Z. died on the 9th January 1875, and was the 12th. The cause of death was unknown From the post-mortem exato me before the autopsy. mination I concluded that death had been caused by hanging or by strangulation. Circumstances coming to case my knowledge afterwards conviuced me that the
certainty.
buried
on
of suicide by hanging. follows a minute account of the graveyard, the soil, soil-water, temperature,?the circumstances which had influenced the progress of the post-mortem was one
[Here
changes.
See the
original.]
A.?External Examination. The male corpse is 176 c. m. long, and is that of a powerfully built and well-nourished individual of about 60, though only an approximate estimate of the age can to the post?mortem changes. 2. Hair be made 1.
owing
of the head brown, greyed ; can be easily stroked out. 3. Teeth bad. 4. Cadaveric rigidity not present, abdomen swollen, scrotum greatly distended with gas. 5. The in the orbits dirty chocolateare destroyed ;
eye-balls
coloured fluid. 6. The cutaneous coverings are mostly After the covered with a thick layer of fungus. the latter the epidermis by irrigation careful removal of is seen to remain fast in many places, while in others it is loosened off in shreds.
corium is partly 7. In the green.
The
partly dirty
dirty reddish-brown, front of the neck, just above the larynx, is a depression, which runs like a groove round the front of the neck towards the sides. This groove is 32 c. m. long and 1 2 c.m, broad. It is narrower at the sides than in the middle. On the right side about 2 c. m. below the lobe of the right ear the mark becomes so faint that it goes any farther back. one cannot decide whether becomes mark the imperceptible 3 c.m. side left the On or under the lobe of the left ear. Inside the groove contrasts and and clear-grey firm, is mark the skin with the dirty brown and softer skin on the other and uneven edges of the groove. 6. side of the sharp
CONTRIBUTIONS TO
FORENSIC
MEDICINE.
The soft parts of the neck under the groove are puffed of the groove and over them out, especially by the ends natural openings of the body the backwards. 9. In there
are no
By Prof. Hermann
Friedberq 0f Breslau. Archives, November 1878.)
(Virchow's [Translated by Surgeon David
intendent, Central Post-mortem
case
B.?Internal Examination. Thorax and Abdomen.
Wilk;IEj Officiating SuperPrison, Bareli.]
appearances 28 weelcs after death in
a
of hanging.
following case contributes to our knowledge of post-mortem changes, and shows for the first time that the injury to the carotid arteries caused by the ligature in the neck of a living man has been still discoverable The
28 weeks after death. On the 21st July 1875 Dr. Jacobi and I examined the immediately after it had been disinterred body of Z On the removal of the: in the churchyard of Breslau. a mouldy smell was perceptible. Of those who present while the body was undressed, all* whoi had known Z. during life recognised; the face with/
coffin lid
were
foreign bodies.
opening the chest the soft parts of the neck 10. Hie skin is firm, almost were partially dissected. leatherlike. The subcutaneous fat is clear yellow, firm and dry. The muscles are of natural oolour and good Before
and below the groove in the appearance. 11. Above neck are layers of extravasated blood, which is coagulated. These layers are found on and under the superficial fascia and between it and the middle fascia. In the and omoregion between the mylo-hyoid, sterno-hyoid) left- side is a layer, 1 c. mi thick> of the on muscles hyoid fluid blood. coagulated blood, with greasy reddish-brown, a smaller extrais the side on right In the same
region
vasation. The extravasated'blood lies not only on the sheaths of the muscles, but also in'the superficial'parts of the muscles. 12. Below the groove, from it to the clavicles, and in the laryngeal fossa^ is extravasated^
THE INDIAN MEDICAL GAZETTE.
272
blood in the subcutaneous areolar tissue and the middle cervical fascia in the front of the neck to the thickness of 2-4 m.m. 13. In the postero-lateral and posterior parts of the neck is a layer of the
(b.)
coagulated on
same
thickness of extravasated coagulated blood in
several
places in the subcutaneous connective tissue, here and there under the fat-layer. 14. The groove of the ligature lies between the hyoid bone to the upper edge of the larynx. The examination of the rest of the neck is reserved. 15. The preliminary examination of the abdomen results as follows. The highest point of the diaphragmatic arch corresponds to the lower border of the 5th rib, The position of the and
intestines is normal. the abdomen.
There is
no
extraneous matter in
(a.) Thorax. the soft parts from the front of the chest there is found from both clavicles to the second rib a layer of coagulated blood up to 1 c. m. thick, which lies partly in the fatty tissue, and partly under it17. On opening the thorax the anterior parts of the 16.
In
removing
lungs so overlap the pericardium as almost to touch. These parts of the lungs appear on the surface partly dirty rose-coloured, partly clear grey, partly slatecoloured, have an elastic feel, and are crepitant. 18.
Both
are in several places united to the old adhesions. 19. In the pleural cavity is bloody fluid,?one tablespoonful on the left side, four tablespoonfuls on the right. 20. The great vessels outside the pericardium are of small circumference.
lungs
parietes by
21. The fat, dirty bright brown pericardium is empty. 22. The heart is of normal size, very flaccid : the coronary vessels are empty. 23. The left auricle and ventricle
are
empty, and the auriculo-ventricular valve shows
nothing abnormal. The right auricle and ventricle empty; in the inner wall of the latter are found scattered miliary, calcareous deposits, loose on the shows endocardium. The auriculo-ventricular valve nothing abnormal. 24. The large vessels are empty. are
25. The mouths of the arteries are normal ; and the musculature of the heart is very soft and reddish brown. 26. The lungs are bulky, and their surface posteriorly and laterally is brownish-red. The lungs are elastic and crepitant. On section all parts of the lung are red with blood, full of air, and without trace of disease. 27. The thoracic aorta shows nothing abnormal. 28. The thyroid offers nothing worthy of notice. 29. Large veins of the neck empty. 30. Immediately above the bifurcation of the right common carotid is a solution of continuity of the intima of the external carotid. The the wound of the intima are 1 c. m., uneven edges of separated from each other, and between them there is on the media a thin layer of clotted blood. The solution of continuity of the intima is annular. The left carotid shows nothing abnormal. 31. Larynx and trachea empthat of the bronchi, ; their mucous membrane, and dark brown-red. 32. Tongue, palate, tonsils, salivary glands, and lymphatic glands show nothing abnormal. 33. Pharynx and oesophagus empty ; mucous membrane dirty brownish. 34. The bones of the thorax and neck
ty
show
nothing
abnormal.
[October 1,
1881.
Abdomen.
35. Omentum very fat, vessels empty. 36. Spleen 12 c. m. long, 6 c. m. broad, 3 c. m. thick, very soft, dirty brown red on section. 37. Left suprarenal capsule shows nothing abnormal. Left kidney 11 c. m. Ions, 6 c. m. broad, 3 c. m. thick, dark brown red on section, and so softened that a closer examination of its tissue is not possible. Eight suprarenal capsule and kidney like the left. 38. Bladder
empty: colour, moist. 39. Prostate, vesiculse, testicles, and penis, and the urethra show nothing abnornal. 40. Rectum empty. 41. Upper part of the duodenum and stomach empty ; mucous membrane greyish brown, moist. 42. Gall-bladder empty. 43 Right lobe of the liver 18 c. m. broad, membrane
mucous
19
of
a
grey
rose
high, 4 c. m. thick ; left lobe 7 c. m. broad, 10 high, 3 c. m. thick. The liver is on section brown-
c. m.
o. m
44. Pancreas normal. 45. small intestine is distendThe fat. 46. Mesentery very ed with gas, contains yellowish slimy material, and has normal coats. 47. The large intestine contains brown soft faeces, and has normal coats. 48. Blood vessels empty. 49. The bones of the abdomen are normal.
red, very soft, and moist.
77?Bead. 50. The soft coverings of the skull are dirty brownred on their inner surface and moist. 51. The skull-cup 52. Dura mater dirty brown is oval, ??| c. m. thick. red, very moist, distended (apparently by gas). Longitudinal sinus empty. 53. On cutting open the dura there escape much gas, and the brains in the form of a thin, dark, chocolate-coloured gruel. 54. All parts of the brain are converted into this uniform, thin chocolate coloured gruel, in which neither pia nor any, parts of the brain can be distinguished. 55. The sinuses of the base of the skull are empty. 56. On removing the dura the parietes and base of the skull are found to be
uninjured. II.
of the injury to the and Strangling. Hanging of
On the causation and carotids in In
a
opinion
cases
significance
report of mine in the year 1851 I expressed an on the causation and significance of the injury
to the carotids found in cases of
hanging and strangling^ enunciated has been confirmed and completed by various writers, and by published observations of my own, I now consider that I ought to go into the matter more thoroughly than I did then. In the year 1828 Amussat communicated to the Academy of Medicine of Paris that in a case of hanging, in which he had carefully examined the soft parts in the neighbourhood of the ligature, he had found the intima and media of. both carotids cut through. Since then Devergie, Kloz, Mildner, von Faber, Simon, Kussmaul, Hofmann, Ogston and myself have published observations which show that the injury of the carotids, rightly esti. mated, is an exceedingly valuable sign of strangulation and of hanging. By the ligature round the neck both in strangling and in hanging, the carotid can be injured when it is sufficiently stretched and squeezed. The As
my view therein
October 1,
1881.]
SURGEON WILKIE ON P. M. APPEARANCES IN HANGING.
in
question consists partly in a rupture of the of the inner and middle coats of the carotid, partly in an extravasation of blood from the vessels of the wall of the carotid (vasa vasorum) which in the outer and middle coats form a wide-meshed net, that reaches nearly to the inner coat. As to the
injury inner
or
(non-vascular)
causation of the
to the carotid
injury by the action of the ligature, I lay greater stress on the stretching than on the squeezing which that vessel suffers from the ligature. Without a stretching of the carotid I could especially not understand those cases in which the rupture of the inner or inner and middle coats is situated at a spot distant from the mark of the ligature, as in cases investigated by Mildner, von Faber, Simon, and Kussmaul. In explaining the origin of the lesion I further lay congestion which occurs in the vessels above the ligature. The distension of the vessels in the wall of the carotid, caused by the congestion, can be stress on the sudden
so great as to end in rupture, and produce an extravasation of blood. Herr Hofmann has honoured me with a letter in which he expresses his opinion that the congestion contributes not only to the infiltration with blood of the wall of the carotid, but also to the rupture of the inner coat of the carotid. To the stimulation of the nerves of the vessels also I ascribe a participation in the rupture of the blood-vessels in the wall 0f the carotid. The
stimulation can either be caused directly by the ligature, be the result of the dyspnoea produced in by it; both cases so raise the blood-pressure that the vessels in the wall of the carotid burst and p0Ur out blood into the wall.
?and
or
In the hitherto published cases of hanging and strangin which the carotid was injured, it was the common carotid of one or of both sides that was affected. On the other hand in the case which I }lave J-ug(. described the right external carotid was the one injured. This calls to mind an experiment with reference to strangulation which Simon carried out on the corpse of a man 21 years of age. He compressed the neck by means of a thin cord between the hyoid bone and larynx; and the result was that the inner and middle coats of
ling
the left external
carotid, immediately above the origin of the superior thyroid artery, and also the inner coat of both right and left internal carotid were ruptured, while
the right and left common carotid remained uninAs the superior thyroid artery arises close above the bifurcation of the common carotid, it must have been the lowest part of the external carotid that was injured in that experiment. This pGrtion of the external carotid, which lies in the carotid triangle, close to the median border of the
jured.
is
only
and
lies
covered so
by cervical
superficially
sterno-mastoid,
fascia, platysma,
that one
and skin ;
easily feel, very fat> plaiaty see its conjecture that, lying as can
and, in persons who are not pulsations. I am inclined to tt does in a position of so little sheUer> the external carotid is, when the ligature lies betlveen the larynx and hyoid bone, more frequently injured than appears from the literature of post-mortem reports in cases of
hanging
273
strangling. How far my conjecture is just, and how often in reality the carotids are injured in hanging and strangling, can only he determined when the carotids are more frequently examined in cases of hanging and strangling than they have been hitherto. and
The rupture of the inner or inner and middle coat of the carotid is not so easily produced in experiments in strangulation in the dead body as it takes place in the living. For in the living the stretching of the carotid, fixed by the ligature, can be caused,?1 thereby, that the living, in being hanged, jump down from a height and suddenly increase the pull on the ligature caused by their body-weight; 2 thereby, that the living, when being strangled or hanged, carry out movements of the body which are partly directed towards freeing the neck from the ligature, are partly spasmodic and partly arise from the death-struggle. When the ligature is so placed that, in spite of that jumping down or of those movements, no sufficient stretching of the carotid results, then the ligature can cause death without any
carotid taking place.
One can see that remembers that it is only necespossible, sary for the ligature to force the root of the tongue into the pharyngeal opening in order to cause death by suffocation, and can in so doing be so placed as not to be in a position to fix the carotid. In a series of cases in which the carotids of men
injury
to the
this is
if
one
showed rupture of the inner or inner and middle the wall of the vessel was altered by disease. coat, Mildner found in his case "rigidity of the arteries.'' Kussmaul found in a preparation in the collection of his father,?one taken from a man that had been hanged,?the carotids atheromatous. In a case of hanging examined by Kussmaul himself the carotid was highly atheromatous. Von Faber found the inner coat of the carotid ruptured in seven cases of hanging ; in five of
hanged
" these the carotids and aorta were atheromatous, in no In case was there rupture in perfectly sound vessels. ? six cases of hanging Simon found the rupture of the inner coat of the carotids twicein one of these cases the arteries were diseased, in the other they were not.
On the ground of these observations it has been asserted that diseased change of the vessel-wall plays a great part in the causation of the rupture of the inner or inner and middle coat of the artery. I canuot endorse this assertion, because in cases of hanging the carotid is sometimes found to be atheromatous without any rupture having taken place, and because also rupture is found in cases in which there is'no diseased change of the carotidin four of tHe above-mentioned six wall. For
example,
examined by Simon there was no rupture, although in 2 of the 4 " the arteries were diseased." Hofmami found the inner coat of the carotid torn in 3 cases of suicidal hanging and 2 cases of judicial hanging ; he eayathat a certain rigidity of the arteries, especially a chronic atheromatous process, facilitates the occurrence of rupture, we cannot confirm, because all the individuals, in whose arteries we found the rupture, were youthful." In one case of strangling and in one of cases
hanging
I
myself
have found the inner coat of the carotid
THE INDIAN MEDICAL GAZETTE.
274 ruptured,
while
the arteries showed
no
pathological
change. Since the ligature can cause death without producing any rupture of the inner or inner and middle coat of the carotid, and as the ligature can also produce this rupture in the dead body, it follows that one is not justified in drawing the conclusion from the mere fact of finding the inner or inner and middle coat of the carotid ruptured that the ligature has produced its effects during life. In so far as the injury of the carotid, caused
strangling
or
hanging,
consists in
by
a
rupture of the
vessels of the outer and middle coat of the carotid, it can, while the circulation has not yet ceased, i. e., while life has not yet been extinguished, produce an extravasation of blood. The extravasation of blood shows itself partly as an undermining with blood, as a bloody infiltrating sugillation or ecchymosis of the wall of the carotid, and partly produces, when the inner coat has been torn, a collection of blood in the wound. The extravasation of blood into the wall of the carotid, or into the ruptured wound thereof, cannot take place after death. The extravasation of blood is then an extremely
valuable sign that the action of the ligature has taken place during life. And it is so, not only when the inner coat of the carotid is ruptured, but also when it is
uninjured. The ecchymosis of the wall of of strangling and hanging shows
the carotid in cases itself as red specks in
the outer or under the inner coat. With regard to ecchymosis of the outer wall of the carotid Hofmann. in the letter to me that I have already quoted, says :?" Much oftener" (than the rupture of the inner coat) " I saw extravasations in the adventitia of the carotid at the place compressed by the ligature from mere points up to the size of split peas or even of beans, generally several together on the bifurcation and also above it. Lately I have observed these twice in cases of banging and once (well marked on both sides) a case of strangling". Ecchymosis of the inner coat of the carotid I have myself observed several times. In a case published by me of a strangled new-born child there were found under the uninjured intima in the uppermost part of the left common carotid two annular ecchymoses, which were 5 m. m. apart, 2?3 m.m. broad, and sharply marked off. Incisions through the uninjured
in
intima showed that the extravasated blood was fluid. In another case published by me of a strangled girl of 27 years of age the uppermost part of the left common carotid showed under the uninjured intima an almost annular, 7?10 m.m. broad, ecchymosis ; while in the uppermost part of the right common carotid there were found a rupture of the intima, and in the periphery of this wound
an
ecchymosis
3?5
m.m.
broad.
Kussmaul wrongly considers the extravasation into the ruptured wound of the carotid as worthless in deciding whether the ligature has acted before or after death. He founds this opinion upon an experiment of Simon. In six experiments in strangulation on the dead body Simon managed to rupture the inner and middle coat of the carotid in 3. In one of the three the inner and middle
[October 1,
1881.
coat was separated in the whole circumference; "the intima had retracted from the ruptured spot," and " some of the thin fluid dark blood present in the artery had got under the loosened-off inner coat." From this experiment Kussmaul draws the conclusion : " The exit of blood under the cellular coat at the point of rupture can there-
fore take place when the rupture occurs in death, and furnishes no assurance that the hanging or the rupture of the vessel has taken place during life." I cannot endorse this view of Kussmaul's. That ex"
periment proves nothing with regard to an exit of blood'' under the cell-coat at the point of rupture ; for no such thing was there. That experiment only shows, that the blood exceptionally present in the artery of the corpse can
get under the loosened-off inner
Such
moistening
a
coat of the carotid.
of the torn inner or inner and middle
in the artery can bo extravasation from the vessels of the carotid-wall, if one study the appearance of the wound after careful irrigation with water. With to the decision in question I desire to call atten-
contained
coats with the blood
from
easily distinguished
an
regard
tion to a circumstance that appears likely to urge to the most careful examination (with the help of a lens, if necessary) of the floor of the wound of the carotid. Where the blood in the wound was fluid, I have, after carefully washing it off by irrigation, found partly a
the middle coat, partly scattered fluid or clotted blood in the middle coat on the floor of the wound; and have drawn tho conclusion that the blood had been poured out from the vascular network that interlaces with the elements of the middle coat. This origin of the blood present in the wound shows still more clearly when the blood is coagulated, and cleaves to the floor of the wound in a greater or less extent of surface ; so that, when tho clot has been carefully removed, little lumps of bloodthe wound. Bloodclot remain sessile on the fl?or clots in the wound of the carotid in cases of hanging have
bloody infiltration of punctiform depfifcs of
been examined
by
Mildner,
Kussmaul, Hofmann,
and
myself.
In the case published by Mildner, that of a man hang" ed at the age of 48, the inner coats of the left carotid were torn transversely at two places opposite to the lower border of the mark of the ligature. The upper border was 3, the lower 2 lines long ; they are parallel to one another at a distance of half an inch. The
edges of the wound were somewhat prominent, gently sloped away, and coloured very red by imbibition. The cellular membrane formed the floor of the rupture
; was
the size of a bean ; was covered with a thin layer of extravasated blood, and was markedly injected and infiltrated with bloody serum." of
a
purple
colour in
an
area
published by Kussmaul
was that of a man The mark of the ligature ran between the larynx and the hyoid bone, and turned backwards towards the tuberosity of the occipital bone. In the left carotid just below the bifurcation the intima " The upper tear ran transwas ruptured in two places. for 15 m. with m. versely finely serrated edges, and the intima was detached 5 m m. upwards in the form of
The
case
hanged
a
at the
age of 55.
three-cornered lappet 8
m. m.
broad.
Under
the
October 1,
1881.]
SURGEON WILKIE ON P. M. APPEARANCES IN HANGING.
flap there was a little clot nearly the size of a lentil. " Neither the media at the part laid bare nor the edges of the rupture in the intima showed swelling or injection." In Hofmann's five cases of hanging, already mentioned, the wound of the carotid consisted in a transverse rupture of the intima, which took in either only a part of or the whole circumference of the calibre of the " artery. In all five cases the rupture was, though little
always insignificantly, sugillated." ed letter to me he explains this
Iu his already-quotappearance thus j?"I have not yet seen a rupture of the media of the carotid ; on the other hand I have five times seen the intima ruptured in the way described in my Manual: the borders of the rupture were mostly separated only by a hair's breadth, which was filled up by a trace of loosely clotted blood, which, just as in the annular rupture, lay upon the laid bare media, and had partly soaked into it." In the case I now publish, that of a man hanged at about the age of 60,1 found an annular of the
rupture
intima of the right external carotid. The uneven borders of the intima at the site of rupture were 1 c m separated for one another, and between them there was
of clotted blood upon the media. I bring forward as noteworthy that I performed the post-mortem in this case 28 weeks after death, and the blood clot was still preserved. iu a future esgay j shall treat of the possibility of extravasarecognizing tions in the dead body at long periods after death heie I will only insist that this possibility raises the diagnostic value of the clot in the wound of the carotid in doubtful cases of hanging and strangling. It may happen that the rupture 0f the intima of the carotid in hanging or strangling take place after the circulation has ceased. In such a case no extravasation takes place into the walls of the carotid. For example, Ogston in two cases of hanging which be hag commu_ nicated to me by letter, and in which thQ ligature had ruptured the inner and middle coat of the right carotid, discovered no extravasation of blood found
a
thin
layer
.
(? no ecchymosis ")
275
certainty.
buried
on
of suicide by hanging. follows a minute account of the graveyard, the soil, soil-water, temperature,?the circumstances which had influenced the progress of the post-mortem was one
[Here
changes.
See the
original.]
A.?External Examination. The male corpse is 176 c. m. long, and is that of a powerfully built and well-nourished individual of about 60, though only an approximate estimate of the age can to the post?mortem changes. 2. Hair be made 1.
owing
of the head brown, greyed ; can be easily stroked out. 3. Teeth bad. 4. Cadaveric rigidity not present, abdomen swollen, scrotum greatly distended with gas. 5. The in the orbits dirty chocolateare destroyed ;
eye-balls
coloured fluid. 6. The cutaneous coverings are mostly After the covered with a thick layer of fungus. the latter the epidermis by irrigation careful removal of is seen to remain fast in many places, while in others it is loosened off in shreds.
corium is partly 7. In the green.
The
partly dirty
dirty reddish-brown, front of the neck, just above the larynx, is a depression, which runs like a groove round the front of the neck towards the sides. This groove is 32 c. m. long and 1 2 c.m, broad. It is narrower at the sides than in the middle. On the right side about 2 c. m. below the lobe of the right ear the mark becomes so faint that it goes any farther back. one cannot decide whether becomes mark the imperceptible 3 c.m. side left the On or under the lobe of the left ear. Inside the groove contrasts and and clear-grey firm, is mark the skin with the dirty brown and softer skin on the other and uneven edges of the groove. 6. side of the sharp
CONTRIBUTIONS TO
FORENSIC
MEDICINE.
The soft parts of the neck under the groove are puffed of the groove and over them out, especially by the ends natural openings of the body the backwards. 9. In there
are no
By Prof. Hermann
Friedberq 0f Breslau. Archives, November 1878.)
(Virchow's [Translated by Surgeon David
intendent, Central Post-mortem
case
B.?Internal Examination. Thorax and Abdomen.
Wilk;IEj Officiating SuperPrison, Bareli.]
appearances 28 weelcs after death in
a
of hanging.
following case contributes to our knowledge of post-mortem changes, and shows for the first time that the injury to the carotid arteries caused by the ligature in the neck of a living man has been still discoverable The
28 weeks after death. On the 21st July 1875 Dr. Jacobi and I examined the immediately after it had been disinterred body of Z On the removal of the: in the churchyard of Breslau. a mouldy smell was perceptible. Of those who present while the body was undressed, all* whoi had known Z. during life recognised; the face with/
coffin lid
were
foreign bodies.
opening the chest the soft parts of the neck 10. Hie skin is firm, almost were partially dissected. leatherlike. The subcutaneous fat is clear yellow, firm and dry. The muscles are of natural oolour and good Before
and below the groove in the appearance. 11. Above neck are layers of extravasated blood, which is coagulated. These layers are found on and under the superficial fascia and between it and the middle fascia. In the and omoregion between the mylo-hyoid, sterno-hyoid) left- side is a layer, 1 c. mi thick> of the on muscles hyoid fluid blood. coagulated blood, with greasy reddish-brown, a smaller extrais the side on right In the same
region
vasation. The extravasated'blood lies not only on the sheaths of the muscles, but also in'the superficial'parts of the muscles. 12. Below the groove, from it to the clavicles, and in the laryngeal fossa^ is extravasated^
THE INDIAN MEDICAL GAZETTE.
272
blood in the subcutaneous areolar tissue and the middle cervical fascia in the front of the neck to the thickness of 2-4 m.m. 13. In the postero-lateral and posterior parts of the neck is a layer of the
(b.)
coagulated on
same
thickness of extravasated coagulated blood in
several
places in the subcutaneous connective tissue, here and there under the fat-layer. 14. The groove of the ligature lies between the hyoid bone to the upper edge of the larynx. The examination of the rest of the neck is reserved. 15. The preliminary examination of the abdomen results as follows. The highest point of the diaphragmatic arch corresponds to the lower border of the 5th rib, The position of the and
intestines is normal. the abdomen.
There is
no
extraneous matter in
(a.) Thorax. the soft parts from the front of the chest there is found from both clavicles to the second rib a layer of coagulated blood up to 1 c. m. thick, which lies partly in the fatty tissue, and partly under it17. On opening the thorax the anterior parts of the 16.
In
removing
lungs so overlap the pericardium as almost to touch. These parts of the lungs appear on the surface partly dirty rose-coloured, partly clear grey, partly slatecoloured, have an elastic feel, and are crepitant. 18.
Both
are in several places united to the old adhesions. 19. In the pleural cavity is bloody fluid,?one tablespoonful on the left side, four tablespoonfuls on the right. 20. The great vessels outside the pericardium are of small circumference.
lungs
parietes by
21. The fat, dirty bright brown pericardium is empty. 22. The heart is of normal size, very flaccid : the coronary vessels are empty. 23. The left auricle and ventricle
are
empty, and the auriculo-ventricular valve shows
nothing abnormal. The right auricle and ventricle empty; in the inner wall of the latter are found scattered miliary, calcareous deposits, loose on the shows endocardium. The auriculo-ventricular valve nothing abnormal. 24. The large vessels are empty. are
25. The mouths of the arteries are normal ; and the musculature of the heart is very soft and reddish brown. 26. The lungs are bulky, and their surface posteriorly and laterally is brownish-red. The lungs are elastic and crepitant. On section all parts of the lung are red with blood, full of air, and without trace of disease. 27. The thoracic aorta shows nothing abnormal. 28. The thyroid offers nothing worthy of notice. 29. Large veins of the neck empty. 30. Immediately above the bifurcation of the right common carotid is a solution of continuity of the intima of the external carotid. The the wound of the intima are 1 c. m., uneven edges of separated from each other, and between them there is on the media a thin layer of clotted blood. The solution of continuity of the intima is annular. The left carotid shows nothing abnormal. 31. Larynx and trachea empthat of the bronchi, ; their mucous membrane, and dark brown-red. 32. Tongue, palate, tonsils, salivary glands, and lymphatic glands show nothing abnormal. 33. Pharynx and oesophagus empty ; mucous membrane dirty brownish. 34. The bones of the thorax and neck
ty
show
nothing
abnormal.
[October 1,
1881.
Abdomen.
35. Omentum very fat, vessels empty. 36. Spleen 12 c. m. long, 6 c. m. broad, 3 c. m. thick, very soft, dirty brown red on section. 37. Left suprarenal capsule shows nothing abnormal. Left kidney 11 c. m. Ions, 6 c. m. broad, 3 c. m. thick, dark brown red on section, and so softened that a closer examination of its tissue is not possible. Eight suprarenal capsule and kidney like the left. 38. Bladder
empty: colour, moist. 39. Prostate, vesiculse, testicles, and penis, and the urethra show nothing abnornal. 40. Rectum empty. 41. Upper part of the duodenum and stomach empty ; mucous membrane greyish brown, moist. 42. Gall-bladder empty. 43 Right lobe of the liver 18 c. m. broad, membrane
mucous
19
of
a
grey
rose
high, 4 c. m. thick ; left lobe 7 c. m. broad, 10 high, 3 c. m. thick. The liver is on section brown-
c. m.
o. m
44. Pancreas normal. 45. small intestine is distendThe fat. 46. Mesentery very ed with gas, contains yellowish slimy material, and has normal coats. 47. The large intestine contains brown soft faeces, and has normal coats. 48. Blood vessels empty. 49. The bones of the abdomen are normal.
red, very soft, and moist.
77?Bead. 50. The soft coverings of the skull are dirty brownred on their inner surface and moist. 51. The skull-cup 52. Dura mater dirty brown is oval, ??| c. m. thick. red, very moist, distended (apparently by gas). Longitudinal sinus empty. 53. On cutting open the dura there escape much gas, and the brains in the form of a thin, dark, chocolate-coloured gruel. 54. All parts of the brain are converted into this uniform, thin chocolate coloured gruel, in which neither pia nor any, parts of the brain can be distinguished. 55. The sinuses of the base of the skull are empty. 56. On removing the dura the parietes and base of the skull are found to be
uninjured. II.
of the injury to the and Strangling. Hanging of
On the causation and carotids in In
a
opinion
cases
significance
report of mine in the year 1851 I expressed an on the causation and significance of the injury
to the carotids found in cases of
hanging and strangling^ enunciated has been confirmed and completed by various writers, and by published observations of my own, I now consider that I ought to go into the matter more thoroughly than I did then. In the year 1828 Amussat communicated to the Academy of Medicine of Paris that in a case of hanging, in which he had carefully examined the soft parts in the neighbourhood of the ligature, he had found the intima and media of. both carotids cut through. Since then Devergie, Kloz, Mildner, von Faber, Simon, Kussmaul, Hofmann, Ogston and myself have published observations which show that the injury of the carotids, rightly esti. mated, is an exceedingly valuable sign of strangulation and of hanging. By the ligature round the neck both in strangling and in hanging, the carotid can be injured when it is sufficiently stretched and squeezed. The As
my view therein
October 1,
1881.]
SURGEON WILKIE ON P. M. APPEARANCES IN HANGING.
in
question consists partly in a rupture of the of the inner and middle coats of the carotid, partly in an extravasation of blood from the vessels of the wall of the carotid (vasa vasorum) which in the outer and middle coats form a wide-meshed net, that reaches nearly to the inner coat. As to the
injury inner
or
(non-vascular)
causation of the
to the carotid
injury by the action of the ligature, I lay greater stress on the stretching than on the squeezing which that vessel suffers from the ligature. Without a stretching of the carotid I could especially not understand those cases in which the rupture of the inner or inner and middle coats is situated at a spot distant from the mark of the ligature, as in cases investigated by Mildner, von Faber, Simon, and Kussmaul. In explaining the origin of the lesion I further lay congestion which occurs in the vessels above the ligature. The distension of the vessels in the wall of the carotid, caused by the congestion, can be stress on the sudden
so great as to end in rupture, and produce an extravasation of blood. Herr Hofmann has honoured me with a letter in which he expresses his opinion that the congestion contributes not only to the infiltration with blood of the wall of the carotid, but also to the rupture of the inner coat of the carotid. To the stimulation of the nerves of the vessels also I ascribe a participation in the rupture of the blood-vessels in the wall 0f the carotid. The
stimulation can either be caused directly by the ligature, be the result of the dyspnoea produced in by it; both cases so raise the blood-pressure that the vessels in the wall of the carotid burst and p0Ur out blood into the wall.
?and
or
In the hitherto published cases of hanging and strangin which the carotid was injured, it was the common carotid of one or of both sides that was affected. On the other hand in the case which I }lave J-ug(. described the right external carotid was the one injured. This calls to mind an experiment with reference to strangulation which Simon carried out on the corpse of a man 21 years of age. He compressed the neck by means of a thin cord between the hyoid bone and larynx; and the result was that the inner and middle coats of
ling
the left external
carotid, immediately above the origin of the superior thyroid artery, and also the inner coat of both right and left internal carotid were ruptured, while
the right and left common carotid remained uninAs the superior thyroid artery arises close above the bifurcation of the common carotid, it must have been the lowest part of the external carotid that was injured in that experiment. This pGrtion of the external carotid, which lies in the carotid triangle, close to the median border of the
jured.
is
only
and
lies
covered so
by cervical
superficially
sterno-mastoid,
fascia, platysma,
that one
and skin ;
easily feel, very fat> plaiaty see its conjecture that, lying as can
and, in persons who are not pulsations. I am inclined to tt does in a position of so little sheUer> the external carotid is, when the ligature lies betlveen the larynx and hyoid bone, more frequently injured than appears from the literature of post-mortem reports in cases of
hanging
273
strangling. How far my conjecture is just, and how often in reality the carotids are injured in hanging and strangling, can only he determined when the carotids are more frequently examined in cases of hanging and strangling than they have been hitherto. and
The rupture of the inner or inner and middle coat of the carotid is not so easily produced in experiments in strangulation in the dead body as it takes place in the living. For in the living the stretching of the carotid, fixed by the ligature, can be caused,?1 thereby, that the living, in being hanged, jump down from a height and suddenly increase the pull on the ligature caused by their body-weight; 2 thereby, that the living, when being strangled or hanged, carry out movements of the body which are partly directed towards freeing the neck from the ligature, are partly spasmodic and partly arise from the death-struggle. When the ligature is so placed that, in spite of that jumping down or of those movements, no sufficient stretching of the carotid results, then the ligature can cause death without any
carotid taking place.
One can see that remembers that it is only necespossible, sary for the ligature to force the root of the tongue into the pharyngeal opening in order to cause death by suffocation, and can in so doing be so placed as not to be in a position to fix the carotid. In a series of cases in which the carotids of men
injury
to the
this is
if
one
showed rupture of the inner or inner and middle the wall of the vessel was altered by disease. coat, Mildner found in his case "rigidity of the arteries.'' Kussmaul found in a preparation in the collection of his father,?one taken from a man that had been hanged,?the carotids atheromatous. In a case of hanging examined by Kussmaul himself the carotid was highly atheromatous. Von Faber found the inner coat of the carotid ruptured in seven cases of hanging ; in five of
hanged
" these the carotids and aorta were atheromatous, in no In case was there rupture in perfectly sound vessels. ? six cases of hanging Simon found the rupture of the inner coat of the carotids twicein one of these cases the arteries were diseased, in the other they were not.
On the ground of these observations it has been asserted that diseased change of the vessel-wall plays a great part in the causation of the rupture of the inner or inner and middle coat of the artery. I canuot endorse this assertion, because in cases of hanging the carotid is sometimes found to be atheromatous without any rupture having taken place, and because also rupture is found in cases in which there is'no diseased change of the carotidin four of tHe above-mentioned six wall. For
example,
examined by Simon there was no rupture, although in 2 of the 4 " the arteries were diseased." Hofmami found the inner coat of the carotid torn in 3 cases of suicidal hanging and 2 cases of judicial hanging ; he eayathat a certain rigidity of the arteries, especially a chronic atheromatous process, facilitates the occurrence of rupture, we cannot confirm, because all the individuals, in whose arteries we found the rupture, were youthful." In one case of strangling and in one of cases
hanging
I
myself
have found the inner coat of the carotid
THE INDIAN MEDICAL GAZETTE.
274 ruptured,
while
the arteries showed
no
pathological
change. Since the ligature can cause death without producing any rupture of the inner or inner and middle coat of the carotid, and as the ligature can also produce this rupture in the dead body, it follows that one is not justified in drawing the conclusion from the mere fact of finding the inner or inner and middle coat of the carotid ruptured that the ligature has produced its effects during life. In so far as the injury of the carotid, caused
strangling
or
hanging,
consists in
by
a
rupture of the
vessels of the outer and middle coat of the carotid, it can, while the circulation has not yet ceased, i. e., while life has not yet been extinguished, produce an extravasation of blood. The extravasation of blood shows itself partly as an undermining with blood, as a bloody infiltrating sugillation or ecchymosis of the wall of the carotid, and partly produces, when the inner coat has been torn, a collection of blood in the wound. The extravasation of blood into the wall of the carotid, or into the ruptured wound thereof, cannot take place after death. The extravasation of blood is then an extremely
valuable sign that the action of the ligature has taken place during life. And it is so, not only when the inner coat of the carotid is ruptured, but also when it is
uninjured. The ecchymosis of the wall of of strangling and hanging shows
the carotid in cases itself as red specks in
the outer or under the inner coat. With regard to ecchymosis of the outer wall of the carotid Hofmann. in the letter to me that I have already quoted, says :?" Much oftener" (than the rupture of the inner coat) " I saw extravasations in the adventitia of the carotid at the place compressed by the ligature from mere points up to the size of split peas or even of beans, generally several together on the bifurcation and also above it. Lately I have observed these twice in cases of banging and once (well marked on both sides) a case of strangling". Ecchymosis of the inner coat of the carotid I have myself observed several times. In a case published by me of a strangled new-born child there were found under the uninjured intima in the uppermost part of the left common carotid two annular ecchymoses, which were 5 m. m. apart, 2?3 m.m. broad, and sharply marked off. Incisions through the uninjured
in
intima showed that the extravasated blood was fluid. In another case published by me of a strangled girl of 27 years of age the uppermost part of the left common carotid showed under the uninjured intima an almost annular, 7?10 m.m. broad, ecchymosis ; while in the uppermost part of the right common carotid there were found a rupture of the intima, and in the periphery of this wound
an
ecchymosis
3?5
m.m.
broad.
Kussmaul wrongly considers the extravasation into the ruptured wound of the carotid as worthless in deciding whether the ligature has acted before or after death. He founds this opinion upon an experiment of Simon. In six experiments in strangulation on the dead body Simon managed to rupture the inner and middle coat of the carotid in 3. In one of the three the inner and middle
[October 1,
1881.
coat was separated in the whole circumference; "the intima had retracted from the ruptured spot," and " some of the thin fluid dark blood present in the artery had got under the loosened-off inner coat." From this experiment Kussmaul draws the conclusion : " The exit of blood under the cellular coat at the point of rupture can there-
fore take place when the rupture occurs in death, and furnishes no assurance that the hanging or the rupture of the vessel has taken place during life." I cannot endorse this view of Kussmaul's. That ex"
periment proves nothing with regard to an exit of blood'' under the cell-coat at the point of rupture ; for no such thing was there. That experiment only shows, that the blood exceptionally present in the artery of the corpse can
get under the loosened-off inner
Such
moistening
a
coat of the carotid.
of the torn inner or inner and middle
in the artery can bo extravasation from the vessels of the carotid-wall, if one study the appearance of the wound after careful irrigation with water. With to the decision in question I desire to call atten-
contained
coats with the blood
from
easily distinguished
an
regard
tion to a circumstance that appears likely to urge to the most careful examination (with the help of a lens, if necessary) of the floor of the wound of the carotid. Where the blood in the wound was fluid, I have, after carefully washing it off by irrigation, found partly a
the middle coat, partly scattered fluid or clotted blood in the middle coat on the floor of the wound; and have drawn tho conclusion that the blood had been poured out from the vascular network that interlaces with the elements of the middle coat. This origin of the blood present in the wound shows still more clearly when the blood is coagulated, and cleaves to the floor of the wound in a greater or less extent of surface ; so that, when tho clot has been carefully removed, little lumps of bloodthe wound. Bloodclot remain sessile on the fl?or clots in the wound of the carotid in cases of hanging have
bloody infiltration of punctiform depfifcs of
been examined
by
Mildner,
Kussmaul, Hofmann,
and
myself.
In the case published by Mildner, that of a man hang" ed at the age of 48, the inner coats of the left carotid were torn transversely at two places opposite to the lower border of the mark of the ligature. The upper border was 3, the lower 2 lines long ; they are parallel to one another at a distance of half an inch. The
edges of the wound were somewhat prominent, gently sloped away, and coloured very red by imbibition. The cellular membrane formed the floor of the rupture
; was
the size of a bean ; was covered with a thin layer of extravasated blood, and was markedly injected and infiltrated with bloody serum." of
a
purple
colour in
an
area
published by Kussmaul
was that of a man The mark of the ligature ran between the larynx and the hyoid bone, and turned backwards towards the tuberosity of the occipital bone. In the left carotid just below the bifurcation the intima " The upper tear ran transwas ruptured in two places. for 15 m. with m. versely finely serrated edges, and the intima was detached 5 m m. upwards in the form of
The
case
hanged
a
at the
age of 55.
three-cornered lappet 8
m. m.
broad.
Under
the
October 1,
1881.]
SURGEON WILKIE ON P. M. APPEARANCES IN HANGING.
flap there was a little clot nearly the size of a lentil. " Neither the media at the part laid bare nor the edges of the rupture in the intima showed swelling or injection." In Hofmann's five cases of hanging, already mentioned, the wound of the carotid consisted in a transverse rupture of the intima, which took in either only a part of or the whole circumference of the calibre of the " artery. In all five cases the rupture was, though little
always insignificantly, sugillated." ed letter to me he explains this
Iu his already-quotappearance thus j?"I have not yet seen a rupture of the media of the carotid ; on the other hand I have five times seen the intima ruptured in the way described in my Manual: the borders of the rupture were mostly separated only by a hair's breadth, which was filled up by a trace of loosely clotted blood, which, just as in the annular rupture, lay upon the laid bare media, and had partly soaked into it." In the case I now publish, that of a man hanged at about the age of 60,1 found an annular of the
rupture
intima of the right external carotid. The uneven borders of the intima at the site of rupture were 1 c m separated for one another, and between them there was
of clotted blood upon the media. I bring forward as noteworthy that I performed the post-mortem in this case 28 weeks after death, and the blood clot was still preserved. iu a future esgay j shall treat of the possibility of extravasarecognizing tions in the dead body at long periods after death heie I will only insist that this possibility raises the diagnostic value of the clot in the wound of the carotid in doubtful cases of hanging and strangling. It may happen that the rupture 0f the intima of the carotid in hanging or strangling take place after the circulation has ceased. In such a case no extravasation takes place into the walls of the carotid. For example, Ogston in two cases of hanging which be hag commu_ nicated to me by letter, and in which thQ ligature had ruptured the inner and middle coat of the right carotid, discovered no extravasation of blood found
a
thin
layer
.
(? no ecchymosis ")
275
