FORENSIC MEDICINE AND TOXICOLOGY
W.G. AITCHISON ROBERTSON
M.D., D.Sc., F.R.C.P.E.
LECTURER ON FORENSIC MEDICINE, SCHOOL OF MEDICINE, EDINBURGH; LATE EXAMINER IN THE UNIVERSITIES OF EDINBURGH AND ST. ANDREWS; FOR THE TRIPLE BOARD; DIPLOMA IN PUBLIC HEALTH, ETC.
BAILLIERE, TINDALL AND COX
8, HENRIETTA STREET, COVENT GARDEN
PREFACE TO NINTH EDITION
I trust that, having thoroughly revised the "Aids to Forensic Medicine," it may prove as useful to students preparing for examination in the future as it has been in the past.
W.G. AITCHISON ROBERTSON.
SURGEONS' HALL, EDINBURGH, November, 1921.
PREFACE TO EIGHTH EDITION
This work of the late Dr. William Murrell having met with such a large measure of success, the publishers thought it would be well to bring out a new edition, and invited me to revise the last impression.
This I have done, and while retaining Dr. Murrell's text closely, I have made large additions, in order to bring the "Aids" up to present requirements. I have also rearranged the matter with the object of making the various sections more consecutive than they were previously.
W.G. AITCHISON ROBERTSON.
SURGEONS' HALL, EDINBURGH, June, 1914.
I. Crimes 1 II. Medical Evidence 2 III. Personal Identity 10 IV. Examination of Persons found Dead 12 V. Modes of Sudden Death 13 VI. Signs of Death 16 VII. Death from Anaesthetics, etc. 19 VIII. Presumption of Death; Survivorship 20 IX. Assaults, Murder, Manslaughter, etc. 21 X. Wounds and Mechanical Injuries 21 XI. Contused Wounds, etc. 22 XII. Incised Wounds 23 XIII. Gunshot Wounds 24 XIV. Wounds of Various Parts of the Body 26 XV. Detection of Blood-Stains, etc. 30 XVI. Death by Suffocation 34 XVII. Death by Hanging 35 XVIII. Death by Strangulation 35 XIX. Death by Drowning 36 XX. Death from Starvation 38 XXI. Death from Lightning and Electricity 38 XXII. Death from Cold or Heat 39 XXIII. Pregnancy 40 XXIV. Delivery 41 XXV. Foeticide or Criminal Abortion 42 XXVI. Infanticide 44 XXVII. Evidences of Live-Birth 46 XXVIII. Cause of Death in the Foetus 50 XXIX. Duration of Pregnancy 50 XXX. Viability of Children 51 XXXI. Legitimacy 52 XXXII. Superfoetation 53 XXXIII. Inheritance 54 XXXIV. Impotence and Sterility 54 XXXV. Rape 55 XXXVI. Unnatural Offences 59 XXXVII. Blackmailing 60 XXXVIII. Marriage and Divorce 60 XXXIX. Feigned Diseases 63 XL. Mental Unsoundness 67 XLI. Idiocy, Imbecility, Cretinism 68 XLII. Dementia 70 XLIII. Mania, Lucid Intervals, Undue Influence, Responsibility, etc. 71 XLIV. Examination of Persons of Unsound Mind 76 XLV. Inebriates Acts 78
I. Definition of a Poison 80 II. Scheduled Poisons 80 III. Classification of Poisons 83 IV. Evidence of Poisoning 85 V. Symptoms and Post-Mortem Appearances of Different Classes of Poisons 86 VI. Duty of Practitioner in Supposed Case of Poisoning 89 VII. Treatment of Poisoning 90 VIII. Detection of Poison 91 IX. The Mineral Acids 94 X. Sulphuric Acid 95 XI. Nitric Acid 97 XII. Hydrochloric Acid 98 XIII. Oxalic Acid 98 XIV. Carbolic Acid 100 XV. Potash, Soda, and Ammonia 101 XVI. Potassium Salts, etc. 103 XVII. Nitrate of Potassium, etc. 103 XVIII. Barium Salts 104 XIX. Iodine—Iodide of Potassium 104 XX. Phosphorus 105 XXI. Arsenic and its Preparations 107 XXII. Antimony and its Preparations 112 XXIII. Mercury and its Preparations 113 XXIV. Lead and its Preparations 116 XXV. Copper and its Preparations 117 XXVI. Zinc, Silver, Bismuth, and Chromium 118 XXVII. Gaseous Poisons 120 XXVIII. Vegetable Irritants 123 XXIX. Opium and Morphine 124 XXX. Belladonna, Hyoscyamus, and Stramonium 127 XXXI. Cocaine 128 XXXII. Camphor 129 XXXIII. Tetrachlorethane 129 XXXIV. Alcohol, Ether, and Chloroform 130 XXXV. Chloral Hydrate 134 XXXVI. Petroleum and Paraffin Oil 134 XXXVII. Antipyrine, Antefebrin, Phenacetin, and Aniline 135 XXXVIII. Sulphonal, Trional, Tetronal, Veronal, Paraldehyde 137 XXXIX. Conium and Calabar Bean 138 XL. Tobacco and Lobelia 139 XLI. Hydrocyanic Acid 140 XLII. Aconite 143 XLIII. Digitalis 144 XLIV. Nux Vomica, Strychnine, and Brucine 145 XLV. Cantharides 146 XLVI. Abortifacients 147 XLVII. Poisonous Fungi and Toxic Foods 148 XLVIII. Ptomaines or Cadaveric Alkaloids 150
AIDS TO FORENSIC MEDICINE AND TOXICOLOGY
Forensic medicine is also called Medical Jurisprudence or Legal Medicine, and includes all questions which bring medical matters into relation with the law. It deals, therefore, with (1) crimes and (2) civil injuries.
1. A crime is the voluntary act of a person of sound mind harmful to others and also unjust. No act is a crime unless it is plainly forbidden by law. To constitute a crime, two circumstances are necessary to be proved—(a) that the act has been committed, (b) that a guilty mind or malice was present. The act may be one of omission or of commission. Every person who commits a crime may be punished, unless he is under the age of seven years, is insane, or has been made to commit it under compulsion.
Crimes are divided into misdemeanours and felonies. The distinction is not very definite, but, as a rule, the former are less serious forms of crime, and are punishable with a term of imprisonment, generally under two years; while felonies comprise the more serious charges, as murder, manslaughter, rape, which involve the capital sentence or long terms of imprisonment.
An offence is a trivial breach of the criminal law, and is punishable on summary conviction before a magistrate or justices only, while the more serious crimes (indictable offences) must be tried before a jury.
2. Civil injuries differ from crimes in that the former are compensated by damages awarded, while the latter are punished; any person, whether injured or not, may prosecute for a crime, while only the sufferer can sue for a civil injury. The Crown may remit punishment for a crime, but not for a civil injury.
On being called, the medical witness enters the witness-box and takes the oath. This is very generally done by uplifting the right hand and repeating the oath (Scottish form), or by kissing the Bible, or by making a solemn affirmation.
1. He may be called to give ordinary evidence as a common witness. Thus he may be asked to detail the facts of an accident which he has observed, and of the inferences he has deduced. This evidence is what any lay observer might be asked.
2. Expert Witness.—On the other hand, he may be examined on matters of a technical or professional character. The medical man then gives evidence of a skilled or expert nature. He may be asked his opinion on certain facts narrated—e.g., if a certain wound would be immediately fatal. Again, he may be asked whether he concurs with opinions held by other medical authorities.
In important cases specialists are often called to give evidence of a skilled nature. Thus the hospital surgeon, the nerve specialist, or the mental consultant may be served with a subpoena to appear at court on a certain date to give evidence. The evidence of such skilled observers will, it is supposed, carry greater weight with the jury than would the evidence of an ordinary practitioner.
Skilled witnesses may hear the evidence of ordinary witnesses in regard to the case in which they are to give evidence, and it is, indeed, better that they should understand the case thoroughly, but they are not usually allowed to hear the evidence of other expert witnesses.
In civil cases the medical witness should, previous to the trial, make an agreement with the solicitor who has called him with reference to the fee he is to receive. Before consenting to appear as a witness the practitioner should insist on having all the facts of the case put before him in writing. In this way only can he decide as to whether in his opinion the plaintiff or defendant is right as regards the medical evidence. If summoned by the side on which he thinks the medical testimony is correct, then it is his duty to consent to appear. If, however, he is of opinion that the medical evidence is clearly and correctly on the opposite side, then he ought to refuse to appear and give evidence; and, indeed, the lawyer would not desire his presence in the witness-box unless he could uphold the case.
Whether an expert witness who has no personal knowledge of the facts is bound to attend on a subpoena is a moot point. It would be safer for him to do so, and to explain to the judge before taking the oath that his memory has not been sufficiently 'refreshed.' The solicitor, if he desires his evidence, will probably see that the fee is forthcoming.
A witness may be subjected to three examinations: first, by the party on whose side he is engaged, which is called the 'examination in chief,' and in which he affords the basis for the next examination or 'cross-examination' by the opposite side. The third is the 're-examination' by his own side. In the first he merely gives a clear statement of facts or of his opinions. In the next his testimony is subjected to rigid examination in order to weaken his previous statements. In the third he is allowed to clear up any discrepancies in the cross-examination, but he must not introduce any new matter which would render him liable to another cross-examination.
The medical witness should answer questions put to him as clearly and as concisely as possible. He should make his statements in plain and simple language, avoiding as much as possible technical terms and figurative expressions, and should not quote authorities in support of his opinions.
An expert witness when giving evidence may refer to notes for the purpose of refreshing his memory, but only if the notes were taken by him at the time when the observations were made, or as soon after as practicable.
There are various courts in which a medical witness may be called on to give evidence:
1. The Coroner's Court.—When a coroner is informed that the dead body of a person is lying within his jurisdiction, and that there is reasonable cause to suspect that such person died either a violent or unnatural death, or died a sudden death of which the cause is unknown, he must summon a jury of not less than twelve men to investigate the matter—in other words, hold an inquest—and if the deceased had received medical treatment, the coroner may summon the medical attendant to give evidence. By the Coroners (Emergency Provisions) Act of 1917, the number of the jury has been cut down to a minimum of seven and a maximum of eleven men. By the Juries Act of 1918, the coroner has the power of holding a court without a jury if, in his discretion, it appears to be unnecessary. In charges of murder, manslaughter, deaths of prisoners in prison, inmates of asylums or inebriates' homes, or of infants in nursing homes, he must summon a jury. The coroner may be satisfied with the evidence as to the cause of a person's death, and may dispense with an inquest and grant a burial certificate.
Cases are notified to the coroner by the police, parish officer, any medical practitioner, registrar of deaths, or by any private individual.
Witnesses, having been cited to appear, are examined on oath by the coroner, who must, in criminal cases at least, take down the evidence in writing. This is then read over to each witness, who signs it, and this forms his deposition. At the end of each case the coroner sums up, and the jury return their verdict or inquisition, either unanimously or by a majority.
If this charges any person with murder or manslaughter, he is committed by the coroner to prison to await trial, or, if not present, the coroner may issue a warrant for his arrest.
A chemical analysis of the contents of the stomach, etc., in suspected cases of poisoning is usually done by a special analyst named by the coroner. If any witness disobeys the summons to attend the inquest, he renders himself liable to a fine not exceeding L2 2s., but in addition the coroner may commit him to prison for contempt of court. In criminal cases the witnesses are bound over to appear at the assizes to give evidence there. The coroner may give an order for the exhumation of a body if he thinks the evidence warrants a post-mortem examination.
Coroners' inquests are held in all cases of sudden or violent death, where the cause of death is not clear; in cases of assault, where death has taken place immediately or some time afterwards; in cases of homicide or suicide; where the medical attendant refuses to give a certificate of death; where the attendants on the deceased have been culpably negligent; or in certain cases of uncertified deaths.
The medical witness should be very careful in giving evidence before a coroner. Even though the inquest be held in a coach-house or barn, yet it has to be remembered it is a court of law. If the case goes on for trial before a superior court, your deposition made to the coroner forms the basis of your examination. Any misstatements or discrepancies in your evidence will be carefully inquired into, and you will make a bad impression on judge and jury if you modify, retract, or explain away your evidence as given to the coroner. You had your opportunity of making any amendments on your evidence when the coroner read over to you your deposition before you signed it as true.
By the Licensing Act of 1902, an inquest may not be held in any premises licensed for the sale of intoxicating liquor if other suitable premises have been provided.
The duties of the coroner are based partly on Common Law, and are also defined by statute, principally by the Coroners Act of 1887 (50 and 51 Vict. c. 71). They have been modified, however, by subsequent Acts—e.g., the Act of 1892, the Coroners (Emergency Provisions) Act, 1917, and the Juries Act of 1918.
The fee payable to a medical witness for giving evidence at an inquest is one guinea, with an extra guinea for making a post-mortem examination and report (in the metropolitan area these fees are doubled). The coroner must sign the order authorizing the payment, and should an inquest be adjourned to a later day, no further fee is payable. If the deceased died in a hospital, infirmary, or lunatic asylum, the medical witness is not paid any fee. Should a medical witness neglect to make the post-mortem examination after receiving the order to do so, he is liable to a fine of L5.
In Scotland the Procurator Fiscal fulfils many of the duties of the coroner, but he cannot hold a public inquiry. He interrogates the witnesses privately, and these questions with the answers form the precognition. More serious cases are dealt with by the Sheriff of each county, and capital charges must be dealt with by the High Court of Justiciary. In Scotland the verdicts of the jury may be 'guilty,' 'not guilty,' or 'not proven.'
2. The Magistrate's Court or Petty Sessions is also a court of preliminary inquiry. The prisoner may be dealt with summarily, as, for example, in minor assault cases, or, if the case is of sufficient gravity, and the evidence justifies such a course, may be committed for trial. The fee for a medical witness who resides within three miles of the court is ten shillings and sixpence; if at a greater distance, one guinea.
In the Metropolis the prisoner in the first instance is brought before a magistrate, technically known as the 'beak,' who, in addition to being a person of great acumen, is a stipendiary, and thus occupies a superior position to the ordinary 'J.P.,' who is one of the great unpaid. In the City of London is the Mansion House Justice-Room, presided over by the Lord Mayor or one of the Aldermen. The prisoner may ultimately be sent for trial to the Central Criminal Court, known as the Old Bailey, or elsewhere.
3. Quarter Sessions.—These are held every quarter by Justices of the Peace. All cases can be tried before the sessions except felonies or cases which involve difficult legal questions. In London this court is known as the Central Criminal Court, and it also acts as the Assize Court. In Borough Sessions a barrister known as the Recorder is appointed as sole judge.
4. The Assizes deal with both criminal and civil cases. There is the Crown Court, where criminal cases are tried, and there is the Civil Court, where civil cases are heard. Before a case sent up by a lower court can be tried by the judge and petty jury, it is investigated by the grand jury, which is composed of superior individuals. If they find a 'true bill,' the case goes on; but if they 'throw it out,' the accused is at liberty to take his departure. At the Court of Assize the prisoner is tried by a jury of twelve. In bringing in the verdict the jury must be unanimous. If they cannot agree, the case must be retried before a new jury. At the Assize Court the medical witness gets a guinea a day, with two shillings extra to pay for his bed and board for every night he is away from home, with his second-class railway fare, if there is a second class on the railway by which he travels. If there is no railway, and he has to walk, he is entitled to threepence a mile for refreshments both ways.
5. Court of Criminal Appeal.—This was established in 1908, and consists of three judges. A right of appeal may be based (1) solely on a question of law; (2) on certificate from the judge who tried the prisoner; (3) on mitigation of sentence.
Speaking generally, in the Superior Courts the fees which may be claimed by medical men called on to give evidence are a guinea a day if resident in the town in which the case is tried, and from two to three guineas a day if resident at a distance from the place of trial, this to include everything except travelling expenses. The medical witness also receives a reasonable allowance for hotel and travelling expenses.
If a witness is summoned to appear before two courts at the same time, he must obey the summons of the higher court. Criminal cases take precedence of civil.
A medical man has no right to claim privilege as an excuse for not divulging professional secrets in a court of law, and the less he talks about professional etiquette the better. Still, in a civil case, if he were to make an emphatic protest, the matter in all probability would not be pressed. In a criminal case he would promptly be reminded of the nature of his oath.
A medical man may be required to furnish a formal written report. It may be the history of a fatal illness or the result of a post-mortem examination. These reports must be drawn up very carefully, and no technical terms should be employed.
No witness on being sworn can be compelled to 'kiss the book.' The Oaths Act (51 and 52 Vict., c. 46, Sec. 5) declares, without any qualification, that 'if any person to whom an oath is administered desires to swear with uplifted hand, in the form and manner in which an oath is usually administered in Scotland, he shall be permitted to do so, and the oath shall be administered to him in such form and manner without further question.' The witness takes the oath standing, with the bare right hand uplifted above the head, the formula being: 'I swear by Almighty God that I will speak the truth, the whole truth, and nothing but the truth.' The presiding judge should say the words, and the witness should repeat them after him. There is no kissing of the book, and the words 'So help me, God,' which occur in the English form, are not employed. It will be noted that the Scotch form constitutes an oath, and is not an affirmation. The judge has no right to ask if you object on religious grounds, or to put any question. He is bound by the provisions of the Act, and the enactment applies not only to all forms of the witness oath, whether in civil or criminal courts, or before coroners, but to every oath which may be lawfully administered either in Great Britain or Ireland.
A witness engaged to give expert evidence should demand his fee before going into court, or, at all events, before being sworn.
With regard to notes, these should be made at the time, on the spot, and may be used by the witness in court as a refresher to the memory, though not altogether to supply its place. All evidence is made up of testimony, but all testimony is not evidence. The witness must not introduce hearsay testimony. In one case only is hearsay evidence admissible, and that is in the case of a dying declaration. This is a statement made by a dying person as to how his injuries were inflicted. These declarations are accepted because the law presumes that a dying man is anxious to speak the truth. But the person must believe that he is actually on the point of death, with absolutely no hope of recovery. A statement was rejected because the dying person, in using the expression 'I have no hope of recovery,' requested that the words 'at present' should be added. If after making the statement the patient were to say, 'I hope now I shall get better,' it would invalidate the declaration. To make the declaration admissible as evidence, death must ensue. If possible, a magistrate should take the dying declaration; but if he is not available, the medical man, without any suggestions or comments of his own, should write down the statements made by the dying person, and see them signed and witnessed. It must be made clear to the court that at the time of making his statement the witness was under the full conviction of approaching or impending death.
It is but seldom that medical evidence is required with regard to the identification of the living, though it may sometimes be so, as in the celebrated Tichborne case. The medical man may in such cases be consulted as to family resemblance, marks on the body, naevi materni, scars and tattoo marks, or with regard to the organs of generation in cases of doubtful sex. Tattoo marks may disappear during life; the brighter colours, as vermilion, as a rule, more readily than those made with carbon, as Indian ink; after death the colouring-matter may be found in the proximal glands. If the tattooing is superficial (merely underneath the cuticle) the marks may possibly be removed by acetic acid or cantharides, or even by picking out the colouring-matter with a fine needle. With regard to scars and their permanence, it will be remembered that scars occasioned by actual loss of substance, or by wounds healed by granulation, never disappear. The scars of leech-bites, lancet-wounds, or cupping instruments, may disappear after a lapse of time. It is difficult, if not impossible, to give any certain or positive opinion as to the age of a scar; recent scars are pink in colour; old scars are white and glistening. The cicatrix resulting from a wound depends upon its situation. Of incised wounds an elliptical cicatrix is typical, linear being chiefly found between the fingers and toes. By way of disguise the hair may be dyed black with lead acetate or nitrate of silver; detected by allowing the hair to grow, or by steeping some of it in dilute nitric acid, and testing with iodide of potassium for lead, and hydrochloric acid for silver. The hair may be bleached with chlorine or peroxide of hydrogen, detected by letting the hair grow and by its unnatural feeling and the irregularity of the bleaching.
Finger-print impressions are the most trustworthy of all means of identification. Such a print is obtained by rubbing the pulp of the finger in lampblack, and then impressing it on a glazed card. The impression reveals the fine lines which exist at the tips of the fingers. The arrangement of these lines is special to each person, and cannot be changed. Hence this method is employed by the police in the identification of prisoners.
In the determination of cases of doubtful sex in the living, the following points should be noticed: the size of the penis or clitoris, and whether perforate or not, the form of the prepuce, the presence or absence of nymphae and of testicles or ovaries. Openings must be carefully sounded as to their communication with bladder or uterus. After puberty, inquiry should be made as to menstrual or vicarious discharges, the general development of the body, the growth of hair, the tone of voice, and the behaviour of the individual towards either sex.
With regard to the identification of the dead in cases of death by accident or violence, the medical man's assistance may be called. The sex of the skeleton, if that only be found, may be judged from the bones of the female generally being smaller and more slender than those of the male, by the female thorax being deeper, the costal cartilages longer, the ilia more expanded, the sacrum flatter and broader, the coccyx movable and turned back, the tuberosities of the ischia wider apart, the pubes shallow, and the whole pelvis shallower and with larger outlets. But of all these signs the only one of any real value is the roundness of the pubic arch in the female, as compared with the pointed arch in the male. Before puberty the sex cannot be determined from an examination of the bones.
Age may be calculated from the presence, nature and number of the erupted teeth; from the cartilages of the ribs, which gradually ossify as age advances; from the angle formed by the ramus of the lower jaw with its body (obtuse in infancy, a right angle in the adult, and again obtuse in the aged from loss of the teeth); and in the young from the condition of the epiphyses with regard to their attachment to their respective shafts.
To determine stature, the whole skeleton should be laid out and measured, 1-1/2 to 2 inches being allowed for the soft parts.
IV.—EXAMINATION OF PERSONS FOUND DEAD
When a medical man is called to a case of sudden death, he should carefully note anything likely to throw any light on the cause of death. He should notice the place where the body was found, the position and attitude of the body, the soil or surface on which the body lies, the position of surrounding objects, and the condition of the clothes. He should also notice if there are any signs of a struggle having taken place, if the hands are clenched, if the face is distorted, if there has been foaming at the mouth, and if urine or faeces have been passed involuntarily. Urine may be drawn off with a catheter and tested for albumin and sugar.
If required to make a post-mortem examination, every cavity and important organ of the body must be carefully and minutely examined, the seat of injury being inspected first.
V.—MODES OF SUDDEN DEATH
There are three modes in which death may occur: (1) Syncope; (2) asphyxia; (3) coma.
1. Syncope is death beginning at the heart—in other words, failure of circulation. It may arise from—(1) Anaemia, or deficiency of blood due to haemorrhage, such as occurs in injuries, or from bleeding from the lungs, stomach, uterus, or other internal organs. (2) Asthenia, or failure of the heart's action, met with in starvation, in exhausting diseases, such as phthisis, cancer, pernicious anaemia, and Bright's disease, and in some cases of poisoning—for example, aconite.
The symptoms of syncope are faintness, giddiness, pallor, slow, weak, and irregular pulse, sighing respiration, insensibility, dilated pupils, and convulsions.
Post mortem the heart is found empty and contracted. When, however, there is sudden stoppage of the heart, the right and left cavities contain blood in the normal quantities, and blood is found in the venae cavae and in the arterial trunks. There is no engorgement of either lungs or brain.
2. Asphyxia, or death beginning at the lungs, may be due to obstruction of the air-passages from foreign bodies in the larynx, drowning, suffocation, strangling, and hanging; from injury to the cervical cord; effusion into the pleurae, with consequent pressure on the lungs; embolism of the pulmonary artery; and from spasmodic contraction of the thoracic and abdominal muscles in strychnine-poisoning.
The symptoms of this condition are fighting for breath, giddiness, relaxation of the sphincters, and convulsions.
Post mortem, cadaveric lividity is well marked, especially in nose, lips, ears, etc.; the right cavities of the heart and the venae cavae are found gorged with dark fluid blood. The pulmonary veins, the left cavities of the heart, and the aorta, are either empty or contain but little blood. The lungs are dark and engorged with blood, and the lining of the air-tubes is bright red in colour. Much bloody froth escapes on cutting into the lungs. Numerous small haemorrhages (Tardieu's spots) are found on the surface and in the substance of the internal organs, as well as in the skin of the neck and face.
3. Coma, or death beginning at the brain, may arise from concussion; compression; cerebral pressure from haemorrhage and other forms of apoplexy; blocking of a cerebral artery from embolism; dietetic and uraemic conditions; and from opium and other narcotic poisons.
The symptoms of this condition are stupor, loss of consciousness, and stertorous breathing.
The post-mortem signs are congestion of the substance of the brain and its membranes, with accumulation of the blood in the cavities of the heart, more on the right side than on the left.
It must be remembered that, owing to the interdependence of all the vital functions, there is no line of demarcation between the various modes of death. In all cases of sudden death think of angina pectoris and the rupture of an aneurism.
The following is a list of some of the commoner causes of sudden death:
(a) Instantaneously Sudden Death—
1. Syncope (by far the commonest cause).
2. Aortic incompetence.
3. Rupture of heart.
4. Rupture of a valve.
5. Rupture of aortic aneurism.
6. Embolism of coronary artery.
7. Angina pectoris.
(b) Less Sudden but Unexpected Death—
1. Cerebral haemorrhage or embolism.
2. Mitral and tricuspid valvular lesions if the patient exerts himself.
3. Rupture of a gastric or duodenal ulcer; rupture of liver, spleen, or extra-uterine gestation, or abdominal aneurism.
4. Suffocation during an epileptic fit; vomited matter or other material drawn into the trachea or air-passages; croup.
5. Arterio-sclerosis may lead to thrombosis, embolism, or aneurism.
6. Poisoning, as by hydrocyanic acid, cyanide of potassium, inhalation of carbonic acid or coal gas, oedema of glottis following inhalation of ammonia.
7. Rapid onset of some acute specific disease, such as pneumonia or diphtheria; collapse from cholera.
8. Heat-stroke, lightning, shocks of electricity of high tension.
9. Mental or physical shock.
10. Exertion while the stomach is overloaded.
11. Diabetic coma; uraemia.
12. Status lymphaticus. This is a general hyperplastic condition of the lymphatic structures in the body, and is seen in enlargement of tonsils, thymus, spleen, as well as of Peyer's patches and mesenteric glands. It is a frequent cause of death during chloroform anaesthesia for slight operations in young people.
In addition, it may be as well to remember that death sometimes occurs suddenly in exophthalmic goitre, hypertrophy of the thymus, and in Addison's disease.
In some cases of sudden death nothing has been found post mortem, even when the autopsy has been made by skilled observers, and the brain and cord have been submitted to microscopical examination.
VI.—SIGNS OF DEATH
(1) Cadaveric appearance; ashy white colour. (2) Cessation of the circulation and respiration, no sound being heard by the stethoscope. Cessation of the circulation may be determined by (a) placing a ligature round the base of a finger (Magnus' test); (b) injecting a solution of fluorescin (Icard's test); (c) looking through the web of the fingers at a bright light (diaphanous test); (d) the dulling of a steel needle when thrust into the living body; (e) the clear outline of the dead heart when viewed in the fluorescent screen. (3) The state of the eye; the tension is at once lost; iris insensible to light, fundus yellow in colour; cornea dull and sunken. (4) The state of the skin; pale, livid, with loss of elasticity. (5) Extinction of muscular irritability. The above signs afford no means of determining how long life has been extinct. The following, however, do:
Cooling of the Body.—The average internal temperature of the body is from 98 deg. to 100 deg. F. The time taken in cooling is from fifteen to twenty hours, but it may be modified by the kind of death, the age of the person, the presence or absence of clothing on the body, the surrounding temperature, and the stillness or otherwise of the air about the body. Still, the body, other things being equal, may be said to be quite cold in about twelve hours.
Hypostasis or post-mortem staining is due to the settling down of the blood in the most dependent parts of the body while the body is cooling. It is a sure sign of death, and occurs in all forms of death, even in that due to haemorrhage, although not so marked in degree. Post-mortem staining (cadaveric lividity) begins to appear in from eight to twelve hours after death, and its position on the body will help to determine the length of time the body has lain in the position in which it was found. The staining is of a dull red or slaty blue colour. It must be distinguished from ecchymosis the result of a bruise, by making an incision into the part; in the case of hypostasis a few small bloody points of divided arteries will be seen, in the case of ecchymosis the subcutaneous tissues are infiltrated with blood-clot. Internally, hypostasis must not be mistaken for congestion of the brain or lungs, or the results of inflammation of the intestines. If the intestine is pulled straight, inflammatory redness is continuous, hypostasis is disconnected. About the neck hypostasis must not be mistaken for the mark of a cord or other ligature. When the blood is of a bright red colour after death (as happens in poisoning by CO or HCN, or in death from cold), the hypostasis is bright red also.
Cadaveric Rigidity—Rigor Mortis.—For some time after death the muscles continue to contract under stimuli. When this irritability ceases—and it seldom exceeds two hours—rigidity and hardening sets in, and in all cases precedes putrefaction. It is caused by the coagulation of the muscle plasma. It commences in the muscles of the back of the neck and lower jaw, and then passes into the muscles of the face, front of the neck, chest, upper extremities, and lastly to the lower extremities.
It has been noticed in the new-born infant, as well as in the foetus. It lasts from sixteen to twenty hours or more. In lingering diseases, after violent exertion, and in warm climates, it sets in quickly, and disappears in two or three hours; in those who are in perfect health and die from accident or asphyxia, it may not come on until from ten to twenty-four hours, and may last three or four days. After death from convulsions or strychnine-poisoning, the body may pass at once into rigor mortis. Rigor mortis must be distinguished from cadaveric spasm or the death clutch; in the former, articles in the hands are readily removable, in the latter this is not the case. In tetanic spasm the limbs when bent return to their former position; not so in rigor mortis.
Putrefaction appears in from one to three days after death, as a greenish-blue discoloration of the abdomen; in the drowned, over the head and face. This increases, becomes darker and more general, a strong putrefactive odour is developed, the thorax and abdomen become distended with gas, and the epidermis peels off. The muscles then become pulpy, and assume a dark greenish colour, the whole body at length becoming changed into a soft, semi-fluid mass. The organ first showing the putrefactive change is the trachea; that which resists putrefaction longest is the uterus. These putrefactive changes are modified by the fat or lean condition of the body, the temperature (putrefaction taking place more rapidly in summer than in winter), access of air, the period, place, mode of interment, age, etc. Bodies which remain in water putrefy more slowly than those in air.
Saponification.—In bodies which are very fat and have lain in water or moist soil for from one to three years this process takes place, the fat uniting with the ammonia given off by the decomposition to form adipocere. This consists of a margarate or stearate of ammonium with lime, oxide of iron, potash, certain fatty acids, and a yellowish odorous matter. It has a fatty, unctuous feel, is either pure white or pale yellow, with an odour of decayed cheese. Small portions of the body may show signs of this change in six weeks.
Post-Mortem Examination.—Never make an autopsy in criminal cases without a written order from the coroner or Procurator Fiscal. If authorized, however, first have the body identified, then photographed if it has not been identified. A medical man representing the accused may be present, but only by consent of the Crown authorities or of the Sheriff. Clothing should be examined for blood-stains, cuts, etc.
Examine external surface of body and take accurate measurements of wounds, marks, deformities, tattooings; note degree and distribution of post-mortem staining, rigidity, etc.
Examine brain by making incision from ear to ear across vertex, reflect scalp forwards and backwards, and saw off calvarium. Examine brain carefully externally and on section.
Examine organs of chest and abdomen through an incision made from symphysis menti to pubis, reflecting tissues from chest wall and cutting through costal cartilages.
In cases of suspected poisoning have several clean jars into which you place the stomach with contents, intestines with contents, piece of liver, kidney, spleen, etc., and seal each up carefully, attaching label with name of deceased, date, and contained organs, and transmit these personally to the analyst.
Exhumation.—A body which has been buried cannot be exhumed without an order from a coroner, fiscal, or from the Home Secretary. There is no legal limit in England as to when a body may be exhumed; in Scotland, however, if an interval of twenty years has elapsed, an accused person cannot be prosecuted (prescription of crime).
VII.—DEATH FROM ANAESTHETICS, ETC.
The coroner in England and Wales and Ireland must inquire into every case of death during the administration of an anaesthetic. The anaesthetist has to appear at the inquest, and must answer a long series of questions relative to the administration of the drug.
Before, therefore, giving an anaesthetic, and so as to furnish yourself with a proper defence in the event of death occurring, you ought to examine the heart, lungs, and kidneys of the patient to see if they are healthy. Should a fatal result follow, the anaesthetist will require to prove that it was necessary to give the anaesthetic, that the one employed was the most suitable, that the patient was in a fit state of health to have it administered, that it was given skilfully and in moderate amount, that he had the usual remedies at hand in case of failure of the heart or lungs, and that he employed every means in his power to resuscitate the patient.
The condition of the lungs is of more importance than the state of the heart.
The chloroformist ought always to use the best chloroform.
An anaesthetic should never be administered except in the presence of a third person. This applies especially to dentists who give gas to females.
Malpractice.—In every case where a medical man attends a patient, he must give him that amount of care, skill, knowledge, or judgment, that the law expects of him. If he does not, then the charge of malpractice may be brought against him. It is most frequently alleged in connection with surgical affections—e.g., overlooking a fracture or dislocation. Before a major operation is performed, it is well to get a written agreement.
VIII.—PRESUMPTION OF DEATH; SURVIVORSHIP
Presumption of Death.—If a person be unheard of for seven years, the court may, on application by the nearest relative, presume death to have taken place. If, however, it can be shown that in all probability death had occurred in a certain accident or shipwreck, the decree may be made much earlier.
Presumption of Survivorship.—When two or more related persons perish in a common accident, it may be necessary, in order to decide questions of succession, to determine which of them died first. It is generally accepted that the stronger and more vigorous will survive longest.
IX.—ASSAULT, MURDER, MANSLAUGHTER, ETC.
Assault.—This is an attempt or offer to do violence to another person; it is not necessary that actual injury has been done, but evil intention must be proved. When a corporal hurt has been sustained, then assault and battery has been committed. The assault may be aggravated by the use of weapons, etc.
Homicide may be justifiable, as in the case of judicial execution, or excusable, as in defence of one's family or property.
Felonious homicide is murder. This means that a human being has been killed by another maliciously and deliberately or with reckless disregard of consequences.
Manslaughter or Culpable Homicide (Scotland) is the unlawful killing of a human being without malice—as homicide after great provocation; signalman who allows a train to pass, and so collide with another in front.
X.—WOUNDS AND MECHANICAL INJURIES
A wound may be defined as a 'breach of continuity in the structures of the body, whether external or internal, suddenly occasioned by mechanical violence.' The law does not define 'a wound,' but the true skin must be broken. Wounds are dangerous from shock, haemorrhage, from the supervention of crysipelas or pyaemia, and from malum regimen on the part of the patient or surgeon. Is the wound dangerous to life? This question can only be answered by a full consideration of all the circumstances of the case; a guarded prognosis is wise in all cases.
Burns are caused by flames, highly heated solids, or very cold solids, as solid carbonic acid; scalds, by steam or hot fluids. Burns may cause death from shock, suffocation, oedema glottidis, inflammation of serous surfaces, bronchitis, pneumonia, duodenal ulcer, coma, or exhaustion. A burn of the skin inflicted during life is followed by a bleb containing serum; the edges of this blister are bright red, and the base, seen after removing the cuticle, is red and inflamed; if sustained after death, a bleb, if present, contains but little fluid, and there are no signs of vital reaction. There are six degrees of burns: (1) Superficial inflammation; (2) formation of vesicles; (3) destruction of superficial layer of skin; (4) destruction of cellular tissue; (5) deep parts charred; (6) carbonization of bones.
The larger the area of skin burnt, the more grave is the prognosis. Burns of the abdomen and genital organs are especially dangerous. Young children are specially liable to die after burns.
XI.—CONTUSED WOUNDS AND INJURIES UNACCOMPANIED BY SOLUTION OF CONTINUITY
If a blow be inflicted with a blunt instrument, there is produced a bruise, or ecchymosis, of which it is unnecessary here to describe the appearance and progress. A bruise may be distinguished from a post-mortem stain by the cuticle in the former often being abraded and raised. When an incision is made into the bruise, the whole of the subcutaneous tissues are found to be infiltrated with blood-clot, and there is no clear margin. In the case of a post-mortem stain the edges are sharply defined, not raised, and, on section, mere bloody points are seen which are the cut ends of the divided blood vessels.
XII.—INCISED WOUNDS AND THOSE ACCOMPANIED BY SOLUTION OF CONTINUITY
These comprise incised, punctured, and lacerated wounds. In a recent incised wound inflicted during life there is copious haemorrhage, the cellular tissue is filled with blood, the edges of the wound gape and are everted, and the cavity of the wound is filled with coagula.
Lacerated wounds combine the characters of incised and contused wounds. They are caused by falls, being ridden over, machinery crushes, bites, blows from blunt weapons, etc. The wounds heal by suppuration.
Punctured wounds come intermediate between incised and lacerated. They are greater in depth than in length, being caused by sword or rapier thrusts. They cause little haemorrhage externally, but death may be due to internal haemorrhage. They may be complicated by (1) the introduction of septic material adhering to the instrument; (2) the entrance of foreign bodies which lodge in the wound, not only carrying in septic matter, but acting as mechanical irritants; (3) injury to deeper parts, which may at the time be difficult to detect.
An apparently incised wound may be produced by a hard, blunt weapon over a bone—e.g., shin or cranium. It is often difficult to distinguish between a wound of the scalp inflicted with a knife and one made by a blow with a stick. A puncture with a sharp-edged, pointed knife leaves a fusiform or spindle-shaped wound. A wound from a blow with a stick might be of this character, or it might present a jagged, swollen appearance at the margin, with much contusion of the surrounding tissues. If the wound is seen soon after it is inflicted, examination with a lens may disclose irregularities of the margins, or little bridges of connective tissue or vessels running across the wound, and so be inconsistent with its production by a cutting instrument. Lacerated wounds as a rule bleed less freely than those which are incised. Symptoms of concussion would favour the theory of the injury having been inflicted by a heavy instrument. Again, it is often difficult to decide whether the injury which caused death was the result of a blow or a fall. A heavy blow with a stick may at once cause fatal effusion of blood, but this might equally result from fracture of the skull resulting from a fall. The wound should be carefully examined for foreign bodies, such as grit, dirt, or sand. The distinction between incised wounds inflicted during life and after death is found in the fact that a wound inflicted during life presents the appearances already described, whereas in a post-mortem incised wound only a small quantity of liquid venous blood is effused; the edges are close, yielding, inelastic; the blood is not effused into the cellular tissue, and there are no signs of vital reaction. The presence of inflammatory reaction or pus shows that the wound must have been inflicted some time before death, probably two or three days.
Self-inflicted wounds are made by the person himself in order to divert suspicion, or in order to bring accusation against another. Such wounds are always in front, not over vital organs, and superficial in character. Note the condition of the clothes in such cases.
These may be punctured, contused, or lacerated. Round balls make a larger opening than those which are conical. Small shot fired at a short distance make one large ragged opening; while at distances greater than 3 feet the shot scatter and there is no central opening. The Lee-Metford bullet is more destructive than the Mauser. The former is the larger, but the difference in size is not great. The Martini-Henry bullet weighs 480 grains, the Lee-Metford 215, and the Mauser 173. Speaking generally, a gunshot wound, unlike a punctured wound, becomes larger as it increases in depth; the aperture of entrance is round, clean, with inverted edges, and that of exit larger, less regular than that of entrance, and with everted edges.
In the case of high-velocity bullets from smooth-bore rifles, including the Mauser and Lee-Metford, the aperture of entry is small; the aperture of exit is slightly larger, and tends to be more slit-like. There is but little tendency to carry in portions of clothing or septic material, and the wound heals by first intention, if reasonable precautions be taken. The external cicatrices finally look very similar to those produced by bad acne pustules.
The contents of all gunshot wounds should be preserved, as they may be useful in evidence. A pocket revolver, as a rule, leaves the bullet in the body.
Wounds inflicted by firearms may be due to accident, homicide, or suicide. Blackening of the wound, singeing of the hair, scorching of the skin and clothing, show that the weapon was fired at close quarters, whilst blackening of the hand points to suicide. Even when the weapon is fired quite close there may be no blackening of the skin, and the hand is not always blackened in cases of suicide. Smokeless powder does not blacken the skin. Wounds on the back of the body are not usually self-inflicted, but a suicide may elect to blow off the back of his head. A wound in the back may be met with in a sportsman who indulges in the careless habit of dragging a loaded gun after him. If a revolver is found tightly grasped in the hand it is probably a case of suicide, whilst if it lies lightly in the hand it may be suicide or homicide. If no weapon is found near the body, it is not conclusive proof that it is not suicide, for it may have been thrown into a river or pond, or to some distance and picked up by a passer-by.
A bullet penetrating the skull even from a distance of 3,000 yards may act as an explosive, scattering the contents in all directions; but the bullet from a revolver will usually be found in the cranium.
The prognosis depends partly on the extent of the injury and the parts involved, but there is also risk from secondary haemorrhage, and from such complications as pleurisy, pericarditis, and peritonitis. Death may result from shock, haemorrhage, injury to brain or important nervous structures.
XIV.—WOUNDS OF VARIOUS PARTS OF THE BODY
1. Of the Head.—Wounds of the scalp are likely to be followed by (1) erysipelatous inflammation; (2) inflammation of the tendinous structures, with or without suppuration. A severe blow on the vertex may cause fracture of the base of the skull. Injuries of the brain include concussion, compression, wounds, contusion, and inflammation. Concussion is a common effect of blows or violent shocks, and the symptoms follow immediately on the accident, death sometimes taking place without reaction. Compression may be caused by depressed bone or effused blood (rupture of middle meningeal artery) and serum. The symptoms may come on suddenly or gradually. Wounds of the brain present very great difficulties, and vary greatly in their effect, very slight wounds producing severe symptoms, and vice versa. A person may receive an injury to the head, recover from the first effects, and then die with all the symptoms of compression from internal haemorrhage. This is due to the fact that the primary syncope arrests the haemorrhage, which returns during the subsequent reaction, or on the occurrence of any excitement. Inflammation of the meninges or brain may follow injuries, not only to the brain itself, but to the scalp and adjacent parts, as the orbit and ear. Inflammation does not usually come on at once, but after variable periods.
2. Injuries to the Spinal Cord may be due to concussion, compression (fracture-dislocation), or wounds. That the wound has penetrated the meninges is shown by the escape of cerebro-spinal fluid. The cord and nerves may be injured (1) by the puncture; (2) by extravasation of blood and the formation of a clot; and (3) by subsequent septic inflammation. Division or complete compression of the cord at or above the level of the fourth cervical vertebra is immediately fatal (as happens in judicial hanging). When the injury is below the fourth, the diaphragm continues forcibly in action, but the lungs are imperfectly expanded, and life will not be maintained for more than a day or two. When the injury is in the dorsal region, there is paralysis of the legs and of the sphincters of the bladder and rectum, but power is retained in the arms and the upper intercostal muscles act, the extent of paralysis depending on the level of the lesion. In injuries to the lumbar region the legs may be partly paralysed, and the rectal and bladder sphincters may be involved.
Railway spine, or traumatic neurasthenia, may be set up by concussion of the cord as a result of blows or falls. Passengers after railway accidents, or miners, often suffer from this affection.
3. Of the Face.—These produce great disfigurement and inconvenience, and there is a risk of injury to the brain. The seventh nerve may be involved, giving rise to facial paralysis. Punctured wounds of the orbit are especially dangerous. Wounds apparently confined to the external parts often conceal deep-seated mischief.
4. Of the Eye.—The iris may be injured by sharp blows, as from the cork of a soda-water bottle. It is usually followed by haemorrhage into the anterior chamber, and there may be separation of the iris from its ciliary border. Wounds at the edge of the cornea are often followed by prolapse of the iris. Acute traumatic iritis or irido-cyclitis may supervene four or five days after the injury. The lens is frequently wounded in addition to the cornea and iris. In dislocation of the lens into the anterior chamber as the result of a blow, the lens appears like a large drop of oil lying at the back of the cornea, the margin exhibiting a brilliant yellow reflex. Partial dislocations of the lens as the result of severe blows generally terminate in cataract.
5. Of the Throat.—Very frequently inflicted by suicides. Division of the carotid artery is fatal, and of the internal jugular vein very dangerous on account of entrance of air. Wounds of the larynx and trachea are not necessarily or immediately dangerous, but septic pneumonia is very apt to follow. Wounds of the throat inflicted by suicides are commonly situated at the upper part, involving the hyoid bone and the thyroid and cricoid cartilages. The larynx is opened, but the large vessels often escape. In most suicidal wounds of the throat the direction is from left to right, the incision being slightly inclined from above downwards. At the termination of a suicidal cut-throat the skin is the last structure divided, the wound being shallower as it reaches its termination; the wounds often show parallelism. The weapon is often firmly grasped in the hand. Inquiry should be made as to whether the patient is right or left handed, or ambidextrous.
Homicidal cut throat is usually very severe and situated low down in the neck or far to the side.
6. Of the Chest.—Incised wounds of the walls are not of necessity dangerous; but severe blows, by causing fracture of the bones and internal injuries, are often fatal. The symptoms of penetrating wounds of the chest are—(1) The passage of blood and air through the wound; (2) haemoptysis; (3) pneumothorax; and (4) protrusion of the lung forming a tumour covered with pleura. Fracture of the ribs may be due to direct violence, as from a blow, when the ends are driven inwards, or to indirect violence, as from a squeeze in a crowd, when the ends are driven outwards.
7. Of the Lungs.—These usually cause haemorrhage, and are frequently followed by pleurisy, either dry or with effusion, and by pneumonia.
8. Of the Heart.—Penetrating wounds are fatal from haemorrhage, of the base more speedily than of the apex; but life may be prolonged for some time even after a severe wound to the heart. Injury to the right ventricle is the most fatal injury and the most frequent. Rupture from disease usually occurs in the left ventricle; rupture from a crush is usually towards the base and on the right side.
9. Of the Aorta and Pulmonary Artery.—Fatal.
10. Of the Diaphragm.—Generally fatal, owing to the severe injury of the other abdominal organs. If the diaphragm be ruptured, hernia of the organs may result.
11. Of the Abdomen.—Of the walls, may be dangerous from division of the epigastric artery; ventral hernia may follow, internal haemorrhage, etc. Blows on the abdomen are prone to cause death from cardiac inhibition.
12. Of the Liver.—May divide the large vessels. Venous blood flows profusely from a punctured wound of the liver. Wounds of the gall-bladder cause effusion of bile and peritoneal inflammation. Laceration of the liver may result from external violence without leaving any outward sign of the injury; it is commonly fatal. There is rapid and acute anaemia from the pouring out of blood into the abdominal cavity. This may also occur with injuries of other organs in the abdomen.
13. Of the Spleen.—Fatal haemorrhage may result from penetrating wounds or from rupture due to kicks, blows, crushes, especially if the spleen be enlarged.
14. Of the Stomach.—May be fatal from shock, from haemorrhage, from extravasation of contents, or from inflammation. The danger is materially lessened by prompt surgical intervention.
15. Of the Intestines.—May be fatal in the same way as those of the stomach. More dangerous in the small than in the large intestines.
16. Of the Kidneys.—May prove fatal from haemorrhage, extravasation of urine, or inflammation.
17. Of the Bladder.—Dangerous from extravasation of urine. In fracture of the pelvis the bladder is often injured, and extraperitoneal infiltration of urine occurs, with frequently a fatal issue.
18. Of Genital Organs.—Incised wounds of penis may produce fatal haemorrhage. Removal of testicles may prove fatal from shock to nervous system. Wounds of the spermatic cord may be dangerous from haemorrhage. Wounds to the vulva are dangerous, owing to haemorrhage from the large plexus of veins without valves.
XV.—DETECTION OF BLOOD-STAINS, ETC.
Stains may require detection on clothing, on cutting instruments, on floors and furniture, etc. The following are the distinctive characters of blood-stains:
(a) Ocular Inspection.—Blood-stains on dark-coloured materials, which in daylight might be easily overlooked, may be readily detected by the use of artificial light, as that of a candle, brought near the cloth. Blood-spots when recent are of a bright red colour if arterial, of a purple hue if venous, the latter becoming brighter on exposure to the air. After a few hours blood-stains assume a reddish-brown or chocolate tint, which they maintain for years. This change is due to the conversion of haemoglobin into methaemoglobin, and finally into haematin. The change of colour in warm weather usually occurs in less than twenty-four hours. The colour is determined, not entirely by the age of the stain, but is influenced by the presence or absence of impurities in the air, such as the vapours of sulphurous, sulphuric, and hydrochloric acids. If recent, a jelly-like material may be seen by the aid of a magnifying-glass lying between the fibres. If old, a cinnabar-red streak is seen on drawing a needle across the stain.
(b) Microscopic Demonstration.—With the aid of the microscope, blood may be detected by the presence of the characteristic blood-corpuscles. The human blood-corpuscle is a non-nucleated, biconcave disc, having a diameter of about 1/3500 of an inch. All mammalian red corpuscles have the same shape, except those of the camel, which are oval. The corpuscles of birds, fishes, reptiles, and amphibians, are oval and nucleated. The corpuscles of most mammals are smaller than those of man, but the size of a corpuscle is affected by various circumstances, such as drying or moisture, so that the medical witness is rarely justified in going farther than stating whether the stain is that of the blood of a mammal or not. Unfortunately, the corpuscles are usually so dried that little information regarding their size can be given.
(c) Action of Water.—Water has a solvent action on blood, fresh stains rapidly dissolving when the material on which they occur is placed in cold distilled water, forming a bright red solution. The haematin of old stains dissolves very slowly, so employ a weak solution of ammonia, and this will give a solution of alkaline haematin. Rust is not soluble in water.
(d) Action of Heat.—Blood-stains on knives may be removed by heating the metal, when the blood will peel off, at once distinguishing it from rust. Should the blood-stain on the metal be long exposed to the air, rust may be mixed with the blood, when the test will fail. The solution obtained in water is coagulated by heat, the colour entirely destroyed, and a flocculent muddy-brown precipitate formed.
(e) Action of Caustic Potash.—The solution of blood obtained in water is boiled, when a coagulum is formed soluble in hot caustic potash, the solution formed being greenish by transmitted and red by reflected light.
(f) Action of Nitric Acid.—Nitric acid added to a watery solution produces a whitish-grey precipitate.
(g) Action of Guaiacum.—Tincture of guaiacum produces in the watery solution a reddish-white precipitate of the resin, but on addition of an aqueous solution of peroxide of hydrogen, or of an ethereal solution of the same substance (known as ozonic ether), a blue or bluish-green colour is developed. This test is delicate, and succeeds best in dilute solutions. It is not absolutely indicative of the presence of blood, for tincture of guaiacum is coloured blue by milk, saliva, and pus.
(h) Haemin Crystals (Teichman's Crystals).—These are produced by heating a drop of blood, or a watery solution of it, with a minute crystal of sodium chloride on a glass slide and evaporating to dryness. A cover-glass is placed over this, and a drop of glacial acetic acid allowed to run in. It is again heated until bubbles appear. Crystals of haemin may now be detected by the microscope. They are dark brown or yellow rhombic prisms.
An improvement on this test is the use of formic acid alone; on slowly evaporating it, numerous very small dark crystals are visible if haemoglobin has been present (Whitney's test).
(i) Spectroscopic Appearances.—If a solution of a recent stain be examined by the spectroscope, we get two absorption bands situated between the lines D and E, the one nearer E being doubly as broad as the other. These bands indicate oxyhaemoglobin.
If we now add a little ammonium sulphide to this solution, we get the spectrum of reduced haemoglobin, which is a single broad absorption band situated in the interval between the preceding oxyhaemoglobin bands. By shaking the solution, oxyhaemoglobin is again reproduced, and gives its special absorption bands.
If ammonia be added to the original solution, alkaline haematin is produced, or if acetic acid be chosen, acid haematin is produced, and each gives its appropriate absorption bands.
Methaemoglobin is formed in stains which have been exposed to the air for a few days, and haematin is found in old stains. Haemochromogen gives a very characteristic spectrum, and is obtained by reducing alkaline haematin by ammonium sulphide. Carbon monoxide haemoglobin gives a spectrum which resembles that of oxyhaemoglobin, but it is not reduced by ammonium sulphide.
(j) Precipitin Test.—This allows us to tell whether the blood is from a human being or not. A specific serum must be obtained from a rabbit which is sensitized as follows: 10 c.c. of human blood is injected into its peritoneal cavity at intervals, until from three to five injections have been given. The serum of this animal's blood will then give a white precipitate only when brought into contact with dilute solutions of human blood, but with the blood of no other animal. This is known also as the 'biologic,' or Uhlenhuth's test.
Rust Stains.—These are yellowish-red in colour, and do not stiffen the cloth. The iron may be dissolved by placing the stain in a dilute solution of hydrochloric acid, when, on adding ferrocyanide of potassium, Prussian blue is produced.
Fruit Stains are seldom so dark as blood-stains. Solutions of these do not change colour or coagulate on boiling; ammonia changes the colour to blue or green; acid brightens the original colour, while chlorine bleaches it.
Hairs.—Human hairs must be identified and distinguished from those of the lower mammals. If the hair has been pulled out from the root, the microscope will show that the bulbous root has a concave surface which fitted over the hair papilla, or that the root is encased in a fatty sheath.
Fibres of Clothing.—Microscopically, wool fibres are coarse, curly, and striated transversely; cotton fibres appear as flattened bands twisted into spirals; linen fibres are round, jointed at frequent intervals, with small root-like filaments; silk fibres are solid, continuous, and highly glistening.
XVI.—DEATH BY SUFFOCATION
Signs and Symptoms.—There are usually three stages:
1. Exaggerated respiratory activity; air hunger; anxiety; congested appearance of face; ringing in ears.
2. Loss of consciousness; convulsions; relaxation of sphincters.
3. Respirations feeble and gasping, and soon cease; convulsions of stretching character; heart continues to beat for three to four minutes after breathing ceases.
Post-Mortem Appearances—External.—Cadaveric lividity well marked; nose, lips, ears, finger-tips almost black in colour; appearance may be placid or, if asphyxia has been sudden, the tongue may be protruded and eyeballs prominent, with much bloody mucus escaping from mouth and nose.
Internal.—The blood is dark and remains fluid; great engorgement of venous system, right side of heart, great veins of thorax and abdomen, liver, spleen, etc. Lungs dark purple in colour; much bloody froth escapes on squeezing them; mucous lining of trachea and bronchi congested and bright red in colour; air-cells distended or ruptured; many small haemorrhages on surface of lungs and other organs, as well as in their substance (Tardieu's spots), due to rupture of venous capillaries from increased vascular pressure.
XVII.—DEATH BY HANGING
In hanging, death occurs by asphyxia, as in drowning. Sensibility is soon lost, and death takes place in four or five minutes. The eyes in some cases are brilliant and staring, tongue swollen and livid, blood or bloody froth is found about the mouth and nostrils, and the hands are clenched. In other cases the countenance is placid, with an almost entire absence of the signs just given. The mark on the neck, which may be more or less interrupted by the beard, shows the course of the cord, which in hanging is obliquely round the neck following the line of the jaw, but straight round in strangulation. In judicial hanging, death is not due to asphyxiation, but, owing to the long drop, the cervical vertebrae are dislocated, and the spinal cord injured so high up that almost instant death takes place. On dissection the muscles and ligaments of the windpipe may be found stretched, bruised, or torn, and the inner coats of the carotid arteries are sometimes found divided. In ordinary suicidal hanging there may be entire absence of injury to the soft parts about the neck, the length of the drop modifying these appearances. The mark of the cord is not a sign of hanging, is a purely cadaveric phenomenon, and may be produced some hours after death.
XVIII.—DEATH BY STRANGULATION
This differs from hanging in that the body is not suspended. It may be effected by a ligature round the neck, or by direct pressure on the windpipe with the hand, in which case death is said to be caused by throttling. Strangulation is frequently suicidal, but may be accidental. When homicidal, much injury is done to the neck, owing to the force with which the ligature is drawn. In throttling, the marks of the finger-nails are found on the neck.
XIX.—DEATH BY DROWNING
Death by drowning occurs when breathing is arrested by watery or semi-fluid substances—blood, urine, etc. The fluid acts mechanically by entering the air-cells of the lung and preventing the due oxidation of the blood. The post-mortem appearances include those usually present in death by asphyxia, together with the following, peculiar to death by drowning: Excoriations of the fingers, with sand or mud under the nails; fragments of plants grasped in the hand; water in the stomach (this is a vital act, and shows that the person fell into the water alive); fine froth at the mouth and nostrils; cutis anserina; retraction of penis and scrotum. On post-mortem examination, the lungs are found to be increased in size ('ballooned'); on section, froth, water mud, sand, in air-tubes. The presence of this fine (often blood-stained) froth is the most characteristic sign of drowning. Froth like that of soap-suds in the trachea is an indication of a vital act, and must not be mistaken for the tenacious mucus of bronchitis. The presence of vomited matters in the trachea and bronchi is a valuable sign of drowning. The blood collects in the venous system, and is dark and fluid. Tardieu's spots are not so frequently met with in cases of drowning as in other forms of asphyxia. The other signs of death by asphyxia are present. Wounds may be present on the body, due to falling on stakes, injuries from passing vessels, etc.
The methods of performing artificial respiration in the case of the apparently drowned are the following (the best and most easily performed is Schaefer's prone pressure method):
1. Schaefer's.—Place the patient on his face, with a folded coat under the lower part of the chest. Unfasten the collar and neckband. Go to work at once. Kneel over him athwart or on one side facing his head. Place your hands flat over the lower part of his back, and make pressure on his ribs on both sides, and throw the weight of your body on to them so as to squeeze out the air from his chest. Get back into position at once, but leave your hands as they were. Do this every five seconds, and get someone to time you with a watch. Keep this going for half an hour, and when you are tired get someone to relieve you.
Other people may apply hot flannels to the limbs and hot water to the feet. Hypodermic injections of 1/50 grain of atropine, suprarenal or pituitary extracts, may be found useful.
2. Silvester's.—In this method the capacity of the chest is increased by raising the arms above the head, holding them by the elbows, and thus dragging upon and elevating the ribs, the chest being emptied by lowering the arms against the sides of the chest and exerting lateral pressure on the thorax. The patient is in the supine position—but first the water must have been drained from the mouth and nose by keeping the body in the prone position. The tongue must be kept forward by transfixing with a pin.
3. Marshall Hall's.—This consists in placing the patient in the prone position, with a folded coat under the chest, and rolling the body alternately into the lateral and prone positions.
4. Howard's.—This consists in emptying the thorax by forcibly compressing the lower part of the chest; on relaxing the pressure the chest again fills with air. Here the patient is placed in the supine position.
The objections to the supine position are that the tongue falls back, and not only blocks the entrance of air, but prevents the escape of water, mucus, and froth from the air-passages.
5. Laborde's Method.—This consists in holding the tongue by means of a handkerchief, and rhythmically drawing it out fully at the rate of fifteen times per minute. This excites the respiratory centre, and this method may be employed along with any of the other methods.
XX.—DEATH FROM STARVATION
The post-mortem appearances in death from starvation are as follows: There is marked general emaciation; the skin is dry, shrivelled, and covered with a brown, bad-smelling excretion; the muscles soft, atrophied, and free from fat; the liver is small, but the gall-bladder is distended with bile. The heart, lungs, and internal organs are shrivelled and bloodless. The stomach is sometimes quite healthy; in other cases it may be collapsed, empty, and ulcerated. The intestines are also contracted, empty, and translucent.
In the absence of any disease productive of extreme emaciation (e.g., tuberculosis, stricture of oesophagus, diabetes, Addison's disease), such a state of body will furnish a strong presumption of death by starvation.
In the case of children there is not always absolute deprivation of food, but what is supplied is insufficient in quantity or of improper quality. The defence commonly set up is that the child died either of marasmus or of tuberculosis.
In cases where it is alleged that a child has been starved and ill-used, one must examine the body for signs of neglect—e.g., dirtiness of skin and hair, presence of vermin, bruises or skin eruptions. Compare its weight with a normal child of the same age and sex. If the disproportion be great and signs of neglect present, then the probability is great (provided there be no actual disease present) that the child has been starved.
XXI.—DEATH FROM LIGHTNING AND ELECTRICITY
The signs of death from lightning vary greatly. In some cases there are no signs; in others the body may be most curiously marked. Wounds of various characters—contused, lacerated, and punctured—may be produced. There may be burns, vesications, and ecchymoses; arborescent markings are not uncommon. The hair may be singed or burnt and the clothing damaged. Rigor mortis is very rapid in its onset and transient. Post mortem there are no characteristic signs, but the blood may be dark in colour and fluid. The presence or absence of a storm may assist the diagnosis.
Injuries by electrical currents of high pressure are not uncommon; speaking generally, 1,000 to 2,000 volts will kill. In America, where electricity is adopted as the official means of destroying criminals, 1,500 volts is regarded as the lethal dose, but there are many instances of persons having been exposed to higher voltages without bad effects. The alternating current is supposed to be more fatal than the continuous. Much depends on whether the contact is good (perspiring hands or damp clothes). Death has been attributed in these cases to respiratory arrest or sudden cessation of the heart's action. The best treatment is artificial respiration, but the inhalation of nitrite of amyl may prove useful. Rescuers must be careful that they, also, do not receive a shock. The patient should be handled with india-rubber gloves or through a blanket thrown over him.
XXII.—DEATH FROM COLD OR HEAT
Cold.—The weak, aged, or infants, readily succumb to low temperatures. The symptoms are increasing lassitude, drowsiness, coma, with sometimes illusions of sight. Post mortem, bright red patches are found on the skin surface, and the blood remains fluid for long.
Heat.—Death may result from syncope, the result of exposure to great heat.
Sunstroke.—The person loses consciousness and falls down insensible; the body temperature may be 112 deg. F., the pulse is full, and a peculiar pungent odour is given off from the skin. Coma, convulsions with (rarely) delirium, may precede death. Treatment consists in lowering the body temperature by application of cold cloths, stimulants, strychnine or digitalin hypodermically.
The signs of the existence of pregnancy are of two kinds, uncertain and certain, or maternal and foetal. Amongst the former class are included—Cessation of menstruation (which may occur without pregnancy); morning vomiting; salivation; enlargement of the breasts and of the abdomen; quickening. It must be borne in mind that every woman with a big abdomen is not necessarily pregnant. The tests which afford conclusive evidence of the existence of a foetus in the uterus are—Ballottement, the uterine souffle, intermittent uterine contractions, foetal movements, and, above all, the pulsation of the foetal heart. The uterine souffle is synchronous with the maternal pulse; the foetal heart is not, being about 120 beats per minute.
Evidence of pregnancy may also be afforded by the discharge from the uterus of an early ovum, of moles, hydatids, etc. Disease of the uterus and ovarian dropsy may be mistaken for pregnancy. Careful examination is necessary to determine the nature of the condition present. Pregnancy may be pleaded in bar of immediate capital punishment, in which case the woman must be shown to be 'quick with child.' A woman may also plead pregnancy to delay her trial in Scotland, and both in England and Scotland, in civil cases, to produce a successor to estates, to increase damages for seduction, in compensation cases where a husband has been killed, to obtain increased damages, etc. A woman may become pregnant within a month of her last delivery.
In cases of rape and suspected pregnancy, it must be borne in mind that a medical man who examines a woman under any circumstances against her will renders himself liable to heavy damages, and that the law will not support him in so doing. If, on being requested to permit an examination, the woman refuse, such refusal may go against her, but of this she is the best judge. The duty of the medical man ends on making the suggestion.
The signs of recent delivery are as follows: The face is pale, with dark circles round the eyes; the pulse quickened; the skin soft, warm, and covered with a peculiar sweat; the breasts full, tense, and knotty; the abdomen distended, its integuments relaxed, with irregular light pink streaks on the lower part. The labia and vagina show signs of distension and injury. For the first three or four days there is a discharge from the uterus more or less sanguineous in character, consisting of blood, mucus, epithelium, and shreds of membrane. During the next four or five days it becomes of a dirty green colour, and in a few days more of a yellowish, milky, mucous character, continuing for two to three weeks. The change in character of the lochial discharge is due to the quantity of blood decreasing and its place being taken by fatty granules and leucocytes. The os uteri is soft, patulous, and its edges are torn. The uterus may be felt for two or three hours above the pubis as a hard round ball, regaining its normal size in about eight weeks after delivery. Most of these signs disappear about the tenth day, after which it becomes impossible to fix the date of delivery.
In the dead the external parts have the same appearance as given above. The uterus will vary in appearance according to the time elapsed since delivery. If death occurred immediately after delivery, the uterus will be wide open, about 9 or 10 inches long, with clots of blood inside, and the inner surface lined by decidua.
The signs of a previous delivery consist in silvery streaks in the skin of the abdomen, which, however, may be due to distension from other causes; similar marks on the breast; circular and jagged condition of the os uteri (the virgin os being oval and smooth); marks of rupture of the perineum or fourchette; absence of the vaginal rugae; dark-coloured areola round the nipples, etc. The difference between the virgin corpus luteum and that of recent pregnancy is not so marked as to justify a confident use of it for medico-legal purposes.
XXV.—FOETICIDE, OR CRIMINAL ABORTION
This consists in giving to any woman, or causing to be taken by her, with intent to procure her miscarriage, any poison or other noxious thing, or using for the same purpose any instruments or other means whatsoever. It is a felony to procure or attempt to procure the miscarriage of a woman, whether she be pregnant or not, and it is a felony for the woman, if pregnant, to attempt to procure her own miscarriage. It is a misdemeanour for any person or persons to procure drugs or instruments for a like purpose. It is not necessary that the woman be quick with child. The offence is the intent to procure the miscarriage of any woman, whether she be or be not with child. When from any causes it is necessary to procure abortion, a medical man should do so only after consultation with a brother practitioner. Even in these cases there is no exemption legally. Any medical man who gives even the most harmless medicine where he suspects the possibility of pregnancy may render himself liable to grave suspicion should the woman abort.
In medicine, an abortion is said to occur when the foetus is expelled before the sixth month; after that it is premature birth. In law, however, any expulsion of the contents of the uterus before the full time is an abortion or miscarriage.
In deciding whether any substance expelled from the uterus is really a foetus or a mole, and therefore the result of conception, or the coat of the uterus, and unconnected with pregnancy, the examination of the substances expelled must be carefully made. Moles are blighted foetuses. An examination of the woman will be necessary, though it is not easy during the early months of pregnancy, and especially in those who have borne children, to say whether abortion has taken place or not. The history must be inquired into; the regular or exceptional use of drugs to promote menstruation is important, for in the former case no criminal intent may exist, although pregnancy be present. The state of the breasts, the hymen, and the os uteri, should all be carefully examined. Putting a few apparently unimportant questions as to the frequent use of purgatives, the presence or absence of constipation, will often assist the diagnosis as showing that the woman has acted in an unusual manner. Abortion may be procured by the introduction of instruments, by falls, violent exercise, blows on the abdomen, etc. In the hands of ignorant persons the use of instruments (sounds, bougies, skewers, etc.) is attended with great danger. Perforation of the vaginal walls, bladder, cervix, or uterus, may follow their use. Septic pelvic peritonitis may ensue, and the woman may lose her life. The person who has employed such means for inducing abortion is liable to be charged with the crime of murder. There is no evidence to show that ergot, savin, bitter-apple, pennyroyal, or any other drug administered internally, will cause a woman to abort, except when taken in such large doses that actual poisoning results, with inflammation of the contents of the true pelvis. In such cases reflex uterine contractions may be set up, and abortion may follow. Diachylon pills are largely employed to induce abortion, and very often the woman taking them suffers severely from lead-poisoning.
Infanticide, or the murder of a new-born child, is not treated as a specific crime, but is tried by the same rules as in cases of felonious homicide. The term is applied technically to those cases in which the mother kills her child at, or soon after, its birth. She is often in such a condition of mental anxiety as not to be responsible for her actions. It is usually committed with the object of concealing delivery, and to hide the fact that the girl has, in popular language, 'strayed from the paths of virtue.' The child must have had a separate existence. To constitute 'live birth,' the child must have been alive after its body was entirely born—that is, entirely outside the maternal passages—and it must have had an independent circulation, though this does not imply the severance of the umbilical cord. Every child is held in law to be born dead until it has been shown to have been born alive. Killing a child in the act of birth and before it is fully born is not infanticide, but if before birth injuries are inflicted which result in death after birth, it is murder. Medical evidence will be called to show that the child was born alive.
The methods of death usually employed are—(1) Suffocation by the hand or a cloth. (2) Strangulation with the hands, by a tape or ribbon, or by the umbilical cord itself. (3) Blows on the head, or dashing the child against the wall. (4) Drowning by putting it in the privy or in a bucket of water. (5) Omission: by neglecting to do what is absolutely necessary for the newly-born child—e.g., not separating the cord; allowing it to lie under the bed-clothes and be suffocated.
With regard to the question of the maturity of a child, the differences between a child of six or seven months and one at full term may be stated as follows:
Between the sixth and seventh month, length of child 10 to 14 inches—that is, the length of the child after the fifth month is about double the lunar months—weight 1 to 3 pounds; skin, dusky red, covered with downy hair (lanugo) and sebaceous matter; membrana pupillaris disappearing; nails not reaching to ends of fingers; meconium at upper part of large intestine; testes near kidneys; no appearance of convolutions in brain; points of ossification in four divisions of sternum.
At nine months, length of child 18 to 22 inches; weight, 7 to 8 pounds; skin rosy; lanugo only about shoulders; sebaceous matter on the body; hair on head about an inch long; testes past inguinal ring; clitoris covered by the labia; membrana pupillaris disappeared; nails reach to ends of fingers; meconium at termination of large intestine; points of ossification in centre of cartilage at lower end of femur, about 1-1/2 to 2-1/2 lines in diameter; umbilicus midway between the ensiform cartilage and pubis.
Owing to the difficulty of proving that the crime of infanticide has been committed, the woman may in England be tried for concealment of birth, and in Scotland for concealment of pregnancy, if she conceal her pregnancy during the whole time and fail to call for assistance in the birth. Either of these charges would only be brought against a woman who had obviously been pregnant, and now the child is missing or its dead body has been found. It is expected that every pregnant woman should make provision for the child about to be born, and so should have talked about it or have made clothes, etc., for it. The punishment for concealment is imprisonment for any term not exceeding two years. The charge of concealment is very often alternative to infanticide. To substantiate the charge, however, it must be proved that there had been a secret disposition of the dead body of the infant, as well as an endeavour to conceal its birth.
A woman may be delivered of a child unconsciously, for the contractile power of the womb is independent of volition. Under an anaesthetic the uterus acts as energetically as if the patient were in the full possession of her senses.
Nowadays a woman is rarely hanged for infanticide, and it is a mere travesty of justice to pass on her the death sentence, well knowing that it will never be executed.
XXVII.—EVIDENCES OF LIVE BIRTH
The signs of live birth prior to respiration are negative and positive. A negative opinion may be formed when evidence is found of the child having undergone intra-uterine maceration. In this case the body will be flaccid and flattened; the ilia prominent; the head soft and yielding; the cuticle more or less detached, and raised into large bullae; the skin of a red or brownish-red colour; the cavities filled with abundant bloody serum; the umbilical cord straight and flaccid.
A positive opinion is justified when such injuries are found on the body as could not have been inflicted during birth, and are attended with such haemorrhage as could only have occurred while the blood was circulating. Fractures of the cranium from accidental falls (precipitate labour) are as a rule stellate, and are situated on the vertex or in the parietal protuberance. The fractures from violence are more extensive, usually depressed, and accompanied by laceration of the scalp.
The evidences of live birth after respiration has taken place are usually deduced from the condition of the lungs, though indications are also found in other organs. The diaphragm is more arched before than after respiration, and rises higher in the thorax in the former case than in the latter. The lungs before respiration are situated in the back of the thorax, and do not fill that cavity; they are of a dark, red-brown colour and of the consistence of liver, without mottling. After respiration they expand and occupy the whole thorax, and closely surround the heart and thymus gland. The portions containing air are of a light brick-red colour, and crepitate under the finger. The lungs are mottled from the presence of islands of aerated tissue, surrounded by arteries and veins. The weight of the lungs before respiration is about 550 grains, after an hour's respiration 900 grains; but this test is of little value. The ratio of the weight of the lungs to that of the body (Ploucquet's test), which is also unreliable, is, before respiration, about 1 to 70; after, 1 to 35. Lungs in which respiration has taken place float in water; those in which it has not, sink. There are exceptions to this rule, on which, however, is founded the hydrostatic test. As originally performed, this test consisted merely in placing the lungs, with or without the heart, in water, and noticing whether they sank or floated. The test is now modified by squeezing, and by cutting the lungs up into pieces.
The objections to the test as originally performed are—(1) That the lungs may sink as the result of disease—e.g., double pneumonia. (2) That respiration may have been so limited in extent that the lungs may sink, owing to large portions of lung tissue remaining unexpanded (atelectasis). (3) Putrefaction may cause the lungs to float when respiration has not taken place. (4) The lungs may have been inflated artificially. Few of these objections apply, however, when the hydrostatic test, modified by pressure, is employed. To take these objections in detail, it may be stated: (1) If the lungs sink from disease, the question of live birth is answered. (2) This objection is too refined for practical use. The lungs sink, there is an absence of any of the signs of suffocation, and the matter ends. The examiner has only to describe the conditions which he finds, and is not required to indulge in conjectures as to the amount of respiration which may or may not have taken place. (3) Gas due to putrefaction collects under the pleural membrane, and can be expelled by pressure, and is not found in the air cells. The lungs decompose late, hence in a fresh body putrefaction of the lungs is absent; in a putrefied child, if the lungs sink, it must have been stillborn. The so-called emphysema pulmonum neonatorum is simply incipient putrefaction.
The lung test simply shows that the child has breathed, but affords no proof that the child has been born alive. The child may have breathed as soon as its head protruded, the rest of the body being in the maternal passages. The child is not born alive until it has been completely expelled, although it is not necessary that the umbilical cord should have been cut.
In addition to these tests, live birth may be suspected from the following conditions: The stomach may contain milk or food, recognized by the microscope and by Trommer's test for sugar; the large intestines in stillborn children are filled with meconium, in those born alive they are usually empty; the bladder is generally emptied soon after birth; the skin is in a condition of exfoliation soon after birth. The organs of circulation undergo the following changes after birth, and the extent to which these changes have advanced will give an idea of how long the child has lived: The ductus arteriosus begins to contract within a few seconds of birth; at the end of a week it is about the size of a crow quill, and about the tenth day is obliterated. The umbilical arteries and vein: the arteries are remarkably diminished in calibre at the end of twenty-four hours, and obliterated almost up to the iliacs in three days; the umbilical vein and the ductus venosus are generally completely contracted by the fifth day. The foramen ovale becomes obliterated at extremely variable periods, and may continue open even in the adult.
Importance of late has been attached to the stomach-bowel test. If the stomach and duodenum contain air, and consequently float in water, the chances are that the child did not die immediately after birth; this is known as Breslau's second life test, and the lower the air in the intestinal canal, the greater is the probability that the child survived birth.
The umbilical cord in a new-born child is fresh, firm, round, and bluish in colour; blood is contained in its vessels. The cord may be ruptured by the child falling from the maternal parts in a precipitate labour, and the ruptured parts present ragged ends. It is seldom that a child bleeds to death from an untied or cut umbilical cord, and the chances in a torn cord are still more remote. The changes in the cord are as follows: First it shrinks from the ligature towards the navel; this change may begin early, and is rarely delayed beyond thirty hours; the cord becomes flabby, and there is a distinct inflammatory circle round its insertion. The next change is that of desiccation or mummification; the cord becomes reddish-brown, then flattened and shrivelled, then translucent and of the colour of parchment, and falls off about the fifth day. The third stage, that of cicatrization, then ensues about the tenth to the twelfth day. The bright red rim round the insertion of the cord, with inflammatory thickening and slight purulent secretion, may be considered as evidence of live birth, and the stage at which the separation of the cord by ulcerative process has arrived will point to the probable duration of time the child has existed after birth.
There are many fallacies in the application of any of these tests, and the whole subject bristles with difficulties. The medical witness would do well to exhibit a cautious reserve, for if the child dies immediately after birth it is almost impossible to prove that it was born alive.
XXVIII.—CAUSE OF DEATH IN THE FOETUS
The death of the foetus may be due to—(1) Immaturity or intra-uterine malnutrition, or simply from deficient vitality; (2) complications occurring during or immediately after birth, which may either be unavoidable or inherent in the process of parturition, or may be induced with criminal intent.
In the latter category come such accidents as the pressure of tumours in the pelvic passages, or disease of the bones in the mother, or pressure on the cord from malposition of the child during labour, asphyxiation from the funis being twisted tightly round the neck or limbs, or from injuries due to falls on the floor in sudden labours. Where the death of the foetus has been induced with criminal intent, it may be due to punctured wounds of the fontanelles, orbits, heart, or spinal marrow; dislocation of the neck; separation of the head from the body; fracture of the bones of the head and face; strangulation; suffocation; drowning in the closet pan or privy, or from being thrown into water.
Under the head of infanticide by commission, we have injuries of all kinds; under infanticide by omission, neglecting to tie the cord, allowing it to be suffocated by discharges in the bed, neglect to provide food, clothes, and warmth, for the new-born child.
XXIX.—DURATION OF PREGNANCY
The natural period of gestation is considered as forty weeks, ten lunar months, or 280 days. A medical witness would have to admit the possibility of gestation being prolonged to 300 days, and if this time were not very materially exceeded it would be well to give the woman the benefit of the doubt. It may be mentioned that 300 days is the extreme limit fixed by the French and Scottish law. No fixed period is assigned in English or American law to the duration of pregnancy, though it is allowed that utero-gestation may be greatly prolonged. In a recent case decided, the Lord Chancellor accepted a case where it was alleged pregnancy had extended to 331 days. A child only five months old may live, for a short time at all events. There is considerable difficulty in many cases in fixing the date of conception. The data from which it is calculated are the following: (1) Peculiar sensations attending conception, which are not sufficiently defined to be recognized by those conceiving for the first time. (2) Cessation of the catamenia. Other causes may, however, cause this; and, on the other hand, a woman may menstruate during the whole period of her pregnancy. This datum also gives a variable period, and may involve an error of several days or a month, for the menses may be arrested by cold, etc., at one monthly period, and the woman become pregnant before the next. (3) The period of quickening. This, when perceived (which is not always the case), also occurs at variable periods from the tenth to the twenty-sixth week. (4) A single coitus. This does not, however, correspond to the time of fertilization. Several days may elapse before the spermatozoa meet with an ovum and fertilize it.
In Scotland a child born six months after marriage is legitimate, which is allowing an ample margin.
XXX.—VIABILITY OF CHILDREN
A child may be born alive, but may not be viable, by which is meant that it is not endowed with a capacity of maintaining its life. Speaking generally, 180 days represents the lowest limit at which a child is viable, but prolonged survival under these circumstances is the exception. Many cases, however, have been recorded in which children born at six months have been reared. The signs of immaturity and maturity may be thus tabulated: