble suicidal wounds. As exceptions to this rule, Bergeret[650] mentions some cases where females in attacks of hysteria have inflicted severe contusions on themselves, and have preferred charges of attempted murder against innocent persons. Like suicides also the hands are seldom injured, though they may be much so in resisting homicide. In other respects, however, these wounds differ from suicidal wounds. Thus they are not usually situated over a “mortal” spot, and they are often numerous and _scattered_, sometimes parallel and sometimes not. The wounds in the dress do not correspond even as often as in suicide. In comparing cuts in clothing with those on the body, it is important to find what articles were worn at the time the assault was alleged to have taken place, and to make sure that the clothes examined were those worn or alleged to have been worn. It may not be necessary that the clothes examined should have been really worn, for if they were alleged to have been worn and were not, the examination of them will almost always show the deception or the self-inflicted nature of the wounds. Then take careful note of the position, direction, form, and size of the cut and the apparent sharpness of the weapon in the several layers, and see if they correspond with one another and with the wounds on the body in those various particulars. In imputed wounds the clothes are generally cut when off the body and can seldom be done so as to deceive a careful examiner. Several wounds cannot exist in the same region of the body without some being bloody and showing the marks of it on the clothes. Even a single wound of the clothes generally shows blood on the inner surface if there is a corresponding wound of the body underneath. In simulated and imputed injuries the blood-stain may be on the outside of the clothing instead of on the inside, showing that it was artificial and not natural. An impostor may either do too much or too little, and the medical witness should be on guard against both alternatives. Taylor[651] mentions a case which occurred in London some time ago, in which there were _two_ cuts in the shirt near together exactly alike in size, form, and direction, making it evident that the weapon had gone through a fold of the shirt. This proved that the shirt could not have been worn at the time it was cut, for if the shirt was folded while on the body the weapon must have gone through the fold and then through another layer of shirt, making three cuts instead of two, or five instead of four, before it could have reached the body. This and other facts made self-infliction of the slight wound on the chest probable. The same author cites another case showing the imperfect manner in which the cuts in the clothes are made in imputed wounds, the clothes being off the body at the time. The case occurred in Nottingham in 1872, the accused being charged with wounding the plaintiff on the highway by stabbing him in the arm, though there was no robbery or other motive for the act. The coat and shirt sleeve were found cut, but there was no corresponding cut in the lining of the coat sleeve. The charge was clearly false, and was trumped up by the youth who was the plaintiff because he wished to leave the place where he had been sent for private study. In examining a case where the self-inflicted nature of imputed wounds is in question, the following are some of the many points to keep in mind in the examination and to be ascertained by the examination: (1) The relative position of the plaintiff and the assailant at the time of the alleged attack. This can be compared with the position as stated by the plaintiff or other witnesses. (2) The situation, direction, depth, nature, and number of the wounds. (3) The situation and direction of blood-marks or wounds on the dress or person of either or both. (4) The marks of blood and the quantity of it at the spot of the alleged struggle. (5) The signs of a struggle and the various other points of circumstantial evidence gone over in considering suicidal and homicidal wounds. Though a severe blow may cause a slight mark, it does not follow that a slight mark implies a severe injury, else the exception is made the rule. The inconsistency of the story of the plaintiff is generally so palpable that imposture is evident, but prejudice and unjust suspicion are often excited against those accused. Thus Taylor[652] states that “a strong suspicion was raised against the then Duke of Cumberland, in 1810, in reference to the death of Sellis, when a skilful examination of the wounds on the deceased would have shown that they might have been self-inflicted.” The same author also cites the case of M. Armand, a merchant of Montpelier, who at Aix in March, 1864, was tried for an alleged murderous assault on, or imputed murderous strangulation of, his servant. The excoriation on the back of the neck was so slight as to escape the observation of some medical men, and it was evidently self-inflicted, either accidentally or purposely, as the facts showed. The assertions of a number of medical men were taken by the court to support the servant’s story to the effect that his master had struck him a severe blow on the back of his neck, rendering him insensible for many hours from concussion of the brain. The evidence given chiefly by Tardieu for the defence showed the story of the complainant to be a fabrication, and the accused was justly acquitted. WAS A WOUND ACCIDENTAL? In answering this question we must distinguish accidental wounds from those self-inflicted and those inflicted by another. These three classes comprise all wounds. In case of a trial for murder it may be alleged by the defence that the wound was caused by accident or that it was due to suicide from a fall, falls being a common class of accidental wounds. So we have to judge between accident on the one hand and homicide and suicide on the other hand. The question arises especially in cases where the injury causing death is one commonly due to accident. As to the QUESTION BETWEEN ACCIDENTAL AND SUICIDAL WOUNDS, they are often easily distinguished, especially if the body has not been disturbed. In suicide there is clear evidence of design, and the circumstantial evidence helps to make the case clear. It may not always be possible to decide, however, as an accidental wound may sometimes resemble a suicidal or homicidal one. Accident is often shown by the _nature_ of the wound. Thus it is rare for an accidental mortal wound to be caused by a knife or similar weapon held in the hand and forced into the body by a fall, the blow of an opening door, etc. But such exceptional cases have been reported. Incised and punctured wounds are, therefore, very rarely accidental, and most accidental wounds are contused wounds or contusions. Again, accident is often shown by the _situation_ of the wound, which should be on an exposed part of the body unless the accident is due to a fall from a height, when the wound may be almost anywhere. But such injuries are easily shown to be due to falls. The fall, of course, may be accidental, suicidal, or homicidal. Some wounds in exposed parts forbid accident on account of their nature, _i.e._, deep incised wounds of the throat. If the deceased has a life insurance, suicide is less probable, as the insurance is not paid in case of suicide. In fine, accidental wounds are distinguished from suicidal by—(1) Their _nature_; accidental wounds are almost always contused, suicidal very rarely so, only in cases of lunatics and delirious persons and where suicide is accomplished by a fall. (2) The situation of the wound or wounds indicates their origin. We have already studied the situation of suicidal wounds and have also seen that accidental wounds are only on exposed parts, except when the injury clearly indicates a fall from a height. The evidence from the direction of wounds rarely applies, as this is valuable only in incised and punctured wounds, which are seldom accidental. Both kinds of wounds are usually few in number except in case of a fall from a height or a crush, though sometimes suicidal wounds are multiple. The evidence from weapons, if there be any, points strongly to suicide. The signs of a struggle are hardly consistent with either suicide or accident. The only case in which they might occur would be where a struggle occurred to prevent a suicide from throwing himself off a height or before a vehicle or railway train. In such a case accident would be excluded by the signs of a struggle, and the question would lie between homicide and suicide. The examination of the clothes of the deceased would furnish no evidence unless some letter or paper were found stating the purpose of committing suicide. Little or no evidence would be furnished by the position of the body when found in cases which might otherwise be doubtful. Organic lesions or other facts predisposing to suicide would furnish presumptive evidence against the wounds being accidental. Of all these various points the first, as to the nature of the wounds, is by itself the most valuable and conclusive. But this gives us no assistance in clearing up a case where it is doubtful whether a fall from a height or a crush by a vehicle or railway train was accidental or suicidal. Some of the other points mentioned may aid us in such a case, and also the fact that such injuries are far more often accidental than suicidal. But in these cases, also, certain circumstances may show that the fall was not the result of accident. Accidental wounds are generally caused by a fall or a crush, and the fact of their accidental character is generally established by the circumstances of the event. Certain accidental wounds present characteristics which allow the true nature of the wounds to be determined. But in some cases a suspicion may arise and the question may be asked as to WHETHER THE WOUND WAS ACCIDENTAL OR HOMICIDAL. For instance, if a person receives fatal homicidal injuries, and just before or after death the body is thrown from a height or is run over and crushed, it may be hard to determine the murderous element among the many wounds. This is the case if the homicidal wounds were contusions or were caused by blunt instruments, but rarely, if ever so, if they are incised or punctured wounds or both. But even in the former instance, a close examination of the lesions and of the locality of the injury can often clear up the case. Thus in a case mentioned by Vibert,[653] as cited by Hofmann after Taylor, a woman was found dead at the foot of some stairs in a cave. She had died of a fracture of the skull and of the spine, produced by the fall. But about four or five feet above the level of the top step there was found on the wall the fresh marks of an arterial jet of blood. Examination showed a wound in the right temporal region which had opened the temporal artery, and it was therefore thought that the woman was wounded at the top of the stairway and then thrown down, which was afterward proved to be true. In another case, reported by M. Tourdes, a man knocked down and killed by an axe, which crushed his skull and caused the brain to exude, was placed in a road frequented at night by heavy wagons. The head was placed in the rut, but the coagulated blood and brain formed a puddle which did not appear on the wheels or their track, and no bloody furrow was caused by their passage. The same author mentions the case of a woman plainly strangulated by the hands and then thrown into the ditch of the fortifications of Paris. It is especially with regard to fractures of the skull that the question often comes up as to the accidental or homicidal nature of the injury, as to whether it is due to a fall or a wound. Sometimes a depressed fracture may show the form of the instrument. An extensive comminuted fracture of the skull may indicate greater violence than would be received from a fall from the little height which the circumstances may allow. As to the slighter degrees of fracture, the disposition of the fracture itself often shows less than the form and site of the ecchymosis, the lesion of the scalp, and the place and position of the body when found. In such cases the traces of a struggle, the existence of other wounds, etc., may be of great importance. In distinguishing between homicide and accident, as in distinguishing between the latter and suicide, the most obscure and difficult cases are those where the injury has been caused by a fall from a height or by a crush. This is illustrated by the case of Madame de Tourville, which is quoted by Taylor.[654] She was killed in July, 1876, by a fall from a precipice. Her husband, a lawyer, was accused of murder committed by pushing her over a precipice in the Stelvio Pass. The place where her dead body was found was at a considerable depth below, and the injury was chiefly in the head, which had been crushed by the fall. The body showed no evidence of intentional violence. The prisoner’s guilt was established on the following points: (1) The false and inconsistent statements made as to the occurrence; (2) the marks of the body having been dragged some distance so that a part of the dress was found, in a bloody condition, some way from the body; (3) there were marks of blood on the prisoner’s hands and clothing. After a long trial he was convicted, though the sentence was afterward commuted to imprisonment for life. Of course, as we have already stated, if a person is responsible for a fall he is also responsible for the results of the fall. This applies to many of the contused injuries and deaths from falls in prize-fights and drunken brawls. We may sum up the points of evidence which help us to distinguish between an accidental and a homicidal injury much as we did when the question lay between accident and suicide. (1) The evidence from the nature of the wound is not quite so conclusive as when the question lies between suicide and accident. For contusions and contused wounds are far more often homicidal than suicidal, and accidental wounds are almost always of this class. If, however, the wounds are incised or punctured, this fact points almost certainly to homicide. (2) As to situation, a homicidal wound may be situated almost anywhere; an accidental wound, except in falls from a height, only on an exposed place. (3) The direction of the wound can seldom help us in the case of contused wounds which, practically, are the only ones in question, though it may possibly be incompatible with accident. (4) As to the number of wounds, homicidal wounds are far more apt to be multiple either in a small area or scattered in such a way that an accident could hardly account for them all. (5) A weapon may give evidence more often here than when suicide is in question, for a weapon may be used to inflict contused wounds which may resemble those received in a fall. The evidence furnished by a weapon or blood, hair, etc., on the weapon, etc., is strongly in favor of murder. (6) The evidence from a struggle is also more important because it is more often found. A struggle may occur in homicide, and only in homicide, as a rule, so that signs of a struggle are strong evidence of murder and against the idea of accident. (7) The examination of the clothes and body of the deceased may give valuable evidence, showing, as it may, signs of a struggle or other marks of an assailant and indicating murder. (8) Examination of the position and attitude of the body and of the spot where it lay and the ground around may furnish more or less proof of murder, as in the case quoted above. Thus the track of the murderer may be discovered or the body may have been interfered with and moved or robbed, all indicating homicide. In any case, whether it is desired to distinguish accidental from suicidal or homicidal wounds, those cases present the most difficulty which result from falls from a height or crushes. But, as the case of Madame de Tourville shows, the above given and other circumstances may often show even then that the fall or the crush was not the result of accident. FALLS FROM A HEIGHT may, therefore, be the result of suicide, homicide, or accident. The injuries are similar in all three cases. A fall of six to eight metres causes, as a rule, numerous lesions, and shows such a traumatism that the case usually excludes the possibility or, at least, the probability that the wounds resulted from blows. Sometimes, however, the gravity of the lesion is not proportional to the height of the fall. Thus Vibert[655] relates the case of a man, afterward employed for several years in the École de Médicine, who jumped from the top of the column of the Bastile, a height of fifty metres. He rebounded on to some canvas stretched at the foot of the monument, then fell to the ground, and was able to get up and walk away. Curiously enough, he killed himself later by jumping from the top of an omnibus in motion. In the case of falls from a height, it is especially true that with grave lesions internally the skin may be intact or only slightly ecchymosed or eroded, or the ecchymosis may be only deeply seated so as not to appear superficially. In the latter case, if life had continued the ecchymosis might have shown itself at some spot on the surface in a few days, but these falls from a height are fatal as a rule. In falls from a height, besides ecchymoses, which may occur where there are no other injuries or may fail where there are many injuries, the _lesions_ consist of fractures of bones and ruptures of internal organs, with or without surface wounds. The _fractures_ may be of a number of bones, and especially of those which first touched the ground, though the skull may be fractured at some part whether or not it was struck in the fall. These fractures are often comminuted, especially fractures of the skull and pelvis, and when the fall is from a great height. Ruptures of muscles may occur with the fractures. Ruptures of internal organs are not rare in such cases. According to Vibert,[656] the order of frequency of rupture of the various organs is as follows: liver, spleen, kidneys, lungs, heart, stomach, intestines, bladder, brain. Rupture of the liver occurs especially on the anterior and inferior surfaces and the bleeding is rather abundant. The healthy spleen does not rupture readily, except from a severe traumatism, but if it is hypertrophied it may rupture spontaneously from muscular violence. The lung may be ruptured internally without showing the rupture on the surface and with the ribs intact. Two such cases are mentioned by Vibert,[657] and he refers to others mentioned by Nelaton and Holmes. Rupture of the brain without fracture of the skull is very rare, though cases have been observed and reported, among others by Casper-Liman. In falls from a height the rupture of the aorta, mesentery, diaphragm, and larynx have been noted. It should be remembered in this connection that rupture of the liver, intestine, bladder, etc., may be caused by contusions without sign of violence externally, and such cases cannot, therefore, be attributed to falls unless there are other signs of the latter. In _crushes_ caused by a heavy vehicle, the lesions resemble in many respects those due to a fall from a height. Thus we find fractures and internal ruptures, but we more often and regularly find subcutaneous ecchymoses and ecchymoses between the muscles. The skin is often stripped up extensively and the injuries are generally limited to the region injured. It is rare to find that the cause of the injury leaves no trace on the skin, for it usually gives the form to the erosions or ecchymoses. Sometimes, for instance, the marks of a horseshoe are clearly visible. Ruptures of internal organs may occur here too when there are slight external marks of violence or even none at all. Thus Vibert[658] relates the case of a man with the head crushed, but with no signs of injury to the trunk save a few erosions at the level of the sternum, who had not only rupture of the kidneys, the liver, and the spleen, but also of the lungs and of the heart. In the heart the apex was completely detached and floating in the pericardium, which was intact. There was no fracture of the ribs nor subcutaneous or sub-muscular ecchymoses. The age of the subject was thirty-two, so that the costal cartilages were not probably ossified, which may have accounted for the absence of fracture of the ribs. _Crushes by the fall of heavy weights_ resemble the latter class of crushes, and differ from falls from a height in the fact that the wounds are usually limited to one region. The lesions themselves are more or less similar. Similar internal lesions may be caused by the compression of the chest and body by the knee of a murderer, which may occasion rupture of the internal organs, fractures of ribs, etc. Thus, too, from the pressure of a crowd the ribs may be fractured and the lungs injured. It is particularly in these cases of injury from crushes or falls from a height that we may have most difficulty, as far as the medical evidence goes, of distinguishing between accident, suicide, and murder. But the various points and considerations mentioned above will sometimes enable the medical witness to clear up the case. In some cases the non-medical evidence, circumstantial and otherwise, may be sufficient of itself, or at least in conjunction with the medical evidence. In falls from a less high place the difficulty is somewhat different, for here there may arise the question between a fall and a contusion or contused wound, and the question generally lies between accident and murder, or, very rarely, between accident and suicide. We have referred to both of these questions above, and from the facts mentioned the case can often be solved. OF MORE THAN ONE INJURY WHICH WAS THE FIRST INFLICTED? We can sometimes tell the order in which wounds were received, but the question is rarely answerable with certainty. If one wound is mortal and one or more are not, whether the wounds are suicidal or homicidal, it has sometimes been considered that the former must have been inflicted last. But we cannot admit that as a general rule the most grave wound was the last inflicted. For the murderer or suicide, especially the former, may go on wounding after the infliction of a mortal wound, especially as it is the exception, and not the rule, to die instantly after a mortal wound. Several assailants may have inflicted wounds at the same time, which would still further increase the difficulty. The question might then arise, Which assailant had inflicted the mortal wound or which had first inflicted a mortal wound? Under such circumstances, it would not be easy to give a specific answer. There are several signs which may indicate which wound was first inflicted in certain cases. An instrument may become duller or even bent or twisted after and on account of the first wound, and the subsequent wounds would vary accordingly. The wound of the clothes corresponding to the first stab-wound may be and often is only bloody internally, while the second and following wounds are bloody on both sides. The following case quoted by Taylor[659] from the _Annales d’Hygiene_, 1847, p. 461, illustrates this point. A man received three stabs from an assailant, one in the back at the level of the eighth rib, traversing the lung and heart and causing rapid death, and two on the left elbow, cutting the coat and shirt but only grazing the skin. The first one was evidently the first inflicted, for both the wounds in the clothing on the arm were bloody externally at the edges, although there was no blood effused here. The correctness of this opinion was confirmed at the trial. The point of a knife arrested and broken off in a bone may show that this was the last wound. The amount of bleeding may show which was the first wound. Thus if several severe wounds have been inflicted, all or several of which would naturally cause profuse hemorrhage, and one showed signs of such hemorrhage while another did not, the former would be likely to be the first wound inflicted. Or if one showed slight hemorrhage where much would be expected, this fact would indicate that it was one of the last inflicted. The absence of the signs of spurting blood may tell which of two or more fatal wounds were first inflicted, for this would indicate that this wound was inflicted when the heart action was weakened by loss of blood or even after death, and the other wound or wounds which did not present this sign would have been the first received. In fact, if any of the signs are present about a wound which we have seen to indicate that a wound was inflicted at any time after death, this would show that this wound was not the first received, and that the other or others were inflicted earlier. Questions as to the CONSEQUENCES of WOUNDS NOT FATAL may often be brought up in civil actions for damages. In certain countries the question of the consequences as to _incapacity_ may determine whether an injury shall be the ground of a criminal as well as of a civil action. Thus in France an injury which involves an incapacity of twenty days or more subjects the assailant to a criminal action. The term “incapacity” in this instance refers to general incapacity and not to incapacity for fine and professional work. The latter, however, comes in under the civil action which may be instituted against the assailant or those directly or indirectly responsible for the injury. The amount of the incapacity, its causes, whether due wholly or partly or not at all to the given injury, the probable duration of the incapacity, the treatment which it has and will necessitate, and many other such questions form part of the medical testimony required in such cases. Sometimes with slight wounds the results, accompaniments, and complications may prolong the incapacity very greatly, as also the state of health and the habits of the wounded person, the neglect of treatment, improper treatment, etc. Any bodily or mental infirmity or ill-health which may result from an injury and its necessary treatment in the past and future, all these questions and many more unnecessary to mention may be required of the medical witness. No general rules can be laid down for all such cases. In giving his testimony the medical man must depend in any particular case upon his knowledge, judgment, and experience. We can seldom give a precise solution of the _question of survival_ to determine the succession or inheritance if several of a family die together in an accident. In case of death from inanition, cold or heat, or in drowning especially, if some have wounds more or less grave in themselves, we can sometimes form an opinion. With wounds we cannot often do so, although in case of murder, the nature of the wounds, the position of the bodies, the examination of the spot of the accident or tragedy, may sometimes help us to form an opinion. INCISED AND PUNCTURED WOUNDS AND WOUNDS OF BLUNT INSTRUMENTS REGIONALLY CONSIDERED. The several varieties of wounds which we have been considering vary considerably in their nature, their effects, their danger, and in many other ways according to the region of the body in which they are situated. Some of these varieties are common in one situation and almost never occur in others. Although the nature of wounds found in the several regions of the body is not as important for a medical jurist as their danger and their influence in causing death, we will now consider the differences they exhibit on account of the region in which they occur. WOUNDS OF THE HEAD. These are often characterized by their apparent harmlessness and their real gravity sooner or later. We might almost make the opposite statement and say that those apparently grave are often virtually harmless, though this would be true only in a limited sense and in certain cases. As to their _nature_, we find punctured wounds extremely rarely, incised and lacerated wounds often, while contusions and contused wounds are still more common. _Incised and lacerated wounds_ of the head involve the scalp almost exclusively. These wounds heal remarkably well, even when the attachment is merely by a narrow pedicle, owing to the abundant blood-supply. Hemorrhage from the incised wounds is often free, for the vessels cannot retract, but it is seldom dangerous unless the wounds are very extensive. The only way in which they differ materially from similar wounds elsewhere is in the greater frequency of complicating erysipelas here than elsewhere. This is probably owing to the presence of septic conditions, as the head is generally dirtier than other parts of the body, and slight wounds especially are neglected. If the scalp is shaved over a wide margin and cleaned like other parts of the body, erysipelas is found little or no oftener than with similar wounds elsewhere. The density of the scalp is so great that the redness and swelling accompanying inflammations is comparatively slight. If erysipelas follows slight wounds of the head, there is some reason to suspect constitutional predisposition or careless treatment. From infection of such wounds of the scalp abscess or diffuse cellulitis of the scalp may develop as well as erysipelas. The constitutional symptoms in such a case may be marked or even severe, but the prognosis is favorable. In very rare cases necrosis of the skull may result or the inflammation may even extend to the brain. These incised and lacerated wounds of the scalp are usually accidental or inflicted by another; they are rarely self-inflicted. _Contusions and contused wounds_ are the most common forms of injury to the head. These two kinds of injuries are almost invariably inflicted by another or are accidental. We have already seen that contused wounds of the scalp or over the eyebrow may closely resemble incised wounds in these localities. This fact should be borne in mind, as careful examination can usually distinguish them if they are fresh and until they begin to granulate. These wounds are liable to the same complications as incised wounds, in fact more liable, as the contusion makes the wound more susceptible to inflammation and the edges are more apt to be infected at the time of the injury. One of the _results_ of contusions of the head is the extravasation of blood, most often between the aponeurosis of the occipito-frontalis muscle and the pericranium. These extravasations are usually in the form of a hematoma. Such hematomata often present a hard circular or oval rim with a softer centre, and may readily be mistaken for fracture of the skull with depression. The diagnosis between hematoma and depressed fracture is not usually difficult, however, for with hematoma the ridge is elevated above the level of the skull and is movable on the surface of the skull; also the wounded edges often pit on pressure. With depressed fracture, on the other hand, the edge is at or about the level of the rest of the skull; it is sharper, more irregular, and less evenly circular. Contusions and the resulting hematoma may occasionally end by suppurating, but this event is rare. Contusions and contused wounds may occasionally show the marks of a weapon, indicating that they were inflicted by another. Also the position of the injury will indicate its origin, whether it is accidental or inflicted by another, for the former would not naturally occur on the vertex unless the fall was from a considerable height. Another result of injuries to the head, especially of contusions and contused wounds, is FRACTURE OF THE SKULL. This may be simple or compound, depressed or not, etc. Fractures are serious inasmuch as they imply a degree of violence which may do damage to the brain. The fracture itself, especially if properly treated, affords a good prognosis, irrespective of any brain lesion. One variety of fracture of the skull offers an exception to this favorable prognosis, and that is fractures of the base of the skull. These may be fatal directly from injury of the vital centres at the base of the brain or soon fatal from hemorrhage in these parts. Or the fatal result may be secondary to an inflammation or meningitis which good treatment is often unable to prevent. It should not be considered that these fractures are uniformly fatal, for quite a considerable proportion recover. Fracture of the base usually occurs as the result of a fall. The injured person may land on the feet or buttocks, and yet receive a fracture of the base of the skull, the force of the fall being transmitted through the spine to the base of the skull. Fracture of the base of the skull usually occurs from an injury to the vault, not by _contre coup_, but by extension of a fissure found higher up in the skull. This extension takes place in the same meridian line of the skull with that of the force which produced the fracture, and in this way the base of the skull is fractured in different parts according to the point and direction of the application of the force. Thus in case the force compresses the skull antero-posteriorly the fracture will pass antero-posteriorly toward the base from the front or the back, whichever received the blow (see Fig. 13). Fractures of the vault of the skull occasionally occur opposite to the point struck; this may occur by _contre coup_, but not always so, as not infrequently in such rare cases a close examination may reveal an extension of a fissure from the point injured to the opposite pole of the skull. The shape and rarely the size of a fracture of the skull, especially if punctured in character, may show the shape and more rarely the size of the instrument or object which produced it. Apart from fracture of the base, the prognosis in fracture of the skull is serious, mainly on account of the danger of inflammation, which is greater in compound fractures, and also on account of the more remote danger of irritation from depressed fragments causing epilepsy, insanity, etc., at a later period. [Illustration: FIG. 13.—Several Fractures of the Left Half of the Base of the Skull, Running Parallel to One Another and Approaching One Another, also Separation of the Mastoid Suture. The injury was caused by a fall on the left side of the back of the head.] A circumstance that Taylor[660] says is connected with fracture of the skull with depression—namely, that the person, sensible as long as the object producing the fracture remained wedged in, became insensible and began to manifest other fatal symptoms as soon as it was removed—must be extremely exceptional. It may be explained, if it occurs, by the occurrence of hemorrhage after the object which occluded an open vessel by its presence or its pressure was removed. For it should be remembered that the symptoms of compression in a depressed fracture of the skull are very rarely due to the compressing effect of the depressed bone, but rather to an injury of the brain, intracranial hemorrhage, or a local and temporary interference with the circulation. [Illustration: FIG. 14.—“Terraced” Fracture of the Left Parietal Bone near the Sagittal Suture, caused by the Lower Part of the Rim of a Round-Headed Hammer. The blow was struck from the right side. ½ natural size.] We may truly say that wounds of the head are dangerous in proportion as they affect the brain. The existence of affection of the brain may be hard to tell from the appearances, for an injured person may recover from the first effects of a comparatively slight wound and yet die suddenly later. =Concussion= is the name applied to one of the effects on the brain of a more or less violent blow directly on the head or transmitted indirectly to the head. Though the term “concussion” implies a functional rather than an organic lesion, yet in the majority of cases it is equivalent to laceration of the brain. With laceration of the brain there is usually more or less effusion of blood which may be limited to a very thin layer. Concussion may exist without laceration of the brain. Even death has been known to occur from concussion of the brain without any visible signs of injury to the brain, so that the concussion must have been functional and the fatal result due to shock of the nervous system. Fatal concussion does not, therefore, necessitate the existence of compression or visible injury of the brain. Concussion may sometimes be due to a violent fall upon the feet, in which case the shock is transmitted through the spinal column to the head with or without fracture of the base of the skull. It was in this way that the Duke of Orleans, the son of Louis Philippe, died. [Illustration: FIG. 15.—Fractures of the Skull caused by a Four-sided Hammer. One caused by the Corner, the Other by the End of the Head of the Hammer. ¼ natural size.] [Illustration: FIG. 16.—Four-sided Fracture caused by a Hatchet-Shaped Instrument, the Edges Formed by Depression of the Broken Outer Table of the Skull.] The _symptoms of_ concussion show all degrees of severity. Thus the injured person may become confused and giddy with or without falling, he may become pallid and nauseated and may vomit, but after a short period he recovers gradually. [Illustration: FIG. 17.—Fracture of Parietal Bone with Depression, caused by the Blow of an Axe.] With a more severe injury, with which there is generally some laceration of the brain, the injured person falls and lies quiet and relaxed, apparently unconscious, though often he can be partly roused. Paralysis and anæsthesia are absent. The heart is feeble and fluttering, the skin cold and clammy. The pupils, as a rule, react to light, but otherwise vary considerably. Urine and fæces may be passed involuntarily. As he begins to regain consciousness, vomiting usually occurs. Consciousness usually returns within twenty-four or forty-eight hours, when headache and indisposition to exertion are complained of, and this may last for a long time. Occasionally the symptoms instead of abating increase, and coma supervenes, often indicating meningitis, encephalitis, or intracranial hemorrhage. In other cases the person may die almost immediately on the spot where he fell, while in still others apparent recovery takes place and death occurs later either suddenly or after a reappearance of symptoms. In such cases, _abscess of the brain_ may occur and be the cause of the fatal result. These abscesses are the result of the injury, which may be almost anything from a compound fracture to a slight contusion not leaving any scar. The abscess may occur within a week[661] or not until after months or years. This interval of apparent recovery may lead to the false supposition that death was not due to the injury, but to some intervening cause. It is well to bear in mind that about half of the cases of abscess of the brain are not traumatic. A large majority of these are due to suppuration in the middle ear, a few to septic diseases or tuberculosis. The situation of the abscess often distinguishes between the traumatic and non-traumatic varieties. The traumatic variety is usually found beneath the injury or sometimes directly opposite, where the brain is injured by a kind of focussing of the radiated effects of the blow. The cases of abscess of the brain due to ear disease are usually found in the temporal lobe of the brain lying over the position of the ear or in the cerebellum behind it. The uncertainty of the nature and the extent of the cerebral injury in so-called contusion of the brain renders it necessary to be very careful in giving a _prognosis_. Any injury should be considered serious which has produced unconsciousness, for such an injury may produce enough laceration of the brain to render serious danger possible or even probable. We have seen that as a rule the symptoms of concussion come on immediately, but it is possible that symptoms at first so slight as to escape notice may become serious in a few hours or days. A gradual hemorrhage may sometimes account for this. The knowledge of certain acts performed or a conversation held at the last moment before the injury may be retained after recovery from concussion of the brain. This is not necessarily the case, for instead of remembering up to the moment of the injury, the injured person may remember only up to a certain time shortly before, or a part and not everything may be remembered. [Illustration: FIG. 18.—Wounds of the Vault of the Cranium caused by Artillery Side-Arms, followed by Death shortly after.] The _diagnosis_ of concussion of the brain _from alcoholism_ is sometimes a matter of medico-legal interest or importance. Concussion may be so slight as to simulate intoxication. The history often clears the case up. The history of a blow or a fall or the presence of marks of violence on the head indicates concussion, though the blow or fall may not have caused the symptoms, which may be due to alcoholism. The odor of the breath may indicate alcoholism, but here too we may have both present and the concussion may be responsible for the symptoms. Or again the alcohol may have been given as a heart stimulant after the accident. This combination often occurs. If there is no odor in the breath, the presumption is in favor of concussion. As mistakes are still not infrequently made in diagnosis, those cases in which there is any ground for doubt should be carefully watched for developments. In general, the existence of concussion is more often overlooked than the coexisting alcoholism, so that if there is any doubt in a given case it should be treated as one of cerebral injury. The injury which causes the concussion in such cases is often due to the alcoholism. We may be able to verify this supposition if the injury is such as would be likely to be caused by a fall. There may be nothing found in the brain after death to distinguish between concussion and alcoholism. A bruise on the head only indicates a probability of concussion, for the bruise and alcoholism may both be present, the former perhaps due to the latter. The presence of alcohol in the stomach would indicate the existence of alcoholism. Another effect of an injury which has caused concussion of the brain is an _extravasation_ or _effusion of blood_. Extravasation of blood in or on the brain is one of the commonest causes of death from injury to the head. It may occur with or without marks of external injury. A person suffering from such an extravasation of blood may recover from the first effects of the injury, and at a varying time afterward the symptoms may return and increase so as to result fatally. In such a case the opening of the bleeding vessel may have become plugged until some exertion, emotion, or excitement on the part of the injured person has loosened the plug. A hemorrhage may have ceased from partial syncope and return with a stronger heart action due perhaps to the administration of alcohol. This effusion may occur on the surface of the brain in connection with a superficial laceration of the brain or just beneath or outside the dura mater and not involving the brain directly. The latter cases are almost always due to the effects of violence, though there is at least one case of apparently spontaneous rupture of the middle meningeal artery. The violence which causes a rupture of the branches of this artery may be so slight as to leave no bruise or so severe as to cause fracture of the skull. The most important symptom of such extradural hemorrhage is a period of consciousness after recovery from the first effects of the injury, then stupor may appear and deepen into coma. A subdural hemorrhage may cause almost the same symptoms, though the injury is usually such as has produced a depressed fracture. This hemorrhage is most often due to the rupture of a number of small vessels under the fracture, though if one larger vessel is ruptured it is most often the middle cerebral. A thin layer of hemorrhage in connection with a superficial laceration of the brain is of frequent occurrence with or without the other two forms of intracranial hemorrhage. If the brain is lacerated we may have convulsions in addition to other symptoms. Death occurring during or soon after a prize-fight may occur from some of the above classes of intracranial extravasations. It may be questioned whether the blows or a fall caused the hemorrhage. It is generally due to a fall in such cases, but may be due to blows, but the guilt is the same unless the fall was accidental. As the result of severe traumatism the vessels of the interior of the cerebrum may be ruptured or hemorrhage may occur into the ventricles of the brain. In such cases the symptoms will resemble those of ordinary apoplexy, only the cause is different from the latter and the injury is usually so severe as to leave no doubt as to the existence of a traumatism. The following question may arise in cases of intracranial hemorrhage and especially in the latter class of such cases, _i.e._, in cerebral hemorrhage: WAS THE EXTRAVASATION OF BLOOD DUE TO DISEASE OR VIOLENCE?—It may be alleged in defence that the hemorrhage was the natural result of disease. Where the hemorrhage is extradural or subdural or in connection with a superficial laceration of the brain, the cause is almost always traumatic. We have referred to one case of extradural hemorrhage from spontaneous rupture of the middle meningeal artery.[662] Subdural hemorrhage may occur from _Pachymeningitis hæmorrhagica interna_, but this condition is readily diagnosed on post-mortem examination and often with considerable certainty during life. A history of alcoholism, headache, impaired intellect, unsteady gait, occasional losses of consciousness, stupor increasing to coma, etc., indicates such a condition. It is in cases of cerebral hemorrhage that there is the most difficulty in discriminating between that due to disease and that due to injury. It may be alleged that the hemorrhage was from diseased vessels, or that the effects of a blow, which cannot be denied, were aggravated by disease of the cerebral vessels or by excitement due to intoxication or passion. Cerebral hemorrhage from disease is rare before 40 years of age, except in alcoholics. When the hemorrhage is due to disease the blood-vessels are diseased. The most frequent site of such hemorrhages is the course of the lenticulo-striate artery in the ganglia of the base or the white substance of the centrum ovale. When injury is the cause of the hemorrhage it is usually found beneath the point injured or directly opposite to this. External signs of the blow are generally visible if it be severe enough to cause a cerebral hemorrhage. The vessels may be perfectly healthy and the victim quite young if the hemorrhage is due to an injury, also the ruptured vessels may be plainly torn. The most difficult cases are those where there is the history of an injury and at the same time such a condition of disease of the cerebral vessels, etc., as would account for spontaneous hemorrhage. Where the injury was slight in the case of alcoholics or aged people the medical witness should be especially careful in stating that a cerebral hemorrhage was due to the injury. Then, too, in the act of falling from the occurrence of a cerebral hemorrhage due to disease the head may be injured and show marks of violence. It should be borne in mind that an injury to the head may be inflicted when disease of the brain, vessels, or membranes already exists. In such a case a slight blow might cause extensive hemorrhage, but as that which accelerates causes, death, even though it might sooner or later have occurred in the same manner without injury, is due to the injury inflicted. From the above considerations we see that spontaneous cerebral hemorrhage and that due to disease are not always easily distinguished from that due to violence. In severe injuries the structure of the brain is plainly bruised, etc., but the greatest difficulty exists in cases of slight violence where arteritis of the cerebral blood-vessels coexists. The spontaneous extravasation of blood in or upon the brain from excitement does not usually occur except with diseased vessels, old age, or alcoholism. It is rare, therefore, in the young and healthy. If there is any doubt as to the origin of the hemorrhage, the medical witness should state the cause most probable in his judgment. Taylor[663] supposes the case of a man excited by passion, alcohol, or both, who becomes insensible and dies after being struck a blow so slight that it would not have affected a healthy person. If examination reveals a quantity of blood effused into the substance of the brain, there can be little doubt in the mind of the medical man that the excitement was the principal cause of the effusion. On the other hand, if a severe blow or a violent fall on the head had been received in a personal conflict with another and it is found that death was due to an effusion of blood upon the surface, there can be little doubt in the mind of the medical examiner that death was due to the blow, which would satisfactorily account for the conditions found without reference to coexisting excitement, etc. In fact, in all cases where a question is raised as to the cause of the hemorrhage, it is most important to consider whether the violence was not sufficient to account for the hemorrhage without the coexistence of disease or excitement. It is also most important to bear in mind that after severe injuries, as after a fall, causing extensive fracture of the skull, followed or not with extravasation of blood, the injured person may walk about and die some distance from the place of the accident and where no chance for a similar accident exists. In this way the suspicion of murder may be occasioned, as illustrated in the following case cited by Taylor:[664] A man was accused of the murder of his companion, who was found dead in a stable with fracture of the temporal bone which had caused rupture of the middle meningeal artery. The accused stated that the deceased had been injured by falling from his horse the day before. After the fall, however, the deceased had gone into a public-house, where he remained some time drinking before returning to the stable. The extravasation had here taken place gradually, as is characteristic of hemorrhage from the middle meningeal artery, and perhaps the excitement due to the drinking had influenced it. THE DATE OF AN EFFUSION OF BLOOD may sometimes be a matter of importance in determining whether a given extravasation of blood in or on the brain was caused by a recent blow or had existed previously. The color and consistence of these effusions indicate whether they are old or recent; the precise date we cannot state, but the information we can give is often all that is required. The color of recent effusions is red, which changes after some days to a chocolate or brown, which generally turns to an ochre color (see Plate I.). This latter color may be met with from twelve to twenty-five days after the injury. The consistence of the coagula also becomes firmer with age, and as the coagula become firmer they are more or less laminated and the expressed lymph may lie between the laminæ or around the coagula. [Illustration: MEDICAL JURISPRUDENCE—PLATE I. EXTRAVASATIONS IN SEVERAL PORTIONS OF THE ARACHNOID, WITH HEMORRHAGES IN NEIGHBORING PORTIONS OF THE BRAIN. DEATH IN FOUR DAYS. CEREBRAL ABSCESS. EPILEPSY, PARESIS. DEATH 3¼ YEARS AFTER THE INJURY. RECENT AND OLD CEREBRAL EFFUSIONS.] On account of the many layers of the brain coverings, a rough diagram of the coverings as given by Taylor[1] may be of much use to the medical expert in illustrating his evidence so as to make it clear to the court (see Fig. 19). =Wounds of the brain= vary very widely in their immediate results according to the part of the brain injured. Thus sometimes a slight wound of the brain may be instantly fatal and often a severe wound in another part is not so. Extensive wounds may occur especially in the frontal lobes with remarkably slight disturbance. If a person with a wound of the brain survives the first effects of the injury the danger of inflammation remains. This danger may not be removed for a long time, for the inflammation may develop very slowly, not showing itself for from three to ten weeks or even later. Thus Taylor[665] cites the case of a child who was accidentally shot through the brain. The symptoms of inflammation did not appear until the twenty-sixth day and death occurred on the twenty-ninth day. [Illustration: FIG. 19.—Diagramatic Representation of the Skull and Membranes of the Brain for Exhibition in Court. _a_, Skull with outer and inner tables and diploë; _b_, dura mater; _c_, arachnoid membrane; _d_, pia mater.] =Wounds of the face= heal remarkably well on account of its great vascularity. If severe they may leave great deformity or disfigurement, which may be the ground of a civil suit and thus require the testimony of a medical expert. If the wound involves the orbit or its contents it may be more serious, either from a fracture of the thin upper or inner wall of the orbit, separating it from the brain, or from extension of a secondary inflammation of the contents of the orbit to the brain. Wounds of the eyebrow may cause supra-orbital neuralgia or amaurosis from paralysis of the upper lid. Some fractures of the nose, especially those due to severe injury near the root of the nose, may be more serious than they appear. For in such cases, of which the writer has seen several, the fracture is not confined to the nose, but involves also the ethmoid bone and its cribriform plate forming part of the base of the skull. In such a case a fatal meningitis is a common result. [Illustration: FIG. 20.—Double Fracture of the Thyroid and Cricoid Cartilages of the Larynx, from the Blow of a Flat-Iron.] =Wounds of the neck= are very rarely accidental, more often homicidal, but most often suicidal. In nature they are most often incised wounds. As we have already seen, the kind and condition of the weapon used is often indicated by the character of the wound. We have also seen that in many cases a suicidal wound of the neck can be distinguished from a homicidal one with more or less probability or even certainty. Wounds of the neck are often dangerous, and they may be rapidly fatal if they divide the main vessels, especially the carotid arteries. Wounds of the larynx, trachea, and œsophagus are grave and often fatal from entrance of blood into the air-passages or from subsequent œdema or inflammation occluding the air-passages. Wounds of the sympathetic and pneumogastric nerves may be fatal, and those of the recurrent laryngeal nerves cause aphonia. The situation of the average suicidal or homicidal cut-throat wound is in front, generally across the thyro-hyoid membrane, sometimes dividing the cricoid-thyroid membrane, and not at the side of the neck where the great vessels lie and would be more easily divided. The force is expended, as a rule, before the great vessels are reached. The epiglottis may be cut or detached and the incision may even reach the posterior wall of the pharynx, but the majority of the suicidal cases recover with proper treatment. The homicidal cases are more often fatal from division of the great vessels, though, as already stated, in either class of cases a fatal result may occur if the air-passages are opened from the entrance of blood into them and the consequent asphyxia. CONTUSIONS of the neck may be so severe as to cause unconsciousness or even death. The latter may be due to a reflex inhibitory action, as in cases of death from a blow upon the pit of the stomach. As a result of such contusions we may have a fracture of the larynx usually confined to the thyroid and cricoid cartilages (see Fig. 20). This may be followed by hemorrhage from the larynx, some of which may pass down into the trachea and threaten death from asphyxia. Later emphysema often develops throughout the tissues of the neck, and there is great danger of œdema of the larynx. The prognosis is serious unless tracheotomy is performed early or the case is closely watched. It is most serious where the cricoid cartilage had been fractured, as this requires a greater degree of violence. Whereas incised wounds of the throat are most often suicidal, contusions are most often accidental or inflicted by another. Among the latter class of injuries may be included the so-called _garroting_, by which a person is seized violently around the throat, usually from behind, and generally with a view to strangle and rob. In such cases the larynx or trachea may be injured in the same way as by a contusing blow. WOUNDS AND INJURIES OF THE SPINE AND SPINAL CORD. Injuries of the spine resemble more or less closely those of the head. FRACTURES OF THE SPINE generally occur in combination with dislocation, as fracture-dislocation. Thus displacement is generally present and causes a fatal compression or crushing of the cord. When the cord has once been crushed at the site of the displacement of the fracture-dislocation there is no hope of its ever healing. Therefore the lower end of the cord is never again in functional connection with the brain. These injuries are more rapidly fatal the higher up they are. If the injury is above the fourth cervical vertebra death is nearly immediate, for then even diaphragmatic breathing is impossible, and the injured person dies of asphyxia. Fracture of the odontoid process of the axis, which regularly occurs in hanging, may occur from falls on the head, etc., and is not always immediately fatal. Thus in one case[666] the person lived fifteen months and in another case sixteen months. In the latter case the fracture was due to the patient turning in bed while his head was pressed on the pillow. In some cases it may be questioned how far this injury may result from disease of the bones or ligaments. Therefore a careful examination of these parts should be made after death, which will usually enable us to answer this question, which may be brought up by the defence. It is hardly necessary for our purpose to enumerate the symptoms of fracture-dislocation of the spine. Of course the patients are almost always unable to walk and so are bed-ridden. A marked feature of fracture-dislocation of the spine is the length of time intervening between the injury and the fatal termination, and yet the injury is wholly responsible for the death of the injured person. This delay may last for months or even for years with careful treatment. But sooner or later the case generally ends fatally, though not necessarily so. Where the cord has been entirely crushed the result is almost always fatal; where the cord is not so injured recovery may and often does occur. According to Lutaud, fractures of the spine are sometimes followed by secondary paralysis coming on after healing of the fracture. At the outset we can seldom give a definite _prognosis_, which can only be given after watching the developments of the case. The prognosis is more favorable in fracture of the arches alone or when the injury is in the lower part of the spine and not very severe. The commonest cause of fracture-dislocation of the spine is forced flexion of the spinal column. Injuries to the spine are generally the result of falls or blows on the spine, especially in its lower part. Lutaud[667] states that after forced flexion of the spine without fracture paraplegia may sometimes occur, which is attributed to forced elongation of the cord. This paraplegia, which may seem to be grave, is completely recovered from as a rule. Incised or punctured wounds of the spinal cord are rare, as it is so well protected except in the very highest part behind. Here between the occiput and the atlas and between the latter and the axis, and to a less extent between the axis and the third cervical vertebra, the cord is more exposed, owing to the narrowness of the laminæ. It is here that _pithing_ is done, which is almost instantly fatal, as the medulla oblongata and upper part of the spinal cord are the parts injured, and they contain the respiratory and other vital centres. Pithing may be done with such a small needle-like instrument as to leave scarcely any trace. Only a slightly bloody streak may persist, which may appear superficial if the instrument is introduced obliquely. Such a mark in this location with no other apparent cause of death should always lead to an examination of the upper part of the cord, which will always reveal the cause of death in such cases. Pithing is practised especially in infanticide. As with the brain, so with the spinal cord, we may have CONCUSSION due to the shock of a contusing blow. Concussion of the spinal cord, as of the brain, may be fatal without showing scarcely a mark of violence externally or internally. As the cord is so well protected from injury, it must be extremely rare to have concussion of the cord without some actual lesion of its substance. As concussion of the cord is not often the result of the injuries of which we are treating, but rather of railroad injuries and the like, it will not be considered at length in this connection. As a result of a blow or fall on the spine or communicated to it, hemorrhage may occur in the substance of the cord or around it between or outside its membranes. In very rare cases such a hemorrhage may occur spontaneously as the result of disease, of which the writer has seen one case. It may be associated with concussion or laceration of the cord. It may destroy life directly by extension or indirectly by leading to a spreading inflammation. Hemorrhage in or about the cord causes a gradual compression of the cord, and in cases of fracture of the spine often adds to the compression due to the displacement of the bones. In hemorrhage into the substance of the cord paralysis comes on early or immediately and may be complete while symptoms of irritation fail. The latter symptoms are most marked in meningeal hemorrhage in which paralysis is delayed in appearance and generally incomplete. The products of an inflammation due to an injury may compress the spinal cord in the same way that hemorrhage does. Wounds and injuries of the varieties we are considering, affecting the spine and spinal cord, are generally accidental, less often homicidal, and almost never suicidal. WOUNDS OF THE THORAX AND THORACIC ORGANS. =Wounds of the thorax caused by incising, puncturing, or blunt instruments.= These wounds are most often punctured wounds; contused wounds are common and incised wounds are not rare. They are perhaps most often homicidal in origin or at least inflicted by another, and the accidental origin of these wounds is probably the least common. Incised or punctured non-penetrating wounds of the thoracic wall are rarely grave. Bleeding, as a rule, is not serious, though it may be quite free. Such wounds may be accompanied by emphysema, though not penetrating, owing to the movements of the chest and a valve-like action of the edges of the wound. Contused wounds of the thorax are more dangerous, especially if the violence was great, owing to the complicating fracture of the ribs, rupture of the thoracic viscera, etc. FRACTURE OF THE RIBS is a common result of contusions of the chest. It is more dangerous when due to a direct blow or injury, as then the splintering occurs internally and may wound the lungs, heart, or large vessels, while with fracture from indirect violence, from compression of the chest, the splintering of the ribs occurs externally. Fracture of the upper ribs requires more force than that required to fracture the lower ones, and consequently the former is the more dangerous. The diagnosis of fracture of the ribs is generally quite easy by means of crepitus felt or heard, false motion, local tenderness, etc. FRACTURE OF THE STERNUM may be serious if depressed on account of the wounding of the viscera behind it. Devergie[668] cites such a case where the depressed portion of the sternum produced a transverse non-penetrating wound of the heart about an inch in length, which had caused death in thirteen days. Simple fracture of the sternum without displacement of the fragments is rarely serious unless injury of the thoracic viscera is produced by the same violence. Wounds or injuries of the thorax are grave or not according as they penetrate or injure the thoracic viscera or do not do so. A wound may just penetrate the thoracic wall without wounding the thoracic viscera, and is then serious as a rule only when followed by inflammation. In fact, many of the penetrating wounds of the thorax wounding the viscera are only grave on account of consecutive inflammation. We have already seen that various characteristics of wounds of the thorax, especially of stab-wounds, enable us to determine the kind of weapon used, its size, sharpness, etc., and sometimes to identify the weapon itself. In much the same way we can often determine whether the wound was suicidally or homicidally inflicted. The cause of death in wounds of the thorax may be directly due to the wounding of one or more of the thoracic viscera, or it may be due to the inflammation occasioned by it. Wounds of the lower part of the thorax may involve at the same time the thoracic cavity proper and its contained viscera, the diaphragm and the abdomen and its viscera. This is the order in which the different parts would be met with in a wound from behind forward; the order might be the reverse of this in a wound from before backward. Penetrating wounds of the thorax may involve the lungs, heart, or great blood-vessels. Of these, the lungs are most often injured, which is easily accounted for by the greater size of the lungs. In =wounds of the lungs= the immediate danger is from hemorrhage. The hemorrhage appears externally through the wound and from the mouth, being coughed up. Where the lungs are injured by a blow, fall, or crush without external injury, blood appears in the mouth only. The blood coughed up from the lungs is bright red and frothy, and it may also be frothy at the external wound. Hemorrhage from the external wound may be slight, especially if the wound is oblique and acts as a valve. In wounds of the lungs most of the blood may collect in the pleura or in the lungs, and thus, by compression from without or by displacement by the blood within it, prevents air from entering the lungs and produces asphyxia, which may be fatal. More or less dyspnœa usually occurs at first. Emphysema is generally present in the cellular tissues, but this latter symptom may also occur at times with non-penetrating wounds of the chest. If death does not occur speedily from hemorrhage by compression of the lungs or heart, there are good hopes of saving the patient, but the prognosis should be reserved. For even when the first effects of the wound of the lung are survived, the patient may die from the effects of inflammation, recurring hemorrhage, or a too sudden relaxation of regimen. Thus, for instance, if too much food, talking, or exertion are indulged in the case may on this account terminate fatally, and such aggravating causes of death may mitigate the sentence. =Wounds of the heart= are among the most fatal. Although it was once considered, and is usually thought now by laymen, that wounds of the heart must be necessarily and instantly fatal, the facts are otherwise. If the wound is small and oblique life may be prolonged, and cases are recorded[669] in which wounds of the heart were not directly fatal, and in some of which recovery would have probably resulted if not for other diseases. Cases in which the heart wall was wounded but not penetrated, and in which healing took place, are not very rare.[670] Thus Callender removed a needle from the substance of the heart. But there is perhaps only one case[671] on record in which a wound penetrating the cavities of the heart was recovered from. It is the rule rather than the exception that wounds of the heart, penetrating or not, are not immediately fatal. Thus in a series of twenty-nine cases of penetrating wounds mentioned by Devergie,[672] as collected by Ollivier and Sanson, only two ended fatally within forty-eight hours, the rest in periods ranging from four to twenty-eight days. This delay in the fatal result has been attributed to the arrangement of the muscle fibres crossing one another and tending to close the wound, or at least to make it smaller. As to the various parts of the heart wounded, the right side, especially the ventricle, is most often wounded. Thus out of fifty-four cases of wounds of the heart, Taylor[673] states that the right ventricle was wounded in twenty-nine cases, both ventricles in nine, the right auricle in three, and the left auricle in one case. This greater frequency of wounds of the right side of the heart is easily accounted for by its more exposed position anteriorly, just beneath the chest wall in a part of its extent. The rapidity of death depends largely upon the site and extent of the wound. Lutaud[674] states that out of twenty-four cases of wounds of the right ventricle only two were fatal within forty-eight hours, and out of twelve cases of wounds of the left ventricle three were not immediately fatal. Wounds of the auricles are generally fatal immediately, especially if the cavity is extensively laid open. It is the general opinion that wounds of the auricles are most rapidly fatal, next those of the right ventricle, and lastly those of the left ventricle. This difference is probably due to the comparative thickness of the walls of these parts. Thus the wall of the left ventricle is so thick as to tend to close a wound unless it be extensive. In wounds of the heart death rarely occurs from external hemorrhage, which may be quite slight or even altogether wanting where the wound is due to a crush or fracture of the ribs. Death is usually due to the compression of the heart by the blood in the pericardium. This usually causes syncope, or a slighter pressure may be fatal by causing cerebral or pulmonary anæmia or shock. Death may occur suddenly in this manner or not until after some time. Thus in penetrating stab-wounds little or no blood probably escapes at first, in most cases, but it may ooze or, later on, suddenly burst out into the pericardium. Therefore after a wound of the heart the patient does not, as a rule, die immediately, as formerly and often at the present time erroneously supposed. This fact is of little importance as a rule in surgery, for the patients generally die sooner or later, but it is of importance in medical jurisprudence, for upon it may hang the solution of questions of murder, suicide, or justifiable homicide. It also accounts for the fact that the injured person can exercise voluntary power after the injury. Thus Watson[675] met with a case where a man ran eighteen yards and died six hours after a stab-wound of the right ventricle. The coronary artery was divided and the pericardium was filled with blood. Also Boileau met with an accidental penetrating stab-wound through both ventricles in a soldier who ran two hundred yards, then fell and died in five minutes. A boy admitted to Guy’s Hospital in 1879 lived forty-two hours with a bayonet-wound transfixing the right auricle, the septum, the left ventricle, the mitral valve, and entering the left auricle. Minute wounds of the chest are sometimes made by needles, etc., in the region of the heart with the intention of killing infants or children. Taylor[676] also mentions the case of a fatal wound of the heart from a needle, the result of accident. We have already cited the case of a needle lodged in the heart wall and removed by Callender by operation. That the puncture of the heart by a small instrument is not necessarily serious is proved by the experiments of Senn,[677] by which he found that “the heart can be punctured with a perfectly aseptic, medium-sized aspirator needle without any great immediate or remote danger.” In cases of RUPTURE OF THE HEART the question may come up as to whether it was the result of disease or violence. We have already seen that rupture of the heart may occur from falls or crushes without marks of violence to the chest. In general, we may say that in rupture of the heart from violence the right side and base are most often involved, while in rupture from disease the left ventricle is generally ruptured, especially near the apex. The exciting causes of rupture of a diseased heart are often violent emotions or exertion, which may both be present in a quarrel with another and cause rupture without direct violence. The cause need be but slight if the heart is diseased, whether the cause is a natural one or outward violence. Rupture from disease may therefore excite suspicions of murder, but those cases can usually be satisfactorily solved by examination of the organ post mortem. A slight degree of violence may cause rupture of a diseased heart about ready for rupture from natural causes. When a diseased heart ruptures during a quarrel, the symptoms of rupture of the heart may be observed to come on suddenly before and without the infliction of any violence. =Wounds of Arteries and Veins=, especially within the thorax.—Wounds of large trunks are generally speedily mortal. In the chest we may occasionally meet with wounds of the intercostal or internal mammary vessels or the vena azygos veins. These wounds are often serious and may be fatal. We have already seen that blood in the large cavities of the body, like the chest, is commonly not coagulated, or at least the greater part of it. We have already seen, too, that after wounds of the carotid artery the victim may preserve the power of locomotion for a short time, but not the power of struggling. This fact may be important to help distinguish between murder and suicide. In such wounds of the carotid the voice may be lost, as the trachea is often divided. Death from wounds of large vessels may be due to loss of blood, and if this danger is passed the case may still terminate fatally, as in a case where the brachial was tied for injury and death occurred in three days from gangrene. The wounds of comparatively small vessels may prove fatal from hemorrhage, etc. In wounds of blood-vessels death may occur from the _entrance of air_ into them. In some cases where this is supposed to have occurred it is quite probable that death was really due to hemorrhage. A considerable quantity of air may enter the circulation, especially the arterial circulation, without a fatal result. When death does occur it is owing (1) to “mechanical over-distention of the right ventricle of the heart and paralysis in the diastole,” or (2) to “asphyxia from obstruction to the pulmonary circulation consequent upon embolism of the pulmonary artery.”[678] Senn found that fatal air embolism could hardly occur spontaneously in a healthy jugular vein, as the walls collapse readily from atmospheric pressure. =Wounds and Ruptures of the Diaphragm.=—These may be due to weapons, fracture of the ribs, falls or crushes, and disease. They also occur as the result of congenital malformation, though these cases seldom survive long. These injuries are generally homicidal or accidental in origin. As a rule, the viscera are wounded at the same time, or, if not wounded, at least herniated, and may thus become strangulated. It is therefore hard to estimate the danger in such cases, but the prognosis is at all times serious. The most serious cases of such injury to the diaphragm are due to violent contusions or falls when the stomach and intestines are full. The hemorrhage is usually slight, but hernia of one or more of the abdominal viscera usually occurs in such cases, and is said to be more readily produced during inspiration when the fibres are on the stretch. According to Devergie, rupture of the diaphragm with hernia is more common on the left side in the central tendon in front of the crura and at the junction of the left muscular leaflet. Also on either side of the ensiform cartilage and especially on the left side there occurs an area of the diaphragm which may be congenitally weak or even absent, and here too rupture and hernia are likely to occur. _Phrenic_ or _diaphragmatic hernia_ occurs especially after lacerated wounds, even after the wounds have apparently healed. If hernia occurs long after the injury was inflicted, it may be asked whether the wound was the cause of the hernia, and so of death. This can only be determined by examination. Almost any or all of the movable abdominal viscera may be found in a diaphragmatic hernia. It was once supposed that this accident would be immediately fatal, but this is far from the truth. Devergie relates the case where a person lived nine months with the stomach and colon in the chest and died from another cause. Thus a person may have a phrenic hernia and die from another cause, or having had a rupture or wound of the diaphragm he may suddenly acquire a diaphragmatic hernia by reason of a blow or sudden exertion, or the latter may strangulate an existing hernia. A person with a diaphragmatic hernia may have the power of moving or walking, but is more or less incapacitated owing to the compression of the lungs which exists and the consequent dyspnœa, etc. WOUNDS AND CONTUSED INJURIES OF THE ABDOMINAL WALL AND VISCERA. Such wounds and injuries of the abdominal wall may be incised, punctured, or due to blunt instruments, etc. They are usually homicidal or accidental, seldom suicidal except in delirious patients or lunatics. The cause of death in such cases may be due to hemorrhage, shock, etc., or to secondary inflammation, which is especially likely to occur in penetrating wounds. The kind of weapon used may often be judged from the nature of the wound. Incised and non-penetrating punctured wounds are usually simple and not grave, but may be otherwise from hemorrhage from the deep epigastric artery, or from inflammation in or between the muscles, or in the subperitoneal connective tissue. In the latter case peritonitis may occur, but is rare. A ventral hernia may, however, result later on, as also from a cicatrix, especially if it is transverse. In such cases the question arises whether the natural results of the wound were aggravated by unskilful or improper treatment or even wilful neglect on the part of the patient or practitioner. CONTUSIONS of the abdomen are more serious often than those of the chest, for there is less power of resistance. We have already seen that death may occur from a contusion of the abdomen too slight to show a mark of ecchymosis or a serious injury internally. This has been attributed by some to an effect on the solar plexus or reflexly on the cardiac plexus causing a fatal inhibition. Lutaud and others have expressed the doubt whether the cases reported by Travers, Allison, Watson, Cooper, Vibert, and others were carefully examined, and have inferred that some visible organic change must have been present. Some such cases, however, have been examined with especial reference to this point, and no physical injuries and no other cause of death elsewhere has been found. There is no ground, therefore, for a jury to doubt that a contusion of the abdomen was the cause of death because there are no visible marks of injury. Again, it is a well-known fact that the blows severe enough to cause rupture of the abdominal viscera may sometimes leave no trace of violence in or on the abdominal wall. On the other hand, it must be remembered that effusions of blood may be found post mortem in the sheaths of muscles without indicating violence, so that blood may be found effused in considerable quantity in and around the abdominal muscles without violence having been done. In such cases, therefore, we should note whether abrasions or ecchymoses of the skin are absent or not. If they are absent and there is no other evidence of a blow, the medical witness should hesitate to attribute such an effusion of blood between the muscles to an act of violence. As in the case of the chest, so wounds of the abdomen are serious, as a rule, mainly as they involve the abdominal viscera. The viscera may be wounded by a penetrating wound or by rupture, and the fatal result is due sometimes to internal hemorrhage or to shock, but generally to secondary septic peritonitis, which may be fatal in a few hours or only after days or weeks. Occasionally wounds of the abdominal viscera undergo spontaneous cure without surgical interference and with or without medical treatment. But as a rule they are fatal unless they receive proper surgical treatment. A wound of the abdominal wall may be penetrating without wounding any of the viscera. Such wounds may be fatal if they are infected, otherwise they usually heal readily and without danger unless they are extensive and the abdominal contents are exposed to the air. The gravity of penetrating wounds varies somewhat with the particular viscus or viscera injured. It is well not to examine wounds of the abdomen by the finger or probe too freely unless a laparotomy is anticipated; for a simple wound or penetrating wound without wounding of the viscera may thus be infected. Enough examination is necessary to diagnose between a simple and a penetrating wound of the abdominal wall. RUPTURE OR WOUNDS OF THE ABDOMINAL VISCERA. THE LIVER is most often wounded of any of the abdominal viscera, with the possible exception of the intestines, because of its size, and it is most often ruptured partly because of its size, but mostly owing to its friable consistence. Such injuries most often involve the right lobe, as it is much the larger of the two principal lobes. The anterior surface and inferior border is the most frequent site both of wounds and ruptures of the organ. Ruptures rarely pass entirely through the organ, but are generally not more than an inch or two in depth. They are usually directed antero-posteriorly or obliquely, rarely transversely, and the lacerated granular edges are not much separated as a rule (see Fig. 21). Rupture of the liver may be due to a blow, crush, or fall, or even to sudden muscular action if the organ is large and fatty. Thus Taylor[679] relates the case of a woman who died after child-birth of uræmic convulsions, and in whom there was quite an extensive hemorrhage into the liver beneath its capsule, and apparently due to violent muscular contraction. As we have already seen, the liver may be ruptured without the abdomen showing the marks of external violence. Rupture or wound of the liver is one of the causes of the fatality of wounds and injuries of the abdomen. The fatal result may be and often is due to hemorrhage; in other cases it is due to shock or the occurrence of peritonitis. Wounds of the liver heal readily and hemorrhage is arrested at once, as a rule, by the approximation of the edges. There may be little blood in and about the wound, but it collects in the right iliac region or in the pelvis and is not wholly coagulated. Unless the wound or rupture involves the vena cava, portal vein, or a large branch of either of these, the hemorrhage is apt to be slow and the victim may survive hours or even days, except for active exertion or repeated violence. Two cases illustrating the slowness of the hemorrhage have occurred in Guy’s Hospital. In one[680] the man, showing no urgent symptoms at the time, was sent away, and died a few hours later in a police-station. In this case the liver was ruptured nearly through its thickness, and a basinful of blood had been effused, causing death. In the other case,[681] which occurred to Wilks, the patient survived the accident ten days, and Taylor[682] cites a case which was reported to have ended fatally eight years after the accident. As a rule the injury is fatal, without treatment, within forty-eight hours. Not being immediately fatal as a rule, the victim of a rupture or wound of the liver can walk about, and may be capable of more or less severe muscular exertion after the injury, though the fact of such exertion has sometimes been used by the defence to prove that the rupture was not due to the particular violence in question. [Illustration: FIG. 21.—Ruptures of the Liver from a Fall from a Considerable Height, causing Immediate Death.] _Wounds and ruptures of the gall-bladder_ result in the effusion of bile. While rupture of the liver is not necessarily followed by peritonitis, rupture of the gall-bladder with the effusion of bile generally causes peritonitis, and is fatal in this way and not from hemorrhage. Rupture of the gall-bladder may be favored by the presence of gall-stones, but the result is still attributable to the injury. SPLEEN.—Ruptures of the spleen may be due to a bruising violence in this region, and here too the skin may not show the marks of the contusion, though this fact is still employed by the defence to try to disprove the connection between the injury and the result. It is important to remember, from a medico-legal point of view, that an enlarged and softened spleen may be ruptured from a comparatively slight muscular exertion. This might occur in a sudden movement to avoid a blow, and the charge of manslaughter might be affected by the mode of the production of the injury and the previous abnormal condition. Only direct violence is liable to rupture the healthy normal spleen. Rupture and wounds of the spleen may be and generally are fatal from hemorrhage, owing to the vascularity of the organ; more rarely are they fatal from shock. Peritonitis is not a result to be expected. The hemorrhage accumulates in the lower and left side of the abdomen or in the pelvis, and coagulation is imperfect if present at all. KIDNEYS.—These are occasionally ruptured from violence, but more often from accident. Wounds of the kidney are rare, owing to the depth from the surface at which they lie. They are more accessible from behind. A wound from behind is generally extra-peritoneal unless it perforates the organ; not so a wound from in front. Accidents in which the lumbar region is forcedly flexed are most apt to be followed by injury to the kidney. The injury may cause no prominent symptoms, but usually lumbar pain and tenderness, frequent micturition and hematuria, and in severe cases the symptoms of hemorrhage and shock are present. The injury may be speedily fatal from hemorrhage or collapse, or more slowly fatal from peritonitis, when the peritoneum is involved, or from abscess and septic infection, or from uræmia if the other kidney is diseased. Slight injuries are generally recovered from. As is the case with the liver and spleen, so after injuries of the kidney the victim may walk about, etc., unless there is copious and immediate hemorrhage. THE BLADDER may be wounded directly through the hypogastrium, vagina, or rectum; it may be punctured by a broken fragment of the pelvis, especially the pubis, or it may frequently be ruptured from blows, crushes, or falls. The latter accident occurs especially where the bladder is distended. The bladder may also rupture spontaneously from over-distention, which may or may not be favored by disease of the bladder wall, in which case rupture occurs more easily. Medico-legally the question may arise whether the rupture was spontaneous or due to injury. In this connection it should be remembered that the injury may leave no external mark of violence, and a case is recorded in which the bladder was ruptured by a fall in wrestling; but the question can be determined only by an examination of the bladder. If the wall of the bladder is thinned by the pressure of a calculus or from other causes, or if it is weakened by tubercular, syphilitic, or carcinomatous deposits or ulcerations, it may be spontaneously ruptured from slight distention or a slight degree of violence may rupture it. If violence has been employed it is responsible for the rupture, though the diseased condition may act as a mitigating circumstance; not so a distended bladder, as the latter is not abnormal. In spontaneous rupture from over-distention without disease of the bladder wall, stricture, hypertrophied prostate, or some such condition must be present to account for the over-distention. Spontaneous rupture of the bladder can, therefore, only occur when either disease of the bladder wall or obstruction of the urethra is present. No condition excludes rupture from violence. If there is an injury followed by the symptoms of rupture of the bladder and death and the bladder and urethra are healthy, there can be little doubt that death was due to the injury. Wounds or rupture of the bladder may be extra-peritoneal or intra-peritoneal. Rupture from disease of the bladder wall occurs at the site of the diseased and weakened spot, which is most often at the base of the bladder. Rupture of the bladder from violence occurs most often on the postero-superior wall, running downward from the urachus, in which case the peritoneum would be involved. A punctured wound of the bladder wall may be so minute that the leakage is very slow and the customary symptoms may be obscured, or the opening may be valvular in character, perhaps allowing escape of urine only when the bladder is not distended. The _symptoms_ consist of pain, inability to micturate, and the presence of blood in the little fluid which can be drawn by a catheter. Fluid injected is not all returned and the bladder cannot be distended. After a time varying from a few hours to a few days, depending upon the size of the opening and the condition of the urine, peritonitis or peri-vesical cellulitis is set up, the former being generally fatal, the latter not necessarily so. Prompt surgical treatment may save the patient’s life by avoiding peritonitis. Extra-peritoneal ruptures are far less dangerous than intra-peritoneal, as in the former case cellulitis and abscess in the cellular tissue around the bladder, which may subsequently be treated by operation and drainage, take the place of peritonitis in the latter case, for which prevention is the only safe treatment. In extra-peritoneal rupture death, if it occurs, is generally due to septicæmia; in the intra-peritoneal variety it is due to peritonitis. These cases of injury to the bladder may die suddenly and speedily from shock or from peritonitis in three to seven days, or not until fifteen days or so. In punctured and incised wounds the urine escapes more slowly, peritonitis develops less early, and death is longer delayed. Hemorrhage in injury to the bladder is not usually serious; the blood is found partly in the bladder, partly in the pelvis, where the fluid extravasated by peritonitis is also found. The victim of a wound or rupture of the bladder may often walk about for some time after the injury. STOMACH AND INTESTINES.—Punctured wounds, or, more rarely, incised wounds of the abdomen may involve these organs, or they may be ruptured by blows, crushes, and falls, or from disease. Stab-wounds of these viscera may be multiple from a single stab, the instrument traversing one coil, perhaps, and then wounding others, though this is less often the case than with gunshot wounds. Ruptures too may be multiple, though less often so than wounds. The ileum is most liable to rupture, though several cases of rupture of the jejunum are on record. Like the bladder, the stomach and, to a less extent, the intestines are more liable to be ruptured when distended. Ruptures of the stomach or intestines are seldom attended with much hemorrhage, while wounds may occasionally cause a serious and fatal hemorrhage from the wounding of a large blood-vessel. The principal danger lies in the leakage of the contents of the stomach and intestines, which almost always sets up a septic peritonitis. This may sometimes become localized and go on to spontaneous cure, though as a rule it becomes general and is fatal. In such cases early operation may avoid the fatal peritonitis. A punctured wound may be so small as to be closed by the mucous membrane, avoiding the escape of the contents of the gut. Or a wound may not entirely penetrate the wall of the stomach or intestines, which only gives way some days, perhaps, after the injury, though the injury is entirely responsible for the delayed result. These injuries are sometimes fatal immediately or very speedily from shock, while in other cases of very extensive injury there may be almost no shock, and the victim is aware of no serious injury. It is an important point to remember medico-legally that spontaneous rupture of the stomach or intestines may occur owing to ulceration due to disease. This can be determined by a careful examination of the wall of the stomach or intestines at the site of the rupture. A slight injury may also cause rupture if the wall of the gut is weakened by disease, as the disease causes greater liability to rupture. Here too it is to be remembered that a severe injury causing rupture may leave no mark of violence on the abdominal wall. The power of walking or other muscular exertion after such injuries of the stomach or intestines is not infrequently preserved, as recorded in numerous cases.[683] The prognosis in such injuries of the stomach and intestines is always extremely grave. INCISED, PUNCTURED, AND CONTUSED WOUNDS OF THE GENITAL ORGANS. These are not common as medico-legal cases. Self-castration or mutilation is sometimes practised by lunatics, idiots, or even intoxicated persons. Thus a man who, while intoxicated, cut off his genital organs and died the next day from the effects of hemorrhage was seen by Demarquay.[684] Circumcision in infants is also sometimes fatal from phlegmonous inflammation.[685] Incised, lacerated, or contused wounds of the female genitals may be fatal from hemorrhage from many small vessels. Deeply incised wounds of the female genitals proves wilful and deliberate malice; accident is out of the question and suicide is improbable in such cases. But we sometimes have to determine between accidental, self-inflicted, and homicidal wounds of these parts, as accidental wounds may occasionally resemble those made by design and so may furnish more or less difficulty, unless all the circumstances are known. Thus Taylor[686] relates the case of a child in whom a sharp-pointed stick entered and passed through the posterior wall of the vagina as she fell from a tree. The stick was removed by a woman, and the child died in a little over a day from peritonitis. Unless the circumstances were known, this case might have caused suspicion of homicide. Lunatics, idiots, and drunkards sometimes inflict on themselves wounds unlike ordinary suicidal ones. In other cases the various points we have enumerated in a previous section to distinguish between suicide, homicide, and accident may be applied to solve the case. Contused wounds, such as kicks, etc., of the female genitals may be fatal from hemorrhage due to the laceration of the parts.[687] Like the wounds of the eyebrows, contused wounds of the vulva may sometimes resemble incised wounds owing to the sharp bony surfaces beneath. Careful examination allows a discrimination to be made from incised wounds. If hemorrhage occurs a long time after the alleged violence, it is probably due to natural causes, especially in cases of metrorrhagia, etc. It may be alleged in defence that contused wounds of the female genitals were inflicted post mortem, but besides the other features which we have already seen help to distinguish between ante-mortem and post-mortem wounds, we may add that kicks and other contusions of the vulva, if fatal, are so from hemorrhage or effusion of blood, and no post-mortem hemorrhage is enough to cause death. INCISED, PUNCTURED, AND CONTUSED WOUNDS OF THE EXTREMITIES. These may be fatal if a large blood vessel or vessels are opened, or sometimes if a compound fracture or wound of a joint becomes infected. They may also in some cases be fatal from shock, from the severity of the injury. As a rule they are the cause of civil suits, not of criminal ones. The various injuries may cause disability for a longer or shorter time, or even permanently, and more or less deformity may also remain. This may be the case with fractures, especially if they occur near the joints, in which case great caution should be exercised in giving an opinion or prognosis. It is a common mistaken idea of the laity that a fractured or dislocated limb can be made in every case as good as before the injury. On the contrary, they not infrequently leave a slight deformity and impairment of function, sometimes even under the best treatment. Dislocations may also leave a lasting disability or weakness, often owing to the carelessness of the injured person. Wounds of an artery or vein, or both, may result in an aneurism or an arterio-venous aneurism. Wounds of nerves may cause paralysis and anæsthesia of the parts supplied. Wounds of muscles or tendons may cause weakness or complete loss of motion of particular joints. Wounds of the soft parts, if infected, may lead to cellulitis and phlegmonous inflammation, which may result in much injury. Wounds of joints, if penetrating, are serious, for without the proper treatment they may result in suppuration in the joint, disorganization of the joint, and final ankylosis. Before the use of antiseptic treatment such wounds were not uncommonly fatal. Fractures, simple or compound, or contusions of bone especially in young subjects, may be followed by osteo-periostitis and its consequences, which may require a long time for recovery after the fracture is entirely recovered from, and a still longer time before the limb can be used. These and many other of the various results of wounds and injuries of the extremities, causing deformity or disability, or both, can often be cured or improved by surgical treatment or operation. THE MEDICO-LEGAL CONSIDERATION OF GUNSHOT WOUNDS. BY ROSWELL PARK, A.M., M.D., _Professor of Surgery in the University of Buffalo_; _Attending Surgeon to the Buffalo General Hospital_; _Fellow of the German Congress of Surgeons_; _of the American Orthopædic Association_; _of the American Genito-Urinary Surgeons’ Association_; _of the New York Academy of Medicine_, _etc., etc._ GUNSHOT WOUNDS. GENERAL CONSIDERATIONS. FEW medical men there are who have long engaged in practice who have not been compelled to take part in some medico-legal controversy in cases of accidental or alleged homicidal gunshot wounds. So soon as death occurs the surgeon ceases to work as such, but may continue to work as a medical jurist, and in preparation for this event must be ready to answer any questions bearing upon the case which, though possibly ridiculous in surgery, are or may be necessary in law. He may be called upon to testify as to the precise nature of a wound inflicted upon the body of a man seen before or after death; as to the means by which it was inflicted; whether the purport was suicidal or homicidal; how much blood was lost; whether the weapon was near to or at a distance from the body when fired; whether it were possible that the deceased could have fired it himself; whether after the reception of the wound the person could have moved or performed any act—in other words, whether death was instantaneous. He may be asked also as to genuine or spurious blood-stains, whether genuine blood-stains were human or from some other animal; whether possibly they were from the body of the deceased. He will be expected to tell from what direction the bullet or missile was fired; which the wound of entrance and which of exit, and many other things possible concerning the circumstances under which death occurred. It is unnecessary to state that questions of this nature call not only for conventional surgical skill, but for the highest degree of shrewdness and general information, as well as sometimes for expert knowledge with regard to small-arms and their ballistics. It has been well said that the first duty of a medical jurist is to cultivate a habit of minute observation. When this is combined with a knowledge of what the law requires and with the results of a technical education, he will be able to meet all or nearly all of the scientific questions which may be asked of him. A learned judge once said that “a medical man when he sees a dead body should notice everything.” Certainly he should make a minute scrutiny of the body to note whether there are upon the dress or hands of the deceased marks of blood, or whether blood-stains are noted in different parts of the room; whether the body or any part of it is cold or warm; whether the limbs are cold or rigid or pliant, since by these means the accurate date of death may be more accurately determined. EXAMINATION AND DESCRIPTION. In determining facts attending a suspicious case of gunshot wound, there should be noted, if known, 1st, the exact time of death, as well as of infliction of the wound; 2d, location and attitude of the body; 3d, condition of clothing; 4th, anything of importance in its environment; 5th, external appearance of the body, as well as state of countenance; 6th, exact description of all marks of violence and of blood-stains; 7th, the presence of cadaveric rigidity and the surface upon which cadaver has been lying, as well as its age and condition of general nourishment; 8th, time when deceased was last seen alive or known to have been alive; 9th, time after death at which examination is made; 10th, all physical circumstances corroborating or arousing suspicions of suicide or homicide; 11th, account of an accurate internal post-mortem examination, in which direction of the bullet or missile is noted, along with a careful description of parts disturbed or injured in its course, large vessels or nerves cut across, effusions of blood, and in every way as accurate a description as possible of the exact damage done. To this also should be added a minute scrutiny of other parts, in order to establish clearly that death was due to the alleged injury, or on the other hand that it may have resulted from natural causes, and that the injury in question was only a consecutive and contributing cause. Especially should there be examined those organs in which occur the most common causes of death, namely, the brain, the heart and great blood-vessels, and the viscera. Moreover, if an operation has been performed the post-mortem examiner should be prepared to speak with reasonable positiveness as to whether said operation was, in the first place, necessary if life were to be preserved, and, in the second place, whether death were due to the injury proper or to the attempt to save life thus made necessary. For the determination of all this, obviously the best time for the performance of the examination is the earliest possible moment after death. Nevertheless, bodies are sometimes exhumed for this purpose, and much information is obtainable even after a considerable interval of time. If death has been caused by a bullet which has not passed through the body, but lodged, it should by all means be obtained, since evidence of the greatest value may inhere in it. Moreover, in first noting the position of the body, the direction of the wound, or the location of a blood-clot upon the floor or clothing or elsewhere, may indicate to the surgeon or other astute person the point at which the bullet may be found concealed or buried in some soft or hard object. This bullet should be recovered, if possible, at all events, although if taken from the body itself the evidence it conveys may possibly weigh more heavily than if removed from some object outside the body. The exact number of gunshot wounds with a minute description and location of each should be committed to paper at once, as well as any statement, if at all reliable, concerning the number of shots fired, since valuable deductions may be reached as to the number of bullets which have passed through or which have lodged within the body. It is well sometimes, also, before dissecting out the bullet-wound, to insert first a stiff and then a flexible probe or something which shall, if possible, follow the bullet-track, since occasionally a question comes up of the direction in which it was fired. Even though surgeons well know that such questions are impossible of satisfactory answer, owing to the manner in which a bullet is diverted in its course by the various tissues of the body, it will nevertheless create a good impression as to the thoroughness and exactness of an examination should it be brought out, in answer to questioning, that this had been done. Many an excellent surgeon has been surprised upon the stand by the question from one of the counsel as to whether he knew that some certain writer had stated that it was always well, in trying to determine the course and direction of a bullet, to put the patient or the body, as the case might be, in the exact position in which it was when the shot was fired, providing this be known. The accomplished surgeon knows that this is a matter of very trifling import, but the witness’ status will be much better established with the jury if he can show himself familiar with this possible method of examination. When a suspected person is brought before a magistrate, accused of homicidal attempt, it is very likely that the judge will require a written statement or opinion from the surgeon in attendance as to the extent and danger of the victim’s injuries, and especially as to whether these are of a character dangerous to life. The meaning of these words is left entirely to the sagacity of the surgeon. A mere naked declaration of this fact is insufficient. He must, if called upon by the court, give his grounds for his belief, and these may be rigorously examined by counsel. He will also probably be asked as to the presumable duration of life and possibly the effect of operation. Thus the prisoner’s immediate liberty or restraint may depend upon the surgeon’s words. Perhaps the only advice which can be offered here is to qualify between injuries directly dangerous to life and those in which life is endangered merely by possible complications, such as sepsis, gangrene, etc. Still, aside from wounds which are either fatal or may be nearly completely recovered from, there is another quite large class of those causing grievous bodily harm in which it is a question for the jury always to decide what was the intent of the accused. A medical witness may thus in such a case be of great assistance to the court by giving an account of the injury devoid of technicalities, and of its possible consequences. It should also always be stated, if known, whether the patient was under the influence of liquor or any narcotic at the moment of injury. In the examination of wounds either of the living or dead body, it should always be determined for medico-legal purposes whether there is about them fluid or coagulated blood or ecchymosis, that is, livid discoloration of the skin from effused blood. The color of the ecchymotic spot will give a valuable clew as to the time between the infliction of the wound and death. Putrefaction of such a wound must not be mistaken for gangrene. In giving reports on such cases care should be taken to distinguish between facts and inferences. In fact, the inferences had better be kept unreported or confined to a separate statement. Should there be any possible suspicion of a combination of poisoning and gunshot wound, the stomach contents should be carefully preserved and sealed up in the presence of witnesses before turning over the same to the analytical chemist, whose receipt for the package, with a careful description of the same, will probably have to be placed in evidence. Any fact on the condition of the stomach with regard to digestion is always worth noting. In the case of Reg. _v._ Spicer (Berks Lent Assizes, 1846) a most important point hinged on the examination of the stomach. The body was found at the foot of a stairway. The prisoner stated that after he and his wife had had their dinner he heard a fall. The woman had died instantaneously and the death occurred about the dinner-hour. Upon examination the stomach was found empty, without a trace of food. It was, therefore, clear that a part at least of the prisoner’s story was untrue. Evidence as to whether the wounds were superficial or deep may be of value. If the edges are swollen or large, or if granulation or cicatrization have commenced, it is evident that the person must have lived some hours or some days after their reception. The same is true of suppuration, adhesion, or gangrene. It must also be remembered in this connection that very few gunshot wounds will show much change in less than ten or twelve hours save that due to the extravasation of blood. Should the question come up as to whether a gunshot wound had been inflicted before or after death, we may remember the principal characteristics of a wound inflicted during life, which are more or less eversion, more or less hemorrhage with diffusion of blood into the tissues, and the presence of clots. In a wound made after death little or no blood is effused, unless it come from some vessel very near the surface, in which case it will be venous in character and will not coagulate as does that which is poured out of a wound in the living. The track of the bullet also will not be found filled with coagula. In these respects a little will depend upon whether the body has lost its animal heat or not. The gunshot puncture of a divided artery in a dead body will present a very different appearance from one inflicted before death, even though it be the cause of death. Bleeding after death is exclusively venous, and there does not occur extravasation of blood in the cellular tissues, nor does it coagulate. Questions of this character come up sometimes in the case of multiple wounds or injuries, and it is, at times, of importance to be able to determine whether the assault or injury has been continued after death. Changes in color of an ecchymosed spot rarely begin until after the expiration of twenty-four hours, when its dark margins become lighter, and as time goes on the whole area passes through successive shades of violet, green, and yellow; its area may also increase sometimes to remarkable proportions, but the central portions are always darker than the periphery, the darkest spot corresponding to the centre of violence. Ecchymosis is longer in disappearing in the old than in the young. Its various features also will vary a little in accordance with the tissues bruised. Gunshot wounds pertaining to spurious suicidal attempts are usually found not to involve vital parts, while they will have most of the characteristics of injuries inflicted from a weapon near at hand. The skin or the clothing will show powder-marks, and if a wad is a feature of the cartridge used, it may be found in one place or the other. In these cases there is also relatively more laceration and bruising, while sometimes the hand which held the weapon may be blackened or burnt by the discharge of the same. Self-inflicted wounds, in other words, must necessarily partake of the character of near wounds. EVIDENCE FROM THE SITUATION OF THE WOUND. It has been generally noted that suicidal wounds are for the most part confined to the front or lateral parts of the body; gunshot wounds of this character being found usually in the region of the heart, the face, and the temples. The presence of an injury to these parts is not necessarily indicative of suicide, but the existence of such injuries in other parts of the body is at least negative evidence of homicidal attempt. Moreover, Orfila has observed that it is not so much the situation as the direction of the wound which gives evidence for or against the presumption of suicide. The question has been raised whether it were possible to have a gunshot wound without external evidence. There has been recorded more than one case where a bullet entering through the open mouth has penetrated the brain without passing through the vertex of the skull and has killed instantly without leaving any external mark. It is very necessary to establish, if possible, the direction of such a wound, and this may be coupled with a knowledge of the right-handedness or the left-handedness of the person who inflicted it, or may shed light in this way upon some personal peculiarity which may lead to the detection of the guilty person. Thus it is said of Sir Astley Cooper that in one instance he remarked that a certain wound could not have been inflicted except by a left-handed person, and that his observation led to the detection of the murderer. It has been stated that for the detection of the weapon or instrument used it should be placed first in one hand of the deceased and then in the other, while the other extremities are so manipulated that it may be clearly determined whether suicidal attempt were possible or no. There is ordinarily little difficulty experienced in distinguishing suicidal from accidental wounds. In the former case extraneous signs and circumstances point more clearly to the intent of the deceased than do, perhaps, the peculiarities of the wound itself. This is to be settled mainly by the evidence of those who find the body; in other words, by circumstantial evidence. In suicides ordinarily one wound only is met with. At any rate, probably one only that has destroyed life. Consequently the presence of several wounds, each of which was necessarily fatal, constitutes almost conclusive evidence of murder, the strength of the same depending upon the necessary fatality of more than one of these. Thus it is hardly conceivable that a suicide should shoot himself through the heart and through the brain; the coexistence of two such wounds would be almost conclusive of homicide. The existence of multiple wounds is a rather strong presumption of insanity or drunkenness of the person who inflicted them. Men who kill when under the influence of liquor not infrequently inflict injuries enough to be several times fatal. The coexistence of wounds made by cutting weapons, as well as firearms, is not unknown. These are occasionally suicidal, ordinarily they betoken murderous attempt. If suicidal the deceased will ordinarily be found to have been a lunatic. But evidence is to be obtained also from signs and circumstances separable from the wound itself. Thus the position of the body may be such as to invalidate the theory of accident or suicide. The position of the weapon, too, is something to be noted with great care. Whether, for instance, this be firmly held within the hand of the corpse, or whether it had been simply placed there after his death; whether it be found where it would seem to have been most naturally dropped after its discharge, or found somewhere where it could scarcely have been placed or thrown by the deceased; whether it be found at such a point that it is clearly evident from other signs it could not have been dropped by the deceased, since death must have been caused too quickly for him to have traversed the intervening space. EVIDENCE FROM THE WEAPON AND PROJECTILE. Evidence of great value may be obtained often from the weapon itself. First of all, from the position in which it is found, as stated above; second, from a careful examination of itself. It should be noted whether there be any blood upon it, and whether this be so fresh as not to have caused any rust; whether it may possibly be so smeared with blood as to indicate a hand-to-hand conflict; or whether any part of the weapon may have been used as a club or bludgeon, as would be shown by the presence upon it of hair entangled in dry blood. When such blood is removed from the weapon it should be carefully examined with the microscope, since from the detection and identification of hair or fibres of fabric evidence of the greatest value may be adduced. Next it should be ascertained whether a weapon shows signs of having been recently discharged or whether it be evident that it could not have been so, and such determination of the time element as may be afforded by a study of this kind should be contrasted with that made after a study of the wound. If the weapon be a revolver or a repeating arm of any kind, it should be determined if possible how many cartridges or bullets have been fired, and whether at or about the same time, and this information should be compared with the evidences obtained from the body and from the room or locality in which the suicide or murder occurred. If, for instance, it be determined that three cartridges have been fired and but two bullet-wounds are found in the body, an examination of the room may show where went the third bullet. Next the calibre of the weapon should be noted and the weight of the ball which it discharged and its dimensions should be compared with any which may be found in or about the body. The weight of the bullets attached to cartridges of various sizes and makes is usually stamped upon the packages in which they are sold, or can readily be obtained from the makers of the same. A bullet taken from a body weighing after its removal more than do the other bullets undischarged in the weapon by which an injury is alleged to have been inflicted is rather presumptive evidence against the injury from that source. CAN A BULLET LOSE IN WEIGHT BETWEEN THE TIME WHEN IT LEAVES THE BORE OF A GUN AND ITS DISCOVERY IN A BODY?—Here springs up a question upon which some very interesting evidence has been adduced in different trials. To discuss this matter completely the question should be divided into two, the first being: DOES A BULLET SUFFER LOSS OF WEIGHT DURING ITS COURSE THROUGH THE PIECE AND THE AIR BEFORE IT COMES IN CONTACT WITH THE BODY?—A personal letter received from Captain Charles Shaler, of the Ordnance Department of the United States Army, in reply to certain questions, tends to fully settle that a lead bullet suffers a certain loss of weight in the barrel due to the friction between the bullet and the bore; this is known as “leading” and varies according to circumstances. “Patching” the bullet is often resorted to in order to reduce the leading; lubrication is also practised. The fusing of a bullet takes place especially with lead bullets. A ball which has been partly fused in the bore will lose the fused portions in the bore or in flight, and will move irregularly on account of the resulting irregularity of form. A .45-calibre, 500-grain service bullet, lead alloyed with tin, was weighed without lubricant and was found to weigh 500.5 grains. It was then lubricated in the cannelures and was fired into a butt composed of three barrels placed end to end and filled with sawdust. Tho bullet was recovered, no lubricant being found in the cannelures, and re-weighed, the weight obtained being 485.5. The loss of weight was, therefore, 15 grains or three per cent, some of which may have been due to the bullet penetrating the sawdust. A German-silver “jacketed” .30-calibre bullet, weighing before firing 231 grains, fired without lubrication, when recovered and re-weighed was found to have suffered a loss of weight of one-half grain or one-quarter of one per cent. The other part of the main question is: DOES THE BULLET LOSE IN WEIGHT IN ITS COURSE THROUGH THE BODY?—This is, of course, intended to pertain only to those instances in which there is no evidence of splitting or division of the bullet, and refers only to the effect of friction or attrition. June 5th, 1878, in Saratoga County, Mrs. Jesse Billings was accidentally killed by a bullet. Her husband was arrested and tried for murder. On the first trial he was acquitted. A second trial, however, was held, and some very interesting expert testimony was brought out on matters pertaining to these questions. The medical evidence is published in full by Dr. Lewis Balch, of Albany, in the Transactions of the Medical Society of the State of New York for 1881. The rifle from which the bullet was supposed to have been fired was found in a well, and was sworn to have belonged to Jesse Billings. In it was found a cartridge of the type known as the Commercial Long No. 44. This gun became an important factor in the case, and most of the evidence as to whether it was the weapon with which the murder had been committed was referred to the medical experts. The defence in the first trial claimed that all the lead fired was found in Mrs. Billings’ head. On the second trial the same claim was not made, but that it was a smaller bullet than a .44 and its weight less than 220 grains; that in consequence this rifle could not have been that from which the shot was fired, for it only called for a .44 ball, and that it would have thrown a bullet with such force that it must have gone entirely through the head. They further claimed that powder-marks and grains of powder were found in the window-sash, showing that the weapon was fired near the window, and that the hole in the glass was not large enough to admit a full-sized .44 ball. The verdict was mainly won upon these statements. A question for the medical experts to answer was, what would be the effect upon the skull of a .44-calibre ball fired from a Ballard rifle, the ball weighing 220 grains and the charge of powder being 28 grains? also what would be the effect upon the ball? Experts from the Ordnance Corps and from the rifle factories were able to testify that the bullet found in Mrs. Billings’ head was originally a .44-calibre ball; also that its markings showed the peculiar left-handed twist used in rifling this particular arm. The defence maintained that it could not have been a .44, claiming that the hole in the window-pane showed that. The original window produced in court was no criterion, since from repeated handling the hole made by the bullet had become enlarged and changed in shape. Both of the experts for the defence believed that the ball could not make a hole smaller than itself when passing through glass. This necessarily supposes that the ball after being fired is the same calibre as before, which, as shown above, is not always the case. So Dr. Balch fired forty-five rounds from the Billings rifle with 220 grains of lead and 28 grains of powder. The shots were fired through glass set in sashes, the glass being 28×13¼, double thick and American make. The rifle was discharged at varying angles and at distances varying from two to seventy feet, and he obtained one shot where the hole made would not admit a full-sized ball. His summary was as follows: Balls unable to pass through 1 Balls partly passed 3 Balls passed 18 Cartridge passed 21 Glass broken out 2 — Total 45 Other rounds were fired from a Colt’s navy revolver, old style, .36 calibre, at distances varying from ten to twenty feet. The holes made were so large that the barrels and ramrods could be passed without touching. The examination of the one instance noted above where the aperture in the glass was smaller than the ball is explained by Balch as follows: “A ball conoidal in form, passing with great velocity, strikes glass, penetrates, but does not break the glass at the point of entrance. The point struck is instantly disintegrated, and so rapid is the stroke that it has not time to call upon the surrounding particles for support; hence the smallness of the hole. As glass is made it varies in elasticity; some parts which are to be cut into panes cool faster than others. A bullet striking the portion of the glass which has cooled quickly strikes an object which will yield somewhat to the force; in doing this a hole will be made smaller than if that more brittle had been struck. Furthermore, all rifles taper more or less from breech to muzzle, that is, the muzzle will measure one or more thousandths or hundredths less than the breech. The bullet being forced through the narrow aperture yields to the pressure and becomes smaller. The gun under consideration was measured at the New York Armory, and found to be .44 at the breech or chamber and .423 at the muzzle. Considering these various facts, statements that a ball of known size will make a hole through glass smaller than the size of the ball when fired do not admit of doubt as to their verity. Some statements bearing on this same point contained in a recent letter from Captain Shaler, of the United States Army, deserve mention here. The following experiment was made in Washington by Captain Lyon in October, 1880: “Noticing a statement in a newspaper to the effect that a ball fired from a rifle would, in passing through glass, make a round hole smaller than the diameter of the ball used, the following experiment was made: “Service ammunition used, in a calibre .45 Springfield rifle to penetrate glass. ═════════════════════╤═══════════════════╤════════════════════════ Time Fired. │ Size of Hole made │ Remarks. │ in Glass, inches. │ ─────────────────────┼───────────────────┼──────────────────────── 1 │ 0.570 │ 2 │ 0.550 │ 3 │ 0.600 │ 4 │ 0.600 │ 5 │ 0.575 │ 6 │ 0.575 │ The frame holding the 7 │ 0.590 │ glass was placed 25 8 │ 0.620 │ yards from the muzzle 9 │ 0.600 │ of the gun. │ │ Average size of hole │ 0.586 │ Calibre of bullet │ 0.458 │ │ ────── │ Difference │ 0.125 │ ─────────────────────┴───────────────────┴──────────────────────── “From the above it will be noted that there is no uniformity in the size of the holes and that they all exceed the diameter of the bullet. “These experiments were supplemented by some made recently in which a sash containing six panes of ordinary window-glass was placed at twenty-five yards from the firer and the glass was successively penetrated (a separate pane being used in each case) by bullets from a service .45-calibre Springfield rifle, a .30-calibre Springfield rifle, a .45-calibre Colt’s revolver and a .22-calibre revolver. In every case the hole made was much larger than the bullet making it.” With reference also to the effect of a ball being smaller than its original diameter after it leaves the piece, Captain Shaler states: “All very compressible bullets forced by inertia lose a certain amount even though they also gain force by slugging. Forcing by inertia tends to shorten the bullet and increase the diameter, while slugging tends to lengthen the bullet and reduce its diameter. Whether the bullet is smaller after it leaves the piece depends upon the bullet used and the method of forcing employed.” To return to the Billings case, it was claimed that the bullet was also too small. It weighed 165 grains, 55 less than when it was fired from the rifle. Balch found in firing at human skulls, the subjects in all the trials but two being placed in a sitting posture, sometimes with a sash like the Billings window in front of the subject, that the ball lost lead in accordance with the resistance it met with and the amount of bone ploughed in its passage. These experiments conclusively prove that the weight of a ball taken from a body after being fired, it having traversed a bone in its flight, is by no means evidence of its weight before firing; in other words, a ball always loses some lead when passing through bone. With the same rifle as that produced at the trial he made a series of experiments in the dissecting-room, endeavoring to make a bullet enter the skull at the same point and in nearly as possible the same direction as in the case of the murdered woman. In six such experiments there were varying losses of lead, all the bullets used being the same general weight. In two trials the distance was but ten feet from the muzzle, yet more lead was lost than in any of the other four. The least loss recorded took place at the longest distance, thirty-five feet. This in part accounts for the loss of lead, for at ten feet the bullet has not acquired its greatest penetrating power, for he showed by experiment that a 220-grain bullet fired at a human skull will lose more lead than was missing from the Billings bullet, thus disposing of the question raised by the defence that a ball could not have weighed 220 grains before being fired. Just how to account for the missing lead has never been clearly established. We have to remember that a few grains may be left in the bore of a rifle, especially if rusty; that in passing through glass another portion is lost, and finally it is scarcely conceivable that any bullet should penetrate an adult skull, especially in the neighborhood of the mastoid processes, without losing quite a perceptible percentage of its mass by friction. It was also claimed by the defence that the ball taken from Mrs. Billings’ head had been fired from a weapon of low velocity, which was held to account for the fact that the ball failed to pass out of the skull. The rifle when tested at the Government Arsenal showed a mean velocity of 999 feet per second. Had it been as high as was supposed by the defence, namely, 1,300 or 1,400 feet, the argument that a bullet driven with this force would always go through the skull would have more weight, but with the velocity found by actual test the energy of the ball was lessened to nearly one-half of that supposed. The bullet which killed Mrs. Billings did not pass entirely through the skull. It ploughed into the opposite side and broke before it a triangular piece of bone which broke the skin externally. This shows the resistance of external fascia against perforation. A study of the lines of fracture in this particular case proved very interesting, but perhaps would be somewhat irrelevant here. A measurement of the skull and of the bullet-track through it shows the former to have been of more than ordinary thickness and density, and the channel ploughed in the bone by the bullet along the base of it to have been nearly two inches in length. Dr. Balch gives the following conclusions to his very interesting evidence: 1st. A leaden ball passing through bone loses lead in proportion to the amount of bone traversed. 2d. If the petrous portion of the temporal bone be the part struck by the ball and struck squarely at the base, that portion of the bone is crumbled or broken in such exceedingly fine pieces as to defy restoration. 3d. That if the ball struck any part of the skull the petrous portion will be broken, but can be usually recognized and generally put together again. 4th. That a ball of given calibre fired through glass may make a hole enough smaller than the full size of the ball before firing to prevent an unfired ball of like calibre passing. In all this kind of experimentation upon cadavers for the purpose of eliciting evidence by reproducing as nearly as possible ante-mortem injuries, we must not forget that Casper has strongly insisted that “it is extremely difficult to break up the organic cohesion of dead organs.... If we endeavor to fracture the skull of a dead adult we shall find that an amount of force which if applied in life would indubitably produce fissures if not fracture, or complete crushing of the skull, leaves the dead skull quite uninjured.... The most powerful blows struck down upon the body, laid down horizontally, were without result, and only after repeated violent blows were we able to produce perhaps one or a few fissures in the occipital or parietal bone, or in the temporal bone (squamous portion), and usually in the latter. We were unable to produce more considerable effects, such as complete smashing of the skull or fissures of its base, even in one single instance. The dead skull seems to have considerably more power of resistance, and after its removal fissures of the bone were more easily produced by similar blows” (Vol. I., p. 245). And again: “The result of my experiments on the dead body in regard to gunshot wounds could only be to make more complete the proof of the resistance of the dead corporeal tissues, in contradistinction to the tissues when alive. After I had already learned this peculiarity from my experiments with contused wounds, this peculiar resistent property was found to be confirmed in a most remarkable manner” (“Forensic Medicine,” Vol. I., p. 271). If the number of bullets known to have been fired, or, more important still, which have been found exceeds the number which could have been discharged from the weapon in question, a very large element of doubt and uncertainty is introduced which must be quieted by other and more circumstantial evidence. Should two different weapons be in question, it is very necessary to establish from which of them the bullets have been discharged. This can be done mainly by weight and evident calibre of the bullets, or some other peculiarity; possibly in disputed cases even by analysis of the metal. =Wounds by Shot-Guns.=—In most of what has been said it has been supposed that the injury has been inflicted by an arm of the kind commonly described under the terms pistol, revolver, or rifle. Gunshot wounds are, however, occasionally inflicted with shot-guns and a charge of shot varying in size from small bird-shot up to that generally known as buck-shot. It is characteristic of such missiles that they separate after their discharge from the gun, and a determination of the degree of their separation is approximately a determination of the distance of the mark from the muzzle of the weapon. In suicide or accidental discharges of a shot-gun the muzzle is so near the body that the charge of shot acts very much as would a single bullet of the size of the bore of the gun, and near wounds thus inflicted, while necessarily large, have about them a minimum laceration and disturbance of tissue, so that perhaps only by their size could one say, viewing the wound alone, that the weapon used had been a shot-gun. On the other hand, at a distance of a few feet the shot begin to separate to such an extent that there is much more laceration of tissue, and after separation to an indeterminate, because variable, number of feet we get such marks as individual shot may make. This distance is indeterminate because it is predicated on the size of the gun, the dimensions of shot, and the weight of the charge of powder. The writer, for instance, has recently seen one case where the muzzle of the gun could not have been more than two feet away from the surface of the foot at which it was discharged, the consequence being a round and very slightly ragged hole through the mid-tarsal region from dorsum to sole. It is possible for a single grain of shot to produce death. Such a case is related by Ollivier d’Angers: a thief scaling a wall received at a distance of fifteen paces a charge of shot from a fowling-piece; he fell dead immediately. The charge had struck him in the breast, centring over a space of three or four inches, but one shot had penetrated the aorta over the attachment of the sigmoid valves, and another had traversed the entire wall of this vessel. POWDER-MARKS.—A very important part of evidence in case of near wounds of gunshot character pertains to the powder-marks upon the clothing and skin. Naturally every one knows that when a weapon is discharged near a given surface there will be more or less powder-marking upon that surface, the same being due to particles of gunpowder which are incompletely or not at all consumed, and which are black because of the charcoal they contain; but the circumstances under which powder-marks of a given character can be inflicted are so extremely variable that no statistics or information of value in a general way can be given. Thus the fineness of the marks will depend upon the fineness of the powder, and the area covered and the depth of the marking upon the same, upon the distance of the muzzle from the surface; and the only way to make out the exact distance of the muzzle from the surface at the time of the infliction of a given wound is to use the same weapon, if possible, with cartridges or charges out of the same lot as that used at the time of injury. Distances could, perhaps, be stated in round numbers, but their value would only be remotely approximate, and in a given case the best evidence is to be obtained by experiment with the fire-arm in question. =Dimensions of Perforations.=—At different times a great deal of weight has been attached to the dimension of the perforation through such objects as wood, glass, or even through the bones of the body, made by the bullet which is supposed or known to have destroyed life. Wrong inferences have been drawn sometimes from a study of undischarged bullets or cartridges similar, at least before firing, to that which has been taken from a given body. It has been stated, for instance, that such a bullet was too large to have passed through such an aperture or to have made such a hole, or that it was so much smaller than a certain hole that it was not the particular missile which made that perforation. Upon this matter has hinged a great deal of uncertainty and consequently a good deal of study. The size of opening which a bullet of given calibre will make through wood depends upon the distance of the weapon, the firing charge, the velocity of the bullet, the extent to which its shape has been altered by passing through the given barrier, by the heat of the explosion, by the impact of the air upon the heated and consequently softened metal, and by the density and thickness of the wood, as well as by the resistance which it may have offered mainly from its being fixed in place or movable. There is, however, ordinarily less question about the size of a similar hole through a piece of glass or bone. It is generally supposed that a bullet passing through a window-pane will shatter it. This depends, however, mainly upon the perfection of fixation of the glass in its resting-place. If for purposes of experiment panes of glass be tacked into a shutter and bullets be fired at them from varying distances, they will be practically invariably shattered. It is, however, quite different if the pane of glass be firmly fixed in a frame by means of putty which has become old and hard, and especially if the window-frame itself be closely fitted in the casing. Under these circumstances a bullet will often make a clearly punched hole, or one with very few radiating lines of fracture. Experiment, therefore, to secure evidence should be made under circumstances exactly parallel to those which necessitate such evidence. EVIDENCE FROM EXAMINATION OF THE DEAD BODY. =Fractures.=—Considerable evidence of great interest with respect to the effect of a bullet-wound upon the skull and the possibility of fractures being produced at the base by _contre coup_ will be found in the statement of the case of The People _v._ Elisha B. Fero, published by Dr. Charles T. Porter, of Albany, in the _Journal of Psychological Medicine_, April, 1870. Mrs. Fero was murdered while in her bed and was found to have been bruised about the head and body, her husband claiming that the deed was that of a robber who had attacked them both. He was found with slight bruises or scratches about the face and black marks as if from burnt powder between the middle fingers of his right hand. The first autopsy appears to have been carelessly made, but a flattened conical ball weighing twenty-six and one-half grains was found lodged in the middle of the right cerebral hemisphere. It had not gone completely through the brain. Its base fitted the shells of the metallic cartridges used in Fero’s revolver. Eight days after death a second examination was made, after which the head was removed and preserved in 95% alcohol. A theory of the prosecution was that Mrs. Fero was murdered by her husband; that he shot her, as well as struck her numerous blows upon both sides of the head and its front and back with some broad, heavy, and elastic body, making fractures found on autopsy. Not the least interesting part of the testimony is that referring to the condition of tissues alleged to have been bruised after long preservation in alcohol. The expert testimony in this case appeared to show that such fractures as were found, without reference to the fact of external bruises, were due to the unskilful manner in which the skull-cap was removed. In this connection it is well right here to emphasize the fact that fresh fractures can be produced in the skull by too forcible or injudicious efforts to remove the calvarium when making autopsies, or that fractures previously existing can be extended or complicated in the same way. Shaw in his “Manual of Anatomy” says: “The question whether there has been a fracture of the cranium previous to death is sometimes more difficult to decide than a person not accustomed to make dissections might imagine. If the fracture has occurred immediately before the patient’s death, there will be found coagulated blood upon the bones and in the fissures. If the patient has survived for some time, there will be marks of inflammation and, perhaps, pus in contact with the skull, but if a fracture has been made in making the examination, which sometimes happens in even very careful dissectors’ hands, the blood in the fracture will not be coagulated, nor will there be any effusions around the portions. In Beck’s _Medical Journal_, Vol. XXII., p. 28, Mr. Alcock some time since stated in a public lecture in London that he had known a fracture of the base of the skull produced by the awkward and violent tearing of the upper portion by the saw in penetrating enough to divide the bones, and this to be mistaken by the inexperienced operator for fracture of the skull producing death. Being a medico-legal case, it might have led to melancholy consequences had not the error been detected by an observer.” That an extensive and often complicated fracture by _contre coup_ can occur as the result of gunshot injuries of the skull is a fact well known to all surgeons of experience and laid down in all text-books and illustrated in all large museums. In view of these well-known facts, it would always be well to insist in cases of this kind that the saw alone should be used and not the hammer nor the chisel. When a cranial bone is fractured blood is poured out from the ruptured vessels, as is always the case with any bone. Its amount varies indefinitely with the number and size of the ruptured vessels, the activity of circulation, the length of time a person lives, etc. The blood may collect in circumscribed masses or become infiltrated in the surrounding tissues, although usually both phenomena are observed. The extent to which infiltration takes place depends upon the quantity of blood and the nature of the surrounding tissues. In loose tissues like those about the orbit infiltration is much more rapid and extensive. =Examination of the Weapon.=—French medical jurists have tried to indicate how we may determine the time elapsed between the death of a person and the discharge of a weapon found near the body, but exact statements in this matter are utterly out of the question. Certain facts bearing on the subject are these: When recently discharged there will be found adhering to the barrel of the piece and consisting of the fouling of which sportsmen complain, a quantity of potassium sulfid mixed with charcoal. This is shown by its forming a strong alkaline solution with water, evolving an odor of hydrogen sulfid, and a dark precipitate with a solution of acetate of lead. Depending upon the degree of exposure to air and moisture, after some hours or days this sulfid becomes converted into potassium sulfate, which forms a neutral solution with water and gives a white precipitate with acetate of lead; but if a considerable time has elapsed since the discharge of the piece oxid of iron (iron rust) with traces of sulfate may be found (_Ann. d’Hygiene_, 1834, p. 458; 1837, p. 197; 1842, p. 368). WAS THE WEAPON FIRED FROM A DISTANCE OR NEAR BY?—A gunshot injury from a bullet implies at least one wound, namely, that of entrance, and perhaps another, that of exit. It does not always happen that the bullet passes through the body. The appearance of the wound of entrance is usually one of irregular circular puncture, its edges perhaps slightly torn or lacerated, with a purplish or dark areola, varying in width from a line or two to one-half inch. When the weapon is fired close to the body there are likely to be more or less powder-marks, and possibly actual burning from the heat and flame of the gunpowder. If the part of the body injured had been covered by clothing at the time, the marks of powder and of burning would probably be confined to the same. Bleeding is usually slight and occurs more commonly from the wound of entrance than from that of exit. Regularity of either of these wounds depends in large measure upon the angle at which the bullet has struck the surface. When striking very obliquely the wound may be more oval or the bullet may have ploughed a furrow or a channel, by a study of which the relative position of the assailant and the assailed at the moment of injury may, perhaps, be determined. It is of importance to determine if possible the approximate distance at which the bullet was fired, since the question of self-defence, for instance, may hinge upon evidence of this character. The charge of powder and the weight of the bullet being known, one may sometimes estimate this distance by the depth of penetration or the appearance of the bullet. Still, the nature of the tissues must figure largely in such consideration. Many suicides who shoot themselves in the head show only one wound of entrance and none of exit. =Experiments Testing Powder-Marks.=—Powder-marks and burns from weapons ordinarily used will scarcely appear when the distance has exceeded ten or twelve feet. LaChese, of Antwerp, found that in firing a gun even from a distance of only four feet the skin was only partially blackened. As the result of experiments made with a Ballard rifle, old style, .44 calibre, with bullets of 220 grains and 28 grains of powder, Dr. Balch, of Albany, found that powder-marks were made at distances as follows: At two feet, particles too numerous to count, with some of the lubricant blown upon the board; At four feet the same; At six feet the same; At eight feet, nine grains of powder; At ten feet, five grains of powder in one case and six in another. That these were powder-grains were shown in court by picking some of them out, placing them on a glass, and igniting them with a galvano-caustic point. From those at ten feet no distinct flash could be elicited; from those obtained at eight feet distinct flashes were seen (Trans. New York State Med. Soc., 1881). In the celebrated case of Peytle, brought in 1839 for the murder of his wife, who had been killed by two bullets entering near the nose, the eyebrows, lashes, and lids were completely burned, and a large number of powder grains were imbedded in the cheeks. Experiments being made in order to ascertain the distance necessary to produce these effects, it was found that the weapon must have been held within a distance of twelve inches. =Wounds of Entrance and of Exit.=—A great deal has been written in time past about the peculiarities of the wounds of entrance and of exit, much of which cannot be maintained under expert criticism. It is true that the wound of entrance will usually be well defined, the skin slightly depressed and appearing as above noted. It is true also that powder-marks will appear about this wound rather than that of exit. Usually, too, the orifice of exit is larger, less regular, its edges everted slightly, with more or less laceration of the skin, and quite free from any powder-marks or evidence of burning. The depression at the border of the wound of entrance differs after some days, by which time the contused margins slough away, and its appearance is daily changed by a process of granulation providing the individual recover or live long enough. According to Dupuytren, the hole in the clothing is smaller than that made by the same bullet in the skin. These are all points worth remembering when fitting bullets into wounds which they are supposed to have made; but the conditions under which gunshot punctures occur are constantly varying, and the significance of local markings is mainly the product of experience, care, observation, and reasoning. Thus the shape of either of these wounds will depend naturally upon the integrity of the bullet and its original shape and dimensions. Matthysen’s experiments give the following: A pistol fired at twelve paces distance, with a ball 15 mm. in diameter, made a wound in chest of 8¼ mm. diameter, and at its point of exit at the back one of 10 mm. In two experiments at the same distance as above, the entrance wound was 4 mm. larger in diameter than that of exit, and when a larger ball with a diameter of 17 mm. was used the same results were preserved, both wounds being less in size than the ball which made them. A spherical ball will usually cause more loss of substance than a conical, while the latter will cause usually more irregularity of outline and may even give the wound of entrance a slit-like appearance. Complications may also occur from other sources; a single wound of entrance may give rise to two or more wounds of exit due to splitting of the bullet, or if the bullet have been divided and the larger part lodged in the bone, only the smaller portion passing out, the wound of exit may in reality be much smaller than that of entrance. Again, a bullet may split into fragments before striking the body, and of these one may enter the body, or one or more of them lodge. Multiple wounds are possible even from one bullet, as when it passes through two different parts of the body. Again, when two wounds, for instance, are discovered, one of them may be regarded as that of exit, when in reality they may be two wounds of entrance, neither bullet having left the body. So while it is possible in some cases to decide which is which, too much dependence should not be placed upon appearances of this kind, least of all until after a careful autopsy has been made. =Course of the Projectile.=—When a bullet traverses a body the two apertures may be nearly opposite to each other, although the bullet may not have taken a direct course between them, having been deflected by tissues of varying density in its course. This leads to the mention of the effect of animal tissues upon the course of bullets, with which works on military surgery deal extensively. The following is a remarkable illustration, yet authentic, of a devious path of a ball. In a duel with pistols between two students at Strasburg one fell, apparently mortally wounded in the neck, but recovered without feeling any inconvenience from his wound. It was found that the bullet had struck the larynx and had gone completely around the neck. It was taken out by simply making an incision over it. Other instances may be cited where bullets have made a circuit around the head, thorax, or abdomen. The ball may make a half circuit of the body and lodge or emerge at a point opposite that at which it entered, thus leading one to suppose that it must have passed directly through (Wharton and Stille). As the writer of a chapter on the effect of projectiles of small-arms, in the Third Surgical Volume of the “Medical and Surgical History of the War of the Rebellion,” p. 709, says: “Such bullets attain great range and effectiveness as oppose least frontage of resistance to air; their velocity consequently is greater. Rotation upon their long axes tends to give them steadier flight and more direct course. By their pointed apices they pierce more easily the structures opposed to them. Such bullets, owing to the elasticity of the skin, make a wound of entrance perhaps a trifle smaller in diameter than themselves, while spherical balls are more likely to carry a portion of the integument in with them.” The differences of structure and density of the muscle tissues and their aponeuroses encountered by a bullet in its passage materially influence the directness of its course unless its velocity be very great, while round bullets are the more easily deflected from their course. The track of a small conical bullet passing swiftly through a muscle is more cleanly cut than that made by a round bullet, but in all gunshot wounds there is usually found a regular canal, with lacerated walls, with more or less destruction along the area of injury, shading off concentrically until lost in healthy tissue. There is always loss of substance dependent on muscle tension or direction of the bullet, whether transverse or obliquely to the direction of the muscle fibres; the more fibrous structures are torn and lacerated or simply perforated, mainly owing to their different tension at the instant; their openings seldom correspond to those of the muscle tissues or those upon the surface of the body, because of the constant change in the relation of the parts due to muscle action. This makes it often difficult to follow the course of a bullet with accuracy. The irregularity of a bullet-track due to these causes constitutes one of the great sources of danger, since cavities and pouches thus formed give lodgment to foreign matter driven in with the bullet, by retention of which a fertile source of sepsis is maintained. Gunshot injuries of bone may be classified as contusions, simple fractures, partial fractures, penetrations, perforations, and complete fractures with more or less comminution or loss of substance, all of these, of course, in the surgical sense compound. These are all manifestations of mechanical force acting in accordance with established laws. On autopsy these will be ascertained, while one or more portions or all of a bullet may be found imbedded in or attached to some bone. The best illustration of such accidents will be found in the “Medical and Surgical History of the War of the Rebellion.” Such questions as pertain to the position of the wounded person when shot or that of his antagonist, and other similar inquiries, can only be settled by reference to particular circumstances of individual cases. Position of the wound may help a little. A bullet-wound directly in the centre of the top of the head could scarcely be received by a person standing unless his assailant occupied an elevated position. If accompanied by evidence of severe blows by which the deceased might have been knocked down, it might show that he had been shot after falling. =Wounds by Small Shot.=—Small shot rarely traverse the entire body unless discharged from such proximity as to make a clean, round opening. Paley relates the following instance: A boy was shot in the neck by the accidental explosion of his own gun, No. 8 shot. He died instantly. He was lying forward of the muzzle so that it was nearly in contact with the skin of the neck. A large round hole was produced, in diameter one and one-half inches, whose edges were slightly darkened by powder. The wound of exit at the back of the neck, at the third vertebra, was a mere slit in the skin scarcely an inch in length with the diameter placed vertically. The smallness of this aperture may have been owing to the greater part of the charge being lodged in the body. Dr. Lowe states that in some experiments it was found that a round aperture might be produced by a discharge of small shot at a much greater distance than that assigned by Dr. LaChese, namely, ten to twelve inches. Even admitting such exceptional instances, it will scarcely ever occur that a wound from a small shot can be mistaken for one produced by a leaden bullet. De Vergie has shown that when the ball enters a portion of the body well covered with fat, this often protrudes between the edges of the wound and may alter its character. If clothing have been carried in some shreds of it may show upon the wound, and such fragments of texture will nearly always characterize the wound at once as that of entrance. =Wounds by Blank Charges.=—Experience has shown that no matter with what the piece is charged, it is capable, when fired close by, of producing a wound which may prove fatal. Thus a gun loaded with wadding or gunpowder only may cause death. A portion of clothing may be carried into the wound and lead to death from hemorrhage, or death may occur from many secondary causes, such as tetanus or sepsis. Accidents so frequently occur from weapons discharged in sport, not loaded with ball or shot, that it is worth while to bear this in mind. It has been observed, for instance, that persons attempting to commit suicide have forgotten to put a bullet in the pistol, nevertheless the discharge of the weapon into the mouth has sufficed, from the wadding alone, to produce a considerable laceration and hemorrhage (Taylor). Many fatal accidents have taken place by the discharge of wadding from cannon. LaChese has ascertained by experiment that a piece charged with gunpowder alone is capable of producing a penetrating wound somewhat resembling that produced by gunshot, when the piece is large and fired within six feet of the body (_Ann. d’Hygiene_, 1836, p. 368). This arises from unexploded grains of powder acting as pellets of small shot. Sweet has experimented with pistols loaded with gunpowder and wadding in order to determine the effect of their discharge at different distances. At twelve inches he found that the clothing was lacerated and the skin abraded, but the wadding did not penetrate; at six inches the clothes were lacerated and the wadding penetrated to the depth of one-half inch; at one and one-half inches from the chest the wadding passed into the thoracic cavity between the ribs, and at a second experiment carried away a portion of the ribs. It is probable that an ordinary wadding such as loosely wrapped paper, rag, or similar material, especially as prepared by one not accustomed to military use of a weapon, would not produce a wound which would resemble that made by a bullet, and it is doubtful whether such a wound could be produced at a greater distance than six inches from the body. It is on record that in Paris, in 1858, a circus cannon of four inches bore, loaded with three ounces of grain powder retained by a wad of old theatre bills loosely folded together and rammed home with only moderate force, was discharged in the direction of the boxes at a distance of about one hundred and fifty feet. A man seated in one of these boxes opposite the muzzle of the gun, leaning forward, his arms crossed upon the handle of his umbrella, had his arm broken above the elbow immediately upon its discharge. Several portions of wadding were found beneath the place where the man sat, but no marks existed upon his clothing nor upon the anterior part of the arm, which must have been inaccessible to any projectile that did not first strike the forearm. It was concluded that the fracture had been caused by the violent and sudden starting of the man backward, which must have brought his arm against the hard part of the partition. An experiment tried with the cannon proved that any wadding that could be made with paper was dispersed in passing, or lost all power of mischief, at much less distance than one hundred and twenty feet (_Annales d’Hygiene_, 1859, p. 420, Wharton and Stille). =The Mannlicher Rifle.=—It may be of interest here to note the effects of the rifle-bullets used in the most recently invented improved arms. The last new projectile used in the German army, 1892, with the Mannlicher rifle, has an inner core of lead inclosed in a casing of steel or firm metal, which prevents the lead, even when softened by heat, from becoming deformed and enlarged by contact. The weight of the bullet is much less than any of the old, but to its higher rate of velocity and its pointed shape, which is preserved, must be ascribed its greater perforating power. Owing to this immense velocity and the small surface of contact, it meets with little resistance on striking a person, has no time to stretch the various tissues it encounters, causes little or no commotion of the neighboring parts, and merely punches a hole, carrying the contused elements before it clear out of the wound without seriously damaging the surrounding wall of the bullet-track. This absence of contusion must lead to more frequent deaths from hemorrhage, while when this arm is used we shall hear very little of deflection or deviation of the bullet from its path, since it has sufficient power to pass directly through any part of the body which it may meet on its way. The result in battle will be a reduction of the list of wounded, but a terrible augmentation of that of the dead. IDENTITY FROM A FLASH OF GUNPOWDER. Taylor states the following: “Among the singular questions which have arisen out of this subject is the following: whether the person who fires a gun or pistol during a dark night can be identified by means of the light produced during the discharge. This question was first negatively answered by a class in physical science in France, whereas later a case tending to show that their decision was erroneous was subsequently reported by Fodere. A woman positively swore that she saw the face of the prisoner, who fired at another during the night, surrounded by a kind of glory, and that she was thereby enabled to identify him. This statement was confirmed by the deposition of the wounded party. Desgranges, of Lyons, performed many experiments on this subject, and he concluded that away from every source of light the prisoner who fired the gun might be identified within a moderate distance; if the flash were very strong, the smoke very dense, and the distance great, the person firing the piece could not be identified. The question was raised in England in the case of Reg. _v._ White at the Croydon Autumn Assizes, 1839. A gentleman was shot at while driving home on a dark night, being wounded in the leg. When he saw the flash of the gun he saw that the piece was levelled toward him, and the light of the flash enabled him to recognize at once the features of the accused. In cross-examination he said he was quite sure he could see the prisoner and was not mistaken as to his identity; but the accused was skilfully defended and he was acquitted. A similar case was tried at the Lewes Lent Assizes, 1862, Reg. _v._ Stapley. The prisoner shot at the prosecutor on a dark December evening, and the latter swore that he distinctly saw the prisoner by the flash of the gun and could identify him by the light on his features. His evidence was corroborated and the man was convicted. A case is also quoted, Rex _v._ Haines, in which some police officials were shot at by a highwayman during a dark night. One of these stated that he could distinctly see from the flash of the pistol that the robber rode a dark-brown horse of remarkable shape, and that he had since identified the horse at a stable in London. He also was positive that the prisoner had on a rough brown great-coat. There seems to be enough evidence in this direction to show that identification under these circumstances is occasionally possible. GENERAL MEDICO-LEGAL CONSIDERATIONS. The result of the wonderful advance in the practice of surgery made during the past fifteen years has been in a large measure to revolutionize the treatment of gunshot wounds, and inasmuch as the result of many homicidal attempts will depend in large measure upon what the surgeon can do for the victim of assault, it may not be amiss to very briefly epitomize in this place something of what modern surgeons believe with regard to the best treatment of bullet-wounds, expressed in a general way. They have learned, among other things, that the harm which a bullet does is done by it during its flight, and that after it has come to a stop it is, _per se_, an almost invariably harmless foreign body. This is practically always the case unless it has carried in with it foreign material which may serve as a source of septic infection. In time past there has always been a strong feeling, which had, however, nothing scientific to justify it, that every gunshot wound was a poisoned one. Of late, since bacteriology has attained the proportion of a science, it has been held that bullets were necessarily sterilized by the heat of the discharge of powder behind them. Very recently Dr. B. Von Beck, Medical Director of the 14th German Army Corps, has made experiments upon the amount of heat imparted to leaden and other bullets after firing. After making an allowance for specific heat and the conductivity of the different metals used, he found that even when the projectiles encountered resistance from three to four times greater than that offered by the human body the results were as follows: Temperature of leaden bullets of .45 calibre, when recovered, 69° C.; of .30 calibre, covered with steel, when recovered, 78° C.; of .30 calibre, covered with copper, when recovered, 101° C. He states that these experiments disprove the theory that certain lesions in wounds can be in any way attributed to the heat imparted by the bullet. While these experiments prove that the bullets may be heated to the above degrees when recovered, they by no means prove that they are so heated at the time when they inflicted the wound. During the year 1892 some very interesting experiments were carried on by Dr. Lagarde, of the Army Medical Department (_New York Medical Journal_, Oct. 22d, 1892, p. 458). He experimented by deliberately infecting bullets and then firing them into cotton, and animals as well, studying the effect both on the bullets themselves and upon the animals. Some of these bullets were taken from the original packages, while others had been intentionally rolled in dirt. The experiments were carefully carried out and appear reliable, and the conclusions given by the author, which interest us here, are as follows: (1) The vast majority of cartridges in original packages are sterile or free from septic germs because of the disinfection and absolute cleanliness observed in the process of their manufacture. (2) The majority of gunshot wounds are aseptic because the vast majority of the projectiles inflicting them are either sterile or free from septic germs. (3) The heat developed by the act of firing is not sufficient to destroy all the organic matter of the projectile, the cherished notions of three centuries or more to the contrary notwithstanding. The results as set forth justify the assumption that a septic bullet _can_ infect a gunshot wound. The average bullet-wound, however, is sterile so far as infection from the bullet is concerned, and in accordance with this view of its usual innocence there need be no longer the clamor for removal of the missile which the fears of previous generations have nearly always called for; and the best practice among _military surgeons_ of to-day is rather to let the bullet remain where lodged than to make a more serious wound for its removal. Exceptions to this rule occur only in cases where operation is called for on account of injury done by the bullet while still in motion. It is also held to be a violation of simple physiological and surgical rules to probe or carelessly search for a bullet whose location cannot be made out from a study of signs and symptoms in a given case. The act of probing breaks up blood-clot, often brings on fresh hemorrhage, is in a majority of cases unsatisfactory, frequently introduces specific elements from without, and really gives little, if any, more information than can be gathered from a study of the case without the use of the probe. If every ordinary bullet-wound which did not call for immediate operation because of injury to some essential or vital part—such as a large blood-vessel or nerve-trunk, or some of the viscera—were antiseptically and hermetically sealed at the very outset, there would be a much smaller percentage of death from gunshot wounds, either in civil or military practice, than now obtains. And it might be a matter upon which to go to the jury whether violation of such rules, to-day, does not mitigate the offence of the accused. Recent discoveries in so-called cerebral localization have instigated numerous operations upon the skull and brain for the relief of pressure, as from blood-clot, or for removal of depressed bone or a bullet which twenty years ago would have been impossible. The brain is no longer the _terra incognita_ of the past generation of medical men, and it is now often possible for the surgeon to intervene in such a way as to save life in cases previously considered hopeless; in fact, such is now his duty when consent can be gained, and it should be held that he is culpable when deficient in general knowledge in this respect. In wounds of the thoracic cavity it should now be held that so long as air has entered through a bullet-wound there are cases where free incision, even with removal of ribs, can scarcely increase the dangers, while permitting opportunity for much more accurate exploration and determination of life-saving methods. The experiments of numerous investigators, the writer included, have shown that bullet-wounds of the heart need not be always and invariably fatal, and have afforded an element of hope from the possible surgery of even this organ. The writer looks forward to the time when some accomplished yet daring surgeon, getting the right patient at the right time and in the right place, _i.e._, where conveniences are at hand, shall, in some case of perforating wound of the pericardium or of the heart itself, resect some portion of the anterior thoracic wall, lay open the pericardium, maintaining meanwhile artificial respiration if necessary, and suture a wound in the heart-substance, thereafter closing the pericardium and external wound, and save life which would otherwise be surely sacrificed. With others he has done this upon animals, hence why may it not be done in man? In the mean time for, first, the recognition and, second, the surgical treatment of perforating wounds of the abdominal viscera, American surgeons have won for themselves the greatest credit, and an already long list of successful laparotomies after gunshot wounds of the intestines, with intestinal suture or resection, has shown the very great value of this procedure, even though it has kept some would-be murderers from the gallows. These lines are inserted here because the time and effort which surgeons have devoted to this kind of surgery deserve only the highest encomiums and encouragement from the legal profession, although to our deep regret they have not always met with the same. OF THE VARIOUS CONDITIONS WHICH COMPLICATE GUNSHOT WOUNDS AND MAKE THEIR RESULTS UNCERTAIN, =Delirium Tremens= is one of the commonest and must always be regarded as one of the most serious. It is well known to surgeons that a slight injury even, and often a severe one, is enough to provoke manifestations of this character in intemperate persons. The medico-legal question under these circumstances is this: Would the same amount of injury have been likely to cause death in a person of ordinary health and vigor? The law as applied to these cases has been stated by Lord Hale: “It is sufficient to prove that the death of a person was accelerated by the malicious acts of the person, although the former labored under a mental disease at the time of the act. The intent of the accused may often be judged by the character of the wound and the means of its infliction. Drunkenness of the victim admits of no excuse when his assailant is aware, or ought to have been aware, of the condition of his victim. It is held that the assailant ought to have known that violence of any kind to such a person is likely to be attended by dangerous results. It is known also that a wound which accelerates death causes death.” The commissioners who were appointed to define criminal law on the subject of homicide have thus expressed themselves: “Art. 3. It is homicide although the effect of the injury be merely to accelerate the death of one laboring under some previous injury or infirmity, for although if timely remedies or skilful treatment had been applied, death might have been prevented” (Taylor, p. 327). =Death from Surgical Operations Necessitated by Gunshot Wound.=—The modern treatment of serious or so-called penetrating gunshot wounds where the cranium, thoracic viscera, or the abdominal viscera, especially the intestines, have been perforated one or more times, calls for surgical procedures which are of severity and danger in proportion to the gravity of the wound which necessitates them, and which, while they often save life, must necessarily often fail. Indeed, such operations may prove fatal upon the operating-table, _i.e._, patients may die before the conclusion of the operation. The question may, therefore, arise whether the person who inflicted the wound should be held responsible for his act, or whether by the intervention of the surgeon the responsibility may not at least be shifted from the shoulders of the accused. The law in this respect is explicit and regards such operation as the outcome of necessity and a legitimate part of treatment, so that if it be undertaken in good faith, with reasonable care and skill, the accused will be held responsible, be the result what it may. The question of necessity and the plan of operation are left to the judgment of the surgeon in charge. Considering the responsibility involved in such cases and the possibility of a suit being raised, we should always advise the operator to secure the counsel of other surgeons or practitioners in his vicinity. The verdict of such a counsel of talent will always stand. According to Lord Hale, when death takes place from an unskilful operation under such circumstances, and not from the wound, the responsibility of the prisoner naturally ceases, but the burden of proof that such has been unskilfully performed rests naturally with the defence. It is much better also in these cases that the primary responsibility be borne by one surgeon from the beginning of the case, though he may associate with himself as many others as he chooses, since the ends of justice have more than once been defeated by a division of such responsibilities. Should it be made to appear that the surgeon in charge has not availed himself of such means as are supposed to be in the hands of every competent practitioner and has neglected ordinary antiseptic precautions, it would not be difficult to show that the operation had been unskilfully performed, and the prisoner would naturally get the benefit of such defence. At the present date of writing there exists a large class of the profession who still continue to do surgery according to the views and practices of twenty or thirty years ago, and who, while perhaps carrying out some of the forms of antiseptic surgery, are still ignorant of its fundamental principles and consequently guilty of neglect, since there is now no reason why all should not practise them. The writer holds to the view that if it can be shown that these precautions were not adopted when others would have adopted them, it constitutes criminal neglect. On the other hand, circumstances may arise where a simple or a more serious operation would have saved life, as, for instance, in cases of hemorrhage, and where a surgeon from timidity or carelessness has failed to take the necessary steps. Such neglect as this should inure to the benefit of the accused, but when at any time it can be shown that the possible benefits of operation have been offered to the deceased before his death and have been declined, the surgeon at least is relieved of all further responsibility. Among the dangers of operations under these circumstances are of course to be reckoned those pertaining to the use of anæsthetics. The surgeon in charge, however, is responsible for the selection of his assistants, at least when assistants are at hand, and must be regarded as equally competent in this as in other features of the operation; and even though the patient die from collapse or the anæsthetic, the burden of proof must rest with the defence to show that it had been unskilfully administered. NOTE.—The assistance which the microscope may afford in the procurement of evidence in cases of gunshot wound is beautifully illustrated in the expert testimony reported by Dr. James, of St. Louis, in the presidential address before the American Society of Microscopists, in Washington, August, 1891, printed in Vol. XIII. of its Transactions. It occurred in St. Louis, in the case of The People _v._ Vail, who had a pistol in his pocket at the instant when his wife fell from a wagon against him, knocking him, as he claimed, against the wheel of the wagon, the pistol being discharged by accident. By a minute study of the fibres of the various textures making up his overcoat and of the effect of the explosion of powder upon textile fabrics almost in contact with it, he was enabled to establish the accident and secure the acquittal of the accused. DEATH BY HEAT AND COLD, INCLUDING INSOLATION IN ITS MEDICO-LEGAL ASPECTS. BY ENOCH V. STODDARD, A.M., M.D., _Emeritus Professor of Materia Medica and Hygiene in the University of Buffalo_; _Member of the Medical Society of the State of New York and of the Central New York Medical Association_; _Fellow of the New York Academy of Medicine and of the American Academy of Medicine_; _Late Surgeon 65th Regt. N. Y. Vols._; _Late Health Commissioner, Rochester, N. Y._; _etc., etc._ DEATH BY HEAT AND COLD. TEMPERATURE OF THE BODY. The production and regulation of heat in the body is a problem by no means elucidated. We consider heat production to be of internal origin, by a complex process involving tissue metamorphosis, chemical changes in nutrient elements, muscular movements, etc. Heat regulation is accomplished, not only by variation in the loss of heat by the body, but by what is more important, variations in the amount of heat generated. It is an accepted physiological conclusion that there exists in the body a thermotaxic nervous mechanism which controls its normal, as well as its abnormal, manifestations of heat. The average temperature of the body in health is 37° C. (98.6° F.), in the axilla. Taken in the vagina or rectum, .9° C. (1.3° F.) higher is noted. The daily average range of variation is about 1° C. (1.8° F.). In disease or injury considerable variations occur; very high, as well as very low, temperatures are met. In severe neuroses and some forms of malarial disease a temperature of 42.2° C. (115° F.) has been recorded, and after an injury 71° C. (122° F.).[688] Very low temperatures are reported in several cases of acute alcoholism, accompanied by exposure to cold, where a temperature of 28.8° C. (75° F.) in the rectum was noted, recovery following.[689] Such extreme temperatures, though authentic, are exceptional. Very high temperatures in febrile conditions are borne because remitting; and low temperatures, subject to periods of elevation, are met in wasting and other conditions. Very high and very low temperatures are also noted, just before death, in acute diseases and conditions specially involving the nervous system. The degree to which the temperature may be raised without destroying life has been investigated by Berger, Bernard, Chossat, and others.[690] Their experiments show that if an elevation of temperature of the body 7.20° C. (13° F.) be maintained for any length of time in warm-blooded animals, death ensues. Depression of the temperature of warm-blooded animals 12° C. (20° F.), or even less than these degrees below the normal, results fatally. Portions of the body may be frozen and yet, under appropriate treatment, recover. But freezing of the whole body must necessarily prove fatal. Great differences in ability to endure extremes of heat and cold appear among different nations and in different individuals. The very young and the very old are unable to bear exposure to extreme cold. In both, the capacity for heat production is low and the vital powers are soon enfeebled to a critical degree. The healthy adult can, with proper precautions, safely endure great extremes of heat and cold. The experience of arctic explorers in the expeditions of Kane, Nares, Greely, and others has demonstrated the power of endurance, for a considerable period, of a temperature from 90° to 100° F. below the freezing-point. On the other hand, laborers employed in pottery and other establishments, using ovens raised to 148° to 315° C. (300° to 600° F.) or higher, are often exposed for some time without injury to temperatures approaching these intense figures. EFFECTS OF EXTREME COLD. Legal inquiry into the conditions of death from cold occurs almost entirely in cases of unintentional exposure. Cold has been employed, however, with homicidal intent. The depressing influence of continued low temperatures is observed in the death-rates of cities, in winters of protracted severity, where the proportionate mortality among infants, the aged and enfeebled shows marked increase. While age is a prominent predisposing and contributing factor, other causes exist. Exhaustion from severe and prolonged exertion, deprivation of food, intoxication, former illness, and other conditions of depression lessen the powers of the body to resist cold. Thus an exposure which might be safely borne in perfect health might result fatally in the same person in conditions of depression just referred to (Case 1). Investigation may be demanded in case of the death of A. Young children. B. The injured. C. The insane. =A. In Young Children.=—This may be in the new-born or older children. In the _new-born_ exposure to cold soon causes death, as warmth is essential to the life of the young being. The length of time necessary to a fatal issue is modified by several conditions. In the immature or prematurely born infant the resisting power is much less than in the child born at full term and otherwise healthy. In cases of suspected infanticide by exposure the question of the maturity of the child at birth is to be decided. Careful examination of the place in which the body was discovered should be made as to its lack of warmth; and the degree of external cold at the time of probable exposure should be recorded. The circumstances as to whether the exposure was inadvertent or accidental, as in cases of premature or unexpected delivery, or whether from intentional and deliberate purpose or from culpable neglect, should be carefully considered. The post-mortem examination should decide whether the appearances and conditions of the body are those peculiar to death from cold (Case 2). Death may occur from culpably careless exposure to cold, as a contributory if not as a direct cause, in such conditions of enfeeblement. Criminal neglect to provide medical attendance, food, and other essentials has been proven in some cases of the so-called “faith cure” or “prayer cure.” Exposure may be resorted to with deliberate homicidal intent. It may, in some cases of death, become an important legal question to decide whether a studied and persistent neglect of this nature may not have been followed, with the purpose of getting rid of a troublesome care (Cases 2 and 3). =B. Exposure of the injured or wounded=, thereby inducing some grave condition or complication which under proper care would have been avoided, may raise an important question in injuries inflicted by another, with or without criminal intent. It is undeniable that serious or fatal results may follow a slight wound, otherwise trivial, where the injured person was subjected, accidentally or intentionally, to extreme cold for a considerable period. While such cases are comparatively rare, they may demand investigation. =C. Exposure of the Insane.=—While it must be admitted that the insane subject is usually indifferent to matters of temperature, death from exposure to cold may call for special examination. Carelessness, incompetence, or wilful neglect on the part of nurses or keepers of insane hospitals, or deliberate criminal intent in such or others having the care of or an interest in the death of an insane person may lead to a judicial inquiry. Sudden death has been reported as occurring, in several cases, _after the ingestion of large quantities of cold water_ when the person was greatly heated. It is somewhat difficult to explain all such cases reported on a single line of causation. Some observers have attributed death to syncope or asthenia by the shock produced, in the sudden effect of the cold upon the sympathetic nervous system inducing heart failure. This seems the most natural explanation. Others consider the causative factor to be the formation of thromboses in the capillaries of the brain, lungs, and other organs, inducing active and obstructive congestions causing death by apnœa or coma. Others regard these cases as similar to “heat apoplexy.” SYMPTOMS. Under the influence of external cold, the vessels of the skin are contracted and the internal splanchnic areas dilated. Thus the surface of the body contains less blood and the internal organs a larger proportion. This vascular change is one of the important factors in maintaining the uniform temperature of the body. The thermometer, placed in the mouth, in such conditions frequently indicates a rise of temperature. This is probably due, not only to the increased volume of blood collected in the internal organs, but also to an increased production of heat through a thermogenic action. In exposure for a time to severe cold the nose, ears, cheeks, hands, feet, and other portions of the body, after the first appearance of dusky lividity, become bloodless and white, lose sensation, and become congealed; a condition known as “frost-bite.” From this, recovery without injury is possible under appropriate treatment, by which the temperature is gradually raised and the circulation restored. Where the latter result is not secured, the part becomes gangrenous and is ultimately removed by a process of inflammation and sloughing. If the application of cold be protracted and the temperature extreme, the loss of heat becomes rapid and symptoms of depression of the heart’s action appear. Painful sensations of the surface and other portions of the body are experienced, succeeded by impaired sensation and anæsthesia. The skin acquires a dusky, reddish, and livid appearance, with the formation occasionally of vesicles or blisters. With the lessened sensation stiffness of the limbs appears, due to failing muscular contractility. The congestion of the central portions of the nervous system induces a condition of advancing stupor, resulting in complete coma with ultimate suspension of respiration and the heart’s action. Death from exposure to cold may be rapid or slow. In cases of recovery the period of reaction is a critical one. The depression of the heart is apt to continue, and gangrene of parts of the body is likely to occur. Ulcers and sores healing with difficulty develop in some cases. TREATMENT. In the treatment of those who are suffering from the effects of extreme cold, the restoration of the congealed or “frost-bitten” portions of the body should be gradually accomplished. Raising the temperature rapidly is liable to induce the death and destruction of the affected parts. Ice or snow should, at first, be rubbed upon the frozen part, to be succeeded later by cold water. The patient should be placed in a cool room and distant from the fire or source of heat. As soon as warmth begins to return the part should be enveloped in wool, cotton, or some substance of poor conducting powers. If the whole body be chilled, frictions of the surface with stimulating lotions are of benefit, wrapping the person in woollen or fur coverings or garments afterward. Hot coffee or alcoholic stimulants are of value as restoratives, but the latter are to be avoided during an exposure to cold. POST-MORTEM APPEARANCES. The appearances indicative of death from cold are sufficiently marked to enable one to decide whether exposure to cold was the chief determining cause of death, provided that a careful consideration of the circumstances of season, temperature, place, and other conditions be also had. In the examination of a body in a case of apparent death from cold, the limbs and internal organs may be found frozen. It must be remembered that this occurs after, not before, death; and the frozen condition must not be mistaken for “rigor mortis.” In cases where a body is found, in freezing conditions of atmosphere, showing commencing putrefaction, the death must not be hastily attributed to cold, which prevents putrefaction. It is evident that if cold was the cause of death the temperature of the body had been raised since that event, or, more probably, death occurred from other causes and the body remained some time before becoming frozen. The finding of a body in the snow or frozen in severe weather must not preclude the search for other causes of death, such as apoplexy, etc., which may have occurred anterior to the freezing. Observers generally have agreed upon the presence of certain post-mortem conditions in cases of death from cold. EXTERNALLY.—Upon the skin are found dusky reddish patches, irregular in outline, which are in sharp contrast with the general pallor of the surface. Krajewskey,[691] Ogston,[692] Dieberg,[693] and others, in the several series of cases reported by them, all describe this condition. The skin otherwise is pale. INTERNALLY.—The viscera, including the brain, are congested. The heart contains a large quantity of blood in the cavities of both sides, and the large vessels leading from it are also full. The color of the blood is a bright red, resembling its arterial hue. This condition has been generally noted and described; but some excellent observers have not referred to it. EFFECTS OF EXTREME HEAT. The application of moderate heat to the surface of the body causes dilatation of the cutaneous capillaries. In such application the exhalant and perspiratory function of the skin is increased, by which means a rise in general body temperature is prevented. If, however, severe physical exertion accompany the exposure, a more pronounced result is induced and a depressing effect upon the nervous system becomes manifest. If the degree of heat be raised and the exertion increased and prolonged, marked depression ensues. Under circumstances of quiet and rest a high degree of temperature is borne by man without depression or discomfort, but with continued and severe muscular effort the rise in animal temperature is productive of distress and depressing conditions. In the Turkish or Russian baths, in the healthy subject, a temperature of 48.8° to 54.4° C. (120° to 130° F.) produces profuse perspiration but no depression, and a plunge in or affusion of cold water is not only borne with impunity but is acceptable. In conditions of heat accompanied by physical exhaustion, such sudden exposure to cold would prove extremely dangerous. In the condition of rest, exposed to external heat, the tendency to elevation of body temperature arises from the external causes alone, which in no way specially modify the nutritive functions. But in the second condition the internal processes of nutrition, which have been subject to great stimulation, are suddenly embarrassed by suppression of the compensating activity of the cutaneous surface, and severe organic and nervous derangements follow. In the summer season the temperature rises to 32.3° C. (90° F.) and even much higher in certain localities. During the prevalence of such heat, the mortality among young children, the aged and enfeebled is very marked; these two periods of life being very susceptible to the depressing effects of heat. A high temperature is easily borne if the air be pure and the atmosphere be not saturated with moisture. Telluric electric conditions also have a modifying influence, undoubted though obscure. In certain occupations an intensely heated atmosphere is endured with impunity for a considerable time, provided the air be maintained in a condition of purity and water be supplied to the person exposed. The stokers upon ocean steam-ships, where a forced draught is employed, are subjected to extreme heat, sometimes reaching 60° C. (140° F.). Resort to forced and continuous ventilation of the stoke-rooms, with short hours of duty, renders tolerance of the high temperatures possible. SUNSTROKE. The terms “_sunstroke_,” “_insolation_,” “_coup de soleil_,” are applied to conditions induced, not alone by exposure to the rays of the sun, but rather by a combination of great heat with other exciting causes. They are used to designate attacks occurring in very hot weather after exposure to solar or other sources of extreme heat. The striking and usual phenomena are exhaustion, unconsciousness, stertorous respiration, and death, occurring by syncope, within a few moments or hours. In a number of cases the symptoms of cerebral apoplexy with death by coma are present. In others, the condition seems one of complete exhaustion. The majority of cases seem to be a combination of these several conditions, with death resulting from syncope. The ordinary phenomena of the attack are pain in the head, hurried respiration sometimes stertorous, violent beating of the heart with failing of its power, oppression within the chest and, occasionally, nausea and vomiting. The pupils are sometimes dilated and sometimes contracted, but in all cases exhibit lessened sensitiveness to light. The suddenness of the attack modifies the symptoms developed. PATHOLOGICAL CONDITIONS. These are exhaustion with syncopic tendency and a rapid rise in the temperature of the body to a point destructive to the activity of the nervous centres. This is accompanied by an abnormal condition of the blood, resulting from loss of its watery portions, with retention of effete products and impaired aeration. A tendency to general stasis, specially marked by congestions of the lungs and brain, is present. The change in the blood is a very important factor. In some cases, not fatal at the outset, this induces a septic condition. The greatly elevated temperature of the body undoubtedly produces certain modifications which type it, in some respects, as a febrile disease; but this, with the septic tendency due to blood changes, is not sufficient to designate it as a purely “_thermal fever_,” as some have claimed. It is something more than this. Sunstroke occurs more commonly in tropical than temperate climates;[694] and usually in the day-time, at the period of greatest solar activity, those attacked being engaged in labor involving considerable exertion. It occasionally, though rarely, occurs at night. The military service affords abundant opportunity for observation. Here the seizures are on the march, rarely in camp. Fatigue, prolonged and extreme exertion, ill-adjusted clothing and accoutrements, with the deprivation of cool water, are fully as active factors as the heat of the sun. The death-rate ranges between forty and fifty per cent, the mild cases being excluded. Death in some cases is marked by syncope, in others by apnœa, though the majority seem to die by a combination of both, as in most cases the pulmonary congestion is more or less pronounced. Undoubtedly the character of the symptoms and mode of death are influenced, in many cases, by individual tendencies leading to apoplectic conditions or to cardiac or other complications. TREATMENT. This must be adjusted to the pathological conditions of the patient. As already indicated, two classes of cases are met: one marked by exhaustion, with tendency to death by syncope; the other, a state of or tendency to cerebral congestion or apoplectic conditions. Exactly opposite methods of treatment are demanded. In the first, frequency and feebleness of the heart’s action, with faintness of the heart sounds and embarrassment of respiration, indicate the tendency to death by nervous exhaustion, and must be met by placing the patient in a condition of absolute rest and quiet in a cool place. Stimulants must be promptly administered, though cautiously on account of the tendency to nausea and vomiting. Hypodermic injections of alcohol or ether, or rectal enemata of turpentine, alcohol, or other stimulants, afford means of securing speedy effects when the stomach is irritable. Carbonate of ammonia and other cardiac stimulants are recommended. Depleting agents, or such as prove depressing, are to be avoided. In some cases, hypodermic injections of small doses of morphine prove beneficial. Individual cases must modify therapeutic procedures. In the second class of cases the tendency to cerebral congestion indicates sedative and depleting procedures. Blood-letting has been recommended by some authors, if employed with extreme judgment and discrimination.[695] Cold applied to the head and also to the whole body by rubbing with ice[696] or by effusion and the wet sheet, or other means, is indicated if the temperature is high (104° to 105° F.). Active catharsis, by promptly acting purgative enemata, is also to be resorted to in most cases. The convulsions occurring in some cases are successfully modified and controlled by inhalations of small quantities of chloroform. POST-MORTEM APPEARANCES. These, though not clearly characteristic, are pronounced. In some cases no distinct conditions are found.[697] Local congestions are present in nearly all cases. Upon the skin are found petechial and livid spots, pallor being occasionally noted. Ecchymoses and subserous hemorrhages are also common. These conditions have been described as resembling those of spotted typhus (Levick). Rigor mortis is marked and occurs early, putrefaction beginning soon after death. The lungs are highly congested and often œdematous, and effusions of serum are frequently found in the pleural cavities.[698] The heart is usually changed in color and consistence, with the left ventricle contracted and the aorta empty, while the right ventricle and pulmonary arteries are dilated and engorged. The blood is fluid and dark.[699] The large vessels of the pia and dura are full of dark blood. Congestion of the cerebral mass is not always noted. The ventricles contain serum; and extravasations of blood into the cervical sympathetic ganglia and vagus are sometimes found. The kidneys are usually moist and œdematous; the liver and spleen congested and dry. BURNS AND SCALDS. For all purposes of practice it is unnecessary to draw any distinction between a burn and a scald, for in reality none exists, except as regards the nature of the causative agent. In some cases requiring investigation, this may prove to be a matter of much importance. =Definition.=—A =burn= is an injury produced by the application to the body of a heated substance, flame or radiant heat. A =scald= is an injury produced by the application of a liquid at or near its boiling-point. APPEARANCES AS INDICATING ORIGIN. A hot body may produce a burn of any intensity, ranging between reddening of the skin and complete charring of the tissues, according as its temperature is elevated and the period of contact prolonged: the shape of the object and its size being indicated by the form of the burn. Metallic substances heated to a temperature of 100° C. (212° F.) are capable of producing redness and vesication and other injurious effects. At this temperature the albuminous elements of the blood and other fluids undergo coagulation. Some bodies require to be heated to redness, or nearly so, in order to produce a defined burn. Very hot and partially-fused solids cause burns of greater severity than where the heated body is of a character favoring prompt removal. In such cases their adhesion to the skin involves the tearing away of the superficial portions of the derma in their removal, or they by their adherence prolong the contact of the heated body, thus intensifying their destructive action. =Metals in a state of fusion= produce burns which cannot be easily distinguished from those caused by solid bodies. Such burns are classed as scalds. Their effects may vary in any degree between slight redness and complete destruction of the tissues with charring. Burns caused by melted solids are less regular in form and outline than those caused by heated solids. They are usually of greater severity on account of the high temperature to which they have been raised.[700] =Boiling Water.=—Scalds by boiling water may be so slight as to produce redness only, or they may be so severe as to cause marked and characteristic symptoms. Those noted in severe cases are an ashy hue of the skin, accompanied by a soaked or sodden appearance and the production of blisters. Occasionally these features are not easily distinguished from those of burns from other sources. Blackening of the skin and charring of the tissues never result from burns by boiling water. As in all burns, a large surface involved renders an early fatal issue probable. In severe cases, not necessarily fatal, gangrene of the parts injured sometimes occurs. Most of those met with are accidental, yet cases of scalding by hot water with intent to injure are not uncommon, aside from injuries and death resulting from explosion of boilers, bursting of steam-pipes, etc. Occasional instances are recorded of death of children, the insane or feeble persons by inadvertent immersion in a bath of hot water (Case 21). Severe and fatal burns of the mouth, fauces, and larynx in young children occur from _inhaling steam_ or swallowing boiling water from a teapot or kettle in an attempt to drink (Case 5). =Burns by burning oil= produce effects and appearances similar to those by melted metals. =Burns by flame= are specially characterized by scorching of the surface. Hairs upon the part actually burned are scorched and usually also those in the vicinity of the burned patches. Such conditions could not result from scalds by hot water, boiling oil, or from a hot body only. =Burns by petroleum= or its derivatives resemble the burns from flame, except that the injured portions of the body are not only scorched but blackened and are usually burned more severely than by flame alone, as the clothing holds the burning substance in contact with the parts. The odor of the agent is also very noticeable. =Burns by Acids and Corrosive Agents.=—The injury produced by a mineral acid, the caustic alkalies, etc., has frequently been the source of judicial inquiry. “Vitriol-throwing,” as it has been termed, has been and occasionally is resorted to with malicious intent to injure. No case of death resulting directly and solely from this cause is recorded, but grave injuries, involving loss of sight, etc., have resulted. A case is referred to by Taylor[701] where sulphuric acid was poured into the ear of a woman while asleep by her husband. Death ensued, after six weeks, from disease of the brain resulting indirectly from the use of the acid. The appearances of a burn by a mineral acid are distinguished from heat burns with little difficulty. The eschar which results is not dry and leathery, as in a burn by heat, but soft and readily sloughing away. There is no redness around the site of the injury, the color of the burn being uniform, and no blisters are formed. There is no blackening of the skin and the hairs are not scorched. The color of the skin around the injured portion may afford valuable evidence of the nature of the agent employed. Nitric acid produces a yellow stain, sulphuric acid a dark brown, and chlorohydric acid a brownish-yellow stain.[702] The clothing also is capable of affording characteristic evidence by the discolorations produced; and the destructive agent employed may be determined by a chemical analysis of the fabric.[703] It is not possible to distinguish a post-mortem from an ante-mortem burn by an acid when no vital reaction has taken place. THE CLASSIFICATION OF BURNS. A classification of burns according to the severity of the injury inflicted is the most practical course. Upon this plan, burns may be divided into four general classes: I. Burns in which the skin or subcutaneous cellular tissues only are injured. II. Burns which involve the muscles, nerves, and blood-vessels. III. Burns involving the internal organs and bones. IV. Burns in which the other three classes are variously mixed. CLASS I.—The skin in cases such as may occur from a brief contact with a hot body or water near the boiling-point shows a slight redness or scorching with no enduring mark. Pain is considerable. CLASS II.—In the mildest cases the cutis is destroyed in its whole thickness, and the parts injured are occupied by eschars of a yellowish-gray or brownish color. The surrounding skin is reddened, and the formation of blisters occurs either immediately or after an interval of a few hours. In these cases a shining cicatrix remains after the healing, without contraction of surrounding parts. In the severer cases the subcutaneous cellular tissue and underlying muscles and nerves are destroyed. The blackish eschars formed are insensible and separate by suppurative process, leaving a granulating surface below. Extensive redness of surrounding tissues, with more or less vesication, is usually noted. The resulting cicatrices, together with the skin and adjoining structures, are prone to contraction, resulting in considerable deformity, according to location and extent. So great is the deformity in injuries of the extremities, or even some parts of the head and trunk, that extensive surgical operations become necessary to relieve it. CLASS III.—Burns of this class are so severe that an immediately fatal issue is usually the result. Such instances involve a prolonged exposure to flame or to a source of intense heat. The appearances described as belonging to the preceding class are in part found here with the addition of charring or carbonizing the parts destroyed. EFFECTS OF BURNS. The effects of burns may be considered as I., _Local_, and II., _Constitutional_. =Local Effects.=—In different instances the effects vary in accordance with the extent and severity of the burn. Redness, blisters, destruction of the cuticle and of the subcutaneous cellular tissue, blackening of the skin, scorching of the hair, and roasting of portions of the body are met with in varying degrees. In some severe cases all these are found upon a single body. The redness produced varies in intensity and extent, according to the nature of the agent producing the burn, its form, and the length of time the part was exposed. Very soon after the infliction of the burn a special line of redness appears between the burned parts and the uninjured skin. This _red line of demarcation_ is formed by intensely injected vessels and becomes a very important medico-legal sign in some cases. The vesication may be single or multiple, consisting of one or two large and full blisters or a number of large and small ones, scattered over the portions burned, some unbroken and still holding their contents, others broken and denuded of cuticle or with breaks from which their serum has escaped upon the surrounding parts. In some cases of burning _cracks or fissures_ in the skin occur, due to the effect of the heat, making it dry and brittle and causing it to rupture by the movements of the patient (Case 8). These fissures are most frequently noted in proximity to the joints.[704] They resemble wounds, and it occurs occasionally that it is important to accurately distinguish their character. In some cases the skin only is fissured; in others the subjacent tissues are also involved. This difference depends upon the depth of the burn. In the first condition the skin splits, leaving the subcutaneous fat exposed, which in some instances is partially melted by the heat and flows out over the edge of the crack upon the surrounding skin (Cases 8, 13). The blood-vessels in such cases usually are not burned and, owing to their elasticity, remain stretching across the fissure (Case 14). The smaller may be seen by careful examination with a lens: they should always be looked for. In the second class of injuries the vessels are involved in the burn and break with the cracking of the skin. The importance of careful observation of these fissures is emphasized in cases of apparent wounds associated with burning. It may be necessary to decide whether the wounds are the result of the action of heat as above described or were caused by some sharp instrument or weapon. Careful inspection of the edges of the wounds will show whether they are ragged, as the result of fissure, or clean-cut by some sharp instrument. The absence of evidences indicating hemorrhage upon the surrounding parts and the detection of uncut blood-vessels extending across the fissure will establish the differential diagnosis. Wounds of the above character resulting from the action of fire may exist on the same body with wounds of actual violence. It is important, therefore, in all cases to examine each wound with special care and record its position, shape, depth, and other characteristics. =Constitutional Effects.=—As in all sudden and violent injuries, the effect of a severe burn upon the nervous system is very marked. This is manifest in the symptoms of “shock,” with pallor and coldness of the surface of the body, a feeble pulse, chills or shivering, and a tendency to collapse. In other cases, proving immediately fatal, these symptoms are followed by obstructed respiration with death from coma succeeding. In other cases convulsions precede death, while in such as are not immediately fatal a reaction more or less imperfect ensues upon the first constitutional symptoms. Death from cerebral congestion or effusion may result before any definite evidence of reaction appears. In some instances pulmonary congestion or œdema occurs, with or without pleural effusion, terminating in death before reaction. This period usually covers the first two days. In some cases immediate death results from the depression produced by the severity of the pain. During the subsequent two weeks a period of inflammatory reaction succeeds, when inflammations of the thoracic and abdominal viscera, with ulcerative processes in some organs, are developed and induce a fatal termination (Cases 10, 11, 16). CAUSES OF DEATH. The causes of death are due to several conditions. This fact is explained in part by the relation which exists between the cerebro-spinal and sympathetic nervous systems, and of the nervous supply of the surface to that of the internal organs, which in cases of extensive injury proportionately modify the conditions of the visceral organs. As death in burning results from various causes, it is convenient to consider them under two classes: 1st. Those _immediately_ fatal. 2d. Those fatal _after an interval_. The FIRST DIVISION would include cases in which the deprivation of fresh air and the presence of asphyxiating products of combustion (carbon monoxide and carbon dioxide) were the immediate causes of death by _suffocation_ or _asphyxia_ (Cases 9, 18). _Accidents_ in endeavoring to escape or _injuries_ by falling walls or timbers may cause death immediately, and burning the body occur subsequently. Immediate death may result from _syncope_ or _collapse_ from the violence of the shock to the nervous system by the pain resulting from the burns. The SECOND DIVISION includes those conditions where death may result early, from a series of causes less immediate than those just mentioned. _Cerebral congestion_ and _effusion_, resulting in death from coma, is not unusual (Case 15). In this connection Taylor[705] cites a case of alleged poisoning by opium, in the treatment of a burn, in a child dying comatose, and emphasizes the undesirability of administering opium or its preparations to children in cases of burns of any severity. The danger claimed to exist is hardly to be considered. In the case referred to, Abernethy, who was a witness in the case, ascribed death to coma induced by the effect of the burn. The powerfully depressing influence of the pain in sensitive organizations and liability to death from shock therefrom must be remembered. _Inflammatory conditions_ of the _respiratory tract_ or organs are common results; _pneumonia_, _bronchitis_, and sudden congestion or œdema of the lungs are frequent (Cases 11, 15, 16). _Inflammation of the intestines_, inducing _peritonitis_ and _ulcerations_ of the intestines with or without resulting hemorrhage, occurs as a frequent lesion (Case 10). _Gangrene_ or _septicæmia_ causes death in other instances. _Exhaustion_, from extensive and prolonged suppuration or from severe and long-continued pain and other conditions, terminates other cases (Case 12). Legally, burns and scalds are included among injuries endangering life, but are not described as wounds. They may be considered dangerous according to the extent of surface which they cover, rather than the depth to which they involve the tissues. The extensive injury to the sensory nerve structures and the suspension of function or destruction of a considerable portion of the perspiratory tracts render large superficial burns far more fatal than those confined to a small part of a limb, for example, which may be deeply burned. From a medico-legal point it is desirable to establish the fact of how large a surface must be injured to prove fatal. The effort to reduce the subject to a statement of an exact minimum area of square inches seems very objectionable and liable to lead to erroneous conclusions. It is possible to make a general statement, subject to some qualifications, which may serve as a basis of conclusion, as each individual case must be considered in its own circumstances. A burn involving two-thirds of the body may be regarded as necessarily fatal; but the injury of a much less proportion, even one-fourth of the surface, has resulted in death. The qualifications to be made in burns of less extent are pronounced. The _part affected_ is of much importance. Burns of the trunk are more fatal than those of the extremities; and those of the genital organs[706] and lower part of the abdomen are especially so (Case 7). The character of the burn, whether single and continuous or multiple and scattered over various portions of the body, is a very important modifying circumstance, involving the questions of excessive pain and the difficulty in insuring necessary treatment for all parts injured. The physical condition of the patient and sensitiveness of the nervous system to pain exert a powerfully determining influence. Burns in children and sensitive, nervous females are specially serious and call for an unfavorable prognosis. =Spontaneous Combustion.=—Spontaneous combustion of the human body has been seriously discussed in this connection, and explanations of popularly reported cases have been attempted. The writer refers to the subject here for the sole purpose of stating that no trustworthy evidence of the possibility of any such condition or result exists. TREATMENT. In cases of severe burns the constitutional as well as the local conditions demand attention. Locally, a great variety of applications has been employed: starch, gum, oxide of zinc, solution of caoutchou, collodion, cotton wadding, a mixture of linseed oil and lime-water on cotton or lint, and many other agents are used. The important consideration is to exclude the air from and to afford a protective covering for the injured surface. The constitutional treatment varies in different cases; but its main object is to relieve pain, induce reaction from the shock, and support the depressed nervous system. For the first opium or its preparations in proper doses is indicated. Alcoholic stimulants in some cases are demanded in addition. After the stage of reaction has occurred the therapeutics must be governed by inflammatory conditions; or later by the exhaustion from continued pain, suppuration, etc. POST-MORTEM APPEARANCES. In the EXTERNAL post-mortem examination of a burned body careful note should be made of the sex, probable age, and every circumstance leading to the establishment of the identity of the individual. The parts burned should be specially examined as to their condition, whether exhibiting redness, vesication, or charring. The amount of surface covered by the burns should be computed; also the relation of the burned parts to those uninjured, whether separated by a sharply marked line of redness or merging into the sound skin without a line of demarcation. The condition of the blisters should be examined as to whether they are full or empty and their contents as to whether consisting of clear or turbid serum. INTERNALLY.—In some cases no lesions are found on examination. These are usually cases where death occurred from shock or severe pain (Case 12). Ordinarily the mucous membrane of the respiratory tracts is congested. In some instances, however, no redness has been discernible. Where death occurred by suffocation and asphyxia, the trachea and bronchial tubes have been found to contain a dark smoky or sooty mucus[707] (Case 9). The serous membranes of the brain, thorax, and abdomen are in many cases found reddened with effusions, more or less considerable, into the ventricles of the brain and the pleural, pericardial, and peritoneal cavities from the sudden inflow of blood from the surface, caused by the local injuries. When the body has been badly charred or incinerated the skeleton usually remains, and it is possible to determine the age from the size and development of the bones and the sex from the shape of the bones of the pelvis. Careful search should be made for special articles of identity. False teeth,[708] a watch and chain, buttons, etc., have alone been sufficient to identify the incinerated remains (Case 23). Where the whole body and even the bones have been reduced to ashes, some portions of bone, etc., may be found on careful search. Sifting the ashes will give some pieces of bone, etc., which may be sufficient to disclose the presence of human remains[709] (Case 24). A chemical analysis of the ashes also will aid in establishing this fact. In cases where cremation of the body has been resorted to to conceal crime, the length of time necessary to entirely consume the human body may become an important question. A period of less than ten hours has been proven sufficient.[710] PERIOD OF THE OCCURRENCE OF DEATH. As already indicated, death may occur from direct causes during the first forty-eight hours after the infliction of the burn, or may take place during a period extending from the second day to the fifth or even the sixth week. In the great majority of cases the fatal result occurs during the first five or six days. In some instances it may be important to establish the fact as to _how long after the infliction of the burn the person may have survived_. Inflammation and suppuration would not ordinarily begin until about the third day, hence the existence of this condition would indicate that the person had probably lived two days or more; and the state of advancement of these processes would afford some further evidence. The existence of intestinal inflammations and ulcerations, which require some days for their appearance and development, would also give some indication of the probable time elapsing. WAS THE BURN ANTE MORTEM OR POST MORTEM? In describing the anatomical characters of a burn occurring during life, =vesication=, the formation of blisters, is regarded as a marked symptom. While it is not an invariable result in a burn of the living body, it is so constant as to become one of the most important factors in answering the question as to the ante-or post-mortem infliction of the burn. Where the burn has been caused by a scalding fluid, or by burning of the clothing, or the direct application of flame, blisters are more likely to occur than where contact with a highly heated body has taken place. In the formation of a blister the cuticle is raised from the derma or true skin by the effusion of a highly albuminous serum, and the surrounding skin is of a bright or coppery red color. The time of the appearance of such a blister is not fixed. It may occur almost immediately or may not do so for several hours, an interval sufficiently long for death to occur from shock. It must be remembered that a burn inflicted in a condition of great depression of the vital powers with insensibility may be followed by no vesication or redness, but upon reaction and return of sensation both redness and blisters may appear (Case 17). In the absence of blisters, therefore, it cannot be decided that for this reason the burn was post mortem. If from a blister formed on the living body the cuticle be carefully removed, the site of the blister will present an intensely reddened base. In the dead body, if the cuticle be removed, no red base appears, but the surface of the blister becomes dry and of a grayish color. On the other hand, if the presence of blisters is noted, can it be concluded that the burn was ante mortem? While their presence affords reason for an affirmative answer, careful examination of the blisters as to their character and contents must be made in order to decide; the presence of apparent blisters is not alone sufficient (Cases 20, 18; Plate II.). Elaborate experiments have been made in order to decide the possibility of producing blisters post mortem. Leuret,[711] in experiments upon dropsical subjects twenty-four hours after death, shows the possibility of raising a blister post-mortem, but one which can be distinguished from one of ante-mortem production, in that it contains a reddish serum very slightly albuminous. He urges extreme care in deciding this question. Christison[712] found it impossible to produce a blister a few hours after death. In a patient unconscious from narcotic poison, heat applied four hours before death produced a blister and a red line was formed around the burns. In the burns produced half an hour after death, in the same patient, blisters formed in two places only, and these were covered by dry skin and contained air. No redness appeared around them. Champouillon[713] agrees with Leuret in his conclusions, from experiments upon dropsical subjects. Kosack[714] considers blisters with albuminous contents diagnostic of burns during life, but states the necessity for care in deciding in the absence of other signs of reaction. Wright[715] was able to produce blisters three and a half hours after death containing a small quantity of pale serum. On the same body, similar experiments fifteen hours after death produced blisters containing no serum. Caspar[716] states, as a result of experiments, that blisters may be produced by flame after death; that they result from vaporization of the fluid beneath the cuticle by the heat employed; that they are not found to contain serum and no line of redness is found at their base. The presence after death of vesications containing serum and surrounded by a reddish base is an evidence that the burn was inflicted ante mortem. He distinctly says: “It is quite impossible to confound a burn inflicted during life with one inflicted after death.” Woodman and Tidy,[717] in an extended series of experiments, conclude that while blisters can be produced post mortem, they are readily distinguished from those formed ante mortem in containing no serum; and even in dropsical subjects, where blisters containing some fluid were formed, the presence of but a mere trace of albumin was shown; and, in all, no redness about the base of the blisters was produced, nor any appearance of redness after removal of the cuticle. Taylor[718] has never observed vesications in post-mortem experiments on infants. He cites a case of drowning where the person, “pulseless and apparently dead,” was imprudently placed in a _hot_ bath. Blisters containing bloody serum were formed over several portions of the body. He concludes that hot water on the living and recently dead body, so far as vesication is concerned, produces similar effects. In experiments on the dead body immediately after death the writer has failed to produce any blister containing serum or fluid. The so-called blisters are produced by the rapid expansion and evaporation of the fluid beneath the cuticle over the portion to which the heat was applied, and differ distinctly from blisters caused during life, in the absence of serum or any redness of adjacent or subjacent parts (Plate II.). Chambert[719] concludes that in living bodies and in dead bodies within twenty-four hours after death blisters can be produced, and that less heat will develop them in the living. He specially emphasizes the difference, in the albuminous character of the contents, of a blister formed ante mortem and of one formed post mortem. Jastrowitz[720] emphasizes the difference between blisters formed during life and those occurring in œdematous conditions. Blisters are to be distinguished from the bullæ arising from putrefaction. There is little danger of confounding such cases. In conditions of putrefaction no redness or line of demarcation exists, and the green discoloration and other conditions of the skin will suffice to establish the diagnosis. Schjerning[721] considers blisters containing highly albuminous serum as diagnostic of burns produced during life. In some conditions of depression of nutrition blisters occasionally form, but are not liable to be confounded with those caused by burning. A second anatomical feature of much importance, even more so than vesication, is the condition of the skin to which the heat was applied. It assumes a dusky red color and a dry and parchment-like condition (Case 8). Surrounding this is an area of grayish-white skin bounded by a sharply defined and deeply injected =red line=, which in turn shades into the color of the surrounding skin. These features are more or less pronounced according to the degree of heat applied and to the length of time of contact; or, in other words, to the depth and severity of the burn (Plate I.). MEANS OF DISTINGUISHING ANTE-MORTEM FROM POST-MORTEM BURNS. Differentially, a distinction is to be made between the surrounding _redness_ and _the line of redness_. The redness due to capillary distention is transient, disappears under pressure during life, and fades after death. The line of redness is permanent, changing but little under pressure, and remains after death. It is a vital reactionary effort, a true line of separation between living and dead tissue, formed in the same manner as the line of demarcation in sphacelus or gangrene. This line of redness, developed only during life and permanent after death, is of great significance in cases with a medico-legal bearing. It has been already stated that in persons in a condition of depressed vitality the appearance of redness and vesication is sometimes very tardy and imperfect, and that death from shock or pain may occur before their development at all. They are vital processes and require time for their appearance in proportion to the activity of the powers of reaction. Hence in cases of burning resulting fatally where vesication and redness do not appear, the circumstances must be carefully considered before deciding that the burns produced were post mortem. With these qualifications, it may be stated that the presence of the red line is almost uniform in burns inflicted during life and absent in those occurring after death. If upon a body bearing evidences of exposure to heat there be found blisters containing highly albuminous serum, and such blisters, after the removal of the cuticle, present a bright red base surrounded by a bright and sharp line of demarcation, with redness of adjacent surface, we are justified in concluding that the burns were inflicted ante mortem or, at farthest, within a few moments of death. If, on the contrary, the red line is absent and the blisters contain a thin watery fluid, with a yellowish and dry condition of their base after removal of the cuticle, the presumption is that the burning occurred post mortem. Where _a number of burns_ are found upon a body, the question whether they were produced simultaneously may be raised. This can be answered by examination as to their condition. If some show signs of recent infliction, while others are in conditions of suppuration or other changes which only occur after an interval, a difference of time in production would be probable. But if all present mainly the same conditions, the probability of their occurring at the same time may be concluded (Plates I. and II.). =The Condition of the Blood.=—Special examination of the blood of persons dying from the effect of burns has been made by competent observers. While it is not at present possible to define an exact and constant condition, specially characteristic, some features of interest have been recently recorded. The color of the blood has been variously reported; in some cases as being of a dark color and in others of a bright arterial hue. Death by asphyxia or suffocation, by the deprivation of oxygen, and by the products of combustion, would be accompanied by a dark or venous hue of the blood. An atmosphere containing an excess of carbon monoxide, resulting from combustion, would cause death by apnœa with an arterial hue to the blood.[722] But other influences must be considered. According to Schjerning,[723] it is difficult to deduce positive conclusions from the condition of the blood. The changes induced by the spleen and kidneys, as well as the varying intensity of the degree of heat to which the body may be subjected, tend to render positive and constant conclusions from this source difficult. Falk[724] refers to the bright red color of the blood found in some cases, and explains this condition in part by the influence of chemical changes in the tissues surrounding the vessels. Wertheim[725] describes certain conditions observed by him and mentions an increase in the number of the leucocytes, together with the presence of hæmoglobin and melanin. Hoppe Seyler meets with similar results and arrives at the same conclusions in his observations. Ponfik,[726] on the contrary, is doubtful of the constant presence of some of these conditions and also of their diagnostic value. Seliger[727] confirms the conclusions of Wertheim, in that he describes the presence of crystalline bodies and of dark discolorations (melanin). Some spectroscopic analyses have disclosed the presence of bands additional to those of normal blood. The lack of uniformity of conditions described and of conclusions reached leaves the subject in a position of uncertainty. Examination of the blood of those dying from burns has not been so extensively and minutely followed as to enable us to decide questions which may arise in any case. EXPLANATION OF PLATE II. FIGURE 1.—ANTE-MORTEM BURN. Scald by steam from a boiler bursting, July, 1892. From a photograph taken sixty hours after the accident. The injury covered one-half of the surface of the body. The red line is sharply marked; the extensive blisters formed are broken and their contents have escaped; the serum drying has produced yellowish discolorations; the blush of redness on adjacent parts is well marked. Death resulted on the fifth day. FIGURE 2.—POST-MORTEM BURN. _Exp. 1._ (Appearances after application of a _tin can containing boiling water_.) The cuticle was raised by expansion. The blisters contained no serum and no red line is developed. FIGURE 3.—POST-MORTEM BURN. _Exp. 2._ (Appearances after the application of _iron at a dull red heat_.) No proper blister formed; the cuticle was raised, as in previous experiment. There was no serum and no red line or redness of adjacent parts. The cuticle is charred at one point, where the iron was brought into contact with it. [Illustration: MEDICAL JURISPRUDENCE—PLATE II. BURN, TWO HOURS AFTER DEATH, BY IRON AT A DULL RED HEAT. BURN, TWO HOURS AFTER DEATH, BY TIN CAN CONTAINING BOILING WATER. BURN BY STEAM, SIXTY HOURS AFTER INJURY. POST-MORTEM AND ANTE-MORTEM BURNS.] WAS DEATH ACCIDENTAL, SUICIDAL, OR HOMICIDAL? Nearly all deaths occurring from burning are accidental, very few homicidal, and hardly more than a few exceptional cases suicidal. It is important in cases of legal investigation to note the position of the body when found and its relation to the apparent source of fire; the parts of the body and clothing burned, etc.; evidences of violence should be carefully observed, such as contusions, fractures of bones, wounds of the soft parts, evidences of strangling, etc. (Case 22). These should be specially sought in the site of the burned portions, as burning and cremation of the victim are sometimes a resort to conceal homicide. In considering the character of the apparent wounds, it must be remembered that extensive injuries, resembling wounds, may result from the effects of fire,[728] and these must be carefully distinguished. Inability to detect special marks of violence need not preclude the possibility of its commission and of its being a possible cause of death (Case 19). The parts burned, the character and depth of the burns, and their relation to the apparent source of burning, with consideration of their probable simultaneous exposure, are all circumstances of weight in forming an opinion. The position of the body in relation to the fire should also be considered. In accidental burning, except in cases of intoxication, epileptic seizures, or other sources of helplessness, the victim is quite likely to be found at a distance from the fire, owing to his efforts to escape. CASES. CASE 1. _Death from Cold._ _Accidental_ (Dr. Hilty in Caspar’s _Vierteljahrschrift_, II., 1865, p. 140).—Male, æt. 52; intoxicated. Severe winter weather; death from exposure. Post mortem: Blood crimson; both sides of heart full; internal organs congested. CASE 2. _Criminal Exposure to Cold_ (_Ann. d’Hygiene_, 1868, Vol. II., p. 173).—Girl, unmarried; sudden delivery when at stool. She stated that she had fainted, and found the child dead when she recovered. The child had breathed and the cord was cut. No marks of violence. Evidence of death being caused by wilful exposure. Imprisoned. CASE 3. _Ill-Treatment and Criminal Exposure_ (_Ann. d’ Hygiene_, Vol. VI., p. 207, 1831).—Man and wife tried for manslaughter of a child, æt. 11. Wife the stepmother. Starvation and ill-treatment by mother, followed by forcing the child, in a cold December day, to get into a barrel of cold water and remain there. Though removed by a servant, she was again placed in the cold water by the mother, death resulting. The woman was sentenced to life imprisonment. CASE 4. _Sunstroke, High Temperature, etc._ (Dr. A. Flint, Jr., _New York Med. Jour._, 1872, p. 168; Dr. Katzenbach, _New York Med. Jour._, 1873, p. 93). CASE 5. _Scald, Drinking from a Tea-kettle._ _Accidental_ (Mr. Sympson, _Brit. Med. Jour._, 1875, June 19th, p. 809).—Boy, æt. 2½ years, drank boiling water from spout of tea-kettle. Inflammation of pharynx and glottis. Tracheotomy; recovered. CASE 6. _Fatal Scald of Insane Person in a Bath_ (_Brit. Med. Jour._, April, 1871, p. 456).—An insane patient fatally scalded in a bath, through carelessness of an attendant. The charge of manslaughter brought against the attendant. CASE 7. _Fatal Burn of Genitals._ _Accidental_ (Caspar, “Forensic Med.,” Vol. I., p. 315).—Female child, 2½ years, fell on a hot flat-iron. Genitals burned; died in eleven days. Vagina gangrenous; blood fluid; lungs anæmic and pale; trachea bright red, etc. CASE 8. _Red, Parchmenty Skin, Cracks, etc._ (Caspar, “Forensic Med.,” Vol. I., p. 307).—While a chimney-sweep was cleaning a chimney a fire was lighted below. Death. The entire skin was of a coppery red color, with yellow patches. No carbonization. Skin parchmenty, with fissures upon the edges of which the fat had melted and flowed out. CASE 9. _Asphyxia. Sooty Mucus, etc._ (Caspar, “Forensic Med.,” Vol. I., p. 314).—Two children, æt. 3 and 7, burned; death from asphyxia. The youngest, the girl, burned externally; the boy was not. Post mortem in both showed the trachea to contain frothy and sooty mucus. Lungs and vessels of thorax and abdomen distended with dark and fluid blood. Brain congested, etc. CASE 10. _Burn of Body._ _Inflammation of Stomach_ (_Amer. Jour. Med. Sciences_, Jan., 1861, p. 137).—Superficial burn of lower part of body. Death on the thirteenth day. Post-mortem examination showed the stomach inflamed and the intestines also. CASE 11. _Accidental Scald._ _Pleurisy_ (Caspar, “Forensic Med.,” Vol. I., p. 312).—Female child, æt. 6; scalded with a pot of boiling coffee overturned upon the side of neck, right axilla, thorax, and right arm. Death on the eighth day. Post-mortem examination revealed inflammation of right pleura, pericardial effusion, etc. Body anæmic. CASE 12. _No Internal Lesion Found_ (Guy’s Hospital Reports, 1860, Vol. VI., p. 146).—Female, æt. 9. Burn of upper part of chest and arms by clothing taking fire. Death on the ninth day. Post-mortem examination revealed no lesion of the internal organs. CASE 13. _Cracks and Fissures of Skin_ (Caspar, “Forensic Med.,” Vol. I., p. 314).—Male, æt. 83. Clothing caught fire; death. Body carbonized. On right side were fissures opening into the abdomen; the viscera could be seen, etc. CASE 14. _Fissures, Vessels Crossing, etc._ (Taylor, “Med. Jurisprudence,” Vol. I., p. 696).—Boy, æt. 2; death in three-quarters of an hour. On legs were fissures and lacerations near each knee. On right thigh a laceration 2¾ inches long, 1/6 inch deep and 1/4 inch wide; fatty tissue seen beneath. No blood effused; small vessels could be seen stretching across the fissures. CASE 15. _Brain Congested, etc._ (Caspar, “Forensic Med.,” p. 316, Vol. I.).—Boy, æt. 1-1/2 years, set fire to his clothing. Death in 1½ days. Post-mortem examination showed congestion of the brain, inflammation of the trachea, engorgement of the lungs with hepatization of the lower part of the right lung. CASE 16. _Burn of Lower Part of Body._ _Death_ (same reference).—Woman, æt. 81; burn of lower part of body, including the gluteal region, the perineum and genital organs (external). Death after several days. Post-mortem examination showed the upper lobe of left lung in a stage of red hepatization, etc. CASE 17. _Tardy Appearance of Redness and Vesication_ (Tidy, “Legal Med.,” Vol. II., p. 124, Case 15).—Woman, insensible from cold, had hot water applied in tins to her sides and feet. The flannel coverings became displaced and the hot tins came in contact with the body. No redness or vesication could be detected two hours afterward. The next day, when consciousness had returned and recovery from insensibility had taken place, the parts had become reddened and vesicated. CASE 18. _Were the Burns Ante Mortem or Post Mortem?_ (Caspar, “Forensic Med.,” Vol. I., p. 317).—Woman intoxicated; clothing caught fire; death due to asphyxia. Some burns apparently caused during life and some after death. The case was decided upon the _character_ of the vesications and their _contents_. Lungs and other organs normal. Right side of heart engorged with dark blood. CASE 19. _Murder._ _Body Burned_ (Dr. Duncan, _Med. Gazette_, Lond., Vol. VIII., p. 170).—Man charged with the murder of his wife and attempting to burn the body afterward. The body was so extensively burned as to remove all means of deciding the cause of death. The man claimed that her clothing took fire when she was intoxicated. Persons in the same house had heard sounds of a struggle before smelling smoke and fire. Furniture was not burned, nor the house. The prisoner was found guilty of murder. CASE 20. _Blisters. Was the Scalding Ante Mortem?_ (Taylor, “Med. Jurisprudence,” 8th Am. Ed., p. 411).—The body of an infant found in a saucepan, boiled. The prisoner admitted that the child had breathed. The boiling water had destroyed the means of positively deciding whether the child had breathed. Blisters found upon it contained yellow serum. Was the child living when put in the water? The prisoner was acquitted. CASE 21. _Scald of a Lunatic in a Bath_ (Taylor, “Med. Jurisprudence,” 8th Am. Ed., p. 411).—Insane patient placed in a hot bath. Temperature 123° F. Death in collapse next day (1879). CASE 22. _Criminal Burning, Strangling_ (Report of Profs. Liebig and Bischoff, of Giessen, March, 1850).—The man Stauff was tried at Darmstadt for the murder of the Countess of Goerlitz, whom he had attacked and murdered in her chamber, and then fired the furniture in order to conceal the crime. It was uncertain whether she had died from injury to the head or from strangulation. The tongue protruded and was swollen, as in cases of strangling, and maintained this condition. He was convicted chiefly on circumstantial evidence. After conviction he confessed that he had strangled her and then set fire to the furniture, which he had piled up about her. CASE 23. _Murder. Body Burned._ _Identified_ (“Report of the Trial of Prof. Webster,” etc., Boston, 1850).—Prof. Webster killed Dr. Parkman and then burned the body, in portions, in a furnace in his laboratory. Search among the cinders of the furnace disclosed pieces of human bones and a set of false teeth which the dentist who made them recognized as made by him for Dr. Parkman, etc. CASE 24. _Murder. Body Entirely Burned._ _Identified_ (the “Druse Case,” Trans. New York State Med. Soc., 1887, p. 417).—Mrs. Druse, with the compulsory aid of her children, killed her husband with an axe. The body was burned in a wood stove, with pine shingles. The ashes were thrown into a swamp near by. They were found and carefully sifted. Pieces of bone of various sizes, identified as human, were found, as also a few porcelain buttons, etc. A few hairs found, with stains, completed the identity. Experiments in this case showed that the body could have been consumed within _ten_ hours. The prisoner was convicted of murder. THE MEDICO-LEGAL RELATIONS OF ELECTRICITY. BY WILLIAM N. BULLARD, M.D. MEDICO-LEGAL RELATIONS OF ELECTRICITY. AS the frequency of accidents caused by electricity is rapidly increasing, we have of late years been enabled to generalize in a manner never before possible in regard to their results, and although our present conclusions must be recognized as provisional and perhaps temporary—to be changed or modified in accordance with future knowledge—yet we have obtained a basis of fact on which we can securely rely. The general laws of injury and accident through electricity have been fairly well determined, although many of the details are not yet thoroughly worked out or understood. The advances of knowledge in this direction are so rapid that an article on this subject, if it deals too closely with details, is liable to become out of date almost before it has left the press. Like all large subjects when first made objects of general interest and investigation, and in regard to which we are on the threshold only of knowledge, the facts discoverable may lead us at any time in unexpected directions and open out new fields of thought and inquiry. We shall try to limit ourselves here, as far as possible, to proved facts, and leave questions doubtful or in dispute to be settled later; contenting ourselves merely with pointing them out and, perhaps, in some cases giving the facts on either side. Electrical accidents and injuries may be divided into those which are caused by the atmospheric electricity—lightning proper, globes of fire, St. Elmo’s fire—and those produced through the agency of mechanical or artificial electricity—electrical machines, batteries, dynamos, etc. The effects caused by these different agents probably vary only in degree: the atmospheric electricity in the form of lightning, etc., being so much more powerful than the charges usually produced artificially as to cause some difference in the results. RESULTS OF ACCIDENTS AND INJURIES FROM ELECTRICAL MACHINES AND CONDUCTORS. =Medical Electricity.=—In the ordinary use of the mild forms of electricity employed for medical purposes, certain phenomena may at times occur, which, although not of any serious import or of long duration, may yet cause considerable inconvenience, pain, or discomfort to the patient or others, and may even be of some importance from a medico-legal point of view. We shall not enter here into the discussion of the proper methods of application of medical electricity, nor do more than point out that if these be not followed with care the patient may be not only not benefited, but made worse, and may even suffer considerable injury. The increase of pain caused by the improper application of certain currents is usually temporary and of minor consequence. But serious and lasting inflammations may be caused by the careless, ignorant, or injudicious use of the stronger currents internally, and metritis and peri-uterine inflammations have been not infrequently reported from the unskilled practice of the methods of Apostoli. These subjects, however, scarcely come under the scope of this article. In addition, however, to these troubles we may have _external_ injuries produced. Even in cases where the current amounts to not more than a few milliamperes burns may be caused by the ordinary electrodes of the galvanic battery. The faradic current when medically used does not, as a rule, produce any external injuries. Such might be caused by a spark from a static machine, but it would be due to gross carelessness, and is very unusual. Burns, however, from the use of the galvanic current are not very uncommon. They usually occur under the electrode after it has been for a few moments stationary in contact with the skin. They occur in certain patients with extraordinary readiness, especially in those with organic spinal lesions, and where the sensation is somewhat diminished, and where also some trophic lesion might be supposed to exist. They are not confined, however, to this class of cases, but may occur in any one if the electrode be retained too long in any one place, and especially if it be allowed to become dry. These burns are peculiar in appearance and can usually be recognized at once. They are circular, as if punched out, about the size of a common pencil or a little smaller, comparatively deep, gray with perhaps a dark ring at the circumference, and frequently surrounded by a reddened area. The edges are sharp. Their peculiarity consists (1) in their painlessness and (2) in their size, regular form, their depth in comparison to their extent, and the sharp limitation of the area of tissue destroyed. One or more may occur under a broad electrode, and they are probably produced at those points where the contact is imperfect or the conduction in some other way impeded. They heal without much difficulty and leave no serious results. Other unpleasant symptoms produced by currents in medical use may be mentioned for the sake of completeness, and also as an introduction to the more serious symptoms caused by stronger currents. Dizziness, vertigo, tinnitus, nausea, vomiting, and syncope are readily caused by even slight currents. The sensation of light in the eyes and the metallic taste in the mouth are the results of medical currents of ordinary strength when applied to the head or in its neighborhood, and stronger currents applied at greater distances cause these sensations. All the above symptoms may be readily caused by even slight currents, whether galvanic or faradic, passed through the head. The syncope thus produced is to be carefully differentiated from the syncope caused psychically by excitement or fear of the application of electricity. Hysterical women, and even persons who show no special signs of nervous instability, may faint at the suggestion of the application of electricity. I have seen a large, strong, well-built Italian man, perfectly sound physically, so far as could be detected, except some slight local neuralgia, faint from pure fright when the electricity was to be applied. But even the application of moderately severe shocks from the ordinary medical battery are not likely to produce serious results. These shocks are ordinarily caused by the opening or closing of the galvanic current, and are most severe when the current passes through some portion of the head. A still more powerful shock may be given by reversing the current in a galvanic battery by means of the commutator. CURRENTS OF HIGH TENSION—STRONG ARTIFICIAL CURRENTS. Passing on now to the consideration of the stronger currents, we come to those used for mechanical purposes, for electric lighting, electric railways, and other analogous objects. These currents start from dynamos or from storage batteries, and accidents are caused by them whenever they are diverted from their proper course and are caused to come in contact with or to pass through any portion of the human body in any considerable strength. Accidents not infrequently occur from direct contact with the batteries or dynamos, but still more frequently they are produced in their circuit along the wires or transmitters. They may also be caused, as some of the most fatal have been, by contact with metallic or other readily conducting objects which have themselves accidentally come in contact with some portion of an electric circuit (usually wires) and have diverted the whole, or more usually a portion, of the current to themselves. Thus was killed a young man in New York, the clerk in a store, who while lifting the metal-edged cover of a show-case brought it in contact with the charged wires of an electric light and received an immediately fatal shock. As a rule, those meeting with accidents from dynamos or electric machines directly are employees of electric companies, who are presumed to have more or less knowledge of the risk of carelessness, or they may be workers in institutions or factories in which such machines are in use. Many of the accidents due to wires also occur to linemen and other employees of electric, telephone, or telegraph companies or of electric railway companies in charge of wires or electric outfit. So long as the current transmitters and terminals (wires, etc.) are properly insulated and in their proper position in relation to other conductors, it is unusual for accidents to occur, except in cases of gross ignorance or carelessness. Unfortunately, however, proper insulation is not always accomplished, and frequently wires and other transmitters are removed from their proper positions by accidents and otherwise. So long as and wherever the system of overhead wires exists, if there be among these wires any which are the transmitters of strong electric currents, there is always a risk, and often a very serious one, that at some time or other one of these current-bearing wires will come into contact with some other non-current-bearing and ordinarily harmless wire in such a manner that the current of the first should be diverted, in whole or in part, on to the ordinarily innocuous wire, which thereby becomes at once charged and dangerous. Such an accident may be due to the displacement of either wire or to any other cause which brings the two in contact, either direct or indirect, at a point where the current-bearing wire is not sufficiently insulated. The current having once passed out of its proper circuit will, of course, follow the paths of best conduction, and may hence suddenly appear in unexpected quarters and produce the most dangerous and even fatal effects. It is accidents of this character which most frequently occur among the people who are neither employees of electric companies nor engaged in factories or buildings where electrical machines are employed. =Insulation of Wires and Other Electrical Transmitters.=—We cannot mention here the various methods employed to insulate wires, as the general principles of insulation are well known. Electric wires even with very strong currents can be insulated and can be kept insulated if sufficient pains be taken and sufficient money be expended. But this is very expensive and in many cases is not done. Only partial insulation is attempted, and even this is not always carried to the degree intended or stipulated. Hence so long as overhead wires of various kinds exist, accidents from the transmission of strong electric currents along ordinarily harmless wires are liable at any time to occur, as practically little or no attempt at keeping the current-bearing wires covered with a thoroughly insulating material is in most cases made. It is usually deemed sufficient that glass or other insulators should be so placed that under ordinary conditions the wire will not come into contact with any conductor which may cause any essential part of its current to diverge. In most cases a so-called insulating material is placed over the wire itself, but this usually is insufficient at the outset or becomes so before very long and is then not renewed. It must not be supposed, however, that underground electric wires or transmitters cannot produce accidents. On the contrary, the current may be diverted from them to the gas or water pipes or to any other conductors which come into contact with them or can attract to themselves a portion of their current. Severe shocks have been experienced by persons attempting to draw water at their faucet from causes of this character. At the same time, so far as mere safety is concerned and freedom from electrical accidents, it would seem that underground wires are preferable to overhead wires. Electrical wires have not infrequently come in contact with telegraph and telephone wires causing unpleasant results. Telephone boxes have been set on fire, and also telegraph boards and tables, and in certain cases what might have been serious conflagrations have been started in this manner. By means of proper arrangements on the telegraph and telephone circuits these dangers can be at least partially avoided, but there is always the risk that the automatic alarms and other contrivances do not act, and the still greater one that persons or things may come into contact with these charged wires and receive dangerous or serious injuries. =Electric Cars.=—The danger from the overhead wires in the trolley system of electric cars would not be great were these wires properly supported, properly insulated, and properly protected. Each of these terms must be explained. Wires which fall for any cause whatever short of being intentionally removed cannot be deemed properly supported in the sense in which we use the term. Any one of these electric wires which falls is liable to produce serious injury to persons or animals (many horses have been killed by them), or to set fire to objects with which it comes into immediate or indirect contact, the amount of injury being in part dependent upon the nature and the condition (wet or dry) of the object and its position in relation to other conductors. Wires as dangerous as these car wires should be so supported that no ordinary accident, no condition of the weather, strong winds, or heavy falls of snow should be capable of wrenching them from their supports, and they should be placed in such positions and with such protection as not to receive blows from passing or falling objects. Secondly, these wires should be properly insulated. This is to be understood to mean that all the wires which carry the electric current, or are liable to carry it, should be attached to their poles or other support in such a manner that no appreciable quantity of electricity is under any circumstances liable to be diverted to the poles or supports, and in this way cause destruction or injury. In addition to this the side wires should be so covered that if any accident occurs, it will be difficult or impossible for the current to pass away from them to other objects. The middle wire on which the trolley runs cannot be thus covered, but must be left bare, and hence, if knocked down or brought into contact with properly conducting objects, must be the most dangerous; but on the other hand from its position it is less liable to accidents. When we say that these wires should be properly protected we mean that such arrangements and contrivances should be used as will prevent them while in their usual position from coming into contact with dangerous objects, particularly with other wires. This may be accomplished by guard wires or in other ways. It is plainly of great importance that this should be specially cared for, and particularly in a city where there are many overhead wires, and perhaps a considerable number of dead or non-used wires. If the electricity comes into contact with one of these no one can tell where it may be transmitted or what harm it may do. The principles which apply to these overhead wires of course apply _ceteris paribus_ to all other electric overhead wires, and in like manner the statements made in regard to the diffusion or spreading of currents in underground wires are applicable to all methods of transmitting electricity mechanically through the ground so far as the conditions are similar. An electric current will always follow the path of best conduction, and where several paths are opened it will follow them proportionally according to the excellence of their conduction or inversely to the amount of their electric resistance. We shall not enter here into any questions in regard to the diffusion of electricity, its transmission through fluids, water, air or other gases, nor shall we discuss the relations of good or bad conductors to electricity except so far as this relates to certain portions of the human body. An elementary knowledge of physics and electricity must be presupposed. We can now enter more directly upon the immediate subject of this article, that is, the effect upon the human body of severe or moderately strong currents of electricity derived from artificial sources. The accidents produced by these currents may be divided into two classes, the direct and the indirect. Under the direct we place all those conditions which are apparently produced by the action of the electricity itself, such as the general shock, the loss of consciousness, the burns, etc. On the other hand, all those accidents are to be considered indirect which are not primarily due to the action of the electric current, but are only secondary results thereof. These are largely determined by the immediate surroundings and conditions at the time. Such, for example, are the surgical injuries due to falls caused by the loss of consciousness produced by the electric shock. INDIRECT ACCIDENTS. These will be considered first, as they do not demand so detailed a description as the direct. They are traumatic in character and are the result either of loss of consciousness, momentary or lasting, or of the involuntary muscular contraction which may be occasioned by the electric shock. They are among the most frequent effects of severe electric shocks. These accidents consist in contusions, fractures, dislocations, wounds, and any other injuries which may be produced from sudden loss of consciousness while in a dangerous position. Death may readily occur either immediately or as the more or less delayed result of such injuries. If the person shocked falls into the water he may be drowned, or if into the fire he will be burnt. The varieties of such accidents dependent on the sudden loss of consciousness produced by the electricity are, of course, innumerable, and their occurrence must largely depend upon the position of the victim at the moment of the shock. We see, perhaps, most of these accidents in linemen on the tops of poles or houses or in other exposed places, but persons who receive shocks when simply standing on the ground or when sitting are not exempt from severe surgical injuries other than burns. They are often cast to the ground with great violence, and not infrequently are thrown to a distance of several feet. This is caused by the violent muscular contraction produced by the electric shock, and it may occasion, like any violent push or fall, severe injuries from contact with the various objects against which they may be forced. Although much rarer, it is also possible that the violence of these muscular contractions may be such as of themselves to cause injury, as rupture of a muscle or tendon. As practically all these indirect accidents are traumatic and surgical in character, they do not differ from other accidents similar in kind, but otherwise caused, and are to be treated on the same general principles as these. DIRECT ACCIDENTS. Quite different from the indirect are the direct accidents; those produced by the immediate (direct) action of the electricity. These are of various kinds, which we shall consider separately. They may be divided into immediate and late symptoms, and they vary much according to the severity of the shock and the constitution of the patient, and the part of the body through which the electricity passes. The character of the current which gives the shock, whether constant or interrupted, also naturally has an influence on the effect. =General Principles.=—A shock may be given in three ways with an ordinary galvanic battery. If the current be sufficiently strong, a distinct shock will be produced when the circuit is closed and again when the circuit is opened, while with a current of the usual strength for medical purposes, the sensation while the current is passing through the body steadily is much less and is often limited to a sensation of burning at the seat of the electrode. A shock may also (thirdly) be produced by a reversal of the current, and the shock thus caused is stronger for the same current than that produced in either of the other ways. The strength of these shocks is shown both by the sensation produced and by the amount of muscular contraction caused. When now a shock is caused by a continuous or constant current which starts from an ordinary dynamo or other electric generator or storer, it is practically always caused by the opening or closing of the circuit, or, what is essentially the same, the diversion of a part or the whole of the current from its proper path to and through some portion of the human body causes a shock at the time of the entrance of the body into the circuit and another at the time of its exit therefrom. Shocks from reversal of current when such current arises from a constant machine might occur, but only through some peculiar accident. Hence the shocks (distinguished from any other effects of electricity) which are received by the person coming into contact with a constant current are felt only at the moment of entering the circuit (closure) and of leaving it (opening). If a person introduces himself between the two wires of an electric circuit in which a constant current is used, in such a manner as to cause the current to pass through his body, he will feel the shock only at the moment when he touches the second wire and completes the circuit, and at the moment when he lets go one of the wires and opens the circuit (unless the current be so strong or be so placed that he can divert to himself sufficient electricity to cause a shock, or, in other words, close a secondary circuit in some other way). While the current is passing through the body, although it may burn and cause tingling and other unpleasant symptoms, there is no proper shock. In other words, an electric shock is caused only by a _change_ in the amount of electricity passing through the body or a portion thereof. If we now consider the effects of =alternating currents=, we find that we have another factor to deal with. The general principles are exactly the same, but inasmuch as the reversal shock is stronger than the closure or opening shocks, other things being equal, we are likely to receive a stronger shock from a current of the same force, and in addition to this, as in alternating machines the reversals occur with considerable rapidity, the person who becomes connected with this circuit receives a number of strong shocks within a short space of time. This is a much more serious matter than to permit a current of equal strength to flow through the body without change. —The effect of this form of electricity on the human body is first stimulating and then tetanizing to the muscles. It consists in a very rapidly interrupted current, the shocks being at times so frequent that they are not singly perceptible. There is probably also a distinct difference in the action of this current from that of the galvanic current aside from its rapid interruption. This is not, however, of so defined a character as to enable us at the present time to distinguish in man the results of severe injuries and deaths caused by this form from those caused by other strong currents. Practically this form of current is but little used, except in medical batteries and for the purposes of experimentation in laboratories. =Static electricity= has, so far as we know, rarely or never caused serious injuries or death. The sparks produced in this way have sometimes caused burns, and it is conceivable that a strong electric current produced in this way might be dangerous. The symptoms could not be distinguished from those caused by other forms of electricity. =Summary.=—The greatest source of danger from electric currents is the shock produced by them. In ordinary constant or continuous currents this is produced only at the moment of the opening and the closure of the circuit. In alternating currents a shock is also produced at each reversal of the machine. Faradic and static currents are rarely or never used mechanically or in the arts. =Resistance.=—The resistance of the human body to electric currents has been very variously estimated. The reasons for these variations are: (1) that the different tissues present different resistances; (2) that the resistance in the same tissue varies greatly under different circumstances. The tissue which offers the greatest resistance and also practically the greatest variation is the skin, or, more properly speaking, the epidermis. The resistance of this is many times as great as that of the rest of the body, and when perfectly dry it is impervious to currents of great strength. Witz states that in using a Ruhmkorf coil with an estimated force of 250,000 volts in Guinea-pigs and rabbits, it is advisable to cut through the skin in order to apply the electrodes directly to the flesh, or, at least, to wet the skin thoroughly, otherwise the shock caused by the full strength of the battery (six jars charged from the coil) would not cause death. Various animals offer rates of resistance which vary somewhat apparently according to the nature of the animal, but are probably largely dependent on the conducting power of its tissues, that is, of its skin. The variations between the resistance of similar animals, according to the condition of the skin at the time of the experiment, are much greater than those which are found between animals of different species under similar conditions, or which are referable to specific susceptibility. Mr. Harold P. Brown testified in the Kemmler case (Court of Appeals, State of New York—State of New York _ex rel._ William Kemmler against Charles F. Durston, agent and warden) that he had in the course of his experiments seen a horse weighing 1,320 pounds, with a resistance of 11,000 ohms, killed by an alternating current at 700 volts. The resistance of the different cutaneous surfaces of the human body as measured by Jolly in Siemens’ units was from 400,000 down to 15,000 in the male and to 8,000 in the female (Siemens’ unit is to the ohm as 1.06 to 1.00). Tschirfew and Watteville made the resistance from 80,000 to 3,000 ohms. Experiments made at the Edison Phonograph Factory and Edison Laboratory in July, 1889, on 259 males between the ages of eleven and fifty-one, showed a resistance, measured between the hands immersed to the wrists in a solution of caustic potash independent of polarization, averaging 986 ohms and varying from 1,970 to 550 ohms. The resistance of 236 men employed at Messrs. Bergmann & Co.’s Electrical Works in New York appears to have averaged 1,184 ohms and to have varied from 1,870 to 610 ohms. These measurements were also taken between the hands, which were washed with soap and water and then dipped in jars containing a solution of caustic potash. The battery consisted of four chromic-acid cells each having an E. M. F. of 2 volts. As shown in all the experiments on animals and more especially in the cases of electrocution, the continuance or duration of the current has much effect on the resistance. As the current continues the resistance diminishes. Thus in the case of McElvaine the resistance between the immersed hands was at the beginning 800 ohms and at the end of the contact of fifty seconds had decreased to 516 ohms. In this case, when the current of 1,500 volts was applied from the forehead to the leg, the resistance was practically steady at only 214 ohms. Of course the small resistance in these cases (electrocutions) depends largely on the perfect contact secured. According to the amount of resistance offered do the effects of severe shocks of electricity differ. This is shown especially well in the action of lightning, but is also true of powerful currents produced mechanically. If the resistance of the skin be slight at the moment of entering the circuit of a strong current, the current will pass through it with comparative ease and without causing much injury; but if on the other hand the resistance is great, the current will be, as it were, momentarily retarded or stored, heat will be developed, and there will ensue a burning and charring of the tissue of a special kind. These burns occur principally at the places where the current is specially resisted, that is, at the point of entrance of the current to the body and at its point of exit. This is the cause of the frequent burns in the heel or sole of the foot in the case of those struck by lightning while standing, as the electricity passes away from the body into the ground and finds a strong resistance at the point of leaving the body. This is also the cause of the burns where the current leaves the body from any other cause, as from the contact or proximity of a metallic object. The greater the resistance so long as the current passes, other things being equal, the more severe is the burn. It is for this reason that in medical electricity we usually use wet sponges on the skin or electrodes moistened with salt and water or with other fluids which will assist in rendering the passage of the electricity through the skin more easy. Solutions of chlorid of sodium and of certain other salts do this. =The mechanical effects= of currents vary thus according to the resistance encountered. They also vary according to the intensity or concentration of the current. If a current of moderate force be applied through a small metallic point, it will burn, pain, and produce active irritative symptoms, while if the same amount be applied over a large surface simultaneously, it may have little or no irritating effect. We have, therefore, three factors in determining the mechanical effect of any electric current on the body: (1) the condition of the body, that is, the amount of resistance which the current will encounter at its entrance and exit; (2) the amount and intensity of the current; and (3) the character of the current. For practical purposes of the more severe currents we have only to deal with the continuous and alternating. SYMPTOMS. DIRECT SYMPTOMS. The direct symptoms produced by powerful mechanical currents of electricity may be divided into three classes: I. The mechanical; II. The essential or internal; III. The mental or psychical. These classes are fairly distinct, but they are not absolute, and certain symptoms are on the borders. The most important mechanical symptoms produced by these currents are =burns=. These occur at all points of strong resistance externally, hence especially at the points of entrance and departure of the current. They vary from all grades, from the lightest possible, where only the fine hairs on the skin are singed, to those of extraordinary depth and severity. The characteristic burn from powerful currents is, however, well distinguished. It consists in a deep hole of various shapes with clear-cut edges surrounded by an inflamed area and containing in its cavity a mass of blackened tissue which only separates from the portions below after several days, and causes a wound which, though not very painful, heals very slowly. The severity of electric burns is often at first sight underrated, and their duration, when severe, is unexpectedly long. It occasionally happens that after a burn of this character appears nearly healed, the surrounding and, in appearance, healthy tissue breaks down, perhaps under a healthy skin, and a destructive process occurs which much retards recovery. This is evidently due to tissue destruction from a strong electric current of such a character as to produce necrobiosis without the external appearances of a burn. These burns are, perhaps, oftenest seen on the hands, but this is only because these parts are more likely to come into contact with the current. They may occur in any portion of the body. =Eyes.=—The injurious effect of electric light upon the eyes has been carefully studied by several competent observers. So far as known it has been caused solely by the arc light. The symptoms produced by exposure of the eyes for a considerable period to the electric light may be slight or severe. In the slighter cases we find merely an acute conjunctivitis with a slight central scotoma which passes off within twenty-four to forty-eight hours. The symptoms are those usual in acute conjunctivitis—photophobia, lachrymation, sensation of a foreign body under the lids, discomfort in the eyes, and swelling of the lids. In the more severe cases all these symptoms are increased; the photophobia and lachrymation may be intense. There is sometimes severe pain in the supra-orbital nerve, and occasionally a tendency to somnolence. In these cases we find an intense conjunctivitis with chymosis, a central scotoma which may render the patient for the time practically blind, and on ophthalmoscopic examination a congestion of the vessels of the retina and choroid, a neuro-retinitis, and sometimes even hemorrhages into the retina. There is sometimes peripapillary œdema and infiltration around the optic nerve. The pupil of the eye in these cases is usually much contracted. There is sometimes loss of epithelium from the cornea. In certain severe cases there is produced in addition to the eye symptoms an erythema of the face. Bresse states that this erythema can be produced on the face, arm, or hand by exposure to the voltaic arc at a distance of thirty to forty centimetres. The blush grows deeper for three or four hours, then remains stationary for a time, and ends in desquamation leaving a very durable pigmentation. The erythema is accompanied by a sensation of smarting. The strength of the light and the length of time required to produce these effects probably vary somewhat according to the color of the light. Emrys Jones states that he is informed that either excess or defect of current gives a less injurious light than the normal current; the excess gives a more violet, the defect a more orange light. On the other hand, Charcot considered that the harmfulness of the electric light was due at any rate in considerable part to the chemical or violet rays, and Bresse found that when violet rays were added to an electric light as by aluminium it was more injurious than before to animals. What part the brilliancy of the light plays in determining the pathological results is not yet fully settled. The heat, however, does not, as a rule, seem to have much effect unless in extraordinary instances where the cornea is burned. =Muscular Contractions.=—Another effect of electricity which is externally visible on the human system is muscular contraction. Slight muscular contractions are produced purposely in many cases in medical treatment therapeutically or for the sake of diagnosis. When the stimuli are sufficiently strong and follow each other with great rapidity, or when a strong continuous current is passed through the muscles, they are brought into a state of continuous contraction or tetanus, and in this condition they will remain for a long period or until the electric stimulus is removed. In cases where a severe electric shock is received as from an electric wire, the muscles which come in contact with the wire immediately contract and remain contracted while the current continues to pass through them. As a result of this we often find that when a severe electric shock has been received through the hands by means of a wire or other conductor the sufferer’s hands are involuntarily closed upon the wire or conductor, and cannot be unclosed by any voluntary effort until the current is stopped. While thus holding the conductor the hands are often very severely burnt. Under these circumstances a strong force is required to remove a person from a charged wire if the current be not turned off, and it can only be done at a considerable risk unless by those expert and provided with special means. Not only the muscles immediately in contact with the conductor, but nearly all the voluntary muscles of the body may be thus affected by a powerful current. Another effect of this involuntary muscular contraction is the forcible muscular movements produced by the shock. As previously stated, when a sufficiently strong shock occurs, the voluntary muscles of the trunk and limbs may be thrown into sudden contraction in such a manner as to throw the person violently and forcibly on to the ground, or against some object or objects in the neighborhood. In this way one may be propelled several feet, and many varieties of surgical injury may be caused. Rarely the force of the contraction is such as of itself to rupture muscles or tendons, and it might even fracture bones or dislocate joints already predisposed. ESSENTIAL OR INTERNAL SYMPTOMS. We pass now to what we may consider the internal or essential conditions of electric shock, leaving the mental or psychical results for examination later. When a person receives a severe electric shock, the symptoms are usually as follows: In the first place there may be little or nothing except a burn or burns, though usually there is some sensation at the moment of the shock. This may be a simple dizziness, and is often accompanied by the sensation of a brilliant flash of light before the eyes, and sometimes by a sense of impending danger. Usually, however, there is a loss of consciousness more or less complete and more or less lasting according to the severity of the shock and the character and course of the current. In the less severe cases this gradually passes away, and in many cases the patient, although weak and feeling shaken and tired, suffers no further ill effects beyond those of the burns and mechanical injuries. Sometimes there follows a general tremor which may last a few hours or for days, and occasionally a clonic rhythmical spasm of one or more extremities. The loss of consciousness may, however, be accompanied or followed by a condition of collapse, in which the pale face, profuse perspiration, cold extremities, and feeble pulse all suggest the administration of stimulants and restoratives. As a rule, in the stage of unconsciousness the face is reddened and rather cyanotic. The pupils are dilated as a rule and the respiration stertorous or absent; the pulse may be full or feeble, sometimes imperceptible for a time. The unconsciousness sometimes lasts for hours, and all means of stimulation, electricity, artificial respiration, rubbing, have to be applied before the patient can be restored. Sometimes this condition is succeeded by delirium (Moyer). In a certain number of cases the shock is immediately fatal, and in others the patients cannot be recalled from their unconsciousness. The secondary results of the shock, aside from the injuries, may be very slight or again may be serious and lasting. They are far more apt to be of the first class, and when long or continued motor or sensory changes unconnected with injuries follow, we are justified in suspecting mental or psychical phenomena. One class of secondary results is the motor. In addition to weakness, unsteadiness and tremor of the limbs and trunk, it is not uncommon for the patient to suffer from grand rhythmical movements, at first, perhaps, of all extremities, but soon limited to the extremity or extremities which were most exposed or injured by the current. We have personally seen these movements, and feel convinced that they can be distinguished from most of the ordinary forms of convulsive motions and tremors. The whole limb is moved at once and not separate muscles, and the movement is a large, rhythmical one, slow and co-ordinated, not at all suggestive of tremor. Movements of this character are sometimes seen in so-called functional disease (hysteria and allied conditions). They more nearly resemble the movements seen in some forms of Jacksonian epilepsy than any others known to me as occurring in organic disease, but I believe them in these cases to be always strongly suggestive, if not absolutely significant, of functional affections. A case reported by Dr. Robert, of El Paso, well illustrates this condition. The patient, a male, twenty-eight years old, received a shock through a telephone wire. When seen first, reaction was slowly taking place, the entire muscular system was in clonic convulsions. Temperature 97°; pulse rapid and of low tension; respiration 50; no cerebral symptoms. An hour later the movements were limited to the left upper and the right lower extremities, and there was pain running from the region of the spine down the left arm. Twenty-four hours after the shock, temperature 99.5°; respiration 40; pulse 100. Had slept well, but the movements in the left arm had never ceased. The next day these motions were limited to the muscles of the forearm, and on the fourth day they had wholly ceased. These convulsions consisted in extensive motions of the whole extremity or of muscles or muscle-groups, and not of simple tremor. If the movements were forcibly controlled, severe pain ensued. Next to the motor symptoms the sensory are the most important. Pain not infrequently occurs after the recovery of consciousness in the affected limb; it is apt to be sharp, severe, darting and neuralgic in character. This may last at intervals for some days, a dull ache occurring at first between the intermissions. It disappears of itself in time without lasting effects. Hyperæsthesia may exist at first. Should this continue, or if anæsthesia not due to secondary traumatic conditions should appear later, we should be inclined to place these symptoms in the third class. Of other symptoms occurring in accidents from currents of high potential, those which seem to be due to the direct action of the electricity are not serious. Buzzing in the ears and a metallic taste in the mouth often occur at the very beginning before the consciousness is involved. Nausea and vomiting frequently occur later. There is often considerable dizziness and vertigo. Patients sometimes complain of sensations as of an electric shock running through the body which occur without cause some hours or even days after the real shock. Some of these sensations are certainly to be reckoned under the mental or psychical symptoms. Susceptibility to the effects of electricity, of lightning, and of thunder-storms, though undoubtedly in many cases psychical, has probably in some cases an actual foundation. This is certainly the case in lightning stroke. On the other hand, in the large majority of cases of electric accidents no such result follows, and in many we are expressly told that such a result was looked for but not found. The temperature, as affected by the electricity alone and not as secondary result of injuries, is not always easy to determine. It seems to be in most cases lowered at first, being in that of Moyer 97.5° and in that of Robert 97°. Later it may rise to a certain extent, usually to not more than 101°, but here again the influence of traumata is difficult to separate. The pulse may be full and soft or weak and compressible. It is frequently very feeble, sometimes almost imperceptible, and often rapid. It is apt to remain rapid and somewhat soft for days in severe cases. The respiration is at first rapid in severe cases unless the shock be so great as to cause its cessation. This rapidity remains for a varying period and then disappears. As a typical case of the results of shock from an electric wire, we will mention the one reported by Dr. F. W. Jackson. The patient, a man twenty-two years old, came in contact with a live electric-light wire, touching it with his hands. He was thrown a distance of about ten feet and then back again, “swinging back and forth two or three times.” His hands were in contact with the wire about three minutes, when the current broke and he fell to the ground unconscious. Was seen two hours later by physician. Temperature 100°; pulse 100, strong and bounding; pupils dilated; headache; nervous and irritable; reflexes increased. The headache was accompanied by insomnia which continued for three days, after which it disappeared, and he resumed work apparently none the worse for his accident. The palmar surfaces of both hands and the anterior surfaces of the forearms were blackened from the tips of the fingers to a point midway between the wrists and the elbows, and these parts were exceedingly sensitive to the touch. The least irritation of the muscles would cause them to contract violently. This condition ceased on the second day. The current was from a fifty-light arc circuit of about 2,100 volts; 6.8 amperes. The accident took place out-of-doors on a very rainy night. The amount of electricity which the patient received was, as in all such cases, very uncertain. FATAL CURRENT. The amount of current which will produce a fatal effect varies with the character of the current and with the points of contact. Currents passing through the head or those which affect the pneumogastric nerves are much more dangerous than others of the same character and equal strength passing through one extremity, for example. The same current will, of course, also produce different effects, according to the facility of its conduction into and through the body, and this depends again on the completeness of the contact and whether the body or the portion thereof concerned enters directly into the circuit or only forms, as it were, a partial conductor and diverts a certain portion only of the current to itself. Again, the condition of the epidermis, whether dry or wet, and the position of the person in relation to good conductors, metallic or otherwise, has much effect. If the skin and clothes be wet, the resistance to the current is lessened and it passes more readily into the body. In the same way, if a person stands in close relation to a good conductor and places his hand on one wire of a high-tension electric circuit, he will receive a much more severe shock than if not connected with such conductor. Thus a person standing in a pool of water (water is a good conductor), and more strongly if standing on the metallic rail of a railway track, and touching one wire of an electric circuit with one hand, receives a much stronger shock than if he were standing on dry land, or if his boots were rubber or he was otherwise insulated. The accidents most frequent in practice are those in which the current has been partially diverted from its original course and the person has not entered fully into the circuit. In such cases it is not usually possible to estimate accurately or even approximately the amount of current which the person has received. No calculations can, therefore, be based on these accidents. Again, we find that a person may be seriously or even fatally injured by a current which another person seems to bear with impunity. D’Arsonval in 1887, in France, advised 500 volts as the maximum for the continuous current and 60 volts as the maximum for the alternating current which might be employed without special permission. Our only accurate knowledge in regard to fatal currents comes from the experience derived from electrocutions. From these it appears that an alternating current of 1,500 volts is deadly if it passes through the body for more than a few seconds and if the contact is perfect. =Death.=—Death may ensue immediately as the result of an electric shock without any evident preliminary symptoms, or it may occur later, either as the direct result of the shock or as the consequence of the exhaustion produced by the burns and other injuries, or directly from the injuries themselves. If death does not occur immediately and if appropriate means of aid are at hand, the sufferer usually survives and the effect of the electric shock gradually passes away. The danger after this arises from the burns and other injuries, and almost all the deaths not immediate are the results of these. ELECTROCUTION. Electricity has been adopted in the State of New York as the agent for the execution of condemned criminals. This has given rise to much discussion as to what form of current were the best adapted for this purpose and as to what amount were required to produce death at once and painlessly. These questions may now be regarded as practically settled, at least so far as regards the purposes mentioned, and we shall only refer incidentally to the discussions and their results. Early in 1890 a committee consisting of Dr. Carlos F. MacDonald, Dr. A. D. Rockwell, and Prof. L. H. Landy made a report to the superintendent of prisons at Albany in regard to the efficiency of the electrical appliances and dynamos placed in the State prisons of Sing Sing, Auburn, and Clinton. This report gave details of various experiments made on animals to determine the amount of current and the time required to produce a fatal result. On the 6th of August, 1890, occurred the first electrocution, that of William Kemmler, alias John Hart, at Auburn Prison. Dr. MacDonald in his official report to the governor in relation to this says: “It is confidently believed that when all the facts in the case are rightly understood the first execution by electricity will be regarded as a successful experiment. As might have been expected at the first execution by this method, there were certain defects of a minor character in the arrangement and operation of the apparatus. But in spite of these defects the important fact remains that unconsciousness was instantly effected and death was painless.” The efficiency, rapidity, and painlessness of this form of execution have been confirmed by the later experiences. Up to the present date (May 26th, 1892) eight condemned criminals have been executed in the State of New York. Apparently all the officials who are intrusted with the care and inspection of this subject seem satisfied that this is, on the whole, the wisest, easiest, and most effective form of death thus far practised among civilized nations. The _Medico-Legal Journal_ of New York, in printing the official report of the recent executions of four men made by Drs. C. F. MacDonald and S. B. Ward to the warden of Sing Sing Prison, states that it furnishes “indisputable evidence of the fact (1) that the deaths were painless and the victims unconscious from the instant of contact; (2) that they were certain and unattended with any of the revolting scenes so frequently witnessed at the scaffold; (3) that the method is humane so far as inflicting physical pain or suffering, and from all sides considered infinitely preferable to the death by hanging; and that so long as capital punishment for murder exists in New York, we need not desire to change the method of punishment.” These claims would seem to be thus far substantiated. The value of this method of execution is now beyond doubt. When properly performed it is rapid, painless, and not repulsive. The criminal has probably no physical sensation of pain or discomfort due to the mode of death from the moment the first shock occurs. Since the rapidity of the transmission of the electric current through the body is in these cases much greater than the rapidity of the transmission of sensation, it seems just to conclude that no sensation from the electricity reaches the consciousness. The only distress suffered by the criminal is the unavoidable mental suffering natural to his position. The mechanical means employed in electrocution are practically the same at Sing Sing, Clinton, and Auburn prisons. A special room is provided for the purpose, which should be, if possible, in the basement with a concrete floor: this room must be of sufficient size to admit readily the criminal with the attendant officers, the warden and other officials in charge or on duty at the execution, and the witnesses for whom seats are usually provided at a little distance from the criminal’s chair, and also to allow of plenty of room for the management of the electrical apparatus, and a good space around the chair in which the criminal is placed. The electrical plant consists of an alternating-current dynamo and its accessories, placed wherever may be convenient, according to the arrangements of the buildings of the institution, but connected by means of wires with the switch-board in the execution-room. In the execution-room also should be the voltmeter, the ammeter, and such other instruments of measurement or precision as may be required. In charge of these and of the switch-board during the execution is the electrical expert, an official paid by the State of New York. Means of communication by electric bells or otherwise are, of course, arranged between the execution-room and the engineer in charge of the dynamo, so that the current can be produced as desired. The chair in which the criminal is placed is made of stout beams of oak and is securely fastened to the floor and insulated. It is perfectly plain, with broad arms and an upright back, which latter can be tilted backward a little by means of a special arrangement and firmly fixed in the desired position. This is accomplished by means of a bar of wood which is firmly attached at one end to the lower portion of the back and runs forward thence parallel to the seat of the chair and alongside of it; to the anterior end of this is fastened a perpendicular bar running downward, which can be raised or lowered at will, and securely fastened at any height. As this is raised or lowered, it raises or lowers the anterior end of the horizontal beam and correspondingly lowers or raises the opposite end to which the back of the chair is attached, thus moving the latter. When the anterior end of the horizontal bar is raised the posterior end is lowered and the back of the chair is straightened. Attached to the upper portion of the back of the chair is a head-rest, which can be raised or lowered as desired: it may, as in the case of Kemmler, have a horizontal arm which projects forward and from which the head-electrode may be suspended. The chair is also furnished with broad leather straps firmly attached, two of which pass around the body, one around each upper arm, one around each lower arm, and one around each leg. There is also a broad conjoined or compound strap which passes over the head, encircling the forehead and the chin and securing the head firmly to the head-rest. When these straps are properly adjusted and fastened, any marked degree of movement is impossible. The adjustment and fastening of these straps can be performed very rapidly, in practiced hands taking not more than forty seconds. The electrodes used have varied slightly in different cases. In the case of Kemmler they each consisted of a bell-shaped rubber cup about four inches in diameter, with a wooden handle through which passed the wires into the bell to end in a metallic disk about three inches in diameter, faced with sponge. The upper electrode was so arranged as to rest firmly on the top of the head, where it was held closely by means of a spiral spring: it was attached to the horizontal arm of the head-rest, a sliding arrangement shaped like a figure 4. The lower electrode was in this case attached to the lower part of the back of the chair, and projected forward at a level with the hollow of the sacrum. There was also connected with it a sliding arrangement, and a spiral spring which in connection with a broad strap around the prisoner’s lower abdomen rendered contact secure. In the later executions these electrodes have been somewhat modified and differently applied. The head-electrode is now so formed as to cover the forehead and temples, and can be easily fastened in this position without a spring. The lower electrodes have been applied to the leg in each case, sometimes apparently to the calf and sometimes more to the outer side, where they are securely strapped. They are made of such a shape as to cover a considerable portion of the surface in this region. It is not a matter of importance to which leg the indifferent electrode is attached, but they have actually been applied in most cases to the right leg, though in some they were attached to the left. They are thoroughly moistened, usually with a solution of salt and water, and a drip may be arranged so as to keep them wet during the passage of the current or other means employed to this effect. The electromotive pressure, as shown by readings of the voltmeter by Professor Laudy, in the cases of Slocum, Smiler, Hood, Jugigo, and Loppy, varied from 1,458 to 1,716 volts. The ammeter showed a variation of from two to seven amperes. The alternating current in the case of McElvaine made roughly 150 periods per second. The number of contacts made in each case and the duration of each contact were as follows: ═══════════════════╤════════════╤═════════════════════════════════════ │ │ TIME, SECONDS. │ Number of ├─────────┬────────┬────────┬───────── │ Contacts. │ 1st. │ 2d. │ 3d. │ 4th. ───────────────────┼────────────┼─────────┼────────┼────────┼───────── Kemmler │ 2 │ 17 │ 70 │ │ Slocum │ 2 │ 27 │ 26 │ │ Smiler │ 4 │ 10 │ 10 │ 10 │ 19 Hood │ 3 │ 20 │ 20 │ 20 │ Jugigo │ 3 │ 15 │ 15 │ 15 │ Loppy │ 4 │ 15 │ 11 │ 15½ │ 10½ McElvaine │ 2 │ 50 │ 36 │ │ Tice │ 4 │ Total time, 50. ───────────────────┴────────────┴───────────────────────────────────── In the case of McElvaine, the first contact of fifty seconds was made through the hands, the second contact of thirty-six seconds from the head to the leg. The hands were immersed in cells containing tepid salt water, connected respectively with the opposite poles of the dynamo. Kennelly states that in this case, with the hands immersed and the electromotive force at 1,600 volts, the current began at 2.0 amperes, and in fifty seconds had increased to 3.1 amperes, indicating a resistance between the electrodes of from 800 ohms at the beginning to 516 ohms at the end. In the second application from the forehead to the leg with an electromotive force of 1,500 volts, the current amounted to 7.0 amperes during the thirty-six seconds contact, indicating a resistance practically steady at 214 ohms. Alternating currents of from 1,600 to 1,700 volts and upward may be considered fatal currents, and as capable of producing death when contact is perfect. Dr. MacDonald goes so far as to say: No human being could survive the passage through his body of an alternating current of more than 1,500 volts for a period of even twenty seconds, contact being perfect.” The physical phenomena caused in the body by electrocution as at present conducted are comparatively simple, and such as we should logically expect. The instant the body of the patient enters into the circuit of the current, all the voluntary muscles appear to be thrown into a condition of violent contraction which continues so long as the current lasts, and on cessation of the current is replaced by a condition of extreme muscular relaxation. All _consciousness_ is apparently lost immediately on the application of the current. This probably has never returned in any case, but on the removal of the body from the circuit of the current the relaxation of the muscles causes movement, and sometimes, as in the case of Kemmler, slight spasmodic movements of the chest have occurred. The pupils in this case were dilated. The condition of contraction and rigidity is renewed at each new application of the current, to cease immediately when the current is removed. In Kemmler chest movements and possibly heart-beat occurred after the first contact, the former perhaps half a minute after the cessation of the current. In Slocum there were chest movements and radial pulsation after the first contact. In Smiler no movement of the chest, but radial pulsation after the third contact. In Jugigo a slight fluttering of the radial pulse when final contact was broken, which rapidly ceased. In Hood no movement or pulse-beat. In some of the patients superficial burns have been caused by imperfect contact of the electrodes, either on the head or at the position of the lower electrode. In Kemmler’s case the cerebral cortex was somewhat affected under the head-electrode. The practical effect of the application of the current to the criminal fastened in the death-chair, as seen by the bystander, is that immediately on its reaching him the whole body is straightened and rendered rigid in extension, the extremities tend to straighten out, and the face may grow red and turgid. There is reported at times swelling and turgidity of the neck. The whole body remains in this tetanic, stiffened condition until the removal of the current, when all the muscles relax and the body sinks back into the chair in a state of complete muscular collapse. MENTAL OR PSYCHICAL SYMPTOMS. The third class of results which are found after electrical shocks from high-tension currents are the mental or psychical. By the use of these terms we do not wish to imply that they are voluntary. They are, however, so far as our present knowledge of pathology reaches, largely functional. This is precisely the class of cases which, when resulting from railway accidents, are placed under the head of railway-brain or railway-spine. They may be considered in the present state of our knowledge as traumatic functional neuroses, though it is probable that when our means of examination and investigation are more complete we may succeed in discovering a visible or perceptible lesion. The symptoms affecting motion and sensation in these cases are frequently accompanied by others of an emotional character, and in many cases there seem to be partially or wholly voluntary conditions and symptoms with the involuntary. There is in many cases a characteristic loss or diminution of the force and power of volition, but in others this is not perceptible. These conditions are so well known when produced by other causes that we do not consider it proper to enter into a full consideration of them here, but we cannot leave this important subject without a few general remarks. No form of affection or disease has caused more discussion among the medical profession or figured more prominently in the courts than this, and even now there are many questions in relation to these conditions still under dispute. Our own view, confirmed both by observation and experience, is that the tendency in New England, at least, has been on the whole to underrate the severity, the duration, and the amount of suffering caused by these conditions. That because there have been cases of malingering, of deception, and of rapid cure after the receipt of damages, and because in addition to this a certain visible emotional and at times apparently controllable element exists, the profession, and above all the laity, are led to conclude that this forms the essential condition and basis of the disease. On the contrary, in a very large proportion of cases the symptoms are such as cannot possibly be voluntarily assumed; they produce extreme discomfort and often much suffering for the patient, and frequently last for years, rendering their victims incapable of carrying on their former occupations. Fortunately in the patients suffering from electric shock the severer forms of these affections are not so common. In most of the cases reported recovery has been more or less rapid. Cases in which previous hysteria or neurasthenia have existed are more liable to these manifestations than persons of a previously equable nervous constitution, but these latter are by no means wholly exempt. To consider these conditions, as is sometimes done, as the fault of the patient seems to us both unwarrantable and unjust. LIGHTNING. We now come to the consideration of the action of electricity in another form, that of natural electricity or lightning. The effects of this are practically the same as those of the forms previously described, except such differences as seem to be fairly accounted for by the vastly greater force of the currents with which we have to deal. Injuries and deaths from lightning stroke have been recognized and described for many centuries, and we have now a large collection of careful observations on them. They occur in most temperate regions with comparative frequency. In France the number of deaths from 1835 to 1852 inclusive (eighteen years) was 1,308. In England, including Wales, there were in twenty years, 1865 to 1884 inclusive, 416 deaths. In 1846 Mr. Eben Merriam, of Brookline, wrote to Mr. Arago that in the three last years about 150 persons had been killed by lightning in the United States. In thirty years, from 1855 to 1884 inclusive, we find 101 deaths in Massachusetts from this cause. =Exposure.=—Injuries and deaths from lightning may occur in various places and under various conditions. The severe lightning strokes are popularly supposed to occur only during thunder-storms, and in this latitude this is undoubtedly, as a rule, true, but lightning strokes are reported to have occurred, particularly in the South, from a clear sky, and there seems no reason to doubt that this may happen. It is said also that dangerous discharges from the earth to the atmosphere may take place at a considerable distance from an atmospheric storm. As a rule, the lightning is more likely to strike some tall object, as a tree or a tower or steeple, and for this reason, and to avoid injury from falling branches, the shelter of trees should not be sought during thunder-storms if lightning stroke be dreaded. Ships at sea are frequently struck by lightning, partly perhaps on account of the height of the masts and partly on account of the metal in or on them. Lightning obeys the same general laws as the other forms of electricity and naturally follows the paths of least resistance. Persons, therefore, who are in the neighborhood of or in contact with good conductors are in more danger of injury by lightning than when surrounded by or in contact with poor conductors. The proximity or contact of a large metallic object exposed in a thunder-storm is consequently more or less dangerous. On the other hand, the absence of tall objects or of specially good conductors of any kind does not insure safety. In many cases persons in fields are struck, and cases are related of persons struck on the prairies in the West. In Fredet’s case a shepherd was found dead in the midst of the barren moors (landes) in Southern France. More accidents appear to occur directly to persons out-of-doors than to those in houses or other buildings. When inside buildings, persons struck are usually near an open door or window through which the lightning enters, and they are more exposed to danger from this source if there be some metal object or good conductor in the vicinity. Persons carrying or wearing metallic objects render themselves thereby more liable to be injured in this way. Not only does the liability to injury from lightning vary somewhat according to the exposure or position of the person, both in relation to the free access of the atmospheric air and to the contact with or neighborhood of metallic objects or other good conductors, but also the severity of the injuries may be largely dependent upon what they are wearing or carrying and the condition of their clothing at the time. If the clothing be wet it will act as a good conductor, as will also any metallic object about the person. We have already referred to the action of metallic objects upon the passage of the electricity to and from the body and to the condition of the skin in relation thereto. The laws of conduction and resistance are precisely the same for the electricity of lightning as for the other forms. Hence the greater the resistance to the electricity at the points where it enters or leaves the body, the deeper will be the burn. Thus we find not infrequently that the lightning, in its course from the head to the feet, meets with a chain or a truss, and almost invariably at least a portion of the current follows this, causing a deep burn where it again passes into the skin. All the external burns of the lightning, except the initial one, are determined by the position and conditions of the body, the clothing, and the conductors near. All electricity obeys the same law and, roughly speaking, follows the path or paths of least resistance. The clothing worn by a person when struck by lightning may be acted upon in the most various ways. Sometimes it is wholly stripped off the unfortunate sufferer, who, as in a case reported by Cook and Boulting, may have to be protected with sacks or other hastily improvised coverings. In a case reported by Nason, a girl of thirteen was struck while in the street and most of her clothes stripped off and torn to shreds, and the top of her hat, which contained steel wires, was torn from the brim. In the case of Wilks the body was stripped entirely naked and absolutely nothing left on except a portion of the left arm of the man’s flannel shirt. The clothing is sometimes torn to the finest shreds, like those of a mouse’s nest, as described by Van Horn, and in another case (Claes), where the patient was struck while on board ship, his woollen jacket was torn into fine bits, which stuck to the ropes, and the deck was covered with fibres of wool as fine as those of cotton-wool. In this case the woof of the trousers was said to have been wholly destroyed, while the web was untouched. The clothing is also often burnt. Not only are holes burnt in it as is usually the case at the point where the lightning strikes and at the point where it leaves the body, but it may be set on fire. It may be found smoking or in flames. Of all portions of the clothing injured, perhaps the coverings of the feet are the most frequently so, as the electricity is very apt to leave the body through the feet, and the resistance opposed is great. Hence the boot or shoe is frequently injured. Sometimes it is pierced as by a bullet, or a large hole is torn in it, or it may be torn to pieces or reduced almost to lint, while the foot remains uninjured. It may be torn, shrivelled, and burnt. In one case the soles of the shoes had disappeared; in another the leg of the boot was clearly divided from the sole and both straps were torn out; while again in another the shoe was carried wholly off. The amount of injury to the clothing does not necessarily correspond to the amount done to the body. A person may be killed by lightning while the clothing is uninjured. On the other hand, the clothing may be torn to pieces, carried away, or even partially burnt, while the portion of the body underneath remains unhurt. =Symptomatology.=—The symptoms of stroke by lightning resemble, in a general way, those due to high-tension currents of electricity. As in the case of the latter, they can be divided into the direct, produced immediately by the lightning itself, and the indirect, or secondary, produced through the medium of other factors. In the milder cases the person struck feels dazed and benumbed and may or may not lose consciousness for a short time. At the moment struck they may have the sensation of a blow, and they often see a blinding flash. On recovery of their faculties there may be a temporary anæsthesia or weakness of one or more extremities, which rarely lasts more than twenty-four hours. There is a general shock to the system, sometimes slight loss of memory for a time, and occasionally nausea and vomiting. There are often discolorations of the skin of medium extent, and frequently burns and blisters. These persons have usually received the stroke on one extremity or have escaped the full force. In the more severe cases the patient loses consciousness immediately and may continue unconscious for some hours. He passes into a condition of collapse with rapid, feeble pulse and cold extremities, and the pupils are dilated. On recovery of his senses the same symptoms as in the less severe cases, only more pronounced, are found. The loss of memory may be marked and the intellect temporarily weakened, while the weakness and anæsthesia of the extremities persist longer. The external injuries, burns, and wounds are liable to be more severe. In the fatal cases where death is directly due to the electricity it is usually instantaneous or at least without recovery of consciousness. It may be caused by shock or by apoplexy, _i.e._, intracranial hemorrhage or by the direct effect of the electricity on the brain. Of course death is often due to burns or to indirect traumatic injuries. The indirect traumatic injuries caused by lightning are due either to the loss of consciousness of the patient, which causes him to fall and thus sustain injury, or to the direct action of the electricity upon him, knocking him down or throwing him to some distance, sometimes with great violence, or lastly, and perhaps the most frequent cause, to the impact or pressure of objects which are torn or cast down by the electricity and by striking or falling on a person produce great injury. Thus persons have been killed by the fall of buildings, sheds, or trees which were struck by the lightning, or their branches. Of course all kinds of traumata may be produced thus. The direct external injuries caused by lightning are burns, subcutaneous hemorrhages, discolorations and markings of the skin either dendritic or metallic, lacerations or wounds. =Burns= occur in nearly all, perhaps all, severe cases of lightning stroke. They may be of any or all degrees, and may extend over very small points or over the whole or nearly the whole body. They may consist in a simple singeing of the hair, or they may be very deep and extend to the bone. As before stated, the deep burns are found at the points of resistance to the current, at its points of entrance and exit from the body, and, to a lesser degree, at all points where its course is impeded. This occurs wherever the clothes are fastened tightly or pressed against the body, hence especially at the neck, waist, knees, and sometimes at the ankles. The position of the burns is determined, therefore, by the point at which the lightning strikes the person, the position at the moment, and by the arrangement of the dress and the presence of metallic substances. In the large majority of cases the upper portion of the body is the part first touched by the lightning, and thence it descends along the body to the ground. We are apt, therefore, to find a severe burn about the upper portion of the body, the head, neck, or shoulders; then a scorching, singeing, or burning, more or less severe, in the form of a stripe or stripes more or less broad down the body: the burns being deeper where the clothes are tighter or where metallic objects come into contact with or are near the body; and finally a deep burn at the nearest point of contact with the ground, usually the heel or some portion of the foot. The burns, however, vary greatly. The eyes may be burnt and severely injured or destroyed. The lightning has been known to enter the mouth and burn the mucous membrane within. The deeper burns not infrequently assume the form of holes. In Heusner’s cases about twenty whitish-gray spots, varying from the size of a lentil to that of a pea, were found on the soles of the feet. The hair is usually singed and may be burnt off in large areas, or wholly as in a case reported by Bernard. =Wounds.=—These may be direct or indirect. We shall speak here only of the first. Like burns they occur usually at the points of greatest resistance, that is, the places of entrance and exit, but they may be found in any part of the body. They may be clean-cut, as if made by a sharp knife, or they may be lacerated and ragged with the edges contused or burnt. They may consist of holes which look as if they had been punched out. =Contusions= or ecchymoses. These may also be produced directly by the lightning, and like burns and wounds are most apt to occur where the resistance is greatest. They may be of considerable importance in a medico-legal sense, as in Fredet’s case, where there were ecchymoses on the neck similar to those produced by the fingers of a hand applied for strangulation. In the case related by Cook and Boulting the right side of the body appeared like an exaggerated example of post-mortem staining. There are sometimes found also dark-brown spots, small or large, which may be soft and, when cut, containing fluid blood, or they may be hard and like parchment, dry, and bloodless on section. Closely connected with these are the so-called dendroid or dendritic marks, which are dark-colored reddish bands or stripes, often more or less dichotomously branched, not disappearing under pressure, found on the bodies of those struck by lightning. Though usually of the form mentioned, they may assume other shapes, as that of an irregular star with zig-zag rays. Balfour has figured an excellent example of these. =Metallic staining= of the skin has been known to occur where metals were in contact with it at the time of the lightning stroke. These stains may be permanent and are due to the introduction of the finely divided metal. Richardson has succeeded in producing this artificially in animals. He found two conditions required, that the metallic conductor should be sufficiently fine to offer resistance to the current and that the current itself should be an electric discharge of low tension. Loss of hair is said to have occurred from lightning, though the hair was not burnt. One case has been reported where after a severe stroke all the hair on the body is said to have fallen out. SYMPTOMS. Under this heading we shall consider only such symptoms as are, so far as can be ascertained, the direct result of the electricity and not those secondary to injuries. We will consider first those relating to the nervous system. =Loss of Consciousness.=—This occurs to a greater or less extent in all but the very mildest cases. It varies throughout all degrees from a slight momentary benumbing of the faculties to the most profound stupor or coma. It may then last hours or even days. On recovery the patient is apt to have some loss of memory, to be dazed and confused for some time, and a certain obtuseness or blunting of the intellectual faculties may persist for a considerable period. This loss of consciousness is often accompanied by flushing of the face and dilatation of the pupils, or on the other hand the patient may present all the symptoms of collapse. =Loss of memory= in regard to the lightning stroke after recovery of consciousness is not rare. It is frequently complete so far as any recollection of the lightning goes, and there may be no remembrance of the thunder-storm. Sometimes a defective memory persists together with general mental impairment (James). =Mental Disease.=—A condition of mental impairment lasting at least weeks or months may occur. Mania and the delirium of terror are said to have occurred. Various symptoms of the disturbance of the nervous equilibrium are not uncommon. Among these we may mention tremor, insomnia, and nervous dread of thunder-storms and of electricity. There is no doubt that some persons who have been exposed to lightning stroke do, at least for a time, become unusually susceptible to the influences of atmospheric electricity. =Loss of Motion—Paralysis.=—This is a very frequent result of a stroke from lightning. Hemiplegia is not uncommon. In Bonnet’s case the patient was struck on the head by the lightning, which caused a lacerated wound in the left temple, but did not injure the aponeurosis. On recovery of consciousness the patient was found to have a left hemiplegia involving the face and both extremities accompanied by a diminution of sensation over the left half of the body. The sensation became normal in two days, but a partial hemiplegia remained permanently. In the case of Durand there was a nearly complete right hemiplegia with accompanying hyperæsthesia and some affection of speech. Deglutition and mastication were difficult, and there was persistent hiccough. There was photophobia and hyperæsthesia. The patient improved in two weeks and finally recovered. There is often a temporary hemiplegia. Nearly all forms of paralyses of the extremities may occur. We may have paralysis of all the extremities or of both arms or legs, or monoplegias. Paraplegia occurs not very rarely. It is usually of short duration. It may be accompanied by paralysis of the bladder. Single muscles or muscle groups only may be affected. Ptosis may occur with paralysis of other branches of the third nerve, causing diplopia. Facial paralysis occurs also alone; in one case it lasted only twenty-four hours, in another one month. Difficulty in mastication is sometimes found, but much more frequently difficulty in deglutition is reported. Retention of urine, dysuria, or incontinentia urinæ may all occur, and there is sometimes a paralysis of the rectum, usually temporary, and sometimes obstinate constipation, which in one case was combined with paralysis of the bladder and monoplegia. Aphasia in various degrees and various forms of dysphasia or difficulty in speech are not uncommon. They are apt to be temporary. Loss of co-ordination in the lower extremities with partial paralysis of bladder and rectum is reported. =Convulsions.=—Epilepsy may be brought on by lightning: this would be more likely to occur in a person previously subject to epileptic attacks. Hysterical convulsions and spasms may also be produced, both immediately and as a more remote result, usually in persons predisposed. Tetany and catalepsy are said to occur. Clonic spasms of the whole body and convulsive movements of the limbs are not very infrequent. In some cases a marked sensitiveness remains for a time in the limbs struck, so that if touched they are immediately thrown into clonic spasms. =Disturbances of Sensation.=—_Pain_ occurs in nearly all cases. It is most frequently a secondary result of the burns and other injuries. Not rarely, however, it exists as a direct symptom in the form of a burning or stinging neuralgia in the limb or limbs affected. Sometimes the first sensation on the recovery of consciousness seems to be pain all over the body or confined to some portions only, but the amount and character of the pain, aside from that produced by the injuries, varies much. One patient had a burning pain in the back and leg lasting only half an hour after recovery of consciousness. In another case there were pains all over at the end of the first week. On the whole, severe pain in some or all of the limbs, and less commonly in the head, without paralysis and lasting some days is not rare. In one case reported by Paige the patient had intense pain in the head, neck, arms, and chest; that in the head was constant, severe, and lasted seven days, elsewhere less constant. Pain in the arms accompanied by paralysis and anæsthesia and lasting three months has been reported. Headache is not rare as a later or secondary symptom. Disturbances of sensation other than pain are not rare. A certain amount of hyperæsthesia almost always exists in the portion affected immediately after the stroke. This is often so marked that it cannot be wholly due to the burns or other injuries. It is usually very temporary and ceases in a few hours. In some cases a permanent or lasting sensitiveness to the action of electricity is said to remain. Anæsthesia, loss or diminution of sensation, occurs either with or without paralysis. In the cases reported by Balfour, one boy said he could not feel his legs and another that his arms were cut off. In a case reported by Free there was loss of sensation in the right upper extremity from the elbow to the fingers and in the left lower extremity from the knee to the toes. As a rule, the loss of sensation is temporary and quickly passes away, but it may last, in company with paralysis, for some time. In such cases either an organic lesion or a traumatic neurosis is to be suspected. Paræsthesiæ are very common after lightning stroke. Most frequent, perhaps, is the subjective sensation of numbness. Tingling, formication, and the sense of “pins and needles” may occur. _Reflexes._—As a rule, the deep reflexes seem to remain normal. The superficial reflexes of the parts affected are at least temporarily increased. =Special Senses.=—_Sight._—Affections of the eye. The eye and the surrounding parts may be directly injured by burning. We also find many serious conditions caused by the lightning the pathology of which will be considered later. When a person is first struck he may perceive a flash of light or a ball of fire before losing consciousness. While unconscious the pupils are usually dilated, but react. Sight may be at once totally lost, but this is usually only temporary. There may be amblyopia; photophobia, lachrymation, and pain are not uncommon for a time. Cataract may be produced and other severe ocular affections may result. _Hearing._—Sudden and total deafness may be caused by lightning, as in the case of Cook, where perforation of both tympana was found. This may prove to be only temporary, as in the case of Nason, where the patient, though totally deaf at first, is reported as hearing fairly on the fifth day; on the seventeenth day, however, the hearing was still dull. The deafness may be permanent. With deafness tinnitus is apt to occur. Hyperacustia, or extreme sensitiveness to noise, has also been reported in several cases. _Smell and Taste._—The person affected sometimes has noticed a smell resembling that of sulphur, and this has also been said to have been apparent to others. A metallic taste in the mouth is not rare. =General Symptoms.=—When first struck by lightning and while still unconscious, the patient has usually a flushed and reddened face, with dilated pupils. Immediately following, or perhaps without this preliminary stage, appear the symptoms of collapse. Cyanosis may occur, and the patient may appear to be asphyxiated. Fever, not caused by injuries, may sometimes occur, but certainly not to any extreme degree. In many cases the temperature when taken was normal, and even in cases of severe stroke without serious surgical injury the temperature has not risen above 101°. In these latter cases it is hard to say how far the temperature is affected by the burns which are always present. The pulse is sometimes slow, sometimes rapid and feeble, or almost imperceptible; at times it is irregular. The respiration is apt to be labored. In Paige’s case there was marked dyspnœa. It may be almost imperceptible. It is sometimes slow and sometimes rapid. Nausea and vomiting occur often after recovery of consciousness. Vertigo and reeling may exist from various causes. It is probable that seminal emissions may occur at the moment of shock. Menstruation, when present, may be checked or may continue. Pregnant women do not necessarily abort. PATHOLOGY AND PATHOLOGICAL ANATOMY. A few words must be said in regard to the pathological conditions which may be directly produced by lightning and can be detected during life. The burns, wounds, ecchymoses, dendritic marks, and other external signs have already been fully considered. Certain pathological changes, however, have been found in the eyes which are capable of being verified during life. In addition to swelling and œdema of the lids, to the injuries from burns and to the various paralyses of the ocular muscles, changes in the tissues of the eye itself may occur. In the first place we may find corneal opacities and adhesive iritis. Iridocyclitis may occur. Cataract formation is not rare, and its causation has given rise to many theories. Optic neuritis and neuro-retinitis are sometimes found; and we have sometimes optic atrophy. Structural changes in the choroid may also be caused by lightning. Rupture of the choroid, hemorrhage from the choroid and retina, and partial detachment of the retina may occur from the shock without the patient being struck by the lightning and without rupture of the external tissues. _Ears._—Perforation of the tympanum is reported in more than one case. AUTOPSIES. We shall consider here the pathological conditions found in deaths from electricity, whether due to artificial or to atmospheric sources. The results are or may be the same in either, so far as we now know, and it is probable that the action of the electricity is practically the same in either case, only varying as regards the strength and tension of the current. =Rigor Mortis.=—This has generally been found in cases of death from artificial electricity. In the case of Jugigo, who was executed by electricity, it was present four and one-half hours after death. As regards its occurrence in death by lightning and the rapidity of its onset, there has been much discussion. It is certainly present in many cases, and the probability is there is nothing diagnostic in regard to it in deaths by lightning. When absent, its absence is probably due to the presence of some external factor and has no relation to the form of death. We have, on the other hand, no proof that the rapidity of its onset is increased. =Coagulation of the Blood.=—It has been observed frequently that the blood of persons struck by lightning does not coagulate readily. Sullivan states that in certain cases of complete disorganization after lightning shock the blood is left fluid and incoagulable and its color changed to a deep black. In one of the cases of death from artificial electricity reported by Grange, the heart was found sixty-two hours after death to be filled with liquid blood of a rosy vermilion color, which quickly became darker on contact with the air. A spectroscopic examination of the blood showed the normal lines of oxidized blood reducible by sulphydrate of ammonium. In a case reported by Matzinger the blood as submitted was black and perfectly fluid, the corpuscles, both red and white, were normal, and no fibrin was detected. In those executed by electricity the blood seems to have been fluid and not in any way remarkable. There seems to be no evidence that the bodies of those dying from electricity in any form suffer unusually rapid decomposition. The only absolute sign of death from electricity is decomposition of the tissues, but the usual signs are to be relied upon to the same extent as in ordinary cases of death. =Internal Organs.=—In the cases of death from mechanical electricity no changes in the internal organs other than those due to accidental traumata have been found, except a considerable degree of congestion and sometimes minute hemorrhages in the heart substance beneath the pericardium and into the pulmonary air-vesicles and pleura. In one of Grange’s cases the heart was filled with liquid blood; in the other it was completely empty, the right ventricle collapsed, the walls of the left ventricle hard and contracted. Careful autopsies were made in the cases of the criminals executed by electricity, but no important changes caused by the electric current have been detected either macroscopically or microscopically. A few petechial spots (Tardieu’s spots) are apt to be found underneath the pericardium in the heart tissue and sometimes beneath the pleura. The organs were not extremely congested. In the case of Jugigo the vessels of the spinal cord and its membranes contained if anything less blood than usual. In this case the amount of blood found in the brain seems to have been about normal, the vessels of the dura were moderately dilated and those of the pia “in a medium state of congestion.” In the case of Kemmler the portion of the intracranial contents underneath the head-electrode was somewhat affected directly by the heat, the meningeal vessels in the dura were carbonized, and the brain cortex was sensibly hardened to one-sixth of its depth, “where there was a broken line of vascularity.” The post-mortem temperature in this case seems to have remained unusually high, being 97° F. in the fourth ventricle and 99° F. at the back of the neck three hours after death in a room where the temperature was only 83°. In autopsies after death by lightning the results are in general analogous. The brain and its membranes may be anæmic or congested. Effusions of blood may be found beneath the dura or in the brain substance itself, due to the laceration or injury of vessels. Rupture of the brain is said to have occurred, and Phayre reports a case in which the left hemisphere was entirely destroyed and changed into a dark gray homogeneous fluid mass, only a small portion of the corpus callosum remaining. No extravasation of blood, laceration of the vessels or membranes, or injury of the bones was detected. Ecchymotic spots are frequently found beneath the serous membranes, pericardium, pleura, and peritoneum. Schmitz states that parenchymatous inflammation of the internal organs may occur, and Sullivan reports a case where the stomach was found to be gangrenous over a large surface, the patient having lived several days. Cases of rupture of the heart, the liver, and the spleen are reported. THE MEDICO-LEGAL CONSIDERATION OF DEATH BY MECHANICAL SUFFOCATION INCLUDING HANGING AND STRANGULATION. BY DANIEL SMITH LAMB, A.M., M.D., _Pathologist Army Medical Museum, Washington, D.C._; _Professor of Anatomy Medical Department Howard University, Washington_; _Secretary Association of American Anatomists_; _Late Acting Assistant Surgeon United States Army_; _President of Association of Acting Assistant Surgeons U. S. A._; _Member of Learned Societies_. MECHANICAL SUFFOCATION. =Suffocation= is the name applied to both the act of and condition resulting from the deprivation of atmospheric air. If the deprivation is due to mechanical interference, the term MECHANICAL SUFFOCATION is used. Mechanical interference may be by pressure upon or obstruction within some portion of the respiratory tract. Suffocation by pressure upon the neck is called =hanging= when the constricting force is the weight of the body itself; and =strangulation= in all other cases. German writers designate strangulation by cords, ropes, and the like as _Erdrosselung_, and by the hand as _Erwürgung_; French writers do not make this distinction. In English the word throttling is probably oftener applied to strangulation by the hand than by cords. The term =suffocation= is also applied in a _special_ sense to the act and result of pressure on the mouth, nose, or chest and abdomen, stopping the breathing; or of obstruction within the respiratory tract; or of pressure upon the tract from the œsophagus, etc.; or of breathing of irrespirable gases. Strangulation is almost always homicidal, hanging almost always suicidal, and suffocation (limited) usually accidental, but also often homicidal. Strangulation may be admitted, therefore, as including all cases of suffocation by pressure on the neck, whether by cords or the hand; but excluding hanging. It will facilitate the study of the subject if we use the word ligature as a general term to cover the many forms of cords, ropes, etc., used in strangulation and hanging. The word GARROTING is often used to indicate the forcible compression of the neck by the hands of thieves. The assault is usually made from behind, and the victim is robbed while the throttling proceeds. The brevity of the process explains why death is not more frequent. The word garroting comes from the Spanish; criminal execution in Spain and Italy is usually by means of the GARROTE, a steel collar which is tightened on the neck of the condemned by a screw. The notorious thugs of the East Indies used sometimes a soft loin-cloth, at others a lasso or long thong with a running noose. In Turkey and some other Eastern countries the bowstring is a common mode of execution. An examination of the reported cases of strangulation and hanging shows a great variety of forms of ligature: cords, ropes, thread, thongs, lassos, flexible twigs, bamboos, leather straps, girdles, turbans, fishing-nets, collars, cravats and other forms of neckwear, bonnet strings, handkerchiefs, sheets, etc. Women have even strangled themselves with their own hair (Case 34). Stones, sticks, coal, and other hard substances have sometimes been inserted in the ligature to increase the pressure (Cases 36, 38, 42, 43, 44). Drunken and otherwise helpless persons have been strangled by falling forward with the neck against a firm substance. STRANGULATION. SYMPTOMS AND TREATMENT. The symptoms and post-mortem appearances in strangulation will vary, according as the deprivation of air is sudden or gradual, partial or complete; and whether there is coincident pressure on the great arteries, veins, and nerves of the neck. The deprivation of air disposes to asphyxia; pressure on the great arteries by cutting off the supply of arterial blood to the brain disposes to anæmia of the brain and syncope; pressure on the great veins, by preventing the return of blood to the heart, to congestion of the brain and coma; pressure on the great nerves, the pneumogastrics, to syncope. Statistics of hanging show that in about seventy per cent of cases death is by a mixture of asphyxia and coma. While it is probable that the proportion is less in strangulation, yet it is also probable that a mixed result frequently occurs. Asphyxia is from _α_ priv. and _σφίξις_, pulse—absence of pulse. Apnœa from _α_ priv. and _πνέω_, I breathe—absence of breathing. Syncope, _συνκοπή_, a faint; suspended animation from sudden failure of heart. Coma, _κῶμα_, deep sleep. Richardson[729] makes the following distinction between asphyxia and apnœa: Asphyxia is difficulty of taking in breath; apnœa is breathlessness. There is asphyxia when the blood from the heart can go to the lungs, but there is no access of air; apnœa, when there is access of air, but the blood fails to reach the lungs. In asphyxia the lungs obstruct the circulation; in apnœa the obstruction is in the heart. In asphyxia the air cannot reach the blood; in apnœa the blood cannot reach the air. Quinquaud[730] and Fredericq[731] conclude from experiments on animals that asphyxia is due to the deficiency of oxygen, not to the accumulation of carbon dioxide. Page[732] divides the phenomena witnessed in an animal killed by simply depriving it of air, without interfering with the blood-vessels of the neck, into four stages: First. A short stage. (In the human subject this stage could scarcely last longer than fifty seconds, which is said to be the extreme limit of the most expert divers. The breath can be held longest if a number of deep breaths have previously been taken, so as to surcharge the blood with oxygen.) Second. The stage of “_besoin de réspirer_,” when the want of air begins to be felt; the animal makes vigorous and violent efforts to overcome the obstacle. This stage may continue for three to four minutes. Third. Unconsciousness supervenes with irregular and spasmodic movements; efforts at respiration continue. Fourth. Efforts at respiration cease, but the heart still beats. This stage may last from two to four minutes. Hofmann[733] says that it may last a half-hour. In new-born infants, asphyxiated, it may be quite long. The post-mortem appearances in such an animal were as follows: the lungs were pale, reddish, not much distended; there were a few dilated air-cells toward the anterior border; hemorrhages irregularly dispersed over the surface of the lung, varying in number and size. The right cavities of the heart contained dark fluid blood, the left were empty. The pulmonary artery and systemic veins, even the smallest branches, were gorged with dark blood. Page adds that when the great vessels of the neck are interfered with death may occur “by coma, syncope, and even asthenia.” Colin[734] made twenty-five experiments on horses, and records three of them as follows: they were all strangled with a hempen cord at the middle of the neck. The _first_ was quiet till the second or third minute, then there were violent movements and strong efforts to dilate the chest; at four minutes, spasms; four and one-half minutes, quiet; six minutes, pupils dilated, tongue hanging out, limbs flaccid; blood black. _Second horse_: Carotid artery denuded to observe its action. In fifteen seconds, blood nearly black; four and one-quarter minutes, no pulsation in carotids; five and one-half minutes, no respiratory movement; six minutes, heart-beat ceased, except feeble contraction of auricles, which continued till twenty-first minute. _Third horse_: In five minutes respiration ceased; tracheotomy performed, but there was no attempt to breathe; eight minutes, heart ceased to beat. Similar results were obtained in ruminants and in small animals, except that the larger animals lived longer than the smaller. Faure[735] made the following experiment on a large dog. He tied a cord tightly round its neck; for fifty-five seconds it was quiet, then suddenly it became agitated, threw itself against the wall, rolled on the ground, twisted itself; bloody mucus escaped from the nose and mouth; the teeth were ground together; urine and fæces were passed. The efforts at respiration became very rapid. It fell dead at the end of three and one-half minutes. The symptoms of strangulation in the human subject resemble closely those just described as occurring in the dog. The FIRST or PRELIMINARY STAGE lasts a variable time, according to the suddenness and completeness with which the access of air is prevented; it lasts until there is a demand for the air. In a case of homicide, injuries may be inflicted on the victim in this stage which may have an important bearing on the cause of death. Blows on the head may cause unconsciousness, or even apoplexy; upon the stomach, may cause syncope; stab-wounds may tend to cause death from hemorrhage. The SECOND STAGE begins with the demand for air and lasts till unconsciousness supervenes. It is characterized by frantic efforts to breathe, efforts in which the entire body takes part. If the subject is conscious, he is intensely so; the expression of the face is intense; the eyes may protrude, the hands be clinched; the memory is unusually active, and the events of a lifetime may rapidly pass before the mind in a few minutes. The tongue may be thrust between the clinched teeth and bitten; and urine, fæces, and semen may be discharged. The THIRD STAGE usually appears suddenly, and is characterized by unconsciousness and irregular involuntary movements, _i.e._, spasms; these may end in opisthotonos; the veins become turgid, and hemorrhages may occur from the eyes, nose, mouth, throat, ears, and into the connective tissues of the lungs, pleura, pericardium, etc. The circulation of venous blood in the arteries is shown by the general lividity, especially where the skin is thin, as the lips and tips of fingers. Hofmann[736] states that coincident with the oncoming of unconsciousness and convulsions the respiratory effort becomes expiratory, followed still later by inspiratory efforts. The FOURTH STAGE begins with the cessation of spasms and of efforts to breathe. The subject is quiet, but the heart still beats. The stage ends with the cessation of the heart-beat. Discharges of semen, urine, and fæces may occur in the first and second stages, from terror; in the second and third from the general agitation, and in the third and fourth from paralysis. Strangulation according to Bernard[737] causes a rise in temperature, varying from one to two degrees (Cent.). He thinks that this is due to the changes from arterial to venous blood, especially in the muscles. Lukomsky[738] concluded from experiments that in asphyxia both arterial and venous pressure is increased in the systemic circulation, but diminished in the pulmonary artery. The highest degree of blood pressure coincides with the strongest respiratory movements, especially expiration. He also concluded that the Tardieu spots (subpleural ecchymoses) directly depended on the efforts of breathing and blood pressure. Some writers, as Taylor and Tidy, think that death occurs sooner in the human subject than in the lower animals; where the access of air is suddenly and completely prevented death may be immediate. Tardieu says that death follows pressure of the hand sooner than that of a ligature. Fleischmann[739] placed cords round his own neck between hyoid bone and chin, tied them tightly, sometimes at the side, sometimes at the back, without respiration being interfered with, because there was no pressure on the air passages. But his face grew red, eyes protruded slightly, there was a feeling of great heat in the head, of weight, commencing dizziness, and suddenly a hissing and rustling in his ears. The experiment should stop at this point. The same symptoms occurred from applying the cord over the larynx. The first experiment lasted two minutes, the second a half-minute. The difference was due to the different situation of the cord. Dr. G. M. Hammond[740] gives an account of a personal experiment in strangulation. He sat down; a towel was passed around his neck, and the ends twisted together, making forcible compression of the neck. At first he had a feeling of warmth and tingling, first in the feet, then passing over the entire body; vision partly lost; his head felt as if it would burst; there was confused roaring in ears, like the sound heard on placing the ear to a shell; he remained conscious. In one minute twenty seconds all sensibility was abolished. After a few minutes’ rest a second similar trial was made, with similar results, except that sensibility was lost in fifty-five seconds. A stab with a knife drawing the blood caused no sensation. Should the subject recover from the immediate effects of the strangulation there may yet be serious secondary results. Among these are convulsions and paralysis; extreme swelling of face, neck, and chest; loss of voice; lesions of larynx and lungs; abscesses. Death may occur suddenly and remotely from one of the sequelæ.[741] In the =treatment= of strangulation the first indication obviously is to remove the pressure from the neck. Artificial respiration will probably be required, and may be aided by ammonia applied to the nostrils, tickling of the fauces, and galvanism. Colin[742] states that artificial respiration is useless after cessation of heart-beat. (See the treatment by galvanism under “Suffocation.”) If the body is cold, artificial heat by means of hot bottles, etc. Venesection may be necessary. Colin strongly advises venesection to relieve the distention of the heart. Stimulants and light food are often required. Limousin[743] recommends the use of oxygen. Cobos[744] experimented on animals by injecting oxygen hypodermically, as a means of artificial respiration. His conclusions are that the oxygen is absorbed and carbon dioxide eliminated in the same place. The oxygen thus introduced causes no trouble. Testevin[745] cures asphyxia by hypodermic injection of ether. The after-treatment will depend on the after-conditions. The =prognosis= is good if there is no serious injury to the neck and treatment is promptly applied. POST-MORTEM APPEARANCES. The =post-mortem appearances= in strangulation are external and internal. The external appearances are of two kinds: those directly due to violence and accident and those due to asphyxia. =External Appearances Directly Due to Violence or Accident.=—The MARKS on the neck. In some fatal cases there are either no marks at all or they are but slight; this is more likely to be the case in suicides than homicides, and is usually due to the ligature being soft and yielding. The victim of a homicide may, however, first be stunned and afterward strangled. Marks are said to be plainer after the body has become cold and where subjects have recovered from attempts at suicide. The marks of the ligature in strangulation usually encircle the neck more completely and more horizontally than in hanging. These conditions may, however, be reversed, because a body may be dragged by the neck after strangulation, and there have been suicides by hanging in whom the mark of the cord was horizontal. As a rule, however, a horizontal mark with the knot on the same level as the cord, especially if below the larynx, suggests strangulation rather than hanging; and if there are several marks the probability is even greater. In compression with the fingers the marks are not in a horizontal but oblique line. The mark of the ligature is usually circular, well defined, and corresponds closely to the breadth of the ligature; rather depressed, and usually below the larynx. As a rule this depression is not deep; the skin at the bottom of the groove is usually very pale, while the adjacent parts are red or livid. Sometimes the bottom of the groove shows ecchymoses. Neyding[746] says that suggillations in the groove made by the ligature on the neck are rare, but are oftener found in strangulation than hanging, because the conditions favoring their formation are oftener found in strangulation. In most cases the skin and connective tissue of the groove and of the parts in the vicinity show, microscopically, hyperæmias and hemorrhages. Liman[747] states that when we find suggillation in the groove or its vicinity, we may know that some other form of violence has been applied at the same time as that of the ligature or hand. He had not seen suggillation in the furrow either in strangulation or in hanging, except when the injured persons had lived some time, and in cases of twisting of the umbilical cord. The absence of suggillation and ecchymosis was due, he thought, to the pressure on the capillaries. Bremme[748] says that in the subcutaneous connective tissue of the mark of the ligature there is no hemorrhage either in strangulation or hanging, if death occurs at once and the cord is removed at once after death; but if the cord remains for some time after death there may be hemorrhage, or if death does not occur at once whether the ligature is removed or not. It is impossible to distinguish ante-mortem from post-mortem hemorrhage. The parchment skin seen in hanging is seldom seen in strangulation. Neyding[749] says that the dryness and induration called parchment skin depend mainly on the amount of excoriation of the skin, and this is greater in hanging. Tardieu explains this frequency as being due to the fact that the constriction in hanging lasts a longer time. Liman has seen the parchment skin in those strangled. The violence used may cause ecchymoses and abrasions of the skin of the neck adjacent to the mark of the ligature. The marks of very different constricting ligatures may be quite similar. Taylor[750] mentions a case in which a soft silk handkerchief was used, and the appearance was the same as that of a narrow cord, due to the tightness with which it was tied. Where a hard substance like a piece of coal or stone is inserted into the ligature, usually then a soft cloth, and presses directly against some part of the neck, there is usually a corresponding bruise. Marks of pressure by the thumb and fingers are usually on the front of the neck, and either just above or below the larynx. In many cases these marks are only those of the finger-tips with some scratches. These marks may show definitely the probable size of the assaulting hand, and whether right or left. Marks of strangulation may disappear rapidly after the removal of the ligature. Assailants usually constrict the neck much more violently than is sufficient to cause death. Marks of violence on the neck are, therefore, greater in strangulation than in hanging. A great variety of external injuries other than those on the neck have been found in the different cases reported where other forms of violence were used. With few exceptions such additional injuries indicate homicide. =External Appearances Due to Asphyxia.=—A few of these have already been given under the caption “Symptoms.” If death occurs quickly there may not be any signs of asphyxia. The general LIVIDITY which comes on in the second stage usually remains after death. The face varies in color from violet to black and may be swollen. Casper[751] says that the face has the appearance of any other corpse. Liman[752] found the face livid in only one of fourteen cases. Hofmann[753] says that the cyanosis appears during the agony because of paralysis of the circulation and gravitation of blood. The cyanosis of the face, projection of the eyes, and congestion of the conjunctivæ are due to the expiratory effort. These signs are also seen in fat persons who do not die of strangulation. Tardieu[754] mentions a dotted redness or minute ecchymosis of the conjunctivæ and skin of face, neck, and chest as constant; but this cannot be considered characteristic, because it has been seen, though not so well marked, in death from other causes. It has been found in suffocation from compression of the chest and belly; and also where there is respiratory interference in the prolonged efforts of tedious labor and in convulsions. Liman[755] found it in those who were hung. It is due, according to Hofmann,[756] to increased blood pressure and consequent hemorrhages. It is of importance as tending to show that there was stasis of blood in the head and face during life. Liman[757] found cyanosis in the conjunctivæ, lips, back of mouth, and in the muscles. Maschka[758] in 234 cases of asphyxia found capillary hemorrhages of the eyes and eyelids 87 times. Dastre and Morat[759] claim that in asphyxia the cutaneous circulation becomes more active than in the normal state, while at the same time the vessels of the abdominal cavity are contracted. Laffont[760] considers the mechanism of this peripheral dilatation. POST-MORTEM STAININGS (hypostases) are usually darker in strangulation than in other forms of death. They appear soon, as does also putrefaction, because of the quantity and fluidity of the blood. Signs of HEMORRHAGE from the nose, eyes, and mouth may be visible; as also bloody froth from the mouth and nose. Chevers[761] never saw bleeding from the ears in strangulation. Taylor[762] states that Dr. Geoghegan informed him of a case of suicidal strangulation by a ribbon; the violence was great, there was bleeding from the ear, and the drum was found ruptured. In this case the mark on the neck, which was deep, nearly disappeared after the ligature was removed. Taylor also says Wilde, of Dublin, saw a case of rupture of drum and hemorrhage in strangulation. Pellier[763] says that Littré mentions a case of rupture of tympanic membrane in strangulation by a cord. Zoufal and Hofmann have offered explanations of the occurrence (Case 35). The FACE usually shows pain and suffering; although sometimes the features are calm. In the latter case there may have been syncope. The EYES are usually staring, prominent, and congested, and the pupils dilated. Casper[764] doubts their prominence. Budin and Coyne[765] state that in asphyxia the dilation of the pupil progresses to a maximum and then convulsions occur. Ophthalmoscopic examination during the dyspnœa of asphyxia shows a lessened fulness of the retinal vessels. The TONGUE is often swollen, dark, protruding, and sometimes bitten. Maschka[766] states that if the ligature lies above the hyoid bone, the tongue will be drawn backward; if over or below the bone, the tip of the tongue may appear more or less between the jaws. The HANDS are usually clinched and may have in their grasp articles which, under the circumstances, have a medico-legal value. The EXTERNAL GENERATIVE ORGANS are sometimes congested; erection of the penis may have taken place and persisted. The vagina may be moist. Tardieu, Devergie, and Casper[767] deny that these appearances are usual. INVOLUNTARY DISCHARGES of urine, fæces, and seminal fluid may have occurred. There is nothing characteristic in their appearance. All the external appearances of asphyxia are usually more marked in strangulation than in hanging. =Internal Appearances.=—THE MARK. Usually there is hemorrhage into the loose connective tissue under the mark and in the subjacent muscles; in most cases isolated and circumscribed, but sometimes extending beyond the line of the mark. Hemorrhage from compression by the fingers is more marked than that from ligature.[768] Sometimes there is only fulness of the subcutaneous veins. The CAROTID ARTERIES may suffer rupture of their inner and middle coats, especially in atheromatous subjects and when the compression has been great. Friedberg[769] states that the injury of the carotid, if there is hemorrhage into its middle and internal coats, is a proof that the strangulation occurred during life, and probably from pressure of the fingers on the neck, without any regard to any disease of the artery. He reports two cases. The examiner should be careful not to injure the artery with his forceps. The vessels may contain clots. The NECK occasionally suffers extreme injury, and, owing to the violence used, this occurs oftener in strangulation than in hanging.[770] Occasionally the neck is broken. The HYOID bone may be fractured (see Case 5). Maschka[771] saw one case in eighteen of Erdrosselung and five cases in fifteen of Erwürgen. The TRACHEA is sometimes torn, or may be folded on itself. The cartilages of the LARYNX, especially if calcareous, may be fractured. This is more likely to affect the thyroid than cricoid. The fracture would appear to occur only as the result of enormous force; especially in the young in whom the cartilages are so elastic. The experiments of Keiller[772] on cadavers led him to conclude that falls on the larynx, even from a height and with superadded force, are unlikely to fracture that organ; that severe pressure or violent blows against the larynx from before backward may cause fracture; but that severe lateral pressure, as in ordinary throttling, is more likely than other forms of violence to fracture the alæ of the thyroid or even the cricoid cartilages and also the hyoid bone. Taylor[773] states that Dr. Inman, of Liverpool, had informed him of a case of splitting of rings of windpipe from pressure (see Cases 5, 13). Maschka[774] in fifteen cases of choking found six fractures of the larynx. Chailloux[775] has collected eight cases of fracture of larynx in strangulation. They were all made with the fingers. The experiments of Cavasse[776] seem to show that there is no great difficulty in fracturing the thyroid in strangulation. =Internal Appearances Due to Asphyxia.=—The VEINS of the entire body are distended with very dark and very fluid blood, while the arteries, especially in the young, are mostly empty. Experiments on the lower animals have shown that the pulmonary artery and systemic veins to the finest ramifications are distended with dark blood.[777] THE HEART.—The right side, especially the auricle, is usually full of dark fluid blood, due to the mechanical impediment to the passage of blood through the lungs. If the heart continues to beat after the respiration has ceased the right ventricle is commonly well contracted, like the left cavities, and nearly empty, the lungs being much congested. Sometimes the left cavities of the heart contain blood. This would be most likely to occur if the heart should stop in the diastole. Sometimes clots are found in the right ventricle. Maschka[778] found clots in the heart 25 times in 234 cases of asphyxia. The LUNGS are usually much congested, resembling red hepatization, except that the blood is darker. Hemorrhages (apoplexies) into the substance of the lungs are common. Tardieu found patches of emphysema due to rupture of the surface air-vesicles, giving the surface of the lung the appearance of a layer of white false membrane. Ogston admits this occurrence in pure strangulation but to a less extent in mixed cases. Liman[779] found the lung surface uneven, bosselated, the prominences being of a clearer color and due to emphysema. The lungs were in the same condition of congestion and emphysema in strangulation, suffocation, and hanging. He failed to find the apoplexies described. The lungs are sometimes anæmic. In healthy young subjects, especially children, the blood-vessels of the lungs often empty themselves after the heart stops. The lungs may, therefore, be bloodless, but emphysematous from the violent efforts to breathe. Page’s experiments on the lower animals showed the lungs of a pale reddish color and not much distended; a few dilated air-cells might be seen toward their anterior borders, and there might be small hemorrhages over the surface. His experiments appear to show that subpleural ecchymoses occur as a result of violent and repeated efforts to breathe. Among other experiments[780] he stopped the mouth and nostrils of a young calf long enough to excite violent efforts at respiration; it was then instantly killed by pithing. The lungs were found pale red, not congested, but showed subpleural ecchymoses. Page believed these were due to the changed relation between the capacity of the thorax and volume of lungs. Liman found these ecchymoses in cases of strangulation, hanging, drowning, poisoning, hemorrhage, and œdema of brain, in the new-born, etc. He failed to find them in some cases of suffocation. He believes them due to blood pressure from stasis in the blood-vessels. Ssabinski[781] made many experiments on dogs and cats to ascertain the presence or absence of subpleural ecchymoses in strangulation, drowning, section of pneumogastrics, opening of pleural sac, compression of chest and abdomen, closure of mouth and nose, burial in pulverulent materials, etc. Similar hemorrhages may appear on the mucous and serous membranes, as the respiratory, digestive, and genito-urinary tracts, and pleuræ, pericardium, peritoneum, membranes of brain, and the ependyma. These are sometimes minute and stellate, at others irregular in shape; many are bright-colored. According to Tardieu the punctiform ecchymoses are rarely present except in suffocation. Maschka,[782] in 234 cases of asphyxia, found the lungs congested 135 times, anæmic 10, and œdematous 42. He thinks the subpleural ecchymoses valuable signs of asphyxia. The BRONCHIAL TUBES are usually full of frothy, bloody mucus, and the mucous membrane is much congested and shows abundant ecchymoses. The lining membrane of the LARYNX and TRACHEA is always congested and may be livid; the tube may contain bloody froth or blood alone. Tidy comparing strangulation and hanging concludes that because strangulation is usually homicidal, and greater violence is used, therefore the external marks are more complete in strangulation and the congestion of the air passages is invariably much greater. Maschka found the PHARYNX cyanotic in 216 of 234 cases of asphyxia. The other MUCOUS MEMBRANES are generally much congested. Serum is found in the serous cavities. Maschka[783] considers the rounded, pin-head ecchymoses of the inner surface of the _scalp_ and pericranium valuable evidence of asphyxia. The BRAIN and membranes are sometimes congested; occasionally apoplectic. Maschka[784] found congestion of brain and membranes 48 times and anæmia 30 times in 234 cases of asphyxia. The ABDOMINAL ORGANS are generally darkly congested, although Maschka denies this for the liver and spleen in asphyxia. The congestion of the viscera generally is doubtless due largely to the prior congestion of lungs and engorgement of heart. Page[785] experimented on six kittens, strangling three of them by the hand, the other three by ligature. The results of the post-mortem examinations were nearly similar: the veins were full of dark fluid blood; the right cavities of the heart were similarly gorged, the left empty; lungs pale red, not congested and not distended. Brain normal. The differences were in the lungs; in the first series there were many small, irregular, circumscribed, dark-red ecchymoses scattered over the general surface; in the second, a small number of bright-red ecchymoses, somewhat larger than a large pin-head. Langreuter[786] made some experiments on a cadaver from which enough of the posterior part had been removed to enable him to view the throat. He saw that the lateral digital pressure on the larynx closed the glottis; stronger pressure made the vocal cords override each other. Similar pressure between the larynx and hyoid bone caused apposition of the ary-epiglottic folds and occlusion of the air-passages. He experimented on sixteen bodies to ascertain the effect of blows and pressure on the larynx, with the following results: In eight cases, women, the thyroid cartilage was injured three times, the cricoid four; in eight, men, the thyroid eight and cricoid five. Whence he concluded that the larynx is better protected in women. In the sixteen cases the hyoid bone was fractured ten times. THE PROOF OF DEATH BY STRANGULATION. Tidy[787] says that “nothing short of distinct external marks would justify the medical jurist in pronouncing death to be the result of strangulation.” On the other hand, Taylor[788] considers the condition of the lungs described as characteristic. Liman[789] did not think there were any internal appearances which could distinguish suffocation, strangulation, and hanging from each other. In estimating the value of testimony it will be well to consider the following facts: A victim may be strangled without distinct marks being found. The practice of the thugs shows that this may be done with a soft cloth and carefully regulated pressure without making marks. Taylor,[790] while admitting the possibility, states that this admission “scarcely applies to those cases which require medico-legal investigation.” The subject while intoxicated or in an epileptic or hysterical paroxysm may grasp his neck in gasping for air, and leave finger-marks. Different constricting agents may make quite similar marks. Marks may be made on the neck within a limited time after death, similar to those made during life. Tidy’s experiments led him to fix this limit at three hours for ecchymoses and six hours for non-ecchymosed marks. Taylor,[791] however, doubts if such marks could be made one hour after death. He says that the period cannot be stated positively, and probably varies according to the rapidity with which the body cools. It is, however, unlikely in such post-mortem attempts at deception that the other conditions usual in strangulation would be found—such as lividity and swelling of face; prominence and congestion of eyes; protrusion of tongue; rupture of surface air-vesicles and apoplexies in the lung; congestion of larynx and trachea, etc. No conclusion can be drawn from the presence or absence of any single appearance. A cord may be found near a body or even around its neck; there may even be a mark around the neck. These may be attempts at deception. Marks much like those of violence may be made by tight collars and handkerchiefs remaining until the body is cold. Cases are reported of bodies having been first strangled and then burnt or hung to cover the crime; and of partial suffocation by gags, followed by or coincident with strangulation (see Cases 18, 20, 24). In apoplectics with short and full neck we may find at the borders of the folds of skin in the neck one or more depressions, red or livid, that bear some resemblance to the marks of a ligature; but on section there are no ecchymoses. Froth, tinged with blood, in the air-passages is considered by Tardieu[792] one of the most constant signs of strangulation. The marks of topical medical applications, as plasters, sinapisms, etc., must not be confounded with marks of violence. In strangulation by ligature the marks are usually horizontal; in hanging, oblique. In hanging too they are usually dry and parchmenty. Ecchymoses are more marked in strangulation. The dotted markings of face, neck, and conjunctivæ described by Tardieu are more characteristic of strangulation. The principal distinctions between strangulation and suffocation would be the absence in the latter of marks on the neck. Taylor[793] quotes the case of Marguerite Dixblanc, in which the question was raised whether she had strangled her mistress, Madame Riel, or whether the body had been dragged by a rope around the neck. The question was left unsettled by the medical evidence. The only motive for attempting to simulate strangulation on a corpse would seem to be to inculpate an innocent person.[794] Both suicides and murderers are usually more violent than is necessary to destroy life; murderers more than suicides. Putrefaction may cause external marks to disappear. All marks on a body should be carefully noted; the cavities of the skull, thorax, and abdomen carefully examined; the possibility of death having occurred from other causes, even in strangulation, must be considered. As Taylor well says, our judgment must not be swayed to the extent of abandoning what is probable for what is merely possible. In all cases the cord or strangulating ligature should be carefully examined for marks of blood, for adherent hair or other substances. The precise manner in which the cord has been tied should be noted. STRANGULATION: ACCIDENTAL, SUICIDAL, HOMICIDAL, SIMULATED. The question whether a case of strangulation is accidental, suicidal, or homicidal is very difficult to answer. ACCIDENTAL strangulation is rare. If the body has not been disturbed, there is usually no difficulty in arriving at a conclusion; but if disturbed a satisfactory conclusion may not be reached. It is worthy of mention that the umbilical cord may be twisted around the neck of a new-born infant and may have caused strangulation; the mark may give the appearance of death by violence. SUICIDAL strangulation is rare. The experiments of Fleischman (_supra_) suggest that one may commit suicide by compressing his throat with his fingers (see Case 48). Where a ligature of any kind has been used it is important to notice the number and position of the knots. In a general way a single knot either in front or at the back of the neck might suggest suicide; more than one would suggest homicide. There are, however, exceptions. Suicide has been committed by mere pressure of a cord fixed at both ends a short distance from the ground; by twisting a rope several times around the neck and then tying it (the coils may continue to compress even after death); by tightening the cord with a stick or other firm substance; by tightening the cords or knots by means of the hands or feet or some portion of the lower limbs; by the use of a woollen garter passed twice around the neck and secured in front by two simple knots, strongly tied one to another. It is difficult to simulate suicide; requires great skill and premeditation on the part of a murderer. “The attitude of the body, the condition of the dress, the means of strangulation, the presence of marks of violence or of blood on the person of the deceased, on his clothes or the furniture of the room, or both, rope or ligature, are circumstances from which, if observed at the time, important medical inferences may be drawn.” The assassin either does too little or too much. Taylor[795] cites a number of cases of simulation. Strangulation is generally HOMICIDAL. The marks of fingers or of a ligature on the neck suggest homicide. This is true even if the mark is slight; because infants and weakly persons may be strangled by the pressure of the hands on the throat. Even a strong man, suddenly assaulted, may lose his presence of mind and, with that, his power of resistance; with approaching insensibility his strength still further diminishes. This is true even if his assailant is the less powerful. It requires more address to place a ligature on the neck than to strangle with the hand. A victim may be made insensible by drugs or blows and then strangled by a small amount of compression; or suffocation by gags and strangulation may both be attempted. The importance of considering the position and number of the knots in a cord is mentioned under suicidal strangulation. In homicide, in addition to the marks on the neck, there is likely to be evidence of a struggle and marks of violence elsewhere on the body. It is important, therefore, to notice any evidence of such a struggle. The nature of the cord may assist in identifying the assailant. It must be remembered that homicidal strangulation may be committed without disturbing noise even when other persons are near. =Simulation.=—False accusations of homicidal strangulation are on record. Tardieu[796] states that a distinguished young woman (for some political purpose) was found one evening at the door of her room apparently in great trouble and unable to speak. She first indicated by gestures and then by writing that she had been assaulted by a man who tried to strangle her with his hand, and also struck her twice in the breast with a dagger. She was absolutely mute—did not even attempt to speak—quite contrary to what is always observed in unfinished homicidal strangulation. On examination by Tardieu, no sign of attempt to strangle was found, and the so-called dagger-openings in her dress and corset did not correspond in position. She confessed that she had attempted deception. The celebrated Roux-Armand[797] case was another instance of attempted deception. A servant named Roux was found on the ground in the cellar of his employer Armand; his hands and legs were tied and there was a cord around his neck. He was partly asphyxiated, but after removal of the ligature from his neck he rapidly recovered, except that he was weak and voiceless. He stated by gestures that he had been struck by his employer on the back of the head with a stick and then bound as described. The next day he could speak. Armand was imprisoned. Tardieu examined carefully into the case and the results may be stated as follows: The asphyxia was incipient, else he could not have so rapidly recovered. The cord around his neck had not been tied—simply wound around several times; the mark was slight and there was no ecchymosis. Although the legs and hands were tied, the hands behind the back, there was no doubt but that Roux could and did tie them himself. He had stated that he had been eleven hours in the cellar, in the situation in which he was found. This could not be true, for a very much shorter time, an hour probably at the furthest, would have caused death, in view of the condition of asphyxia in which he was found. Again, if his limbs had been bound for so long, they would have been swollen and discolored; but they were not. Again, if the ligature had been around his neck so long as he said, the impression of it would have been more marked. Again, if his stertorous breathing had lasted long it would have been heard by neighbors. The injury on the back of the head, said to be due to a blow, was believed by Tardieu to be due to dragging him on the ground. He further had stated that when he received the blow on the head he became unconscious, and yet he also described how Armand bound him after knocking him down. Again, he had made no outcry; but if he had been strangled while partly unconscious and afterward recovered his senses, he would have been unable to give an account of the matter; if, however, he had been strangled while conscious, there was no reason why he should not have cried out. His inability to speak the first day was assumed, because what was a simulation of absolute mutism should have been simply a loss of voice. The innocence of Armand was ultimately established. ILLUSTRATIVE CASES. HOMICIDE.