cases. The circulation of unaërated blood through the brain and spinal cord may account for these effects. Efforts to inspire are made during one or two minutes after the closure or compression of the windpipe. The diaphragm and intercostal muscles act spasmodically, but no air enters the lungs; and it is probable that, in the act of hanging, part of the air contained in the organs is convulsively expelled. When the suspension of the body has continued only a few minutes, it has often been found impossible to restore life; and indeed the period at which resuscitation may take place will vary in different subjects according to circumstances. Supposing the hanging to be unattended with violence to the neck, it is possible that some persons might be resuscitated after five minutes' suspension or longer. Others, again, may not be restored when they are cut down immediately after suspension a fact which depends probably on the different degrees to which asphyxia or apoplexy has extended.

Death from the secondary effects.-It by no means follows that, because we have succeeded in restoring the respiratory process, a person is safe. Death often takes place by a relapse at various periods after the accident. A boy, æt. 17, was found hanging. When cut down he was insensible, and his face livid; his lips were of a dark-purple colour, the pulse not perceptible, the pupils dilated and motionless. Artificial respiration was used, and in a quarter of an hour the diaphragm began to act. He breathed at irregular intervals with stertor, and with a rattling noise in the throat. The pulse became perceptible, but often flagging, and the surface of the body was cold. The countenance was still livid, but the pulse and breathing had improved. At the end of another hour an attempt was unsuccessfully made to take some blood from the arm, and the patient was placed in a warm bath. The breathing was stertorous through the night, and in the morning twelve ounces of blood were taken from the arm; but there was no relief. He continued insensible, and cold on the surface: there was frothing at the mouth, and he died twenty-four hours after he was cut down. The vessels of the brain were very full of blood-the only morbid appearance.

In another instance, a man who had hanged himself, was cut down in a state of insensibility. He lay for a considerable time breathing with apoplectic stertor, but eventually recovered. ('Brodie's Lect. on Pathol.' 72.) A powerful athletic man, who had been committed to prison for theft, hanged himself. He was found, apparently dead, hanging by his own handkerchief. He was cut down, and seen half an hour after the Occurrence. The man was then seemingly lifeless; he neither breathed nor moved, nor had any perceptible circulation. The face and neck were much swollen and livid, and the ecchymosed mark of the cord was immediately below the thyroid cartilage: the fingers were bent, and the hands nearly clenched. His head was raised; the windows were thrown open, and blood was abstracted from the arm, which was put into hot water in order to increase the flow. In a few minutes the man began to breathe: the bleeding was allowed to continue until the pulse was felt at the wrist, and the pupils contracted completely on the approach of a light. The breathing was stertorous. Brandy-and-water was injected into the stomach, and warmth was applied to the extremities. In the course of a few hours he rallied; his pulse became firmer and quicker (130), but his head was hot; he was restless, unmanageable, and violently convulsed in the arms and legs. Shortly before death he was calm, and spoke several times: he suddenly became exhausted, and died nineteen hours after he was found hanging. (Lancet,' Jan. 6, 1844.) This was probably a mixed case of asphyxia and congestive apoplexy. The unsuccessful result may perhaps be ascribed to the injury sustained by the cerebral circulation from

TREATMENT IN CASES OF HANGING.

37

constriction of the neck. In hanging as well as in drowning, therefore, a person may in the first instance recover, but subsequently die in spite of medical treatment, probably from the depressing effects produced on the nervous and muscular systems by the circulation of unaërated blood. A case in illustration of this point has been reported by Richardson ('Med. Times and Gaz.' Dec. 17, 1853, p. 639). A man died on the second day after he was cut down. On inspection, the brain was found greatly congested, and there was effusion of serum under the arachnoid membrane. The lungs and heart were congested, and a solid fibrinous deposit was found in the right ventricle.

Treatment.-Exposure to a fresh current of air, cold affusion when the skin is warm, with the vapour of ammonia and other stimuli, may be employed on these occasions. If there should be much cerebral congestion, bleeding may be resorted to on recovery. The application of faradic electricity in the course of the spine might be attended with benefit; but much will depend, as in drowning, upon the time at which assistance is rendered after the body has been cut down. The following case of recovery-in which, however, asphyxia was not complete was reported in the 'Lancet,' Nov. 1839. A robust woman, aged thirty-three, hanged herself while slightly intoxicated. She was missed about ten minutes before she was found suspended to a bedstead, but it was impossible to determine how long she had been thus hanging. Medical assistance was rendered to her in about ten minutes after she had been cut down. She was then quite insensible,her respiration slow and laborious, and her pulse barely perceptible. The countenance was pale; there was no lividity; the lower jaw was depressed, the extremities moderately warm, the hands convulsively clenched, the pupils somewhat dilated and barely susceptible to light. A dusky-red mark, of a quarter of an inch in breadth, was observed encircling the upper part of the neck, forming an angle over the ramus of the jaw on the right side, where the knot of the ligature (a silk handkerchief) had rested; and in consequence of this the constriction was incomplete. The patient was twice copiously bled, mustard-poultices were applied to the calves of the legs, hot water to the feet, and cold applications to the head. After thirty-two ounces of blood had been abstracted, in half an hour the breathing became stertorous, the pupils fully dilated, the lower jaw fell further, the sphincters became relaxed, and the patient appeared to be rapidly sinking. Ammoniacal liniment was rubbed on the chest, and the woman so far recovered in an hour as to be able to swallow; but although she was conscious of pain, she remained comatose until the evening, when she became perfectly sensible of surrounding objects. This was evidently a case of imperfect suspension, where, from respiration still continuing, there was every hope of recovery. The cerebral circulation had here become simply disordered.

In one case cold affusion speedily resuscitated the person. A man had been hanging about two or three minutes when he was cut down, and in four or five minutes afterwards he had ceased to breathe: his features were pallid, and the eyes injected with blood. The heart's action continued, although feeble; the pulse being about 80, and very weak. Artificial respiration was tried without any benefit, when affusion of cold water was resorted to. This, after a short time, led to the complete establishment of respiration: at each affusion there was a deep inspiration. The man was bled to sixteen ounces, and he soon recovered his consciousness. ('Med. Gaz.' vol. 37, p. 75.)

When great cerebral congestion is produced by a close constriction of the throat, copious bleeding will generally be found beneficial. Some Thugs, quite unintentionally, saved the life of a person whom they had

strangled, by cutting his throat. A man fell in with a gang of Thugs, who strangled him. He became unconscious: on recovering his senses he found that his throat had been cut, and that a fellow-traveller lay strangled to death by his side. The wound in the throat was properly treated, and the man recovered in six weeks. He was able to give a description of the gang, which subsequently led to the apprehension of four, who were sentenced to death. As Chevers remarks, it can scarcely be doubted that the violent measure of cutting the man's throat effectually relieved the vessels of the brain of any undue congestion which the throttling might have produced. ('Med. Jurispr. for India,' p. 405.)

These cases bear out the views long since published by Brodie-namely, that after respiration has ceased, the heart continues to act, and to circulate venous blood, for a period of three or four minutes, to the brain and other parts of the system. The exact period of time will, however, depend on the strength of the person. It is on this ground that in hanging there is great hope of restoring a person by artificial respiration. The action of the heart was observed in one case of criminal hanging to continue for so long a period as nine minutes and a half after suspension. A criminal was executed. The execution took place in a passage of the prison, so that the feet of the criminal were only twelve inches from the ground. The pulse was felt by a surgeon on each side. It is stated that in the fifth minute there were one hundred and twenty-eight pulsations. ('Med. Times and Gaz.' July 1, 1854.) In the after-treatment it is advisable that blood should be only sparingly abstracted to relieve any cerebral congestion, because the vital powers are much reduced under the circumstances. Convulsions, and even paralysis, have been observed to precede recovery in experiments on animals.

Period at which death takes place. We learn from those who have been resuscitated, as well as from experiments performed by persons upon themselves, that the insensibility of asphyxia comes on in the most insidious manner in death from hanging, and that a slight constriction of the windpipe will speedily produce loss of consciousness and muscular power. (Devergie, 2, 370.) The only symptoms of which the hanged persons have been conscious were a ringing in the ears, a flash of light before the eyes, then darkness and oblivion. The only useful inference, in a medicolegal view, which can be drawn from observations of this kind is, that asphyxia is not only rapidly induced, but that it supervenes under circumstances where it would not be generally expected to occur-i.e. when the body is in great part supported. Fleischmann found that a cord might be placed round his neck between the chin and hyoid bone, and tightened either laterally or posteriorly without perceptibly interrupting respiration; but while the respiratory process was thus carried on, his face became red, his eyes prominent, and his head felt hot. These symptoms were followed by a sense of weight, a feeling of incipient stupefaction, and a hissing noise in the ears. On the occurrence of this last symptom, the experiment, he says, should be discontinued, or the consequences may be serious. His first experiment on himself lasted two minutes; but in the second, owing to the cord by its pressure more completely interrupting respiration, the noise in the ears appeared in half a minute. When the pressure was applied on the windpipe the effect was instantaneous, but when on the cricoid cartilage it was not immediate. If it was applied between the hyoid bone and the thyroid cartilage, or on the hyoid bone itself, the period during which a person could breathe was extremely short; and this result was more striking when the act of expiration was performed at the moment of applying the pressure. (See also p. 35.) The death of Scott, the American diver, in 1840, shows how readily asphyxia may be induced by a slight compression of

HANGING.

POST-MORTEM APPEARANCES.

39

the throat, even when a person might be supposed to have both the knowledge and the power to save himself. This man was in the habit of making public experiments on hanging, and had frequently before gone through them without danger; but on this occasion, it is probable that a slight shifting of the ligature from under the jawbone caused so much compression on the throat between the chin and larynx as speedily to produce asphyxia. No attempt was made to save him until it was too late, and he was not brought to a hospital until thirty-three minutes had elapsed. He was allowed to hang thirteen minutes-the spectators thinking that the deceased was only prolonging the experiment for their gratification. This case proves that, for a person to die by hanging, it is not necessary that the rope or ligature should completely encircle the neck. Cerebral congestion may take place under these circumstances, and thus lead to the suspension of respiration. (See 'Ann. d'Hyg.' 1858, 1, 177.) The slipping of the ligature, or the means of suspension, behind the angles of the jaw, might suffice to compress the great blood-vessels of the neck, and thus bring on fatal apoplexy.

The very insidious and painless manner in which a person who is suspended passes from life to death, is also well illustrated in the report of the case of Hornshaw. ('Lancet,' Ap. 17, 1847, p. 404.) This man was on three occasions resuscitated from hanging-a feat which, like Scott, he had performed for public gratification. He stated that he lost his senses almost at once; that it seemed as if he could not get his breath, and that some great weight was attached to his feet; he felt that he could not move his hands or legs to save himself, and that the power of thinking was gone. It is not improbable that persons have thus lost their lives by privately attempting these experiments, and their cases have been set down to acts of suicide. There is reason to believe that boys have thus unintentionally destroyed themselves, from a strange principle of imitation or curiosity. The following is one among many instances of this kind. In 1844, a boy, aged fourteen, witnessed an execution at Nottingham, and he was afterwards heard to say that he should like to know how hanging felt. On the same afternoon he was found suspended by a cord from a tree, quite dead; and from the circumstances there could be no doubt that he had been experimenting on the theory and practice of hanging, and that he did not intend to destroy himself. The jury returned a verdict of 'accidental hanging.'

Post-mortem appearances. The external appearances met with in the hanged have been generally taken by medico-legal writers from those seen in the bodies of persons who have been judicially executed, or who have been violently hanged. Thus among them are the following:-Lividity and swelling of the face, especially of the ears and lips, which appear distorted: the eyelids swollen, and of a blueish colour; the eyes red, projecting forwards, and sometimes partially forced out of their cavities; the pupils dilated, the tongue enlarged, livid, and either compressed between the teeth, or sometimes protruded; the lower jaw retracted, and a bloody froth or frothy mucus sometimes escaping from the lips and nostrils. There is a deep and ecchymosed impression or mark around the neck, indicating the course of the cord, the skin being occasionally excoriated; laceration of the muscles and ligaments in the hyoideal region; laceration, fracture, or contusion of the larynx, or of the upper part of the windpipe. There are also, commonly, circumscribed patches of ecchymosis varying in extent, about the upper part of the body and the upper and lower limbs, with a deep livid discoloration of the hands; the fingers are generally much contracted or firmly clenched, and the hands and nails, as well as the ears, are livid; the urine and fæces are sometimes involuntarily expelled at the moment of death. Such appearances will rarely be found in those cases of suicidal hanging which

are likely to come before a medical practitioner. In these, the face is generally pale, and the mark on the neck is a simple depression in the skin, usually without ecchymosis, and acquiring a horny or parchment colour only after some time. Esquirol found, in one instance, that when the body was examined immediately after death, the face was not livid; but it first began to assume a violet hue in eight or ten hours. The editor has seen a similar case. Esquirol thought that when the cord was left round the neck the face would be livid, but if removed immediately after suspension, pale. This view is not, however, borne out by observation. The tongue is not always protruded. Devergie found that there was protrusion of this organ in eleven out of twenty-seven cases. This protrusion was formerly supposed to depend upon the position of the ligature: thus, it was said, when this was below the cricoid cartilage, the whole of the larynx was drawn upwards, and the tongue carried forwards with it, while when above the hyoid bone the tongue was drawn backwards. The protrusion or nonprotrusion of the tongue does not depend upon any mechanical effect of this kind, but simply upon congestion; for it is occasionally met with thus protruding in cases of drowning and suffocation. Besides, the protrusion has not been found to have any direct relation to the position of the ligature. Chevers has noted another characteristic external appearance after death from hanging, viz. that the saliva, after death, trickles from the mouth in a straight vertical line, down the chin and breast, and over the clothes.

There is another appearance on which a remark may be made-namely, the state of the hands. As a general rule, in violent hanging or strangulation, the hands are clenched. This appearance may not always be found, as it may exist and be destroyed before the body undergoes inspection. When the constriction of the neck has been produced suddenly, and with great violence, we may expect to meet with it. Thus it is found in the cases of executed criminals, and in strangulation attended with great violence (see case by Rake, post, p. 58), whether the act be due to homicide or suicide. In cases in which the constriction is gradually produced, the clenched state of the hands may not be found. (Cases post, p. 58.) Convulsions generally attend violent hanging or strangulation. The influence of these on the attitude or dress may not be apparent, unless the body be sitting or lying.

Internally we meet with the appearances described under the head of asphyxia-i.e. engorgement of the lungs and venous system generally with dark-coloured fluid blood: the lungs otherwise present no particular appearances. In one instance these organs were found quite collapsed, and occupying only the back part of the cavity of the chest. The right side of the heart, and the great vessels connected with it, are commonly distended with blood. But when the inspection has been delayed for several days, this distension may not be observed. When made before rigor mortis has set in, all the cavities of the heart may be found gorged with blood. The mucous membrane of the windpipe is more or less congested, and is sometimes covered with a fine bloody mucous froth. This may be owing to imperfectly obstructed respiration, and to spasmodic efforts at breathing. The vessels of the brain are generally found congested; and in some rare instances, it is said, extravasation of blood has been met with on the membranes or in the substance of the organ. Effusion of blood is, however, so rare that Remer found this appearance described only once among one hundred and one cases; and in one hundred and six cases recorded by Casper it was not found in a single instance. In one case of death from hanging, Brodie found a large effusion of blood in the substance of the brain, and he refers to another case in which there was a considerable effusion between the membranes. (Lect. on Pathol.' p. 58.) The venous