351-356._—Man, age about 60, found dead under a tree in the woods
near Prague. No sign of violence. A cord thick as a sugar-loaf around
the neck; another cord attached to a branch of the tree. There was at
first a strong suspicion of violence, but the conclusion reached was
that he had hung himself and that the body had fallen from breaking of
the cord; that death was due to asphyxia was shown by the furrow on
the neck, the dark liquid blood, and the congested lungs. There was no
infiltration below the furrow in the neck, and no lesion of larynx. The
man had shown signs of melancholy.
15. _Friedberg: Virchow’s Archiv, 1878, lxxiv., p. 401._—Suicidal
hanging. Examination twenty-eight weeks after death. The front of
the neck showed a groove above the larynx, firm and of gray color;
ecchymosis in subcutaneous tissue.
16. _Bollinger: Friedreich’s Blätt. f. ger. Med., 1889, xl., p.
7._—Man, age 48; found dead. Had made a ligature out of a night-gown
and tied it around his neck, the other end around top of a low
bed-post; his neck hung by the ligature placed below the larynx.
_Illustrated._
17. _Med. Times and Gaz., London, 1860, ii., p. 39._—Woman; had
collected accounts of celebrated persons who had been hanged; finally
hanged herself.
18. _E. Hoffman: Mitt. d. Wien. Med. Doct. Colleg., 1878, iv., pp.
97-112._—1st. Woman, age about 25; found dead sitting in bed, a
handkerchief around her neck fastened to the bed-curtain. The police
thought she had been killed and then hung, but the physician concluded
that she had committed suicide. An examination of the stomach showed
that she had previously tried to poison herself with arsenic.
19. 2d. Woman, age 51; found hanging in half-lying position.
20. 3d. Man, age 50. First tried to kill himself with phosphorus, then
sulphuric acid; finally hung himself in a half-kneeling position.
21. _Müller-Beninga: Berlin. klin. Woch., 1877, xiv., p. 481._—Man,
age 40; hung himself. There was no swelling of genitals and no soiling
of clothing. Necroscopy showed death from asphyxia, and in urethra near
meatus quite a quantity of seminal fluid, as shown by microscopical
examination.
22. _Tardieu: Op. cit., p. 18._—The Prince of Condé was found hanging
in his room, August 27th, 1830. He was suspended by two handkerchiefs
to a window fastening, his feet, however, touching the floor. The knot
was at the back of the neck (as shown by the illustration), the face
turned slightly to the left, the tongue protruding; face discolored;
mucus at the mouth and nose; arms hanging and stiff; fists shut; heels
raised; knees half bent. The text says that the knot was nearly under
the right ear, but the illustration shows a different position (see
Fig. 22, p. 743).
23. _Allison: Lancet, 1869, i., p. 636._—Three cases of suicide by
hanging, in which there was no mark: 1st. Woman, hung herself with a
piece of sheep-net band; cut down before death. 2d. Man, hung with
plough-string; cut down in about six minutes. 3d. A heavy man.
24. _Tardieu: Op. cit., pp. 93-105._—Woman, died of coma and asphyxia
from suicidal hanging, according to report of Drs. Costan and Facieu.
Tardieu approved their report. It was at first thought a case of
homicide with subsequent hanging, more especially because of the kind
of knot used, _nœud d’artificier_. But Tardieu showed that it was also
a _nœud de batalier_. Her feet touched a chair, and her knees were
bent. There was a neckcloth in front of her mouth, but it did not seem
to have interfered with respiration.
25. _Ibid., pp. 67-72._—The famous case of Marc-Antoine Calas, who
committed suicide by hanging (see Voltaire, “Traité sur le tolérance,”
etc., in _Nouv. Philos. Histor._, 1772, xxxii., p. 30). He hung himself
to a door. No sign of violence. The city hangman said it was impossible
for a man to commit suicide in that way. The father was accused and
convicted of homicide. Tardieu shows that the act was a suicide.
26. _Ibid., p. 72._—Another famous case. A woman, age 30, hung herself
to the key of her bedroom door. Her husband cut her down. He was
accused and convicted of the crime and condemned to prison, where he
died. Tardieu showed that the case was one of suicide.
27. _Hofmann: Wien. med. Presse, 1880, xxi., p. 201._—Man, age 68,
suicide by hanging. There was profuse hemorrhage from both ears.
28. _Ibid.: 1878, xix., pp. 489-493._—Woman, found dead sitting in
bed. She first tried to poison herself with arsenic, then hung herself.
29. _Ibid._—Man, tried to poison himself with phosphorus and sulphuric
acid, then hung himself. There was a transverse rupture of the
sterno-cleido mastoid muscle and suffusion in its sheath.
30. _Maschka: Wien. med. Woch., 1880, xxx., pp. 714, 747, 1075._—Man,
age 63. It was at first a question of suicide by hanging or homicide by
strangling. He concluded that it was the former.
31. _Ibid._—Also man, age 58. Similar case. Same opinion.
32. _Ibid. 1883, xxxiii., pp. 1118-1120._—Woman. age 23. Question
whether she committed suicide by hanging or was strangled and then
hung. Opinion, that it was a case of suicide.
33. _Hofmann: Allg. Wien. med. Zeit., 1870, xv., pp. 192-214._—Man,
age 60. Suicide by hanging or homicide; opinion, that it was the former.
34. _Van Haumeder: Wien. med. Woch., 1882, xxxii., pp.
531-533._—Suicide by hanging or homicide. There were many wounds in
the head; these occurred during the delirium of typhus.
35. _Maschka: “Sammlung gericht. Gutacht.,” etc. (Prag), Leipzig, 1873,
p. 137._—Boy, age 9; found dead in sitting position. Injuries on neck
and elsewhere. Question, had he hung himself or been choked? Were the
injuries inflicted before or after death? Opinion, suicide.
36. _Ibid., p. 144._—Boy, age 13. Found hanging in sitting position.
Question whether murder, suicide, or accident. Opinion, suicide.
37. _Ibid., p. 149._—Woman, age 60; found hanging, sitting position.
Suicide or homicide. Opinion, suicide.
38. _Ibid., p. 156._—Woman, age 30; found hanging. Opinion, suicide.
39. _Ibid., p. 165._—Man, age 63. Suicide by hanging, or homicide by
strangling? Opinion, suicide.
40. _Berliner: Viert. f. ger. Med. und öff. San., 1874, xx., pp.
245-253._—Woman, age 30; found hanging. Opinion, suicide.
41. _Deininger: Friedreich’s Blät. ger. Med., 1884, xxxv., pp.
47-59._—Woman, age 61; found hanging. Opinion given, suicide.
42. _Mader: Bericht d. k. k. Rud. Stift., Wien. (1875), 1876, p.
378._—Woman, age 43; tried to hang herself. She was at once cut
down, bled, and taken to hospital unconscious. Next day, face red;
pulse and temperature normal. Third day, conscious and could speak,
but not aloud; tongue twisted and turned to right; paralysis of right
hypoglossal nerve. Uvula drawn to left. Skin of right limb felt
“furry.” Applied electricity and gave strychnine; phonation was more
distinct during the use of the battery. Two months later she was
still aphonic, but the vocal cords were in better action. The right
hemiparesis was lessened.
43. _Grant: Lancet, 1889, ii., p. 265._—Man, age 48; found sitting
against a door, hung to the knob by a handkerchief.
44. _White: Lancet, 1884, ii., p. 401._—Woman, age 53, insane. Made
several attempts at suicide; once with a stocking around her neck, once
with an apron; the last time by fastening a portion of her dress to a
ladder. She was quickly cut down, cold affusion applied, and artificial
respiration (Sylvester). The eyes were prominent and glassy, pupils
widely dilated, no reaction to light; conjunctivæ insensitive; lips
livid; tongue swollen and pale; face pale; oblique depressed mark on
neck, most marked on left side; skin cold; no pulse; no heart-beat
recognizable; no respiration; no reflex action. Galvanism failed to
arouse any muscular action. The details are too numerous to give all of
them. There was reduplication of heart-sounds for several days, due to
interference with pulmonary circulation. She recovered both bodily and
mental health.
45. _Richards: Indian Med. Gaz., 1886, xxi., p. 78._—Man, age 20;
suicide; was cut down and lived for four days.
46. _Kite: Univ. Med. Mag., 1888-89, i., p. 475._—Man, age 69; suicide.
47. _Terrier: Prog. Méd., 1887, vi., pp. 211-214._—Two men, age 29 and
25, insane. Attempted suicide by hanging. Both resuscitated.
48. _Nobeling: Aertz. Intellig.-bl., 1884, xxxi., p. 213._—Two
suicides by hanging; men, ages 24 and 40.
49. _Ritter: Allg. Wien,. med. Zeit., 1886, xxxi., p. 375._—Soldier,
found hanging. Cut down in ten minutes. Artificial respiration
applied; fifteen minutes later, an effort at respiration; face
changing from blue to white and then to red; pulse small, irregular;
still unconscious; mark of ligature distinct; a few hours later had a
maniacal seizure; gave morphia hypodermically and he slept; was also
aphonic. Gradually recovered and returned to duty.
50. _Strassmann: Viert. f. ger. Med., 1888, xlviii., pp.
379-381._—Three cases of suicidal hanging in men, ages 27, 37, and
40. The last was found kneeling.
51. _Balta: Pest. Med. Chir. Presse, 1892, xxviii., p. 1244._—Man, age
45-50; hanging; suicide. Thyroid cartilage and hyoid bone broken.
[Illustration: FIG. 24.—Double Suicide (see Case 55).]
52. _Hackel: Op. cit., p. 35._—Man, found hanging to a beam by a
sheet. Had previously tried to choke himself with his hands.
53. _Ibid._—Two cases of suicidal hanging where the cord made no mark.
In the first the body hung free; in the second the body was partly
supported. In the first there was no rubbing of the skin; in the second
the body was soon cut down.
54. _Freund: Wien. klin. Woch., 1893, vi., pp. 118-121._—Man, found
hanging; cut down, but could not be resuscitated. Ligature between
hyoid bone and larynx, then crossed over itself about middle line of
neck, passed up along each side of face, knotted above the head, then
thrown over a beam, and on the other side the loop was caught between
his legs.
55. _Hoffman: Op. cit., p. 525, illustrated._—Case communicated by Dr.
Rosen, of Odessa. Man, age 21, and woman, age 17, hung themselves by
same ligature thrown over an open door, one of them on each side. They
had previously tried other means of suicide without success (see Fig.
24).
56. _Ibid., p. 530._—Man found hanging by handkerchief to branch of
tree but sitting on the ground. Mark of handkerchief superficial and
pale. When the necroscopy was made the mark had disappeared. Also a
similar suicide where there was no mark at all.
57. _Ibid., p. 541._—Man found hanging to a window. Another man cut
the cord and the suspended one fell into a cellar, fracturing his skull.
58. _Ibid._—Man found hanging; cut down; the fall caused rupture of
liver.
59. _Ibid., p. 539._—Drunkard hung himself; there was evidence that he
had previously injured himself during his drunkenness.
60. _Ibid._—Boy hung himself because he had been punished by the
schoolmaster. There were marks on his back and lower limbs from the
punishment.
See also Taylor, “Medical Jurisprudence,” pp. 451-452; Tidy, “Medical
Jurisprudence,” _incomplete_ hanging, Cases 33 to 36 and 62; Hofmann,
“Lehrbuch,” p. 538.
HOMICIDE.
61. _Harvey: Indian Med. Gaz., 1876, xi., p. 3._—Woman, age 20,
feeble. Her mother-in-law had kicked her; she probably had fainted;
supposing her to be dead, the husband hanged her to a tree within half
an hour after the supposed death. Autopsy: No marks of injury; oblique
mark of cord on right side of neck; tip of tongue between the teeth;
face somewhat livid; right side of heart full of dark blood; lungs
congested posteriorly.
62. _Ibid., p. 4._—Woman, age 38. Rope close under the chin passed
upward behind the ears. Head bent on chest. Large wound above clavicle.
Under the rope was a depression (made after death) but no hemorrhage.
Much blood in abdomen and a hole in the liver. Kidney bruised and
blackened. Right lung torn through; blood in pleuræ. Wounds were
supposed to be gunshot, but the husband confessed that he had thrust a
sharp solid bamboo into her body and afterward hung it up. She died of
hemorrhage.
63. _Rehm: Friedreich’s Blät. f. ger. Med., 1883, xxxiv., pp.
332-362._—Man, age 73; first roughly maltreated; afterward hung.
64. _Tardieu: Op. cit., p. 125._—Woman found hanging in her room.
Circumstances indicated homicidal strangulation and that the hanging
was done to avert suspicion. Post-mortem examination showed the base
of the tongue ecchymosed, and ecchymosis extending up to the soft
palate; mucous membrane of pharynx congested; connective tissue and
mucous membrane between hyoid bone and larynx congested posteriorly;
epiglottis showed slight ecchymosis, mucous membrane red. These
ecchymoses were not caused by the cord, for the latter was placed below
the hyoid bone and this bone was not broken. There were also marks on
the collar-bone like the mark of two hands.
65. _Ibid., p. 124._—Girl, 15 years old. Body found hanging. Post
mortem showed beyond doubt that she had been violated, then strangled,
then hung. Her head showed many ecchymoses from either the fist or the
foot; blood flowing from left ear. Brain slightly congested. Tongue
between teeth, bitten and bloody. On front of neck were two marks: the
lower were impressions of fingers close together, nearly uninterrupted,
and which had bruised, flattened, and tanned the skin, which here was
dry, hard, and horny. This lesion was above the intraclavicular notch
and extended toward the sides of the neck with regularity of curve and
neatness of imprint, evidently made with the right hand. Above the
first furrow under the skin was a kind of track, less extended, more
regular, a bruising of the same nature as the preceding, but continued,
due to the pressure of the index finger and thumb of left hand. A
little below the jaw was a livid place on the skin, which was otherwise
unaffected by the ligature. There was nothing to indicate a circular
action of the ligature. Froth in larynx and bronchi. Lungs apparently
normal. Food had passed from stomach into œsophagus and air-passages.
66. _Ibid., p._ 122.—Woman found hanging in her room, and was
resuscitated. She stated that the man who lived with her had tried
to strangle her and then hung her. Tardieu saw her in hospital.
Respiration short and embarrassed; pains in neck and jaw. Found narrow,
circular, sinuous, horizontal, uninterrupted line around the neck below
thyroid cartilage; line everywhere equal, deep, and three to four mm.
wide; the skin excoriated and covered with thick crust. Below this were
several superficial excoriations. There were many contusions on other
parts of the body. Tardieu concluded that the mark on the neck was
from attempt to strangle; the wounds elsewhere to prevent resistance.
She had at the time pulmonary consumption. She died of this disease
aggravated by the assault.
67. _Ibid., p. 106._—The Duroulle affair. Woman found hanging.
Presumption of homicide; arrest of husband; acquitted. She was found
with her face to the floor, one end of a cord around her neck; another
similar cord attached seven feet above to a rafter, over which it
passed three times. Bidault and Boulard reported it a suicide. The
results of the post mortem were as follows: Skin of a red-violet color;
face swollen; eyes prominent and congested; conjunctivæ a vinous red;
lips violet; tongue swollen, tip between teeth; froth in air-passages;
lungs congested; brain congested; blood fluid. Circular depression
around neck with congestion of skin above and below; ecchymosis in
subcutaneous tissue on level of angle of jaw and about one centimetre
in size, supposed to correspond to the knot. Tardieu reported that
the marks rather resembled those of strangulation than hanging; the
ecchymoses were more like those produced by the hand over the mouth.
The marks on the face supposed to have been made by a supposed fall of
the body were by him considered to have been caused by violence. He
believed the woman had been strangled and then hung.
68. _Ibid., p._ 130.—The Daugats affair. Man found hanging, sitting
on the ground, head and trunk somewhat inclined to the left; legs
stretched out; clothing not disordered; the part of the cord which
was around the neck was applied to the neck of the waistcoat and
shirt; on his head a woollen cap. The ground had been recently swept.
Necroscopy twenty-four hours afterward. Face pale; right eye open and
prominent, left closed; mouth closed, contained food apparently from
the stomach; tongue retracted; slight mark on neck under which the
tissue was normal: atlas dislocated on axis, but tissues around were
normal; no lesion in spinal canal; penis not erect; moisture having the
odor of urine on the shirt; large ecchymosis and infiltration of left
cheek; extensive contusions on scrotum, with hemorrhagic infiltration,
especially around right testicle. Veins of head engorged with black
fluid blood. Brain normal. Some black fluid blood in right cavities of
heart, left side empty. Lungs black. Other organs normal. Causse and
Orfila concluded that the man had been suffocated and then hung. The
wife and son confessed that they had injured the testicle through the
pantaloons; he then fainted; they then suffocated him with the woollen
cap placed over the mouth and nose; the son kneeled on the man’s belly,
the body was then hung up and the head violently twisted.
69. _Passauer: Viert. f. ger. Med. und öff. San., 1876, xxiv., pp.
26-49._—Woman found hanging in a kneeling position. The ligature on
the neck was loose. The necroscopy showed the following: Tongue between
the teeth; eyelids swollen and livid; livid spots on face and left ear;
lower lip torn; a number of marks on neck; one red stripe not sharply
limited; skin not parchmenty and no ecchymosis; ecchymoses of scalp;
periosteum of skull reddened; hemorrhage in temporal muscle; brain and
pia mater congested; much fluid in ventricle. Larynx and trachea dirty
red-brown; right side of heart empty; a little dark fluid blood in
left; great vessels, including aorta, containing much dark fluid blood.
Lungs congested and œdematous. Liver, spleen, and kidneys congested.
Opinion given that she died of asphyxia and was either choked or
hanged. Reference to Royal College of Medicine, Königsberg, where the
opinion was given that she died of injuries on head and neck and was
afterward hanged.
70. _Becker: Same journal, 1877, xxvii., pp. 463-473._—Woman, age
52; found hanging. Death caused by shock and incipient asphyxia from
strangulation and probably the wounds on head and limbs.
71. _Maschka: “Samm. gericht. Gutacht.,” etc. (Prag), Leipzig, 1873_,
published a number of interesting cases, in each of which there was a
question raised as to the cause of death.
72. _Ibid., p. 127._—Man found dead. Had he been strangled or hung, or
had he died some other way? Opinion, death from paralysis of the brain.
73. _Ibid., p. 133._—Woman, age 42; found hanging; a mark around her
neck. Did she hang herself or die of other injuries? Opinion, died of
other injuries.
74. _Rehm: Friedreich’s Blätt., 1883, xxxiv., pp. 322-362._—Man, age
73; found hanging. Opinion, while weak, sick, and suffering from wounds
inflicted by his own son, he was hanged by his daughter-in-law.
75. _Hofmann: “Lehrbuch,” p. 538._—A father hung his five children,
the eldest 9 years. Another man hung two children, the eldest 13 years.
See also Tidy, “Med. Juris.,” Cases 40, 48, 51, 57(?), 58(?); “Hanging
after Death,” Case 50.
JUDICIAL HANGING.
76. _MacLaren: Indian Med. Gaz., 1873, viii., p. 234._—Three cases of
judicial hanging; hung at the same time and cut down and necroscopy
begun forty minutes afterward; drop twelve inches. In the first and
third there were reflex movements for a few minutes after drop fell.
_First man_, age 40; pupils slightly dilated; no protrusion of tongue
or eyeballs; mark of cord above thyroid cartilage; no discharge of
semen or fæces; ecchymosis under cord, left side; dislocation of atlas
from axis; odontoid ligaments ruptured; transverse ligament uninjured.
Brain and membranes much congested; clear fluid in lateral ventricles.
Lungs collapsed, anæmic; one ounce straw-colored serum (measured) in
pericardium; dark fluid blood in both ventricles of heart; liver much
congested.
77. _Second man_, age 16; pupils widely dilated; eyeballs protruding.
Marks of cord same as in preceding case. No discharge of fæces or
semen. No ecchymosis under cord; dislocation and rupture of ligaments
between axis and third vertebra. Brain did not show well-marked
congestion. Lungs collapsed and anæmic. One and one-quarter ounces
serum (measured) in pericardium. Heart normal; dark blood in both
ventricles; liver normal.
78. _Third man_, age 20; pupils slightly dilated; eyeballs and tongue
not protruded. Marks of cord as in preceding. No discharge of fæces or
semen. Slight ecchymosis under cord; mark in front of neck. Dislocation
of occipital bone from atlas. Brain and membranes much congested. Lungs
collapsed and anæmic. Half ounce serum in pericardium. Heart normal;
dark fluid blood in both ventricles; liver normal.
79. _Cayley: Ibid., p. 122._—Man, age 35; executed by hanging.
Scarcely any convulsive movements after drop fell. Necroscopy two hours
afterward. No congestion or protrusion or swelling of the tongue; no
muscular rigidity or contractions. About half-way around the neck was
indentation of cord, obliquely directed; hardly perceptible in front;
its surface appeared rubbed and compressed; no discoloration; no
ecchymosis under skin. Cord lay across upper part of thyroid cartilage.
Larynx and trachea not injured. Fracture and dislocation of upper
cervical vertebræ. Lungs collapsed, not congested. Pericardium empty;
heart distended, left side with red blood just beginning to clot;
right side with fluid black blood. Liver and other abdominal organs
much congested. No discharge of fæces or semen.
80. _Garden: Same journal, 1880, xv., p. 12._—Man, age 40, weight
about one hundred and twenty pounds; drop two feet; was in a fainting
condition, and had to be supported; was not probably fully conscious
when platform fell. There were spasmodic retractions of arms and legs
for about two minutes; forty seconds after the drop his _jungeas_ fell
off; his penis was in strong erection, and the ejaculatory movements
were seen. Necroscopy one and one-quarter hours after drop fell. Head
and limbs cold; eyes open, natural; tongue not protruding; fingers
clinched; superficial veins contained fluid black blood. Mark of cord
extended from just below left mastoid process, where the knot was
applied, across the thyro-hyoid membranes to a place on right side
about two inches below ear. There was scarcely a trace of it behind.
Skin dark and ecchymosed, but no ecchymosis of subcutaneous connective
tissues. No discoloration nor fracture in neck. Subarachnoidal fluid
in excess; puncta vasculosa unusually numerous. Under surface of
epiglottis reddened and showed two small dark red ecchymoses; mucous
membrane of larynx and trachea pale. Lungs showed venous congestion;
no infarctions or small ecchymoses; right lung emphysematous; the left
showed old firm adhesions throughout. Heart large, flabby, pale, a very
little blood in each ventricle; subpericardial ecchymosis one-fourth
inch square anteriorly, another larger one posteriorly; extensive
pericardial adhesions. Liver and kidneys congested.
81. See two cases of judicial hanging by _Wilkie, same journal, 1881,
xvi., p. 275_.
82. _Porter: Archiv. Laryngol., New York, 1880, i., p. 142._—Redemier
hung. Drop five feet. Pulse beat rapidly a few minutes, then lessened
in frequency and stopped beating in fifteen minutes. During this
time there was violent spasm of muscles of thorax and upper limbs.
Necroscopy, dark groove around neck crossing larynx just below _pomum
Adami_. Brain congested. Lungs emphysematous. Cricoid cartilage
fractured diagonally. Laryngeal mucous membrane showed ecchymosis and
œdema. Vertebræ neither fractured nor dislocated.
83. _Another_ criminal hung at the same time had dislocation of
cervical vertebræ.
84. _Fenwick: Canada Med. Jour., 1867, iii., p. 195._—Man executed;
drop six feet; second cervical vertebra torn from attachment to third;
medulla torn across; hyoid bone and tongue torn from thyroid cartilage;
general congestion of viscera; lenses normal; eyes congested; clot
between sclerotic and choroid coats left eye.
85. _Dyer: Trans. Amer. Ophthal. Soc., 1866, p. 13._—Man, age 24;
weight one hundred and seventy-four and a half pounds; drop three feet;
knot under left ear; for two minutes at intervals, slight motion of
abdomen, like effort at respiration, and at same time knees drawn up
a little. Death speedy and quiet. Cut down at end of thirty minutes.
Necroscopy thirty-five minutes after drop. Body and head moist and
warm; emission of semen; face livid; upper lid discolored; abrasion
of skin under right ear; deep red mark around neck. Eyeballs not
prominent; eyelids closed; corneæ dull; pupils a little dilated. _Both
lenses fractured._ Brain normal; spinal cord normal. Heart empty.
86. _Dyer: Same Trans., 1869, pp. 72-75._—Man hung. One eye showed
_fracture of lens_, the other lens showed fine lines. A second case
showed dislocation of a cataractous lens. A third showed fissure of
lens.
87. _Green: Same Trans., 1876, p. 354._—Man hung; drop seven or eight
feet. Died quietly and without struggle. One-half to one hour after
drop fell, eyes were examined. No lesion of capsule or lens.
88. _Keen: Amer. Jour. Med. Sci., 1870, lix., p. 417._—Two criminals
hung; drop five feet. Hyoid bone fractured in one; no fracture of
vertebræ in other.
89. _Clark: Boston Med. and Surg. Jour., 1858, lviii., p.
480._—Execution of Magee. Man, age 28; weight 130 pounds. Drop seven
to eight feet. No struggle nor convulsion. Urine discharged at once.
Seven minutes after drop fell, heart-beat one hundred; nine minutes,
ninety-eight; twelve minutes, sixty and fainter; fourteen minutes,
not audible; twenty-five minutes, body lowered. Face purple; pupils
dilated; eyes and tongue did not protrude. Mark of cord just above
thyroid cartilage, a deep oblique furrow except a small space under
left ear; knot over mastoid process. Forty minutes, cord and strap
removed; body, especially face, became paler. Necroscopy a little over
an hour after drop fell. Body pale; skin mottled; small ecchymosis
just above line of cord right side. Right sterno-mastoid muscle torn.
Hyoid bone fractured; spine not injured. No seminal discharge. Ninety
minutes, pulsation in right subclavian vein; heart-beat, eighty per
minute; thorax opened, heart exposed; right auricle showed full and
regular contractions and dilatations. The spinal cord was then divided.
One hundred and twenty minutes, heart-beats forty per minute. These
pulsations of right auricle continued at intervals for three and a half
hours longer; readily excited by point of scalpel. Heart normal; left
ventricle contracted; right ventricle not so; no coagulation. Brain
normal; lungs collapsed; liver and spleen congested; mucous membrane
of small intestine pinkish; other organs normal. In the discussion,
Dr. Gay thought the absence of cerebral congestion was due to the
circulation continuing in the left carotid.
90. _Hofmann: Wien. med. Woch., 1880, xxx., pp. 477-480._—Man, a
criminal, hung; after hanging ten minutes, the body was cut down.
Examination half-hour after drop fell. He was resuscitated and partly
regained consciousness, but died three days afterward of œdema of
lungs after repeated severe convulsions. He had tumors of the neck
which probably interfered with the compression of the trachea. See also
Allg. Wien. med. Zeit., 1880, xxv., p. 161, and Wien. med. Blät., 1880,
i., pp. 423-430; translated in Ann. Mal. Oreill. and Larynx, Paris,
1880, vi., pp. 99-112.
91. _Kinkhead: Lancet_, and 701-703.—Cases of hanging. In one, the
body of the third cervical vertebra was broken across and the two
pieces separated; in another case dislocation of second and third
cervical vertebræ.
92. _Nelson: Southern Clinic, 1885, viii., pp. 198-202._—Two colored
men hung; drop five feet. In one there was atlo-axoid dislocation.
93. _Dercum: Phila. Med. Times, 1886-87, xvii., p. 368._—Description
of the brain of a man executed by hanging.
94. _Kirtikar: Trans. M. and P. Soc., Bombay, 1885, vi., pp.
104-107._—Man, age 25, and woman, age 35. Both hanged. Drop nine feet.
Knot tied over cricoid cartilage, a little to left side. In falling,
the knots slipped to below the ear. There was fracture of the body of
third cervical vertebra and rupture of ligaments. The cord was ruptured
in each; in the woman in two places—once at the third cervical, the
other at the dorso-lumbar junction.
95. _Lamb: Med. News, Philadelphia, 1882, xli., pp. 42-45._—Execution
of Guiteau. Drop six feet; knot placed under left ear, but slipped
to back of head. Yellowish furrow a few lines wide around the neck,
directed downward and forward. Sterno-mastoid muscles torn transversely
about midway of their length. Thyro-hyoid ligament ruptured; hyoid
bone and thyroid cartilage widely separated. Large blood-vessels not
injured. No fracture or dislocation of vertebræ.
96. _Thomson and Allen: Catalog. Surg. Sec. Army Med. Mus._; specimens
298 to 302.—Execution of Wirtz. Rope one-half inch diameter; drop
five feet; knot under left ear. Several slight shrugs of shoulders,
after which body was quiet; let down in fifteen minutes. No involuntary
evacuation. Face pale, placid. Eyes partly open; pupils dilated; slight
injection of conjunctivæ. Mouth open; tongue not protruding. Just
above thyroid cartilage extending on right side from median line in
front to spinous process was a dirty brown deep furrow with congested
walls; on left side a line of discoloration due to direct action of
rope. Soft parts above and below the line much swollen, particularly on
right side. Larynx and hyoid bone unnaturally mobile. Right trapezius
muscle torn; sterno-mastoid divided transversely, leaving an interval
of two inches. Slight ecchymoses between muscle and larynx. Ecchymoses
on _ligamentum nuchæ_. Hyoid bone, both greater cornua fractured and
dislocated from body; lesions more marked on right side. Several small
ecchymoses in vicinity. Larynx not injured. Brain normal. No bloody
or frothy mucus in air-passages. Lungs not congested. One drachm of
straw-colored serum in pericardium. Heart empty. Abdominal organs
normal. Bladder somewhat distended with urine.
See also Tidy, “Med. Juris.,” Cases 1 to 4 and 60.
ACCIDENT.
97. _Harvey: Indian Med. Gaz., 1876, xi., p. 3._—Boy, age 1½ years;
was swinging by two ropes attached to two posts; the ropes became
twisted around his neck. Necroscopy showed mark of very small rope in
front of neck from ear to ear; mucous membrane of larynx dark; lungs
much congested.
98. _Hackel: Op. cit., p. 35._—Man, age 19, sitting on a load of wood,
with the lines around his neck, fell and was hung by the lines.
99. _Biggs and Jenkins: New York Med. Jour., 1890, lii., p. 30._—Case
16; child, 6 months old, sitting on a high chair, fell between the
chair guard and seat and was asphyxiated by compression of neck.
See also Tidy (_op. cit._), Cases 53 and 54.
SUFFOCATION.
The term suffocation is applied in a special sense to the act and
condition of preventing access of air in other ways than by pressure on
the neck, as by pressure on the chest, by obstruction at the mouth or
nose, by obstruction in the air-passages or on them from neighboring
organs, by irrespirable gases, etc.
This article will consider all of these except drowning and
irrespirable gases, which are treated of elsewhere by other writers.
=Smothering= is generally understood to mean the act and effect of
stopping the mouth and nose.
CAUSES.
=External Causes.=—OVERLAYING is a frequent cause of suffocation
in infants, which in such cases have usually occupied the same bed
with one or both parents. In some cases the parents have been drunk
or otherwise unable to prevent the injury, and the infant may also
be partly stupefied with the alcohol derived from its mother’s milk.
Infants are also sometimes overlaid by domestic animals. Again, they
have been suffocated by being pressed too closely to the mother’s
breast, or by covering with bedclothes, shawls, etc. Noble[883]
attributes some cases of asphyxia in the new-born to anæmia of the
brain from pressure on the skull by forceps, etc., and recommends as
treatment for this condition hanging the child head downward, so that
the blood may gravitate to the brain (Cases 12 and 30).
Infants are sometimes smothered for mercenary purposes.
Persons have been suffocated by the pressure of a crowd. Pressure on
the chest combined with forcible closure of the mouth and nose was
the method of Burke and Williams, in the notorious _burking_ murders
(Case 58). The close application of a hand, cloth, or plaster over nose
and mouth is of itself sufficient to cause suffocation, especially
in children and feeble persons. Pressure on the abdomen crowds up
the diaphragm and interferes with breathing. It is very likely that
no external mark will be found in cases of pressure on the chest and
abdomen, but the lungs will be marbled and emphysematous.
Taking plaster casts of the face and neck without inserting tubes in
the nostrils has caused death in some cases. Suffocation often follows
the falling of walls, houses, banks of earth, piles of coal or corn or
wheat. One may fall into and be imbedded in some mobile substance as
coal, wheat, corn, quicksand, or nightsoil, and be suffocated. Infants
have been destroyed[884] by burying them in manure, ashes, bran, etc.
In these cases there is not only the entrance of the foreign body into
the air-passages, but the pressure of the mass against the chest and
abdomen.
=Internal Causes.=—The air-passages may be closed up by foreign bodies
within them, or within adjoining organs, especially the œsophagus.
A great variety of substances in one of these two ways has caused
suffocation: mud, cotton, rags, corn, meat, beans, pepper, potato
skins, the fang of a tooth, artificial teeth, buckles, shells, flint,
buttons, screws, crusts of bread, bones, fruit, stones, heads of grass,
coins, slate pencils, nuts, nut-shells, shot, penholders, worms,
fish, etc. (see Cases 6 and 55). Taylor[885] states that there were
eighty-one deaths in one year in England and Wales from food in the
air-passages.
Should an inspiration occur in the act of vomiting, the vomitus may
pass into the air-passages; a similar accident may occur in a person
who attempts to swallow and speak at the same time. Infants have been
suffocated by inspiring vomited milk. Fitz[886] states that food may
pass from the digestive tube to the air-passages after death.
A case of suffocation in an infant by retraction of the base of the
tongue is recorded. It has been stated that negroes have committed
suicide by doubling back the tongue into the throat, or, as it is
called, swallowing the tongue.[887] In giving anæsthetics, the subject
being supine, and the head and neck somewhat flexed, the tongue,
epiglottis, and soft palate may fall backward and suffocation may
follow. Howard[888] states that pulling the tongue forward under such
circumstances may reopen the pharynx, but will not lift the epiglottis.
The thorax should be raised and head and neck extended backward. He
believes that in giving anæsthetics the head should be lower than the
shoulders. In order to avoid vomiting no food should be taken for some
hours before the anæsthetic.
Cases are recorded of artificial teeth having fallen from the mouth
into the air-passages during anæsthesia and sleep, and in epileptic
and puerperal convulsions. It would appear advisable that these teeth
should be worn only while eating (Case 13).
Hemorrhage from the lungs, from rupture of an aneurism or from injury
of the mouth or throat, may make its way into the air-passages and
cause suffocation. So also the bursting of an abscess of the tonsils or
other part near the air-passages (Case 7).
Œdema of the glottis from scalding or other irritation of the fauces
or glottis, or from disease of the kidneys; tumors pressing on some
portion of the air-passages; rapid, profuse bronchial secretion in
infants; acute double pleuritic effusion; cheesy glands ulcerating
into trachea; simultaneous œdema of both lungs—all of these may cause
suffocation (Cases 18 and 49). [For cases of enlarged thymus gland, see
Hofmann, _op. cit._, pp. 587, 588.]
Paralysis of the muscles of swallowing, from diphtheria or other
cause, predisposes to suffocation. Progressive asthenia in which
the muscles are exhausted; injury of spinal cord or pneumogastrics;
paralysis of muscles of respiration from the use of curare; the
spasms of tetanus and strychnia poisoning; the entrance of air into
the pleural cavities with collapse of the lungs—all tend to cause
mechanical suffocation either by pressure or by paralysis (for deaths
in epileptics, see Cases 1, 10, 11, 33, and 40).
It is not necessary that the air-passages should be _absolutely_ closed
to cause suffocation.
The _cause of death_ is more likely to be pure asphyxia, because of the
absence of the complicating pressure of the hand or ligature on the
vessels and nerves of the neck, and of fracture of larynx or vertebræ.
=Symptoms.=—Foreign bodies[889] entering the trachea naturally fall
toward the right bronchial tube instead of the left because of the
size and position of the entrance of the right tube. If then but one
tube is involved, the signs will usually be on the right side; whereas
if the foreign body stop in the larynx or trachea, both sides will be
affected. The latter condition is much more dangerous. The symptoms
would be resonance over the lung with the respiratory murmur partly or
wholly absent; less mobility; puerile breathing on the unaffected side.
In either case there may at first be little disturbance, especially
if the shape of the foreign body is such as not to greatly interfere
with the access of air; otherwise there may be at once, and almost
always will be after a time, more or less urgent dyspnœa. Diminution of
the necessary oxygen may cause convulsions, apoplexy, and other brain
symptoms. Acute emphysema of the portion of lung not obstructed may
follow its forcible distention. The local effect of the foreign body is
an irritation which causes spasm and cough. It may be carried upward by
the expirations and downward again by each inspiration. Inflammation
is likely to appear eventually and may involve the lung. If the
obstruction is not complete there may follow periods of alternation of
good and bad health, ending perhaps in recovery. The foreign body may
be expelled after a greater or lesser interval. On the other hand death
may result from secondary causes. In the absence of correct history
the symptoms may lead to a wrong diagnosis and inappropriate treatment;
as where a patient whose symptoms resulted from the presence of a piece
of bone in the larynx, was treated for syphilis. A foreign body may be
coughed up from the lung into the trachea and fall backward into the
opposite lung.
Partial closure of the larynx, most likely caused by a flat or
irregular substance, rather than globular, may cause gradual asphyxia
with symptoms of apoplexy, making the diagnosis difficult.
When a foreign body remains a long time in the larynx, spasmodic cough
and croupy breathing usually ensue, expectoration tinged with blood,
hoarseness, or complete aphonia, pain, dyspnœa, possibly crepitation
and dulness over the lungs. The case may end suddenly in death from
closure of the glottis, or the foreign body may pass into the trachea
and set up a new train of symptoms, or it may be expelled.
The frequency with which foreign bodies in the pharynx or œsophagus
obstruct respiration, and the facility with which they may usually be
removed, suggest a careful examination. Otherwise the patient may be
treated indefinitely for supposed obstruction in the air-passages.
Foreign bodies in the œsophagus have perforated into the trachea, and
even the lungs, heart, and aorta.
In complete suffocation death will occur in from two to five
minutes (see remarks under Strangulation). Death may also occur
instantaneously.
The experiments of the Committee on Suspended Animation[890] showed
that when the trachea of a dog was exposed, incised, and a tube tied
in, the average time covered by the respiratory efforts after stopping
up the tube with a cork was four minutes five seconds; the heart-beat
stopping at seven minutes eleven seconds on the average. After four
minutes ten seconds it seemed to be impossible for the dog, unaided,
to recover. Faure[891] made the following experiment upon a large dog:
He fixed a cork in the trachea. At first the dog was quiet; it then
extended its neck, parted its jaws, and made efforts as if to vomit;
then tried to walk, but its gait was uncertain; fell down and rose
up. Its eyes became dull, and finally it fell down on its side, and
became convulsed; then after several seconds stretched itself out.
The thoracic movements were at first tumultuous, then became rapidly
feeble; the heart beating very slowly. At the necroscopy the lungs
filled the thorax, were full of thick dark blood and emphysematous.
The blood was black and fluid in the left ventricle and arteries,
and in the right cavities and veins resembled molasses. Liver darkly
congested. There was no mucus in the trachea and no ecchymosis in
the lungs. He also (p. 306) tried the experiment upon a large dog of
fastening boards against its thorax and tightening them by means of
cords. For some minutes it was quiet, but suddenly it became much
agitated, stood upon its hind legs, threw itself against the wall,
rolled on the ground, and uttered frightful cries; finally fell on
its side. There was no movement of the thorax, but the muscles of
the neck and belly were in full and rapid action, dry and sonorous
râles were heard, and a large quantity of mucus appeared at the nose
and mouth. The movements grew feebler, the respirations infrequent,
and at the end of thirty-four minutes it was dead. The necroscopy
showed the blood black and thick; heart relaxed; lungs red, a little
emphysematous, containing but little blood, and on their surface were
blackish points and small red spots.
The death of Desdemona (Shakespeare’s “Othello”) has been much
criticised. The declaration that she was strangled (or suffocated)
does not consist with the symptoms described (see _Med. News_,
Philadelphia, May 1st, 1886, p. 489).
TREATMENT.
The obvious indication is to search for and remove the obstruction. The
means and methods of treatment are fully treated of in surgical works,
but may be briefly mentioned here.
Laryngoscopical examination may be necessary. A curved forceps is
usually the best instrument for removing the foreign body. A tallow
candle may serve to push it into the stomach if there is no bougie at
hand. Suction may be used. Sneezing may be brought on by tickling the
nostrils; coughing by tickling the glottis; vomiting by irritating the
fauces, or by emetic; the body of the subject may be inverted and in
this position the fauces may be tickled, or fingers may be passed back
into the pharynx. Johnson[892] says that at the moment of inversion the
patient should try to take a deep inspiration; this opens the glottis
and facilitates the expulsion of the foreign body. The inspiratory
current has no appreciable effect in retarding the movement of the
foreign body in the direction of gravity.
Noble recommends inversion of the body in new-born infants in which
asphyxia may be supposed to be due to anæmia of the brain. Tracheotomy
or laryngotomy may be necessary. It may be necessary to administer
oxygen. Foreign bodies like beards of grass and fish-heads can be
withdrawn only with difficulty because of their sharp projections.
Intense suffering and dyspnœa in a robust subject may necessitate
venesection. Generally speaking it is better to bring up the foreign
body than to push it down into the stomach. Beveridge suggests to
blow into the ear, to induce a reflex action and cause expulsion of
the foreign body. Cold affusions, artificial respiration, galvanism,
frictions of the limbs, artificial heat, stimulants by mouth and
rectum, may one or all be needed.
Hamilton[893] says that it is useless to expect good results from
electricity if five minutes have elapsed since life appeared to be
extinct; Althaus,[894] that three hours after death the muscles will
cease to respond to faradization; and Richardson,[895] that a low
temperature prolongs the sensitiveness of the muscle.
With regard to insufflation, Le Bon[896] objects to it in asphyxia as
being hurtful and not useful. Colin[897] tamponed the trachea of a
horse; in four minutes fifty seconds it was apparently dead; the tampon
was removed and insufflation practised for fifteen to twenty minutes
without effect. He claims that artificial respiration is useless after
the circulation ceases.
Fell[898] and O’Dwyer[899] recommend forced inspiration. McEwen[900]
uses a tracheal tube by the mouth.
Dew[901] offers a new method of artificial respiration in asphyxia
of the new-born; Lusk[902] considers the subject of life-saving
in still-births; Forest,[903] artificial respiration in the same;
Read[904] discusses Schultze’s method with approval; Duke[905] plunges
the infant into hot water; Richardson[906] recommends artificial
circulation by injection of vessels, or electric excitation;
Jennings[907] recommends the same; Richardson[908] also considers
fully the subject of artificial respiration and electrical excitation;
Woillez[909] has described and recommended what he calls a spirophore.
After the removal of a foreign body the irritation remaining may cause
a sensation as if the body was still lodged.
Death may occur from hemorrhage after its removal.
POST-MORTEM APPEARANCES.
These are mainly those of asphyxia. There may also be evidences of
external violence, homicidal or accidental, as of pressure on the
chest. Persistent deformity, flattening of the nose and lips, and
excoriation of these parts may result from forcible closure of mouth
and nose.
The SKIN AND CONJUNCTIVA usually show patches of lividity and
punctiform ecchymoses; especially lividity on the lips and limbs. The
face may be pale or violet; it is often placid, especially if the
suffocation is accidental. Tardieu[910] admits that infiltration of the
conjunctiva and punctiform ecchymoses of the face, neck, and chest may
also be found sometimes in women after severe labor, and in epileptics.
He records the result of the examination of those who died from
suffocation at the Pont de la Concorde, 1866. The face and upper parts
of the trunk were generally light red to a deep violet or black color,
with punctated blackish ecchymoses on the face, neck, and upper part of
chest.
The EYES are usually congested. Mucus and sometimes bloody froth are
found about the NOSE and MOUTH. The TONGUE may or may not protrude.
The BLOOD is usually dark and very fluid. Wounds after death may bleed.
According to Tardieu[911] fluidity of the blood is most constant in
compression of the chest and abdomen, as also its accumulation in the
vessels and right side of heart. Its color varies from red to black.
The BRAIN and pia mater are generally congested. This is said to be
invariable if the eyes are congested. Mackenzie in thirteen cases found
the brain congested in all.
The HEART varies much in appearance and condition. The right side is
often full of blood; occasionally empty. Sometimes subpericardial
ecchymoses are found, usually along the coronary vessels. The blood in
the heart may be partly coagulated if the agony has been prolonged and
there has been a partial access of air, which is gradually diminished.
Mackenzie[912] found the right cavities full and the left empty in
nine out of thirteen cases. Johnson[913] as a result of experiment
on animals claims that when access of air is prevented there is a
rise in pressure in the arteries, the right side of the heart fills,
the pulmonary capillaries become empty, and therefore the left side
of the heart becomes empty. As a result of further experiments[914]
he verified his former conclusion, and added that in the last stage
of asphyxia there is increased pressure on the pulmonary artery and
lessened pressure in the systemic vessels. He thinks[915] that when
both sides of the heart contain blood, there is paralysis of vaso-motor
nerves and the arteries.
The TRACHEA is usually bright red and often contains bloody froth. The
LARYNX or trachea as well as PHARYNX or ŒSOPHAGUS may contain a foreign
body. If the latter has been removed the resulting irritation may be
seen. The LUNGS are sometimes congested, at others normal; color red or
pale. Sometimes one lung only is affected. They may be emphysematous.
Mackenzie found them congested in all of thirteen cases examined by
him. The lungs of young persons may be found comparatively small,
almost bloodless, and emphysematous. Tardieu, Albi, and others believed
that the _punctiform subpleural ecchymoses_ indicated suffocation, and
were due to small hemorrhages from engorged vessels which ruptured
in the efforts at expiration. These spots are usually round, dark,
from the size of a pin-head to a small lentil, and well defined.
They are not like the petechiæ in the lungs and heart after purpura,
cholera, eruptive fevers, etc., nor like the hemorrhages under the
scalp after tedious labor, all of which are variable in size. These
punctiform spots are usually seen at the root, base, and lower margin
of the lungs. Hofmann states (“Lehrbuch”) that they are found in the
posterior part of the lungs and in the fissures between the lobes. They
are indisputably frequent after death from suffocation, and if well
marked either in adults or infants that have breathed, they indicate
suffocation, unless some other cause of death is clear. Simon, Ogston,
and Tidy, however, have shown that they are sometimes absent in fatal
suffocation, and are sometimes present in the absence of suffocation,
as after hanging and drowning; in fœtuses before labor has begun;
often in still-births, although some of these are probably due to
suffocation from inhaling fluid or from pressure. Also in death from
scarlet fever, heart disease, apoplexy, pneumonia, and pulmonary œdema.
Grosclaude[916] quotes from Pinard, who declares that these ecchymoses
are found in fœtuses which die from arrest of circulation. Grosclaude
himself made a large number of experiments on animals by drowning,
hanging, and strangling, and fracturing the skull. The ecchymoses were
found in nearly all the cases.
The ecchymoses are partly the result of venous stasis, which overcomes
the resistance of some capillaries; and the latter rupture, partly from
the aspirating action of the thoracic wall, the lung being unable to
fill itself with air, but mainly[917] from vaso-motor contraction and
lateral pressure at the maximum of the asphyxia, the time of tetanic
expiration. If the asphyxia is interrupted before this stage, the
spots do not appear. Similar ecchymoses may be found under the scalp,
in the tympanum, retina, nose, epiglottis, larynx, trachea, thymus,
pericardium, in the parietal pleura, along the intercostal vessels,
rarely the peritoneum, in the stomach, and sometimes the intestines;
and in other parts of the body, especially the face, base of neck, and
front of chest; in convulsive affections, as eclampsia and epilepsy,
and in the convulsions of strychnia and prussic acid poisoning there
may be suffusion and congestion of the lungs though not the punctated
spots.
Mackenzie, in thirteen cases of suffocation from various causes, failed
to find the Tardieu spots either externally or internally. Briand and
Chaudé[918] state that they are less constant and characteristic in
those who have been buried in pulverulent substances.
Ogston[919] holds that in infants that are smothered the ecchymoses
are found in greater number in the thymus gland; while in adults dying
from other forms of asphyxia they were found only once in that gland.
The spots are found in clusters in infants that are smothered, but
only single and scattered in adults who die from drowning, hanging or
disease. They were wanting in the lungs of but one infant.
They may be recognized as long as the lung tissue is unchanged. The
apoplectic spots in the lungs seen in strangulation are not found in
suffocation.
Tardieu[920] from experiments on animals and examination of
twenty-three new-born infants who showed traces of violence around the
mouth, found the lungs rather pale and anæmic, subpleural ecchymoses
well marked. All the deaths were rapid. In cases of compression of
chest and abdomen[921] the congestion of the lungs was extensive,
and pulmonary apoplexy frequent; more so than in other forms of
suffocation. He gave strychnia to animals which died in convulsions,
and found very irregular and partial congestions, generally not
marked because death was so prompt; blood always fluid; no subpleural
ecchymoses.
The LIVER, SPLEEN, and KIDNEYS are generally congested; the kidney more
than the other organs named. The spleen is said to be often anæmic.
Semen has sometimes been found, unexpelled, in the urethra.
Page[922] experimented on three kittens, suffocating them in cinders.
The post-mortem examinations showed the veins engorged, left side
of heart empty, right side full of dark, half-clotted blood. Lungs
distended, much congested, color violet; many small fluid hemorrhages
in substance; no subpleural ecchymoses. Frothy mucus tinged with blood
in trachea and bronchi; bronchi congested. Brain and abdominal organs
normal.
PROOF OF DEATH BY SUFFOCATION.
It is sometimes difficult in a given case to state WHETHER DEATH IS DUE
TO SUFFOCATION. There is no lesion which of itself could be accepted as
proof. But a collation of the lesions found taken in connection with
the surroundings of the body will in many if not in most cases lead to
a definite conclusion.
Infants have been found alive four and five hours after having been
buried in the earth.[923] If the pulverulent material has penetrated
into the œsophagus and stomach, the burial has occurred during life.
Exceptionally when burial has occurred after death and traces of the
material are found in the air-passages, they are _not_ found in the
œsophagus or stomach.
The committee on “Suffocation,” of the New York Med. Leg. Soc.,
reported[924] the following group of appearances as evidences of
death by suffocation: The general venous character of the blood, the
turgidity of the larger veins, the congestion of the parenchymatous
organs, especially at the base of the brain, the lungs congested in
a variable degree and œdematous, frothy mucus in the bronchi, the
right side of the heart always fuller than the left. Fitz[925] holds
that suffocation is a condition composed of a group of symptoms and
appearances due most probably to accumulation of carbon dioxide in
the blood and a deficiency of oxygen. The appearances are: The blood
dark and fluid (though in gradual suffocation there may be clots in
the right side of the heart), the right side of the heart full, venous
congestion of the lungs (not constant), interstitial emphysema of the
lungs, and venous congestion of the liver, kidneys, and brain. He
prefers the word _engorgement_ to congestion in this connection.
Tardieu[926] holds that when in infants buried in pulverulent
substances we find emphysema of the lungs in high degree, bloody froth
in the air-passages, abundant subpleural and subpericardial ecchymoses
and the blood fluid, the burial has occurred during life. The same
lesions are found in small animals similarly treated.
It must not be forgotten that an intoxicated person or one in an
epileptic spasm is practically helpless, and can, therefore, be
suffocated, accidentally or otherwise, under circumstances in which one
in possession of his senses would be able to escape.
ACCIDENTAL, HOMICIDAL, AND SUICIDAL SUFFOCATION.
=Accidental suffocation= is frequent, as has already appeared.
=Suicidal suffocation= is very rare. =Homicidal suffocation= occurs.
Foreign bodies have been forced into the air-passages. Smothering has
been done by holding the face in various materials to prevent access
of air; by pressure on the chest; by forcible closure of the mouth and
nose as in burking; by laying compresses over the face, as in the case
of King Benhadad,[927] whom Hazael killed. “And it came to pass on the
morrow that he took a thick cloth and dipped it in water, and spread
it over his face so that he died; and Hazael reigned in his stead.”
Benhadad was already quite ill and not expected to live.
Death by suffocation[928] may be considered as presumptive of homicide
unless the facts are already referable to accident.
In infants, suffocation is, of course, either accidental or homicidal;
in adults usually accidental. The absence of signs of a struggle
in adults suggests accident; unless there is cause of suspicion of
previous stupefying with narcotics.
Taylor[929] calls attention to a dangerous practice among some
attendants upon infants, of putting into the mouth of the child to
quiet it a bag containing sugar; and instances a case in which the
child would have died of suffocation but for the fortunate discovery of
a part of the bag protruding from the mouth.
In ten years, 3,612 deaths were reported in the city of London, of
infants smothered by being overlaid.[930]
Infants may be born into a mass of blood and fæces, from which the
unattended mother in her weakness may be unable to remove them.
Page[931] shows by experiment that the inspiratory effort when
violently exerted is sufficient to convey small objects into the
air-passages. Cinders passed thus into the trachea and œsophagus of
kittens and rabbits. Berenguier[932] experimented on new-born pups,
placing them in ashes, plaster, and starch. In ashes they lived
fifteen hours; these found their way into the middle of the œsophagus,
but were stopped at the glottis. Plaster and starch formed a paste
with the oral mucus and the movement of the mass was not so great
as the ashes. In no case did either of the materials pass beyond
the glottis. Tardieu[933] examined three infants which had been
buried during life. One was in ashes: the nose was obstructed, mouth
full: ashes also in the œsophagus and stomach, but none in larynx
or bronchi. The second infant was in manure; a greenish stuff was
found in the mouth and stomach. The third in bran (confessed to by
the mother); the nose and mouth were full, but there was none in the
throat; a few grains in the trachea. Tardieu experimented on rabbits
and Guinea pigs by burying them in bran, sand, and gravel, some of
them being alive and the others dead. In those buried alive he found
the substance filling the mouth and nose to the base of the tongue;
in most of the cases the œsophagus and trachea were not penetrated.
In the animals first killed and then buried, the substance had not
passed into the mouth or nose. In one case only he found ashes in
the larynx and trachea of a rabbit which had been buried many hours
after death in a box of ashes. Matthyssen[934] held a Guinea pig, head
downward, with its nose under mercury; the lungs were full of globules
of mercury (which has a specific gravity of 13.5). A dog was plunged
head first into liquid plaster-of-Paris; the plaster was found in the
bronchial tubes.
ILLUSTRATIVE CASES.
ACCIDENTAL.
1. _Huppert: Vier. ger. Med. und öff. San., 1876, xxiv., pp.
237-252._—Two cases. A man choked by piece of bread in pharynx.
Second, an epileptic, suffocated by _flexion of chin on larynx_. In
both cases seminal fluid was found in urethra near meatus, unexpelled;
determined by microscope.
2. _Johnson: Lancet, 1878, ii., p. 501._—Boy swallowed penny, became
black in face; eyeballs protruded; symptoms soon subsided. Some hours
afterward it was found that he could not swallow solids, and liquids
only with difficulty and coughing. Throat much irritated; discharge of
mucus sometimes tinged with blood, from mouth; moist rattling noise in
throat in respiration; frequent cough; could not sleep. Laryngoscope
showed penny in upper part of œsophagus, just below laryngeal opening.
Removed by long curved forceps.
3. _Ibid._—Man suddenly fell while at dinner; face blue; breathing
stertorous. Died. Piece of tendon found under epiglottis.
4. _Ibid._—Boy, age 5 years. Button in larynx. Aphonia, dyspnœa,
stridulous breathing. Distress gradually subsided. Many years afterward
found mucous membrane of larynx thickened; vocal cords red and uneven.
5. _Ibid._—Man, drunk, swallowed a half-sovereign. Urgent dyspnœa;
pain in throat; aphonia; stridulous breathing; dysphagia; cough;
copious mucous expectoration. Laryngoscopic examination showed coin
in œsophagus. The crico-thyroid membrane was incised and coin pushed
upward and ejected.
6. _Med. Times and Gaz., 1874, i., p. 486._—Man, age 20, had severe
dyspnœa. In taking a living fish in his teeth (it was about four inches
long and had large dorsal fin), the fish passed into the pharynx and
lay doubled up. Impossible to remove it because of spines. Tracheotomy
at once. Twenty-four hours afterward the fish had decomposed enough to
be partly removed. Patient died of exhaustion.
7. _Littlejohn: Edin. Med. Jour., 1875, xx., p. 780._—Woman found
dead in bed. Suffocated by pus from abscess of tonsil which burst
during sleep. Found pus in air-passages down to smallest bronchi; lungs
congested; right side of heart distended with dark fluid blood; left
side contracted and nearly empty. Blood everywhere fluid. Some lividity
of face. The woman had died quietly lying beside her husband, who was
not awakened.
8. _Sayre: New York Med. Jour., 1874, xix., p. 420._—Girl, age
7, swallowed a bead. Had continuous cough; much pain under middle
of sternum. The bead moved upward and downward in respiration.
Tracheotomy. Four days afterward she coughed the bead out, inspired
once, and apparently died. Artificial respiration used; alcohol
injected into rectum; galvanization of phrenic nerves. She finally
coughed up a piece of thick mucus and recovered.
9. _Duffy: Trans. Med. Soc. No. Car., 1874, p. 126._—Boy, age 8,
swallowed a cow-pea. It lodged in the trachea. Some months afterward,
laryngotomy performed. The boy seemed to die at once. Artificial
respiration used. After a while he expelled first some mucus, then the
pea. Recovered.
10. _Tardieu: Op. cit., p. 290._—Man, age 50, found dead on the floor.
At base of neck and front of chest were many punctated ecchymoses.
Brain and lungs much congested; the latter showed subpleural spots.
Tongue and lips bitten. Death was due to cerebral and pulmonary
congestion from an epileptic seizure.
11. _Oesterlen: Vier. f. ger. Med. und öff. San., 1876, xxiv., p.
10._—Woman, age 30, epileptic. Found dead. Examination showed signs
of asphyxia; blood-vessels engorged, marked œdema of lungs, etc.
Opinion given that she died in epileptic paroxysm, and certain injuries
observed were caused by a fall.
12. _Tardieu: Op. cit., p. 322._—Two children, one 2 months old, the
other 18 months old; in bed together. The older overlay the younger,
which died. Necroscopy: lungs voluminous, in places congested, in
others pale; abundant subpleural ecchymoses; quite emphysematous. Fluid
blood in heart.
13. _Blum: New York Med. Jour., 1885, xlii., p. 207._—Woman, found
dead. Vulcanite plate of usual size, with four teeth attached, found
wedged in trachea about two inches below larynx.
14. _Wyeth: Same journal, 1884, xl., p. 487._—Boy, age 12, inspired
a pin-dart in trying to blow it through a blowgun. Violent cough,
gasping for breath, lividity of face for a few minutes; symptoms
subsided leaving slight cough. The dart had lodged in right bronchus
beyond first bifurcation, as shown by hissing, fluttering sound in both
inspiration and expiration. Tracheotomy. The dart could not be reached.
At a later date the dart was brought up into the mouth by a strong
expiration.
15. _Partridge: Same journal, 1890, li., p. 303._—Child, 4 months old,
found dead; fluid, partly digested milk in air-passages.
16-41. _Biggs and Jenkins: Same journal, 1890, lii., p. 30._—Report
of many cases of fatal suffocation from foreign bodies, etc. Boy, age
15—collar-button in larynx. Boy, age 10—mass of butter in larynx.
Boy, age 5—bronchial gland discharged into trachea at bifurcation.
Boy, age 3—screw in larynx. Boy, age 5—rubber balloon with whistle
attached; it was partly inflated with each expiration. Girl, age 10—a
“jack” in larynx. Man, age 45—had been drinking freely; piece of meat
in larynx. Man, age 40—piece of meat in larynx and pharynx. Man, age
40—ditto. Insane patient—piece of meat in trachea. Man—piece of meat
in larynx. Man, age 40—crackers and cheese in larynx. Child—rubber
nipple in larynx. During administration of ether, patient vomited;
vomitus entered larynx. Two children in bed asleep; one, 3 years
old, overlay the face of the younger, age 5 months. Woman, age 25,
epileptic—fell on a child and smothered it. Two children found dead,
covered with bedclothing. Man, age 21, epileptic—found lying on his
face in bed. Girl, age 12, epileptic—ditto. Woman, age 21—ditto.
Girl, age 18—ditto. Woman, age 35, epileptic—fell on the floor.
Woman, age 28—ditto. Man, age 35, epileptic; vomited while in spasm;
vomitus entered larynx. _From Dr Janeway_: Man, epileptic, fell on his
face in pile of manure, which entered larynx. Man, drunk, lying on his
face.
42. _Roy. Indian Med. Gaz., 1880, xv., p. 71._—Man, believed to be
drunk, had vomited in bed; vomitus entered trachea and bronchi.
43-47. _Mackenzie: Same journal, 1890, xxv., p. 257._—Reports fatal
cases: Boy—bone button in larynx. Sailor—meat in larynx. Boy—vomited
matter in larynx. Infant—while taking the breast, a rush of milk
suddenly filled the air-passages. Also three cases of crushing under
walls; two buried in loose earth; two crushed in a crowd; one by bags
of grain.
48. _Feulard: Bull. Soc. Anat., 1883, viii., pp. 384-386._—Woman, age
79. Piece of beef in larynx. Necroscopy showed hematoma in dura mater.
49. _Poupon: Bull. Soc. Clin., Paris (1882), 1883, vi., pp.
236-238._—Boy, age 5½ years. Death from cheesy gland in trachea.
50. _Pons: Jour. Méd., Bordeaux, 1889-1890, xix., pp. 57-61._—Woman,
age 24. Death from œdema of larynx from presence of particles of food.
51. _Kemény: Wien. med. Blat., 1890, xiii., p. 37._—Man, age 45.
Suffocated by curdled milk in air-passages.
52. _Maschka: Vier. ger. Med., 1885, xliii., pp. 11-14._—Man, age 65.
Accidental compression of chest.
53. _Heidenhain: Same journal, 1886, xliv., pp. 96-101._—Vomited
matter passed into air-passages while subject was drunk.
54. _Langstein: Wien. med. Woch., 1880, xxx., pp. 624-626._—Child
found dead in bed; had vomited food while asleep and breathed it into
air-passages.
55. _Ward: Catalog. Army Med. Mus., Med. Sec., p. 33._—Soldier, age
17; choked to death by lumbricoid worm passing from pharynx into right
bronchus. Specimen 7,737.
SUICIDE.
56. _Sankey: Brit. Med. Jour., 1883, i., p. 88._—Epileptic; found dead
in bed, lying on his back. A round pebble in each nostril; strip of
flannel rolled up and stuffed in throat.
57. _Macleod: Ibid., 1882, ii., p. 1246._—Suicidal maniac. Had to
be fed because he refused food. Was seen to be blue in the face and
breathing hard. His mouth was forced open; roll of flannel found in
throat. Macleod refers to another case, a woman in dissecting-room,
with similar roll of flannel in throat.
See Tidy, “Med. Jur.,” Cases 15 to 17.
HOMICIDE.
58. _Christison: Edin. Med. Jour., 1829, xxxi., pp. 236-250._—The
famous Burking case. A woman was struck down to a sitting posture.
Burke then threw himself on her, kept her down by the weight of
his body, covered her mouth and nose with one hand and placed his
other hand under the chin for ten to fifteen minutes, till she died.
Necroscopy showed a severing of the posterior ligamentous connections
of the third and fourth cervical vertebræ, with blood in spinal canal
but not under the dura mater; cord not injured. Christison made
experiments to ascertain if the injury to spine had been made during
life.
59. _Hackel: Dorpat Diss., 1891, p. 35._—Case of choking with pressure
on breast and belly. Woman found lying on floor, with many injuries.
60. _Tardieu: Op. cit., p. 315._—New-born infant; found buried in
earth. Mother stated that the child had not breathed. Putrefaction had
begun. There was a brownish tint of skin of upper front part of neck
below jaw; drops of sanious fluid flowing from nose; umbilical cord had
not been tied; subcutaneous hemorrhage in right temporal region; brown
bruised surface and contused wounds of pharynx, where particles like
ashes and vomited matter were found. Lungs filled the pleural cavities,
were rose-colored and showed abundant punctated subpleural ecchymoses;
bloody, frothy mucus in trachea and bronchi; some serum in pericardium;
respiration had been complete. Opinion given, that the infant had been
suffocated by obstruction of pharynx, probably by fingers.
61. _Tardieu: Op. cit., p. 323._—New-born infant found under a cask,
partly eaten by a dog. The head showed transverse flattening and
subcutaneous hemorrhage. Lungs voluminous, rosy; abundant subpleural
ecchymoses; hemorrhage in left lung. Heart filled with fluid blood.
Coagulated blood in abdomen. Opinion given, suffocation by pressure on
head, chest, and abdomen. The mother confessed that she had placed the
child under the cask.
62. _Ibid., p. 325._—New-born infant found buried in the earth; gravel
and earth in pharynx and œsophagus down nearly to stomach, and in
trachea and right bronchus. Lungs congested, crepitant. Opinion given,
that the child had been buried while living.
63. _Ibid., p. 326._—New-born infant found in ashes; nose and lips
obstructed, mouth filled; ashes in œsophagus and stomach; none in
larynx or trachea. Lungs distended with air, emphysematous; subpleural
ecchymoses; fluid blood in heart.
64. _Ibid., p. 327._—New-born infant, buried in bran; nose and mouth
filled; some in trachea; none in œsophagus or stomach. Lungs distended
with air, emphysematous; subpleural ecchymoses; heart empty.
65. _Devergie and Raynaud: Ann. d’Hyg., 1852, xlviii., pp.
187-206._—Man found dead on a pile of grain; mouth, nose, and eyes
contained some of the grain; some also in stomach, larynx, trachea, and
bronchi. Some marks of injury on face and other parts of body. Internal
signs of asphyxia. Opinion given, that the case was homicide. The
defence offered was that the man had fallen into the grain.
66. _Rauscher: Friedreich’s Blat., 1886, xxxvii., pp. 324-330._—Woman,
age 71, suffocated by a cloth over nose and mouth.
See Tidy, “Med. Jur.,” Cases 1 to 11.
DEATH FROM SUBMERSION
IN ITS
MEDICO-LEGAL RELATIONS.
BY
IRVING C. ROSSE, A.M., M.D., F.R.G.S. (ENG.),
_Professor of Nervous Diseases, Georgetown University; Membre du
Congrès International d’Anthropologie Criminelle, etc._
DEATH BY SUBMERSION OR DROWNING.
GENERAL CONSIDERATIONS.
THE frequence and importance of drowning having arrested attention
from the days of Noah’s Ark and those of Hippocrates down to the
present time, it is quite possible to array in chronological order the
fictitious, transitory, and positive periods that mark the sequence of
ideas touching the subject.
Mooted questions relative to drowning have been debated since the
fourteenth century; and modern statistics show the great development
of this class of emergency, than which none is of more startling
character. In France between four and five thousand cases of this
kind of accident are officially recognized each year, which is about
one-third of all the accidental deaths, and the number appears to
increase yearly. Nearly the same figures apply to the inland waters of
England and Wales, not including the coast. The Board of Trade Return
shows that out of 86,695 seamen who died in English ships abroad,
53,673 were drowned, and a late report of the Fisherman’s Federation
places the number drowned in the inland waters and upon the immediate
coasts of the United Kingdom and its adjacent islands as 6,268
annually. The many hundreds drowned in the late _Victoria_ disaster
and in the great storm that swept the British Isles are matters of
current knowledge. In our own country accounts of drowning are of daily
occurrence, and help to the drowning forms the greater part of the
work done by that noble governmental branch, the Life Saving Service.
Not only does the sea claim its numerous victims, but the great floods
and cyclones have destroyed thousands, while on the lakes and rivers
drowning accidents are lamentably frequent. If the statistics of such
accidents were as available as those of the late war, for instance, the
exhibit would doubtless be surprising. Where the aggregation of killed
in action is shown to be 67,058, there were drowned 106 officers and
4,838 men. The small regular army lost 5 officers and 89 men from this
cause; the negro troops, 6 officers and 289 men; and the volunteers
furnished a large contingent, the State of Ohio alone having lost 14
officers and 770 men from drowning.[935]
Aside from the point of view of public hygiene and that of pathology,
further evidence is not wanting to show the medico-legal value of the
phenomena of drowning, and the frequency and importance of the judicial
questions that may arise in this class of accidents.
DEFINITION AND PHENOMENA OF DROWNING.
Late studies as to the cause and mechanism of _asphyxia by submersion_
or drowning warrant our speaking of submersion as immersion complete
enough to menace or to extinguish life.
When an animated body or a part only of the body is immersed a
sufficient time in water or any liquid medium whatever in such a way
as to exclude fresh air from the respiratory orifices, suffocation
follows, and death by submersion or drowning takes place.
The phenomena occurring in such instances are mostly those common to
imperfect aeration or non-aeration of the blood, and for this reason
the majority of medical writers describe asphyxia or apnœa, that is,
death beginning at the lungs, as the determining cause of death by
drowning. It must not be thought that asphyxia is always the mode of
death in those submerged, although it is commonly present in a certain
number of cases. Other causes may often modify the circumstances of the
death or directly produce it, as congestion of the brain and syncope,
or the cause of death may be a mixed one. Occasionally one reads
accounts of persons resuscitated from drowning who, on recovering from
the primary effects of the asphyxia, die suddenly without apparent
cause after a lapse of a few minutes or several days. Such cases
are explained as the secondary results of the arrested interstitial
nutrition that took place during the period while breathing was
temporarily arrested. Another secondary cause is physical injury to the
lungs from water penetration, which may result in a fatal pneumonia.
A case related in England last summer is that of a drowning boy who,
on being resuscitated after submersion in contaminated water, suddenly
died of cholera.
MODE OF DEATH IN DROWNING.
Since various lesions may be found, accordingly as the death from
drowning has taken place from one or more of the foregoing modes, it is
necessary to have a clear notion of asphyxia and to study in detail the
mechanism of arrest of the thoracic movements and of the hindrance to
hæmatosis.
Broadly speaking, there will be asphyxia when any obstacle hinders air
from entering the pulmonary vesicles, or when the fluid that penetrates
them is of any other nature than the medium in which the animal is
destined to live. Consequently the name asphyxia is applied generically
to all accidental conditions in which life is threatened by any
intervention whatever of the respiration. (See MECHANICAL SUFFOCATION,
Vol. I., p. 705 _et seq._, and ASPHYXIATING GASES, Vol. IV.)
Submersion in any liquid medium causes asphyxia. This condition may be
caused on being surrounded by a medium devoid of oxygen and improper to
support sufficient hæmatosis, as hydrogen, nitrogen, and the protoxide
of nitrogen, gases not toxic properly speaking, but considered
irrespirable. Diminished respiration from deficiency of oxygen is the
true cause of asphyxia. No animal can maintain the respiratory process
in an atmosphere devoid of oxygen or in one that does not contain
at least ten per cent of this gas, and such quadrupeds as whales,
hippopotami, and seals or the pygopodous birds would drown in the same
manner as a dog if kept submerged long enough. The suppression of the
gaseous exchange by submersion is also fatal to such aquatic insects
as hydrophiles, dytiscidæ, and the like, which drown in the same
manner as the hymenoptera, coleoptera, diptera, or other terrestrial
insects. Ants drown in less than a minute when the body is wet, and
the disappearance of apparent vitality is accompanied by convulsive
movements indicating functional trouble of the nervous apparatus. Sir
John Lubbock found that after eight hours of immersion they could be
restored to life, and several ants after two days and five days were
restored to momentary life with feeble motions, followed by death
in two hours. Even a terrestrial plant when submerged drowns like a
terrestrial animal, the mechanism of asphyxia by submersion being the
same in plants and aerian animals, and due to closure of the principal
way of gaseous exchange.
Notwithstanding the interruption of the gaseous exchange necessary to
support life, there is long persistence of vitality after submersion
of some creatures in which an intra-molecular respiration or gaseous
dialysis with aerated water takes place, as in ants who have not been
wetted before submersion.
The resistance of new-born animals to this mode of asphyxiation is
especially noted in the greater time required to drown a pup than an
adult dog. One minute and a half usually suffices to drown a dog,
while a new-born pup often requires as much as fifty minutes. This
great difference is owing to the less active change of tissue and the
smaller consumption of oxygen in the young animal. The more active the
vital combustion and the greater the demand upon the general store of
oxygen in the blood, the quicker the young animal perishes when the
respiration is obstructed.
It is observed in a general way that all kinds of death caused by
the privation of respirable air have between themselves the greatest
resemblance. Whatever be the obstacle that intercepts the connection
of the lungs with the atmosphere, the apparent differences are only
secondary and the essential symptoms are identical, because all act
in suppressing the functions of the blood and hæmatosis. In fact, the
phenomena of asphyxia are constant and related to disturbances in the
respiration, innervation, and circulation, which vary according as the
asphyxia is the result of submersion or of the absence of oxygen in the
surrounding medium, according as asphyxia is immediate or slow. The
fatal result of asphyxia is owing to the introductory arrest of the
pulmonary circulation, the capillaries of the lungs being incapable of
conveying venous blood. The stagnation of the blood in the lungs is
followed by paresis of the respiratory centre and stoppage of the heart.
STAGES AND SYMPTOMS OF DEATH BY DROWNING.
The authorities are that an individual who dies asphyxiated by
submersion passes through three stages. At first he experiences a
violent shock, followed by an inspiration of surprise, which results
from the contact of water with the lungs causing a reflex cough. Then
for some seconds there is a voluntary suspension of respiration, giving
rise to other forcible involuntary expirations. In this dyspnœic second
period the face and brain become congested, owing to slowing of the
encephalic circulation. Loss of consciousness soon follows, when the
drowning person enters the third stage, which is that of asphyxia. In
this period the individual gasps deeply, the pupils are dilated, the
sphincters paralyzed, and the limbs are agitated by clonic convulsions.
This is followed by complete insensibility and speedy death.
When a fatal termination in drowning results from that form of
neuro-paralysis known as _syncope_, in which death begins at the heart,
we infer from experiments that the sudden loss of consciousness arises
from the violent impressions that the sensitive nerves convey to the
bulb. Such a result is more likely to occur in persons with weak heart
and languid circulation, who are more susceptible to fright and shock
or to the sudden collapse from intense cold. It is also shown that
stammerers, who have a defective innervation of the phrenic and of the
pneumogastric, succumb more rapidly than others.
The importance of syncope as a cause of death in drowning is much
restricted when we consider the fact that the circulation is the
last of the functions extinguished in an animal that for purposes of
experiment has been subjected to submersion. This has been shown in
a sensuous way by experiment, aided by the resources of the graphic
method, which registers the respiratory modifications as shown by the
pneumograph and also the condition of the femoral artery in connection
with a kymographion. The heart continues to beat as much as three
minutes after the animal has succumbed, and recent autopsy gives almost
constant proof of asphyxia. In fact, it is held that syncope takes but
small part in this form of death, the general agreement of opinion
being that nothing short of a syncope that would be fatal either in or
out of the liquid medium can account for the entire absence of some of
the signs of death from asphyxia.
Among the symptoms often present in drowning persons, many relate to
nervous phenomena and the mental state, which may vary with individual
presence of mind and moral force. Persons who have escaped this kind
of death have observed auditory and visual hallucinations, as flashes
of light, the ringing of distant bells, and the like. Just before the
outset of the asphyxiation a rather curious functioning of the brain
known as hypermnesia[936] takes place, in which the revivescence of
ideas, of objects, or of facts relates to anterior impressions long
past that seem to have been forgotten. According to the narratives
of many drowning persons who have escaped the last consequences of
asphyxia, this condition was attended by general exaltation of the
memory of such a nature that their whole previous conscious existence
seemed, in an incredibly short period and with great clearness and
precision, to pass before them in panoramic review. In Admiral
Beaufort’s letter to Dr. Wollaston, the memory impressions are said
to have occurred in retrograde succession. A medical man resuscitated
from drowning reports that just before losing consciousness this
particular cerebral activity, in his case, took on a most realizing
sense of the situation and of the consequences to his family. This
cerebral superexcitement is not, however, a constant thing, nor do all
subjects experience the ineffable agony of drowning. Persons have been
taken from the water apparently dead who, on regaining consciousness,
declared that they experienced neither oppression nor suffering and
had no recollection of what had passed. A very intelligent woman of my
acquaintance, having such an experience a few years since at Newport,
quotes herself as and really believes that she is an instance of a
person once dead and afterward restored to life.
This peculiar vividness of mind has been observed in other kinds
of death than drowning, notably in chronic insanity. A priest with
extended experience at the Government Hospital for the Insane tells me
that he has often noticed the _vaticinatio morientium_ in the form of
so-called lucid interval of the insane when called on to administer
the last rites of the Church. The condition is explainable from the
stoppage of the pulmonary artery and the stimulus caused by circulation
of non-oxygenated blood in the brain.
The condition known as asynesia, or amnesia, sometimes follows the
return to consciousness in persons asphyxiated and apparently dead from
drowning. Dr. F. A. Burrell reports the case of a boy of eighteen,
submerged for six minutes and resuscitated after four and three-quarter
hours, in whom the memory of everything that had occurred from half an
hour previous to the accident up to return of consciousness had been
entirely obliterated. When last heard from the lapse of memory still
remained.[937]
The statement that death from submersion results from true asphyxia or
from asphyxia in a more or less modified form rests on the authority
of a large number of facts. Indeed, recent investigators make the
proportion so much greater than formerly as to warrant the statement
that asphyxia is the generic cause of death by drowning. Dr. S. Coull
Mackenzie[938] reports 305 cases of drowning, in which 297, or 93.37
per cent, died from asphyxiation; 1, or .32 per cent, from syncope;
1, or .32 per cent, from apoplexy and asphyxia; and in 6, or 1.96 per
cent, the mode of death could not be determined because of advanced
putrefaction.
As the post-mortem signs of drowning are known to vary according to
a number of circumstances, it is difficult to deal with the subject
unless certain fundamental points be kept in mind. These relate more
particularly to the external signs and to the different lesions that
follow the mode of death, although they are not constant. Surgeon-Major
E. G. Russell[939] illustrates how widely the post-mortem appearances
may vary in cases of drowning, even when the outward circumstances of
the period of death are identical and the bodies have been subjected
to precisely similar conditions as regards duration of immersion,
subsequent exposure to air, and times of necropsy. He relates that
five persons were drowned while proceeding to a ship in the Hooghley
River. Three died the same death; and at the same time the bodies
were recovered together after the same period of immersion, and were
examined together; thus from beginning to end they had been under
exactly similar conditions, yet there were very marked differences
in the state of preservation of the bodies and in the post-mortem
appearances. After five hours’ exposure in air at 88° F., one body, in
which the tissues were extremely fatty, showed beginning decomposition;
in the other two there were no signs. Decomposition in the scalp, face,
and neck indicative of drowning had begun under water, although in
ordinary cases it first invades the abdomen, genitals, breasts, etc.
Rigor mortis present in one case was absent in the other. The penis was
semi-erect in one case, flaccid in the other, retracted and shrunken in
the third. Emission of semen and expulsion of fæces were also noted.
Tongue not swollen or protruded in any case, and _cutis anserina_
absent in all three, which may have been owing to the high temperature.
Water was inspired into the lungs in two cases. The larynx, trachea,
and bronchi had regular congestion and scarlet ecchymoses in one case
characteristic of asphyxia, and there was muddy water in the stomach.
The first question likely to arise when a drowned body has been found
is the one of identity. All the circumstances in which the body was
observed before its removal to the place where it lies for examination
should therefore be minutely detailed, and all lethal injuries and the
like should be noted with care, since the smallest accessories often
lead to identification. The locality in which a drowned body is found
may be a fact of considerable importance that may help to complete
the chain of evidence in which the matter of crime or of accident
turns upon the question of identity. It must be remembered that bodies
often drift many miles away from the spot where the drowning occurred,
owing to tides or currents. Such a circumstance I noted a few years
ago at Brownsville, Texas, where it was a common sight to see bloated
cadavers going down the Rio Grande. Time and putrefactive changes are
also elements that enter into the matter of recognizing the drowned
cadaver. To resolve this question with desirable precision, the reader
is referred to more detailed instruction in the chapter on Identity.
TREATMENT OF THE APPARENTLY DROWNED.
Help to the drowned does not properly come within the province of
judiciary medicine, being rather a humane question that belongs to
public hygiene. Systematic writers, however, treat the subject at
considerable length, and the statistics of institutions for helping
the drowned give such marvellous results that it would manifestly
not be out of place to cite briefly some of the means employed for
restoring life to persons taken from the water asphyxiated and
apparently dead.
The prime object in resuscitating the drowned is the introduction
of air into the pulmonary vesicles, which is best accomplished by
artificial respiration, and the employment of such means as excite
the nervous system with a view to reanimate sensibility and develop
the reflex movements that contribute to the re-establishment of the
respiratory function.
The exigencies of drowning also call for special means to restore the
animal heat and the circulation, as well as the precaution of removing
mucus and fluids from the obstructed air-passages.
As the knowledge of securing patency of the air-passages by artificial
respiration is generally diffused among medical students and is taught
in some schools, it would be superfluous to repeat in detail the
procedures of Hall, Sylvester, and others.
Laborde’s method of resuscitating those apparently dead has lately
gained some notoriety. It consists in stimulating the respiratory
reflex by regular rhythmical traction of the tongue, which should
be vigorously pulled forward fifteen or eighteen times a minute, to
correspond in frequency to the normal respiration.
Another method, alleged to have marvellous effects over the
respiration, is that of anal dilatation. Its advocates claim
that irritation of the anus is a much more effective measure in
resuscitating the drowning or narcotized.[940]
Respiration may be further promoted by alternate dashes of hot and cold
water on the face and chest, by smelling-salts, tickling the throat
and nares with a feather, and by electrization of the diaphragm and
inspiratory muscles. Protracted galvanism may, however, prove dangerous.
When signs of life appear, a warm tonic stimulating drink should be
given. A hypodermic injection of caffeine is also recommended.
Whatever means are employed should be used on the spot in the open air
and without a moment’s delay.
Restorative efforts may be kept up for two or three hours, although in
the majority of cases life is extinct in the human subject after two
minutes’ submersion or even less, and the chance of restoration after
five minutes’ complete submersion is doubtful. To be sure, trained tank
performers remain under water longer than two minutes, and exceptional
instances occur of recovery after twenty minutes’ submersion in
individuals in a state of syncope or with catalepsy.
CADAVERIC SIGNS IN CASES OF DROWNING.
The signs alleged to be common to death by drowning and characteristic
of it are difficult to deal with, for the reason that there are no sure
signs of drowning and the lesions furnished by necropsy are of feeble
importance. There is consequently a divergence of opinion on this
subject.
EXTERNAL SIGNS.
Among the external diagnostic signs consistent with the supposition of
death by drowning, the presence of froth at the mouth and nostrils is
of first importance. Cadaveric rigidity, pallor, goose-skin, rosy or
violet discolorations on various parts of the body, retraction of the
penis and scrotum, fish-like expression of the eye, peculiar position
of the tongue, maceration of the palmar and plantar epidermis, and
convulsive contraction of the limbs, particularly of the hands, which
may be clinched after the manner that marks death by asphyxia, are all
signs which when united form strong presumption in favor of submersion.
These typical and classic signs may, however, be varied by many
circumstances. Hence the dissidence of authors. Dr. F. W. Draper states
that after inspecting 149 drowned bodies, he has never observed that
important sign of death, the presence of substances grasped in the
hands.[941] Sand or mud in the hollow of the nails and excoriations of
the fingers are also regarded as probable, not certain, signs, since
each of these might have occurred either before or after death. The
peculiar clinched condition of the hand is not pathognomonic, though
strongly suggestive of drowning, as it may appear in asphyxiation
from other causes. I have lately noticed this among the external
appearances of the bodies taken from the Pompeiian excavations. The
further index of drowning known as washer-woman’s or cholera hand,
with non-adherent tendency of the epidermis, is an effect that may be
produced upon the living after a prolonged bath, notably in the aged
and habitually unclean. Nor is the position of the tongue a special
and distinctive characteristic of drowning. Only a few months ago I
observed its presence in some of the victims of mechanical suffocation
in the Ford’s Theatre disaster in Washington.
The shrunken state of the genital organs is apparently of little
positive value as a thanatological sign, since the negative and
opposite state of erection has been often observed, and Dr. Ogston
states that he met semi-erection in twenty-two cases.
The value of “goose-flesh” as a link in the chain of evidence is also
weakened when we consider that it frequently occurs after other violent
modes of death. Anserine skin is often met with during life, and cases
of drowning are recorded where this appearance has been absent.
The aspect of the face and the general position of a drowned cadaver
may likewise vary according to the mode of death. Immobility of the
body in the attitude of agony, the horrible grimaces of asphyxia, the
pale, calm features of syncope, and putrefactive changes are further
circumstances of medico-legal detail that may complicate the problem
and render an autopsy necessary in order to invalidate or confirm the
uncertain conclusions furnished by the external signs.
INTERNAL LESIONS.
Autopsies on the drowned are remarkable owing to their negative
signs. But as an extension of diagnostic means, the autopsy may show
the vertical (though not invariable) position of the epiglottis; the
presence of water and foreign matter in the bronchi; swelling and
emphysema of the lungs; hydræmic engorgement of the liver; fulness of
the right heart and emptiness of the left; fluidity of the blood; water
in the stomach and middle ear; and a characteristic frothy mucus or
lather more or less bloody, which most observers and writers consider
the only constant post-mortem appearance of drowning.
Examination of the respiratory apparatus is of extreme importance in a
question of this kind, for it is contended that the presence of foreign
bodies is a proof of submersion.[942]
This opinion is in part erroneous, since it has been observed that
when a body is submerged after death water will penetrate the larynx,
trachea, and remote bronchi, as well as the stomach and middle ear.
Moreover, Dr. Ogston states that in 48.7 per cent of cases of drowning
no water was found in the lungs.
The emphysematous condition of the lungs, which are said to force
their way out of the chest on removing the sternum, is difficult to
distinguish from the result of putrefaction. Dr. Gilberti shows that in
the drowned the lungs disintegrate rapidly, while the heart, in which
putrefaction begins chronologically, is relatively in a good state of
preservation.[943]
Since many cases have been observed in which both sides of the heart
may be partly filled or both be empty and flaccid, or the left side
distended more than the right, we are obliged to regard the exceptions
concerning this post-mortem sign of drowning as co-extensive with the
rule.
Excessive fluidity of the blood depends upon the rapidity with which
the drowning took place. Slight hydræmia occurs in rapid submersion,
but when the drowning has taken place slowly a large amount of water
passes into the blood. In certain poisonings by opium this fluidity
also exists; but it is claimed that analysis and the spectroscope may
clear up the diagnosis.
Hydræmic engorgement of the liver is regarded as a characteristic fact
by Lacassagne, who claims to be able to diagnosticate drowning from a
single examination of this organ.[944]
It is now generally admitted that the presence in the stomach of a
certain quantity of liquid in which the body was found immersed may be
considered as a sign almost certain of asphyxia by submersion.
Dr. Fagerlund concludes from his experiments that liquids do not
penetrate after death either the stomach or anus unless strong pressure
be made. But when asphyxia occurs in water the liquid is found in the
stomach and the intestines, where it is helped on by peristaltic
movements. The pylorus is an obstacle to the passage of this water,
the movement of which is easier when the stomach is empty and the
submersion prolonged.[945]
The quantity and quality of the water may constitute important
evidence; but to be of full value the water or other fluid found in the
stomach ought to be the same as that in which the immersion has taken
place.
The liquid, which may have been taken just before drowning, should
not be noticed unless it exceeds half a pint; but anything peculiar
in the fluids, either of the lungs or stomach, should be subjected to
microscopic or other examination.
Presence of water in the middle ear is regarded as a thanatological
sign of great value. Dr. Bourgier claims as the result of his
examination that 23 cases out of 27 had water in the middle ear.
Several German observers pretend to have found amniotic liquid in cases
of fœtal asphyxia. The fluid may be aspired by a small pipette.
Many of the foregoing signs and lesions disappear or undergo variable
alterations after sojourn in water, putrefaction, etc. They may, as
they have done in the past, give rise to many controversies, so that
presumptions only can be established. Hence the necessity for careful
and detailed necropsy in such cases, with a view not only to minimize
conjecture and uncertainty, but to prevent opposing counsel from
entering the plea of negligence and incompleteness.
WAS THE DROWNING ACCIDENTAL, SUICIDAL, OR CRIMINAL?
Assuming the probabilities to be in favor of death by submersion, the
question next turns upon the character of the event.
In the absence of lesions it is almost impossible to say whether the
individual fell in, jumped in, or was pushed in the submerging fluid.
The person’s antecedents should be inquired into—whether subject to
epilepsy, vertigo, intemperance, or mental aberration. Alcoholism is
an important factor in accidental drowning, and a person intoxicated
may be drowned in very shallow water. A few years ago a young man over
six feet tall, while bathing in a tributary of the Potomac River, near
Washington, was drowned in only three feet of water. On considering
all these circumstances, it may not be possible, even after careful
inspection of the body and minute exploration of all the organs, to
declare the drowning the consequence of an accident. The existence of
traces of violence or of injury which may have occasioned death or
disability, of such a nature as to render the person unable to defend
himself, would seem to merit particular attention. But their presence
leads to further consideration—were the marks of injury caused by the
water itself, by some object in the water, or were they self-inflicted?
Dislocations, fractures, and other injuries have been caused by jumping
or falling into the water from a great height. I know an instance of a
professional who, on jumping from a height of ninety feet, split his
upper lip on striking the water with his mouth open. The autopsy in
the case of Odlum, the Brooklyn Bridge jumper, is said to have shown
rupture of the liver. On the other hand, many persons jump from great
heights into water with perfect impunity. For many weeks at the London
Aquarium a performer has nightly jumped into a tank from an elevation
of 127 feet, and several persons have successfully jumped from bridges
much higher.
Objects in the water that may account for cadaveric lesions are
numerous. I have known a soldier, a good swimmer, to break his neck
on diving from a river bank.[946] Other traumatic lesions may occur
in a rapid current, from the breaking up of ice, from the screw or
paddle-wheel of a passing steamer, or from aquatic animals.
A matter much discussed in connection with this subject—that of
shark-bites—may enter into the question of survivorship where it
is alleged that several persons during shipwreck or other disasters
at sea have been devoured by sharks. Though an occasional accident,
such bites are more a figment of the mind than a reality, as the
concurrent testimony of disinterested observers will show. After years
of investigation among nautical people and much experience as a swimmer
in widely different parts of the world, I have no personal knowledge
of such injuries, and have met but two persons that had any actual
personal knowledge of shark-bites.
Documentary evidence as to shark-bites is also very scanty. During the
last fifty years soldiers by the tens of thousands have swum at Fort
Monroe, Virginia, yet there is no record of one having been bitten by a
shark; nor have I been able to ascertain that any accident of the kind
has occurred at Malta or at Gibraltar. There does not appear to be a
record of any one ever having been bitten off the British Isles. I have
been unable to ascertain that a single bite of the kind is reported
among the medical records of our War or Navy Department or those of
the Marine Hospital. In the West Indies but few facts are reported
indicating danger from sharks, and these are not well authenticated.
The same may be said as to newspaper accounts, which deserve about as
much credence as the reports concerning sea-serpents. A few years ago a
public journal gave an account of a boy who was bitten while swimming
near New York and afterward died in a hospital.
But medical literature has a few reports of shark-bites. After ten
years’ diligent search I have found seven references, the earliest
in the _London Medical Gazette_, 1823, and the latest in the _London
Lancet_, 1886. The bites occurred in Australia, South Africa, and
India. The Hooghley and Ganges Rivers are the worst place in the world
for sharks and alligators. A particular kind of shark, the _Carcharras
Gangeticus_, which is very fierce and bold, sometimes dashes among the
crowds at the bathing ghâts, and has been known to bite a boy in two
feet of water. All persons bitten at these places generally die from
the bite, for the reason that the shark, living on carrion, portions
of which stick between the teeth, carries infection to those whom it
may afterward bite. The former habit of throwing the dead in the river
is supposed to account for the boldness of these particular sharks in
attacking the human species.
Self-inflicted wounds rather suggest _suicide_, as numerous instances
attest, where one or two kinds of death were intended to make assurance
doubly sure. I once saw an Eskimo stab himself and then jump overboard
from a ship off the Siberian coast. But as a rule suicidal drowning is
unaccompanied by traumatic lesions, unless it be those produced by
falls. Hence the absence of lesions leads to the presumption that the
individual while living fell into the water or other fluid accidentally
or voluntarily.
Exception may be made in the case of infanticide and _homicidal_
submersion as the result of surprise, where a person taken unawares is
suddenly and unexpectedly pushed or thrown into the water. A case in
point is that of a man suddenly robbed and seized by three persons,
who threw him into the river. Another is that of a man who, wishing to
get rid of his wife, gave her arsenic. The effects of the poison being
slow he induced her to take a walk along the river, and when her back
was turned he pushed her rapidly off the bank into the stream, where
she drowned. Death by submersion is rarely the result of murderous
intent, and in the case of adults it is suddenly resorted to in order
to paralyze resistance and facilitate the success of crime.
Submersion is oftener intended to hide a crime. A body may be taken
from the water after murder or rape. Whether the cadaver is recent or
one that has lain in the water a long time, the expert is confronted
with a question of the differences that he may expect to find in a body
drowned and one thrown into the water after death. This difficulty can
only be resolved by considering all the signs and lesions furnished by
the autopsy. No single sign or post-mortem appearance is characteristic
of drowning, and none enables us surely to diagnosticate death by
submersion either in putrid or fresh cadavers. Nor do we have any
significant infallible signs that may serve as a parallel between
the immerged post mortem and the submerged. The exterior signs being
nearly the same in the two, the diagnosis must necessarily depend upon
assembled circumstances, and these are liable to vary.
CIRCUMSTANCES THAT MAY AFFECT THE TIME OF SUBMERSION.
Putrid decomposition is the chief obstacle to diagnosis in a body
that has been drowned. This presents great differences. The death
happening in winter or summer, in a temperate or intertropical country,
and sojourn of the cadaver in salt or fresh water, are each and all
important details to be considered in studying the submergence of a
body.[947]
It is only by studying the events in this order, along with the
immediate signs of death, that the duration of the submergence may
be conjectured. With anatomical appearances as the only guide it is
impossible to fix the time of immersion. Many elements combined may
affect even the gaseous putrefaction that takes place in submerged
bodies. Summer heat and shallow or stagnant water hasten the
development of putrid gas and subcutaneous emphysema which bring
the cadaver to the surface, and that, too, sometimes in spite of
precautions taken to insure the submersion. A case in point is the
body of the Italian admiral, Caraccioli, mentioned in Southey’s “Life
of Nelson.” Bodies weighted with lead or other heavy substance for the
purpose of hiding crime have also been known to float in consequence of
the putrefactive phenomena.
At Evansville, Ind., unsuccessful efforts were made to raise a sunken
steamer with thirty head of cattle between decks. A few days after
the attempt was abandoned the steamer was suddenly seen to float. The
carcasses of the putrefying animals, swollen by gas, had sufficed to
bring the wreck to the surface.
A great development of gas is very noticeable in what is known as a
“blasted” whale, the stomach of which assumes balloon-like proportions.
A few summers ago, at Provincetown, Mass., it was my rare fortune to
be within a few feet of an enormously distended putrid whale, which
suddenly exploded.
In cold countries drowned bodies are longer in coming to the surface.
In Russia, for instance, in spring after the rivers and lakes have
thawed, the bodies of numerous victims of alcoholism and accidental
drowning of the previous winter are taken from the water. Last summer,
at Quebec, I was present when the body of a man drowned the winter
before came to the surface of the St. Lawrence River. On a visit to
the northern lakes many persons connected with the navigation of Lake
Superior told me that bodies drowned in its waters seldom or never came
to the surface.
Specific gravity of the water itself may be an additional cause for
the body coming to the surface. Dr. Tidy says that every structure of
the human body floats in the water of the Dead Sea. The same cannot be
said about the buoyancy of the water of Great Salt Lake, the accounts
of which have been greatly exaggerated. It does not “support a bather
as if he were sitting in an arm-chair and float him like a fresh egg.”
Experience shows that there is no difficulty either in swimming or in
sinking in its waters, the solid constituents of which are estimated to
be about six and a half times more than that of sea-water. Analysis of
Dead Sea water places the solid constituents at 24.580, while that of
Salt Lake is 22.282. Another strong natural brine in the United States
is said to be that of Syracuse Saline, New York, which contains 17.35
per cent of sodium chloride.
It is evident from what has been stated that no positive assertion can
be made as to how soon a drowned body will rise to the surface, and at
best any conclusion as to the date of submersion is so unsatisfactory
that it may be said to be an unscrupulous use of guessing privileges.
Errors in legal medicine are sadder in their consequences than those
of medical diagnosis. The medical legist would therefore do well to
preserve the frame of mind that often doubts and rarely affirms, and he
should be circumspect enough to avoid dogmatic assertions about matters
of uncertainty.
DEATH FROM STARVATION.
IN ITS MEDICO-LEGAL ASPECT.
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._
STARVATION.
GENERAL CONSIDERATIONS.
PHYSIOLOGY teaches that life can only be maintained in the living
organism by a constant equilibrium between its waste and repair.
=Nutrition= is a term by which we describe this double movement of
renewal of the molecular structure of the body, and in this general
sense only, that nutrition is synonymous with the maintenance of the
organism in a stable condition, is it employed here.
This condition of equilibrium is maintained by a regular and constant
supply of _food_.
=A food= may be defined to be a substance which, after introduction
into the body, supplies material for the renewal of its tissues or
sustains some of its vital processes. Foods vary greatly in their
properties as restorative or constructive agencies, some containing
but few essential properties, while others combine almost all of
the elements required. As some foods contribute elements for tissue
restoration, others are specially concerned in the calorifacient
activities of the organism,[948] while others are marked in their
tendency to take part, almost exclusively, in special chemical
processes.[949]
The various articles used as foods contain nutritive elements combined
with innutritious substances. They have been variously classified, but
are conveniently divided into
I. Organic foods, {_a._ Nitrogenous (C.H.O.N.).
{_b._ Non-nitrogenous (C.H.O.), {Oleaginous
{Carbohydrates.
II. Inorganic foods, {_a._ Water, H_{2}O.
{_b._ Saline substances.
Nitrogen enters largely into the composition of the body, and hence
must be abundantly supplied and in combination.
Of the non-nitrogenous elements the most important are _fat_, _sugar_,
and _starch_.
The _inorganic_ principles are essential to the process of nutrition.
_Water_, constituting 87 per cent of the bulk of the body, is demanded
in constant supply; while the _saline substances_ are necessary for the
perfect performance of many of its chemical processes.
It is apparent that no single element can alone carry on the nutrition
of the body, and hence _variety_ in the supply of food, as well as
sufficiency in its quantity, is essential to normal nutrition. Nor are
these the only factors in this complex problem. Proper preparation of
food, its supply at necessary temperatures,[950] and other requirements
enter into the question of normal or sufficient alimentation.[951]
Alimentation is sufficient when it is so regulated that all the
functions of the body are performed in a complete and regular manner.
Insufficient alimentation induces a series of phenomena and a result
which have been designated “_inanition_,” or “starvation.”
The exact amount of aliment required by each individual can only
be stated in a general way. In the circumstances in which he is
placed, the supply must be of such character and quantity as shall be
proportionate to the constructive and reparative needs of his body.
It is possible, however, to state a mean for the various ages and
occupations of life.
Physiologists generally agree that in ordinary conditions of exercise
the following represents the amounts of the several food elements
necessary for the adult individual daily:
Albuminous substances 120 gms. = 4 oz.
Fatty substances 60 ” = 2 ”
Carbohydrates 360 ” =12 ”
Taking the fatty matters as the unit, the daily allowance would bear
the following proportions:
Fats, 1; albuminoids, 2; carbohydrates, 6.
These quantities and especially the fats and carbohydrates, in
conditions of hard muscular labor, must be increased; and the
proportion would then stand:
Fats, 1; albuminoids, 1.7; carbohydrates, 7.
The division of this amount of food elements into proper portions
during twenty-four hours is important. This must be regulated by the
habits and other circumstances of the individual.[952]
The occurrence of death solely from privation of food is comparatively
rare; yet it is sufficiently frequent to be considered as one of
the causes of violent death and to demand investigation, since
circumstances may be such as to constitute a homicide from criminal
neglect or a suicide from intentional abstinence from food.
“=Starvation=,” or “=inanition=,” may be considered as being _acute_
or _chronic_ according as the requisite food has been suddenly and
completely or gradually withheld.
ACUTE STARVATION.
The complete deprivation of food induces a series of modifications of
the functions of the body, differing somewhat from those developed by
a partial and prolonged deprivation. The length of time during which
complete absence of food can be endured varies with circumstances.
In absolute stoppage of the food supply the acute sensations of
hunger pass away after the first one or two days, and are succeeded
by profound functional disturbances with weakness and depressing
sensations over the epigastric region, accompanied by distressing
thirst.[953] The mouth is dry and the tongue heavily coated; the breath
is fetid; the skin is harsh, dry, and exhales a disagreeable odor; the
feces become more and more scanty until the latter days of life, when
diarrhœa usually supervenes; the face and extremities become rapidly
emaciated; the person walks with a weak and tottering gait;[954] the
urine is small in quantity and very acid; muscular feebleness gradually
reaches complete inability to move; ringing in the ears, insomnia and,
in some cases, hallucinations[955] with delirium and convulsions
precede death, though these latter symptoms are not uniformly
observed.[956]
“CHRONIC STARVATION,” “CHRONIC INANITION.”
This form of starvation, met with most extensively during the
prevalence of famine, also occurs in conditions demanding legal
investigation.
=The symptoms= are sufficiently constant and characteristic. Emaciation
becomes extreme, the skin dry and rough, exhaling a disagreeable odor
and often covered with a coating not entirely attributable to filth;
the breath is fetid and offensive. With some exceptions, the victim
retains his consciousness and ability to move about, muscular efforts
becoming more and more feeble; the voice becomes faint; the evacuations
infrequent, dry and dark; the urine scanty and high-colored, death
occurring suddenly at the end, with delirium in some cases.
The length of time during which these symptoms are developed and their
intensity depend mainly upon the amount and character of the aliment
actually supplied during the period before death.
Upon the PULSE and CIRCULATION the effects of starvation are manifest
in increased frequency and feebleness of the cardiac contractions and
lessened force of the cardiac impulse; this is more and more marked
as the anæmic condition becomes profound. In some cases the pulse is
greatly reduced in frequency, as well as in force, dropping as low as
thirty-seven beats in the minute,[957] and auscultation reveals the
existence of cardiac bruits.
In connection with enfeeblement of the circulation, a tendency to
hemorrhagic conditions is common, with purpuric and petechial eruptions
in some cases.
TEMPERATURE.—A subnormal temperature is frequently noted in the
progress of chronic wasting disease. In inanition, which in some
respects induces a similarly profound disturbance of the functions
of nutrition, an analogous lowering of the body temperature occurs.
Chossat clearly shows in his experiments the influence of starvation in
depressing the body temperature. This abasement of temperature does not
remain constant, but daily oscillations appear, differing from those
occurring in conditions of normal alimentation.
While the normal diurnal variation in the fully nourished is about 0.3°
to 1.0° C. (0.5° to 1.7° F.), in the starving this variation reaches
3.28° C. (5.4° F.). This rises to nearly double this amount during
the latter days of life, and is greatly increased above this figure
during the day preceding death. The temperature at the close falls to a
mean of 24.9° C. (76° F.), and at the moment of death has been noted at
18.5° C. (66° F.).
EMACIATION.—Loss of weight is the most striking and constant symptom
of starvation. The rapidity of its production and its extent are
modified by circumstances. A very considerable loss of weight can be
sustained by the ordinary individual without a fatal result.
Chossat[958] fully demonstrated the effects of inanition upon the
various functions and organs of the body in animals, and has drawn the
conclusion that a loss of weight exceeding four-tenths of the entire
weight of the body is productive of a fatal result. These deductions
may be adopted as applicable to the human species. This statement must
be accepted as a mean, as it is capable of variation by circumstances,
such as age, obesity, etc.
Death may occur before so great a loss has been reached in some cases,
and in the obese the fat may disappear entirely and cause a loss
reaching five per cent of the entire weight of the body, in a very fat
animal, without a fatal result.
Bouchardat[959] considers that the important question is the extent
to which the blood and organs of the body contribute to this loss of
weight. Impoverishment of the blood by inanition, which at the time of
death has been found to amount to six-tenths of its solid constituents,
is one of the most vitally serious elements of this loss; and a
relative increase of its watery portion appears, without regard to the
employment of water as a beverage.
It must be remembered that in wasting diseases extreme emaciation may
occur under a liberal diet, and may continue for a considerable time
before death.[960]
_The muscular system_ becomes greatly enfeebled, atrophied, and unable
to perform its functions; the loss sustained by the muscles least used
being most marked. The extent of muscular power possible in starvation
varies in different individuals and in various circumstances.
The vigorous and healthy adult, as a rule, retains muscular power to a
greater extent and for a longer period than the child or aged person,
under similar circumstances.
Exposure to a rigorous climate, prolonged fatigue, etc., rapidly reduce
capacity for muscular effort in conditions of inanition.
THE PERIOD AT WHICH DEATH OCCURS.
This is influenced by many circumstances. It is difficult to fix an
exact period for the duration of life in complete deprivation of food,
or acute starvation, and it is certainly more so in chronic inanition,
when the modifying circumstances are increased in number and complexity.
A large number of cases of prolongation of life during a period of
absolute deprivation of food which has been stated to extend over weeks
and even months, cannot be accepted as free from error, and hence are
not considered here.